[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:]

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    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:]

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    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:]

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    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:]

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    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:]

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    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:]

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    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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