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





          HELPING FAMILIES IN MENTAL HEALTH CRISIS ACT OF 2013

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 3, 2014

                               __________

                           Serial No. 113-136


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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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 Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
MICHAEL C. BURGESS, Texas            FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois               ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan                LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          JIM MATHESON, Utah
PHIL GINGREY, Georgia                GENE GREEN, Texas
CATHY McMORRIS RODGERS, Washington   G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey            JOHN BARROW, Georgia
BILL CASSIDY, Louisiana              DONNA M. CHRISTENSEN, Virgin 
BRETT GUTHRIE, Kentucky                  Islands
H. MORGAN GRIFFITH, Virginia         KATHY CASTOR, Florida
GUS M. BILIRAKIS, Florida            JOHN P. SARBANES, Maryland
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. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     2
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     2
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     4
Hon. Fred Upton, a Representative in Congress from the State of 
  Michigan, opening statement....................................     6
    Prepared statement...........................................     6
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, opening statement...............................     8

                               Witnesses

Sylvia Thompson, Patient Advocate and President, National 
  Alliance on Mental Illness, West Side Los Angeles..............    10
    Prepared statement...........................................    12
David L. Shern, Interim President and CEO, Mental Health America, 
  Alexandria, Virginia...........................................    22
    Prepared statement...........................................    24
    Answers to submitted questions...............................   125
Nancy Jensen, person with lived experience, Wichita, Kansas......    30
    Prepared statement...........................................    32
Mary T. Zdanowicz, Attorney, North Eastham, Massachusetts........    41
    Prepared statement...........................................    43
Michael Welner, M.D., Founder and Chairman, The Forensic Panel...    50
    Prepared statement...........................................    51
    Answers to submitted questions \1\...........................   131

                           Submitted Material

Statement of the American Psychiatric Association, submitted by 
  Mr. Pitts......................................................    86
Article entitled, ``The Definition of Insanity: How a federal 
  agency undermines treatment for the mentally ill,'' The Wall 
  Street Journal, March 31, 2014, submitted by Mr. Pitts.........    88
Statement of Robert Bruce, submitted by Mr. Pitts................    90
Article entitled A Mental-Health Overhaul: A Congressman produces 
  a set of good ideas for a difficult problem, the Wall Street 
  Journal, December 26, 2013, submitted by Mr. Pitts.............    99
Op-Ed by Hon. Tim Murphy, The Philadelphia Inquirer, January 26, 
  2014, submitted by Mr. Pitts...................................   101
Statement of the American Bar Association, submitted by Mr. Pitts   103
Statement of the National Disability Rights Network, submitted by 
  Mr. Pitts......................................................   105
Statement of the National Coalition for Mental Health Recovery, 
  submitted by Mr. Pitts.........................................   108
Statement of the Citizen Commission on Human Rights International 
  \2\, submitted by Mr. Pitts....................................    85
Statement of the Consortium for Citizens with Disabilities, 
  submitted by Mr. Pitts.........................................   112
Statement of the Bazelon Center for Mental Health Law, submitted 
  by Mr. Pitts...................................................   118

----------
\1\ Dr. Welner's response to submitted questions for the record 
  can be found at http://docs.house.gov/meetings/if/if14/
  20140403/102059/hhrg-113-if14-wstate-welnerm-20140403-
  sd002.pdf.
\2\ The statement can be found at http://docs.house.gov/meetings/
  if/if14/20140403/102059/hhrg-113-if14-20140403-sd008.pdf.

 
          HELPING FAMILIES IN MENTAL HEALTH CRISIS ACT OF 2013

                              ----------                              


                        THURSDAY, APRIL 3, 2014

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:31 a.m., in 
room 2322 of the Rayburn House Office Building, Hon. Joe Pitts 
(chairman of the subcommittee) presiding.
    Present: Representatives Pitts, Burgess, Murphy, Blackburn, 
Gingrey, Lance, Cassidy, Guthrie, Griffith, Bilirakis, Ellmers, 
Upton (ex officio), Pallone, Capps, Schakowsky, Green, 
Butterfield, Barrow, Christensen, Sarbanes, DeGette, Tonko, and 
Waxman (ex officio).
    Staff present: Clay Alspach, Chief Counsel, Health; Mike 
Bloomquist, General Counsel; Sean Bonyun, Communications 
Director; Karen Christian, Chief Counsel, Oversight; Noelle 
Clemente, Press Secretary; Brenda Destro, Professional Staff 
Member, Health; Brad Grantz, Policy Coordinator, Oversight and 
Investigations; Sydne Harwick, Legislative Clerk; Robert Horne, 
Professional Staff Member, Health; Katie Novaria, Professional 
Staff Member, Health; Sam Spector, Counsel, Oversight; Heidi 
Stirrup, Health Policy Coordinator; Tom Wilbur, Digital Media 
Advisor; Ziky Ababiya, Democratic Staff Assistant; Karen 
Lightfoot, Democratic Communications Director and Senior Policy 
Advisor; Karen Nelson, Democratic Deputy Committee Staff 
Director for Health, Anne Morris Reid, Democratic Senior 
Professional Staff Member; and Matt Siegler, Democratic 
Counsel.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. The subcommittee will come to order. The Chair 
will recognize himself for an opening statement.
    Millions of Americans suffer with severe mental illnesses, 
such as bipolar disorder, schizophrenia, and major depression, 
and many of them, and their families, struggle to find the 
treatment and help they desperately need.
    I would like to commend my colleague from Pennsylvania, Dr. 
Murphy, for his yearlong investigation into mental health 
issues and for proposing H.R. 3717, the Helping Families in 
Mental Health Crisis Act. Briefly, this bill would reform the 
Community Mental Health Services Block Grant program by 
changing administration, improving data collection, and by 
requiring treatment standards to facilitate care. It would 
enhance Medicaid payments to Federally Qualified Community 
Behavioral Health Centers (FQCBHCs), make adjustments to HIPAA 
and FERPA--the Family Education Rights and Privacy Act--privacy 
regulations, and expand access to certain medical records for 
qualifying caregivers; create an Assistant Secretary for Mental 
Health who will be responsible for coordinating spending at all 
federal agencies on mental health, including at the Substance 
Abuse and Mental Health Services Administration (SAMHSA). It 
would make changes to key Justice Department regulations that 
impact at-risk or imprisoned individuals with mental illness. 
It would increase federal funding for certain Medicaid 
providers and research at the National Institutes of Health. It 
would institute liability protections for physician volunteers 
at FQCBHCs, and it would reform existing mental health programs 
at SAMHSA.
    I would like to welcome all of our witnesses here today. We 
look forward to learning from your expertise and experience.
    [The prepared statement of Mr. Pitts follows:]

               Prepared statement of Hon. Joseph R. Pitts

    The Subcommittee will come to order.
    The Chair will recognize himself for an opening statement.
    Millions of Americans suffer with severe mental illnesses, 
such as bipolar disorder, schizophrenia, and major depression, 
and many of them--and their families--struggle to find the 
treatment and help they desperately need.
    I would like to commend my colleague from Pennsylvania, Dr. 
Murphy, for his year-long investigation into mental health 
issues and for proposing H.R. 3717, the Helping Families in 
Mental Health Crisis Act. Briefly, this bill would:
     Reform the Community Mental Health Services Block 
Grant Program by changing administration, improving data 
collection, and by requiring treatment standards to facilitate 
care;
     Enhance Medicaid payments to Federally Qualified 
Community Behavioral Health Centers (FQCBHCS);
     Make adjustments to HIPAA and FERPA (the Family 
Education Rights and Privacy Act) privacy regulations and 
expand access to certain medical records for qualifying 
caregivers;
     Create an Assistant Secretary for Mental Health 
who will be responsible for coordinating spending at all 
federal agencies on mental health, including at the Substance 
Abuse and Mental Health Services Administration (SAMHSA);
     Make changes to key Justice Department regulations 
that impact at-risk or imprisoned individuals with mental 
illness;
     Increase federal funding for certain Medicaid 
providers and research at the National Institutes of Health;
     Institute liability protections for physician 
volunteers at FQCBHCS; and
     Reform existing mental health programs at SAMHSA.
    I would like to welcome all of our witnesses here today. We 
look forward to learning from your expertise and experience.
    Thank you, and I yield the remainder of my time to --------
----------------------------------.

    Mr. Pitts. I will yield the balance of my time to the 
gentleman from Pennsylvania, Dr. Murphy.

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

    Mr. Murphy. I thank the chairman for convening this 
hearing, and I want to thank the witnesses for being here as 
well.
    In light of yesterday's tragic shooting at Fort Hood 
involving a soldier under treatment for a behavioral health 
disorder, and news this week out of Pittsburgh of a mother who 
said she heard voices commanding her to drown her two young 
children in a bathtub, today's hearing has a sad element of 
timeliness to it. But let us keep in mind, most persons with 
mental illness are not violent, and tragically, are more 
frequently the victims of violence, but you will never hear the 
breaking news of a homeless man being robbed or beaten or a 
person with mental illness losing their job.
    Over the last year, the Oversight and Investigations 
Subcommittee I chair held a series of forums and hearings to 
review our Nation's mental health system, and this bill, the 
Helping Families in Mental Health Crisis Act, is a result of 
those hearings, and with anything, there is misinformation 
about this legislation, which is why I am glad you have 
convened this hearing so we can continue to work forward on 
perfecting it.
    Fifty years ago, our Nation confronted the atrocities of 
asylums, warehouses for those whose illnesses medical science 
could not yet treat, and at that time this committee moved 
legislation to close those places and help individuals live in 
the community. Many were getting treatment and many were not, 
and for half a century operated under the illusion that having 
done something, we did the right thing. We didn't.
    Unfortunately, that illusion has been shattered by the 
heartbreaking daily tragedies that prove our mental health 
system is broken and failing the very people who need help 
most. The stories are haunting and the numbers are staggering. 
3.6 million people with serious mental illness don't get 
treatment. There are over 40,000 suicides a year, 20 soldier 
suicides each day. Another 1.3 million attempted suicides.
    There is only one child psychiatrist for every 2,000 
children with a mental health disorder. It is a system where 
the three largest mental health hospitals are actually jails, 
and there is a shortage of 100,000 psychiatric beds nationwide 
for those who are in acute crisis.
    A rule to protect privacy needs clarification because it 
has frustrated a countless number of physicians and members and 
generated over 70,000 complaints, and the mental health agency 
that until recently employed as many dentists as it did 
psychologists and psychiatrists, and this is what the American 
taxpayer buys for $125 billion.
    That is why we introduced this bill, to engage in 
meaningful reform. It has several of those elements that just 
presented by the chairman in empowering parents and caregivers 
by breaking down the barriers that prevent communication, 
increases access to acute care psychiatric beds, provides 
alternatives to inpatient care through assisted outpatient 
treatment, and expands access to the underserved and rural 
populations; creates an Assistant Secretary of Mental Health to 
scrutinize federal programs and promote evidence-based care; 
ensures mental health patients enrolled in Medicare and 
Medicaid have access to the full range of medications that keep 
them healthy and out of the hospital; advances critical 
research at the National Institutes of Mental Health like the 
Brain Research Initiative; promotes promising evidence-based 
care like the recovery after initial schizophrenic episode; 
improves quality and expands access to integrated medical and 
mental health care at community mental health providers, 
extends health information technologies so mental health 
providers can communicate and work with primary care 
physicians, and ensures greater accountability from the 
Substance Abuse and Mental Health Service Administration.
    For far too long, those who need help have been getting it 
the least, and where there is no help, there is no hope. We 
can, must and will take mental illness out of the shadows of 
ignorance, despair, neglect and denial and into that bright 
light of hope, and it starts with the Helping Families in 
Mental Health Crisis Act.
    I look forward to hearing the comments of our witnesses 
today. I yield back.
    Mr. Pitts. The chair thanks the gentleman and now 
recognizes the ranking member of the subcommittee, Mr. Pallone, 
for 5 minutes for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairman Pitts.
    This is our subcommittee's first proceeding on mental 
health during this Congress, and while I am thankful to you for 
finally convening a panel to talk about this critically 
important issue, I remain conflicted and disappointed that you 
have decided to move straight to a legislative hearing.
    For over a year we have had personal and staff discussions 
about the importance of the Health Subcommittee examining 
mental health in light of some heartbreaking events in the past 
couple of years, and despite this today, I and other members of 
the subcommittee are at a significant disadvantage because we 
haven't been afforded an opportunity to be at the forefront of 
evaluating and focusing on mental illness. As the Health 
Subcommittee, we should be the ones putting a full-scale effort 
into reviewing this and understanding it better.
    Mental illness is an important public health issue. 
According to numbers from the National Alliance on Mental 
Health, it is estimated that one in four adults experience a 
mental illness during the course of a given year. That is about 
55.7 million people. Meanwhile, only about 60 percent of people 
with mental illness get treatment each year. Of these people, 
approximately 11.4 million adults in the United States live 
with a serious mental illness, which includes, among others, 
major depression, schizophrenia, and bipolar disorder. 
Individuals with serious mental illness can be treated 
effectively, but unfortunately, it has been so difficult for 
those who need services to break through the stigma and weigh 
the obstacles associated with mental health, even though we 
know how important mental health is and how interlinked it is 
to all aspects of health and quality of life.
    What some people may not realize is that mental illness is 
not an isolated public health problem. Cardiovascular disease, 
diabetes, and obesity often coexist with mental illness and 
treatment of the mental illness can reduce the effects of these 
disorders. So it is proven that people, families, and 
communities will benefit from increased access to mental health 
services. Despite recent vigorous debate about America's mental 
health policies, there has been no clear solution yet. However, 
we made some significant steps over recent years. The first 
significant milestone was the Paul Wellstone Mental Health 
Parity and Addiction Equity Act, which makes sure that large 
employer-based insurers cannot charge more or place greater 
restrictions on mental health benefits that they do for medical 
benefits. This parity law marked a dramatic and historic step 
for the rights of Americans with mental health and addiction 
illness. When I was the chairman of the Health Subcommittee, I 
was proud to help play a critical role in enacting this 
bipartisan legislation.
    Of course, the parity struggle is not over. The 
implementation of this law is critical. Specifically, we need 
to ensure that there are measures in place for meaningful 
reporting on compliance with the law.
    Another significant milestone was passage of the Affordable 
Care Act. It includes a number of provisions aimed at improving 
coverage for and access to mental health services. So let me 
point out some of the critical details in the ACA. First, 
people can no longer be denied coverage because of preexisting 
conditions, and this includes mental health illness; more 
access to the Medicaid program, which has always provided a 
number of mental health treatments. Mental health treatment now 
comes standard. Every health plan sold through an exchange has 
to cover a variety of medical services, which includes mental 
health and substance abuse treatments. And finally, the ACA 
extends mental health parity to all Americans, not just those 
who are covered by large employers, again, building upon the 
Paul Wellstone law.
    Mr. Chairman, these are just the highlights of the law the 
Republicans aim to repeal. The ACA also includes a number of 
provisions that specifically list mental health and substance 
abuse as priority topics in programs like the National 
Prevention Council, health workforce development initiatives 
and medical homes, and there is still a lot more to do. People 
will only benefit from the progress we have made if services 
are available and if those who need help are not afraid to seek 
it. We need to build from these laws to support the continuum 
of mental health services at all levels of government.
    That is why I believe we must support efforts to increase 
awareness about mental health and reduce the fear, shame, and 
misperceptions that often prevent people from getting the help 
they need, and I am committing to spreading the message that it 
is OK to talk about mental health because treatment is 
effective and people do recover. We must find out which 
treatments are the right treatments and how we can best 
identify Americans who need help, and that is why agencies such 
as the Substance Abuse and Mental Health Services 
Administration and NIMH are so important.
    So Mr. Chairman, there are a number of Democrats on the 
committee who have introduced legislation and expressed 
interesting in working together to improve mental health in 
this country. I hope that if you choose to move forward on the 
bill under consideration today that we can find common ground 
and pass bipartisan legislation. I have some serious concerns 
about some of the provisions of H.R. 3717 but I remain 
committed to working with you and my other colleagues on the 
committee as we make mental health a priority.
    Thank you, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman and now 
recognizes the chairman of the full committee, the gentleman 
from Michigan, Mr. Upton, for 5 minutes for an opening 
statement.

   OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Upton. Well, thank you, Mr. Chairman.
    Mental illness affects millions of Americans and their 
families, yet sadly it is a subject often left unmentioned in 
Congress and in communities across the country, and we are 
working to change that. Yes, we are. Ensuring treatments and 
resources are available and effectively used for those 
suffering with mental illnesses has been a priority of this 
committee throughout the 113th Congress.
    Since January of last year, Oversight and Investigations 
Subcommittee Chairman Tim Murphy has spearheaded a thorough 
review of all federal mental health programs. The subcommittee 
and the committee held a series of public forums, briefings and 
investigative hearings to discern how federal dollars devoted 
to research and treatment into mental illness are being 
prioritized and spent. I want to commend him and those of 
efforts, and those of the ranking member of the Oversight and 
Investigations Subcommittee, Diana DeGette, to ensure a 
bipartisan focus on these vital issues.
    To address the gaps discovered in the extensive and wide-
ranging examination, Chairman Murphy introduced H.R. 3717 last 
year, the Helping Families in Mental Health Crisis Act of 2013. 
The bill addresses issues that are important in diagnosing and 
treating individuals with serious mental illness. It would 
reorient federal funding for mental health to improve the 
delivery of mental health services and help improve the lives 
of mental health patients and their families.
    I am pleased that two important provisions of that bill 
were included in H.R. 4302 that the President signed earlier 
this week, which was sponsored, of course, the overall bill by 
Chairman Pitts. The first provision will help local 
jurisdictions implement assisted outpatient treatment grant 
programs, and the second will improve access to community 
mental health services, bipartisan and bicameral support for 
both of those provisions.
    I would just like to add that to those families who have 
been impacted by mental illness in some form, Congress is aware 
of your plight and we can do better.
    I yield the balance of my time to the vice chair of the 
subcommittee, Dr. Burgess.
    [The prepared statement of Mr. Upton follows:]

                 Prepared statement of Hon. Fred Upton

    Mental illness affects millions of Americans and their 
families, yet sadly it is a subject often left unmentioned in 
Congress and in communities across the country. We are working 
to change that. Ensuring treatments and resources are available 
and effectively used for those suffering with mental illnesses 
has been a priority of this committee throughout the 113th 
Congress.
    Since January 2013, Oversight and Investigations 
Subcommittee Chairman Tim Murphy has spearheaded a thorough 
review of all federal mental health programs. The committee 
held a series of public forums, briefings, and investigative 
hearings to discern how federal dollars devoted to research and 
treatment into mental illness are being prioritized and spent. 
I want to commend Chairman Murphy's efforts, and those of the 
Ranking Member of the Oversight and Investigations 
Subcommittee, Diana DeGette, to ensure a bipartisan focus on 
these vital issues.
    To address the gaps discovered in the extensive and wide-
ranging examination, Chairman Murphy introduced H.R. 3717, the 
Helping Families in Mental Health Crisis Act of 2013. The bill 
addresses issues important in diagnosing and treating 
individuals with serious mental illness. It would reorient 
federal funding for mental health to improve the delivery of 
mental health services and help improve the lives of mental 
health patients and their families.
    I am pleased that two important provisions of H.R. 3717 
were included in H.R. 4302, the Protecting Access to Medicare 
Act of 2014, which was sponsored by Health Subcommittee 
Chairman Pitts and recently signed by the president. The first 
provision will help local jurisdictions implement assisted 
outpatient treatment grant programs, and the second will 
improve access to community mental health services.
    I would just like to add that to those families who have 
been impacted by mental illness in some form--Congress is aware 
of your plight and we can do better.
    I'd like to thank the witnesses for taking the time to 
testify before the Subcommittee this morning. I yield the 
remainder of my time to --------------------------------------
----.

    Mr. Burgess. Well, I thank the chairman for yielding. I 
really do not have prepared comments this morning but I did 
feel obligated to respond.
    I am the vice chairman of this subcommittee as well as the 
vice chairman of the Oversight and Investigations Subcommittee, 
and in total, the committee through its subcommittees, this 
represents the eighth dedicated hearing to mental health and 
mental health issues between the Oversight and Investigations 
Subcommittee and the Subcommittee on Health and the full 
committee in general. So it is not from lack of attention. 
Chairman Murphy has made this the centerpiece of his 
chairmanship of the Oversight and Investigations Subcommittee, 
which is appropriate but that is not a legislative committee, 
so today we are in the Health Subcommittee, and Chairman Pitts 
is encouraging us to have this legislation hearing on 
Congressman Murphy's efforts.
    And then as a Texan, I just have to say across the country, 
our hearts are heavy because of what we saw down in Fort Hood 
last evening. When the news stories began to break, I am sure I 
felt the same as everyone else across the country felt: oh, no, 
not again. It seems like just a few months ago that we were 
down for the memorial service for the 13 soldiers who were lost 
in November of 2009, and now we are facing another series of 
questions surrounding another incident yesterday.
    We know there will be an investigation. We know there will 
be answers to the questions that are forthcoming, but right now 
please let us keep in our thoughts the soldiers at Fort Hood, 
their general officer corps, of course the people in Killeen, 
Texas, Harker Heights, Coppers Cove, those communities. I will 
tell you from firsthand experience during the memorial service 
4 \1/2\ years ago, those communities came together and embraced 
the soldiers at Fort Hood and let them know they were not 
acting alone. Our military has been under great stress for the 
last decade. Surely this is something they didn't need but we 
can all stand in their support.
    Thank you, Mr. Chairman. I will yield back.
    Mr. Pitts. The chair thanks the gentleman and now 
recognizes the ranking member of the full committee, Mr. 
Waxman, 5 minutes for an opening statement.

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

    Mr. Waxman. Thank you, Mr. Chairman.
    One in four adults has a diagnosable form of mental illness 
in any given year. More than 10 million Americans are living 
with serious mental illness, conditions like schizophrenia and 
major depression. But even as the demand for mental health 
services has increased, there has been an unprecedented decline 
in state public mental health spending. The Federal Government 
has stepped in to help fill the gap. The increased coverage 
provided by the Affordable Care Act and the mental health 
benefits it requires will make a substantial improvement in the 
lives of Americans who need these services. Already more than 7 
million Americans signed up for insurance coverage through the 
marketplaces that includes mental health and substance use 
disorder services at parity with medical and surgical benefits.
    The expansion of Medicaid in many states, but not all 
unfortunately, has also made a huge difference, giving millions 
more comparable behavioral health coverage. But there is 
certainly more that can be done.
    Today's hearing is focused on one bill, legislation 
introduced by Congressman Murphy, H.R. 3717, the Helping 
Families in Mental Health Crisis Act of 2013. There are some 
provisions in H.R. 3717 that I strongly support. I support 
reauthorization of programs with strong bipartisan backing like 
the Garrett Lee Smith Suicide Prevention program and National 
Child Traumatic Stress Initiative. I support the provisions 
recognizing the important work of the National Institute of 
Mental Health on brain research that will help us better 
understand the causes of mental illness. I support the campaign 
to raise awareness regarding mental illness among our young 
people, and I support the proposal that would extend electronic 
health record meaningful use incentive payments to mental 
health providers.
    But I must express deep concern about other provisions in 
this bill. I think the bill broadly redefines the privacy 
rights of individuals with a diagnosed mental illness. This 
could discourage many people who need to come forward for care 
from seeking necessary treatment if they fear their privacy 
won't be protected. The bill cuts federal support for mental 
health services administered through the Community Mental 
Health Services Block Grant and conditions States' ongoing 
support on the adoption of new federal standards for 
involuntary treatment that would displace current law. So you 
have the Federal Government cutting the funds but saying if you 
are going to get funds that are left, you have to do it the way 
we tell you to do it. This has always been a State 
responsibility. This is a one-size-fits-all response. I am not 
sure if that is the best way for us to approach it.
    It proposes a dramatic reorganization of mental health 
authorities in the Department of Health and Human Services that 
would minimize the role of the main agency on mental health--
the Substance Abuse Mental Health Services Administration--and 
would reverse efforts to better coordinate mental health and 
substance abuse activities. Separation of these two programs--I 
can't understand the reasoning behind it. And the bill 
undermines the important work of the protection and advocacy 
programs that protect the rights of people with mental illness 
from abuse and neglect.
    The bill has an important provision in it that I think we 
need to look very carefully at, and that is the expansion of 
Medicaid coverage that we are going to mandate under Medicaid, 
and I think the responsibility of the states that have been 
paying for it and shifting those costs to the Federal 
Government. This could be billions and billions and billions of 
dollars at a time when we hear so often from the other side of 
the aisle we can't afford the entitlements of Medicaid the 
entitlements of poor people, and a lot of poor people have the 
greatest problem in accessing mental health services.
    Last year, I and other Democrats introduced mental health 
legislation but key provisions from that legislation are absent 
in Congressman Murphy's bill. Any bill we advance should 
include investments in mental health first aid, mental health 
in the schools, and mental health provider workforce 
development. We should be looking at all ideas that have been 
put forward and working in a bipartisan manner on legislation 
to achieve our shares the goal of improving our system.
    I want to thank all of the witnesses for appearing before 
us today. In particular, I want to take a moment to recognize 
Ms. Jensen, who will share her own personal history with mental 
illness and road to recovery. I also want to acknowledge Ms. 
Thompson, who is a constituent of mine, and will discuss her 
experience as the daughter of a mother with serious mental 
illness. And Ms. Zdanowicz, I know family members close to you 
also have a history of mental illness, and that is true of Dr. 
Shern as well. It takes a great deal of courage for you to come 
here and speak out publicly about such difficult experiences, 
but it is important for the subcommittee to hear your 
perspectives and to share it with our other colleagues in the 
Congress.
    Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman. That concludes 
opening statements. All members' opening statements will be 
made a part of the record.
    I have a UC request. At this time I would ask unanimous 
consent to enter these documents into the record: one by the 
American Psychiatric Association, a Wall Street Journal article 
titled ``The Definition of Insanity: How a Federal Agency 
undermines treatment for the Mentally Ill,'' a statement by 
Robert Bruce, another Wall Street Journal article dated 
December 26, 2013, and an op-ed by Congressman Murphy that 
appeared in the Philadelphia Inquirer January 26, 2014. Without 
objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. We have one panel today with five witnesses. I 
will introduce them in the order that they speak. 
Unfortunately, our first witness, Dr. Michael Welner, is still 
on a train delayed. He will be coming in at any minute. He is 
Founder and Chairman of the Forensic Panel. Ms. Sylvia 
Thompson, Patient Advocate and President of the National 
Alliance on Mental Illness; Dr. David Shern, Interim President 
and CEO of Mental Health America; Ms. Nancy Jensen, a person 
with lived experience, and Ms. Mary Zdanowicz, Attorney and 
former Executive Director of the Treatment Advocacy Center.
    Thank you all for coming. Your written testimony will be 
made a part of the record. You will each be given 5 minutes to 
summarize your written testimony, and we will begin with Ms. 
Thompson. Ms. Thompson, you are recognized for 5 minutes.

STATEMENTS OF SYLVIA THOMPSON, PATIENT ADVOCATE AND PRESIDENT, 
NATIONAL ALLIANCE ON MENTAL ILLNESS, WEST SIDE LOS ANGELES; DR. 
   DAVID L. SHERN, INTERIM PRESIDENT AND CEO, MENTAL HEALTH 
AMERICA, ALEXANDRIA, VIRGINIA; NANCY JENSEN, PERSON WITH LIVED 
 EXPERIENCE, WICHITA, KANSAS; AND MARY T. ZDANOWICZ, ATTORNEY, 
                  NORTH EASTHAM, MASSACHUSETTS

                  STATEMENT OF SYLVIA THOMPSON

    Ms. Thompson. Thank you, Mr. Chairman and members of the 
committee, Representative Waxman. My name is Sylvia Thompson 
and I am a Professional Care Manager as well as President of 
NAMI's West Side Los Angeles affiliate, but that is not why I 
am here today.
    Today I am my mother's daughter. My mother was severely 
mentally ill from as far back as I can remember. So growing up 
in my family was like living in a combat zone. It never felt 
safe because of her drastic mood changes, paranoia, grandiose 
ideas, impulsivity, delusions, depression and inappropriate 
anger often directed at me. As much as we loved our mother, my 
family was powerless to help her because she did not believe 
she was ill. It is called anosognosia. It affects up to 40 
percent of those with schizophrenia and bipolar disorder, and 
that is a conservative estimate. Because she didn't believe she 
was ill, she would not stay in treatment so she could not take 
care of herself nor could she take care of me. She had suicidal 
ideation, delusions, hospitalizations, believed I was 
possessed, and would disappear for days or weeks.
    I am a firm believer in self-determination but for those 
that are capable. We must recognize there is a whole group of 
people like my mother who are too ill to self-direct their own 
care. Just take a look at the news. We can't pretend these 
people don't exist. These tragic stories like this morning, 
they are not the face of mental illness. They are the face of 
mental illness that is severe mental illness that is left 
untreated.
    Our helpline is flooded with calls from family members of 
individuals who are imprisoned by their delusions and 
hallucinations. Parents beg for treatment and cannot get it. 
The current mental health system doesn't help them because 
their child is too ill to volunteer for treatment. The police 
can't help until after they become dangerous. It can't be a 
recovery model or a medical model. We must embrace both because 
one size does not fit all.
    Sometimes the recovery model works but sometimes assisted 
outpatient treatment or involuntary hospitalization is 
initially necessary to get somebody on the recovery path. AOT 
would help the few who have a past history of multiple arrests, 
violence or hospitalizations caused by refusing to stay in 
treatment. Studies show AOT reduces homelessness, 
incarceration, suicide, arrest, and yes, violence. It saves 
money. It reduces force and it saves lives. We need more 
hospital beds. California has only five state hospitals with 
less than 7,000 beds. Because of that, Californians with severe 
mental illness are four times more likely to be incarcerated 
than hospitalized--four times. That would never be tolerated 
for cancer or Alzheimer's disease. Even at its best, California 
would be short over 10,000 hospital beds to help the most 
severely mentally ill get stabilized. We can't pretend that 
hospitals are not needed.
    We have to free family caretakers from HIPAA handcuffs so 
they can provide care to loved ones. How can someone ensure 
their loved one has transportation to an appointment if they 
don't know when the appointment is, or ensure they stay on 
their medications if they don't know what the medicines are. We 
have to prioritize the most severely ill and stop funding non-
evidence-based programs and groups that impede care for the 
most seriously ill.
    Congress created SAMHSA to target mental health services to 
the people most in need. Only four in the 288 programs in 
SAMHSA's national registry of evidence-based practices focus on 
severe mental illness. That is four out of 288.
    I urge you to pass H.R. 3717. I am not a politician, I am 
not a legislator, but I am someone who has spent her life in 
the trenches personally and now professionally. It is wonderful 
to want to improve mental health for everyone but in the 
process we absolutely cannot ignore the most severely ill. They 
are the most vulnerable and they need your help.
    My mother struggled my whole life. Before we gained 
guardianship, she was living in a state of squalor surrounded 
by stacks of newspaper, rotten food, human feces, dead rodents. 
That was how she self-directed her care. No one chooses that 
life. But you should also know, she spoke seven languages 
fluently. She knew every opera libretto and she was a gifted 
pianist. She was passionate, she was creative and she was 
loving. She was someone's daughter, she was someone's sister, 
she was someone's wife, and she was the mother to six amazing 
children who were desperate for her to be well again.
    My mother's inability to acknowledge her illness was not a 
choice. It was a symptom that trapped her and robbed all of us 
of her greatness, robbed me of my mother. I am proud to be my 
mother's daughter. I inherited her passion, her creativity, her 
outside-the-box thinking. In her memory and to prevent others 
from going through what she and our family did, I implore you 
all to please work together to pass H.R. 3717. Thank you.
    [The prepared statement of Ms. Thompson follows:]
    
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    Mr. Pitts. The chair thanks the gentlelady and now 
recognizes Dr. Shern five minutes for his opening statement.

                  STATEMENT OF DAVID L. SHERN

    Mr. Shern. Thank you, Mr. Pitts, members of the committee. 
I am the Interim President and CEO of Mental Health America, 
which is the Nation's oldest mental health advocacy 
organization. We are 105 years old this year. We were founded 
by a person who had bipolar illness and have throughout our 
history stood very firmly for the full inclusion of people with 
mental illnesses in every aspect of American life. We have 240 
affiliates around the country, approximately, and are very 
concerned with America's mental health from a public health 
perspective.
    Prior to joining Mental Health America, I was a tenured 
Professor and Dean at the University of South Florida and a 
mental health researcher, a psychologist by training, and I 
spent my professional career really studying systems of care 
for people with severe mental illnesses, and of particular 
relevance, I think, for our discussion today was a program, an 
NIMH-funded program that we conducted in New York City, an 
experimental program using psychiatric rehabilitation 
technology to engage and serve persons with severe mental 
illnesses who are homeless, living on the streets of New York 
City, about 60 percent of whom also had very serious addiction 
disorders. We were able through the use of peer counselors who 
are involved in the program and a very well understood 
technology, psychiatric rehabilitation technology developed by 
Boston University to engage this very difficult to treat, most 
in need group of individuals. We did that by emphasizing the 
fact that they had choices in terms of how they could organize 
their recovery and empowered them to express those choices and 
empowered our team, our treatment team, to enact those choices.
    Through that process, we successfully housed the majority 
of clients. We significantly reduced their level of psychiatric 
symptomatology. We improved their quality of life.
    The important point is, I thought about these issues a lot, 
and it is clear to me that we have technologies that can be 
used to engage individuals in care. We don't always do it, but 
those technologies are available to us and our challenge is to 
try to implement them more effectively.
    I am also a family member. I think everyone here is a 
family member. I have a feeling if we queried the committee, we 
would find out that there is not one degree of separation 
between many of us and a family member who has a mental health 
problem. My nephew had severe bipolar disorder, particularly 
when he was in high school, and even though I knew all the 
people in the United States who developed the evidence-based 
practices for this because of the inadequate system of care, in 
this case in Pueblo, Colorado, we couldn't get Kyle what he 
needed. Fortunately, my family had the resources to get him 
into residential care and he is doing fine now, but we went 
through a very difficult time, a time when he was confused 
about what was going on with him and so I am very sensitive to 
these issues.
    The reason that I left academia and entered advocacy was to 
try to close this gap between what we know and what is 
routinely available to people, and there are many aspects, as 
many of you have commented already, many aspects of this 
legislation that are very important and that will seek to do 
that, to expand coverage, and as many people have expressed, we 
are very enthusiastic and supportive of those.
    There are, however, some aspects about which we are very 
concerned. We are concerned with the emphasis on assisted 
outpatient treatment. It is very clear to us that the issue is 
having a full engagement-oriented system of care for 
individuals and making those services available to those 
individuals. We are concerned with expansion of the IMD 
exclusion, focusing only on one type of care when we realize, 
as Dr. Arthur Evans testified last week, that is in fact a 
continuum of care which is most important.
    We are concerned with what we conceive as an attack on the 
protection and advocacy system and what we conceive as some 
very fundamental misunderstandings about the role of the 
Substance Abuse and Mental Health Services Administration in 
leading the Nation's health. From our perspective, SAMHSA has 
led every major mental health reform during the last 50 years. 
Is our system what we think it should be? No, it is fragmented, 
it is broken and it is not responding to people. Do we have the 
technology to make a difference? Yes, we do. Are we 
implementing that technology? No, we are not. There are several 
aspects of this bill which will help with that. However, there 
are some premises and some assumptions that are very concerning 
for us and that we feel ultimately will damage the system and 
will make it in fact more difficult for people to access the 
services that they need.
    We have made big progress with the Parity Act and enacting 
that as part of the Affordable Care Act, which was bipartisanly 
adopted by the Senate Finance Committee in the initial markup 
of the bill. It is a chance for us to live into the possibility 
of that Act to get people the services that they need.
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. Shern follows:]
    
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    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes Ms. Jensen 5 minutes for an opening statement.

                   STATEMENT OF NANCY JENSEN

    Ms. Jensen. My name is Nancy Jensen, and I am the author of 
``The Girl Who Cried Wolf,'' which tells the story of my lived 
experienced as a person with mental illness and a survivor of 
the terrible place called Kaufman House in Newton, Kansas.
    The story of Kaufman House vividly shows why parts of this 
bill destroying the funding and effectiveness of both PAIMI and 
recovery programs must be removed. This bill slashes funding 
for PAIMI's program and takes away their ability to combat evil 
and protect the rights of people with mental illness including 
the right to choose their treatment.
    If this bill is law, the Kaufman House would still be 
terrorizing, abusing and enslaving people with mental illness. 
As a former resident, I know how terrible Kaufman House was. 
They called what they were doing therapy. It was not therapy. 
It was sexual and emotional abuse. The Kaufmans forced their 
so-called patients to be nude and do bizarre acts, sex acts, 
while they videotaped it. I was forced to be naked, to sleep on 
a filthy floor and use a bucket for a toilet. I was degraded 
and told I should never get married, never have a child, never 
join a church, and that I would never get a job. Well, as a 
proudly married mother with both faith in God and a job, I 
proved Kaufman wrong.
    The PAIMI program shut down this house of horrors when no 
one else would or could. The PAIMI program freed my friends and 
helped get us justice. I was the first former resident to tell 
the State about the evil. Eleven other Kansans made reports 
after me but the State did absolutely nothing.
    How did PAIMI programs shut down Kaufman House when the 
State adult protective services could not? Well, first, the 
PAIMI Act gives protection and advocacy agencies powers and 
independence to gain access in places like Kaufman House to 
investigate and shut them down. Without a court order, the APS 
was turned away. Second, PAIMI programs provided the P&A enough 
funding so that it could properly investigate the Kaufmans, and 
PAIMI freed us and got us the right treatment and then pressed 
for policy changes. Third, and perhaps the most important, with 
PAIMI, the victim is the client. The client is in charge. With 
the APS, they serve the interests of the provider and the 
State.
    Long story short, thanks to PAIMI and its special powers 
and funding, the Kaufman House was shut down and we obtained 
the right type of treatment, and Arlan and Linda Kaufman were 
found guilty of over 60 charges. The Kaufmans are in prison 
today and I am here testifying. How cool is that?
    This bill also takes away the PAIMI program's ability to 
educate policymakers. The PAIMI program worked with me as a 
survivor to change policy so future Kaufman Houses can never 
happen again. Licenses are now required, guardianship laws are 
fixed, and now there is an abuse and neglect unit.
    PAIMI does not just help victims of abuse. This bill makes 
it harder for people with mental illness to find housing, 
employment and education. It prevents individuals with mental 
illness from receiving the treatment they choose.
    Another important lesson from Kaufman House is the need for 
recovery programs like alternatives conference. You must have 
recovery programs to have recovery.
    Finally, I believe this bill is misnamed. The Helping 
Families in Mental Crisis Act? Well, I want to respectfully 
point out to the subcommittee that the focus needs to be on 
helping the individual with mental illness and crisis and 
through recovery. Yes, families are really important support 
but the focus needs to be on the person and their recovery.
    Thank you.
    [The prepared statement of Ms. Jensen follows:]
    
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    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes Ms. Zdanowicz for 5 minutes for an opening 
statement.

                  STATEMENT OF MARY ZDANOWICZ

    Ms. Zdanowicz. Thank you, Mr. Chairman, members of the 
subcommittee.
    I have been involved in advocacy for people with severe 
mental illnesses and their families for many years, and I 
really have no hope that some of the things that have created 
barriers to treatment would be addressed until Congressman 
Murphy introduced the Helping Families in Mental Health Crisis 
Act.
    I too want to talk about the protection and advocacy 
program, and while I think the original intent of the program 
and the original practice of the program was very important, it 
has lost its way, and I will share a personal experience that 
is very difficult to talk about. My sister has schizophrenia. 
She has been ill since she was 18 years old. She has spent most 
of her adult life in state psychiatric hospitals. For the most 
part she has received good medical care and they have protected 
my sister, who is very vulnerable. But in 1998, the State 
hospital that she was in closed. She was moved to a hospital 
that had less than 500 patients, but because of the loss of 
beds due to the hospital closure, the patient population grew 
from 500 to 750 patients by 2007. I knew what was happening at 
the hospital to some extent, and I was able to get her moved to 
a facility that was safe, but a few years later I was able to 
get her medical records, and I found out what was really 
happening and just how bad things were, and I am still haunted 
to this day by what happened to patients that didn't have a 
family to protect them, and the protection and advocacy 
organization was nowhere to be found.
    The problem is that the bill that created protection and 
advocacy was enacted in 1986. The first finding in that bill is 
that patients or persons with mental illness are vulnerable to 
abuse and serious injury, and so it created a federally funded 
organization independent of States to monitor care of patients 
in hospitals and facilities. Now, at that time there were 
250,000 people in State psychiatric hospitals. Now there are 
fewer than 35,000, and the protection and advocacy 
organizations have changed course as a result, and not 
necessarily in a good way.
    I will give you an example from Massachusetts, which is the 
State where I live. That organization reported spending more 
than $250,000 on lobbying, federal funding on lobbying against 
State measures, and more than $100,000 actually went to 
professional lobbyists, but it isn't just lobbying that is the 
problem. In Massachusetts, that organization got government 
funding to conduct a study of community services, which to me 
is very important because I have a brother with schizophrenia 
who lives in a group home and I am his guardian, and I work 
very closely with staff and the management of that group home 
to make sure he is safe in the community. But I was appalled 
when I read the report, and one of the findings was that 
guardians should not be involved in protective measures that 
should be used for individuals living in the community, and a 
finding that GPS devices that are used for people who have a 
history of wandering and getting injured are a violation of 
individual rights. It is just a perversion. If you look and 
compare with the Alzheimer's Association view on that, they 
find it an appropriate use of electronic devices to have a 
comprehensive safety program for people who need it and may be 
unsafe in the community.
    So I want to say that Congressman Murphy's bill really will 
do what it is named, and that is, it will help families who are 
in mental illness crisis.
    Thank you.
    [The prepared statement of Ms. Zdanowicz follows:]
    
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    Mr. Pitts. The Chair thanks the gentlelady, and notes that 
Dr. Welner still has not been able to get here. If he comes in 
during the panel, we will permit him to give his testimony at 
that time, but I will begin the questioning now and recognize 
myself for 5 minutes for that purpose.
    [The prepared statement of Mr. Welner follows:]
    
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    Mr. Pitts. Ms. Thompson, in your experience, has the HIPAA 
privacy rule been misapplied to the effect that it serves as a 
barrier for helping the very people responsible for providing 
care in the community?
    Ms. Thompson. Absolutely.
    Mr. Pitts. Could you expound on that?
    Ms. Thompson. What my experience was with HIPAA was that my 
family was consistently kept separate from my mother's medical 
needs, health care needs, psychiatric needs. We were unable to 
talk to physicians until we got guardianship at the end, which 
we weren't able to get guardianship until the last 9 months of 
her life because of the difficulty in gaining access to 
physicians telling us what was going on. As a professional 
advocate, I learned how to communicate with doctors. Most 
family members don't have that knowledge. I was fortunate 
enough to have gone through the training and professional 
experience to be able to tell a doctor he doesn't have to say 
anything to me but he has to listen to me. Most family members 
don't know that that is their right to say something. And so 
there is a lack of education on both sides, and the continued 
hiding behind HIPAA has got to stop.
    Mr. Pitts. Ms. Zdanowicz, in your opinion, how has the 
legacy of deinstitutionalization of the mentally ill worked out 
over the past half century?
    Ms. Zdanowicz. Well, this is one of my most passionate 
issues because I have seen the effect of closure of state 
psychiatric hospitals, and that is why I think the IMD 
exclusion is so important. I view it as discriminatory 
provision because it is the only population that is precluded 
from Medicaid coverage in hospitals.
    A perfect example is when the hospital is closed where my 
sister was and she was moved to the other hospital, and there 
were not enough hospital beds left, which created this 
overcrowding, which just prevented people from getting 
treatment. Now, on the other hand, I do want to recognize, 
Congressman Pallone, Congressman Lance, that New Jersey has 
what is a gem in terms of psychiatric hospital treatment, and 
that is the Greystone Psychiatric Hospital, and that is where 
my sister is now and she is receiving just superior treatment. 
So it can be done correctly. But if you continue to close 
hospitals, there won't be enough beds, and people will end up 
where they are now: in jails and prisons. I just finished a 
survey of all the jails and prisons across the country, and I 
can tell you, they are the new psychiatric hospitals.
    Mr. Pitts. Ms. Thompson, back to you. If you could choose 
one thing that the government could have done to help your 
family, what would it be?
    Ms. Thompson. Just one?
    Mr. Pitts. Well, you can name more than one.
    Ms. Thompson. It would be that my mother was protected from 
herself. I come at this from so many different angles. I 
understand patients' rights. I wholeheartedly believe in them. 
I help fight for them. But when someone lacks the capacity, 
there is no shame in lacking capacity. When someone lacks the 
capacity, we need to take care of them, and that did not happen 
with my mother. She fell through the cracks over and over and 
over again, and if there had been more support for her, there 
would have been ongoing treatment for her. When my mother went 
through treatment, she would come back and everything would go 
back the way it was because there was no follow-up. She came 
home, and we didn't have the ability to do what we do.
    I see it with families now. A family member, a son or 
daughter is hospitalized for a 72-hour hold and gets discharged 
home and the parents don't know how to create the right 
environment to keep that person on the road to recovery. They 
don't have the skills. There needs to be ongoing support. There 
needs to be more IMD beds. There needs to be this ongoing 
system of support for family members and for the person with 
the diagnosis.
    Mr. Pitts. My time is expired. The Chair recognizes the 
ranking member, Mr. Pallone, 5 minutes for questions.
    Mr. Pallone. Thank you, Mr. Chairman. I am trying to get 
two topics in with Dr. Shern, so if I cut you off a little bit, 
it is because I am trying to get to the second set of 
questions.
    The first relate to ACA and compliance with parity laws. As 
I said, Mr. Chairman, I am pleased we are having this hearing 
but I am troubled by a number of provisions in this bill, but 
it is a wide-ranging effort to address some important issues.
    I wanted to discuss again the Affordable Care Act and the 
Mental Health Parity and Addiction Equity Act. The Mental 
Health Parity can enshrine in law the principle that mental 
health care is just as important as physical health care, and 
then the Affordable Care Act not only extended this principal 
to the individual health insurance market but also required 
that all expanded Medicaid programs as well as individual and 
small group health insurance plans cover mental health and 
substance abuse services as part of the essential benefits 
package. I hope my Republican colleagues understand that they 
are voting to repeal these advancements for mental health when 
they support the Ryan budget or vote to repeal the ACA.
    So questions. Dr. Shern, what is your view of the 
importance of health insurance coverage and mental health 
parity and expanding access to treatment and improving health?
    Mr. Shern. It is absolutely critically important. Because 
of the development of the mental health treatment system in the 
United States, we have systematically discriminated against 
individuals with mental illnesses. That was largely repaired 
with the parity bill and further extended into markets that the 
parity bill didn't apply to by its unanimous incorporation into 
the Affordable Care Act. Getting to people sooner with 
effective care is critically important in terms of trying to 
stem these problems. Insurance access is a major impediment for 
individuals with mental health and addiction conditions is 
critically important.
    Mr. Pallone. And then secondly, these laws were clearly 
major steps forward but effective implementation and 
enforcement are essential. What more can Congress do to ensure 
health insurers are fully complying with the letter and the 
spirit of both the ACA and the parity law?
    Mr. Shern. I think that this House bill that is under 
consideration provides an excellent opportunity to provide 
resources to the Department of Labor and to the Department of 
Health and Human Services to assess the degree to which the 
parity bill is being effectively implemented across the United 
States and to provide ongoing guidance to insurers and payers 
and primary consumers about what they should expect to be their 
rights under this bill and the appropriate boundaries with 
regard to insurance coverage. So it is a complex bill. Equity 
in coverage is not something that is easily determinable. It 
has a large State influence, so I think it is very important 
that we systematically monitor it, and that would be a very 
helpful addition to this legislation.
    Mr. Pallone. All right. Thank you. Now, I want to get to 
this Wall Street Journal editorial, which I think the chairman 
introduced into the record. They ran an editorial that sharply 
criticized SAMHSA's effort to provide services that help 
individuals prevent, treat, and recover from mental health 
disorders, and they called SAMHSA the vanguard of the legacy 
advocacy and anti-psychiatry movement, accused the agency of 
wasting taxpayer dollars on programs that do not help those 
with the most serious mental illnesses. Obviously these are 
very serious allegations. How would you respond to this 
editorial's characterization of SAMHSA?
    Mr. Shern. It is, from my perspective, almost entirely 
inaccurate. If you look at the major--we talked about the 
deinstitutionalization and the problems with 
deinstitutionalization, and that surely was a policy that was 
well intended but very poorly implemented. If you look at every 
major reform since deinstitutionalization in terms of improving 
services for people with mental illnesses, many of the things 
we talked to you about today, SAMHSA has been the champion of 
the reform. They started the Community Support program, which 
is the first effort to try to build an adequate community 
treatment system for people with severe mental illnesses. They 
started the Child and Adolescent Support program. With 
Congress's support, they implemented the Assistance with Care 
Act. They have implemented acts around people with dual 
disorders. We could go on and on and on.
    I think one of the things that is unfair is this 
characterization of SAMHSA as an entity that is anti-
psychiatry, anti-treatment, anti-medication. That is just not 
true.
    Mr. Pallone. The editorial also claims that very few of 
SAMHSA's evidence-based programs focus on individuals with 
serious mental illnesses. Can you comment on SAMHSA's work in 
that area?
    Mr. Shern. Our estimate is that over 80 percent of--no one 
remembers that SAMHSA is an agency that addresses both mental 
health and substance use issues. If you look at the mental 
health portion, our estimate is about 80 percent to 85 percent 
of their resources are spent on issues related to and persons 
who have severe mental illnesses. So again, I just feel this is 
a gross mischaracterization of the SAMHSA program.
    Mr. Pallone. Thank you.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the vice chairman of the full committee, Ms. 
Blackburn, for 5 minutes for questions.
    Mrs. Blackburn. Thank you, Mr. Chairman. I thank each of 
you who are witnesses for being here and for adding to the work 
that we have done. I do want to thank Dr. Murphy for the work 
he has done with our committee. I think that because of the 
work he has done and concerns that we are hearing from our 
constituents, especially now that we are highlighting this 
issue, we have learned about the size and the scope of 
untreated mental illness and exactly where it affects families 
and individuals.
    We have also, and Ms. Thompson, this speaks to some of 
yours, we have talked about the privacy laws and the impact 
that that has on public safety and also looked at federal 
resources and how those are utilized, and you are certainly 
adding to that discussion today and we appreciate it, and we 
are pleased with the components that the new legislation would 
put in place, some redirection, some refocusing, and we think 
that those are good and they are appropriate.
    I do have a couple of questions that I wanted to ask, and I 
will be brief on these.
    Ms. Thompson, I did want to come to you first. I want to 
thank you for sharing your story. As we looked at HIPAA and 
FERPA and the privacy issues. What I would like to hear from 
you, as we look at reforms, through what you have experienced 
firsthand and what you have learned through your caregiving and 
your advocacy, give me maybe the top three or four things that 
you would say this is what you need to change as you look at 
HIPAA and FERPA reforms. Do you have that laundry list? Could 
you give that to us?
    Ms. Thompson. I don't know if I have a laundry list but I 
can tell you that I think what is important is that when 
somebody is--if somebody--I work with the developmentally 
disabled population as well. It is automatic. They have a 
condition before the age of 18, so there is no HIPAA violation. 
The parents are clearly the guardian. They become the guardian. 
They go through what is legally necessary.
    Mrs. Blackburn. Been through the qualification?
    Ms. Thompson. Correct. What happens with mental illness is 
that oftentimes that doesn't present until after the child is 
no longer a child, so at that point you are trying to shut the 
barn door after the horse has left, if you will forgive the 
analogy. There need to be some qualifications in place with 
HIPAA that make it clear when somebody is not able to make 
decisions when there is a question as to their safety or the 
safety of others, that relinquishes professionals, that doesn't 
allow them to keep their hands tied.
    Mrs. Blackburn. OK. So almost like a revisit of a power of 
attorney?
    Ms. Thompson. Yes. Right now you can try to get the 
individual to sign off but if somebody doesn't think they are 
ill, they are not going to sign off permission. That doesn't 
mean they are not ill and not in need of help.
    Mrs. Blackburn. So you would encourage us to have some type 
of allowance or avenue that that oversight you could negotiate?
    Ms. Thompson. Like a waiver, and maybe that--I don't know. 
As I said before, I am not a legislator. I don't know. Maybe 
having--if the physician deems it necessary or maybe getting 
two physicians to deem it necessary that HIPAA can be broken in 
this instance. It can't just be because somebody is going to 
commit a crime or they are going to kill themselves. They need 
to get help before that.
    Mrs. Blackburn. OK. Ms. Zdanowicz, I can tell you want to 
weigh in on this. I see you nodding your head.
    Ms. Zdanowicz. I have to agree completely. I actually would 
say the same thing. I was unable to get information about 
treatment for my brother and sister until I got guardianship, 
and I paid $5,000 to get guardianship for my sister, who was in 
agreement. She did not object to it. But I had that in order to 
get information, but even with that, for example, when I know 
my brother is in a hospital, a particular hospital, I have been 
told he was transferred there, and I call and they say we can't 
tell you if he's here, and then I will fax my guardianship 
papers and they'll still say HIPAA prevents us from talking 
with you, and then I learn later that they have changed his 
medication in a way that I already know is not helpful and 
there is nothing I can do about it, it is too late.
    People don't understand HIPAA, and I often tell families, 
if you are told that they cannot tell you anything about your 
family member, you are still free to tell them what they need 
to know about your family member. It is a terrible obstacle for 
families to help, and I totally support the revisions to that 
portion of the bill.
    Mrs. Blackburn. Thank you. Yield back.
    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes the ranking member of the full committee, Mr. 
Waxman, 5 minutes for questions.
    Mr. Waxman. Thank you, Mr. Chairman. I want to apologize to 
the panel because there is another subcommittee meeting at the 
same time, and I have been required to go back and forth.
    Ms. Jensen, I want to start by thanking you for being here 
today and telling us your story. It is a deeply personal one, 
and I was struck by the utter failure and inability of 
authorities in your State to bring an end to the terrible 
abuses of people with mental illness, including yourself, at 
the Kaufman House, that is, until the P&A became involved. Can 
you elaborate on whether or not Kansas was an outlier and not 
adequately addressing complaints about the Kaufman House prior 
to the P&A's involvement? Do you think it is unique?
    Ms. Jensen. All I can say is that there were 12 complaints 
to the Adult Protective Services, and he even sued Adult 
Protective Services, and so they quit coming to the door. And 
so I believe that I know for a fact if it wasn't for PAIMI, 
Kaufman House would still be going on.
    Mr. Waxman. We have heard from witnesses today that P&As 
lobby, and in fact, in the testimony, you worked with the P&A 
to change laws that would prevent future Kaufman Houses through 
licensure requirements, guardianship laws and the establishment 
of an abuse and neglect unit. Can you clarify whether the 
federal funding was used for these activities and any other 
lobbying activities? Do you know?
    Ms. Jensen. No, there was no federal funding. I and my 
friend, we just never wanted it to happen again, so we were 
volunteers. We did it ourselves, and it was educating us on the 
issue but there was no financial spending of federal funds to 
get these laws passed.
    Mr. Waxman. Proponents of the PAIMI proposals in H.R. 3717 
claim these provisions will return the program to its roots but 
it seems to me that an 85 percent reduction in federal funding 
would do much more than that. How would a funding reduction of 
this magnitude impact the ability of the P&A in Kansas and P&As 
around the country to protect the rights of people with mental 
illness?
    Ms. Jensen. I am so scared that if you take PAIMI away, and 
that is what would happen, there wouldn't be any protection for 
us if we were being abused, neglected or exploited. There 
wouldn't be anyone coming in and taking us out of that 
situation in order to talk to us and investigate the situation, 
and I just ask you not to do that.
    Mr. Waxman. Well, your testimony is very persuasive and I 
think quite valuable to us to hear that point of view.
    I want to ask Ms. Thompson and Dr. Shern, I am pleased that 
my colleagues and I have some points of bipartisan agreement on 
issues before us. We all believe that mental health care is an 
essential part of our health care system. We agree that we need 
to work to end the stigma that surrounds seeking treatment, and 
we agree that we need to invest in community-based approaches 
for care so that individuals who need help are able to get it. 
I think everybody here on the panel would agree with these 
goals as well. But I also believe that witnesses invited by 
both Republicans and Democrats today agree that expanding 
access to health insurance and improving health coverage of 
mental health services are critical.
    Ms. Thompson, as a general matter, do you think individuals 
who have health insurance have a better chance of getting into 
treatment for their mental health conditions?
    Ms. Thompson. I am sorry. Can you----
    Mr. Waxman. If you have health insurance, don't you have--
--
    Ms. Thompson. Oh, absolutely.
    Ms. Waxman. And do you think including mental health 
coverage as an essential health benefit and requiring it be 
covered at parity with physical health were important steps 
forward?
    Ms. Thompson. Yes.
    Mr. Waxman. And Dr. Shern, do you agree with that?
    Mr. Shern. Absolutely.
    Mr. Waxman. I think, Mr. Chairman, we could learn a lot 
from these witnesses. There is a lot more to the ACA than we 
can fit into 30-second attack ads. But it advances a number of 
essential priorities that both sides agree on, and I hope we 
can agree that it is here to stay, that we should build off of 
these things that we agree on in the law rather than constantly 
focus on repealing or undermining it.
    I see my time is over and I will yield back the balance.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the vice chairman of the subcommittee, Dr. Burgess, 
5 minutes for questions.
    Ms. Zdanowicz. Mr. Chairman, if I may?
    Mr. Pitts. Go ahead.
    Ms. Zdanowicz. I did want to just elaborate on one point 
that was made, and that is about the money that is used, the 
federal funding to lobby, and that is documented. You can find 
that in IRS reports and State lobbying reports that in fact 
federal funding is being used to lobby, and professionally, I 
have seen it done. I have been up against lawyers of protection 
and advocacy organizations lobbying in State capitals against 
State legislation. So it does happen, and it is not the 
original mission, and it takes away from what they are supposed 
to be doing.
    Mr. Waxman. And it is in violation of the rules that say 
that they cannot use that money for lobbying.
    Ms. Zdanowicz. And so I think that in order for them to be 
able to do what they are supposed to do, which is monitor like 
they did when you were being abused, I think that would be a 
significant improvement. So thank you.
    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes Dr. Burgess 5 minutes for questions.
    Mr. Burgess. And please let the record reflect the 
generosity and time that I gave to the ranking member of the 
subcommittee. We don't often have areas of commonality, so I 
thought that was important to have that follow-up.
    The majority of my questions were for Dr. Welner. One of my 
big objections to these types of hearings is we never have an 
M.D. Thank you for calling an M.D. Unfortunately, because of 
travel issues, he has not been able to join us, so I am going 
to submit my questions to Dr. Welner for the record.
    Dr. Shern, your discussion with Ranking Member Pallone 
brought some things to mind, and really, this is more of just 
reminding people of the process, yes, the budget process, the 
legislative process, process in the agencies. Go back just for 
a little bit to the Mental Health Parity Act, and I don't know 
how many people now remember, the Mental Health Parity Act, 
introduced by one of our colleagues, Patrick Kennedy, indeed, 
we had hearings in this subcommittee many, many years ago. The 
Mental Health Parity Act was used as the vehicle to pass the 
Troubled Asset Relief Program, two absolutely unrelated 
proposals. Now, I just want to be clear. I actually opposed 
both of them, so that no vote actually did double service that 
day, but to think that we passed something of the magnitude of 
the Mental Health Parity Act and its effect upon caregivers and 
third-party payers as a vehicle to bail out banks, I am still 
bothered by that nexus. But nevertheless, that is what 
happened. The Mental Health Parity Act had not actually been 
scored, to the best of my recollection, by the Congressional 
Budget Office. I think it estimated some significant budgetary 
outlays over a 10-year period but be that as it may, now the 
Affordable Care Act actually passed sometime after that, about 
a year and a half after that, and was signed by the President 
in March of 2010. The part of the Affordable Care Act dealing 
with essential health benefits was actually subject to a rule. 
The rule was supposed to be published and concluded in August 
of 2012. I don't want to seem cynical here but the actual rule 
was delayed until a couple days after Election Day in 2012. I 
don't know why the Administration would see an advantage to 
doing that but apparently there was. And if you will recall, 
much of the difficulty that subsequently happened to the 
Affordable Care Act was because of that delay. The governors 
were required to disclose whether or not they would participate 
in state exchanges on November 18th. The essential health 
benefit rule was published on November 8th. So that gave them 
precious little time to actually evaluate, is this a good idea 
or a bad idea for my State. To be fair, they were given two 
extensions but finally by January 2013 the governors had to 
declare. Twenty-six States said no, thank you, we are not doing 
an exchange. Four States said well, maybe we will do one but we 
will let the Federal Government set it up. So the fact that so 
many States were not doing their own exchanges and that task 
then fell to the Federal Government and clearly the Center for 
Consumer Information and Insurance Oversight was not up to the 
task of standing up a massive new information technology 
project in the 8 months that they had available, and I think we 
all know the story on that.
    But here is the issue. OK, Mr. Pallone is right. The Mental 
Health Parity Act and the ACA, the nexus of those two things 
does affect stuff. None of that--because the way the 
Congressional Budget Office works, we only get information 
about bills before we pass them. Sometimes we don't even get 
that. But we only get that budgetary information as the 
legislation is coming through the process. We don't get a 
rescore by the Congressional Budget Office when the rulemaking 
happens. So if you take the combination of the Affordable Care 
Act and the essential health benefits, when the Mental Health 
Parity Act was passed it said we are not requiring you, Mr. 
Private Insurance Company or Mrs. Private Insurance Company, to 
offer mental health benefits, but if you do, they need to be on 
a par with other medical services that you offer. So I am 
concerned that there were companies that were going to drop out 
of the mental health business. A year later, we had the 
Affordable Care Act passed and it says this is part of your 
essential benefit package.
    I am from Texas. I will never attribute to coincidence that 
that can be adequately explained by conspiracy, but the Mental 
Health Parity Act was passed in 2008 and the rule was not 
published until last November, and I can't help but wonder if 
the reason the rule was not made public until all of the 
Affordable Care Act stuff was in place was because this is 
going to blow the cost way beyond anything that anyone 
projected for the Mental Health Parity Act or for the ACA. I 
don't know the answer to that question. I think it is one that 
we are going to have to ask our Congressional budget writers to 
help us with but it just underscores the difficulty of making 
budgetary decisions on these types of issues. There are always 
things in the future that will affect them.
    Thank you, Mr. Chairman. I have rambled enough, and I will 
yield back.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentleman from Texas, Mr. Green, 5 minutes for 
questions.
    Mr. Green. Thank you, Mr. Chairman, and Dr. Shern, I think 
we are in agreement that our country has a long way to go to 
improve mental health systems. I am also from Texas but in an 
earlier life I actually did probate work, and one of my judges, 
who was a friend, appointed me to do mental health work, do the 
probable cause hearings and the commitment hearings, and it 
opened my eyes to the Texas mental health code, and actually as 
a State senator, we were able to change some of it.
    I appreciate Dr. Murphy's leadership for many years on this 
issue. I have some concern about part of the legislation, the 
Medicaid IMD exemption. My concern is cost shifting from the 
State if the State does it to the Federal Government.
    But I want to get to the follow-up on my colleague from 
north Texas. Dr. Shern, the Affordable Care Act included 
demonstration in 11 States to test whether undoing the IMD 
exemption for emergency psychiatric care and letting federal 
funds pay for the care in IMDs that States would concurrently 
provide would improve service to the population. It is my 
understanding we don't yet have enough information to know 
whether this demonstration is successful. My question is, it 
seems to me that before we move ahead and spend billions to 
supplant the State funds, we ought to see if this demonstration 
yields any positive results. Can you update us on any of those 
demonstration projects?
    Mr. Shern. I am not aware that evaluations have been 
completed. Our position would be quite consonant with yours. 
When that provision was discussed and been made part of the 
Affordable Care Act, there was a concern that looking at only 
one element in a system of care just really wasn't the 
appropriate way to think about how to build an effective 
community care system. And so we maintained and the law was 
enacted that this had to be evaluated as part of a system of 
care initiative. Our recommendation is that there be no changes 
to the IMD law until the results of that evaluation are 
complete.
    Mr. Green. OK. The Congressional Budget Office, they 
haven't officially scored the provision. My understanding is, 
it is quite expensive, tens of billions possibly. If we had 
tens of billions of dollars to spend on improving the mental 
health system in the United States, how would we direct it and 
where should we really be looking to invest that money to see 
the greatest improvements?
    Mr. Shern. Well, I think that we have heard a lot this 
morning about the importance of assertive engagement-oriented 
outreach. Ms. Thompson talked about how important some of that 
was for her mom and how it would have been helpful had that 
continued when her mom came home. The committee heard in 
testimony from Dr. Arthur Evans, who runs the Philadelphia 
mental health system, about how critically important that there 
be funds available for crisis alternative services, for peer 
engagement and outreach services. We know a lot about what we 
can and should do, and I would much prefer to see those funds 
spent on fully developing a continuum of care in communities 
with assertive outreach and engagement.
    Mr. Green. Well, I am familiar at least in Houston, Harris 
County, with some of the substantial reforms that have been 
made in the last 20 years, for example, our Harris County 
Hospital District. When I would first go see a client or a 
patient, it was literally dismal. It looked like a holding cell 
in the hospital. But they have created a diversion now to where 
you actually have committed to mental health treatment, and it 
is a partnership between the University of Texas where we have 
a psychiatric hospital in Houston, but it is doing better but 
we have less psychiatric beds in Houston, Harris County than we 
did in the 1980s. So that is our big concern.
    I am pleased with Dr. Murphy's bill. It includes a 
provision to extend the liability for doctors who volunteer in 
behavioral health clinics. He and I have had legislation for a 
number of years. It has passed this committee and somehow the 
Senate doesn't do it. It would expand for our FQHCs and not 
just behavioral mental health clinics but our FQHCs where 
volunteer physicians could go in and be under the Federal Torts 
Claims Act, and that makes so much sense. While it is a good 
step forward in increasing the mental health workforce, much 
needs to be done to develop professionals.
    Mr. Chairman, both on our Health Subcommittee and I know on 
our Oversight Committee Dr. Murphy is doing, there are a lot of 
examples of things happening all over the country based on 
local community success, and I think this panel shows that, 
that maybe we should, since we do have the Affordable Care Act 
and mental health parity issues, then maybe we ought to look at 
some of those examples from around the country and see what we 
can do to make sure we get the best bang for our federal dollar 
to help our States and the local communities, because, again, 
oftentimes it is our hospital districts that are providing some 
of that care.
    So I appreciate it, and I yield back my time.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentleman from Pennsylvania, Dr. Murphy, 5 
minutes for questions.
    Mr. Murphy. Thank you. I want to thank all the panel for 
being here. I really appreciate your time.
    A quick question to start off with. I am just going to ask 
each one of you if you have read the bill. Ms. Thompson? It is 
a yes or no.
    Ms. Thompson. Not the whole bill.
    Mr. Murphy. All right. Dr. Shern?
    Mr. Shern. Not the entire bill.
    Mr. Murphy. Ms. Jensen?
    Ms. Jensen. I didn't hear the question.
    Mr. Murphy. Have you read the bill we are talking about?
    Ms. Jensen. Yes, I read the bill.
    Mr. Murphy. The whole thing?
    Ms. Jensen. Yes, the whole thing.
    Mr. Murphy. Thank you. Ms. Zdanowicz?
    Ms. Zdanowicz. And yes, I have read the whole thing.
    Mr. Murphy. Thank you. Ms. Jensen, did anybody else in your 
testimony today advise you on things to say?
    Ms. Jensen. Of course not.
    Mr. Murphy. So I am not sure where you got this statement 
from, that it would make it harder to get housing and 
education. If there is a point in that bill where you feel that 
is, will you make sure you let me know? Because I want to fix 
that. Would you let me know?
    Ms. Jensen. I don't understand what you are saying, sir.
    Mr. Murphy. You had said in your statements that the bill 
would make it harder to get housing and education. If there is 
a place in the bill where that occurs, would you let me know, 
because I want to----
    Ms. Jensen. If you take PAIMI away, we have a hard time 
getting help with housing and education.
    Mr. Murphy. I don't agree, but thank you.
    Dr. Shern, I am just not clear. Are you a clinician that 
treats patients?
    Mr. Shern. No, I am a research psychologist.
    Mr. Murphy. OK. Thank you. You said SAMHSA does not support 
programs that are anti-treatment. Are you familiar with the 
Alternatives Conference?
    Mr. Shern. I am.
    Mr. Murphy. Are you aware that Alternatives is short for 
Alternatives to Treatment?
    Mr. Shern. My interpretation of Alternatives, it is not 
alternatives to treatment, it is alternatives available for 
people to make choices about how to best engineer their 
recovery.
    Mr. Murphy. Do you think everybody is capable of making 
that choice?
    Mr. Shern. I think everybody is capable of understanding 
what is important to them.
    Mr. Murphy. Ms. Thompson referred to something called 
anosognosia. Do you know what that is?
    Mr. Shern. I have heard it described, yes.
    Mr. Murphy. OK. I am disappointed you don't know what it 
is. It is critically important, so I have to go into a little 
lesson here. If a person has a stroke on the right side of 
their brain, and on the left side, their arm doesn't work, a 
characteristic of that is if you say to this person try and 
move your left arm and they don't and you say I think you are 
having a stroke, you need to go to the hospital, that person 
may say it is no big deal, I don't know what that is all about, 
that is anosognosia.
    About 40 to 50 percent of people with severe mental 
illness, schizophrenia, if shown a videotape of them 
hallucinating, delusional, they don't know who they are, they 
think they are the angel Gabriel, Jesus, whatever else, and if 
you say do think that is OK, they will say sounds OK to me, I 
don't understand the problem.
    What Ms. Thompson is referring to for those people who are 
not capable of making decisions on their own to have someone 
else assist them so that they have a right to get better. Would 
you agree that such persons may need some assistance that they 
are not capable of making on their own?
    Mr. Shern. I think the way that you specifically have 
characterized the situation, people would meet the criteria for 
not being competent and----
    Mr. Murphy. Good. We are in agreement there. And do you 
think in the Alternatives Conference, which spends about 
$600,000 a year of taxpayers' money, do you think we should be 
paying for conferences that have things called unleash the 
beast: primal movement workshop, how to make collages, dancing, 
interpretive yoga or how to stop taking your medication? Do you 
think taxpayers should pay for that?
    Mr. Shern. I think it is very important that we have an 
open----
    Mr. Murphy. I am asking, do you think taxpayers should pay 
for those items when we are so short on funds? Do you think we 
should be paying for that for people who have severe mental 
illness?
    Mr. Shern. I think that it is very important that we have 
an open forum to discuss the various----
    Mr. Murphy. I appreciate that. I didn't ask you about an 
open forum. So I am going to take that as a yes and you are 
afraid to say yes.
    Do you know in SAMHSA's--no, it is true. Come on. I want to 
have an open discussion. In SAMHSA's documents that describe 
their strategic plan, it is about 40,000 words, how many times 
does it mention the word ``schizophrenia''?
    Mr. Shern. You know, I have not had an opportunity to count 
them.
    Mr. Murphy. Well, it is easy to count because the answer is 
zero. Do you know how many times it mentions the word 
``bipolar''? Zero. So when you say SAMHSA is focused on severe 
mental illness, my problem is, it is not, and when I had the 
leader of SAMHSA in my office and I said would you change 
anything, she said no.
    So what I see here is, I think SAMHSA plays a very 
important role. I want to see it keep on doing that. But I want 
to make sure we get back to evidence-based care, and I am 
assuming you would be OK with that.
    Mr. Shern. Absolutely.
    Mr. Murphy. That if a program shows that it can work, make 
it work.
    Mr. Shern. Absolutely.
    Mr. Murphy. And let us do that, and why I am concerned here 
is that throughout the Federal Government, we have got money in 
the Department of Defense, Veterans Affairs, Education, HHS, 
who knows where else, and we have to make sure we have got 
programs that work, and the ones that work, expand them, and if 
they don't, eliminate them, and if they are redundant, merge 
them, and that is what I want to have happen with this bill.
    On the parity issue, real quick, I just want to say that 
there is parity for people who have private insurance in the 
Affordable Care Act. There is not parity with Medicaid, so if 
you have more than 16 beds, you are not going to get it, and if 
you see two doctors on the same day, you are not going to get 
it.
    The last question I want to address to Ms. Zdanowicz. Dr. 
Shern called the Journal editorial a gross mischaracterization 
of SAMHSA for leading an anti-psychiatry movement. Do you have 
any comments on that with regard to SAMHSA and providing money 
or grants to groups that fight treatment or discourage 
treatment?
    Ms. Zdanowicz. Yes, and in fact, I have read many of the 
State applications for grants from SAMHSA, CMHS, and when you 
read those, you find very little reference to the most severely 
ill. Much of it is about, this is how we are going to get 
people out of State psychiatric hospitals. It is about how we 
are going to--if we just offer people what they want and make 
sure that we are really nice to them, that they are going to be 
just fine and it is going to settle their symptoms. But the 
question is, well, what if the person wants is a semiautomatic 
machine gun to shoot you because they think that you are the 
devil? Well, then what do you do? Well, then you call the 
police and you get them into jail, and if there was ever a form 
of coercion, that is it.
    Mr. Murphy. Thank you. I have to yield back.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentlelady from California, Ms. Capps, 5 minutes 
for questions.
    Mrs. Capps. Thank you, Mr. Chairman, and I would like to 
thank all of our panelists for your testimony today. I want to 
single you out, Ms. Jensen, because yours was so personal, and 
I appreciate that you are willing to tell your story.
    Dr. Shern, mental health is an important issue that members 
of this committee on both sides of the aisle have a shared 
interest in addressing. I worked in our community in public 
schools before coming to Congress as a public health nurse and 
so I have had experience with this topic, and I am really 
pleased that today it is being discussed.
    We heard from the testimony that there are some provisions 
in this bill that have widespread support and others that are 
perhaps problematic. I know that other members of the committee 
have also expressed interest in the topic and introduced 
legislation on mental health, and I hope that moving forward we 
can have an open dialog--the chairman just mentioned that--
about all of the proposals and ideas.
    That being said, Dr. Shern, are there any provisions not 
included in H.R. 3717 that you feel are important to the 
improving mental health system?
    Mr. Shern. Well, as we have said on a number of occasions, 
I think that understanding that a full continuum of engagement-
oriented and assertive outreach services are critically 
important for effective services for people with severe mental 
illnesses. Additionally, and I think that Dr. Murphy mentioned 
this in his remarks or Mr. Pitts, we are continuing to learn 
about the importance of early identification for people who are 
going to develop disorders that have psychotic features, and I 
think it is critically important that we do a much better job 
at early identification of people who are going to have the 
more severe illnesses, and we are developing a reasonable 
evidence base about the things that are helpful to them because 
that can stem disability. I am also very excited about the peer 
movement, the use of persons who themselves are in recovery to 
help with these engagements and follow a long process, and also 
with appropriate supervision to provide the kind of extension 
of the mental health workforce that is going to be required.
    Mrs. Capps. Yes. Well, that is the point I wanted to pick 
up on because Dr. Welner in his written testimony that I read, 
he noted the importance of having enough mental health 
professionals. Maybe that is a whole other hearing, 
particularly it seems to be a hole in this bill and one that I 
think we should be addressing with more specificity.
    Dr. Shern, one of the key principles both sides of the 
aisle agree on is that we need to do everything possible to 
encourage individuals, and you talked about outreach, 
struggling with mental illness to seek treatment. That is 
actually part of the stigma, recognition and the clear sort of 
lack of understanding that we have about our brain and issues 
that affect it. Treatment does prove to be very helpful, as we 
heard today, and is more successful I think than some of the 
public seems to recognize, and early detection, just as you 
said, and regular treatment are so essential for preventing 
those rare and tragic cases where individuals become violent 
toward themselves or others, and we know people with mental 
illness are actually more likely to be victims, so that is a 
piece of the story that needs to be clearly said as well.
    But the stigma demands, I think, and we should be desirous 
of ways to address the stigma. Privacy concerns are also 
intimately related. That is why I am concerned about the 
changes to our health privacy law that this bill proposes. It 
creates entire new standards for individuals who have what the 
bill loosely defines as serious mental illness, and that is a 
loose definition, unfortunately, and I know these are difficult 
areas to find the right path but that is something we really 
need to get to.
    Dr. Shern, first, can you help us clear up a key point of 
fact? Does HIPAA always require patients to give their 
permission before information is shared or do providers have 
flexibility if there is a threat or if they believe the patient 
lacks capacity?
    Mr. Shern. It is my understanding that there is 
flexibility. You know, I was thinking also the Virginia Tech 
shooting, and when people looked at FERPA and HIPAA then, it 
was clear that there was a lot of misunderstanding about the 
bill and in emergency situations that can be found.
    Mrs. Capps. Yes.
    Mr. Shern. So part of the thing I think we need, and I 
think Ms. Thompson would agree, is just better public education 
about what those laws actually mean.
    Mrs. Capps. I am glad you put that on the record.
    What impact will the changes proposed in the bill have on 
people's willingness? Is that a concern to you, people's 
willingness to seek treatment for mental illness?
    Mr. Shern. It is a concern of mine, a concern of my 
organization, given the coercive nature of some of the 
outpatient treatment programs.
    Mrs. Capps. Thank you. I yield back.
    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes the gentleman from New Jersey, Mr. Lance, 5 minutes 
for questions.
    Mr. Lance. Good morning, and thank you, Mr. Chairman, and 
thank you for your leadership on this issue, and thanks to Dr. 
Murphy as well for his leadership.
    Earlier this week, a bill on which I had worked with 
Congresswoman Matsui of this committee, the Excellence in 
Mental Health Act, was included in a larger piece of 
legislation, and I am pleased that the President has signed 
that into law and I certainly want to work with all members of 
this subcommittee and the full committee as we move forward on 
this challenging issue.
    Ms. Zdanowicz, as I understand it, your sister spent quite 
a few years in New Jersey facilities including the now-closed 
Hagedorn Psychiatric Hospital in Hunterdon County. I grew up in 
Glen Gardner where that facility was located. Before it was 
related to psychiatric concerns, it was related to tubercular 
concerns.
    It is clear from your testimony that many mental health 
facilities in this country are currently unable to meet the 
needs of their communities. In your judgment, would passage of 
legislation in this regard help in States across the country 
including States like New Jersey?
    Ms. Zdanowicz. Absolutely, and the closing of Hagedorn 
Hospital was a travesty. That is the hospital I mentioned that 
was a safe hospital that she was transferred to. She got 
excellent care there. And it was closed. And she then moved to 
Greystone which, as I mentioned before, is a gem. It is a 
wonderful hospital. But as a result of the closure of Hagedorn, 
it is virtually impossible to get anyone into a State 
psychiatric hospital now, and in fact, the State has 
implemented what I will call a gatekeeping process that 
prevents people--when a psychiatrist says this person needs to 
be in a psychiatric hospital because they need more than two 
weeks of treatment, they can be shut down by a nurse who is 
reviewing the process just because the State is trying to keep 
the population down.
    Mr. Lance. Before your sister was at Hagedorn, what was the 
State hospital before that where she was?
    Ms. Zdanowicz. That was Ancora in south Jersey.
    Mr. Lance. In southern New Jersey, yes.
    Ms. Zdanowicz. And it was a very bucolic setting. It was a 
very nice hospital when she first went there. There were less 
than 500 patients, and the care was very good until because of 
the closure of the previous hospital the population grew to 750 
and it was truly bedlam because the hospital, the staff were 
not able to handle it and that was when I was able because I 
had the resources to get her moved to a safer hospital. But it 
wasn't until the Department of Justice came in at the request 
of the State and investigated it, protection and advocacy was 
nowhere to be found, and in fact, I called them at one point, 
but that was not on their radar screen. They were more 
concerned with other issues like legislation for AOT and 
fighting that.
    Mr. Lance. Thank you. Let me say that I was honored as a 
child to know Garrett Hagedorn, who was a State senator from 
Bergen County, and I had the privilege of being the minority 
leader in the State senate before I came here, and I have 
worked on these issues and hope to be able to continue to work 
on these issues here in Washington, and thank you for being 
with us today.
    Let me say that there are, Mr. Chairman, community mental 
health facilities in the district I represent such as the 
Richard Hall Community Health Center in Bridgewater, Township, 
in Somerset County, and I hope that these fine efforts can 
continue and that we can work in a bipartisan capacity on this 
very important issue and we are reminded yet again so 
tragically of the importance of this issue based on what 
happened at Fort Hood yesterday.
    Mr. Chairman, I yield back the balance of my time.
    Mr. Murphy. Would the gentleman yield?
    Mr. Lance. I certainly would.
    Mr. Murphy. I just want to point out, there are 
misunderstandings in the HIPAA law, and Dr. Shern, you have 
never been involved in a case and you shouldn't already have an 
opinion on it.
    This bill does not undo HIPAA laws. It clarifies them, and 
we want to work on language. I have been talking with 
Representative DeGette on this too. We want to make it so that 
all those things that are also in the regulations that go along 
with the law are clarified. It doesn't change anything, but 
there are a lot of misunderstandings. Clinicians misunderstand 
this all the time, so we want to make sure work to clarify 
that, but it doesn't change the law. Thank you.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentlelady from Virgin Islands, Dr. Christensen, 
for 5 minutes for questions.
    Mrs. Christensen. Thank you, Mr. Chairman. I want to ask 
some questions to Dr. Shern about the bill and its impact on 
SAMHSA because the bill makes some significant changes to the 
way the Federal Government's mental health investment is 
structured within the Department of Health and Human Services, 
particularly in Substance Abuse and Mental Health Services 
Administration. I want to make sure that I understand the 
impact these changes could have, particularly to the Community 
Mental Health Services Block Grant and programs of regional and 
national significance.
    Dr. Shern, starting first with the mental health block 
grant, how would H.R. 3717 impact this program?
    Mr. Shern. Well, it is my understanding that the block 
grant would be moved to the Assistant Secretary's office and 
would have a different type of oversight than it currently has 
now, providing less flexibility to States, for example, in 
terms of how those funds are used.
    Mrs. Christensen. So do you support provisions in this bill 
that would condition States' receipt of block grant funding on 
newly established federal involuntary patient or outpatient 
treatment standards and specific criteria for outpatient 
treatment?
    Mr. Shern. No, we wouldn't support that.
    Mr. Murphy. Could the gentlelady ask him to clarify what 
that means because I am not sure.
    Mrs. Christensen. What do you mean? I asked if he would 
support the provisions that would condition the receipt of 
block grants on newly established federal involuntary inpatient 
or outpatient standards, and he said no, he would not.
    Mr. Murphy. But I am not sure he read or understood the 
section there. It would simply say that States--and I 
appreciate the----
    Mrs. Christensen. Is this not on my time?
    Mr. Murphy. I am sorry, ma'am. I was asking to yield. I was 
just trying to clarify. Thank you.
    Mrs. Christensen. If I have time, I will yield at the end.
    As I am sure you are aware, SAMHSA has general authorities 
to conduct programs of regional and national significance in 
mental health and substance abuse prevention and substance 
abuse treatment. I understand funding through these authorities 
accounts for approximately 35 percent of SAMHSA's mental health 
budget and 25 percent of substance abuse spending. Title XI of 
H.R. 3717 would terminate any program by the end of the fiscal 
year that is not explicitly authorized or required by statute 
shall be terminated. So how will this impact SAMHSA's ability 
to continue initiatives pursuant to PRNS authorities like the 
Minority Fellowship program and National Suicide Prevention 
Hotline?
    Mr. Shern. It is my understanding that through the 
appropriation process, Congress can direct and influence 
SAMHSA's agenda. So in many ways, those kinds of relationships 
between the legislative and executive branch are already in 
place. The programs of regional and national significance are 
extremely important. Most of the innovative processes, 
particularly around systems of care issues and many of the 
things we are talking about today, have come through that 
program. So anything that would further constrain that, we 
would oppose.
    Mrs. Christensen. And in your testimony, you convey support 
for an initiative to improve interagency coordination of mental 
health and substance abuse programs within the Department but 
you seem to have some reservations about the way H.R. 3717 
approaches coordination of HHS programs in mental health 
through the establishment of that new Secretary position. Could 
you elaborate on the reservations you might have about that?
    Mr. Shern. Well, our sense is that the Administrator for 
SAMHSA is a direct report to the Secretary of Health and Human 
Services, and so in some sense, interposing another layer of 
government between SAMHSA and the Secretary doesn't seem to us 
to be particularly helpful. Additionally, we believe, and I 
think this was mentioned earlier in testimony today, that it is 
a lot more than HHS that is involved in mental health care. 
Housing is involved, Justice is involved, Labor is involved, et 
cetera, et cetera, and we would concur with Drs. Richard Frank 
and Sherry Gleed in their analysis of the mental health system 
in this country saying that coordination needs to occur 
literally at the White House level because it is those 
interdepartmental issues which are important. Additionally, I 
think since President Bush's commission and its findings, there 
has been increasingly interdepartmental cooperation without 
imposing any additional structural changes to the government.
    Mrs. Christensen. Is there anything else you would like to 
add about any other areas the bill could negatively impact 
SAMHSA?
    Mr. Shern. Well, I think that sort of overbureaucratizing 
and overregulating and trying to more narrowly focus the agenda 
of SAMHSA around a particular set of concerns or issues which, 
generally, I think, are well represented already in their 
portfolio will not be helpful. Certainly, as in any human 
endeavor or any area of government, there are ways that things 
can be improved. I think that the organization has been 
mischaracterized in editorials and publicity surrounding that 
and that anything that can further those kinds of issues will 
be harmful to the people of this country and their mental 
health.
    Mrs. Christensen. Thank you. I yield back my time.
    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes the gentleman from Louisiana, Dr. Cassidy, 5 minutes 
for questions.
    Mr. Cassidy. I yield to Dr. Murphy.
    Mr. Murphy. I thank the gentleman.
    Dr. Shern, you already mentioned you didn't read the bill 
so is there a specific place in this bill that you can make 
reference to where you have these concerns about the Secretary 
of Mental Health and what that person will do to limit care? Is 
there some specific page or paragraph you can reference to 
clarify your conclusions?
    Mr. Shern. I am sorry, Dr. Murphy. I am not understanding 
the question.
    Mr. Murphy. Well, you made a statement to the gentlelady 
that this person who would be the Secretary of Mental Health 
would over bureaucratize and complicate some of these issues. 
Is there a specific place in the bill you can tell me where it 
says that? I need a specific. I don't need concepts or 
philosophy. Because what we are trying to do at this hearing is 
work to improve the bill. So if you think there is something in 
there, it is important this committee has accurate information 
and not impressions. Is there something in the bill? If you 
don't, you can get back to me on that. That is OK.
    Mr. Shern. The question I was responding to had to do with 
conditioning the receipt of block grant funds based on States 
having effective assisted outpatient treatment, and it is my 
understanding, and correct me if I am wrong, that that is in 
fact a provision of the bill.
    Mr. Murphy. There is a provision of the bill. That is not 
the issue with the Secretary of Mental Health.
    Mr. Shern. That wasn't the question, though.
    Mr. Murphy. Well, part of it. You said it would over 
bureaucratize. The person who now handles SAMHSA, do you know 
what her degree is in, what her background is?
    Mr. Shern. She is an attorney.
    Mr. Murphy. Exactly. Haven't we done enough with treating 
people with mental illness as legal cases? We have closed our 
hospitals and filled our prisons. We close our treatment 
centers. We have not given adequate funding to community mental 
health centers and we have replaced the hospital bed with a 
flophouse or a blanket over some steam grate. That is wrong. I 
think it is immoral. That puts us in a third-world category.
    Mr. Shern. I agree with you completely. I think it is one 
thing----
    Mr. Murphy. I want for the record--yes, there is a lot to 
do. A person's background should meet their role. Now, I 
respect that you are here, but also, it is important to 
understand, you don't treat patients. You have never been 
involved in a patient case. You have never been involved in a 
HIPAA discussion. You haven't, and that is important. You are 
here as a citizen. But I want to make it very----
    Mr. Shern. I am here as a research psychologist.
    Mr. Murphy. I understand, sir, but you haven't read the 
bill, OK? Sir, along these lines, let me clarify for the 
committee, the Federal Government spends $125 billion a year 
across many agencies. The Department of Defense has spent $100 
million and the group just said that the money they spent on 
resilience programs and other things doesn't work. DOD has to 
go back and say what did we do wrong. Well, we found out that 
some of the things they are doing are in clearly good programs 
with regard to evidence-based programs, and some of it is not, 
and they need to make sure people are following the program. 
The VA spends a lot of money in mental health but 
unfortunately, a study said that about 20 percent of the time 
when someone goes into a VA hospital for mental health services 
for PTSD, they get appropriate care. The rest of the time they 
don't. That is wrong. Judiciary spends a heck of a lot of money 
and in many States on jails. That is wrong. We should be 
treating these people.
    We have had many witnesses before this committee that do 
that. The purpose of the Secretary of Mental Health--and I 
think you are demeaning the quality of this. I don't want 
someone who is dealing with 60 million Americans that one out 
of five or one of four people who deal with it in life to be 
some back bench low-level person. I want this person to have 
some power and mojo. I want this person to be a clinician of an 
M.D., Ph.D. or D.O. level. I want this person to be one who has 
access behind their title, Assistant Secretary of Mental 
Health, to be able to walk into the office of Judiciary, 
Defense, the VA, Education, HHS and say we want your 
information, we need to know if your programs work or don't 
work or if they are redundant. We have got to make this system 
work.
    Sir, for the last 20 years that SAMHSA has been around, it 
has gotten worse. Now, SAMHSA has done a lot of great things, 
and I applaud them for that, and we want to keep them going. I 
am not interested in getting rid of them. I am interested in 
beefing them up. But I am also saying we need evidence-based 
programs around this country.
    There is a lot of misinformation being thrown out today, so 
I am frustrated, but I also know, you know what? That is the 
nature of the mental health community. For the first time since 
Kennedy was President, for the first time in the last 50 years 
we have an opportunity in this Congress to say we need to 
overhaul this system. There have been some great programs that 
have come through. I applaud Congressman Kennedy and Senator 
Wellstone. Some of those things have been marvelous. But it has 
been piecemeal, and I want us to really approach this in a 
comprehensive way but sometimes in the mental health community, 
we are so used to dealing with dysfunction in ourselves, we 
don't understand when we have an opportunity.
    So here is what I am recommending. When you are given a 
comment and you haven't read the bill, say I haven't read the 
bill, OK? And with regard to this, what we want, what I want is 
from everybody and all the agencies throughout spreading rumors 
about this bill too to my colleagues and other people, send me 
ideas for amendments. Let us work on this, but let us not play 
this game.
    Thank you. I yield back.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentleman from North Carolina, Mr. Butterfield, 
5 minutes for questions.
    Mr. Butterfield. Thank you very much, Mr. Chairman, and 
thank the witnesses for their testimony today. I will try to 
look around Mr. Tonko and see all four of you. That is the 
advantage of being on the bottom tier. That is fine, Paul. That 
is fine.
    But thank you for holding today's hearing. Certainly, 
mental health is a very important issue. It is an important 
issue to all four of you. It is an important issue to us and 
certainly to the people that I represent in North Carolina, and 
so that means that we have to do all that we can at the federal 
level to ensure that people who are living with a mental 
illness receive the treatment and support they deserve.
    Some of my colleagues certainly know in my prior life I was 
a trial judge in North Carolina, served for 15 long years in 32 
counties in my State, and so I have seen firsthand what mental 
illness can do not only to families but to communities, and so 
I thank you for your passion.
    I have read most of Mr. Murphy's bill, and I think it is a 
good step, a step in the right direction. Certainly, there are 
many improvements that we can make, and I thank the chairman 
for offering us an opportunity to offer amendments to the 
legislation and there will be several.
    There are many different people involved in the continuum 
of care for mental illness and it is important that we 
recognize another category, and that is the role of social 
workers in the continuum of care and the important role that 
they play in mental and behavioral health infrastructure in our 
country. The importance of the social work profession will 
continue to increase as the mental and behavioral health 
challenges impact a growing percentage of the population. 
According to the U.S. Bureau of Labor Statistics, the need for 
social workers specializing in mental health and substance 
abuse is expected to grow by 23 percent from 2012 to 2022. That 
is 10 years. That rate is much faster than the average for all 
other occupations. Social work is built on a foundation of 
integrated care working directly with patients, but in settings 
including hospitals and schools and substance abuse prevention 
and treatment programs and family service settings and long-
term care facilities. Social workers have a history of working 
with and across disciplines including psychiatrists, 
pharmacists, nurses and others and will play a central role as 
we seek to improve health outcomes for people with mental and 
behavioral issues.
    I understand that part of the goal of this hearing is to 
identify and fill gaps that exist in the health care workforce 
in an effort to meet the unique needs of different populations 
such as our veterans and people living in urban or rural 
communities or adults.
    Let me go to Dr. Shern if I can very quickly. We know that 
health professions other than M.D.s and Ph.D.s have a growing 
role in meeting the mental health needs in the United States. 
Can you talk about your experiences and/or best practices 
working with other professionals in an integrated and team-
based approach?
    Mr. Shern. Yes, well, I think that that integrated team-
based approach that involves several different disciplines is 
essentially the state of the art in terms of how services are 
best delivered, particularly for people who have complex 
conditions or have, in this case, severe mental illnesses, and 
I think that there are real opportunities and real challenges 
that we confront in terms of adequate health care workforce in 
general and trying to understand and articulate different 
roles, particularly roles for paraprofessionals, peers and 
others and certainly including social work. You know, all of 
this that we are talking about in terms of the integration of 
care, understand that people live in communities, interact with 
complex systems, that is the hallmark of social work's approach 
to these issues. So I think many disciplines are involved. I 
think the best treatment involves a multidisciplinary team and 
I think that is basically considered state of the art in terms 
of services for people with severe mental illness.
    Mr. Butterfield. How do you see an integrated team-based 
approach involving social workers and pharmacists and nurses 
and others in addition to psychiatrists contributing to the 
success of this legislation and addressing mental health needs?
    Mr. Shern. Well, it is clear from research actually that 
was done in the 1970s that multidisciplinary teams can both 
save money in terms of decreasing utilization of the most 
expensive resources and improve outcomes, and the disciplines 
that you mentioned in your question would be the disciplines 
that typically would be involved in those kinds of 
multidisciplinary teams.
    Mr. Butterfield. Finally, let me go to you, Ms. Thompson, 
and thank you very much for your very passionate testimony. On 
another day I will share with this committee my personal story. 
I too grew up in a home with a mother who had mental illness. 
It was paranoia. She was not a harm or threat to anyone except 
herself, but it had a significant impact on her family and her 
work. So thank you for your testimony.
    Do you think this legislation does enough to recognize and 
encourage an integrated team-based approach to addressing 
mental health needs of patients and their families?
    Ms. Thompson. As I said earlier, I haven't read the entire 
bill. From my understanding, it addresses--the issue I have 
with what has happened in my experience was that there was no 
quality of life for my mother, so whatever it takes to create 
an ability for people to have a better quality of life, whether 
they know what it is or not, whether they are able to recognize 
it for themselves or not, that I feel we have an obligation to 
do that.
    Mr. Butterfield. Thank you. My time is expired. I am sorry.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentlelady from North Carolina, Ms. Ellmers, 5 
minutes for questions.
    Mrs. Ellmers. Thank you, Mr. Chairman, and thank you to our 
panel. Each one of you has very important information for us 
today, and I would also like to congratulate and thank my 
colleague, Mr. Murphy, for the work that he has done on this 
issue, especially in relation to the HIPAA situation. As a 
nurse before coming to Congress, I know that much of the 
misinformation is parochial and it is misinterpreted or 
overinterpreted and the clarifications are necessary so that 
each health care professional can understand what can be 
relayed because it is a very crucial time.
    So with that, I do have a question for Ms. Zdanowicz and 
for Ms. Thompson. Both of you are doing important work, and 
your stories are compelling on a personal level as well. In 
North Carolina, the past 10 years, the suicide rate has spiked 
significantly from about 18 percent to 22 percent. I represent 
Fort Bragg, and this affects our military, as you know, and our 
soldiers as well. In fact, a statistic that I am reading here 
that is provided for me says that actually this year into 2014, 
there have been more soldiers who have died by their own hand 
than those on the battlefield. Now, death in itself is not to 
be embraced. However, when we look at that statistic, we know 
the effects are incredible and that we need to deal with this 
issue.
    Obviously, medical beds, or patient beds, and psychiatric 
beds are so essential, and we are in more need today than ever. 
Today, North Carolina has only eight beds in a State 
psychiatric hospital per 100,000 people. So I believe we are at 
the lowest ratio, and one of our largest hospital systems in my 
area of North Carolina, Wake Med, is basically struggling with 
this issue. They treat an average of 314 patients a month whose 
primary diagnosis is psychosis, and this is up one-third over 
the last 2 years. Any given time, there are 25 to 50 patients 
with a diagnosis of mental illness of some form that are not 
necessarily in a dedicated psychiatric unit but are having to 
be placed in other areas of the hospital, and as you can 
imagine, that is difficult for the patient, the family and then 
also the health care professionals who are taking care of them.
    Ms. Zdanowicz, can you give us some points and guidance on 
how we can improve this mental health bed situation?
    Ms. Zdanowicz. Well, I would love to tell you that we could 
convince States to increase the number of beds and increase the 
number of long-term and intermediate-care beds that are just 
disappearing but that is not going to happen, and that is why 
assisted outpatient treatment is so important because it is a 
way of keeping individuals who are not safe in the community 
without medication on treatment, and there is empirical 
evidence to show that it reduces hospitalization, reduces 
incarceration, which, as I mentioned before, the jails and 
prisons are the new State psychiatric hospitals. If we don't 
have those kinds of facilities, we have to have a way of 
ensuring that people who don't realize that they are ill, that 
won't take their medication any other way have a means of 
getting that support, and it is not just a court order of 
somebody telling them. It comes with services. And I know 
people who have experienced it, and it does not scare people 
away and in fact it improves their lives. So unless we can get 
more beds, this is a solution with the population we are 
talking about, not everyone but the population we are concerned 
about.
    Mrs. Ellmers. Thank you.
    And Ms. Thompson, I just want to thank you for the work 
that you are doing. In Randolph County, which is one of my 
counties that I represent, the crisis intervention training for 
law enforcement is making a significant difference. Basically 
this is sponsored by you and NAMI, and it has been incredible 
work in the ability to have those law enforcement officers in 
the situation, know when they have to react and be able to 
engage and deescalate the situation, and it has made a huge 
difference. However, we need to continue to show that this 
program is working and we need greater coverage and reaching 
out to some of the other law enforcement. How can we extend 
this program? Do you know of the barriers? I know I am running 
out of time, but can you identify the barriers that we can 
address that might actually be able to help this situation?
    Ms. Thompson. The situation in terms of getting more people 
informed?
    Mrs. Ellmers. Yes, or getting this program in place for 
more law enforcement to learn about----
    Ms. Thompson. This program is vital. You need to give 
people the tools on how to deal with people in crisis, because 
if you don't, that is where the abuse comes from. That is 
really the abuse in the police department. That is where all of 
that comes from is because you are asking them to deal with 
something that they have no knowledge, that is not their skill 
set, and it is not fair to them and it is not fair to the 
individual.
    But that needs to be funded. I mean, there is no way--we 
can't do it alone. NAMI is trying desperately. We are a 
volunteer-based organization. We are a nonprofit organization. 
We try to reach out to law enforcement as much as we can. We 
need help. We need funding.
    Mrs. Ellmers. Thank you so much, and again, thank you to 
our entire panel.
    Thank you. I yield back the remainder of my time.
    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes the gentleman from Florida, Mr. Bilirakis, 5 minutes 
for questions.
    Mr. Bilirakis. Thank you so very much, Mr. Chairman. I want 
to thank the panel for their testimony and of course coming to 
Washington and sharing with us.
    In addition to being on the E&C Committee, I also serve as 
Vice Chairman of the Veterans' Affairs Committee, and we have 
held several hearings over the years on the mental health 
issues and of course, it is an extremely important issue. As a 
matter of fact, Time magazine wrote back in 2012 that ``more 
U.S. military personnel have died by suicide since the war in 
Afghanistan began than have died fighting there.'' When they 
take their own lives, these deaths diminish us as a whole. It 
leaves behind spouses, children, parents, and siblings who must 
deal with the loss and their own grief.
    So when I look at H.R. 3717, and thank you, representative 
Murphy, for filing the bill, the Helping Families in Mental 
Health Crisis Act, I look at it from the viewpoint of our 
veterans and their families, in addition to the general 
population.
    I want to thank the witnesses again for coming here today 
and talking about these issues. It is so very important. It is 
an invisible wound that millions grapple with each day. It 
carries a stigma, as you said, and we need to help remove the 
stigma so people aren't afraid to seek help. Mental health 
issues are just as serious as visible physical wounds, in my 
opinion. We must responsibly address this problem. Too many 
Americans and their families are suffering, and they deserve 
proper care, in my opinion.
    Your experiences dealing with family members with mental 
health issues, or living with it, or treating it helps inform a 
lot of us in the debate. Again, thank you for being here. I 
really appreciate it.
    And I would like to yield the rest of my time to 
Representative Murphy.
    Mr. Murphy. I thank the gentleman for yielding.
    A couple other clarifying points I want to make for 
members. This bill does not cut 85 percent of federal funding 
for the programs. It does not. There are multiple sources for 
that federal funding. This is one of them. And so it is very 
important that people are dealing with the facts.
    Also, Dr. Shern, you referred to a coercive feature of 
assisted outpatient treatment that would make people seek 
treatment. Are you aware of the programs Ms. Zdanowicz is 
talking about here with regard to the evidence on when AOT can 
work to reduce incarceration, et cetera?
    Mr. Shern. Yes, I am.
    Mr. Murphy. So what I am trying to find out here, and I 
recognize not all States do things the same way.
    Mr. Shern. Right.
    Mr. Murphy. For example, California has one county that 
does this; the rest don't. And some States do it better than 
others. I think New York does a pretty good job on that.
    But in this bill, are you aware of how we define who would 
qualify for assisted outpatient treatment?
    Mr. Shern. Generally, yes.
    Mr. Murphy. Well, we very narrowly defined that. They to be 
incarcerated before, had multiple hospitalizations, but the 
rest we leave up to the States because I think States should 
decide a lot of this too. So I want to make sure we are making 
it clear. There is no coercion involved here but we are saying 
States have to have something on the books.
    But let me ask the panelists this----
    Mr. Shern. Can you clarify that a bit, the no coercion 
involved in assisted outpatient treatment?
    Mr. Murphy. I am saying with regard to the States, they can 
put this together any way they want but we are saying----
    Mr. Shern. Coercion of the States?
    Mr. Murphy. Yes. What we are saying here is that as an 
alternative to just waiting until someone is in imminent 
danger, until someone has a knife to their head or someone 
else's. We want to provide a mechanism by which people are not 
just waiting for that ``someone is about to die'' standard. 
That is something established in the 1700s. We need to be doing 
more.
    So what I want to ask here is, I am open to other ideas, 
and what else could we do to make sure people--we have this 
integrated care, this wraparound care. I mean, we know when 
someone is in an acute crisis, that they need a lot of help and 
long term. What would be a couple of those things? Ms. 
Thompson, can you think of anything that we should make sure we 
include here?
    Ms. Thompson. Well, I think how HIPAA is addressed is vital 
because, you know, waiting until somebody is at a risk to 
themselves and others is waiting way too long to help them. We 
are waiting way too long to step in.
    Mr. Murphy. So making sure we have some way that families 
can participate more would be helpful?
    Ms. Thompson. That is correct.
    Mr. Murphy. Dr. Shern, do you have any recommendations of 
ways we could help provide some integrated wraparound services? 
I mean, we have some in here now under the Excellence in Health 
Care. You don't have to answer now but if you can provide us 
some ideas, I would love to hear them.
    Mr. Shern. Sure, and I think we have a pretty good evidence 
base with regard to that and I think that where AOT has been 
shown to be successful is in New York where there was a $125 
million appropriation to enhance services.
    Mr. Murphy. Ms. Zdanowicz, do you have any other 
suggestions that we can do? I know you are in support of AOT 
but any other things States should be doing?
    Ms. Zdanowicz. Well, I mentioned earlier, I just finished a 
survey of jails and prisons around the country, and this is 
where we need more help, and it is something that is being 
overlooked. I think it is coming to the forefront now. But that 
is where are so many people with mental illnesses who are 
refusing treatment, and what happens to them in those 
situations, I have talked to jails and learned just how 
horrible and dangerous and heartbreaking it is, and I think it 
is something that we have to focus on and not only just 
providing treatment in the institutions but keeping them out of 
the institutions, and I have talked to police officers trained 
to deal with people with mental illness. I was in a meeting 
where they asked, after hearing all the evidence, you know, the 
recovery-based peer support programs the State provides, a 
police officer stood up and said well, when I call the State, I 
can't get any help for this homeless person who is psychotic 
and delusional. So I think those are the areas that we need to 
have more integrated services.
    Mr. Murphy. Mr. Chairman, for the record, I just want to 
point out that in support of what Dr. Shern is saying, a report 
says that ACT works but a report says we also found evidence in 
the case manager data that receiving AOT combined with ACT 
services--assertive community treatment--substantially lowers 
risk of hospitalization compared to receiving ACT alone. So we 
will work with you on that. Thank you.
    Mr. Pitts. The gentleman yields back. The chair now notes 
that the subcommittee members have concluded their questions, 
and without objection, the Chair recognizes the gentleman from 
New York who is also on the full committee, Mr. Tonko, 5 
minutes for questions.
    Mr. Tonko. Thank you, Mr. Chair.
    Preliminarily, I state to our colleague and my friend, Mr. 
Murphy, that many of us are engaged in regard to this bill. We 
have read the bill and have sent you specific suggestions on 
how we believe the bill can be improved. We all agree that 
there are serious issues that need to be addressed but there 
are also serious reservations out there to some provisions in 
the instant bill. I think your intent is right, and we want to 
continue to work with you, but it needs to be a collaborative 
process. I commit to keeping an open dialog here so as to 
exchange on behalf of the issues and to recognize the 
importance of the issues here, the people most importantly 
impacted by mental health disorders and mental illnesses are of 
high need. So we need to recognize that and move forward with 
the sense that more than one point of view needs to be 
exchanged here in order for us to move forward most 
effectively.
    I also want to make the record clear that the protection 
and advocacy organizations are already precluded, prohibited by 
federal law from using any federal funds for lobbying purposes. 
Any lobbying activities conducted by these organizations, most 
notable organizations, are done with private dollars. 
Certainly, this would be restricted as lobbying activities with 
private funds which as I am sure my colleagues on the other 
side of the aisle would agree with in the way of yesterday's 
Supreme Court ruling could raise significant free-speech 
concerns, and I think those free-speech concerns are essential 
here for these organizations using private dollars.
    With that being said, I thank you again, Mr. Chair, for the 
opportunity. This issue is near and dear to my heart. I served 
in the New York State Assembly before coming to Congress. One 
of my proudest achievements in 25 years of service in that body 
was Timothy's Law. I was the prime sponsor of mental health 
parity in New York. I have the utmost respect for the mental 
health community and for those who advocate. Their resilience, 
their determination is stellar, and I recognize that, and I 
recognize the work done by the Oversight and Investigations 
Subcommittee to examine issues surrounding mental health.
    While there are many aspects of this bill with which I 
strongly disagree in its current form, I think that the intent 
is right on and it is in the right place, and I hope that we 
can continue to have bipartisan discussions to improve the 
bill. Those struggling with mental illnesses deserve nothing 
less.
    So Mr. Shern, in your testimony you speak to the fact that 
our treatment systems should be welcoming rather than 
frightening. I couldn't agree more. And I think everyone in 
this room recognizes that voluntary community-based treatment 
is always preferable and leads to better outcomes in the long 
run.
    One of the more difficult questions we are weighing as a 
panel is what circumstances more coercive forms of treatment, 
whether this is assisted outpatient treatment or inpatient 
hospitalization might be necessary. In your opinion, when is it 
appropriate, if ever, to resort to these more coercive forms of 
treatment when dealing with an individual with serious mental 
illness?
    Mr. Shern. Well, I think, in situations in which a person 
doesn't have the capacity to make the decisions necessary to 
preserve their safety or is a threat to another person, which 
is the standard sort of commitment that laws that exist across 
the country. At that point in time we have provisions for 
involuntarily treating individuals. When we implemented our New 
York City program, our Manhattan program for people who had 
severe mental illnesses and were living on the streets of New 
York, I personally witnessed people literally running from our 
program because of--literally running, jumping onto the Staten 
Island Ferry by slipping under the door right before the ferry 
took off rather than be engaged by our program. So I personally 
have experienced people running from care because of coercive 
interventions.
    Mr. Tonko. And Mr. Shern, does the evidence show that 
assisted outpatient treatment programs are more effective than 
similarly resourced assertive community treatment programs?
    Mr. Shern. It is my understanding that those situations in 
which AOT has been shown to be effective both in the Duke 
trials and in the New York State experience were situations in 
which there were enhanced services available. Compelling people 
into a service system that doesn't exist is not going to make a 
difference.
    Mr. Tonko. And when States have adopted more expansive 
need-for-treatment standards for civil commitment, have we seen 
an impact on individuals seeking care voluntarily?
    Mr. Shern. Coercive interventions can chase people from 
care.
    Mr. Tonko. Thank you very much, and with that, I yield back 
as I see I have exhausted my time.
    Mr. Pitts. The Chair thanks the gentleman. The Chair 
overlooked one member of the subcommittee, so at this time 
yields 5 minutes to Mr. Griffith from Virginia.
    Mr. Griffith. Thank you very much, Mr. Chairman, and I 
apologize to both you, Mr. Chairman, and to our panelists. I 
have been involved in another hearing as well and so I have 
been running up and down the stairs trying to make sure I got 
here.
    I want to agree with Representative Tonko in saying that 
putting this forward by Dr. Murphy is a big step. Somebody has 
to put it forward. We have been studying it for a little while. 
He decided to take that leap, and I commend him for that 
because that is very, very important. There are things in a 
bipartisan fashion that we can work on to improve the bill, and 
I heard Dr. Murphy say earlier he is looking for those 
suggestions.
    That being said, I also want to underscore that HIPAA does 
have to be addressed. It doesn't mean we want to undo the 
principles of HIPAA. It doesn't mean we want to, you know, let 
everybody have access. But we heard so much testimony from so 
many family members who wanted to help, people who loved the 
individual with mental health problems who wanted to be there 
for them, and in many cases were not able to be there to take 
care of them because they were blocked. They were blocked from 
having the necessary knowledge to know whether or not they were 
a risk to themselves or to others. They were blocked because 
they didn't know exactly what was going on. So we have to 
improve that.
    Where I would like to see improvements in this bill is in 
figuring out how to define that because when you look at 
Section 301, we have a real opportunity to work on that across 
the board, all parties coming together and figuring out how we 
do that. My concerns particularly relate to two groups of 
individuals. You have got the elderly. It is pretty obvious 
that with an elderly person, if you have competing children--I 
used to do divorce work in my small town private practice. I 
did a lot of criminal work. People will fight over all kinds of 
things and particularly when it becomes mom or dad, family 
members get into a fight. So we have to figure out a system 
where if you have got a child who hasn't been involved in mom's 
life for 20 years, that they don't come waltzing in and knock 
Ms. Thompson out because all family members get it.
    Also, I worry in that same situation, that young men, we 
have heard so much testimony that young men particularly in 
that suspect group, 14 to 18 is a problem but 14 to, I think it 
was 28--Dr. Murphy can correct me on my ages--where there is a 
lot of onset of first signs of mental illness and they don't 
get treatment. Fourteen to 18, parents are still involved. On 
that 18th birthday, they get knocked out. And whether that is 
what HIPAA is supposed to do or not, it is the way it is 
interpreted, and if you are worried about a lawyer suing you 
for giving away the information, you are not going to do it as 
a doctor. No matter what different people may think it means, 
Dr. Murphy is right. We have got to clarify it. But then I also 
worry if you have too big a door for people to get information, 
does that estranged father come back in, never having 
participated in his son's life and now the son is 22 and he 
decides he wants to come in and knock mom out.
    So that is the scenario that I am looking at. I think we 
can make improvements. And with that, Mr. Chairman, I yield to 
Dr. Murphy.
    Mr. Murphy. I thank the gentleman. I also thank you for 
your commitment to help us improve that language. It is 
important. We have had too many people raise concerns so we 
have to do it the right way.
    Dr. Shern, you had mentioned that you are aware--well, let 
me ask you, are you aware of any study at all, empirical, 
published study, that supports your understanding that broader 
commitment standards drive people away from seeking treatment? 
Are you aware of any particular study offhand or can you 
provide that for us?
    Mr. Shern. I can look into it. I am not aware of any 
offhand.
    Mr. Murphy. OK. I appreciate that, because you made the 
statement. I want it backed up with evidence.
    I also want to say that what I was reading before, the 
quote I forgot to reference is where it said that AOT combined 
with ACT services substantially lowers risk of hospitalization 
compared to receiving ACT alone. This is the study done by Duke 
University Policy Research Associates and the University of 
Virginia School of Law on the New York State assisted 
outpatient treatment program evaluation. So there is a lot we 
can learn from New York.
    One other thing I want to mention, when I refer to some of 
the concerns I have, and Ms. Jensen, you brought a very 
compelling story forward on what happened with that horrible 
place you were in, and I am glad you fought hard to shut it 
down, but also some of these groups also cause some problems 
too. A case we heard was from Joe Bruce. His son William was 
diagnosed with some psychosis. He was in Maine. And these 
advocates came in. This family was completely cut off from 
being able to talk to their son, which is a HIPAA issue, yet 
these advocates could talk to him, coached him during a hearing 
on this, and told him to say when he was asked if he was going 
to be a harm to himself or someone else say no. He listened to 
their coaching. He was dismissed from the hospital. He went 
home. He took a hatchet and chopped his mother to pieces.
    This was very moving testimony this committee heard. We 
don't think a group like this has any business telling someone 
get them out of treatment altogether. We want professionals 
involved who are looking out for the best interest of the 
patients all the way through.
    Mr. Chairman, I want to thank you for this hearing today. 
We have heard some powerful information. I look forward to 
working with my colleagues on both sides of the aisle on this. 
The good news is, we have elevated this to the level of 
Congressional discussion instead of keeping it in the dark 
shadows. We have understood that this isn't just an issue of 
violent mentally ill. We have to work together. I am excited 
about this, and I want to leave with a message of hope for the 
many people who are struggling with mental illness. We will 
continue to listen to you. We want to work together. We have 
got to change this system and help you all.
    With that, I yield back.
    Mr. Pitts. The Chair thanks the gentleman, and thanks him 
for his leadership on this issue. This has been a very 
important hearing, very compelling testimony, very informative. 
Thank you very much to the witnesses for coming.
    Now, we have members who may have follow-up questions who 
were not able to attend. They are in other hearings. We will 
send you the written questions. We ask that you please respond 
promptly. Do you have something?
    Mr. Tonko. Yes, Mr. Chair. We ask that these documents be 
included in the record.
    Mr. Pitts. We have a unanimous consent request to include 
in the record testimony of the National Disability Rights 
Network; a letter from the American Psychiatric Association; 
testimony by the National Coalition of Mental Health Recovery; 
testimony titled Helping Families in Mental Crisis Act, H.R. 
3717 by the Citizen Commission on Human Rights \*\; a letter by 
Consortium for Citizens with Disabilities; and testimony by 
Judge David Bazelon Center for Mental Health Law. Without 
objection, so ordered.
---------------------------------------------------------------------------
    \*\ The information has been retained in committee files and is 
also available at http://docs.house.gov/meetings/if/if14/20140403/
102059/hhrg-113-if14-20140403-sd008.pdf.
---------------------------------------------------------------------------
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. I remind members that they have 10 business days 
to submit questions for the record. That means members should 
submit their questions by the close of business on Thursday, 
April 17.
    Thank you again very much for attending. Without objection, 
the subcommittee is adjourned.
    [Whereupon, at 12:48 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    [Dr. Welner's response to submitted questions for the 
record has been retained in committee files and can be found at 
http://docs.house.gov/meetings/if/if14/20140403/102059/hhrg-
113-if14-wstate-welnerm-20140403-sd002.pdf.]

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