    [House Hearing, 113 Congress]
    [From the U.S. Government Publishing Office]

        WHERE HAVE ALL THE PATIENTS GONE? EXAMINING THE PSYCHIATRIC BED
                                    SHORTAGE

    =======================================================================

                                    HEARING

                                   BEFORE THE

                  SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED THIRTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 MARCH 26, 2014

                                   __________

                               Serial No. 113-130

          Printed for the use of the Committee on Energy and Commerce
                            energycommerce.house.gov

                                   ----------

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                        COMMITTEE ON ENERGY AND COMMERCE

                              FRED UPTON, Michigan
                                     Chairman
    RALPH M. HALL, Texas                 HENRY A. WAXMAN, California
    JOE BARTON, Texas                      Ranking Member
      Chairman Emeritus                  JOHN D. DINGELL, Michigan
    ED WHITFIELD, Kentucky                 Chairman Emeritus
    JOHN SHIMKUS, Illinois               FRANK PALLONE, Jr., New Jersey
    JOSEPH R. PITTS, Pennsylvania        BOBBY L. RUSH, Illinois
    GREG WALDEN, Oregon                  ANNA G. ESHOO, California
    LEE TERRY, Nebraska                  ELIOT L. ENGEL, New York
    MIKE ROGERS, Michigan                GENE GREEN, Texas
    TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
    MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
    MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
      Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
    PHIL GINGREY, Georgia                JIM MATHESON, Utah
    STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
    ROBERT E. LATTA, Ohio                JOHN BARROW, Georgia
    CATHY McMORRIS RODGERS, Washington   DORIS O. MATSUI, California
    GREGG HARPER, Mississippi            DONNA M. CHRISTENSEN, Virgin
    LEONARD LANCE, New Jersey                Islands
    BILL CASSIDY, Louisiana              KATHY CASTOR, Florida
    BRETT GUTHRIE, Kentucky              JOHN P. SARBANES, Maryland
    PETE OLSON, Texas                    JERRY McNERNEY, California
    DAVID B. McKINLEY, West Virginia     BRUCE L. BRALEY, Iowa
    CORY GARDNER, Colorado               PETER WELCH, Vermont
    MIKE POMPEO, Kansas                  BEN RAY LUJAN, New Mexico
    ADAM KINZINGER, Illinois             PAUL TONKO, New York
    H. MORGAN GRIFFITH, Virginia         JOHN A. YARMUTH, Kentucky
    GUS M. BILIRAKIS, Florida
    BILL JOHNSON, Missouri
    BILLY LONG, Missouri
    RENEE L. ELLMERS, North Carolina
                  Subcommittee on Oversight and Investigations

                            TIM MURPHY, Pennsylvania
                                     Chairman
    MICHAEL C. BURGESS, Texas            DIANA DeGETTE, Colorado
      Vice Chairman                        Ranking Member
    MARSHA BLACKBURN, Tennessee          BRUCE L. BRALEY, Iowa
    PHIL GINGREY, Georgia                BEN RAY LUJAN, New Mexico
    STEVE SCALISE, Louisiana             JANICE D. SCHAKOWSKY, Illinois
    GREGG HARPER, Mississippi            G.K. BUTTERFIELD, North Carolina
    PETE OLSON, Texas                    KATHY CASTOR, Florida
    CORY GARDNER, Colorado               PETER WELCH, Vermont
    H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
    BILL JOHNSON, Ohio                   JOHN A. YARMUTH, Kentucky
    BILLY LONG, Missouri                 GENE GREEN, Texas
    RENEE L. ELLMERS, North Carolina     HENRY A. WAXMAN, California (ex
    JOE BARTON, Texas                        officio)
    FRED UPTON, Michigan (ex officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Tim Murphy, a Representative in Congress from the
      Commonwealth of Pennsylvania, opening statement................     1
        Prepared statement...........................................     3
    Hon. Diana DeGette, a Representative in Congress from the state
      of Colorado, opening statement.................................     5
    Hon. Henry A. Waxman, a Representative in Congress from the state
      of California, opening statement...............................     7

                                   Witnesses

    Lisa Ashley, parent of a son with serious mental illness,
      Sacramento, California.........................................     9
        Prepared statement...........................................    12
    Jeffrey L. Geller, M.D., M.P.H., Professor of Psychiatry and
      Director of Public Sector Psychiatry, University of
      Massachusetts Medical School, Worcester, Massachusetts.........    17
        Prepared statement...........................................    19
        Answers to submitted questions...............................   120
    Jon M. Hirshon, M.D., M.P.H., Ph.D., FACEP, Task Force Chair,
      2014 American College of Emergency Physicians National Report
      Card on Emergency Care, and Associate Professor, Department of
      Emergency Medicine, University of Maryland School of Medicine,
      Baltimore, Maryland............................................    37
        Prepared statement...........................................    39
        Answers to submitted questions...............................   176
    Michael C. Biasotti, Chief of Police and Immediate Past President
      of New York State Association of Chiefs of Police, and parent
      of a daughter with serious mental illness, New Windsor, New
      York...........................................................    51
        Prepared statement...........................................    53
        Answers to submitted questions...............................   178
    Thomas J. Dart, Sheriff, Cook County Sheriff's Office, Chicago,
      Illinois.......................................................    65
        Prepared statement...........................................    68
    Steve Leifman, Associate Administrative Judge, Miami-Dade County
      Court, Eleventh Judicial Circuit of Florida, Miami, Florida....    74
        Prepared statement...........................................    77
    Gunther Stern, Executive Director, Georgetown Ministry Center,
      Washington, D.C................................................    97
        Prepared statement...........................................    99
    Hakeem Rahim, Ed.M., M.A., Speaker and Mental Health Educator and
      Advocate, Hempstead, New York..................................   103
        Prepared statement...........................................   105
    Lamarr D. Edgerson, Psy.D., LMFT, NBCCH, Clinical Mental Health
      Counselor, Director at Large, American Mental Health Counselors
      Association, Family Harmony, Albuquerque, New Mexico...........   107
        Prepared statement...........................................   109
    Arthur C. Evans, Jr., Ph.D., Commissioner, Department of
      Behavioral Health and Intellectual Disability Services,
      University of Pennsylvania, Philadelphia, Pennsylvania.........   129
        Prepared statement...........................................   131
        Answers to submitted questions...............................   181

                               Submitted Material

    Article entitled, ``Dashed Hopes; Broken Promises; More Despair:
      How the Lack of State Participation in the Medicaid Expansion
      Will Punish Americans with Mental Illness,'' by the American
      Mental Health Counselors Association, submitted by Mr. Waxman
      \1\
    Letter of March 26, 2014 from the National Association of
      Psychiatric Health Systems to the subcommittee, submitted by
      Mr. Murphy.....................................................   163
    Articles submitted by Mr. Burgess................................   165

    ----------
    \1\ The article is available at http://docs.house.gov/meetings/
      if/if02/20140326/101980/hhrg-113-if02-20140326-sd004.pdf.

        WHERE HAVE ALL THE PATIENTS GONE? EXAMINING THE PSYCHIATRIC BED
                                    SHORTAGE

                                  ----------

                           WEDNESDAY, MARCH 26, 2014

                      House of Representatives,
          Subcommittee on Oversight and Investigations,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:02 a.m., in
    room 2123 of the Rayburn House Office Building, Hon. Tim Murphy
    (chairman of the subcommittee) presiding.
        Present: Representatives Murphy, Burgess, Blackburn,
    Harper, Griffith, Johnson, Ellmers, DeGette, Braley,
    Schakowsky, Butterfield, Castor, Tonko, Green, and Waxman (ex
    officio).
        Staff present: Leighton Brown, Deputy Press Secretary;
    Karen Christian, Chief Counsel, Oversight and Investigations;
    Noelle Clemente, Press Secretary; Brad Grantz, Policy
    Coordinator, Oversight and Investigations; Brittany Havens,
    Legislative Clerk; Sean Hayes, Counsel, Oversight and
    Investigations; Alan Slobodin, Deputy Chief Counsel, Oversight;
    Sam Spector, Counsel, Oversight and Investigations; Tom Wilbur,
    Digital Media Advisor; Jessica Wilkerson, Legislative Clerk;
    Brian Cohen, Democratic Staff Director, Oversight and
    Investigations, and Senior Policy Advisor; Hannah Green,
    Democratic Staff Assistant; Elizabeth Letter, Democratic Press
    Secretary; Karen Lightfoot, Democratic Communications Director
    and Senior Policy Advisor; Anne Morris Reid, Democratic Senior
    Professional Staff Member; and Stephen Salsbury, Democratic
    Investigator.

       OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
             CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

        Mr. Murphy. Good morning. I now convene this morning's
    hearing entitled ``Where Have All the Patients Gone? Examining
    the Psychiatric Bed Shortage.''
        Right after the December 14, 2012, elementary school
    shootings in Newtown, Connecticut, the Subcommittee on
    Oversight and Investigations began a review of federal programs
    and resources devoted to mental health and serious mental
    illness. Recent events have shown the continuing importance of
    this inquiry, including the September 2013 Navy Yard shooting
    just a couple of miles from where we sit this morning, in
    Washington, D.C. Other tragic cases, like Seung-Hui Cho, James
    Holmes, Jared Loughner, and Adam Lanza, all exhibited a record
    of untreated severe mental illness prior to their crimes. It is
    a reflection of the total dysfunction of our current mental
    health system that despite clear warning signs, these
    individuals failed to receive inpatient or outpatient treatment
    for their illnesses that might have averted these tragedies.
    And they all leave us wondering, what would have happened if--
    --
        What would have happened if Aaron Alexis was not just given
    sleeping pills at the VA hospitals, or if there was hospital
    bed or outpatient treatment available for others who later
    became violent, involved in a crime, unable to pay their bills,
    or tossed out on the street?
        Part of the problem is that our laws on involuntary
    commitment are in dire need of modernization. It is simply
    unreasonable, if not a danger to public safety, that our
    current system often waits until an individual is on the brink
    of harming himself or others, or has already done so, before
    any action can be taken. The scarcity of effective inpatient or
    outpatient treatment options in the community, as illustrated
    by the premature release of Gus Deeds, son of Virginia Senator
    Creigh Deeds, from emergency custody because of the lack of
    psychiatric hospital beds, is also to blame, and it is a sad,
    sad ending. In our heart we cannot begin to imagine a parent's
    grief when told there is no place for your son or daughter to
    get help.
        Nationwide, we face an alarming shortage in inpatient
    psychiatric beds that, if not addressed, will result in more
    tragic outcomes. This is part of the long-term legacy of
    deinstitutionalization, the emptying out of State psychiatric
    hospitals resulting from the financial burden for community-
    based care being shifted from the State to the Federal
    Government. With the deinstitutionalization, the number of
    available inpatient psychiatric beds has fallen considerably.
    The number of beds has decreased in the 1950s from 559,000 to
    just 43,000 today. Back in the 1950s, half of every hospital
    bed was a psychiatric bed. We needed to close those old
    hospitals that had become asylums, lockups and, quite frankly,
    they were dumping grounds.
        But where did all the patients go? They were supposed to be
    in community treatment. They were supposed to be on the road to
    recovery. But for many, that simply did not happen.
        The result is that individuals with serious mental illness
    who are unable to obtain treatment through ordinary means are
    in too many cases homeless or entangled in the criminal justice
    system, including being locked up in jails or prisons.
        Right now, the country's three largest jail systems in Cook
    County, Illinois, Los Angeles County; and New York City have
    more than 11,000 prisoners receiving treatment on any given day
    and are, in fact, the largest mental health treatment
    facilities in the country. These jails are many times larger
    than the largest State psychiatric hospitals.
        Not surprisingly, neither living on the streets nor being
    confined to a high-security cellblock are known to improve the
    chances that an individual's serious mental illness will
    stabilize, let alone prepare them, where possible, for eventual
    reentry into the community, to find housing, to find jobs, and
    to find confidence in their future.
        It is an unplanned, albeit entirely unacceptable
    consequence of deinstitutionalization that the State
    psychiatric asylums, dismantled out of concern for the humane
    treatment and care of individuals with serious mental illness,
    have now effectively been replaced by confinement in prisons
    and homeless shelters and tied to hospital beds.
        What can we do earlier in people's lives to get them
    evidence-based treatment, community support, and on the road to
    recovery, not the road to recidivism? Where is the humanity in
    saying there are no beds to treat a person suffering from acute
    schizophrenia, delusions, agitation, and aggression and what
    they are offered is sedation and being restrained in ER
    hospital bed for days?
        This morning, to provide some perspective on the far-
    reaching implications of the current psychiatric bed shortage
    and to hear some creative approaches to address it, we will be
    receiving testimony from individuals with a wealth of
    experience across the full range of public services consumed by
    the seriously mentally ill across our Nation. These include
    Lisa Ashley, the mother of a son with serious mental illness
    who has been boarded multiple times at the emergency
    department; Dr. Jeffrey Geller, a psychiatrist and co-author of
    a report on the trends and consequences of closing public
    psychiatric hospitals; Dr. Jon Mark Hirshon, an ER physician
    and Task Force Chair on a recent study of emergency care
    compiled by the American College of Emergency Physicians; Chief
    Mike Biasotti, immediate past President of the New York State
    Association of Chiefs of Police and parent of a daughter with
    serious mental illness; Sheriff Tom Dart, of the Cook County,
    Illinois, Sheriff's Office, who oversees one of the largest
    single site county pre-detention facilities in the United
    States; the Hon. Steve Leifman, Associate Administrative Judge,
    Miami-Dade County Court, 11th Judicial Circuit of Florida;
    Gunther Stern, Executive Director of Georgetown Ministry
    Center, a shelter and clubhouse caring for Washington D.C.'s
    homeless; Hakeem Rahim, a Mental Health Educator and Advocate;
    LaMarr Edgerson, a Clinical Mental Health Counselor and
    Director at Large of the American Mental Health Counselors
    Association; and Dr. Arthur Evans, Jr., Commissioner of
    Philadelphia's Department of Behavioral Health and Intellectual
    DisAbility Services. I thank you all for being with us this
    morning and giving us so much of your time.
        [The prepared statement of Mr. Murphy follows:]

                     Prepared statement of Hon. Tim Murphy

        Right after the December 14, 2012 elementary school
    shootings in Newtown, Connecticut, the Subcommittee on
    Oversight and Investigations began a review of federal programs
    and resources devoted to mental health and serious mental
    illness.
        Recent events have shown the continuing importance of this
    inquiry, including the September 2013 Navy Yard shooting just a
    couple of miles from where we sit this morning, in Washington,
    D.C.
        Other tragic cases, like Seung-Hui Cho, James Holmes, Jared
    Loughner, and Adam Lanza, all exhibited a record of untreated
    severe mental illness prior to their crimes. It is a reflection
    of the total dysfunction of our current mental health system
    that despite clear warning signs, these individuals failed to
    receive inpatient or outpatient treatment for their illnesses
    that might have averted these tragedies.
        They all leave us wondering what would have happened if.
        What would have happened if Aaron Alexis was not just given
    sleeping pills at the VA? Or if there was an available hospital
    bed or outpatient treatment available for others who later
    became violent, involved in a crime, unable to pay bills, or
    tossed out on the street?
        Part of the problem is that our laws on involuntary
    commitment are in dire need of modernization--it is simply
    unreasonable, if not a danger to public safety, that our
    current system often waits until an individual is on the brink
    of harming himself or others, or has already done so, before
    any action can be taken. The scarcity of effective inpatient or
    outpatient treatment options in the community, as illustrated
    by the premature release of Gus Deeds, son of Virginia senator
    Creigh Deeds, from emergency custody because of the lack of
    psychiatric beds, is also to blame. A sad ending that in our
    heart we cannot begin to imagine a parent's grief when told
    there is no place for your son to get help.
        Nationwide, we face an alarming shortage in inpatient
    psychiatric beds that, if not addressed, will result in more
    tragic outcomes. This is part of the long-term legacy of
    deinstitutionalization, the emptying out of state psychiatric
    hospitals resulting from the financial burden for
    communitybased care being shifted from the state to the federal
    government. With deinstitutionalization, the number of
    available inpatient psychiatric beds has fallen considerably.
    On the whole, the number of beds has decreased from 559,000 in
    the 1950s to just 43,000 today. We needed to close those old
    hospitals that had become asylums, lock-ups, and dumping
    grounds.
        But where did all the patients go? They were supposed to be
    in community treatment--on the road to recovery--but for many
    that did not happen.
        The result is that individuals with serious mental illness
    who are unable to obtain treatment through ordinary means are
    now homeless or entangled in the criminal justice system,
    including being locked up in jails and prisons.
        Right now, the country's three largest jail systems--in
    Cook County, Illinois; Los Angeles County; and New York City--
    have more than 11,000 prisoners receiving treatment on any
    given day and are, in fact, the largest mental health treatment
    facilities in the country. These jails are many times larger
    than the largest state psychiatric hospitals.
        Not surprisingly, neither living on the streets nor being
    confined to a high-security cellblock are known to improve the
    chances that an individual's serious mental illness will
    stabilize, let alone prepare them, where possible, for eventual
    reentry into the community, to find housing, jobs, and
    confidence for their future.
        It is an unplanned, albeit entirely unacceptable
    consequence of deinstitutionalization that the state
    psychiatric asylums, dismantled out of concern for the humane
    treatment and care of individuals with serious mental illness,
    have now effectively been replaced by confinement in prisons
    and homeless shelters.
        What can we do earlier in people's lives to get them
    evidence-based treatment, community support, and on the road to
    recovery not recidivism?
        Where is the humanity in saying there are no beds to treat
    a person suffering from schizophrenia, delusions, and
    aggression so we will sedate you and restrain you to an ER bed
    for days?
        This morning, to provide some perspective on the far-
    reaching implications of the current psychiatric bed shortage
    and to hear some creative approaches to address it, we'll be
    receiving testimony from individuals with a wealth of
    experience across the full range of public services consumed by
    the seriously mentally ill. These include:
         Lisa Ashley, the mother of a son with serious
    mental illness who has been boarded multiple times at the
    emergency department;
         Dr. Jeffrey Geller, a psychiatrist and co-author
    of a report on the trends and consequences of closing public
    psychiatric hospitals;
         Dr. Jon Mark Hirshon, an ER physician and Task
    Force Chair on a recent study of emergency care compiled by the
    American College of Emergency Physicians;
         Chief Mike Biasotti, Immediate Past President of
    the New York State Association of Chiefs of Police and parent
    of a daughter with serious mental illness;
         Sheriff Tom Dart, of the Cook County, IL Sheriff's
    Office, who oversees one of the largest single site county pre-
    detention facilities in the U.S.;
         The Honorable Steve Leifman, Associate
    Administrative Judge, Miami-Dade County Court, 11th Judicial
    Circuit of Florida;
         Gunther Stern, Executive Director of Georgetown
    Ministry Center, a shelter and clubhouse caring for Washington
    D.C.'s homeless;
         Hakeem Rahim, a mental health educator and
    advocate;
         LaMarr Edgerson, a clinical mental health
    counselor and Director at Large of the American Mental Health
    Counselors Association; and
         Dr. Arthur Evans, Jr., Commissioner of
    Philadelphia's Department of Behavioral Health and Intellectual
    DisAbility Services.
        I thank them all for joining us this morning.

                                    #  #  #

        Mr. Murphy. I would now like to give the ranking member an
    opportunity to deliver brief remarks of her own. Ms. DeGette.

     OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
                  CONGRESS FROM THE STATE OF COLORADO

        Ms. DeGette. Thank you very much, Mr. Chairman. I want to
    thank you for having this hearing and also for your continued
    leadership on the important topic of mental health. I want to
    thank all of the witnesses for appearing before us today. I
    think this sets a record as the biggest panel we have ever had
    in this subcommittee, and I am looking forward to hearing each
    one of your perspectives. It is rare we ever get so much
    knowledge and such a breadth gathered in one place.
        Mr. Rahim, I am especially glad that you are here with us
    this morning. This is our fourth hearing in this subcommittee
    on mental health during this Congress, but this is the first
    time we have ever heard directly from somebody who can share
    his own personal history with mental illness and sit before us
    as a testament to the possibility of recovery. I know it takes
    a lot of courage to tell these personal stories in public, and
    I want to commend you for being here.
        I also want to commend Ms. Ashley and Mr. Biasotti for
    being here today as parents because I have been approached by
    so many parents in my district who know that I am working on
    these issues, talking to me about the heartbreak of having
    young adults or teenagers who are dealing with these issues and
    what it is like as a family member. All of you can add really
    good perspective to this, and I want to thank you.
        The question for this hearing, where have all the patients
    gone, is a very important one. Individuals with serious mental
    illnesses like bipolar disorder or schizophrenia are showing up
    in emergency rooms, encountering the criminal justice system
    and becoming homeless far too often. One reason why this
    problem is getting worse is because of budget cuts for mental
    health and addiction services at the State and local level. The
    American Mental Health Counselors Association reported that
    between 2009 and 2012, States have cut nearly $5 billion in
    mental health services.
        Mr. Chairman, I am concerned about the impact of these
    cuts, and I hope that we can address them today, and also as we
    continue our joint efforts to work towards comprehensive mental
    health legislation, how we can address these cuts because, to
    be honest, if there are no beds for folks to go to, then
    anything we can do is going to be useless, and so we are going
    to have to work with State and local governments to figure out
    how to fund the appropriate amount of beds that we need.
        It is also important to address the issue of patients with
    mental illnesses showing up in the ER, which we all know is
    less effective and more expensive to receive treatment than
    other alternatives, but I do think if these folks do show up in
    the ER, there are ways to improve the way they are treated
    there.
        But I also want to focus our attention on an even more
    important question: how can we keep people with serious mental
    illness out of the emergency room in the first place? When
    people show up in the ER, it means that they have reached a
    crisis point and that represents a broader failure of our
    mental health system in this country. Our goal should be
    preventing crises from arising in the first place by investing
    in approaches to identify the early signs and symptoms of
    mental illness and to make sure that patients have quality
    health insurance and can get timely and effective mental health
    treatment and support services, and I will bet you every single
    provider, parent and patient in this room would agree with what
    I just said.
        I don't want to downplay the concerns about the lack of
    inpatient beds for patients who need them. Despite our best
    efforts, there still will be instances where more intensive
    interventions are needed. But I hope that we can agree that
    these should be exceedingly rare occurrences and that having
    more inpatient beds is only a partial solution. The benefits
    provided by the Mental Health Parity and Addiction Equity Act
    and the Affordable Care Act will help prevent these ER crises
    if implemented correctly. They will provide millions of
    Americans with access to quality, affordable health insurance
    that includes coverage for mental health services. We need to
    build from these laws to support the continuum of mental health
    services at all levels of government, and I must say, I was
    very proud that we were able to include mental health parity in
    the Affordable Care Act. This will be very important for
    patients.
        We also need to remember that recovery, even for
    individuals living with serious mental illness, is possible, or
    certainly at least management. Mr. Rahim is proof that
    individuals with access to the right range of services not only
    can we greatly reduce the number of individuals in crisis
    winding up in prisons or emergency rooms but we can produce
    hardworking, contributing members of society as well. As well
    as your bill that you have introduced, Mr. Chairman, there is a
    lot of other legislation out there, and I know we intend to
    continue working together to try to have some kind of
    comprehensive legislation that will begin to address all of
    these issues.
        Thank you so much, Mr. Chairman.
        Mr. Murphy. I thank the gentlelady for her comments, and
    yes, we will continue to work together.
        I now recognize the gentlelady from North Carolina, Mrs.
    Ellmers, if you want to make an opening statement.
        Mrs. Ellmers. Thank you, Mr. Chairman. I just want to make
    a brief statement, especially due to the size of our panel, and
    I am very anxious to hear from all of you on these issues.
        You know, I served as a nurse for 21 years before coming to
    Congress, and there is nothing that is more heartbreaking than
    when you see a situation of mental illness and a family who is
    struggling to deal with that. I just want to say thank you to
    all of you. I want to take that opportunity because you coming
    forward will help us to finally deal with the situation, and it
    is a multifaceted situation and we all have to come together.
    This is not a political one, this is not one that we can't
    reach across the aisle and work together on.
        So thank you to all of you, and God bless all of you.
        Mr. Murphy. The gentlelady yields back. Anybody on this
    side want any more of the remaining time? If not, we will now
    recognize the ranking member of the full committee, Mr. Waxman,
    for an opening statement, 5 minutes.

    OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF CALIFORNIA

        Mr. Waxman. Thank you very much, Mr. Chairman.
        Today's hearing addresses an important issue affecting
    treatment and outcomes for patients with mental illnesses. We
    will hear today that budget cuts and other factors have
    resulted in a lack of inpatient beds for intensive psychiatric
    treatment, meaning that patients with serious mental illness
    who show up to the emergency room at a crisis point are forced
    to wait far too long, for days at a time, for an inpatient
    psychiatric bed.
        This is a growing problem, but it is not a new one. A
    decade ago, as ranking member of the Oversight Committee, I
    released a report finding that all too often, jails and
    juvenile detention facilities have had to provide care for
    individuals with mental illnesses. This report found that due
    to lack of available treatment, youth with serious mental
    disorders were placed in detention without any criminal charges
    pending against them. In other cases, youth who had been
    charged with crimes but who had served their time or were
    otherwise able to be released remained incarcerated for
    extended periods of time because no inpatient bed, residential
    placement or outpatient appointment was available. That
    investigation found that two-thirds of juvenile detention
    facilities were holding youth waiting for mental health
    treatment, and that in one 6-month period, nearly 15,000
    incarcerated youth were waiting for mental health services.
        Mr. Chairman, I share your desire to end these practices.
    That is why I supported the Affordable Care Act, which provides
    health insurance coverage, including coverage for mental
    illness, to millions of Americans, and that is why I have
    opposed Republican efforts to repeal this law and take this
    coverage away. It is also why I hope that this hearing does not
    ignore the elephant in the room: the impact on millions of
    Americans with mental illnesses of the failure by 24 States to
    expand their Medicaid programs under the Affordable Care Act.
        Last month the American Mental Health Counselors
    Association released a new study titled ``Dashed Hopes, Broken
    Promises, More Despair,'' and I would like to ask that this
    report be made part of the hearing record.
        Mr. Murphy. Without objection, yes, it will be included.
        [The information appears at http://docs.house.gov/meetings/
    if/if02/20140326/101980/hhrg-113-if02-20140326-sd004.pdf.]
        Mr. Waxman. Dr. Edgerson is here today to testify on behalf
    of the organization, and I appreciate him joining us.
        The report found that the failure by states to expand their
    Medicaid programs is causing nearly four million people who are
    in serious psychological distress or have a serious mental
    illness or substance disorder to go without health insurance.
    That is four million Americans in need who are left without
    coverage, largely because of Republican governors' ideological
    obsession with rejecting everything associated with the
    Affordable Care Act.
        Mr. Chairman, this includes over 200,000 people with mental
    illnesses in your home State of Pennsylvania.
        The report described the impact of this lack of coverage,
    finding that ``The lack of health insurance coverage keeps
    people with mental illness from obtaining needed services and
    treatments and follow-up care with the goal of achieving long-
    term recovery and quality of life.''
        This is a tragedy and a shame. If these four million
    Americans obtained coverage, they would receive better ongoing
    treatment and care, and they would be less likely to end up in
    a hospital emergency room, or worse, a prison, with a mental
    health crisis.
        Mr. Chairman, I know you want to help individuals with
    mental illnesses. We have both introduced mental health
    legislation, and I hope that as we move forward, we can find
    common ground with these bills.
        But the biggest and easiest step we can take to improve
    care for those with serious mental illnesses is to make sure
    they have health insurance. The Medicaid expansion is a good
    deal for the states, and it is desperately needed by millions
    of Americans. This committee should be working together to make
    sure that regardless of where they live, Americans in all 50
    states can obtain this coverage.
        I yield back the balance of my time.
        Mr. Murphy. The gentleman yields back. Thank you.
        I also have a letter from the National Association of
    Psychiatric Health Systems, also commenting on this topic today
    of psychiatric beds, and so I ask without objection to include
    that in the record as well.
        [The information appears at the conclusion of the hearing.]
        Mr. Murphy. I have already introduced all of our witnesses
    today, so I am now going to swear you in. So you are aware, the
    committee is holding an investigative hearing, and we have the
    practice of taking testimony under oath. Do any of you object
    to taking an oath? All right. The Chair then advises you that
    under the rules of the House and the rules of the committee,
    you are entitled to be advised by counsel. Do any of you desire
    to be advised by counsel during your testimony today? It
    shouldn't be an issue. Thank you. In that case, if you would
    please rise and raise your right hand, and I will swear you in.
        [Witnesses sworn.]
        Mr. Murphy. You may now sit down, and you are under oath
    and subject to the penalties set forth in Title XVIII, section
    1001 of the United States Code. We will now recognize each of
    you to give a 5-minute opening statement.
        I recognize first Ms. Ashley. Make sure your microphone is
    on and it is pulled close to you. Thank you.

     TESTIMONY OF LISA ASHLEY, PARENT OF A SON WITH SERIOUS MENTAL
       ILLNESS, SACRAMENTO, CALIFORNIA; JEFFREY L. GELLER, M.D.,
     M.P.H., PROFESSOR OF PSYCHIATRY AND DIRECTOR OF PUBLIC SECTOR
        PSYCHIATRY, UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL,
    WORCESTER, MASSACHUSETTS; JON M. HIRSHON, M.D., M.P.H., PH.D.,
      FACEP, TASK FORCE CHAIR, 2014 AMERICAN COLLEGE OF EMERGENCY
        PHYSICIANS NATIONAL REPORT CARD ON EMERGENCY CARE, AND
        ASSOCIATE PROFESSOR, DEPARTMENT OF EMERGENCY MEDICINE,
    UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE, BALTIMORE, MARYLAND;
        MICHAEL C. BIASOTTI, CHIEF OF POLICE AND IMMEDIATE PAST
     PRESIDENT OF NEW YORK STATE ASSOCIATION OF CHIEFS OF POLICE,
       AND PARENT OF A DAUGHTER WITH SERIOUS MENTAL ILLNESS, NEW
        WINDSOR, NEW YORK; THOMAS J. DART, SHERIFF, COOK COUNTY
     SHERIFF'S OFFICE, CHICAGO, ILLINOIS; STEVE LEIFMAN, ASSOCIATE
        ADMINISTRATIVE JUDGE, MIAMI-DADE COUNTY COURT, ELEVENTH
      JUDICIAL CIRCUIT OF FLORIDA, MIAMI, FLORIDA; GUNTHER STERN,
      EXECUTIVE DIRECTOR, GEORGETOWN MINISTRY CENTER, WASHINGTON,
      D.C.; HAKEEM RAHIM, ED.M., M.A., SPEAKER AND MENTAL HEALTH
    EDUCATOR AND ADVOCATE, HEMPSTEAD, NEW YORK; LAMARR D. EDGERSON,
    PSY.D., LMFT, NBCCH, CLINICAL MENTAL HEALTH COUNSELOR, DIRECTOR
    AT LARGE, AMERICAN MENTAL HEALTH COUNSELORS ASSOCIATION, FAMILY
      HARMONY, ALBUQUERQUE, NEW MEXICO; AND ARTHUR C. EVANS, JR.,
       PH.D., COMMISSIONER, DEPARTMENT OF BEHAVIORAL HEALTH AND
     INTELLECTUAL DISABILITY SERVICES, UNIVERSITY OF PENNSYLVANIA,
                       PHILADELPHIA, PENNSYLVANIA

                        TESTIMONY OF LISA ASHLEY

        Ms. Ashley. Hello, and good morning, Mr. Chairman and
    members of the subcommittee. Thank you for inviting me here to
    tell my son's story with the emergency room department in my
    vicinity.
        I am a Nurse Practitioner with a master's degree. I have
    been in pediatric practice for 38 years, but that is not why I
    am here today. I am here as a mother of a son who is now 27 and
    diagnosed with paranoid schizophrenia 2 years ago. It has been
    a long and difficult story which I share with many parents.
        My son was about 20 or 21 years old when I knew something
    was wrong but it wasn't until he went homeless when he was in
    L.A. and went missing for 3 weeks that I knew for sure. Of
    course he saw nothing wrong. When I was finally able to locate
    him, I brought him back to Sacramento. He was delusional,
    thinking the FBI was watching him, there were satellites in the
    sky monitoring his thoughts, having auditory hallucinations,
    could not have a conversation, laughing to himself, and not
    caring for his hygiene. Prior to this, my son was extremely
    bright, received 740 out of 800 on his math SATs, and was
    accepted to seven universities for mechanical engineering. His
    bizarre behavior went on for months but he refused to see a
    psychiatrist. He was bonded to his primary medical provider,
    who saw him several times trying to get him on a hold. I felt
    helpless and extremely frustrated. Even calling the police did
    not help because they did not feel that he was a harm to
    himself or others.
        I am specifically going to tell a story regarding his
    hospital emergency department stays three times over a 2-year
    period. Each time, I struggled with pain and anguish to see my
    beautiful son taken into custody, especially for the first
    time, because he didn't know how sick he was and how very
    confused as to why he could not go home with me, and I cried my
    heart out.
        The first time was in May 2012. He had been sick over a
    year before I was able to get him some help. His first time in
    the emergency room was approximately 12 hours. I couldn't
    believe they had to hold him there that long, not knowing there
    was a shortage of psych beds in the county. He was then
    transferred to a psych facility locally and remained 2 weeks,
    just as long as my insurance would allow him. Although it was
    very difficult to have my son hospitalized, I know he was in
    good hands and it relieved some of my anxiety, but still, it
    was nothing like I had ever been through and having to trust a
    system that was so foreign to you and difficult, I worried
    every minute.
        The second time was not quite as smooth. In January of
    2013, my son asked voluntarily to be taken to the hospital
    because his head felt like it was on fire. He was anxious and
    very distressed. I dropped everything, knowing that he was
    asking to go, he must have felt pretty bad. I brought him to
    the same emergency room that morning, we reached the triage
    nurse. I identified myself as an employee and a nurse
    practitioner. I explained my son was a paranoid schizophrenic
    and he was in psychosis. I tried to remain calm as the triage
    nurses took his blood pressure and temperature and then
    assigned him to a gurney in the hallway with at least eight
    other patients, which included children, all waiting to be seen
    by a doctor. It was not long before my son started to get
    agitated and wanting to leave. The R.N. called the social
    worker to help intervene. She could not quiet him down. As he
    tried to approach the exit, the emergency room policeman tried
    to stop him by holding him back. His behavior escalated. My son
    was screaming at him not to touch him. When schizophrenics are
    in psychosis, they do not want to be touched. In front of all
    the children and adults waiting in the hallway, the police
    officer wrestled him to the ground and handcuffed him.
        I tell you this because I brought him to the hospital for
    medical treatment, not for police handcuffing him, and their
    intervention escalating his psychosis made it worse. If he had
    been able to go to some kind of psych facility, he would have
    gotten medical attention rather than police detention. Doctors
    would have known how to deal with him, calm him down, isolate
    him from others. The emergency room is not a quiet place and
    they are not trained to deal with psychiatric illnesses and
    certainly not serious mental illness.
        They then placed him on a gurney and put him in four-point
    restraints and then medicated him. He was there on a Friday
    morning the whole day, all day Saturday, all day Sunday and all
    day Monday afternoon because they could not find a psych bed
    anywhere. He stayed in a room tied to his bed for four days,
    heavily medicated. Seeing him helpless tied to a bed for days
    was like a nightmare. This was my son, and I was helpless
    except to keep him company and try to reassure him things would
    be all right. I was angry they couldn't find him a place. Does
    it really take that long to find a psych bed?
        Finally, on Monday, I was told there was an opening at a
    hospital in San Francisco, which is 100 miles east of
    Sacramento. They finally took him there later that day. I was
    unable to be involved in his care because he was so far away
    except for weekends. It was very frustrating. I didn't
    understand why he needed to go so far away from his family
    member, who cared for him and loved him.
        By the way, if I hadn't had private insurance, he never
    would have gone to that hospital because they don't accept
    public monies, so because I had private insurance, they took
    him. Otherwise, who knows? He might still be there.
        The third time was in November. Again, his head was burning
    and voices were screaming at him. I took him back to the
    hospital. They put him on a gurney in the hallway again. I was
    able to be proactive and talk with other providers prior to
    this, and set up a plan so that the second intervention would
    never, ever happen to him again. I was able to make some phone
    calls, and after two days get him into a local psych facility,
    where he stayed another 3 days.
        My son is fairly stable since that time in November. He has
    not required any additional hospitalization but he attends
    regular psychiatric visits and takes his medications regularly,
    and I pray every day that he continues to stay out of the
    emergency room because there are no other alternatives for him.
        Thank you.
        [The prepared statement of Ms. Ashley follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Ms. Ashley. I appreciate your moving
    testimony.
        I forgot to mention at the time to keep your comments to 5
    minutes, so if you hear my gavel tapping, that is why.
        Doctor, you are next.

                     TESTIMONY OF JEFFREY L. GELLER

        Dr. Geller. Mr. Chairman, Representatives, ladies and
    gentlemen, good morning. I am Dr. Jeffrey Geller, a board-
    certified psychiatrist, currently Professor of Psychiatry at
    the University of Massachusetts Medical School, Medical
    Director of the Worcester Recovery Center and Hospital, and
    Staff Psychiatrist at the Carson Community Mental Health
    Center.
        I have consulted public mental health systems and State
    hospitals in one-half of the States in the United States, the
    District of Columbia and Puerto Rico. I am the author of 250
    publications in the professional literature, and the book,
    ``Women of the Asylum.'' I serve on many professional boards
    but I come here today representing only my own experience
    taking care of patients with serious mental illness for 40
    years.
        Just yesterday, there were 22 psychiatric patients in a
    general hospital emergency room in a city of 150,000 not far
    from here waiting for disposition. Why? What is to be done?
        On May 3, 1854, President Franklin Pierce vetoed a bill
    that would have made the Federal Government responsible for
    America's population with serious mental illness. His veto
    message includes the following beliefs of his: State hospitals
    or public psychiatric hospitals are meritorious institutions
    doing good. They fulfill a historic role belonging to the
    States, meeting the needs of a population outside the purview
    of the Federal Government and susceptible to becoming the
    responsibility of the Federal Government if the Federal
    Government provided any opportunity to the States to shift the
    burden.
        The Federal Government left the care of the serious
    mentally ill to the states until Congress passed and President
    Kennedy signed the Mental Retardation Facilities and Community
    Mental Health Centers Construction Act of 1963. From then until
    now, federal actions such as Medicaid, Medicare, the IMD
    exclusion and many others have resulted in the unintended
    consequences of massive proportions, not the least of which is
    deinstitutionalization. We created the perfect formula for the
    current debacle: an expanding array of fiscal incentives for
    States to move people out of state hospitals, inadequate
    resources to meet the needs of State residents with serious
    mental illness in the community, no beds in State hospitals to
    meet the needs of former State hospital patients, who did not
    find the community the panacea promised by the Supreme Court
    and were dangerous outside of hospitals, no beds to meet the
    needs of new cases of serious mental illness requiring a
    hospital level of care, and a public more willing to build
    jails and prisons than hospitals because they found no solace
    in a state system they saw as pushing ill-prepared folks with
    mental illness into their neighborhoods.
        How did this lead to individuals waiting in hospital
    emergency departments, or EDs, for weeks, sometimes a month?
    Pick any State. There are no available beds in the State's
    public psychiatric hospitals because there are too few beds. A
    patient on the psychiatric unit in a general hospital has been
    approved for transfer to the State hospital but cannot be
    transferred because there is no available bed. Thus, the
    general hospital psychiatric unit is populated by some patients
    who are stuck there awaiting state hospital transfer. An
    individual is brought to the general hospital's emergency
    department by police, family, ambulance, or comes on her own.
    The individual was assessed and determined to need
    hospitalization. The individual cannot be admitted to the
    psychiatric unit in the same hospital as the emergency
    department because there are no beds there.
        What happens next is, a hospital emergency department staff
    or a member of a contracted crisis team starts a bed search. A
    bed search means calling every hospital in the State seeking a
    bed. Frequently, the bed search is fruitless. There are no beds
    available anywhere because all the hospitals are in the same
    situation as the psychiatric unit in the hospital the worker is
    calling from. So the individual remains in the emergency
    department waiting for an available bed. The days waiting
    benefit no one. The ED becomes overcrowded. The patient is a
    patient in name only. He is not getting treatment except that
    he is receiving food, a bed or gurney, and maybe some
    medication. He might as well be waiting on a bench in a train
    station. Or the individual is simply released from the
    emergency department because there is no place else for her to
    go. The threshold for holding somebody in the emergency
    department awaiting admission keeps creeping up. Many released
    folks are picked up by the police, processed through the
    courts, sent to the State hospital for a forensic evaluation,
    further decreasing available beds to the person awaiting a bed
    in the emergency department.
        Congress can enact measures to ameliorate the problems of
    boarders in emergency departments. These include: provide
    States with opportunities to obtain IMD exclusion waivers with
    maintenance of effort; make SSI and SSDI payments to eligible
    individuals independent of where they reside and require their
    contribution for room and board to be the same in all locations
    including jails and prisons; individuals keep their Medicaid
    and Medicare in all settings. Improve the federal grant process
    for research into prevention and early intervention; provide
    grants to States to create or expand crisis intervention teams
    so that such a program is available in every city and town; set
    fair and reasonable Medicaid payment rates for psychiatric
    services at community mental health centers and Federally
    Qualified Health Centers; incentivize States to actually use
    the assisted outpatient treatment statutes they have; define
    Medicaid and Medicare payments to clubhouses in ways that do
    not destroy the mission of clubhouses; incentivize States to
    establish mental health courts.
        Mr. Chairman, Representatives, it is time the Federal
    Government took explicit action through bipartisan, bicameral
    efforts to remedy the calamitous state of the public care and
    treatment of persons with serious mental illness in the United
    States today.
        Thank you.
        [The prepared statement of Dr. Geller follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Doctor.
        Dr. Hirshon, you are recognized for 5 minutes.

                      TESTIMONY OF JON M. HIRSHON

        Dr. Hirshon. In emergency departments throughout the
    country, we emergency physicians expect the unexpected. This is
    what we are trained to do. Even so, there is one thing that we
    all know is happening: increasing demand by patients in need of
    acute psychiatric care.
        Mr. Chairman and members of the subcommittee, thank you for
    this opportunity to testify today on behalf of the American
    College of Emergency Physicians. ACEP is the largest specialty
    organization in emergency medicine with more than 32,000
    members in all 50 States and the District of Columbia.
        My purpose today is to help you understand that we are in
    the midst of a national crisis, facing a dramatic increase in
    vulnerable mental health patients seeking emergent and urgent
    care. America's mental health services are experiencing
    increasing demand while concurrently receiving decreased
    funding, which drives psychiatric patients to the ED, or
    emergency department.
        In 2000, psychiatric patients to the ED accounted for only
    5.4 percent of all ED visits, but by 2007, that number had
    risen to 12.5 percent, well over a doubling of the number of
    psychiatric patients. Until more services and funding are made
    available to address this crisis, EDs will be the safety net
    for these patients. This is due in large part to the federal
    Emergency Medicine Treatment and Labor Act, EMTALA, which
    mandates medical screening evaluation and stabilization for
    anyone seeking care in an ED. Additionally, unlike many other
    health care settings, EDs are open 24 hours a day, 7 days a
    week every day of the year.
        Emergency physicians do their best to provide care to
    patients with psychiatric conditions but the ED is not the
    ideal location for these services. ED crowding leads to delays
    in care and have been associated with poor clinical outcomes.
    For patients with mental health and/or substance abuse
    problems, prolonged ED stays are associated with increased risk
    of worsening symptoms. Without available appropriate inpatient
    resources for admitted patients, these patients wait or are
    boarded in the ED until an inpatient bed becomes available or
    an accepting facility can be found.
        When the normal capacity of the ED is overwhelmed with
    boarded patients, there remains absolutely no room for surge
    capacity, which would be critical in the event of a manmade or
    natural disaster.
        In a recent ACEP survey, 99 percent of emergency physicians
    reported admitting psychiatric patients daily while 80 percent
    said that they were boarding psychiatric patients in their EDs.
    Acutely ill psychiatric patients require more physician, more
    nurse and more hospital resources. ED staff spends more than
    three times as long looking for a psychiatric bed as they would
    for a non-psychiatric patient.
        Other factors contribute to the extended ED boarding times
    for psychiatric patients including defensive medicine or threat
    of legal action, required preauthorization for inpatient
    services, medical clearance prior to psychiatric evaluation,
    substance abuse-related issues, and inadequate outpatient
    services. As communities have seen, many of these issues are
    systems issues and beyond the control of the clinician. It is
    imperative that access to high-quality inpatient and community
    mental health care be a priority.
        I go into further detail on suggested solutions in my
    written testimony but some important ones include full capacity
    protocols to improve the movement of admitted patients to
    inpatient floors, separate psychiatric ED and behavioral health
    annexes to help address urgent and emergent psychiatric needs,
    regionalized care and telemedicine to help efficiently and
    effectively address increasing demand, as well as the
    elimination of out-of-network insurance issues and community
    and State mental health buy-in.
        Let me leave you with this: the increasing burden of mental
    illness in this country combined with a lack of resources to
    care for these individuals is a national crisis. Mass
    deinstitutionalization of mental health patients over the past
    few decades did not result in successful community integration
    of individuals needing psychiatric services, in part because
    the necessary services and funding were not put in place for
    adequate community support.
        Systematic changes are needed in the way we care for these
    individuals with mental illness in this country. How we deal
    with these vulnerable individuals is an important measure of
    who we are as a society. Necessary resources must be made
    available for additional inpatient and outpatient treatment
    beds with the corresponding professional staff as well as for
    critically needed research. Otherwise mental health services
    will continue to deteriorate and these individuals, often our
    family members, will continue to be at risk for abuse and
    neglect, seeking care in EDs for lack of any other support.
        I thank you for your attention to this alarming problem.
        [The prepared statement of Dr. Hirshon follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Doctor.
        Chief Biasotti, you can pull that microphone right up next
    to you, please. Thank you.

                    TESTIMONY OF MICHAEL C. BIASOTTI

        Chief Biasotti. Good morning, Chairman Murphy and Ms.
    DeGette. I am the immediate past President of the New York
    State Association of Chiefs of Police and Chief of Police in
    New Windsor, New York. I am in my 38th year of service.
        My wife, Barbara, who is a psychologist, is here today with
    me. We have a daughter with schizophrenia who has been
    involuntarily hospitalized in excess of 20 times. Barbara and I
    met when she, like many moms, turned to the police for help
    when her, now our daughter became psychotic, disruptive and
    threatening. She was self-medicating, unemployed and
    deteriorating, despite my wife's heroic efforts to help her.
    Then she went into assisted outpatient treatment. It saved her
    life.
        In 2011, while at the United States Naval Postgraduate
    School's s Center for Homeland Defense and Security, I
    published a survey of over 2,400 senior law enforcement
    officers titled ``Management of the Severely Mentally Ill and
    its Effects on Homeland Security.'' It found that the mentally
    ill consume a disproportionate percentage of law enforcement
    resources. Many commit low-level crimes. One hundred and sixty
    thousand attempt suicide, 3 million become crime victims, and
    164,000 are homeless each year.
        The survey essentially found that we have two mental health
    systems today, serving two mutually exclusive populations.
    Community programs serve those who seek and accept treatment.
    Those who refuse, or are too sick to seek voluntary treatment,
    become law enforcement responsibilities. Officers in the survey
    were frustrated that mental health officials seemed unwilling
    to recognize or take responsibility for this second more
    symptomatic group. Ignoring them puts patients, the public and
    police at risk and costs more than keeping care within the
    mental health system.
        As an example, there are fewer than 100,000 mentally ill in
    psychiatric hospitals but over 300,000 in jails and prisons.
    The officers I surveyed pointed out the drain on resources it
    takes to investigate, arrest, fill out paperwork and
    participate in the trials of all of them. Add to that the
    sheriffs, district attorneys, judges, prisons, jails and
    corrections officers it takes to manage each of them and you
    see the scope of the problem.
        Many more related incidents, like suicides, fights and
    nuisance calls take police time, but don't result in arrest or
    incarceration. Overly restrictive commitment standards and the
    shortage of hospital beds are major sources of frustration for
    officers. Hospitals are so overcrowded they often can't admit
    new patients and discharge many before they are completely
    stable. They become what we call round trippers or frequent
    flyers. One officer referred to it as a human catch and release
    program. Anyone who asks for help is generally not sick enough
    to be admitted, so involuntary admission, that is, being a
    danger to self or others, becomes the main pathway for
    treatment. Officers are called to defuse situations and then
    have to drive in some cases hours to transport individuals to
    hospitals and then wait hours in the emergency rooms, only to
    find the hospital refuses admission because there are no beds
    or that the commitment standard is so restrictive. The only
    remaining solution for our officers is to arrest these people
    with serious mental illness for whatever minor violation
    exists, something that they are loathe to do to sick people who
    need medical help, not incarceration.
        Finally, while everyone knows that everyday mental illness
    is not associated with violence, untreated serious mental
    illness clearly is. The officers in the survey deal with that
    reality every day. You in Congress dealt with it when Ronald
    Reagan and Gabrielle Giffords were shot; two guards in the
    Capitol building were killed, and the Navy Yard shooting
    happened. Representatives DeGette, Gardner and Griffith have
    experienced the worst of the worst in their States.
        We have to stop pretending that violence is not associated
    with untreated serious mental illness. We have to stop
    pretending that everyone is well enough to volunteer for
    treatment and then self-direct their own care; some clearly are
    not.
        As I wrote in the intro to the survey, police and sheriffs
    are being overwhelmed dealing with the unintended consequences
    of a policy change that in effect removed the daily care of our
    Nation's severely mentally ill population from the medical
    community and placed it with the criminal justice system. This
    policy change has caused a spike in the frequency of arrests of
    severely mentally ill persons, prisons, and jail populations as
    well as the homeless population and has become a major consumer
    of law enforcement resources nationwide.
        If I could make one recommendation, it would be to prevent
    individuals from deteriorating to the point where law
    enforcement becomes involved. Return care and treatment of the
    most seriously ill back to the mental health system. Make the
    seriously mentally ill first in line for services rather than
    last. As a law enforcement officer and a father, I know that
    treatment before tragedy is a far better policy than treatment
    after tragedy.
        Thank you so much.
        [The prepared statement of Chief Biasotti follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Chief.
        Mr. Dart, you are recognized for 5 minutes.

                      TESTIMONY OF THOMAS J. DART

        Sheriff Dart. Thank you, Mr. Chairman and the committee,
    for having me here today.
        I am the Sheriff of Cook County, and as the Sheriff, I run
    the Cook County Jail, which is the largest single site jail in
    the country. My office is in the jail. Our average daily
    population is between 10,000 to 12,000 inmates and it costs
    about $143 a day to house someone there.
        Since becoming Sheriff in 2006, I have seen an explosion in
    the percentage of seriously mentally ill individuals housed in
    the jail. I have seen firsthand the devastating impact cuts to
    mental health programs and services have had on the mentally
    ill in Illinois. This is a crisis we must all care about
    because it affects all of us. I find it ironic that in the
    1950s we thought it was inhumane to house people in state
    hospitals but now in the 21st century we are OK with them being
    in jails and prisons.
        On any given day, an average of 30 to 35 percent of my
    population suffers from a serious mental illness. The diagnoses
    fall into two main categories: mood disorders such as major
    depressive disorder or bipolar disorder, or a psychotic
    disorder such as schizophrenia. While some mentally ill
    individuals are charged with violent offenses, the majority are
    charged with crimes seemingly committed to survive, including
    retail theft, trespassing, prostitution and drug possession.
        A cursory review of our statistics tells the story. Last
    year in one of my living units, 1,265 men were in that dorm on
    low-level drug-related offenses. The average length of stay was
    87 days. At $143 a day, it costs over $12,000 just to house
    these individuals pretrial because they cannot afford to post a
    minimal bail or have nowhere to live. Many of these inmates
    ultimately are sentenced to probation, more often than not, or
    sentenced to time while they were sitting with me.
        The unfortunate and undeniable conclusion is that because
    of dramatic and sustained cuts in mental health funding, we
    have criminalized mental illness in this country and county
    jails and State prison facilities are where the majority of
    mental health care and treatment is administered.
        Three recent case studies illustrate this. J.J. was
    arrested by the Chicago Police Department last May after a
    failed attempt to steal sheets or towels from a local Walgreens
    drug store. When we spoke to him shortly after his arrest, he
    explained that he took the items off the shelf and as he walked
    past the cashier and he asked her to charge him. He was
    arrested and charged with retail theft. The value of the items
    he stole were $29.99. He spent 110 days in my jail before being
    sentenced to probation. During his custody, he was stabilized
    on medication and received drug and mental health treatment.
    The taxpayers of Cook County spent close to $16,000 after his
    failed attempt to steal $29 worth of sheets.
        J.D. suffers from a psychotic disorder and has visions that
    terrify him. He was arrested in California on a warrant from my
    county. While in custody in California, he removed one of his
    eyeballs in an attempt to stop seeing his visions. He lost
    sight in that eye. So we were alerted to this issue. He was
    transferred to our custody 2 weeks ago and recently attempted
    to remove his other eye. While staff acted quickly, we were
    able to stop that from occurring. We presently have him where
    he wears a helmet and face mask and has gloves on his hands.
        T.A. was arrested over 100 times. Her most recent arrest
    came after she attempted to steal $20 from a person's purse
    during a church service. She is a chronic self-mutilator. She
    attacks her arms with her own fingernails or any objects she
    can find. To keep her safe while in our custody, we make
    special mittens for her that go up to her armpits. Incredibly,
    she was sentenced to a prison term and recently was transferred
    to a state hospital. We are awaiting right now her imminent
    return to Chicago. She has cost us, the taxpayers,
    conservatively, over a million dollars for all of her custody.
        What we have done in our county now is my staff interviews
    every detainee before they appear in bond court regarding their
    mental health history. Those who admit to a history are
    identified for the public defender's office and then we make
    efforts to try to appeal to the judges for alternative
    programs. Unlike State prisoners who have fixed release dates,
    pretrial detainees may be released at any time, which
    significantly complicates our ability to provide discharge
    planning. The inmates are offered written information on
    available community resources and enrollment in County Care and
    allowed access to a telephone to contact someone to arrange for
    transportation home or to identified housing. If the inmate
    requires discharge to a facility in the next day, we will
    shelter them overnight before we will try to get them to a
    hospital. If the inmate requires assistance with transportation
    to his or her home or a shelter, we will drive them there. If
    the inmate is stable, coordinated releases are typically
    initiated by our health care provider and the steps are
    followed. Additionally, we communicate with the party the
    inmate is being released to. Once it is confirmed the party is
    outside the jail, someone from our records unit will go out
    there to make sure that person is there. The past practice
    always had been, we released them out to the street where they
    would wander around aimlessly for hours, if not days.
        If the inmate is unstable and in need of psychiatric
    hospitalization in the community, he or she is petitioned by a
    licensed mental health professional. A certificate for
    involuntary hospitalization is completed by psychiatrists and
    accompanies the individual to the receiving hospital.
        Finally, in August, I launched the Mental Health Help Line.
    It is a 24-hour help line dedicated to assisting former
    mentally ill detainees or families of mentally ill detainees.
    The phone line is manned by members of my policy team and
    supported by our mental health staff. It has been an invaluable
    resource to the families who communicate with us through this
    help line. We receive calls on this help line 24 hours a day, 7
    days a week.
        In conclusion, we are in an unsustainable position. I often
    refer to the jail as the last car on a long train. Every single
    day and at every step before a person comes in to the jail,
    there is discretion: discretion to arrest, to charge and to set
    bond. But as custodian, I am obligated to care for those
    individuals. Every day I am faced with the mental health crisis
    in this county and in the country. I see the pain of those
    suffering from mental illness and the pain of their families
    who have struggled to care for them and provide them with
    resources. The question that plagues me, that keeps me up at
    night, is where do we go from here?
        As that question is debated, I will continue to do all I
    can to care for, protect and advocate for increased funding to
    address mental illness in our country and I will continue to
    provide the best care I can for the mentally ill. This is truly
    a crisis that we can no longer ignore.
        Thank you.
        [The prepared statement of Sheriff Dart follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Sheriff.
        I now recognize Judge Leifman for 5 minutes.

                       TESTIMONY OF STEVE LEIFMAN

        Mr. Leifman. Thank you very much, Mr. Chairman, members of
    the subcommittee. My name is Steve Leifman. I am a Judge for
    Miami-Dade County and I chair the Florida Supreme Court Task
    Force on Substance Abuse, Mental Illness and Issues in the
    Court.
        You asked where have the patients gone. Sadly, the answer
    is jail and prisons, and this is an American travesty. As you
    already stated, in 1955 there were some 550,000 people in State
    psychiatric hospitals around this country. If nothing had
    changed and we use today's population, there would have been
    about 1.5 million people in State psychiatric hospitals today.
        Last year, 1.5 million people with serious mental illnesses
    were arrested in this country. On any given day in the United
    States, we have approximately 500,000 people with serious
    mental illnesses in jails and prisons and another 850,000 in
    the community on some type of community control or probation.
    Since 1955, we have closed 90 percent of the hospital beds in
    this country and we have seen a corresponding increase of 400
    percent of the number of people going to jail with mental
    illnesses, and because jails are not conducive to treatment and
    courts do not know what to do with this population, people with
    mental illnesses generally stay four to eight times longer in
    jail than anyone else with the exact same charge who does not
    have a mental illness and costs seven times more.
        I had no idea that when I become a judge I was actually
    becoming the gatekeeper to the largest psychiatric facility in
    the State of Florida, and tragically, that is the Miami-Dade
    County Jail. I see more people on any given day with mental
    illness than most psychiatrists see in a month.
        People with mental illnesses in this country are three
    times more likely to be arrested than to be hospitalized, and
    in my State, it is nine times more likely. The closing of the
    hospitals is not the only and primary reason all these
    individuals had ended up in hospitals. It is a combination that
    created the perfect storm. It includes the IMD exclusion. It
    includes what Medicaid pays for its services. It includes the
    war on drugs. It includes the reduction of hospital beds. It
    includes the antiquated involuntary hospital laws. They have
    all conspired to create this perfect, perfect storm. And if
    this wasn't bad enough, just listen to the costs this is having
    to our communities.
        We worked with the Florida Mental Health Institute at the
    University of South Florida and Tampa. We wanted to know who
    the highest utilizers of criminal justice and mental health
    services were in my county so that we could wrap our arms
    around this population to see if we could get them services so
    they didn't keep reoffending. I thought I would get a list of
    thousands of individuals back. They send me a list of 97
    people, and I guarantee every one of you have these same 97 in
    your communities. These 97 individuals, primarily men,
    primarily diagnosed with schizophrenia, over 5 years were
    arrested 2,200 times. They spent 27,000 days in the Dade County
    Jail, 13,000 days at a psychiatric hospital or an emergency
    room, and cost taxpayers $13 million, and we got absolutely
    nothing for it. We would have been better off sending them to
    Harvard and maybe giving them an opportunity for an education.
    It is an outrage.
        The other part of the problem is that where we spend our
    money is killing us. In Florida, we spend one-third of all of
    our adult public mental health dollars--that is almost a
    quarter of a billion dollars--to try to restore competency for
    2,700 people. We have between 170,000 and 180,000 people in any
    given year in Florida who at the time of their arrest need
    acute mental health care treatment but we spend a third of our
    money trying to restore competency so we can try these 2,700
    people. Well, 70 percent of these individuals have three things
    happen to them. Either the charges are dropped because the
    witnesses disappear, they get credit for time served because
    they have been in the system so long and they walk out of the
    front door of the courthouse without any access to treatment,
    or they get probation and they walk out of the courthouse with
    any access to treatment and we just spent a quarter of a
    billion dollars, and that money is coming out of the community
    mental health system, making it harder for people to get
    access. It actually meets the definition of insanity. We keep
    doing the same thing again and again and we expect a different
    outcome.
        It is even worse at the prison level, and on competency
    restoration, in the United States we are spending almost $3.5
    billion and we are getting very little return for that money.
        The fastest growing population in Florida's prisons are
    people with mental illnesses. While our prison population has
    begun to stabilize over the last 2 years, the mental health
    population continues to grow at exceedingly alarming rates.
    Over the last 15 years, the percentage of people with mental
    illnesses has grown by 178 percent. We went from about 6,500
    people with serious mental illnesses 15 years ago to 18,000
    today. It is growing so fast that it is projected to double
    again in the next 10 years. Florida needs to start building 10
    new prisons for the next 10 years just to get to this
    population. It will cost my State $3.5 billion to deal with
    this population if we don't do something soon to correct the
    problem.
        We are looking at a huge cost and we are getting very
    little for our outcome. We have a three-legged stool that is
    wobbling and about to break, and there are three parts that I
    really hope that you are able to address. The first part is how
    and what we finance through federal Medicaid dollars for mental
    health services. It doesn't work. The second somebody is no
    longer a danger to self or others, Medicaid will cut them off
    and the hospital will discharge them back to the community,
    often to homelessness, often into the criminal justice system.
        The second part that needs to be addressed is the
    antiquated involuntary hospitalization laws. Most of these laws
    were written before we had TV, microwave ovens, computers,
    brain imaging and antipsychotic medication. It is an absurdity.
    The first laws come from 1788 out of New York. It doesn't work.
    People cannot get into the system to get treatment, and then
    when they are ready to be discharged, there is nothing for
    them.
        The third part is that we need to have a coordinated system
    in the criminal justice system to make sure we can take care of
    this population, and let me just make two quick points. We are
    doing some significant things in Miami-Dade County that are
    having huge impacts. We have trained over 4,000 police officers
    in order to identify people with mental illnesses in the
    community. Last year, the city of Miami and Miami-Dade County
    did 10,000 mental health calls. These 4,000 officers only made
    27 arrests out of these 10,000 calls. Our jail audit plummeted
    from 7,800 to 5,000, allowing the county to close a jail and
    saving $12 million. We also have post-arrest diversion programs
    where if someone comes in, we get them treated and make sure
    that they are not just discharged to the community without any
    assistance.
        We are saving lives, we are saving dollars, and we are
    starting to make the system work, but we need to fix those
    other three pieces. We also need to begin to use advanced
    technology, which we are beginning to do. We are part of a
    unique private and public partnership in Dade County where we
    are working to see if predictive analytics can actually be used
    in the behavioral health space so that we can have an
    unfragmented system of care, more accountability, and make sure
    that people with mental illnesses are treated fairly and
    properly.
        Thank you very much.
        [The prepared statement of Judge Leifman follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Judge. I was afraid to gavel a
    judge.
        Judge Leifman. And I appreciate that, and I won't hold
    anyone in contempt today, so appreciate the reciprocation.
        Mr. Murphy. I don't think this is your jurisdiction, so we
    are good.
        Judge Leifman. Thank you.
        Mr. Murphy. But thank you for your testimony.
        Mr. Stern, you are recognized for 5 minutes.

                       TESTIMONY OF GUNTHER STERN

        Mr. Stern. Thank you for hearing me today. I am here to
    talk about people who are homeless with severe, untreated
    mental illness. I have been working with homeless people for
    nearly 30 years, for the last 24 at Georgetown Ministry Center.
    Our goal back in 1990 was to put ourselves out of business by
    ending homelessness. Instead, homelessness has become a career
    for me and so many others. It has now been 10 years since
    cities around the country including Washington, D.C., issued
    their 10-year-plan to end homelessness. Not much has changed.
        Why is homelessness so hard to solve? From my perspective,
    it is because we lack the tools to intervene when a person's
    life has devolved to the point where he or she has moved out
    onto the street because of an untreated mental illness. When I
    began to work with the homeless population nearly 30 years ago,
    deinstitutionalization was in full swing. At the time many
    people I was working with were cycling in and out of hospitals.
    The community mental health centers were trying to figure out
    what their role was.
        As deinstitutionalization has continued, I have noticed
    that it is increasingly harder to access beds for people in
    acute psychiatric crisis. In the past 2 years, I have only seen
    two people admitted to the hospital. More typically now, people
    referred for psychiatric crisis get poor or no intervention and
    are returned to the street, almost always because they refuse
    treatment.
        Georgetown Ministry Center brings free psychiatric and
    medical care to the streets but very few people with untreated
    mental illness are willing to engage in conversations with our
    psychiatrists about their mental health. It is the nature of
    the illness.
        However, when we talk about a shortage of beds for
    treatment, we are not talking about the people I work with
    because these people with limited or no insight into their
    illness don't think they need treatment and vehemently refuse
    treatment when it is offered.
        Homeless people are real people with families like yours
    and mine, families that care. Greg is someone I met sitting on
    a park bench near our center. He was shabbily dressed and
    smelled bad. He would drink, I assume to tame the voices that I
    knew he heard because of the frequent spontaneous smiles and
    grimaces. All this belied the fact that Greg was once a gifted
    constitutional lawyer who delighted his children with his dry
    wit. They were in their late teens when he began to show the
    signs of what would become a profoundly disabling bipolar
    disorder. Not long after, he disappeared. He would call
    occasionally on birthdays or out of the blue for no reason. The
    kids tried so hard to keep up with him. They wanted desperately
    to make him whole again but it was futile. Greg drifted from
    city to city around the country, ending up in our center,
    ultimately in our small shelter one winter 8 years ago. Greg
    was a delight some of the time. His thick southern drawl and
    witty conversation would enchant volunteers, but other times he
    was withdrawn and surly. In January of 2006, Greg became sick.
    We encouraged him to go to the hospital and he said that he
    would. Instead, he disappeared. A week later I received a call
    from the medical examiner's office. They needed a body
    identified. It was Greg. The bodies never look the way you
    remember a person. Only Greg's face and hair showed from the
    white shroud covering his body. It took a few moments to work
    out that these were the features of the person that I once
    knew.
        A few years later, I met Greg's two adult children. They
    had learned he had died in Washington 3 years after the fact.
    Each of them traveled, one from New York, the other from
    Phoenix, to meet here and see the place where their dad spent
    his final days. They needed to know what his last days were
    like. I shared coffee with them, and they told stories about
    him and they asked questions about his final days. They laughed
    and they cried. You could tell that they loved and missed their
    father.
        There are so many stories I could tell if I had time about
    mothers, brothers, sons, daughters who have wept for their
    relatives lost to mental illness. If the families had the tools
    to intervene, they would intervene.
        Most of all, what I want to impart here is that people who
    live on the street are real people with families and hopes and
    dreams abandoned because of an illness that has robbed them of
    their competency. The other important takeaway is that almost
    all the people I see on the street are there because they have
    refused treatment, not for rational reasons but because illness
    has insidiously robbed them of their insight to understand that
    they have an illness and that treatment can help them.
        So finally, what I have concluded after nearly 30 years of
    working with people who are homeless is that all I can do is
    provide some comfort and harm reduction. Until we are given
    tools for more assertive interventions, we will not resolve
    homelessness.
        Thank you.
        [The prepared statement of Mr. Stern follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Mr. Stern.
        Mr. Rahim, you are recognized for 5 minutes.

                       TESTIMONY OF HAKEEM RAHIM

        Mr. Rahim. Chairman Murphy, Ranking Member DeGette and
    members of the subcommittee, my journey with mental illness
    began in 1998 during my freshman year at Harvard University.
    That fall I experienced a terrifying panic attack. In that
    episode I had heart palpitations, sweaty palms and dizziness
    yet I did not know it was an anxiety-induced state. What I did
    know, however, was the deep terror I felt.
        My journey continued when I had my first manic episode.
    During the spring of 1999, I roamed the streets of Hempstead,
    New York, possessed with a prophetic delusion that I had to
    share with any and every one I met. Concerned, my parents sent
    me to my father's homeland of Grenada to relax and be with
    family. However, while there, I plunged into a deep depression.
    I returned to Harvard that fall and struggled through the year
    battling anxiety and depression.
        In the spring of 2000, I was consumed by my second manic
    episode. My next 2 weeks were filled with sleepless nights and
    endless writing sessions. I showered less frequently and ate
    sporadically. During this manic episode, I experienced
    psychosis. I had visions of Jesus, heard cars talking and spoke
    foreign languages. Upon hearing my condition, my parents rushed
    to pick me up from Harvard's campus. That same evening, my
    parents decided to take me to a psychiatric hospital in Queens.
    When we arrived at the emergency room, I was taken to the
    triage area. Over the next few hours, I was held in a curtained
    room in the ER. I tossed and turned and remained restless, as
    now I had not slept in 24 hours. My parents sat in the
    curtained room with me until I was admitted to the hospital
    later that night.
        Accompanied by two hospital aides, I was transported to the
    psychiatric ward in a hospital van. I walked through the dimly
    lit ward door and was met by approximately six staff members.
    They gave me a hospital gown, requested I change into it, and
    encouraged me to relax when they noted my agitated state. When
    I continued to toss, the staff stated they were going to put
    straps around my arms and legs. After placing the straps, they
    then said they were going to give me a sedative to help me
    sleep. I felt a prick on my upper arm.
        The next morning I awoke, drowsy and unable to speak. I
    walked to the common room on the ward, sat down and began to
    hold my breath. I received another sedative. I was hospitalized
    for 2 weeks. The first week is a blur due to my mental
    confusion and the psychiatric medication administered to me.
        However, I do remember some of my experiences. I interacted
    frequently with staff and the other patients. One staff member
    I felt an affinity toward and spoke with him frequently. He
    advised me to focus on getting better and to not come back to
    the hospital as so many other patients had. My psychiatrist on
    the ward diagnosed me with bipolar disorder and briefly
    explained that I would be on several medications. Upon my
    release from the hospital I found and met with a psychiatrist
    in Brooklyn.
        During my hospitalization, I accepted my illness and began
    my arduous road to recovery. I cannot pinpoint what triggered
    my immediate acceptance, but I am grateful it did not take
    years for me to obtain insight. Over the course of my 16-year
    journey with mental illness, I have simultaneously embraced my
    diagnosis and realized that I am more than a label. I have
    embraced that I am more than medication, therapist appointments
    and support groups. I have learned that I am not bipolar, I am
    Hakeem Rahim, and not just any one piece of my treatment
    regimen.
        At the same time, I have learned that a good treatment
    regimen has to be accompanied by positive coping skills, diet,
    exercise for brain health, along with spirituality and
    spiritual perspective.
        The biggest challenge I faced getting to where I am now was
    openly acknowledging my mental illness. For so long, I felt a
    deep and personal shame for having bipolar disorder. This shame
    was so entrenched that I even felt uncomfortable sharing my
    diagnosis with close friends and even family members.
        In 2012, I decided to speak openly and joined NAMI's In Our
    Own Voice program. Through the In Our Own Voice program, I have
    shared my story with over 600 people including individuals
    living with mental illness and their family members. Currently,
    I am the NAMI Queens/Nassau's Let's Talk Mental Illness
    presenter. Through the Let's Talk Mental Illness program, I
    have shared my story and provided much needed awareness to over
    5,000 high school students and middle school students at 37
    schools. I see the importance in and will continue to speak up
    for mental health and mental illness education in schools and
    beyond.
        Millions of people in America desire to give voice to their
    struggles, but cannot because of stigma. I am fueled by the
    desire to break the silence. I am inspired by students who want
    to learn about mental illness to help a friend or a struggling
    parent who is hurting. I am strengthened by people who have
    decided to out themselves in an effort to normalize mental
    illness. Mental illness education and awareness is essential to
    combat stigma, end suffering and to normalize seeking help.
        I am grateful to my parents, family and loved ones who have
    supported me. I am also grateful for this committee for picking
    up this topic as well as this panel because it is my hope that
    the ideas put forth today will transform the already shifting
    conversation around mental illness, and I thank you very much.
        [The prepared statement of Mr. Rahim follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Mr. Rahim. We appreciate that.
        Dr. Edgerson.

                    TESTIMONY OF LAMARR D. EDGERSON

        Mr. Edgerson. My name is Dr. LaMarr Demetri Edgerson, and I
    wish to thank the chairman and ranking member for the
    opportunity to testify today at this very important hearing on
    the psychiatric bed shortage. My doctorate is in psychology. I
    am a clinical mental health counselor and licensed marriage and
    family therapist.
        The population we are focusing on today is the population
    that I primarily serve in my private practice. Over the past
    year, I have served as the Director at Large for the American
    Mental Health Counselors Association, also known as AMHCA. I am
    here representing AMHCA's 7,100 members. I am also a board
    member and two-time past President of the New Mexico Mental
    Health Counselors Association.
        Clinical mental health counselors are primary mental health
    care providers who offer high-quality, comprehensive,
    integrative, cost-effective services across the life span of
    the individual. We are uniquely qualified licensed clinicians
    trying to provide mental health assessment, prevention,
    diagnosis and treatment.
        I grew up in the welfare system with inadequate health
    insurance. Since the age of 18 years I have provided health
    care for patients. My career began as an enlisted member of the
    United States Air Force where I served for 20 years as a medic.
    As a clinical mental health counselor, I now see children,
    adults and families in a private practice in Albuquerque, New
    Mexico. My specialty is trauma.
        Evidence all around demonstrates the Nation's mental health
    care system is in crisis. It is generating increasing demand
    for inpatient psychiatric beds while simultaneously decreasing
    its supply. Because patients have trouble accessing services in
    a community, they use the emergency department for basic and
    intermediate care. Our current mental health system still
    suffers from poor transition from inpatient institutions to
    community-based treatment.
        In a recent scholarly article, Ms. Nalini Pande estimated
    that psychiatric boarding lost nearly $4 million a year in
    revenue from service that could have been provided in lieu of
    boarding at just one 450-bed teaching hospital here. Ms. Pande
    also found that as patients waited, sometimes for hours, some
    for days, their psychiatric health deteriorated. Patients who
    often came in with manageable psychiatric illness subsequently
    turned into patients with acute needs.
        But still, there is more than meets the eye. We at AMHCA
    believe some policymakers are going down the wrong path in
    addressing the problem of hospital boarding. The barrier to
    treatment is accessing timely, effective, quality mental health
    service in the community. Surmounting these barriers requires
    continuous comprehensive health insurance coverage that enables
    access to essential inpatient and outpatient care, prescription
    drugs, early intervention, and prevention programs. All of
    those essential benefits are provided in health plans governed
    by the Affordable Care Act and new State Medicaid expansion
    programs, and some are available to Medicare beneficiaries as
    well.
        We can work smarter to have a better health care system
    that systematically reduces crisis situations from developing.
    In addition to the importance of State Medicaid expansion,
    Medicare mental health services too have never been fully
    modernized to include newer providers like clinical mental
    health counselors and marriage and family therapists such as
    proposed by Representatives Chris Gibson and Mike Thompson in
    H.R. 3662. Comprehensive and stable health insurance coverage
    is the key to cost-effective, efficient, timely mental health
    services in the United States.
        The new State Medicaid expansion effort has the potential
    for millions of currently uninsured Americans with mental
    health diagnoses to obtain greatly expanded access to mental
    health and substance use treatment in an integrated community-
    based setting with a person-centered treatment focus, the exact
    objectives, I believe, all policymakers are trying to achieve
    today.
        Unfortunately, 25 States are refusing to participate in the
    new Medicaid expansion program, which will continue to leave
    millions of uninsured people with serious mental health
    conditions out in the coverage cold. AMHCA believes it is a
    huge and costly mistake that Congress under Medicare and State
    policymakers under Medicaid have decided to deny their most
    vulnerable citizens State health insurance coverage with
    comprehensive health care and mental health services.
        In summary, Medicare and mental health provider coverage
    modernization and State Medicaid expansion will provide health
    insurance coverage to millions of people with serious mental
    health conditions who have had difficulty accessing needed and
    timely service. These changes are necessary to dramatically
    reduce the chances of future crisis situations and increasing
    emergency department visits.
        Thank you again for the opportunity to present this
    testimony today before the committee.
        [The prepared statement of Mr. Edgerson follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Doctor. We appreciate that.
        Dr. Evans, you are recognized for 5 minutes.

                   TESTIMONY OF ARTHUR C. EVANS, JR.

        Mr. Evans. Thank you. Mr. Chairman Dr. Murphy, Ranking
    Member Representative DeGette and members of the committee,
    thank you for inviting me to participate in this hearing. I am
    Dr. Arthur C. Evans, Jr., Commissioner of the Philadelphia
    Department of Behavioral Health and Intellectual disAbility
    Services, and I also have a faculty appointment at the
    University of Pennsylvania School of Medicine.
        I appear here today on behalf of the American Psychological
    Association, which is the largest scientific and professional
    organization representing psychology.
        As the Commissioner of the Department of Behavioral Health,
    my job is to ensure that the resources are deployed to address
    the needs of 1.5 million people in the city of Philadelphia.
        So today what I wanted to do is to talk as an
    administrator, as someone who is trained as both a scientist
    and a practitioner, and also a family member myself, and I want
    to start by saying I think all of the issues that we have heard
    today are solvable problems. I absolutely believe that. I think
    we have evidence both in Philadelphia and around the country
    that all of the issues that we have heard today are solvable I
    think with political will, with resources and with leadership.
        I really appreciate the family members who have testified
    today and especially Mr. Rahim, who gave his personal story,
    because I think that we have to hear that people can and do
    recover, and I want to start my comments by just giving a few
    examples of things that I think that we can do to improve the
    Nation's mental health systems.
        First of all, people can and do recover, and we know from
    the research, we know from clinical practice that given the
    right resources, given the right types of services, people can
    do really well who have even the most serious forms of mental
    illness. Unfortunately, our systems are set up in a way that
    they don't acknowledge that. We have systems that are geared
    towards maintaining people, addressing people when they are in
    crisis, and you heard some of the stories of people who have
    family members who have a very difficult time getting help, and
    the reason that is, is because of the way we finance our mental
    health system. It is diagnostically driven. People either have
    to have a diagnosis or to be in crisis. So one of the first
    issues I think we have to take on is, how are we financing our
    services and are we doing things and are we financing our
    service system in such a way that we have the resources to do
    outreach and to do early intervention.
        Secondly, I think that any discussion around psychiatric
    bed capacity has to deal with the efficiency of the current
    system. There are a number of things that we can do to improve
    the current efficiency, and I will give you a couple of
    examples from Philadelphia. We have in Philadelphia a unit that
    has people who historically would have been in the State
    hospital, very long lengths of stay, numbering sometimes in the
    months. We have employed evidence-based practices, both on the
    unit and in deploying ACT teams, or Assertive Community
    Treatment teams, who have also been trained up in evidence-
    based practices, and we are starting to see a reduction in
    lengths of stay. I use that as an example because when we talk
    about increasing bed capacity and not addressing the
    inefficiencies in the current system, it is not a good use of
    our resources, and I think we have to take on those issues.
        Similarly, we use a pay-for-performance system because we
    believe as a payer that it is really important to have
    accountability around the services that are provided. We have
    saved over $4 million over a 2-year period simply by working
    with our inpatient treatment providers, focusing on things like
    continuity of care, making sure that when people are admitted
    that if they have a case manager that those people are coming
    onto the units, working with people so that there is a smooth
    transition. Those kinds of efficiencies can go a long way in
    increasing capacity.
        I also believe that we have to have a public health
    strategy. We cannot simply have a treatment strategy around
    this. When people have difficulty getting into services,
    sometimes that is because people don't know how to navigate the
    system but often it is because there is stigma associated with
    mental illness that prevents people from reaching out for help
    and so part of our strategies have to be to reduce stigma and
    make it more likely for people to reach out for help. That is
    one of the reasons that we support things like mental health
    first-aid that help people to understand how to intervene.
        Fourthly, I think that we have to think about cross-systems
    financing. Many of the issues--if you talk to mental health
    commissioners around the country and you ask them what are the
    top three issues, I would almost guarantee you that every
    single one of them would have housing as one of their top
    issues related to the administration of their system and so as
    we are talking about this, we have to think not only about
    services within the mental health system but we have to think
    about other services that people need to be successful.
        So with that, I will stop and hopefully we will have
    questions that we can talk more about those.
        [The prepared statement of Mr. Evans follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Dr. Evans. As we go into comments
    here, or questions from Members of Congress, I just want to
    have a special thank you for this panel. We have had a number
    of hearings and panels on this issue of mental health, and I
    recognize members have very busy lives and some are at other
    hearings and other areas, but for those members who missed your
    testimony, I think their lives are the poorer for it, and to
    watch how someone would walk through the system is pretty
    difficult. So let me recognize myself for 5 minutes.
        Ms. Ashley, your experience you related to us in your
    testimony concerning your son's admission and boarding in a
    local ER from hours to days, I mean, it is alarming to us. So
    were there any other places in the area, were you informed of
    any other place in the area where you could have taken your son
    instead of having those long delays in the hospital?
        Ms. Ashley. You mean another emergency room?
        Mr. Murphy. Yes.
        Ms. Ashley. Well, my insurance only pays for the hospital
    that we went to.
        Mr. Murphy. OK. And Dr. Hirshon, in this case, and we had
    heard this also, for example, on 60 Minutes when State Senator
    Creigh Deeds was talking about his own son, he couldn't find a
    place. Is that part of the problem that occurs too with
    emergency rooms in terms of getting someone to----
        Mr. Hirshon. Yes, the issue of finding an inpatient
    facility can be very problematic. You have to find a place that
    is going to accept that patient, and historically, there may
    have been insurance issues as well. And so, in Maryland we have
    tried to devise mechanisms to improve this. One of the things
    we have now is kind of a central listing of the hospitals that
    have inpatient facilities, that have beds available, but even
    that is problematic getting the hospitals to buy into it. So
    this is a traditional problem, especially if you have someone
    who has got a dual diagnosis. Perhaps they are an adolescent
    with bipolar and maybe substance abuse. They can wait--I have
    had friends had patients wait for 13 days in their emergency
    department looking for a place to stay.
        Mr. Murphy. Thank you.
        Sheriff Dart, any idea what your total costs per year in
    dealing with folks with mental illness in your jail are?
        Sheriff Dart. You know, Mr. Chairman, that has always been
    a difficult number for us to ascertain, but just as a rule of
    thumb, it is in the ballpark clearly double, closer to triple
    the cost of an average detainee, so we are talking just
    tripling every expense that we have there, but the difficulty
    where it gets to be sort of quantifying this is that they come
    back to us so quickly. So it isn't even as if you took the one
    detainee and said OK, he cost more than the other ones and----
        Mr. Murphy. You are talking about some of those costs,
    $12,000 for pretrial costs and other things with that. Now, is
    any of this federal money that is used to help these patients,
    these inmates while they are there?
        Sheriff Dart. No, no, virtually none. It is all county-
    related money.
        Mr. Murphy. OK. Let me ask also, in this past winter, I
    heard about a homeless man who had mental illness in
    Washington, D.C., couldn't take him in because it was only 32
    degrees. But once the temperature hit zero, it would be OK. Is
    that true, this story that I heard, Mr. Stern?
        Mr. Stern. Actually, I think Washington did sort of a
    heroic job over past years. They had buses, metro buses out
    when it got, I think below 15 degrees, and there was
    hypothermia in effect under 32 degrees.
        Mr. Murphy. When I look upon this, and we talk about
    somebody being--we are not going to provide help until there is
    a crisis, they threaten to kill someone, themselves, or you had
    talked about people who are not even aware of their symptoms.
    In this case, now they are an imminent threat because they are
    not even aware of their illness. It is sad that we have to go
    to that extent.
        Mr. Stern. Yes. I mean, the one thing that I would say is,
    on the day it got really cold, I went out to the bus, and there
    were three people on the bus. I then went under a bridge nearby
    and there were five or six people there who refused to go on
    the bus, so there is that.
        Mr. Murphy. Thank you.
        Dr. Evans, as you heard these stories about how much is
    spent--Judge Leifman talked about this, Sheriff Dart talked
    about this, Chief Biasotti, all these other folks. If you had
    that kind of money, could you make a difference? I mean, we are
    spending it in hospital beds and emergency rooms where they are
    not getting treatment. We are spending it in jails. We are
    spending it in courts. Could you keep people out of those
    systems if Medicaid and other things paid for that kind of
    thing?
        Mr. Evans. There is no question that we can and we do. For
    example, in Philadelphia, take the issue of homelessness.
    Because we have a mayor that has been pretty interested in this
    issue, he has been able to convince the Philadelphia Housing
    Authority to make available Section 8 vouchers to my
    department, which does homeless outreach. Over the last several
    years, we have had approximately 200 vouchers a year, and with
    that, we have been able to get over 500 people off of the
    streets of Philadelphia who were formerly homeless, many of
    whom have serious mental illness and/or substance use problems,
    and the way we were able to do that is to use those housing
    resources matched with Medicaid-funded behavioral health care
    services, and to date we have about 93 percent of those people
    are still in stable housing. So I think that these are solvable
    issues. I think it takes creative financing and I think it
    takes innovations in how we deliver services.
        Mr. Murphy. We look forward to hearing some specific
    comments from you and others too on what needs to change in
    some of the definitions of care so that money can be spent in
    helping people, preventing problems and treating them.
        I have to ask you, Mr. Rahim, because you have Ms. Ashley
    at the table here, who has a son who is a good man but dealing
    with schizophrenia, do you have advice for parents and for
    other people dealing with this?
        Mr. Rahim. I believe that Dr. Evans said it best, that
    mental illness is treatable and I think a lot of the panel said
    mental illness is treatable but I think we have to have the
    education to know that it is treatable and that it is something
    that you can overcome, and I think having faced this as well as
    evidence-based practices will do so much.
        Mr. Murphy. Thank you. That is a good message of hope.
        Ms. DeGette.
        Ms. DeGette. Thank you. Let me follow up on that statement,
    Mr. Rahim, by you and Dr. Evans.
        Dr. Evans, you talked about how evidence-based practices
    and lengths of stay can really be used for treatment, and part
    of the problem, part of some of these illnesses is people don't
    realize that they are ill, and part of it is stigma. So my
    question to you is, from what I understand from what you are
    saying and others, is that if we can identify someone with
    severe mental illness early on and get them into that
    treatment, we actually can stabilize their situation. Is that
    correct?
        Mr. Evans. That is absolutely correct, and the research is
    pretty clear on this. If you can intervene with people early,
    particularly after their first episode, and there are evidence-
    based treatments for people who are experiencing their first
    episode, you can dramatically change the trajectory of their
    illness and significantly improve clinical outcomes.
        Ms. DeGette. And I would assume you would agree with me
    that probably the way to do that early identification is not
    when they present in an emergency room or a jail, correct?
        Mr. Evans. That would be correct.
        Ms. DeGette. And I would assume, Dr. Hirshon, you would
    agree with that from an emergency room perspective as well.
    That is not the ideal way to identify a severe mental illness
    and treat it, correct?
        Dr. Hirshon. We take care of emergent and urgent, you know,
    acute psychiatric problems but my preference would be not to
    have to deal with that, I mean, to find support systems, both
    inpatient and outpatient, that they don't come at 3 o'clock in
    the morning homeless and cold because they have no other place
    to go, and so yes, I would----
        Ms. DeGette. And have to find a bed.
        And Mr. Dart, you would agree with that from a penal
    perspective as well, correct?
        Sheriff Dart. Oh, absolutely, on two fronts. One, frankly,
    during the cold weather, we have people affirmatively commit
    offenses so they can come into our housing. I talk with the
    detainees on a regular basis. They will tell me frequently they
    don't want to leave the jail because it is the best place they
    can go for treatment, they feel safe, they don't get harmed out
    in the community, and we have had some where when we release
    them, they will try to break back into the jail as a result of
    that, and Congresswoman, the one thing that always has troubled
    me, when you think about it, each and every one of these
    people, we have a full file on them, not only on their criminal
    background but their mental health needs. Why we can't follow
    them out in simple case management type of fashion, and even if
    we just break the cycle for a short period of time, we would
    save tremendous amounts of money.
        Ms. DeGette. You don't know this, Sheriff, but I started my
    career as a public defender, and so I know this very, very
    well. I had so many clients in those days who you could just
    see they were severely mentally ill, and there was nothing we
    could do with them.
        Now, I want to ask you again, Dr. Hirshon, I mean, if we
    had a better system like one Dr. Evans is talking about to
    identify and to treat folks at an early stage, then when
    somebody really did have an acute problem, the emergency system
    would be better equipped to deal with those folks because
    theoretically, there would be fewer of them, correct?
        Dr. Hirshon. Well, there would be fewer but there would
    also be more structure to support them. So a lot of this is the
    lack of a kind of systematic structure to support these people
    who are either coming in because they have acute needs or
    because of their social circumstances. So the idea to have that
    improved structure both from a mental as well as social
    perspective I think is very critical.
        Ms. DeGette. Yes, and I want to ask you, Ms. Ashley, as a
    fellow mom here, you would much rather--you, as a nurse,
    identified that your son had severe psychiatric problems from
    an early stage but you didn't have any recourse to get him the
    kind of treatment he needed except for continually taking him
    to the emergency room. Is that what I heard you saying?
        Ms. Ashley. Yes, that is right. I worked very closely with
    his primary medical provider, who obviously knew there was
    something wrong with him, but my son would continuously deny
    going to the emergency room to get psychiatric evaluation. The
    psychiatric people were even willing to come to his medical
    appointment to evaluate him. That is how tight our community
    was. And still my son would say no, he would not go. So I
    actually had to set up a situation where he went to the
    emergency room to get lab work done and then have him received
    by the psychiatrist and his primary medical provider to put him
    on a hold.
        Ms. DeGette. Thank you.
        Now, Dr. Evans, just if you can briefly tell me, you have
    got several projects going on. Where do you get the funding for
    those projects?
        Mr. Evans. So Philadelphia is unique in that the city
    manages all of the public sector behavioral health services
    that come in. The city is capitated for the entire Medicaid
    population so we manage the Medicaid benefit for everyone who
    has----
        Ms. DeGette. So you are getting Medicaid benefits?
        Mr. Evans. They are getting Medicaid, but we also receive
    State, federal, local grant dollars as well.
        Ms. DeGette. And I just want to finish up with you, Mr.
    Rahim. You heard what Ms. Ashley was talking about. Her son was
    denying what was happening and she had to sort of trick him.
    What do you think about people who get diagnosed with these
    diseases? Is it the stigma? Is it the nature of the disease?
    And what is your opinion what we can do to get folks into
    treatment like you were able to do and to accept the disease,
    very briefly?
        Mr. Rahim. So, I have to very much recognize that mental
    illness is individual to each person. There are so many
    different diagnoses, and each person, even with the same
    diagnosis, responds differently to the medication, responds
    differently to the knowledge that they may even have it, or
    even responds differently to their parents' care and concern.
    So I mean, with that--and I do want to acknowledge that. I am a
    voice but I am not the only voice, and there are so many people
    out there, so I just want to acknowledge that to your point,
    that is, it is so different, and it is hard. This is hard, you
    know, this is not easy. So even if you have the care provided,
    it is still a journey, one, and two, you still have to
    recognize that everybody is different.
        Ms. DeGette. Thank you. Thank you very much, Mr. Chairman.
        Mr. Murphy. Thank you. I now recognize the vice chair of
    the full committee from Tennessee, Mrs. Blackburn, for 5
    minutes.
        Mrs. Blackburn. Thank you, Mr. Chairman.
        I want to thank each of you for taking the time to be here
    and for your willingness to tell your stories, and I think it
    is such an important component, and it is important for us to
    have your insights as we look at the issue. The chairman has
    been on this since day one, and looking for a way to reach
    parity and to provide some certainty for those that suffer from
    mental illness. So we appreciate that you are helping us work
    through this process.
        Dr. Hirshon, I want to come to you first. Going back to the
    American College of Emergency Physicians 2014 State by State
    report card that is out there, and looking at the data relative
    to 5 years earlier, and you look at the declines in the
    psychiatric beds across the country. Has that been consistent
    in your rural, suburban and urban issues? Where are we seeing
    the greatest attrition in the number of beds? Because one of
    the things we hear from people, especially in our rural areas,
    is, they have no access and they don't know where to turn.
        Dr. Hirshon. So I would say that each jurisdiction, each
    region, each State is different. It is a little hard to say.
    But as a general rule, access to care in rural settings is much
    more difficult. And the other thing to recognize is that even
    if you have insurance, insurance doesn't mean access because
    you have to find someone who can take that insurance and who
    will be there to give you the services. So as a general rule,
    the rural settings and the areas in which there are fewer
    services are disproportionately impacted. So I would agree with
    that.
        Mrs. Blackburn. OK. How do we fix that? How do we fix that
    disparity? What do you think? Because the access is so
    critical, and as you said, you may have access to the queue but
    that does not mean you have access to the physician, and what
    we are seeing with the implementation of Obamacare, the
    President's health care law. So many people say well, I have
    got an insurance card now, and of course, in Tennessee, we saw
    this with the advent of TennCare back in the 1990s but there
    was nowhere that they could go for the care or it may be 180
    miles away, which is debilitating when you are trying to access
    this. So what do you think?
        Dr. Hirshon. I think again that, you know, not just
    psychiatric care but many types of care, you have to look for
    creative solutions, and one of the solutions for that is
    regionalization of care. So for example, if you have got a
    regional center of excellence for psychiatric care, to be able
    to utilize that either through telemedicine so they can do
    evaluations long distance or in a setting in which they don't
    have a psychiatric provider there or there is a way that you
    can use that regionalization to help improve the care I think
    is one potential model. I think we need to do research to look
    for better ways to be able to provide care, recognizing that
    our technology--there is an increased demand but our ability to
    perhaps meet that demand can be adjusted.
        Mrs. Blackburn. OK.
        Ms. Ashley, I see you shaking your head. You like the idea
    of using the telemedicine concepts?
        Ms. Ashley. Yes. At UC Davis, we already use telemedicine
    for medical diagnoses and so forth, and so I definitely can see
    telemedicine with good case management follow-up definitely
    would be very helpful to the family and the consumer.
        Mrs. Blackburn. So would you classify that primarily as
    using the telemedicine concept as an assistance in early
    intervention or where would that have the greatest impact?
        Ms. Ashley. At the very beginning.
        Mrs. Blackburn. The very beginning, being able to utilize
    that.
        I have just a couple of seconds left. Dr. Geller,
    deinstitutionalization, and you talked about that in your
    testimony and you said it was not initiated as a considered
    policy but as an accident of history. I want you to expand on
    that for just a moment.
        Dr. Geller. Sure. If you look at the literature throughout
    the era, you don't find any literature that talks about
    deinstitutionalization before it happened. It was labeled
    retrospectively. Some of the downsizing occurred because of the
    introduction of psychotropic medications, and some because of
    advocacy. But the major incentive for deinstitutionalization is
    the IMD rule. The IMD exclusion means that if I am in a State
    hospital, my State pays dollar for dollar for my care. If I am
    in a community, my State pays no more than 50 cents on the
    dollar and may pay as little as 13 cents on the dollar. So that
    any State has a vested interest in moving people from State
    hospitals to the community, the cost shift from State tax
    dollars to federal tax dollars, and I believe that has been the
    major incentive. It was never designed policy.
        Mrs. Blackburn. So it was done for the money.
        I yield back.
        Mr. Murphy. Thank you. I now recognize Mr. Butterfield for
    5 minutes.
        Mr. Butterfield. Thank you very much, Mr. Chairman, for
    convening this hearing, and thank all of the witnesses for your
    testimony today, but more importantly, thank you for your
    passion. I understand what mental health is all about, and I
    thank you so very much.
        I missed some of your testimony but I have been reading as
    quickly as I could. Dr. Edgerson's testimony, I have it in my
    hand, and it is very interesting and it is very correct. You
    dwell on the Medicaid expansion aspect of health care, and I
    thank you for raising that because that is critically
    important. As most of us know, this committee wrote the
    Affordable Care Act. It was written several years ago, and the
    Energy and Commerce Committee is the proud author of that
    legislation, and as part of that legislation, it was our intent
    to expand the Medicaid provision so that low-income, childless
    adults could receive the benefit of health care. We mandated
    that the States expand their program, and that part of the law
    was tested in the U.S. Supreme Court, and unfortunately, the
    Court said that we overstepped our authority, and even though
    it was a proper exercise of legislation that we could not
    compel the States to expand their Medicaid program, and that
    was very disappointing to me. And now 25 States have refused to
    participate in that expansion, and my State of North Carolina
    happens to one of those States. My State turns down nearly $5
    million per day which could help provide care to those with
    mental health issues, and so I am appalled, not only appalled
    at my State but the other States that have chosen not to expand
    their Medicaid program because we need it.
        The Medicaid expansion would not have been a cost to the
    States, at least for the first 3 years. All of the costs would
    be borne by the Federal Government. Following that, the Federal
    Government would pay 90 percent of the cost of care, and so we
    have low-income individuals all across the country who are
    suffering from mental health issues, from substance abuse who
    are not getting the care that they rightfully deserve.
        I live in a low-income community. It is an African American
    community in North Carolina, and I can tell you that mental
    health and substance abuse issues are pervasive all across my
    community. Before coming to Congress 10 years ago, I was a
    trial judge, not only in my community but in 32 counties
    throughout my region. I was one of 10 judges who presided over
    the most serious cases in 32 counties, and I can tell you that
    we need to extend a hand of friendship and a safety net for
    those who are in need. And so I applaud you for lifting up the
    whole idea of Medicaid expansion.
        Now I get to the question, Dr. Edgerson. I had to get that
    off my chest because I understand mental health, not as much as
    the 10 of you, but I clearly understand it. I understand the
    cost of not treating and detecting mental health issues, and I
    know that we would be a better nation if we just slowed down
    long enough to recognize the importance of this issue, and
    while I am on that, Mr. Chairman, I want to thank you. I think
    Ms. Blackburn was correct, that you have lifted this issue up
    as a priority of yours from day one, and I thank you for it.
        Dr. Edgerson, it is estimated that 189,000 people in my
    State with mental illness would be eligible for Medicaid if my
    State would expand Medicaid. How many of the individuals
    presenting in the emergency rooms with psychiatric and
    psychological issues would have avoided an emergency room visit
    if Medicaid had been expanded and they were able to seek
    treatment before their disease became a crisis?
        Mr. Edgerson. I cannot give you an exact number. However,
    what generally happens is, if there is not one thing that we
    know, we know we can go to the emergency department if we are
    having any kind of crisis. A lot of people do not necessarily
    have to go to an emergency department because the crisis can be
    averted in the beginning, and this is where I believe that
    clinical mental health counselors and marriage and family
    therapists can come in. So while I may not know that I have a
    mental health issue, my friend or my family member may know,
    and they may be able to convince me or persuade me, hey, why
    don't you go and talk to this person here and maybe we can help
    you out, and for me, that is where the beginning steps are
    because once I create the relationship with that patient or
    client, then they are less likely to go into a crisis scenario
    and end up in an emergency department.
        Mr. Butterfield. Thank you.
        My next question is to you, Mr. Dart, and I heard some of
    your testimony earlier, and you talked about some people
    believe that jail is the best place for treatment, and you are
    absolutely correct. Some in the audience or some watching on
    television may find that incomprehensible but that is a fact in
    real life.
        When I was a trial judge, people would inappropriately--
    they didn't know they were being inappropriate--they would call
    me at home the night before their loved one was to be sentenced
    and they knew that the next day the loved one would probably be
    getting out of jail and returning to the community, and
    families would literally call me and beg me--many of them knew
    me personally. We had grown up together years ago. They would
    call and plead with me as a judge not to release their loved
    one because they could get better care and treatment in the
    facility as opposed to the community, and they felt that
    releasing their loved one would be a danger to the inmate and
    to the community. So thank you for bringing that up and
    reminding me of those days when I was on the bench.
        You have been very kind, Mr. Chairman. Thank you very much.
    I yield back.
        Mr. Murphy. I now recognized the vice chair of the
    subcommittee, Dr. Burgess, for 5 minutes.
        Mr. Burgess. Thank you, Mr. Chairman.
        Mr. Rahim, I just have to say, I don't think it was part of
    your prepared remarks but your comments about the
    individualization of care and the personalization of care,
    those words are golden and I hope that everyone on this dais
    heard those and will consider them.
        Dr. Geller, thank you for your thoughtful chronicling of
    the problem. I cannot go back as far as Franklin Pierce but I
    did practice medicine in the 1980s and 1990s, not psychiatry
    but more in the general medicine realm, but I remember during
    that time the vast expansion of psychiatric facilities that
    occurred. I am not sure if I know why that expansion occurred
    but then as a result of probably actions by perhaps this
    subcommittee in April of 1992, a lot of that was curtailed, and
    in fact, just researching for this hearing, there is an article
    from 1993 that talked about in one 4-year period the number of
    psychiatric institutions doubled, and the graphic they have is
    1984 to 1988. This was a major scandal in the country. A
    company known then as National Medical Enterprises eventually
    entered into some sort of consent decree with the Department of
    Justice and many of the private insurers sued the hospital
    company for overutilization or overhospitalization of patients.
        So it seems like we went from there where there was too
    much activity going on to now where there is not enough. I
    can't help but feel the emphasis on administrative pricing and
    not paying attention to the individual care that Mr. Rahim
    talked about is perhaps responsible, but I think this
    subcommittee would do well to remember that it was 20 years ago
    where we were talking about a very different problem. You were
    probably--I don't want to presuppose, but you were probably in
    practice at that time. Is that correct?
        Dr. Geller. Yes, sir.
        Mr. Burgess. Do you recall the events that I am talking
    about?
        Dr. Geller. Yes, sir.
        Mr. Burgess. And what is your observation? I mean, help us
    here. You were there, a psychiatrist on the ground, when this
    was going on. In your opinion, what is it that happened that
    caused that rapid expansion of psychiatric meds and their
    overutilization and then the contraction that followed?
        Dr. Geller. The expansion that you are talking about was
    largely accounted for by private psychiatric hospitals,
    generally chain hospitals, that saw an opportunity to make
    money quickly. When managed care began to require pre
    authorization and the possibilities for admission became more
    stringent, those hospitals quickly disappeared. While all that
    is happening, the public psychiatric hospitals were still
    shrinking, and if I could take a moment?
        Mr. Burgess. Sure.
        Dr. Geller. What we seem to not be spending time on is that
    we are talking about psychiatric disorders, and while resources
    are necessary, ``build it and they will come'' does not apply
    to all the people who have psychiatric disorders. We had a
    demonstration of that in western Massachusetts. We had a
    federal court-ordered consent decree in 1978. Western
    Massachusetts, the catchment area, is larger than five of the
    States in the United States. At that time western Massachusetts
    had more per capita expenditure for mental health services than
    any State in the United States and there wasn't another State
    that came close. And we still had some of the same problems.
        Mr. Burgess. Yes, sir.
        Dr. Geller. We have a population, some of whom have
    something called anosognosia. They don't recognize they have an
    illness. You need more than just resources.
        Mr. Burgess. Let me ask you, Dr. Hirshon, in the few
    seconds I have left. I mean, you bought up EMTALA, and as a
    practicing physician, I am familiar with that. One of the great
    venerable institutions in my neck of the woods, Parkland
    Hospital, got into a great deal of difficulty with their
    psychiatric emergency room not too terribly long ago, in fact,
    put the whole institution at risk because of some federal
    regulations that they ran afoul of, but eventually they went to
    outsourcing their psychiatric emergency room to a private
    hospital facility. In your experience, does it seem like more
    hospitals are going to be doing this?
        Dr. Hirshon. My sense is that it is more complicated than
    simply a single answer. You have to look at it from both the
    patient's perspective as well as the provider's perspective,
    and coming up with solutions that allow you to meet the
    patient's needs. If it is outsourced in one jurisdiction, that
    might work, but again, I think recognizing that there is a
    limited number of resources, looking for ways to more
    efficiently and effectively utilize those resources will be
    key.
        Mr. Burgess. Thank you, Mr. Chairman. I will yield back.
        Mr. Murphy. Thank you. The doctor yields back.
        Mr. Tonko, you are recognized for 5 minutes.
        Mr. Tonko. Thank you, Mr. Chair, and I appreciate your
    continued use of this subcommittee to shed light on the issues
    related to mental health. For far too long now, mental health
    issues have been swept away in the shadows, so anything we can
    do to raise the profile and reduce the stigma associated with
    mental illnesses is a very worthy endeavor indeed.
        As amply demonstrated today, the lack of available
    psychiatric beds, particularly in times of crises, can be a
    pressing issue. For example, we all witnessed the tragedy that
    occurred in neighboring Virginia when State Senator Creigh
    Deeds was unable to locate an available bed for his son in
    time. However, we also all share a goal of deescalating in
    treating these types of situations before they do reach the
    stage where a patient requires hospital-based care.
        So with that in mind, Dr. Evans, from your experience, how
    can we improve our mental health delivery system in a way that
    reduces the demand factor for inpatient psychiatric care?
        Mr. Evans. Thank you for that question. I think that, you
    know, any discussion about psychiatric bed capacity focuses on
    expanding bed capacity, and I think that is a trap. Prior to
    being in Philadelphia, I was also the Deputy Commissioner in
    the State of Connecticut, so the past 15 years I have been in
    administrative positions that have to make decisions about how
    resources are deployed in a mental health system, and I can
    tell you that the fundamental issue is that we have to build a
    very strong community-based system. That is the fundamental
    problem. Psychiatric bed capacity is only a symptom of a deeper
    problem, and I think you hear the testimony of all the people
    here, they talk about the difficulty when it is clear that a
    family member or even a person is having a problem. Well, there
    are not the resources to do the kind of outreach to individuals
    when they are at that point, and the way we finance our service
    system, we have to wait until people are at a crisis point, and
    you know, that is not only the problem of the mental health
    systems but it really has to do with the fact that unless we
    create the kind of flexibility where mental health systems can
    do the kind of assertive outreach, we are going to continue to
    have this problem.
        I remember, maybe it was Dr. Geller that said, you know,
    one of the problems with mental illness is that often people
    don't recognize that they have a problem, and if people don't
    recognize that they have a problem, you can build as many beds
    as you want, people are not going to get there unless they are
    forced into those beds. The solution is to have resources in
    the community where people can--for example, in Philadelphia,
    we have mobile crisis teams that can go out and reach out to
    people before they are hospitalized. Those kinds of services I
    think are critical.
        Mr. Tonko. Thank you. And so as you build that
    infrastructure and that holistic response, Dr. Evans, what is
    the appropriate way to measure the amount of inpatient beds
    that would be required in a given community?
        Mr. Evans. I think that that is a very difficult question
    to answer, and people have used things like population and so
    forth. The reality is that it depends on how your service
    system is structured. If you have a service system that has
    resources on the front end, for example, in Philadelphia, we
    have a network of five crisis response centers, so we don't
    have the problem of people going to emergency departments who
    are in psychiatric crisis, not to the extent that you have in
    other cities. We have a mobile crisis team that can do
    outreach, and so in Philadelphia that might look different than
    another system that might be similarly resourced in terms of
    the amount of money but doesn't have those kinds of services.
        I think the issue is, we have to build a very strong
    community-based system that prevents people from going into
    crisis and we have to have the services so that when people
    come out of those beds, that we are able to help them in their
    process of recovery, we are able to help them to stabilize and
    we are able to do things like helping people get supported
    employment or to use supported employment, for example, which
    dramatically decreases hospitalization. So those kinds of
    community-based services are really important in terms of the
    capacity that you need.
        Mr. Tonko. Thank you. And Dr. Geller, in your testimony you
    rely heavily on the fact that State investments in mental
    health have been predicated upon where they can shift most of
    the cost to the Federal Government. In your opinion, how could
    we address the Medicaid IMD exclusion without leading to a
    disinvestment by our States' mental health services?
        Dr. Geller. That is an excellent question. In my testimony,
    I mentioned that the Federal Government should offer the IMD
    exclusion waivers to States, requiring a maintenance of effort.
    The American Psychiatric Association has a position statement
    that is rather specific on this--I could certainly provide it
    to you--that indicates that a State who took such a waiver
    would be required to continue its expenditure as averaged over
    the past 5 years from all sources that they spent previously.
    That is not just the department of mental health but the
    department of children's services, department of corrections
    and so on and so forth. If there was a requirement for
    maintenance of effort, there couldn't be a reverse shift.
        Mr. Tonko. Thank you. I agree with that maintenance of
    effort, so thank you very much, and again, to the entire panel,
    your testimony is very much appreciated.
        Mr. Murphy. I now recognize the gentleman from Virginia,
    Mr. Griffith, for 5 minutes.
        Mr. Griffith. Thank you, Mr. Chairman.
        First, Dr. Geller, if you could provide that information to
    me as well that you were just talking about?
        Dr. Geller. Yes, sir.
        Mr. Griffith. It is very interesting. I found your
    testimony and everybody's testimony very informative.
        Mr. Chairman, I appreciate you having these hearings. I
    have to say that I don't understand mental illness. It worries
    me because I don't, and it is one of those areas where I least
    like these hearings that the chairman has called because
    normally I have a pretty good idea of where I think we ought to
    go when it comes to these mental health issues. I have to
    confess that I am learning something every time we even have a
    hearing, but I am also concerned that I don't think that we
    have all the answers or that we even have any idea what all the
    answers are, so I appreciate you all helping us try to figure
    that out. As representatives of the people, it is interesting
    because we are all trying, I think, Democrats and Republicans
    on this subcommittee, to figure out what we can do to make the
    situation better.
        I don't, however, believe that in the short term we are
    going to be able to make huge differences because we are going
    to have to do some trial and error. We are going to have to try
    to do some new things and some different things, and I
    appreciate that.
        In that regard, I guess I will look to Mr. Dart and to
    Judge Leifman. How can we make the court system better? We are
    not going to overnight say OK, none of the folks with mental
    illnesses are going to come into the court systems, but what
    can we do to make the court system better? You have heard from
    Ms. DeGette, who has a public defender background, and Judge,
    now Congressman Butterfield. I was a criminal defense attorney
    for 27 years, and I have to commend one of my judges back home.
    He hasn't set up a mental health court but has a mental health
    docket where she deals with folks who have those issues and
    tries to identify those in advance so that they can have the
    experts present to help on that.
        But what types of things can we do to encourage the States
    and the federal system to do a better job? Until we fix it,
    what can we do to help out in the court systems?
        Sheriff Dart. Thank you, Congressman. I will be quick,
    because Judge Leifman and I have talked before about these
    things.
        Getting the courts more engaged is imperative. In our court
    system, they have been completely disengaged. Whenever you ask
    them about solutions, they say well, we have a mental health
    court so it is done. Their mental health court usually handles
    about 150 cases total a year. I usually have about 3,500
    mentally ill in my jail in a day. So we can't be diverted when
    people have programs that are inherently good but aren't
    getting at the heart of the problem.
        What we have been doing internally is trying to identify
    people literally as they are dropped off from being arrested
    the night before, downloading quickly their information on
    their mental illness, and then we put a file together for the
    public defender. I am a former State's attorney. We put a file
    together for the public defender to plead with the judge that
    this person is not necessarily a criminal, put them in an
    alternative setting such as a nursing home setting. We have
    been doing that at my jail where I put electronic bracelets on
    their legs, I monitor them at this setting. The results are
    fantastic, as you can imagine, compared to what the other
    treatment would be, which is, I put them in a four by eight
    cell with a complete stranger with their own issues as well.
        So we have been doing that, and then on the back end, we
    have been pretty much winging it, and that is why, Congressman,
    when you talk about trial and error, that really is the route
    that we have been going. It can't get any worse than it is now
    so let us try some new things. So on the back end what we have
    been doing is, we ourselves are putting together case plans for
    them. We drive them to locations where we potentially can get
    housing for them so they can be there and be stabilized, and
    then we run a 24-hour hotline when they are in crisis to get
    out to them to help them. But it is just what you said,
    Congressman. We are at a trial-and-error stage right now but
    there are things such as that that certain judicial circuits
    could be doing. Others are better. Ours is a real struggle.
        Mr. Griffith. Judge?
        Judge Leifman. Thank you for your question. We have created
    an organization called the Judges Leadership Initiative with a
    parallel organization called the Psychiatric Leadership Group,
    and we are working with the American Psychiatric Foundation,
    and what we are doing now is, we have about 400 judges involved
    in this operation and we are going around the country. We have
    developed a curriculum to teach judges how to identify people
    in court who may have a serious mental illness, how to
    deescalate a situation in court so they don't make it worse,
    but more importantly, how to work in the community to set up
    the kind of supports you need to be able to divert this
    population, and so what we recommend are a couple things. A
    pre-arrest-type diversion where you work with law enforcement
    to teach them a program called crisis intervention team
    policing where the police are actually taught how to
    deescalate, where to transport and how to avoid an arrest. Our
    statistics are phenomenal. As I mentioned, we have closed a
    jail as a result of our CIT officers in Dade County. We have
    also taught them to set up post-arrest diversion programs so
    that you take low-level offenses that don't need to be in jail
    or felonies that are nonviolent and you make sure that they get
    access to treatment.
        Sheriff Dart is correct. The mental health court only
    handles a fraction of the cases, and the data is such that
    unless they are taking the right people, they actually can do
    more harm than good, so you have to be very careful and you
    have to be educated.
        Mr. Griffith. And Mr. Chairman, I know I am out of time but
    could we give Chief Biasotti--I know I mispronounced that. I
    apologize. But could we give the chief a moment to comment on
    that as well?
        Mr. Murphy. Yes.
        Chief Biasotti. I would say our main concern law
    enforcement-wise is the seriously mentally ill group that is
    unaware of their illness. I mean, that is wherein the problem
    lies for us. The police departments, your county directors know
    who these certain groups of people are because we deal with
    them every day, and there are answers that we can deal with
    that.
        In a case that we had not long ago, we had a woman severely
    mentally ill, went into a house, no one was home, took the pit
    bull and put it in a closet, went upstairs, took all the
    clothing out of the woman's closet, put her dishes from
    upstairs downstairs, moved all the pictures, spent the day. The
    woman came home--the homeowner--and walked in on her and of
    course, you know, had a cow right then and there, called the
    police. The police come, and she was totally out of her mind,
    psychotic, carrying on. So when I arrived at the police station
    on a different matter, I heard this screaming coming from our
    booking area. She was in the booking area, you know, voices
    were talking to her and she was complaining she was being raped
    by whatever at the time while she is sitting there. So I made a
    decision at that point, which a lot of people don't do, but
    being familiar with this topic I said listen, we are not
    arresting her for burglary. I said she is going to go to the
    psych unit but I am going to send a letter with her saying that
    she is obviously dangerous. She could have been killed. Whoever
    came home could have shot and killed her is most likely to
    happen. I said if we arrest her, she is going to go to the
    county jail, she is going to be a major problem for them. From
    there our officers are going to go out to grand jury where they
    are going to move to indict her for whatever. She will be in
    jail for a year before they decide that she is so mentally ill
    that she can't stand trial, and then she will be back here
    again. I said so let us get her into the system now and put her
    through that service. But I accompanied that with a letter to
    our county mental health director saying I strongly suggest
    that, you know, she is proven to be dangerous, she has a long
    history, to herself, mostly; I suggest that you enter her into
    the assisted outpatient treatment program. This program, they
    provide the services to her through this program. She has not
    been a problem since. They monitor her, make sure that she is
    in some kind of treatment, and as long as she is in treatment,
    she is not a problem. However, if we went the legal system as
    we normally would do, we would be dealing with her every few
    weeks because she has anosognosia, she does not believe she is
    ill.
        And I know, you know, stigmatism is a big concern, and my
    wife and I both pray for the day that our daughter has the
    insight that Mr. Rahim has into her illness because I believe
    if she had that insight, she could seek what everybody is
    talking about, care in the community. It has been 20 years
    almost and she does not have that insight. She has voices, and
    they are, as she is concerned, a supreme being.
        Mr. Griffith. I hate to cut you off but my time is way
    over.
        Chief Biasotti. I am sorry.
        Mr. Griffith. That is all right. No, I appreciate the
    testimony.
        Thank you, Mr. Chairman, and I yield back.
        Mr. Murphy. That was valuable because New York, as I
    understand, has actually reduced their incarceration rates and
    homeless rates, I think by 70 percent. It has been a massive
    savings.
        Chief Biasotti. That is correct, through AOT.
        Mr. Murphy. Thank you. Ms. Schakowsky, you are recognized
    for 5 minutes.
        Ms. Schakowsky. Well, I am so glad I got here because I
    wanted to say a special welcome to my great friend, Sheriff Tom
    Dart. We were seatmates for a while in the Illinois General
    Assembly. And I wanted to really talk to you about a problem I
    know you are struggling with so much.
        The New York Times article ``Inside a Mental Hospital
    Called Jail'' really focused on the largest mental health
    center in America. It is a huge compound here in Chicago with
    thousands of people suffering from mania, psychosis, other
    disorders, all surrounded by high fences and barbwire. That is
    the county jail.
        So I wish you would just briefly discuss how cuts to mental
    health programs and services have affected individuals with
    mental illness that are now in your custody.
        Sheriff Dart. Thank you so much, Congresswoman, and it is
    great seeing you again.
        You know, you almost don't know where to start because up
    until about 5 years ago, the normal process in our jail 5, 6
    years ago and, frankly, from my understanding, in most jails
    around the country now, when you get that court order to
    release somebody, you release them. The court is ordering their
    release and you have got to let them go, so you let them go.
    What we were seeing is out in front of our jail, there were
    people that just wandered around, stayed there, and as I had
    mentioned earlier, we have people trying to break back in. One
    threw a planter through a window to crawl back into the jail,
    and then we had to arrest him.
        The reality of it is, is that when we were releasing
    people, they had nowhere to go, and in the face of that, in our
    State we have made tremendous cuts, I mean, just over the last
    10 years. We are one of the leading States in cutting mental
    health funding, period, and in the city of Chicago, we just cut
    in half our clinics in the community. So when the people leave,
    not only do they have nowhere to go, there was no plan
    whatsoever, and as I had referenced earlier, I do think this is
    doable with not great expenditures because we literally have
    everything about this person in our possession. So if you are
    trying to think of case plans and diagnosing them and what
    would be the best strategies, there is a myriad of things we
    can do, but when you have no place for them to go--I used to
    hand out a resource book in my first couple of years as sheriff
    to give people a place to go. I had to stop doing that because
    everything in it was wrong because most of the things that we
    were trying to steer people toward were all closing, and so we
    were then setting them up to fail because there was nothing
    really out there.
        And so the cuts are so tremendous, it has left all the
    locals including ourselves trying to devise unique, creative
    strategies on what to do including, as I say, I will drive
    people now. If I can find homes for them, we will drive them
    there. I mean, I will contact their family members ahead of
    time to get them to come pick people up, and mind you, we are
    happy to do this, but I don't think in anyone's estimation
    sheriffs should be doing this. We are supposed to lock people
    up, and that is really sort of supposed to be the end of it,
    but there is nothing else out there, and in our county in
    particular, it has really been bad, and it is desperate, and it
    is really heartbreaking. I talk with the detainees frequently,
    and do we have bad people in the jail who have committed
    offenses who have mental illness? Yes, we have those. The vast
    majority of them, though, are good people who are suffering
    from mental illness and the reason they are there is because of
    the mental illness. It is not because they are a criminal, and
    yet we treat them like criminals, they are housed with
    criminals, and then when we leave them, we basically pat them
    on the back and say good luck and we will see you soon, and
    then we are all puzzled that they are back with me.
        Ms. Schakowsky. So it is not just a matter then of driving
    them to a place. It is that at the end of the day there is no
    place for many of them, right?
        Sheriff Dart. There is no place for them, and there is no
    one to work with them because they need a certain level of case
    managing to make sure they stay on their meds, that when they
    do go into crisis they are not left to doing what is going on
    right now, which they call myself and my staff and we try to
    figure out what we can help them with. There are things that we
    can do that will not be expensive that can help and it be a
    continuum of care. It could work with people. It won't be 100
    percent successful but it can't conceivably be any worse than
    what we do now.
        Ms. Schakowsky. And what are those simple things?
        Sheriff Dart. Oh, upon leaving the jail, if I had someone
    from a county agency, State agency that would literally be
    their case manager who would just literally work with them
    through housing issues, staying on their meds so that they
    don't start self-medicating which is, you know, no surprise
    that we are having this heroin epidemic in our county because
    it is the next best thing to their meds is the heroin and so
    cheap these days. They stay on their meds. Housing--there is
    some housing available. It is not the best but it is not that
    expensive. I was paying for housing out of my own budget but I
    have run out of money now. So as Judge Leifman said, if we had
    a continuum working with the medical side but also with the
    judiciary, we could have something that could be somewhat of a
    model for a lot of people and not that expensive.
        Ms. Schakowsky. Thank you very much, and thanks for what
    you are doing.
        Sheriff Dart. Thank you so much. It is great seeing you.
        Mr. Murphy. I just want to follow, Sheriff Dart. You heard
    Chief Biasotti talk about New York has assisted outpatient
    treatment where they make sure, as long as that person has been
    shown to be a safety risk or they have had an episode of
    violence or jail time before, they can work with a judge and
    they work on an agreement to stay on their medication and get
    in treatment. Now, I understand you don't have that in Cook
    County. Am I correct?
        Sheriff Dart. No. We had some intervention just literally
    days ago from our State Supreme Court to try to rearrange and
    help our local judiciary in doing their job, but we have not
    had engagement from our judiciary. I will be honest with you:
    you need an enlightened judiciary who clearly understands the
    distinction between criminal law and mental illness and know
    that there are other paths to go. Because otherwise you are
    left with, frankly, Mr. Chairman, isolated judges who get it,
    who will run certain courts and frankly take risks. We for
    years now, as I say, have been putting all these files together
    to hand to the public defender to just show the mental health
    background here, the lack of criminality, and yet they go up
    and they might as well be talking in a foreign language to the
    judge. The judge does the same thing. They throw them in the
    jail and we continue to do the same work.
        So an enlightened judiciary that is engaged with it, and it
    does happen in other jurisdictions. It would be absolutely
    remarkable. It would save money.
        Mr. Murphy. Thank you. Mrs. Ellmers, you are recognized for
    5 minutes.
        Mrs. Ellmers. Thank you, Mr. Chairman, and again, thank you
    to the panel. This is one of those situations where I have
    questions for every one of you, but unfortunately, we don't
    have enough time for that, so I will try to stay focused to the
    point of how we can as legislators help this issue and try to
    focus on those areas where we think there is the greatest need,
    at least to get it started, because Mr. Dart, as you have
    pointed out, we are in a pretty bad place right now so anything
    we do is going to improve the situation, and I am very
    concerned about those who are being released from jail and, you
    know, not able to continue their treatment, because as you have
    pointed out, it is just cyclic, and Mr. Biasotti as well.
        Ms. Ashley, I do want to go back to one of the issues that
    has been raised, and I know we are discussing medical coverage.
    I know some of my colleagues are saying if we just had a bigger
    Medicaid system, that that might actually help the situation.
    You know, obviously you know we are dealing with that every day
    here, trying to make our health care coverage system work
    better. If I remember correctly from your testimony and
    previous questions, you said you have private insurance that
    your son was able to receive treatment under. Is that correct?
        Ms. Ashley. Yes, it is. I have him as a disabled adult
    under my insurance.
        Mrs. Ellmers. OK. So you actually have insurance coverage
    but still had the difficulties. It wasn't just an issue of here
    is my insurance card, therefore I am going to get mental health
    services for my son?
        Ms. Ashley. Right. In fact, he is denied some services in
    the community because he does have private insurance.
        Mrs. Ellmers. I see. OK.
        Ms. Ashley. Even though he has SSI and Medi-Cal, they have
    no way to bill the insurance to get it denied and then go on
    Medi-Cal, so I don't even have access to a lot of the support
    services that are available in my community because he is on
    private insurance, and people have even told me to take him off
    private insurance, and really, having private insurance is what
    gets him hospitalized quickly because the lights go off when
    they see that I have private insurance versus Medi-Cal or
    Medicaid.
        Mrs. Ellmers. I see. Now, to that point, one of the things
    that I was wondering, when you were describing your situation
    in the emergency room, and I have seen this in so many
    hospitals where they literally brought me to the designated
    area in the emergency room that they have literally put
    together because of this situation so that they can give the
    best treatment possible but they are still hampered because
    they are obviously not a psychiatric unit, and they are dealing
    with the situation. Was he able to at least start receiving
    mental health treatment while he was there in the emergency
    room? I mean, was that pretty much at a standstill until he
    received the psychiatric bed?
        Ms. Ashley. Right. He was put in four-point restraints and
    heavily sedated until they transferred him to the hospital.
        Mrs. Ellmers. OK. And you did mention that, so I thank you
    for that. And again, that is an area we are trying to fix. You
    know, there are so many pieces and parts to this issue.
        Mr. Biasotti, one of the things that I would like to
    clarify even just for committee is the difference between civil
    commitment and forensic commitment, if you can answer that
    question, because I think that will help us as well because I
    think sometimes we do find ourselves again struggling with the
    situation of those who do not acknowledge that they have a
    problem and yet they are having a psychotic episode.
        Chief Biasotti. And that is where the problem lies. The
    police will bring the person from their home or from wherever
    the instance occurs to the emergency room, usually against
    their will, under a State code for imminent dangerousness and
    then they are relying on the interview at the hospital for the
    psychiatrist to make a determination that they meet the
    standards to hold for a 72-hour period for evaluation for
    commitment under that standard. So I think Dr. Geller could
    probably help me with the difference between the civil--I am
    more familiar with how we would do it.
        Mrs. Ellmers. Dr. Geller, would you like to expand on that
    then?
        Dr. Geller. Sure. Every State has its mental health act,
    and that allows people to be civilly committed, usually on a
    standard of dangerous to self, dangerous to others or gravely
    in need of care, and there is no crime involved. Forensic
    commitment would mean that a person has been charged and booked
    and then they are going to be committed usually initially for a
    determination of competency to stand trial, criminal
    responsibility, or both, that you heard about earlier. If they
    cannot stand trial or are found not guilty by reason of
    insanity, then they can be further committed under a criminal
    statute of that State.
        Mrs. Ellmers. And yes, Dr. Hirshon?
        Dr. Hirshon. I think it may vary state by state but in my
    state, what happens is, there is a fixed number of inpatient
    beds, and these individuals who are on forensic, not the ones
    who have been convicted but they are often the pretrial folks
    will be taking up the beds that I will be looking for from the
    emergency department. So it doubly impacts it because it then
    backs up my system because the forensic folks are being housed
    in that situation.
        Chief Biasotti. And if I could add, from a law enforcement
    aspect, most of the people that we are talking about we are
    bringing in not because of crimes, we are bringing them in just
    because of bizarre activity or dangerousness. The criminal
    aspect, we would have to make an arrest and it would go through
    the jail system and they would arrange for psychiatric
    evaluation.
        Mrs. Ellmers. And Judge Leifman, I think you look like you
    wanted to indicate, and I realize I have gone over my time but
    I would love to hear from you.
        Judge Leifman. What is happening is, the forensic beds are
    actually taking over the civil beds, because it is
    constitutional, because if you are arrested on a felony
    generally and you are incompetent to stand trial, you have to
    go----
        Mrs. Ellmers. To a----
        Judge Leifman. --for competency restoration. So as the
    States don't want to expand those budgets, they just start to
    use the civil beds for forensic beds. So it is really creating
    this horrible pressure.
        Mrs. Ellmers. I see. Well, thank you all, and Mr. Rahim too
    and Ms. Ashley for your personal stories. It is so important
    for us to hear because we need to understand how we can deal
    with this situation better, and again, thank you to all of you.
    This has been a very, very good subcommittee hearing, and I am
    hoping that we will really be able to fix this problem. Thank
    you.
        Mr. Murphy. Thank you, Mrs. Ellmers. I now recognize Mr.
    Harper for 5 minutes.
        Mr. Harper. Thank you, Mr. Chairman, and I thank each of
    you for being here and helping us, and we hope in the process
    we will be able to look at some suggestions and directions and
    things that may help you.
        Chief Biasotti, if I could ask you, you know, you have
    described obviously law enforcement being the front line on
    counteracting the impacts of serious mental illness in the
    community. What kind of burden is this on your resources and
    your department?
        Chief Biasotti. Well, that is the problem. That is what my
    paper focused on, and it was that most police agencies are very
    small in this country. The big cities are the anomalies. So for
    instance, in my department, which is considered midsized with
    an authorized staff of 50 officers, we will have three or four
    cars per shift, a minimum of three on the road per shift. So
    normally when we deal with a severely mentally ill person who
    is acting violent, it requires at least two of our officers. So
    that is two out of three people available. Now we have one
    officer for a municipality, a good-sized municipality, until
    those officers are free. A lot of times the ambulance can't
    take them because they are too combative and the hospital wants
    you to stay with them while they are in the emergency room
    until they make a determination as they are staying, which is
    because if they decide they are not staying, they don't want
    this psychotic person in their lobby and you need to take them
    back to where you came from. So it is a great depletion of
    resources for law enforcement nationwide, especially those in
    the rural areas.
        Mr. Harper. You know, I actually was a city prosecutor for
    about 6 years before I came here, and that was always the
    thing, and I appreciate what you said you do because sometimes
    you know they don't need to be incarcerated; they need to get
    help. Because not every department does it that way. So I want
    to commend you for that.
        Chief Biasotti. Well, it is difficult because you also have
    a crime victim that doesn't understand why the person that
    broke into their house is not going to jail, so you have to
    have cooperation on a lot of levels. But also to that end, what
    I wanted to bring up quickly is, I got to work with Governor
    Cuomo's office on the SAFE Act, the back end, Kendra's Law, and
    one thing that I think we are hopeful is going to make a change
    is, one of the changes in Kendra's Law mandates that in prison
    settings, those who are receiving psychiatric care in the
    prison will be evaluated upon release for inclusion into an
    assisted outpatient treatment program, which hadn't happened
    before. Before that, your time is up and you're out the door
    and there goes your treatment. So we are hoping that that is
    going to make changes and lessen recidivism.
        Mr. Harper. Thank you very much.
        Dr. Evans, I was looking at your title as we were going
    here, and I am also seeing what Ms. Ashley has gone through on
    a personal level, and what you have too, Chief. I have a 24-
    year-old son with fragile X syndrome, so he has intellectual
    disabilities. So how do you distinguish between, you know,
    classic mental illnesses or someone with an intellectual
    disability that someone who is not trained may not recognize?
    Give us some wisdom or advice. What do you--how do you handle
    that?
        Mr. Evans. Sure. So the easy way to make the distinction is
    that if a person has an intellectual disability, that is pretty
    much permanent. So those kinds of disabilities are lifelong,
    and our goal there is not necessarily recovery but it is really
    to help people have a high quality of life, to have self-
    determination. Mental illnesses are treatable, and one can have
    a very severe mental illness, schizophrenia, for example,
    bipolar illness, and can recover and can do well. It doesn't
    happen all the time but the majority of the time and so that is
    really the distinction. We work with people differently based
    on that.
        Mr. Harper. You know, with my son, if he were out by
    himself, if he was maybe in a sensory overload moment, it might
    be misinterpreted as to what he has, so training and
    understanding and realizing that every case, every person is
    different I know is an important thing for you.
        Mr. Evans. It is, and I think that educating the community
    about mental illnesses and intellectual disabilities is a real
    important part of this because you have heard the impact that
    stigma has on people reaching out for help, on the shame that
    comes with that, and I think that our strategies have to not
    only include how do we change the service system but like we
    have done with other illnesses like cancer. You know, 30, 40
    years ago, people used to whisper that and now people have
    marches about that and walks about that, and I think it has
    changed how people reach out for help when they need it. It has
    changed how we funded research and treatment. And I think the
    same thing applies to mental illness and behavioral health
    conditions.
        Mr. Harper. Thank you, Dr. Evans, and thanks to each of
    you. Mr. Chairman, I yield back.
        Mr. Murphy. Thank you. Dr. Burgess asked, we have two items
    here from the New York Times and from Freedom magazine
    regarding some cases from 1992 and 1993 that he would like to
    have submitted into the record, so without objection.
        [The information appears at the conclusion of the hearing.]
        Mr. Murphy. And Ms. DeGette, you have a clarifying
    question?
        Ms. DeGette. I just have a clarifying comment, Mr.
    Chairman, and I just want to say again, I have been on this
    subcommittee for 18 years, and this is, I think, maybe the best
    panel we have ever had, so thank you all for coming. You have
    practical solutions. You had different takes on the mental
    health system, and I hope that each of you will be willing to
    make yourselves a resource to the chairman and myself as we
    move forward in our efforts.
        Chief, you referred to Kendra's Law, and I just wanted to
    put in the record what that is, so you can correct me if I am
    wrong. I understand what this is. It is a law that was passed
    in New York that establishes more structured treatment combined
    with resources across the mental health system, and it is
    designed to get treatment to folks earlier on without having
    them participate in the penal system like Sheriff Dart was
    talking about or in the emergency room system. It is designed
    to get them treatment. But of course, you have to have an
    investment to do that of resources.
        The chairman and I were up here talking about this, and if
    you did have this investment of resources and you were really
    able to implement things like this, it would actually probably
    save money because you wouldn't be putting these people in
    incarceration or in very expensive ER situations. Every single
    person here is nodding their head. I would like to just say
    that for the record.
        Thank you very much.
        Chief Biasotti. If I can say, the shame of it is, we have
    45 States that have a very similar law but very few use it.
        Ms. DeGette. Because they are probably not putting the
    resources into it, right?
        Chief Biasotti. That is correct.
        Ms. DeGette. Thank you. And we are going to try to work to
    see what the federal partnership that we can have with all 50
    States to help this along.
        Thank you, Mr. Chairman.
        Mr. Murphy. Thank you. And Chief, along those lines, I
    understand, for example, California has a law on the books but
    only Nevada County, only one county, uses it.
        Chief Biasotti. In California, it is optional by county,
    and only one county, correct.
        Mr. Murphy. Let me say this. Deep thanks--oh, Dr. Burgess
    wants a brief comment.
        Mr. Burgess. Just as a brief follow-up. Dr. Evans, in your
    testimony you talk about the introduction of peer specialists.
    This has come up before in briefings that we have had. This
    strikes me as likely one of the most cost-effective ways to get
    rational treatment decisions and to keep people in their
    treatment. So I do hope you will share with the committee your
    experience with that. We are constrained under budgetary rules.
    We can never score a savings from something that will actually
    save money. It always scores as a cost. But perhaps this is one
    of those areas where spending the money wisely would in fact be
    a good investment. I thank you for bringing that to our
    committee today.
        Mr. Evans. Could I just----
        Mr. Burgess. Sure.
        Mr. Murphy. Real quick.
        Mr. Evans. I think that there are data that support that
    peer services are cost-effective. I think it is probably the
    most important thing that we have done in our service that not
    only gives people hope but one of the real challenges is
    keeping people engaged in treatment, and we have found nothing
    that is more effective than a person who has gone through the
    experience, connecting with another individual, and keeping
    that person connected, giving that person hope, frankly. It
    makes a huge difference, and we have one program where we have
    instituted peers. We have reduced our crisis visits by a third,
    and half of those visits would have resulted in an inpatient
    stay. So we have saved millions of dollars, we believe, by
    implementing peer services.
        Mr. Burgess. Thank you. I yield back.
        Mr. Murphy. Mr. Rahim, you wanted to comment on that?
        Mr. Rahim. Again, thank you so much for giving patients
    voice, and I think a couple of words. I know Mr. Dart talked
    about enlightenment, but I think enlightenment means
    compassion, dignity and education. So I think each of us has an
    ability to be compassionate and we have ability to treat each
    patient as an individual and with dignity, and I think through
    contact with people who are doing well and then that follow-up
    education as a foundation and groundwork, we can do so much
    good. So I do thank you again.
        Mr. Murphy. And again, my thanks to the whole panel. Just a
    couple of suggestions. While you are in town, I hope you stop
    in at your Member of Congress and say it is important to do
    some mental health reforms.
        I am committed to do this and I know Representative DeGette
    is too. It has been since 1963, as you referenced, Dr. Geller,
    the last time this country really did some major mental health
    reforms. It is long overdue. I know you are all passionate
    about this but I hope you energize your own Members of Congress
    as well to help them understand the importance of moving
    forward on this.
        Even though you spoke for 5 minutes and you added a few
    minutes to other things, oftentimes people go through life and
    wonder if their voice makes a difference, it does. Yours does,
    and it will continue to echo throughout the House of
    Representatives and this Nation. So I thank you a great deal
    for all that. And Mr. Rahim, you used the word ``hope.'' Where
    there is no help, there is no hope, and we will make sure we
    continue to work on that help.
        So in conclusion, again, thank you to all the witnesses and
    members that participated in today's hearing. I remind members
    they have 10 business days to submit questions for the record,
    and I ask that all witnesses agree to respond promptly to the
    questions. Thanks so much. God bless.
        [Whereupon, at 12:25 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

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