[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]



 
                 FEDERAL EFFORTS ON MENTAL HEALTH: WHY 
                    GREATER HHS LEADERSHIP IS NEEDED

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

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           FEBRUARY 11, 2015

                               __________

                            Serial No. 114-8
                            
                            
                            
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                   COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman
JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Chairman Emeritus                    Ranking Member
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania        ELIOT L. ENGEL, New York
GREG WALDEN, Oregon                  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
STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
GREGG HARPER, Mississippi            JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
PETE OLSON, Texas                    BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia     PAUL TONKO, New York
MIKE POMPEO, Kansas                  JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois             YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia         DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILL JOHNSON, Ohio                   JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                     Massachusetts
RENEE L. ELLMERS, North Carolina     TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota

              Subcommittee on Oversight and Investigations

                        TIM MURPHY, Pennsylvania
                                 Chairman
DAVID B. McKINLEY, West Virginia     DIANA DeGETTE, Colorado
  Vice Chairman                        Ranking Member
MICHAEL C. BURGESS, Texas            JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
LARRY BUCSHON, Indiana               JOHN A. YARMUTH, Kentucky
BILL FLORES, Texas                   YVETTE D. CLARKE, New York
SUSAN W. BROOKS, Indiana             JOSEPH P. KENNEDY, III, 
MARKWAYNE MULLIN, Oklahoma               Massachusetts
RICHARD HUDSON, North Carolina       GENE GREEN, Texas
CHRIS COLLINS, New York              PETER WELCH, Vermont
KEVIN CRAMER, North Dakota           FRANK PALLONE, Jr., New Jersey (ex 
JOE BARTON, Texas                        officio)
FRED UPTON, Michigan (ex officio)
  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     4
Hon. Diana DeGette, a Representative in Congress from the state 
  of Colorado, opening statement.................................     5
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................     7
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     8
Hon. Fred Upton, a Representative in Congress from the state of 
  Michigan, prepared statement...................................    76

                               Witnesses

Linda T. Kohn, Ph.D., Director, Health Care, U.S. Government 
  Accountability Office..........................................    10
    Prepared statement...........................................    13
Richard G. Frank, Ph.D., Assistant Secretary for Planning and 
  Evaluation, U.S. Department of Health and Human Services.......    23
    Prepared statement...........................................    27
    Answers to submitted questions...............................    80
Pamela S. Hyde, J.D., Administrator, Substance Abuse and Mental 
  Health Services Administration.................................    24
    Prepared statement...........................................    27
    Answers to submitted questions...............................    87

                           Submitted Material

Subcommittee memorandum..........................................    77


 FEDERAL EFFORTS ON MENTAL HEALTH: WHY GREATER HHS LEADERSHIP IS NEEDED

                              ----------                              


                      WEDNESDAY, FEBRUARY 11, 2015

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:05 a.m., in 
room 2123 of the Rayburn House Office Building, Hon. Tim Murphy 
(chairman of the subcommittee) presiding.
    Members present: Representatives Murphy, McKinley, Burgess, 
Blackburn, Griffith, Bucshon, Flores, Brooks, Mullin, Hudson, 
Collins, Cramer, DeGette, Schakowsky, Tonko, Yarmuth, Clarke, 
Kennedy, and Pallone (ex officio).
    Staff present: Gary Andres, Staff Director; Sean Bonyun, 
Communications Director; Karen Christian, General Counsel; 
Noelle Clemente, Press Secretary; Brad Grantz, Policy 
Coordinator, Oversight and Investigations; Brittany Havens, 
Legislative Clerk; Charles Ingebretson, Chief Counsel, 
Oversight and Investigations; Peter Kielty, Deputy General 
Counsel; Alan Slobodin, Deputy Chief Counsel, Oversight; Sam 
Spector, Counsel, Oversight; Peter Bodner, Democratic Counsel; 
Hannah Green, Democratic Policy Analyst; Tiffany Guarascio, 
Democratic Deputy Staff Director and Chief Health Advisor; 
Elizabeth Letter, Democratic Professional Staff Member; and 
Nick Richter, Democratic Staff Assistant.

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

    Mr. Murphy. Good morning. I now convene this morning's 
hearing entitled, ``Federal Efforts on Mental Health: Why 
Greater HHS Leadership is Needed.''
    In December 2013, Laura Pogliano of Maryland sent to me a 
poem she wrote about what it is like to raise a child with 
schizophrenia, as opposed to other life-threatening conditions. 
Here is an excerpt: ``Your child's illness is afforded the 
cooperation of caregivers and parents to attend to it. My 
child's illness is left to the right to refuse care laws, 
leaving him to get as sick as he can possibly be, and choose 
suicide, death, starvation, and continued illness with severe 
brain damage. Your child is never arrested or jailed because he 
is sick. My child is almost always arrested at some point. Your 
child can have any bed in any hospital in the country across 
the board. My child can only have a psychiatric bed. And there 
is an estimated deficit of 100,000 beds in this country, and 
the wait for one can take 6 months or longer in some places. 
Your child can tell people if he is sick. My child cannot, or 
he won't get a job or a date or an apartment. Your child can 
get a fun trip sponsored by an organization that assists sick 
children. My child can't go on any trips usually, and neither 
can his family.''
    Despite her struggles getting Zac into care, Laura 
considered herself lucky, telling USA Today in November that, 
even though her son's mental illness has driven her to 
bankruptcy, sidetracked her career, and left her clinically 
depressed, she called herself lucky, though Zac was in and out 
of a hospital 13 times in 6 years. She said, even though he has 
fantasies that he is rich, hallucinations that he is being 
followed, and delusions that his mother is a robot, even though 
he has slept with a butcher knife under his pillow, Laura 
considered herself lucky that Zac wasn't in jail or homeless.
    Last month, Zac was found dead in his apartment. He was 23 
years old.
    Laura had dreams for her son, Zac, just like every parent 
does. For countless parents, those dreams are tragically cut 
short. She searched for help and faced barriers to care. 
Federal laws, HIPAA laws, state laws. We have criminalized 
mental illness so you can't get help unless you are homicidal, 
suicidal, or you are well enough to understand you have 
problems and ask for help.
    This has been a growing problem since states closed down 
their old asylums, as they should have, but what did the 
Federal Government do here to take care of this problem, to 
meet the needs of millions of Americans with serious mental 
illness and their families?
    Today, we will hear how our mental health system is an 
abject failure for those families. Its failure is not a 
Democrat or Republican issue; it knows no party label, and to 
be honest, this spans multiple administrations, but the cost is 
enormous for the 10 million Americans with serious mental 
illness. Those with schizophrenia die 25 years earlier than the 
rest of the population. Forty thousand people in this country 
died last year from suicide, while another million attempted it 
in the last year. And that is a trend that is getting worse. 
Rates of homelessness, incarceration, unemployment, substance 
abuse, violence, victimization, and suicide among those with 
serious mental illness continue to soar. These are the very 
human, very tragic, and very deadly results of a very, very bad 
report card.
    Today, thanks to a diligent year-long review of Federal 
efforts related to severe mental illness conducted at the 
bipartisan request of this committee, the Government 
Accountability Office has produced unassailable evidence that 
our mental health system is dysfunctional, disjointed, and a 
disaster.
    No Federal agency has had a more central role in the 
disaster than the Department of Health and Human Services. HHS 
is charged with leading the Federal Government's public health 
efforts related to mental health, and the Substance Abuse and 
Mental Health Services Administration, otherwise known as 
SAMHSA, is required to promote coordination of programs related 
to mental illness throughout the Federal Government. At the 
onset of our investigation 2 years ago, we found it troubling 
that no one in the Federal Government kept track of all the 
Federal programs serving individuals with severe mental 
illness. My colleague and I, Representative Diana DeGette, 
asked GAO to take on this task. Following a detailed survey of 
eight Federal departments, including the Department of Defense, 
Veterans Affairs, and HHS, the GAO identified at least 112 
separate Federal programs supporting individuals with severe 
mental illness. But most damning in this GAO report were these 
two principal findings. One, interagency coordination for 
programs supporting individuals with serious mental illness, a 
key function of SAMHSA, is lacking. And number two, to see 
whether programs specifically targeted at individuals with 
serious mental illness are working, agencies evaluated fewer 
than \1/3\ of them.
    Now, you can't manage what you don't measure. For families 
who want and need treatment, HHS has given families 
bureaucracy, burdens and barriers instead.
    We spend a lot of money in this country on mental illness, 
and the term evidence is thrown around like candy to prevent 
people from asking where is the real proof that this works. GAO 
offered two recommendations to correct these failings. HHS 
rejected them both. In each instance, HHS dismissed GAO's 
concerns rather than presenting evidence to dispute GAO's 
conclusions or volunteering improvements, or having the 
humility to say maybe we ought to do something about this.
    When you have a mental health system that is as broken as 
the one we face today, with a report card so tragic, you would 
think that the Federal agency charged with coordinating a 
myriad of activities supporting individuals with severe mental 
illness would be open to recommendations from an experienced, 
nonpartisan authority, steeped in the practices of good 
government. HHS, in rejecting both of GAO's recommendations, 
and failing to identify any aspect of either recommendation 
worth working with or leaning from, is essentially saying there 
is no room for improvement, and that the agency is doing 
everything right at present. This is unbelievable.
    The hubris shown by HHS is downright insulting and callous 
to the millions of families and individuals suffering under 
this broken system. This is a clear example of unaccountable 
government; one that refuses to recognize its failings even 
when it is presented with constructive recommendations for 
improvement.
    We want to help in this committee, this Congress wants to 
help, but we can't help you if you are not even willing to 
admit there is a problem. We are not talking simply about 
wasted dollars or lost program efficiencies. We are talking 
about lives ruined, about dreams that are shattered, we are 
talking about preventable tragedies and lives lost.
    I have spoken before about individuals with schizophrenia 
and bipolar disorders who aren't just in denial, but have the 
very real medical pathology that they cannot recognize they 
have an illness. It is called anosognosia, and it is a symptom 
found in stroke victims, Alzheimer patients, and persons with 
schizophrenia. HHS and SAMHSA are similarly in denial. You are 
so out of touch with understanding their own failures that it 
causes greater pain to millions of American families. 
Meanwhile, the lives of individuals with severe mental illness 
and their families remain in the balance.
    This morning, we will hear from the author of the GAO 
report, as well as representatives from HHS. These include Dr. 
Linda Kohn, Director of Health Care at GAO; Dr. Richard Frank, 
Assistant Secretary for Planning and Evaluation at HHS; and 
Pamela Hyde, Esquire, the Administrator of SAMHSA. I thank them 
all for joining us this morning, and I would like to give the 
ranking member an opportunity to deliver remarks of her own.
    [The prepared statement of Mr. Murphy follows:]

                 Prepared statement of Hon. Tim Murphy

    In December 2013, Laura Pogliano of Maryland sent to me a 
poem she wrote about the what it's like to raise a child with 
schizophrenia as opposed to other life-threatening conditions. 
Here's an excerpt:
    Your child's illness is afforded the cooperation of 
caregivers and parents to attend to it.
    My child's illness is left to the Right to Refuse Care 
Laws, leaving him to get as sick as he can possibly be, and 
choose suicide, death, starvation, continued illness with 
severe brain damage.
    Your child is never arrested or jailed because he's sick.
    My child is almost always arrested at some point.
    Your child can have any bed in any hospital in the country, 
across the board.
    My child can ONLY have a psychiatric bed, and there's an 
estimated deficit of 100,000 beds in this country, and the wait 
for one can take 6 months or longer in some places.
    Your child can tell people he's sick. My child cannot, or 
he won't get a job, or a date, or an apartment.
    Your child can get a fun trip sponsored by an organization 
that assists sick children.
    My child can't go on any trips, usually, and neither can 
his family...
    Despite her struggles getting Zac into care, Laura 
considered herself lucky, telling USA Today in November that 
``even though her son's mental illness has driven her to 
bankruptcy, sidetracked her career and left her clinically 
depressed.''
    She called herself ``lucky'' even though Zac was in and out 
of the hospital 13 times in 6 years.
    ``Even though he has fantasies (he's rich), hallucinations 
(he's being followed) and delusions (Mom is a robot). Even 
though he's slept with a butcher knife under his pillow.''
    Laura considered herself lucky that Zac wasn't in jail or 
homeless.
    Last month, Zac was found dead in his apartment. He was 23.
    Laura had dreams for her son Zac just like every parent 
does.
    For countless parents, those dreams are tragically cut 
short.
    She searched for help and to face barriers to care--federal 
laws, HIPAA laws, state laws. We've criminalized mental illness 
so you get help unless you are homicidal, suicidal, or well 
enough to understand you have a problem.
    This has been a growing problem since states closed down 
their old asylums--as they should have. But what did the 
federal government do here?
    Today, we'll hear how our mental health system is an abject 
failure for those families. Its failure is not a Republican or 
Democrat issue. It knows no party label and spans multiple 
Administrations.
    The cost is enormous for the ten million Americans with 
serious mental illness.
    Those with schizophrenia die 25 years earlier than the rest 
of the population.
    40,000 die from suicide while another million will have 
attempted it in the last year alone, a trend that's getting 
worse
    Rates of homelessness, incarceration, unemployment, 
substance abuse, violence, victimization, and suicide amongst 
those with serious mental illness continue to soar.
    These are the very human, very tragic, and very deadly 
results of a very, very bad report card.
    Today, thanks to a diligent year-long review of federal 
efforts related to severe mental illness conducted at the 
bipartisan request of this Subcommittee, the Government 
Accountability Office (GAO) has produced unassailable evidence 
that our mental health system is dysfunctional, disjointed, and 
a disaster.
    No federal agency has had a more central role in the 
disaster than the Department of Health and Human Services 
(HHS). HHS is charged with leading the federal government's 
public health efforts related to mental health, and the 
Substance Abuse and Mental Health Services Administration 
(SAMHSA) is required to promote coordination of programs 
relating to mental illness throughout the federal government.
    At the onset of our investigation two years ago, we found 
it troubling that no one in the federal government kept track 
of all of the federal programs serving individuals with severe 
mental illness. My colleague Diana DeGette and I asked GAO to 
take on this task. Following a survey of eight federal 
agencies, including the Departments of Defense, Veterans 
Affairs, and HHS, GAO identified at least 112 separate federal 
programs supporting individuals with severe mental illness.
    Most damning in the GAO report were these two principle 
findings:
    (1) interagency coordination for programs supporting 
individuals with serious mental illness, a key function of 
SAMHSA, is lacking
    (2) to see whether programs specifically targeting 
individuals with serious mental illness are working, agencies 
evaluated fewer than one-third of them.
    You can't manage what you don't measure, which is why HHS 
has given families and individuals who want and need treatment 
bureaucracy, burdens, and barriers instead.
    We spend a lot of money and the term ``evidence'' is thrown 
around like candy--to prevent people from asking where the true 
proof that it really works.
    GAO offered two recommendations to correct these failings; 
HHS rejected them both, in each instance dismissing GAO's 
concerns rather than presenting evidence to dispute GAO's 
conclusions orvolunteering improvements.
    When you have a mental health system as broken as the one 
we face today with a report card so tragic, you would think 
that the federal agency charged with coordinating the myriad of 
activities supporting individuals with severe mental illness 
would be open to recommendations from an experienced, 
nonpartisan authority steeped in the practices of good 
government. HHS, in rejecting both of GAO's recommendations--
and failing to identify any aspect of either recommendation 
worth working with or learning from--is essentially saying 
there is no room for improvement, and that the agency is doing 
everything right at present. It's unbelievable.
    The hubris shown by HHS is downright insulting to the 
millions of families and individuals suffering under this 
broken system.
    This is a clear example of unaccountable government--one 
that refuses to recognize its failings, even when it is 
presented with constructive recommendations for improvement. We 
are not talking simply about wasted dollars or lost program 
efficiencies. We are talking about lives ruined, dreams 
shattered, and preventable tragedies.
    I've spoken before about individuals with schizophrenia and 
bipolar disorder who aren't just in denial but who have the 
very real medical pathology that they cannot recognize they 
have an illness. It's called anosognosia, and it's a symptom 
found in stroke victims and persons with schizophrenia.
    HHS and SAMHSA are similarly in denial. They are so out of 
touch with understanding their own failures that is tgreater 
pain to millions of American families. Meanwhile, the lives of 
individuals with severe mental illness, and their families, 
remain in the balance.
    This morning, we will hear from the author of the GAO 
report, as well as representatives of HHS. These include:
     Linda T. Kohn, PhD, Director, Health Care at GAO;
     Richard G. Frank, PhD. Assistant Secretary for 
Planning and Evaluation at HHS; and
     Pamela S. Hyde, Esquire, Administrator of SAMHSA.
    I thank them all for joining us this morning.

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

    Ms. DeGette. Thank you, Mr. Chairman.
    This is an issue that is important to both of us, and so I 
am really glad that you have convened this hearing as part of 
our continuing oversight of the Federal Government's mental 
health programs.
    This hearing, as the chairman mentioned, follows a report 
by the GAO released last week, which raises questions about the 
more than 100 programs that generally support individuals with 
serious mental illness, and 30 programs that specifically 
target those individuals.
    In particular, the GAO report raises questions about the 
coordination and evaluation of mental health programs, and 
offers recommendations to help us improve the mental health 
system.
    I look forward to hearing our witnesses' testimony today 
because they are very familiar with the report and the issues 
that it raises, and I know that we will all be able to see 
further insights and context for our understanding of the 
Federal role in mental health care.
    The report provides us with an importance chance to assess 
current Federal efforts to address mental health, and to see 
where there is room for improvement in our system. And I know 
we can all agree there is ample room for improvement. I want to 
hear about how we can ensure that Federal programs actually 
assist people who need them, and I also think we need to talk 
about how to assess the efficacy and cost of those programs.
    While it is important to talk about providing services and 
support to those with serious mental illnesses, I think we also 
need to have a broader conversation about mental health in this 
country. According to the National Institute of Mental Health, 
we have nearly 44 million individuals, almost 19 percent of all 
U.S. adults, living with mental illness every year. And, Mr. 
Chairman, as we have discussed, sometimes if we can help folks 
in the early stages of mental illness, then that helps us begin 
to prevent the disintegration into very, very serious mental 
illness and worse.
    So we have spent a lot of time on this subcommittee looking 
at mental health issues. We have learned about the need to 
appropriately target mental health funding, and the need to 
adequately fund mental health research. We have learned about 
the importance of health insurance that provides coverage for 
those with mental illnesses. I know, Mr. Chairman, that you 
want to pass mental health legislation that will make a real 
difference. I do too. I hope there are ways that we can work 
through these issues and concerns on a bipartisan basis, with 
the focus group that we have put together over the last year. I 
think we should work together to put the lessons learned in 
these Oversight hearings into practice.
    I want to thank all of the witnesses for being here today. 
It is important to hear from all of you. I know we can agree 
there is always room for improvement, and we look forward to 
hearing from you about how we can do that.
    With that, I will yield the balance of my time to 
Representative Kennedy.
    Mr. Kennedy. I want to thank the ranking member, and I 
thank the chairman for calling this important hearing. I thank 
the witnesses for their testimony today, and for your work on 
an extraordinarily important issue.
    This report outlines alarming lapses in coordination at the 
Federal level. It raises questions about how Federal funds are 
being spent, and points a finger at our Nation's patchwork 
mental health system for failing to meet the needs of millions 
of Americans.
    Back home, I see communities on the frontlines of a growing 
crisis, looking for the Federal Government for support. From 
substance abuse to at-risk youth, our failure to delivery 
dependable, affordable, and accessible mental health care is 
costing lives back at home.
    So instead of throwing in the towel, we should see this 
report as a rallying cry. We must do better, devote more 
resources to mental illness, invest in our efforts at improving 
coordination, evaluation, and delivery of care. But for that to 
work, we need to know the scope of the problem and the range of 
our response. We must have the commitment of our Federal 
partners to take on a growing problem. Lasting mental health 
reforms are long overdue, and I look forward to working with 
all of you. And I want to thank again the chairman and ranking 
member for calling this important hearing.
    I yield back.
    Mr. Murphy. Yields back. Thank you.
    I now recognize the vice chair of the full committee, Mrs. 
Blackburn of Tennessee, for 5 minutes.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Chairman. And I want to 
welcome our witnesses, and highlight a couple of things that 
have already been said that I think are important to all of us 
on the panel.
    As the chairman mentioned, 10 million adults in the U.S. 
had a serious mental illness during 2013. That should not be 
lost on us. And we also were very concerned about coordination 
of care, and we are going to have some questions about that. I 
have discussed this with some of the mental health 
professionals in my district who are involved in this 
coordination of care. And Ms. DeGette's comments are so on 
point with so much of what we are going to look at, the money 
that is spent. Your budget is a hefty budget for substance 
abuse and mental illness, but the lack of coordination of care, 
the lack of the resources meeting the needs at the local and 
state agencies, how this feeds through, this is something that 
does cause us concern. We are pleased to hear from the GAO 
today, and we want to look at where the recommendations the GAO 
has, how they have fallen on deaf ears at HHS and SAMHSA, and 
we are concerned about the delivery of parity, if you will, in 
mental illness and addressing those needs, and we are concerned 
with what appears to be a great deal of indifference when it 
comes to just spending money but not getting results.
    So I will yield back my time, Mr. Chairman, or yield to 
whomever would like to have the time. And we look forward to 
hearing from our witnesses.
    Mr. Murphy. Thank you.
    Does anybody on this side wish to make any comments? If 
not, then we will proceed. Thank you.
    Mr. Pallone. I am sorry, Mr. Pallone is here now. Mr. 
Pallone is recognized for 5 minutes.

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

    Mr. Pallone. Thank you, Mr. Chairman. Thank you for 
convening the hearing today. And I am glad we are taking this 
opportunity to examine how the Federal Government supports 
individuals with serious mental illness, but also looking into 
how we can strengthen our mental health system for the future. 
We all agree that there are ways we can do better.
    The GAO report we are talking about today calls for 
improved coordination and evaluation of Federal programs that 
help those with serious mental illness. And these are valuable 
goals, but I want to make sure we don't discount the work HHS, 
SAMHSA, and other Federal agencies are already doing in these 
areas.
    The GAO report identified 112 programs across the Federal 
Government that support those with serious mental illness. Now, 
within that group, there are 30 programs that specifically 
focus on individuals with serious mental illness. GAO, however, 
did not review the merits or quality of these programs, so we 
should hear from HHS and SAMHSA about the work they are doing, 
how these programs help individuals with a variety of needs, 
and how these agencies plan to build upon these programs moving 
forward.
    It is also important to emphasize that HHS, SAMHSA, and 
their partners across the Federal Government do coordinate on 
mental health programming. The GAO report notes that, and I 
quote, ``Staff from 90 percent of the programs targeted serious 
mental illness reported coordinating with their counterparts 
and other programs.''
    HHS coordinates with a number of departments and agencies, 
including the Department of Defense, the Department of Veterans 
Affairs, the Department of Education, to carry out critical 
programs for individuals with serious mental illness. SAMHSA 
also co-chairs the HHS Behavioral Health Coordinating Council, 
which includes a Subcommittee on Serious Mental Illness.
    The GAO report also noted that SAMHSA had completed, or was 
in the process of completing, nine program evaluations in the 
past several years, and I look forward to hearing from SAMHSA 
about the results of these evaluations, and how they have 
improved program efficiency and effectiveness, as well as how 
SAMHSA utilizes other monitoring and evaluation tools. Notably, 
the GAO report did not review the programs that provide 
reimbursement of insured services for individuals with serious 
mental illness, including Medicare and Medicaid. These programs 
are a huge part of the work HHS does to support early diagnosis 
and treatment of mental illness.
    And lastly, Mr. Chairman, I want to highlight the role of 
the Affordable Care Act in guaranteeing coverage of mental 
health services. Continuing implementation of the ACA will go a 
long way in ensuring that people with serious mental illness 
have access to the treatments they need. In fact, we should 
support programs that focus on prevention and early diagnosis 
of mental illness. We can more effectively support individuals 
with serious mental illness by treating them early in the 
course of their illnesses, and altering the trajectory of their 
condition.
    So again, I want to thank our witnesses. And I would like 
to yield my remaining time to the gentleman from New York, Mr. 
Tonko.
    Mr. Tonko. I thank the ranking member of our Energy and 
Commerce Committee for yielding. And I thank you, Mr. Chair, 
and, Ranking Member DeGette, for holding this hearing on such a 
critically important topic.
    As I travel around my congressional district in the capital 
region of New York, I hear stories daily from individuals and 
families as they struggle with the ravages of mental illness. 
Their pain is indeed real, and we must commit this Congress to 
doing everything within its power to ease their burdens.
    In that vein, I welcome today's hearing, and the underlying 
GAO report that we are here to discuss as it advances the 
conversation on some basic good governance questions on how the 
Federal Government should approach programs aimed at helping 
individuals with serious mental illness. And while I concur 
with the report's conclusion that high-level coordination can 
be essential to identifying gaps in services and evaluating 
overall efforts, it is important to keep in mind that 
coordination is not an end unto itself. Where additional 
interagency coordination, whether at the programmatic or 
department level, can be an effective use of the Federal 
Government's time and money, and more importantly, is 
beneficial to individuals with serious mental illness, we 
should welcome it. Where it does not meet that test, we should 
not be adding additional layers of bureaucracy that divert time 
and resources from the people that need it the most.
    As such, I look forward to hearing from our witnesses today 
on where coordination efforts can be built upon so that we can 
have an improved outcome for those living with mental illness.
    And I thank you and yield back the balance of my time.
    Mr. Murphy. The gentleman yields back.
    So at this point, we will proceed with testimony of our 
witnesses. I would now like to introduce the panel.
    First, we have Dr. Linda Kohn, who is Director with the 
Health Care Team at the U.S. Government Accountability Office, 
where she works on issues related to public health, health 
information technology, and medical research programs. Welcome. 
Dr. Richard Frank is the Assistant Secretary for Planning and 
Evaluation at the U.S. Department of Health and Human Services. 
In this role, he advises the Secretary on development of health 
and disability, human services data, and science policy, and 
provides advice and analysis on economic policy. Welcome here. 
And the Honorable Pamela Hyde is accompanying Dr. Frank. Ms. 
Hyde is the Administrator of the Substance Abuse and Mental 
Health Services Administration, otherwise known as SAMHSA. Ms. 
Hyde has more than 35 years of experience in management and 
consulting for public health care and human service agencies.
    I will now swear in our witnesses.
    You are all aware that the committee is holding an 
investigative hearing, and when doing so, has the practice of 
taking testimony under oath. Do any of you have any objections 
to testifying under oath? Seeing that no one has an objection, 
the chair then advises you that under the rules of the House 
and the rules of the committee, you are entitled to be advised 
by counsel. Do any of you desire to be advised by counsel 
during testimony today? And all the witnesses decline. In that 
case, would you all please rise and raise your right hand, and 
I will swear you in?
    [Witnesses sworn.]
    Mr. Murphy. You are now under oath and subject to the 
penalties set forth in Title XVIII, section 1001 of the United 
States Code.
    You may now each give a 5-minute summary of your written 
statement. Please make sure the microphone is turned on and 
close to your face.
    Dr. Kohn, you may begin. Make sure the microphone is on and 
pulled close.
    Ms. Kohn. Is it on? Got it. OK.
    Mr. Murphy. Thank you.

STATEMENTS OF LINDA T. KOHN, PH.D., DIRECTOR, HEALTH CARE, U.S. 
  GOVERNMENT ACCOUNTABILITY OFFICE; RICHARD G. FRANK, PH.D., 
     ASSISTANT SECRETARY FOR PLANNING AND EVALUATION, U.S. 
DEPARTMENT OF HEALTH AND HUMAN SERVICES; ACCOMPANIED BY PAMELA 
S. HYDE, J.D., ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH 
                    SERVICES ADMINISTRATION

               STATEMENT OF LINDA T. KOHN, PH.D.

    Ms. Kohn. Thank you, Chairman Murphy, Ranking Member 
DeGette, and members of the subcommittee. I am pleased to be 
here today to talk about GAO's recent report on Federal 
programs related to serious mental illness. Our report calls 
for leadership from HHS to coordinate Federal efforts in 
addressing the needs of this very vulnerable population.
    Our report has three major findings, and I will touch 
briefly on each. First, we found 112 programs across eight 
different agencies that serve the needs of people with serious 
mental illness, and 30 of these programs target or specifically 
focus on people with serious mental illness. We believe it is 
unlikely that all the programs were identified because agencies 
had difficulty identifying them, not because they weren't 
willing to, that was not an issue, but the agencies didn't 
always have information on the extent to which a program was 
serving the seriously mentally ill, although they knew that 
their programs were serving that population; for example, a 
program related to homelessness.
    The list we think is also incomplete because agencies 
varied in how they decided which programs to include in their 
responses to us. So, for example, DoD identified all of their 
suicide prevention programs in their list of programs for the 
seriously mentally ill, but SAMHSA initially did not because 
they saw the program as serving a broader population. 
Subsequently, SAMHSA added these programs to the list.
    There was another example, HUD and VA jointly administer a 
housing program for disabled veterans. VA put it on the list of 
programs, HUD didn't put it on the list of programs. So there 
are a number of examples like that, and it is that kind of 
variation that can limit comparability among similar programs. 
So this list is a starting point, not an ending point.
    Our second objective related to coordination, and we found 
that while the staff involved in implementing these programs 
reported taking steps to coordinate activities with staff in 
other agencies, we were unable to identify any formal mechanism 
to support interagency coordination at a higher level. And such 
coordination, GAO believes, could help comprehensively identify 
the programs, resources, and potential gaps or duplication in 
Federal efforts that support the seriously mentally ill.
    In the past, HHS has led the Federal Executive Steering 
Committee for Mental Health with members from across the 
Federal Government, but that group hasn't met since 2009. HHS 
told us that another group, the Behavioral Health Coordinating 
Council, performed some of the activities previously done by 
the Steering Committee, but that council is limited to HHS and 
doesn't have members from across the Federal Government.
    We identified examples of other interagency committees, but 
they tended to be broader in scope, such as the focus on 
homelessness or focused on a specific population such as 
veterans. It is important to emphasize, and has been noted, 
that the staff that carry out the programs reported to us that 
they were working with colleagues in different agencies, and 
trying to coordinate their efforts. That is a very positive 
thing in place, however, staff at the program level are not 
necessarily in the right position to identify possible gaps, 
potential duplication, whether Federal resources are being 
spent wisely. Getting that kind of an overarching perspective 
requires some higher level, interagency coordination, and we 
called on HHS to establish a mechanism for that. HHS did not 
agree because they said that coordination is already occurring 
at the programmatic level, but for the reasons I noted, we 
continue to believe that action is necessary.
    Our third recommendation related to evaluation, and we 
found that as of September 2014, across the 30 programs that 
specifically target the seriously mentally ill, fewer than \1/
2\ had evaluations that were done in the last 5 years or were 
underway. Of the completed evaluations, SAMHSA had evaluated 
the greatest proportion of their programs, seven of the 13 
programs they listed, and had two evaluations underway. And 
there were a couple of other evaluations that were done at DoD.
    We recognize program evaluations can be costly and very 
time-consuming, and that the agencies need to prioritize those 
efforts. Our report also notes that the agencies reported to us 
that they do other program monitoring activities. They look at 
data performance measures, they stay on top of the literature 
to understand how to improve programs and identify 
improvements, and again, that is a very important component, 
but we don't believe that performance monitoring takes the 
place of formal program evaluations that can examine the 
overall effectiveness of a program.
    We called on four agencies that sponsor programs that 
target the seriously mentally ill; specifically, DoD, Justice, 
HHS, and VA, to document which of their programs should be 
evaluated and how often. DoD, Justice, and VA agreed with our 
recommendation; HHS did not agree, and suggested our report 
overemphasized the role of evaluations, but again, we continue 
to believe that action is needed.
    That concludes my prepared remarks. Thank you very much.
    [The prepared statement of Ms. Kohn follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
        
     Mr. Murphy. Thank you, Dr. Kohn.
    Dr. Frank, you are recognized for 5 minutes.

              STATEMENT OF RICHARD G. FRANK, PH.D.

    Mr. Frank. Good morning, Chairman Murphy, Ranking Member 
DeGette, and members of the subcommittee. My name is Richard 
Frank, and I am the Assistant Secretary for Planning and 
Evaluation. I am pleased to be here to discuss coordination of 
care for people with serious mental illness. I have dedicated 
much of my career to studying mental health care and mental 
health policies, so it is gratifying to participate in a 
serious conversation on this issue.
    The occasion that brings us here is the release of GAO's 
report on efforts to coordinate care for people with serious 
mental illness. Past GAO reports on serious mental illness have 
had profound effects on this Nation's mental health policy. I 
think of the 1977 report, Returning the Mentally Disabled to 
the Community, Government Needs to Do More, as having set the 
standard. The GAO showed how government could best support 
people with serious mental illness by improving the care they 
receive from community providers.
    Today's report falls short of that earlier effort. It 
doesn't adequately make the connection between government 
activities and meeting the complex needs of people with serious 
mental illness.
    In the time I have with you, I aim to make some of those 
connections; one, by offering a more complete view of HHS 
programs that serve people with serious mental illnesses; two, 
by describing the investments that we are making to coordinate 
services for this population; and three, to explain our 
evaluation efforts.
    Serious mental illnesses are not a diagnosis. Serious 
mental illness is how we talk about a collection of conditions 
and impairments that disrupt peoples' lives, much as the 
chairman mentioned. Therefore, serious mental illness does not 
fall easily into quantified categories of programs, peoples, 
and dollars.
    Let me begin first by outlining the role of the Federal 
Government in serving people with serious mental illnesses, and 
putting that into context.
    Medicare and Medicaid Supplemental Security Income and 
Social Security Disability Insurance are the largest sources of 
public support for people with serious mental illnesses. With 
regard to HHS programs that pay for and deliver mental health 
services, Medicare and Medicaid account for 40 percent of 
national spending on mental health care, and an even larger 
share of care for people with serious mental illnesses. All 
other Federal programs, including SAMHSA's programs, account 
for 5 percent of spending. The remaining 55 percent is made up 
of spending by private insurance, state and local government 
expenditures, and out-of-pocket payments by households. By 
focusing on the 5 percent, the GAO report overlooks much of HHS 
activities regarding caregiving and support for people with 
serious mental illnesses. HHS leadership recognizes the need to 
coordinate services for this population. Coordination can be 
thought of in a number of ways. It can occur at the level of 
formal coordination across large Federal agencies, at the 
program level, at the provider level, or at the level of the 
individual beneficiaries where providers, programs, and people 
interact.
    People do not live their lives according to program 
boundaries, and we have learned not to run our programs as if 
they do. As a result, we have been making substantial 
investments in new organizations and institutions that 
coordinate public services at the level of the individual 
beneficiary. A few important examples include SAMHSA's Primary 
Behavioral Health Care Integration, or PBHCI, Program, Medicaid 
Health Homes, and the Integrated Care demonstration for 
beneficiaries that are dually eligible for Medicare and 
Medicaid.
    The GAO report also raised the issue of evaluation to 
develop evidence to guide program design and funding decisions. 
We have, and are conducting a variety of important and rigorous 
evaluations of programs that coordinate care for people with 
serious mental illnesses. They include evaluations of programs 
run by SAMHSA, CMS, Social Security, HUD, and by states using 
Federal program funds. The results of evaluations have shaped 
legislation, program design and regulations.
    I will highlight two to give you a flavor of our efforts. 
First, ASPE has worked with SAMHSA to evaluate primary 
behavioral health care integration programs, showing how 
coordination across providers affects health and mental health 
of people with serious mental illnesses. Second, we will be 
evaluating early intervention programs for serious mental 
illnesses, in conjunction with the Social Security 
Administration and in relation to SAMHSA's block grant set 
aside. In addition, SAMHSA, ASPE, and CMS are jointly 
developing new performance and quality measures that are 
essential to conducting evaluations and monitoring progress.
    This Administration has shown a deep commitment to 
addressing mental health care, and support for serious mental 
illnesses, specifically. It is that commitment that was an 
important factor in my returning to work here at HHS. I am 
proud of the record to date, but I know we can do more. More 
needs to be done, and I hope to join you in doing just that.
    Thank you.
    Mr. Murphy. Thank you.
    Ms. Hyde, you are recognized for 5 minutes.

               STATEMENT OF PAMELA S. HYDE, J.D.

    Ms. Hyde. Good morning, Chairman Murphy, Ranking Member 
DeGette, and members of the subcommittee. My name is Pamela 
Hyde and I am the Administrator of the Substance Abuse and 
Mental Health Services Administration.
    In 2014, over \3/4\ of SAMHSA's mental health funding was 
targeted toward improving the lives of persons with serious 
mental illness, or SMI. Individuals with SMI in their families, 
like those I have met, served, and advocated for over 4 
decades, are the reason we are, at SAMHSA, working so hard to 
coordinate critical Federal programs to maximize the impact on 
the ground for those who need it the most. For example, SAMHSA 
and other HHS agencies work with the U.S. Interagency Council 
on Homelessness, the Departments of Veterans Affairs and 
Housing and Urban Development, to prioritize the needs of 
veterans and individuals experiencing chronic homelessness; 
many of whom have serious mental illnesses. Because of these 
joint efforts, 25,000 fewer people experienced chronic 
homelessness in 2014 than in 2013, and the number of homeless 
veterans has declined 33 percent.
    I also represent Secretary Burwell as co-chair of the 
President's Interagency Task Force on Military and Veterans 
Mental Health. Through this effort, SAMHSA is working with the 
Department of Defense, VA, and the White House to address the 
mental health needs of military families. SAMHSA also leads the 
Interdepartmental Federal Working Group on suicide prevention, 
and helps fund and support the Federal and private sector 
collaboration that developed, and is beginning to implement the 
Surgeon General's national strategy on suicide prevention.
    In 2014, the National Suicide Prevention Lifeline, funded 
by SAMHSA, and coordinated with the VA, served over 1.3 million 
Americans.
    SAMHSA's Children's Mental Health Initiative coordinates 
mental health, education, juvenile justice, and human services 
structures that serve young people with serious emotional 
disturbances. Evaluations of this program have demonstrated 
impressive results in improving functioning, reducing arrests, 
suicidal thoughts, and days spent in inpatient care, and 
increasing family satisfaction with services.
    Along with the Assistant Secretary for Health, I co-chair 
the Secretary's Behavioral Health Coordinating Council, which 
includes a new subcommittee focused on the needs of persons 
with SMI, and other subcommittees that address issues affecting 
SMI individuals and their families across multiple programs.
    SAMHSA also coordinates Federal efforts informally. For 
example, SAMHSA worked with the Departments of Labor and 
Education to develop and disseminate a toolkit about supported 
employment for persons with SMI. In 2014, SAMHSA implemented a 
new grant program to test how to help states take this 
evidence-based practice to scale.
    In 2014, SAMHSA also implemented new congressional language 
requiring that at least 5 percent of each state's mental health 
block grant funds be used to provide treatment and services for 
individuals with first-episode serious mental illness. SAMHSA 
is coordinating with the National Institute of Mental Health to 
provide guidance and technical assistance to help states 
implement evidence-based interventions to prevent the 
disability often associated with early onset SMI.
    Also new in 2014 is the President's Now is The Time plan, 
which grew out of the tragedy in Newtown, Connecticut, and 
received broad bipartisan support by Congress. This series of 
programs allows us to increase the behavioral health workforce, 
train and support school personnel, and assist youth and young 
adults, especially those with serious emotional disturbances, 
to be identified and receive the treatment they need for 
emerging mental health and substance use problems as they 
transition to adulthood. These new programs necessitate robust 
interdepartmental coordination with other HHS agencies. The 
Departments of Education and Justice, and state education and 
behavioral health entities, as well as students, families, and 
community responders.
    And in collaboration with the Departments of Treasury and 
Labor, SAMHSA and other HHS agencies have coordinated efforts 
to help individuals with significant behavioral health needs 
enroll in newly available affordable care coverage, and to help 
plans and consumers know about their obligations and rights 
under National parity legislation.
    Even though much has been accomplished, we recognize the 
need to do more. The President's 2016 budget proposes a new 
SAMHSA Crisis Services Program to bring together multiple 
state, Federal, and community funding streams, and service 
deliver infrastructures so that emergency rooms, inpatient 
residential and treatment facilities, and jail cells will not 
be the only options for SMI individuals in crisis and their 
families.
    SAMHSA works every day to coordinate and collaborate within 
the Federal Government and across the country to assure 
evidence-based treatment is available and delivered so 
individuals with SMI and their families can live satisfying and 
productive lives. We appreciate Congress' continuing 
partnership in these efforts.
    Thank you.
    [The prepared statement of Mr. Frank and Ms. Hyde follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
           
    Mr. Murphy. Thank you. I thank the witnesses for their 
testimony.
    I am now going to recognize myself for 5 minutes. Just for 
the record, I just want to make it clear, Dr. Kohn, you have 
never treated a patient with mental illness, correct?
    Ms. Kohn. No, I have not.
    Mr. Murphy. Dr. Frank, you never have? You have never 
treated anybody with mental illness, right? That is not your 
field, correct? And, Ms. Hyde, you have never treated anybody 
in the service for mental illness, correct?
    Ms. Hyde. Right.
    Mr. Murphy. I just want to be on the record. That way--yes.
    So, Dr. Kohn, despite HHS's disagreement with your 
recommendations, does GAO stand by its report and its 
recommendations?
    Ms. Kohn. We do. We continue to believe that action is 
needed in both areas. We think there can be greater 
coordination to provide that overarching perspective. It is not 
that we didn't acknowledge a number of----
    Mr. Murphy. OK, I just need to have that yes or no. I----
    Ms. Kohn. Yes.
    Mr. Murphy. Thank you. Dr. Frank, in this 2006 book that 
you wrote, Better But Not Well, you wrote that individuals with 
a mental illness have flexible entitlements to an array of 
largely uncoordinated programs and resources. The resources 
flow from a dizzying range of Federal, state, and private 
organizations. Do you still believe that?
    Mr. Frank. I believe that continues to be the case.
    Mr. Murphy. I want to post these two posters. One is a list 
of all the Federal programs on the right there, and then I have 
put together, based upon the GAO report, the organizational 
flowchart of the programs on the left, using your term dizzying 
array.
    So you still believe that? Yes?
    Mr. Frank. I believe that there is a complex set of needs 
provided by a complex set of organizations for people with 
serious mental illness.
    Mr. Murphy. The law states that SAMHSA must promote the 
coordination of service programs conducted by other 
departments, agencies and organizations, and individuals that 
are or may be related to the problems of individuals suffering 
from mental illness. So yes or no, do you believe SAMHSA is 
responsible for the interagency coordination of mental health 
programs?
    Mr. Frank. I am focused with----
    Mr. Murphy. Well, it is a yes or no. I have just read you 
what is the regulations of law. Is that true or not?
    Mr. Frank. Well, SAMHSA has some responsibilities. What I 
want to do is point out that it is very important in our view 
how services actually get coordinated on the ground for people, 
and part of that is----
    Mr. Murphy. That is a good point.
    Mr. Frank [continuing]. On a Federal level, but part of it 
is also done in other places that involve Federal activities.
    Mr. Murphy. Well, that is a good point. So let me look at 
the bottom line here because I don't want to just talk about 
bureaucracy and the beltway--people don't understand that.
    So first I have a slide up, heart disease mortality rate. 
As you can see, it is going down over the last 10 years. Let us 
look at the next slide. Stroke mortality rate. That is going 
down. Next slide, HIV/AIDS mortality rate, that is going down. 
Next slide, auto accident mortality rate, that is going down. 
The next slide, cancer mortality rate, that is going down. Now, 
none of these are within your wheelhouse, but let us look at 
the next slide. Wow. Suicide mortality rate, it is getting 
worse.
    Ms. Hyde, you just talked about these programs you have; 
one of them being the suicide plans, and I think you even said 
you thought it was having some success, but I look at this--do 
you intend to take any action to respond to either or both of 
the recommendations by GAO about the need to better evaluate 
and coordinate these programs?
    Ms. Hyde. We have taken significant action in this arena 
and brought together a public-private partnership that has 
developed with the Surgeon General a national strategy for 
suicide prevention.
    Mr. Murphy. Well, they said some of these----
    Ms. Hyde. It is only a----
    Mr. Murphy [continuing]. Organizations haven't met for 5 
years.
    Ms. Hyde. It is only a couple of years old. We are just 
beginning to implement----
    Mr. Murphy These organizations have been in place for a 
long time. The mandate of SAMHSA to meet has been in place for 
a long time. The GAO report says that some of these groups 
haven't met since 2009. Now, you said that there is a new group 
which has met once in January. So when you talk about 
coordination of these programs, I just want to deal with--we 
are trying to help here, but I oftentimes tell people when they 
come to this committee, if you want to meet a friendly 
Congress, come in and say, you know what, we messed up big time 
and we have to change this. But when you give me this litany of 
all these successes, and I look at that, that is 40,000 people 
died in this country last year. Forty thousand. One point two 
million suicide attempts requiring some help.
    Now, if we were to also look at the employment rate among 
the mentally ill, it also is getting worse. You also have 
states saying a huge number of people in jails, increase in 
homelessness. I don't know where these numbers come from, but 
when I go around to different states, I am sure where you are 
from colleagues, it is a problem. So you are obligated under 
the law to coordinate these programs. You have the 
Congressional Committee that has jurisdiction over your agency. 
It is concerned over this lack of coordination in this area. 
And here the nonpartisan Government Accountability Office is 
concerned about this. The Assistant Secretary for Planning and 
Evaluation of HHS sitting next to you is concerned about this 
lack of coordination in this area. So are you going to take 
action to change this coordination, not to say we have done it 
in the past, everything is fine, but are you going to make 
further changes on coordination?
    Ms. Hyde. You asked about one thing, and you made a comment 
about a separate thing. So we have taken significant action on 
suicide. We are concerned about those numbers and working on 
it. We have plans in place and a public-private partnership 
that is working to develop approaches to deal with zero suicide 
and health care, and other clinical guidelines and other 
approaches to measuring and dealing with getting people to pay 
attention----
    Mr. Murphy. Well, I----
    Ms. Hyde [continuing]. To suicide. So we have a lot of work 
going on in----
    Mr. Murphy. I appreciate that, and I think----
    Ms. Hyde [continuing]. Coordinating suicide efforts. You 
asked a different question about a different entity.
    Mr. Murphy. Well, it is all related here, and the issue too 
is, as Dr. Kohn also said, that at first, SAMHSA couldn't even 
acknowledge that suicide was related to serious mental illness 
is a problem.
    I am out of time. I will now recognize Ms. DeGette for 5 
minutes.
    Ms. DeGette. Administrator Hyde, I will give you the 
opportunity to respond to the second question that the chairman 
asked, if you would like to, very briefly.
    Ms. Hyde. Yes, we initially didn't--obviously, not everyone 
who has suicidal ideation, or decides that they may want to 
make a plan to hurt themselves, has a serious mental illness, 
but about 90 percent of them do have mental health issues. So 
when first asked was that an SMI program, we were concerned 
with calling it an SMI program. As we went through the work 
with GAO, the distinction between a program that supports 
people with serious mental illness versus a program that is 
specifically and only designated for those individuals was 
made, and in that case, we brought our program into the SMI 
tent.
    Ms. DeGette. And actually, that is a perfect segue, Dr. 
Kohn, to the question I wanted to ask you, which is, you 
testified and your report really talked about how agencies had 
difficulty identifying which programs served the seriously 
mentally ill. Is that because of definitional problems? In 
other words, you might have a program that has a lot of 
mentally ill people it is serving, some of them serious, some 
of them not, by definition. Is it a definitional issue 
sometimes?
    Ms. Kohn. It may be sometimes. We provided a definition of 
what we meant by program, what we meant by serious mental 
illness, what we meant by serious emotional disturbance, SED. 
We provided those definitions. So sometimes it could be that 
there were definitional issues and they counted the programs 
differently. Sometimes an agency might have rolled up their 
programs into 1, another one disaggregated the programs.
    Ms. DeGette. OK, so it is. Dr. Frank, I want to ask you, 
throughout all of your agency's programs, is there one clear 
definition of seriously mentally ill that all of the different 
programs are broken into?
    Mr. Frank. As I mentioned in my testimony, it is very 
difficult to draw a line around a program and say that that 
is----
    Ms. DeGette. So your answer is no, it is not specifically 
polled out?
    Mr. Frank. We have a definition of serious mental illness--
--
    Ms. DeGette. Right.
    Mr. Frank [continuing]. So we can identify the people and 
we can identify the services they need, but there are many 
programs----
    Ms. DeGette. But the programs aren't just separated out for 
that.
    Mr. Frank. The programs don't cut that----
    Ms. DeGette. Administrator Hyde, is this true in SAMHSA as 
well?
    Ms. Hyde. That is correct. There are multiple definitions 
of serious mental illness both in the law and in peoples' 
parlance and how they use that term.
    Ms. DeGette. Do you think in evaluating the programs at 
your agencies, it would be important to make this distinction 
or not? Yes or no will work here if you can do that.
    Ms. Hyde. For any particular program, yes. We are in the 
process of actually redefining SMI for purposes of the block 
grants because the definitions and the DSM and the standards 
for determining who has what diagnoses have changed.
    Ms. DeGette. And, Dr. Frank?
    Mr. Frank. Could you repeat the question?
    Ms. DeGette. Yes, the question is do you think it would be 
important to be able to more clearly identify illnesses--or 
treatments affecting seriously mentally ill patients, or is 
that impossible?
    Mr. Frank. I think the most important thing is to identify 
the people and then we can sort of work up to the programs----
    Ms. DeGette. What the programs they need, OK.
    One of the things Dr. Kohn talked about in her report that 
really struck me was that a lot of the programs throughout the 
Federal Government have really not been evaluated for efficacy. 
And I am wondering, Administrator Hyde, if you can talk about 
what she says, in particular, about SAMHSA, because I am a very 
evidence-based person. If you have a program targeted at the 
mentally ill in general, the seriously mentally ill in 
particular, one might think that you would want to have 
evidence that it works.
    Ms. Hyde. If you look at the report, actually, SAMHSA is 
doing a good job at evaluating our programs. And I am very 
proud, actually, of the work we have done to create a Center 
for Behavioral Health Statistics and Quality to actually 
develop our capacity to do quality measurement, and to do 
evaluations.
    Ms. DeGette. And so you think that kind of evaluation is 
important?
    Ms. Hyde. Absolutely, and we----
    Ms. DeGette. And----
    Ms. Hyde [continuing]. Are doing a lot of it.
    Ms. DeGette. And, Dr. Frank, what about through the other 
agencies?
    Mr. Frank. Yes, we do a tremendous amount of evaluation.
    Ms. DeGette. OK, but a lot of your programs have not been 
evaluated----
    Mr. Frank. Well, actually----
    Ms. DeGette [continuing]. Like that.
    Mr. Frank [continuing]. I think that one of the problems in 
the report is when you overlook 89 percent of the money that we 
spend, and pretend we don't evaluate there, you miss all the 
evaluations we are doing. So we have lots of Medicaid----
    Ms. DeGette. But of the ones you looked at----
    Mr. Frank. Well----
    Ms. DeGette [continuing]. Some of them were not being 
evaluated.
    Mr. Frank. Some of them were not, for example----
    Ms. DeGette. Do you intend to evaluate them?
    Mr. Frank. Well, let us take a particular example. One of 
the four programs that they pointed out was a technical 
assistance program. OK? We don't usually evaluate small 
technical assistance programs, whereas we do evaluate treatment 
programs. And so there is a distinction, and those were not 
brought out very clearly in the report.
    Ms. DeGette. If you could supplement your answers with more 
specific----
    Mr. Frank. Yes.
    Ms. DeGette [continuing]. That would be helpful.
    Thank you, Mr. Chairman.
    Mr. Murphy. Sure thing. Can I just ask, as a clarification, 
because as this hearing goes on we are going to need this 
distinction, when Congresswoman DeGette asked about defining 
things for serious mental illness, and you said we should 
identify the people, what does that mean?
    Mr. Frank. What I think is very important to do is, as you 
said earlier, work from the bottom line up. So let us find the 
people we are worried about here, people with serious mental 
illness, let us look at what they need, let us look at what 
they are getting, and then when they are not getting what they 
need, let us figure out how to fix that.
    Mr. Murphy. So you are acknowledging that is not taking 
place right now.
    Mr. Frank. Excuse me?
    Mr. Murphy. So you are acknowledging that is not taking 
place right now.
    Mr. Frank. I am acknowledging that it--well, as you held 
out, my view of this is better but not well, which means----
    Mr. Murphy. All right.
    Mr. Frank [continuing]. We are getting better.
    Mr. Murphy. Mrs. Blackburn, recognized for 5 minutes.
    Mrs. Blackburn. Thank you, Mr. Chairman.
    Let us stay with this issue of efficacy because I think it 
is so important. And, Ms. Hyde, I want to come to you on this. 
Your strategic plan, the 2011-2014 strategic plan, does 
acknowledge the need for coordination to solve the problems of 
homelessness, joblessness, educational challenges of the 
serious mental ill. The GAO report says this is not taking 
place, so we are wanting to see where the outcomes are. So does 
SAMHSA believe that the present state of program staff level, 
as opposed to agency level coordination, within and across 
different agencies, and Mr. Frank talked a little bit about 
this, that it is adequate to achieve the GAO-approved standards 
of interagency coordination, despite the concerns expressed by 
the GAO report?
    Ms. Hyde. I think we can always do better, but we do a 
significant amount of work with Justice, with VA, with DoD, 
with a number of other agencies that touch and work with our 
population----
    Mrs. Blackburn. Ms. Hyde, let me interrupt you right there. 
Yes, you are doing work, but we are not seeing that you are 
achieving outcomes. Now, you get $3.6 billion a year. How much 
of that money, and I want a detail on this, how much of that 
money is going to make it down to the local and state agency 
level to help with these problems, and how much of that are you 
all keeping here in D.C. over at the agency? I want to know 
where this money is going and where it is meeting the need, 
because we are not seeing the outcomes. And you can submit that 
to me.
    Dr. Frank, let me come to you. You say serious mental 
illness is a collection of problems. And yes, you have 
substance abuse and mental health, we understand that. Should 
Congress help you out on this? Should we help you and legislate 
a definition of serious mental illness? Do you need us to do 
that to help you get to the point of saying here is a problem, 
we can define it, here is an action item, here is what the 
expected outcome. Yes or no?
    Mr. Frank. I don't think there is a lot of disagreement. I 
think there are ambiguities around the edges, but I would say 
that if you and I and the chairman and the ranking member sat 
down, we would come to a 99 percent agreement on what we are 
talking about here.
    Mrs. Blackburn. OK. Well, then let us pull Congress into 
this, and as we are trying to get to a point of coordination, 
how about working with the Energy and Commerce Committee, or 
perhaps keeping an open mind to GAO's recommendations rather 
than rejecting them outright, so that we can say here is the 
definition of serious mental illness, and here is what the 
expected outcomes are going to be to help individuals. See, I 
don't think we are ever going to get to mental health parity 
unless we can do this. We can admit there is a problem in how 
we address it, how we expend these funds.
    So are you all willing to keep an open mind to the GAO's 
report say maybe we are not meeting the need, and maybe we are 
missing the mark on this one? Are you open-minded about that?
    Mr. Frank. Ms. Kohn?
    Mrs. Blackburn. Each of you. Go ahead.
    Mr. Frank. Yes, OK. I am certainly open-minded to--I think 
the problem that we started the hearing off with that the 
chairman raised, which is what do we do for people on the 
ground, how do we coordinate their care, is absolutely 
something that we have an open mind about how to deal with.
    Mrs. Blackburn. Are you open-minded to working with us----
    Mr. Frank. Absolutely.
    Mrs. Blackburn [continuing]. To get to the bottom of this? 
OK, Ms.----
    Mr. Frank. Absolutely.
    Mrs. Blackburn. Ms. Hyde?
    Mr. Frank. Can I add one other point?
    Mrs. Blackburn. Sure.
    Mr. Frank. I think the very important thing though is we 
need to talk about all of HHS programs, and all the tools we 
have in the toolkit in order to fix the problem, and not just 
focus on 11 percent of the action.
    Mrs. Blackburn. Yes.
    Mr. Frank. We need to focus on 100 percent.
    Mrs. Blackburn. On the total thing. I appreciate that.
    Let me ask you this, Dr. Frank, I only have 24 seconds 
left. If we were to move to zero-base budgeting, where you 
start from dollar one ever year and build out your programs 
based on what is working, would that be helpful to you? So 
would you have more flexibility there?
    Mr. Frank. I was reading Robert McNamara's biography the 
other day. I am not sure where I stand on zero-base budgeting 
there.
    Mrs. Blackburn. OK. I yield back.
    Mr. Murphy. Thank you.
    Now recognize the ranking member of the full committee, Mr. 
Pallone, for 5 minutes.
    Mr. Pallone. Thank you, Mr. Chairman.
    There are always going to be opportunities to strengthen 
and expand the Federal programs that serve individuals living 
with serious mental illness, and I know that the officials here 
from HHS would agree with that statement.
    So I would like to learn more about the new programs and 
other improvements that the department has made since fiscal 
year 2013 when GAO conducted its evaluation, and how the 
department plans to expand its work in the future.
    So in fiscal year 2014, SAMHSA implemented a new set-aside 
in the mental health services block grant requiring the states 
to use 5 percent of their block grant funds to support 
treatment for individuals in the early stages of serious mental 
illness.
    Administrator Hyde, can you describe how states will be 
using that funding, and how will SAMHSA be monitoring and 
evaluating this initiative?
    Ms. Hyde. Thank you for the question. First of all, we are 
very pleased with this set-aside approach. We are working with 
all 50 states and working with NIMH to provide guidance and 
technical assistance to them based on evidence-based approaches 
that NIMH has developed.
    Some of the states get very little money out of this 5 
percent set-aside because the block grant is, frankly, not 
enough money for the country. So to the extent that it is a 
very small amount, it is going to be hard to do a consistent 
evaluation. We are working with each state to try to make sure 
within their system they can identify what they are doing, and 
in some states, for example, they are actually putting their 
own money and multiplying these dollars by as much as seven 
times. So different states are going to have different capacity 
to give us, feed us back what they have been able to do with 
it. Some states, they will be able to train people on what the 
new evidence-based approaches are. And other cases, they will 
be able to actually put services on the ground. And in many 
states, Medicaid is going to pay for the actual service for 
some people, whereas the state will be using our dollars to 
evaluate, to oversee, to train, and to direct the traffic.
    Mr. Pallone. OK, thanks. In your testimony, you mentioned 
that many people living with serious mental illness are 
unemployed. And in fiscal year 2014, SAMHSA launched the 
Transforming Lives Through Supported Employment program to help 
address this problem. Can you elaborate on how this program 
specifically supports individuals with serious mental illness, 
and what other partners does SAMHSA work with on this program?
    Ms. Hyde. Yes. This is a program that we work with the 
Department of Labor, and now within HHS because the program has 
moved over to the Administration on Community Living to 
implement an evidence-based practice that we developed through 
evaluation and through research and approaches a few years ago 
to develop a toolkit that is actually specifically for people 
with serious mental illness, and specifically supports them in 
gaining and maintaining employment.
    We have seen increases in employment using that approach. 
And so what we are trying to do with this very small amount of 
transformative money is help a state figure out how to take 
that to scale using their multiple systems and approaches 
within their state. So their labor departments, their job 
departments, whatever departments they have that make those 
things and those supports available in their state.
    Mr. Pallone. OK. Last week, SAMHSA outlined additional 
plans to support individuals with serious mental illness in its 
fiscal year 2016 budget request. So I wanted to ask you if you 
could tell us about the demonstration program that SAMHSA has 
proposed to improve state and local responses to behavioral 
health crisis.
    Ms. Hyde. Yes, thank you for that question. The crisis 
program which I mentioned is, again, one we are really excited 
about because there has been a lot of conversation about 
emergency rooms and appropriate use of emergency rooms, and 
that is the only option that people have, or people ending up 
in jails and prisons when they really should be getting 
treatment, or lack of inpatient beds, and all of that, when you 
look at it, surrounds the issue of how you deal with a crisis. 
How do you prevent it, how do you de-escalate it, and how do 
you follow up so that it doesn't happen again, and how do you 
engage the family as well as the individual in managing that 
process.
    So we are proposing a crisis services system program to try 
to see if we can bring those multiple funding streams and 
multiple systems together in a few communities to test and 
demonstrate how best to do that. These are multifaceted systems 
that have to work with that. We do have some evidence that if 
we do it right, we can prevent the need for so many inpatient 
beds, and certainly prevent the boarding and other kinds of 
inappropriate emergency room use.
    Mr. Pallone. Did you want to mention any other initiatives 
that HHS hopes to launch or expand in the next fiscal year to 
support individuals with serious mental illness?
    Ms. Hyde. Well, we are expanding other areas for veterans' 
mental health, we are expanding mental health workforce issues, 
because that is a huge and growing issue for our ability to 
meet goals. And we are actually also expanding tribal mental 
health issues to try to make sure that we can address mental 
health issues in Indian country, which have been sorely 
unaddressed, especially for young people who are dealing with 
suicide issues, bullying issues, job issues, and other things.
    So we are trying very hard to focus on this transition-aged 
youth. We also have a healthy transitions program that we are 
going to continue in the next fiscal year through the 
President's budget. So trying to put all of that together to 
deal with that group or that set of young people, first episode 
issues and trying to prevent, as the chairman said and Ms. 
DeGette said, to try to prevent it from getting to be a more 
serious problem later.
    Mr. Pallone. Thank you.
    Mr. Murphy. Thank you. Just as a follow up to something 
that Mr. Pallone had mentioned, and you talked about the block 
grant program, I want to clarify, in your draft block grant 
application here, when it comes to the block grants, you 
actually say that these block grants--you don't talk about 
being for serious mental illness. In fact, you say the 
opposite, ``it is about everyone, not just those with illness 
or disease, but families, communities, and the whole 
population, with an emphasis on prevention and wellness.'' That 
is not serious mental illness. So I want to make it clear that 
when you are responding to Members on this, if it is partly 
related to mental illness, let us know that, but don't tell us 
the whole thing is related to that because it is not.
    Ms. Hyde. Mr. Chairman, the people with serious mental 
illness have been documented to have significant health 
problems. They die sooner----
    Mr. Murphy. Yes.
    Ms. Hyde [continuing]. Than other people, and some cases 
with serious mental illness, years and years earlier, mostly 
from preventable health issues.
    Mr. Murphy. Right.
    Ms. Hyde. So our wellness efforts are definitely directed 
toward people with serious mental illness who, we don't want 
them to die----
    Mr. Murphy. I----
    Ms. Hyde [continuing]. And we don't want them to have 
diabetes.
    Mr. Murphy. I will challenge that later, but I need to get 
on to the next Member.
    Mr. McKinley is recognized for 5 minutes.
    Mr. McKinley. Thank you, Mr. Chairman. And thank you for 
holding this hearing. I think that this is something that you 
have been championing for the 4 years I have been in Congress, 
and I really applaud you for the efforts of trying to get 
better attention on serious mental illness. So congratulations 
on continuing to move this.
    But, Ms. Kohn, I have a question of you, if you could. You 
heard a lot of the testimony. I saw you studying those charts 
that showed the mortality rate dropping, and we have heard some 
folks here explain how they really are making progress. That is 
the spin of Washington.
    So my question is, based on what you have heard, what you 
have studied, do you believe that HHS and SAMHSA have done 
everything they can to reduce the chance of duplication, and in 
particular, really supporting mental illness in this country? 
Do you think they are doing everything they can?
    Ms. Kohn. Our report acknowledges the variety of activities 
they are undertaking right now, but we do believe there is room 
for improvement, particularly in areas related to greater 
interagency coordination, and greater evaluation as part of 
helping uncover, develop, advance the data--the evidence base 
for treatment of mental illness----
    Mr. McKinley. OK, thank you.
    Ms. Kohn [continuing]. And serious mental illness.
    Mr. McKinley. Ms. Hyde, you appeared at this committee back 
in 2013, and you acknowledged apparently during that, I wasn't 
on the committee at the time, that some of the organizations 
that SAMHSA is funding may be running programs or expressing 
opinions that are at odds with SAMHSA. Is that still accurate?
    Ms. Hyde. When we fund a program, we fund them for a 
specific activity. They may have positions that they take 
before Congress or in the press, or any place else, that they 
have a right to take, that is not associated with our program.
    Mr. McKinley. But are you funding agencies that--for 
example, one was apparently cited during that meeting that you 
were funding a group that encouraged individuals with serious 
mental illness to experiment going off their doctor-prescribed 
medicines.
    Ms. Hyde. We do not fund going off medications. We do fund 
assistance and helping----
    Mr. McKinley. But----
    Ms. Hyde [continuing]. People understand medications and 
how best to work with their doctors.
    Mr. McKinley. But you are funding the National Coalition of 
Mental Health Recovery. Dr. Fischer has put out articles about 
how it is designed to help people--in their literature, their 
newsletter, how to come off their psychiatric medicine on their 
own. So----
    Ms. Hyde. We do not fund that organization for----
    Mr. McKinley. I am sorry, but----
    Ms. Hyde [continuing]. Any of those positions.
    Mr. McKinley [continuing]. You funded it to $330,000.
    Ms. Hyde. If you listen to my whole sentence, we don't fund 
that organization for that position----
    Mr. McKinley. Well, I saw you make fun of the other--so I 
guess I need to get--because I saw your look, and I may be deaf 
but I can read body language and I saw your disgust with the 
question asked earlier. So I am concerned that you are funding 
some of these programs, and I hope that you will be more 
cognizant, more careful about the agencies that you are 
funding.
    I am curious about one other that I haven't seen. Is SAMHSA 
taking a position on the--I guess it is the medical use or 
maybe just the use of marijuana for relieving anxiety? Has 
SAMHSA taken a position on whether or not marijuana is a drug 
that might help people with mental illness?
    Ms. Hyde. Our position on marijuana is that for young 
people, it is unacceptable and inappropriate in any case, in 
any state, anywhere. And our efforts around marijuana are 
primarily around prevention and dealing with underage use where 
the evidence shows that it has negative educational and social 
and other implications for young people. Same is true of 
alcohol.
    Mr. McKinley. OK, but I am just staying with marijuana----
    Ms. Hyde. That is in our effort----
    Mr. McKinley [continuing]. That the epidemiological studies 
have indicated that there is beyond a doubt that the marijuana 
use increases the risk of schizophrenia. Do you agree with that 
report that I have a copy of here?
    Ms. Hyde. We are concerned about the issues with marijuana, 
and we are working with NIDA and with other entities within HHS 
to look at----
    Mr. McKinley. So do you fund----
    Ms. Hyde [continuing]. The research issues.
    Mr. McKinley. Do you fund--we have such short time. You 
know the game here. Do you fund any organization that supports 
the use of marijuana as a treatment?
    Ms. Hyde. I don't know the answer to that.
    Mr. McKinley. Could you get back to me on that----
    Ms. Hyde. I don't know whether or not the----
    Mr. McKinley [continuing]. Please?
    Ms. Hyde [continuing]. American Psychological Association 
supports it, and we do fund them.
    Mr. McKinley. OK, in the time frame that I have----
    Ms. Hyde. I don't know whether or not other organizations--
--
    Mr. McKinley [continuing]. Dr. Frank----
    Ms. Hyde [continuing]. Support that.
    Mr. McKinley. Dr. Frank, if you could, please, last week we 
had on a meeting here about the influenza and the vaccines, do 
you know of any group that the HHS is funding along the same 
line of reasoning, any group that we are funding that is 
advocating not using vaccines?
    Mr. Frank. I don't know the answer to that question. I 
would be happy to find out and get back to you on it.
    Mr. McKinley. You understand the question?
    Mr. Frank. No, I understand the question, I just don't know 
the answer.
    Mr. McKinley. Yes, OK. If you could please.
    Mr. Frank. Yes.
    Mr. McKinley. It would make a lot of----
    Mr. Frank. I think it is a perfectly reasonable question, I 
just don't know the answer.
    Mr. McKinley. OK, if you could get back to us and----
    Mr. Frank. Sure.
    Mr. McKinley. Thank you very much. I----
    Mr. Murphy. Thank you. Mr. Kennedy, you are recognized for 
5 minutes.
    Mr. Kennedy. Thank you, Mr. Chairman. And I thank the 
witnesses again for their testimony.
    I just want to put the discussion today in context, which I 
think is an extraordinarily important discussion, and hopefully 
we can try to find some ways to work together on making sure 
that these programs are getting to a population that needs some 
extra assistance.
    But, Dr. Frank, I think in the HHS response letter, they 
put into context that--of Federal Government expenditures on 
mental health, Medicaid pays for about 27 percent, Medicare is 
about 13 percent, private insurance is about 26 percent, and 
all of the other programs that are subject to today's 
discussion are roughly 5 percent. Is that right?
    Mr. Frank. Correct.
    Mr. Kennedy. So the discussion that we are having here, as 
integral as it is to making sure the system works better, we 
are also talking about 5 percent of the overall mental health 
spending in this country. So if we are looking at a much more 
systemic approach, one would say we should also focus on the 95 
percent of the rest of that funding, and how to reform that 
delivery system and make sure that care is much enhanced. Is 
that fair to say?
    Mr. Frank. Yes. I think that is exactly the point I was 
making, not to in any way diminish our need to pay attention to 
the 5 percent, but the other part, the other 40 percent really 
needs attention, and that is why our integration efforts on 
Health Homes, on duals, on expanding SNPs, on expanding case 
management, are so important because they happen in that other 
part.
    Mr. Kennedy. When I am back home, Doctor, I hear all the 
time about lack of beds, lack of availability at doctors, lack 
of wraparound services. It strikes me that a lot of that has to 
do with incentives and the way the Federal Government 
reimburses doctors, hospitals, clinicians that are working in 
this field. You align those incentives properly, you are going 
to get the beds, the treatment facilities, the incentives for 
doctors to treat. Is that fair to say?
    Mr. Frank. I am an economist and I believe that.
    Mr. Kennedy. OK, thank you.
    So with that as context, I do want to go back to the basis 
of the report for a quick minute. The report indicates, ``that 
coordination specific to serious mental illness was lacking 
among interagencies, committees,'' but it goes on to say that, 
I believe again, ``staff from 90 percent of the programs 
targeted serious mental illness reported coordinating with the 
counterparts in other programs.''
    The coordination we are talking about doesn't happen 
because it is legislated, it will only be enhanced if there is 
a cultural change at some senior staff level, and a willingness 
to implement both the letter and the spirit of the law.
    Dr. Frank, how can we engage senior staff, and does that 
interaction at the staff level suffice, or is more senior staff 
interaction necessary? We will start with you and go from 
there.
    Mr. Frank. I think your point about culture is very 
important, and I think this Administration has been 
extraordinarily attentive to building that culture. 
Administrator Hyde has had a central role in that, taking steps 
to reach out far beyond their 5 percent there into Medicaid and 
into other areas. Our Secretary is extraordinarily supportive 
of these matters. And so the result is we have tremendous 
amount of joint activities with HUD, with SSA, with Labor, with 
Treasury, et cetera, and it is really those types of focused 
working groups across the government that have really, I think, 
improved our ability to coordinate with in a variety of 
problem-specific areas.
    Mr. Kennedy. Thank you, doctor. I will just stop you there 
because I have about a minute left. And, Ms. Hyde, if you have 
a response to that.
    Ms. Hyde. I think I would just echo Dr. Frank. The 
recommendation that was made was about a specific type of 
infrastructure that we think isn't going to be the best way to 
address the issue on the ground. So that is the distinction we 
are trying to make here, that we have a lot of coordination 
going on, we believe in coordination, but the particular 
recommendation and the approach seems just like more 
bureaucracy.
    Mr. Kennedy. So if creating that or strengthening that 
interagency working group from the senior level isn't the right 
way, and understanding that you are pushing coordination now, I 
realize I only have about 30 seconds, but what would you 
suggest, in 30 seconds, to really push that out to the lowest 
levels on the ground and try to enhance that coordination even 
more so? I think it is hard to debate the fact that that is 
needed.
    Ms. Hyde. I think it is multifaceted. We have to have 
person-to-person interactions, we have to have working groups 
on specific issues as what we described, we have to have staff-
to-staff level programmatic interactions, and we have to push 
our grant programs to require coordination at the state and 
grantee level. So we are doing all of those things, and trying 
to bring that together where it works on the ground for 
individuals.
    Mr. Kennedy. Thank you. I yield back my extra 7 seconds.
    Mr. Murphy. Do you want Dr. Kohn to also answer your 
question too because she didn't get a chance to answer----
    Mr. Kennedy. Yes, if you don't mind.
    Mr. Murphy [continuing]. That question?
    Mr. Kennedy. Thank you.
    Mr. Murphy. Dr. Kohn?
    Mr. Kennedy. Please.
    Ms. Kohn. OK, sure. Thank you. I don't think what we are 
putting out here is an either/or, that if there is coordination 
at a local level that, therefore, coordination at the Federal 
level is unneeded, or vice-versa, that coordination at the 
Federal level will supplant the coordination that happens at 
the local level. I don't think there is that kind of a trade-
off. And the concerns we were raising about lack of 
coordination at the Federal level inhibits our understanding of 
the Federal footprint in this area. What are the programs in 
place, recognizing that there is a lot there in Medicare and 
Medicaid and Social Security, as the OMB letter in response to 
this committee had shown, but we didn't start from that 
spending side. We started from the programs, the population 
served. As Dr. Frank noted, people don't fall into neat program 
categories, and that is why that coordination becomes so 
important because that coordination helps identify if there is 
any potential overlap or duplication, are there gaps, are there 
programs that are complementary that aren't being linked 
together, need some stronger linkages so we maximize our 
existing resources in our existing programs. If it is a gap and 
nobody is looking at it right now, then how does the 
coordination happen? It is by definition not visible.
    So the coordination we talk about is not instead of the 
coordination at the local level, it is in addition to.
    Mr. Kennedy. Thank you. Thanks for the extra time.
    Mr. Murphy. Thank you. Mr. Griffith, you are recognized for 
5 minutes.
    Mr. Griffith. Thank you, Mr. Chairman. And I appreciate 
having 5 minutes, but I wish I had a lot more. I would like to 
get the information that Mrs. Blackburn asked for earlier in 
regard to the money as it flows to the state and local levels 
as well. So when you report to her, if you could make sure I 
get a copy of that, I would greatly appreciate it.
    I am going to need some yes-or-no answers because I have to 
fly through this because of the time limitations that we do 
have. But GAO noted that SAMHSA officials did not initially 
include any of their suicide prevention programs among those 
that can support individuals with serious mental illness. Isn't 
that true, Ms. Hyde, yes or no?
    Ms. Hyde. I explained why. Yes.
    Mr. Griffith. And SAMHSA explained to GAO that the suicide 
prevention services it administered were not limited only to 
individuals with serious mental illness, and served a broader 
population. That is also true, isn't it? Yes.
    Ms. Hyde. It does serve a broader population.
    Mr. Griffith. And at the subcommittee's hearing on suicide 
prevention held last September, the Chief Medical Officer of 
the American Foundation for Suicide Prevention noted that in 
more than 120 studies of completed suicides, at least 90 
percent of the individuals involved were suffering from a 
mental illness at the time of their deaths. And I thought I 
heard you say earlier that you agreed with that number, is that 
correct?
    Ms. Hyde. That is correct.
    Mr. Griffith. And my one concern there is that, of course, 
we had the 10 percent. Would you also consider that 90 percent 
to be serious mentally ill, yes or no?
    Ms. Hyde. I don't think researchers think that that is all 
serious mental illness as it might be defined in a functional 
level.
    Mr. Griffith. But it is pretty serious when somebody ends 
up dead, isn't it?
    Ms. Hyde. Absolutely. That is why we had the----
    Mr. Griffith. All right.
    Ms. Hyde [continuing]. Conversation about----
    Mr. Griffith. And----
    Ms. Hyde [continuing]. What to include in----
    Mr. Griffith [continuing]. After further discussion with 
GAO, SAMHSA included its suicide prevention programs, among 
those that can support individuals with serious mental illness. 
Isn't that also true?
    Ms. Hyde. I am sorry, can you repeat that question?
    Mr. Griffith. I can. After further discussion, you then 
submitted the suicide prevention programs, among those that can 
support individuals with serious mental illness, even though 
earlier you had not included them because you thought it was a 
broader audience. Isn't that true?
    Ms. Hyde. We were trying to understand----
    Mr. Griffith. Yes or no.
    Ms. Hyde [continuing]. What GAO wanted, yes.
    Mr. Griffith. OK. And DoD officials initially identified 
all of their suicide prevention programs as supporting 
individuals with serious mental illness. Do you think that 
there might be some institutional bias on the part of SAMHSA in 
favor of dealing with mild as opposed to more severe behavior 
or health conditions that make it more difficult for SAMHSA to 
recognize and act upon the unique nature and impacts of serious 
mental illness or serious emotional disturbances?
    Ms. Hyde. Goodness, no. We were trying to be honest and 
fair about the answer to the question.
    Mr. Griffith. All right. And I appreciate that.
    Here is the reason that I am so concerned on these issues, 
and while I recognize that you all have said previously that it 
is getting better but it is not fixed, I do appreciate that. I 
was a, what we call in our neck of the woods, a street lawyer 
for many years. I can still see the eyes of the mother who 
dealt with, while she was a client of mine, for years her 
paranoid schizophrenic son who ultimately committed suicide. I 
can see a former client standing in the courthouse with his son 
crouched on a bench because he was back into the court system, 
not in the mental health system but the criminal court system, 
yet again, and not knowing what to do. I can see the faces of 
the deputies as they started to go out of the building to deal 
with a verbal fight in the parking lot of the courthouse where 
a son and a father were having a verbal altercation after a 
hearing in the criminal court system, and I had to advise the 
deputies to back off because of the mental illness of the son. 
He would have a violent reaction to the uniforms, not to the 
individuals but to the uniforms, but he would not be violent 
with his father, and they agreed to do that. And then my wife, 
who continues to practice law although I have come here now, 
last week was dealing with, in the juvenile system where she is 
a practitioner and a substitute judge, dealing with a child who 
attempted suicide, having a serious emotional disturbance, 
learning that they couldn't deal with one plan that the 
hospital had come up with because he hadn't been hospitalized 
twice in the last year, he had only been hospitalized twice in 
the last 13 months. And when I said are there questions, I have 
HHS and SAMHSA coming in, are there questions I should ask 
about what we are going to do about this child who is someone I 
know, and who may very well end up being successful at some 
point if we don't do it right. I said are there questions I can 
ask, and her response was, no, they don't have anything to do 
with this.
    I ask you, do you believe that you all need to be 
coordinating to such an extent that experienced practitioners 
in law would know that you have something to do with it when 
there is a suicide attempt, or that there might be a program to 
help? I asked those questions. Nothing came back. And I noticed 
in your report that you had something on the Garrett Lee Smith 
Youth Suicide Prevention Program listed in the GAO study, and I 
texted my wife and I said any of the contacts related to any of 
the cases you have done in juvenile court for the last 16 or 17 
years, have you ever heard of this. Answer is no. So I present 
you with this indictment, and I hope to get some response at a 
later time because my time is up.
    And I yield back.
    Mr. Murphy. Thank you.
    Now recognize Mr. Tonko for 5 minutes.
    Mr. Tonko. Thank you, Mr. Chair.
    Dr. Frank, has the failure of some of our states to expand 
Medicaid eligibility in accordance with the Affordable Care Act 
affected in any way the ability to treat those with mental 
illness or mental health disorders?
    Mr. Frank. Indeed it has. Just to give you a flavor. Among 
people with serious mental illness, in 2010 for example, call 
that the before period, nearly 21 percent of them were 
uninsured and they were disproportionally low-income. And so, 
in fact, the states where you are seeing expansion are getting 
more of those people covered than the states that aren't. That 
opens up a lot of new opportunities for treatment because, as 
you know, Medicaid offers a broad package of services that are 
specifically, in many cases, tailored to people with serious 
mental illnesses.
    Mr. Tonko. Yes. And would you have any data that are 
directly speaking to the mortality rates in those states that 
you could provide to the committee?
    Mr. Frank. I think it is too early to tell now, but just so 
you will know, we are doing an evaluation of the Medicaid 
expansions, and we are doing segments of that evaluation that 
focus specifically on vulnerable populations like those with 
serious mental illness.
    Mr. Tonko. Yes. And if I could ask the three of you, and I 
will start with Dr. Kohn, how do you define serious mental 
illness?
    Ms. Kohn. In our report, we used scientific definitions 
that we worked with SAMHSA to develop. It includes conditions 
such as major depression, bipolar disorder, schizophrenia, 
PTSD. We used a definition that goes about half a page of a 
footnote. It is a scientific definition.
    Mr. Tonko. OK. Dr. Frank?
    Mr. Frank. Well, rather than give you the science, I will 
give you something that most of us would believe in common 
parlance. So typically, I think schizophrenia, bipolar 
disorder, major depression, some forms of major depression, 
some forms of trauma, PTSD, and a variety of other things 
depending on their functional capacity is what I think we 
typically think of serious mental illness.
    Mr. Tonko. And, Administrator Hyde?
    Ms. Hyde. Generally, it is a combination of diagnosis and 
functioning and history. So you generally have to look at all 
three of them to see what the functioning level is. The 
diagnosis is important but not in and of itself enough.
    Mr. Tonko. And so, therefore, is serious mental illness a 
static state?
    Ms. Hyde. Not necessarily.
    Mr. Tonko. OK. Well, there has been a lot of emphasis today 
on SAMHSA's work on treating mental illness, and specifically 
serious mental illness, but we need to keep in mind, I believe, 
that these individuals represent a small portion of the overall 
population living with mental illness. And we also need to keep 
in mind that we will be more effective with these patients by 
treating them early in the course of their illness, and perhaps 
altering the trajectory of their condition, rather than 
reacting to crisis situations that arise time and time again. 
SAMHSA plays an important role in the prevention and early 
detection of serious mental illness, and I have seen that in 
programs that reach my district.
    So, Administrator Hyde, can you discuss some of the ways 
that SAMHSA supports the prevention and early diagnosis of 
serious mental illness?
    Ms. Hyde. Yes, thank you for that question. One of the ways 
we are doing that is to implement the RAISE Program, which is 
the evidence-based practice that NIMH has developed, that is 
interventions both medical and psychosocial interventions done 
at an earlier point in the trajectory of an illness after a 
first episode. We are doing a lot of work in that area. We are 
also starting to look at what is called the prodrome, or prior 
to the first episode. NIMH is beginning to work in this area, 
and we are working with them to try to identify what would be 
the best way to look at that issue.
    We are also looking at healthy transitions, or the 
transition that young people have from age 16 or so to 25, 
which is where a lot of this early first episode happens, and 
we are trying to put programs on the ground to make sure that 
those families and those young people are supported as they 
move into adulthood. And so there are a number of programs like 
that where we are trying to get upstream. We are also doing a 
lot of jail diversion work, trying to make sure that 
individuals who may be headed for jail because of a mental 
health issue can be diverted into treatment and to appropriate 
community-based supports instead of jail. Same thing is true 
with homelessness. People who are homeless on the streets with 
serious mental illness, if we can get them housed in evidence-
based supporting housing programs we can see very good 
trajectories, reduction of emergency room use, et cetera.
    So we have pieces of all of those kinds of programs working 
with our colleagues and other departments.
    Mr. Tonko. I thank you. And I believe we should not lose 
sight of the agency's other critical activities, and how they 
advance your mission as well. So I thank you all for your 
responses.
    I yield back.
    Mr. Murphy. Thank you. And we are glad you moved forward on 
that program with RAISE. We know it is something that this 
committee has raised, the appropriators funded it, and we are 
glad you followed through on what Congress told you to.
    I now recognize Mrs. Brooks of Indiana for 5 minutes.
    Mrs. Brooks. Thank you, Mr. Chairman, and thank you for 
holding this hearing.
    In August of last year, I held a mental health listing 
session in Hamilton County, just north of Indianapolis, 
Indiana, and pulled together advocacy groups, family groups, 
doctors, and luckily, head of our state HHS component FSSA as a 
psychiatrist, Dr. John Wernert, and he participated in this 
session. And we talked about the pressing issues of mental 
health in our state and in our country, and ways that Congress 
could respond. And I have to tell you, a theme of that was the 
fragmentation issue. And even now, as still a relatively new 
Member of Congress, I am amazed at the number of people with 
mental health issues contact our offices, and come to our 
events, including recently a young woman who brought to a 
public meeting stacks and stacks and file folders of her 
correspondence with different agencies, trying to seek help for 
her schizophrenia. And it broke my heart. And then when I read 
this GAO report about the fragmentation, and would just ask all 
of you to look once again at the chairman's chart, and I would 
ask you to take that back to SAMHSA, and I applaud GAO for 
putting together, or attempting to put together, the 
comprehensive inventory, but if healthy people in a discussion 
have a hard time getting through the bureaucracy, how do 
mentally ill people and seriously mentally ill people get help?
    And so, Dr. Kohn, why was it such a challenge in GAO's 
opinion to identify all of these different programs? What 
happened?
    Ms. Kohn. I don't think it had been asked before, so OMB 
had identified where the spending was from the budget 
documents. I think this was one of the first times that the 
agencies were being asked, and so it took a lot of 
conversation. There was a lot of back-and-forth. We had to 
develop a questionnaire and go agency by agency by agency, and 
work with them to try to get the information.
    So I think to some extent, they hadn't been asked that 
before, at least not the folks we were talking to.
    Mrs. Brooks. If I could, there was an organization called 
the Federal Executive Steering Committee that you pointed out 
in your report that was in place after another analysis of our 
mental health system early in the 2000s, and it was in place 
from 2003 until 2008, and it seemed to bring together at very 
high levels the many agencies we are talking about, but it was 
disbanded or has not met since 2009. Is that correct, Dr. Kohn?
    Ms. Kohn. That is correct. It hasn't met since 2009.
    Mrs. Brooks. And so, Ms. Hyde, you indicate all of this 
coordination, but it seems to be at the highest levels only 
within HHS, is that correct? Why was that disbanded? Why was 
the Federal Executive Steering Committee, which brought 
together at the highest levels, why was it disbanded?
    Ms. Hyde. The Steering Committee had accomplished a lot, 
but much of the coordination work had moved into the 
programmatic area.
    Mrs. Brooks. What do you think it accomplished? When we 
have seen the growing numbers, what did it accomplish and why 
would it disband?
    Ms. Hyde. Well, I think it had difficulty solving the 
problem. I think that is our whole point, is one Federal, high-
level coordinating body by itself is not going to solve the 
problem.
    That group did identify programmatic areas where 
coordination needed to happen, and that began to happen at the 
programmatic level. We haven't talked at all about what the 
issue beyond coordination is, which is the lack of services, 
the lack of support, and then as we are getting more people 
able to get access to coverage and services, then that is going 
to be a much bigger and more appropriate way to get services to 
people.
    Mrs. Brooks. Well, and I would agree that there are a lack 
of services and a lack of support, but when there are billions 
of dollars being spent, and I guess I want to ask you, Dr. 
Frank, because you talked about, and my time is running short, 
you talked about populations and programs specific to 
populations, well, what if you are a middle-aged woman who is 
not a veteran, who is not a young person, who is not homeless, 
who is not in the workplace, what programs are there for people 
who don't fit into these populations?
    Mr. Frank. Thank you. I actually start in exactly the same 
place you do with a broken heart for these people and families 
that face these problems, and have trouble navigating their way 
through the system. I think that is exactly it. I think where 
we were uncomfortable with the GAO report was that there wasn't 
enough attention paid to that question you just asked which is, 
we have been trying to build health homes, we have been trying 
to build patient-centered medical homes so that there would be 
a place that people could rely on to help them navigate the 
system, get them through, and make sure their care is 
coordinated across the realm. And that is really a lot of the 
places we have been putting our investments in, coordination.
    Mrs. Brooks. Thank you. My time has run out. We have, 
obviously, much work to do.
    I yield back.
    Mr. Murphy. Thank you.
    Now recognize Mr. Yarmuth for 5 minutes.
    Mr. Yarmuth. Thank you, Mr. Chairman. I thank the witnesses 
for their testimony.
    Anybody who has been in this job for any period of time 
understands the extent to which mental illness impacts our 
various communities and the country as a whole. Tens of 
millions of people affected. And clearly, we have made 
progress. I was proud to have supported the Mental Health 
Parity Act that has made an enormous impact, and obviously 
embodying that in the Affordable Care Act with the expansion of 
Medicaid, in my state has made a remarkable difference. And, 
you know, I don't think any of us would disagree with the 
notion that coordination is important, and evaluation of 
programs is important. We also can't lose sight of the amount 
of resources that are committed to these kinds of activities. 
And I am a member of the Budget Committee and I have seen how 
budget cuts have affected many areas of our social safety net 
and our human services initiatives. Now we are down the return 
of sequestration in October of this year, and we had an 
experiment with it a couple of years ago.
    Dr. Frank and Administrator Hyde, would you talk to us 
about the impact of sequestration potentially on the treatment 
of mental illness throughout the country, and what happened a 
couple of years ago, what impact, if any, there was and what 
the new potential cuts are and how they could impact the same 
kind of care?
    Ms. Hyde. I can talk first about SAMHSA because that is the 
thing I know the best. But certainly, cuts in programs have 
made us tighten, it has made us do less grants, so less ability 
to help communities out there, less ability to do new programs. 
The one set of new programs we have been able to do is in the 
President's Now is The Time plan, which I described. It also, 
frankly, makes us take a second look at how much money we spend 
on things that are not services, so it does make us tighten our 
evaluation efforts at times, and it just overall makes us deal 
with a system that is already significantly underfunded 
compared to a lot of the other, heart disease and other 
mortalities that we are trying to deal with. So I actually 
could give you some comparisons between how much we spend for 
certain of these diseases and the numbers of people that we 
have associated with them, and I think you would be able to see 
what those impacts of those dollars are.
    Mr. Yarmuth. Dr. Frank, you want to comment?
    Mr. Frank. I would agree with that. I do think it has hurt 
our evaluation efforts a bit. I also think it shows up in 
exactly some of the places we have been talking about here 
because we work with HUD on supportive housing, we work with 
Labor on supportive employment type of activities, and for each 
of those we have had to scale back. And so, for example, our 
plans to end chronic homelessness by next year have had to get 
scaled back because the number of housing vouchers has been 
scaled back.
    Mr. Yarmuth. All right, thank you for that. Going back to 
the question of evaluation for a minute, Dr. Kohn, I haven't 
read the GAO report but it seems to me that it might be very 
difficult to accurately assess some of the efficacy of these 
programs because, say you are dealing with a homeless vet with 
PTSD, the program may be able to prevent that vet from 
committing suicide, but certainly hasn't cured his mental 
illness. Do you have a model for evaluation of an efficacy of 
serious mental health programs in the GAO report, and I guess I 
would ask if you do, then I would have Dr. Frank and Ms. Hyde 
comment on whether this is a problematic thing.
    Ms. Kohn. The report doesn't tell the agencies in this area 
to evaluate all of their programs all the time. We say that the 
agencies need to prioritize which programs should be evaluated 
and what is a time schedule for that, because they are costly, 
they are time-consuming, and so we are just telling the 
agencies to prioritize which programs do need to be evaluated.
    Yes, GAO has a number of reports and guidance that it has 
issued in terms of best practices for evaluation. It includes 
having an outside agency doing the evaluation, identifying best 
practices, what works, what doesn't work in the program, making 
recommendations that the agency can act on in terms of how to 
improve the program. So there is guidance there. The other 
piece of the evaluation, of course, is leadership in driving 
the evaluation, asking the question and hearing the answer.
    Mr. Yarmuth. My time is up, Mr. Chairman. I yield back. 
Thank you.
    Mr. Murphy. Thank you. I now recognize Mr. Mullin for 5 
minutes.
    Mr. Mullin. Thank you, Mr. Chairman.
    If you could, could you put that up for me? Ms. Hyde, do 
you recognize what this is here?
    Ms. Hyde. Yes, it is a--yes.
    Mr. Mullin. It is a screenshot from SAMHSA's Web site. I 
believe it is called building blocks for a healthy future, is 
that correct?
    Ms. Hyde. That is correct.
    Mr. Mullin. Can you briefly tell me what that Web site 
does?
    Ms. Hyde. It engages young people and their parents in 
emotional health development. We do have a responsibility to do 
prevention----
    Mr. Mullin. What is the ages----
    Ms. Hyde [continuing]. In young people.
    Mr. Mullin [continuing]. For that?
    Ms. Hyde. I don't remember off the top of my head the 
complete age range, but it is the younger----
    Mr. Mullin. It is for substance abuse----
    Ms. Hyde [continuing]. It is the younger kids.
    Mr. Mullin [continuing]. For young children from the age 
of----
    Ms. Hyde. Yes.
    Mr. Mullin [continuing]. Three to six----
    Ms. Hyde. Yes.
    Mr. Mullin [continuing]. Which I am sure that is a high 
number that we have to deal with. I mean I have five kids from 
10 years to 4 years old, and I am sure there is a high rate of 
substance abuse for 3-year-olds, yet do you know how much money 
we have spent on that Web site?
    Ms. Hyde. Actually, the science tells us that the earlier 
we start----
    Mr. Mullin. No, I----
    Ms. Hyde [continuing]. The better.
    Mr. Mullin. Do you know how much money we have spent on----
    Ms. Hyde. I don't know that off the top of my head. I can 
tell you----
    Mr. Mullin. Ma'am, you are the administrator.
    Ms. Hyde [continuing]. Though that is important that we 
are----
    Mr. Mullin. Ma'am----
    Ms. Hyde. We are----
    Mr. Mullin [continuing]. You are the administrator----
    Ms. Hyde. Yes.
    Mr. Mullin [continuing]. And you don't know how much that 
Web site costs. Because I went through that last night, and 
there is a whole bunch of songs on there which are all knock-
offs of Old McDonald and Yankee Doodle, and I have a 3-year-old 
and I couldn't keep her attention for no time at all on that. 
And guess what, you have had 15,000 visitors, that is it, to 
that Web site for an average of 3 minutes, at a cost of 
$436,000. Now, do you think that is using taxpayer money 
wisely?
    Ms. Hyde. Actually, we are going through a----
    Mr. Mullin. No, ma'am, that isn't what I asked you.
    Ms. Hyde [continuing]. Something we call----
    Mr. Mullin. I said do you think that is a good use of 
taxpayer money?
    Ms. Hyde. I don't know. Please let me finish the question 
and I will tell you. We are actually going through our Web 
sites right now. This is one of them. It is on the list to re-
examine----
    Mr. Mullin. Going through, ma'am----
    Ms. Hyde [continuing]. Whether or not----
    Mr. Mullin [continuing]. The money is already spent. Was it 
a good use of taxpayers' money? $436,000.
    Ms. Hyde. I----
    Mr. Mullin. A total of 15,000 visitors. In Oklahoma alone, 
that would provide 176 outpatient services for the mental ill 
for a full year.
    Ms. Hyde. That is what we are assessing and evaluating 
right now. We are going through each of those Web sites to 
determine whether or not they are appropriate or need to be 
continued, or eliminated or otherwise dealt with.
    Mr. Mullin. How long does it take, ma'am, because we are 
continually putting money in there? We are managing the Web 
site. And what we want to do is efficient and be more 
efficient.
    We have heard throughout this entire hearing that we are 
here to help. We understand there is an issue, but what has 
happened is we are running into a roadblock, and instead of you 
admitting that there is a problem, what ends up happening is 
you get defensive about it. That is not helpful. That doesn't 
prevent anything. All that does is cause a division between us. 
We are not here to make you look bad, we are here to find out 
and see if you are being efficient with the money being spent. 
And so far what I am finding out is no, no, it is not. It is 
not being efficient.
    I have a big stake in this. I have five kids that go to 
school every single day. These are real issues facing every 
parent out there, and yet we are wasting money on a Web site, 
or putting money out here, $436,000, you don't even know how 
much you have spent, and you can't even tell me if it is being 
efficient. Instead, you are saying you are going through it and 
evaluating. We have heard that over and over again today. We 
are going through it, we are going through it, we are going 
through it. You know what, as a business owner, if everything I 
was being evaluated on, I was having to go back and re-evaluate 
it, I would deem that as a failure. Maybe it is time to relook 
at the whole program and say is it really delivering the 
services, is it really coordinating with officials on the 
mentally ill. So far what I have heard, the answer to that is 
no, absolutely not.
    Dr. Kohn, you had mentioned, let me find it here, you noted 
that part of the problem with tackling serious mental illness 
is the Steering and Coordinating Committees that has been 
established to handle the response to the mental illness over 
the past decade are no longer active or focused mainly on 
substance abuse. Is that correct?
    Ms. Kohn. That is correct?
    Mr. Mullin. OK. I yield back. Thank you.
    Mr. Murphy. Thank you.
    Now recognize Ms. Clarke for 5 minutes.
    Ms. Clarke. Thank you, Mr. Chairman. And I thank our 
witnesses for sharing your expertise with us this morning.
    My first question is to Dr. Frank. Unfortunately, many 
states have refused to expand Medicaid coverage under the 
Affordable Care Act, and according to the American Mental 
Health Counselors Association, nearly 3.7 million uninsured 
adults with serious mental health and substance abuse 
conditions will not be covered in states that failed to expand 
Medicaid. To me, that decision is astoundingly shortsighted.
    Dr. Frank, why is Medicaid expansion so critical to this 
population?
    Mr. Frank. Well, in the Chairman's opening remarks, he made 
a very strong case outlining how people experiencing serious 
mental illnesses have their work disrupted, have their 
education disrupted, have their functioning disrupted. And so 
people who have trouble attaching to the workforce, attaching 
to the mainstream of society, tend to have low incomes, tend to 
rely on public programs like Medicaid. And so people in those 
circumstances have a chance to get the best evidence-based 
treatment if they are covered by Medicaid, whereas if they 
aren't, those chances are much lower. And so I think that is 
why it is so important.
    Ms. Clarke. Thank you, Dr. Frank.
    I want to switch over to Administrator Hyde and ask a bit 
about living in a community setting. The report doesn't mention 
the Americans With Disabilities Act, the Olmstead decision, and 
how SAMHSA has been in the forefront of pushing for a service 
system where people with serious mental illness can live in a 
most integrated community setting. How does SAMHSA work to help 
people with serious mental illness living in the community?
    Ms. Hyde. Thank you for the question. We have taken a 
leadership role with a number of other Federal agencies both 
within HHS and outside, DOJ, Office of Civil Rights, to look at 
the Olmstead decision and try to implement it, and try to help 
states understand what they can do. We try to look at the 
housing needs and how people can develop housing, we try to 
look at the employment needs and income needs and how people 
can develop that, and we try to look at the social supports 
that individuals need in the community, and we provide 
training, and sometimes we call them policy academies, bringing 
states together so they can learn from each other, and trying 
to make sure that they have the information they need and the 
program designs that they need, because there are evidence-
based practices to try to develop that. We also try to bring 
things like HUD vouchers and other kinds of resources to the 
table that SAMHSA coordinates with but doesn't control.
    Ms. Clarke. Well, that model is one that I think, 
particularly in a place like New York City where I am from, is 
a preferable one. There seems to be a reliance on the criminal 
justice system to sort of be that community living environment, 
and we have found that there have been a lot of challenges 
within our city's jail systems, for instance, with individuals 
who have been incarcerated and not treated, and the conditions 
under which they have had to live have really compounded their 
illnesses. So I want to commend you for your vision here, and 
make sure that as we go forward, we look at a broader view of 
practices that do work. It is unfortunate that the report 
didn't mention it.
    I wanted to circle back. I know my colleague, Mr. Tonko, 
spoke to intervention, particularly in preventing recidivism. I 
want to talk about early intervention for children, and get a 
sense of the work of the programs that you are doing through 
SAMHSA in early intervention. Could you speak to a little bit 
of that as well?
    Ms. Hyde. Yes, thank you again for the question. If you are 
talking about young children, we have a program called LAUNCH--
--
    Ms. Clarke. Yes, young children.
    Ms. Hyde [continuing]. Which is for zero to 8-year-olds.
    Ms. Clarke. Yes.
    Ms. Hyde. Specifically to build emotional health 
development and to look at early needs that might be emerging 
there. We have some new work that we are doing on the framework 
of Now is The Time to try to look at working with schools and 
communities to be able to identify emerging behavioral health 
issues before they become an issue. We have other prevention 
activities that IOM helped us look at, the Institute of 
Medicine, a few years ago, and bringing both behavioral 
health--well, substance abuse and mental health, because they 
often go together, so issues like what is happening in schools, 
bullying, parenting, bringing multiple systems together to help 
make sure that young person is able to grow and develop in a 
positive way. We are also doing a significant amount of work on 
trauma because we understand increasingly what trauma does to 
young people, and how it creates, actually, adult problems. We 
are also looking at the fact that, frankly, most adult 
behavioral health issues start before the age of 24, and in 
fact, \1/2\ of them before the age of 14. So the younger we can 
start, the better we can build skills and resiliency, capacity, 
moving into adulthood.
    So we do a fair amount of that work. As I said earlier 
though, \3/4\ of our dollars actually go toward persons, at 
least in our mental health environment, goes to persons with 
serious mental illness.
    Ms. Clarke. I thank you for your work, Administrator.
    And I yield back. Thank you, Mr. Chairman.
    Mr. Murphy. Now recognize Mr. Collins for 5 minutes.
    Mr. Collins. Thank you, Mr. Chairman.
    If you could, Ms. Hyde, just kind of keep the questions as 
brief as you can because of the time. I am going to start with 
a fairly simple one. Could you give yourself a grade of 1 to 10 
on how good a job you are doing?
    Ms. Hyde. Tens being good?
    Mr. Collins. Yes.
    Ms. Hyde. I think we are doing 10. I think we have a lot--
--
    Mr. Collins. OK, you are a 10.
    Ms. Hyde [continuing]. More work to do.
    Mr. Collins. That is pretty arrogant in my book, but we 
will put that aside. So you have said you are underfunded, you 
need more money, so I am just going to dive right in and say, 
as you have looked at programs the last couple of years, which 
ones you have just said here, you are going to look at this. 
How many programs have you looked at and terminated because 
they weren't a good use of taxpayer funds in the last 2 years?
    Ms. Hyde. We actually have several programs that have been 
proposed for reduction, some of which Congress has reduced, and 
others of which have continued to be funded.
    Mr. Collins. Could you give me a list, if you could, of 
those that are being recommended and those that have actually 
had their reductions?
    Ms. Hyde. OK.
    Mr. Collins. And when you say you are underfunded, are you 
constantly looking at and evaluating each program like the one 
that Representative Mullin said $436,000, which I think it is 
pretty obvious was wasted money? Are you looking at those, and 
who is doing that evaluation?
    Ms. Hyde. Yes, if you look at the GAO report, I think you 
will see that SAMHSA is actually doing more than----
    Mr. Collins. Who in your organization? Do you have like 
certain people?
    Ms. Hyde. It depends on the situation. In some cases----
    Mr. Collins. Well, either you do or you don't----
    Ms. Hyde [continuing]. We do it internally.
    Mr. Collins [continuing]. Have certain people.
    Ms. Hyde. Some cases ASPE does it, and other cases----
    Mr. Collins. Who is going to evaluate this sing-along 
program?
    Ms. Hyde. Well, as I was trying to explain, we are starting 
the process of evaluating----
    Mr. Collins. No----
    Ms. Hyde [continuing]. That.
    Mr. Collins [continuing]. Who? Who will evaluate that, how 
quickly will it be evaluated, and when could you provide this 
committee an answer on whether that program will be terminated 
and that money, since you are underfunded, redeployed?
    Ms. Hyde. We will be glad to answer that question for you.
    Mr. Collins. And when will I expect that answer? I mean you 
are a 10, so it should be tomorrow. Is that fair if you are a 
10? If you were an 8, I could give you a week or so but since 
you are a 10, is it fair to say you could get that to me 
tomorrow? Who is going to evaluate it, when will we get the 
answers? I am just asking you, can I get that answer tomorrow?
    Ms. Hyde. We will get you an answer as soon as we can.
    Mr. Collins. I guess the answer is no. Well, I think you 
just went from a 10 to about a 7.
    As I look at doing evaluations, best practices, are you 
identifying best practices that other states can learn from? 
Like this state, this program in South Carolina is exceptional, 
they are really working well, let us roll this out across the 
country. Are you identifying actively best practices to assure 
that taxpayer money is being well spent, and since you are 
underfunded, it is even more important?
    Ms. Hyde. Yes, we have a registry of evidence-based 
practices that we are actually in the process of redoing 
because we need to do a better job on that.
    Mr. Collins. You need to do a better job, but you are a 10, 
so that is interesting. Can you provide me a list of the best 
practices that you have identified, very specific, not just 
general let us all do better, specific best practices that you 
have shared with other agencies? Could you get that to me 
tomorrow? You said you already have a list, could you get that 
to me tomorrow?
    Ms. Hyde. We will do our best to get it to you as soon as 
we can. I don't----
    Mr. Collins. So you can't get it to me tomorrow. You just 
jumped from a 7 to a 5. I am asking for direct answers. You 
said you have it. If you have it, you should be able to get it 
to me at 1 o'clock this afternoon. So either you do or you 
don't have it. Do you have it?
    Ms. Hyde. We have the list. I don't know if I can----
    Mr. Collins. So can you get it to me today?
    Mr. Murphy. Well, let us----
    Ms. Hyde [continuing]. Do some electronic version----
    Ms. DeGette. Mr. Chairman----
    Mr. Murphy. Well, let----
    Ms. DeGette [continuing]. We have a standard practice in 
this committee----
    Mr. Murphy. We will expect that.
    Ms. DeGette [continuing]. For witnesses to respond to 
questions.
    Mr. Murphy. Thank you.
    Mr. Collins. Quickly and directly. I am just saying, do you 
have it?
    Ms. Hyde. I can get you a list of what we have, yes.
    Mr. Collins. Tomorrow?
    Mr. Murphy. I think she said she will get----
    Ms. DeGette. Mr. Chairman----
    Mr. Murphy [continuing]. That. We will expect that----
    Ms. DeGette [continuing]. We have a standard practice, I 
would ask--I would urge all of the Members----
    Mr. Murphy. Yes, I----
    Ms. DeGette [continuing]. Of this committee to hold to that 
standard practice----
    Mr. Murphy. That is OK. We will expect that information. 
OK.
    Ms. DeGette [continuing]. And to respect the witnesses.
    Mr. Collins. Yes, and I would appreciate more direct 
answers. I haven't actually had too many employees or witnesses 
who would say they walk on water, and on a scale of 1 to 10 are 
a 10, so I am just taking you at your word. I thought you were 
going to tell me you were an 8. I am surprised at the 10.
    So all I am suggesting is best practices work. You say you 
are underfunded. We have an example here of $436,000 that I 
think, generally speaking, will come back, and I would like 
that as quickly as possible, as wasted taxpayer money that 
could been redirected elsewhere. So I would appreciate a prompt 
response as soon as you can get it to me, and that would be my 
request.
    And I yield back.
    Mr. Murphy. Thank you. We are going to do a second round of 
questions here. I know some Members are coming back--Mr. Cramer 
is here now. All right then, we will have Mr. Cramer. Go ahead, 
I will recognize you for 5 minutes.
    Mr. Cramer. Thank you, Mr. Chairman, and thank you to the 
witnesses.
    I just have one question for Ms. Hyde I was reading the HHS 
budget justification, and in your opening, I think you said 
something to the effect that--and maybe you could tell me what 
you said, what percentage of the SAMHSA budget was dedicated 
last year to SMI?
    Ms. Hyde. SAMHSA's budget is in four buckets. Generally 
speaking, we talk about the substance abuse part of our----
    Mr. Cramer. Right.
    Ms. Hyde [continuing]. Budget as being a little less than 
70 percent. So the vast majority of our budget is substance 
abuse. Of the 30 percent or so that is mental health, \3/4\ of 
that goes to serious mental illness.
    Mr. Cramer. That is what I thought--OK, thank you for that 
clarification. Because in the budget justification put out by 
HHS where it talks about SAMHSA, it never mentions serious 
mental illness. Can you reconcile that omission with the 
commitment that you are talking about today? That just seems 
like somebody is not as committed to it perhaps as you are. Or 
am I mistaken? Because I couldn't find it. I couldn't find any 
mention of SMI in the budget justification from HHS.
    Ms. Hyde. The particular programs that there are some 
programs that are very specifically for serious mental illness 
or serious emotional disturbance. That is the general rubric. 
The block grant programs are that. It is a huge program. What 
we talked about, the primary behavioral health care program is 
specifically for that. A number of other of our programs we 
have already talked about serve people with serious mental 
illness, but they are not targeted to those individuals.
    Mr. Cramer. I guess it is the lack of reference or 
mentioning even raises for me the question of the seriousness 
of the commitment to this particular issue, which is not a 
small issue, this is a very big issue, a very big concern for 
me. If you want to elaborate, I am willing, otherwise I yield 
back.
    Ms. Hyde. Just a quick----
    Mr. Cramer. Sure.
    Ms. Hyde [continuing]. Response. The----
    Mr. Murphy. You can respond.
    Ms. Hyde. The program I told you for fiscal year 2016, the 
reason I was hesitating, I didn't know which justification you 
were talking about, CJ 15 or 14 or----
    Mr. Cramer. Yes.
    Ms. Hyde [continuing]. Sixteen. The new programs that I was 
telling you about, specifically the crisis one, specifically 
mentions serious mental illness. I have that here if you would 
like to see it.
    Mr. Cramer. OK, very well. Yes, what I am talking about is, 
the SAMHSA in brief never mentions serious mental illness. And 
I just--again, what it raises for me, and I think a lot of us 
are struggling with this, is the serious level of commitment to 
SMI, and we hope going forward that there is a greater 
acknowledgement and greater evidence that this commitment is 
real and it is going to be dealt with in substantive ways, as 
opposed to what we did last year.
    I yield back.
    Mr. Murphy. Thank you. Gentleman yields back.
    I do want to say that it is a tradition of this committee 
to let witnesses complete their things. That is why I am even 
asking, after Members have finished their time, to give more 
time to do those things. And so if there was things that the 
witnesses do want to finish up, we will be respectful of that 
because we do want to hear your comments on this. The second 
round, let me raise something here because part of this is some 
of the committee's frustration with getting responses.
    Ms. Hyde, so these are a few questions about what we have 
requested from you. In emails my staff received this morning 
from someone who I think is on your staff, someone named Brian 
Altman who--just so I understand, does Mr. Altman work for you 
or at least represent you when it comes to the committee? Does 
that name sound familiar?
    Ms. Hyde. Mr. Altman is here with me today, yes.
    Mr. Murphy. OK, good. And he has been in that position, I 
guess, for at least this last year from what I understand. So 
as you may know, we wrote Mr. Altman on March 20, 2014, almost 
a year ago, to ask for some very specific information, 
following up on a meeting that was had with several SAMHSA 
officials that very day. We sent our request with as much 
specificity as possible to the department, and specifically to 
Mr. Altman, to respond. Since then, I have to say, this 
committee is very disappointed, we have received very little of 
what we have requested, despite our repeated efforts to follow 
up on that request. I am not sure I have a record of every 
communication of my office and the department on this matter, 
but we followed up on April 7, June 12, June 16, June 26, July 
14, July 22, and September 18, and again, despite all of this, 
we still don't have the overwhelming majority of the 
information we requested, or a satisfactory explanation of why 
it doesn't exist.
    So I was really astounded this morning to be told that my 
staff received an e-mail from Mr. Altman at 8:15 saying the 
following, ``We are still reviewing the multitude of reports 
you have requested, and will provide the reports as soon as 
possible.'' He further writes, ``We have checked with program 
staff and there are no documents regarding technical assistance 
provided to the disability rights center in Maine following the 
Bruce case.'' Now, you are familiar with the Bruce case, we 
spoke about this before. This is the one where the Disability 
Rights Center, in the medical record of the hospital it says 
someone advised him when asked, are you going to harm yourself, 
he said no, someone advised him, are you going to hurt someone 
else, and he said no, under the advice of someone from that 
agency. He then went home and shortly thereafter killed his 
mother. He was on medication, wasn't in treatment, et cetera, 
and so you can understand our concern that we have asked almost 
a year ago, tell us what SAMHSA is looking into this. Now, I 
understand part of the issue is I don't think states are 
required to tell you what they are doing, and I think that is 
important because they receive significant funding from you. So 
I hope you understand our committee's frustration. This is a 
serious case involving a homicide, and someone who was advised 
by an organization that you fund to stop care, despite the 
pleas of the family and the pleas of the treating psychiatrist 
to say this is a dangerous person. So please understand the 
seriousness of our request. We do want to make sure that you 
understand. You are busy, I understand, but this committee will 
make sure we get those records, and you will comply with that, 
right? I appreciate that. Thank you.
    Now, with regard to this organization, Dr. Kohn, you say in 
your report that PAIMI--I think that is one of the things--you 
look at some of the evaluations done, I think you even 
mentioned that they are one of the ones that seems to have a 
report that has good accountability written in there, am I 
correct?
    Ms. Kohn. We identified an example of an evaluation that 
was done that was consistent with some of the principles that 
GAO has talked about. We didn't evaluate that program or the 
quality of that evaluation, we simply cite it as an example.
    Mr. Murphy. So are you aware that the people who did that 
evaluation are people, several of them who are funded by 
SAMHSA, are part of these programs? Were you aware that--I 
don't know if you dug deep enough to know who these people 
were, but several of them appears were on the payroll or have 
direct funding related to this. Are you aware of that?
    Ms. Kohn. We just cite it as an example. We didn't hold it 
up----
    Mr. Murphy. I----
    Ms. Kohn [continuing]. As a----
    Mr. Murphy. I didn't think so. That is OK. I didn't think 
so.
    Ms. Kohn [continuing]. We didn't draw any conclusions about 
the program.
    Mr. Murphy. But it was nonetheless listed. When you say \1/
3\ of the programs, I think, actually had evaluations done, 
and, Dr. Frank, you said that the programs within HHS have many 
of these evaluations, but as I look at this list, Ms. Hyde, I 
am looking at people who--first of all, the evaluation team, I 
don't see a single psychiatrist or psychologist there. I see a 
couple of social workers. I don't know if they practice still. 
I see several attorneys, but in answering the question, 
protection and advocacy for people with mental illness, I want 
to know if they are advocating for those people to get better.
    This case of Mr. Bruce and other cases they have had around 
the country, I want to make sure that they are saying if they 
are in jail and they are getting abused, we are standing up for 
you. If they are in an institution being ignored, we are going 
to stand up for you. But the key should be getting care. And I 
look at this and I must admit this looks like the fox guarding 
the henhouse.
    And so, Dr. Kohn, I hope you will take another look at this 
because I see people here that really should not be telling you 
whether or not a program works. Of course they are going to say 
it works. They get funding from it. Some of these actually are 
the--the person, Curtis Decker, who runs the PAIMI Trade 
Association. Of course he is going to say he is doing a great 
job. I look at other people who say they received money from 
SAMHSA, the projects they work on with SAMHSA. So it is a 
concern that I think when we see these evaluations, and an 
internal evaluation is no use, and particularly because--I 
think it was perhaps you, Ms. Hyde, or, Dr. Frank, saying it is 
important that outside organizations look at this. I agree 
wholeheartedly. That is the way we should look at this. Is the 
research done correctly, and bottom line, are we getting 
results. Not just what they are doing there, and I think under 
these programs too, and we were talking about prevention, I 
want to know if we are getting results. I wish we knew how to 
prevent schizophrenia. I know last summer we identified 108 
genotypes of schizophrenia. I wish we could cure it but we 
can't cure it. We can certainly do early interventions and 
minimize, for a while, not awareness of it, but try and delay 
some of the symptoms. But we don't take of these otherwise, and 
so that is some advice to you.
    And I recognize Ms. DeGette.
    Ms. DeGette. Mr. Chairman, I think this is the best 
subcommittee in the House. This is the subcommittee where Mr. 
Dingell made his name, and I like to think of myself as the 
heir to John Dingell's legacy. And in all his years on this 
subcommittee, he never took the cheap shot, he never attacked 
witnesses personally, he never put them into traps, and I was 
appalled today at the--and you have been with me on this 
committee for 2 years. You know you have never heard me say 
something like this. I was appalled at the way two of the new 
Members of this subcommittee, Mr. Mullin and Mr. Collins, 
conducted themselves today, because this is a serious and 
legitimate investigation. This is an investigation about the 
way our Federal agencies are handling serious mental illness, 
and to bring them in and to refuse to allow these very serious, 
high-level government officials to answer questions, to trap 
them in to a when did you stop beating your wife type of 
answer, it is disrespectful to the witnesses and it undermines 
this committee's grand tradition. So I am glad you said 
something about this, but, however, both of those individuals 
were gone by the time you did. So I hope you admonish them that 
is not in the grand tradition of this subcommittee.
    Now, having said that, I want to follow up on their 
questions. The first one I want to follow up on, Administrator 
Hyde, is the question that Mr. Mullin was asking you about that 
chart. You were attempting to answer the question and he would 
not let you do that. So I am going to ask you, I think that Mr. 
Mullin raises a good point, there are a number of programs 
including some online things that would seem to many of us to 
be unrelated to what SAMHSA should be doing on serious mental 
health issues. You were trying to say, I think, that you were 
evaluating these. Can you please let us know what you are doing 
with these online programs, what criteria you are using, what 
the purpose they have, and when you are going to finish that 
evaluation?
    Ms. Hyde. Thank you, Ms. DeGette. I was trying to say, yes, 
that in fact, we are trying to evaluate this. It is on our 
evaluation list. We are trying to take a look at it. I don't 
have it in front of me here today the numbers he is putting 
out, so I can't say if that is yes, no, or otherwise. We are 
looking at a number of our Web sites who have been actually 
held by a number of contractors, and we are bringing it inside 
so we can control a little bit more about what goes up on those 
Web sites. So we have had a very explicit approach to trying to 
get at the issue of are the Web sites and is the content what 
it should be. So we have done a fair amount of work about that, 
but we are in the middle of it, we are not complete, and this 
is one of them that is literally on the next list that we are 
looking at.
    Ms. DeGette. And what is your time frame for review and 
completion of that?
    Ms. Hyde. Actually, I just got the ability to get that 
scheduled, so I know it is scheduled for next week but I don't 
have a specific time----
    Ms. DeGette. So it is going to be soon.
    Ms. Hyde. With me. It is personally being scheduled with 
me----
    Ms. DeGette. Now, some of these things that this committee 
has, frankly, been quite critical of that you are reviewing, 
those have been around for quite some number of years, is that 
correct?
    Ms. Hyde. That is correct, and sometimes what appears on 
its face to be a coloring book or a song, sometimes there is 
actually science behind the use of those for young children, 
for message and for outcomes. I don't have the answer here 
today in front of me whether this one fits that mold or not.
    Ms. DeGette. Well, perhaps----
    Ms. Hyde. I wouldn't write it off----
    Ms. DeGette. Yes.
    Ms. Hyde [continuing]. On its face.
    Ms. DeGette. So perhaps when you do finish that evaluation, 
you will supplement your testimony and let us know if you think 
that is worthwhile or not.
    Ms. Hyde. I will.
    Ms. DeGette. And the chairman also asked you, and we did 
ask you in the last hearing about that case where apparently it 
was a contractor of SAMHSA apparently told the person to stop 
taking their medication. Can we get the information on that to 
see if SAMHSA had any awareness of that, and if there are other 
situations like that, or how you are choosing those 
contractors? I think that would be helpful to this committee.
    Ms. Hyde. We are working on that. I know it has taken a 
while. We want to be absolutely clear though, because we 
understand the seriousness of the question we are being asked, 
so to the extent that we are reviewing bunches of records, and 
if we see anything that looks inappropriate, we want to go back 
and check it even yet again to make sure that it is or is not--
--
    Ms. DeGette. And so when do you think----
    Ms. Hyde [continuing]. So----
    Ms. DeGette [continuing]. You might be able to get us that 
information?
    Ms. Hyde. It is very high on our list to do. I can't give 
you a specific date, but we have been working through it and we 
are pretty close to being able to give you an answer.
    Ms. DeGette. Thank you very much.
    Thank you, I yield back, Mr. Chairman.
    Mr. Murphy. Thank you. I do want to say, we don't mention 
Members' names when someone disagrees with them, but we will 
follow up, but please understand, a lot of this that I think is 
our frustration is I think sometimes it is just a gut check. 
Like when you were before this committee last year when I asked 
you about the painting, the $26,000 painting of two people 
sitting on a rock, and you told me that was for awareness. I 
think there are some times we just want to see our leaders have 
a gut check to say, you know what, maybe that is not a wise 
spending of taxpayers' money, and that I think sing-along songs 
with the circle, or whatever those other things are, do they 
really work? I think that is what we would like to hear more 
about. So we are looking forward to getting that information.
    And now I want to recognize Mr. Griffith for 5 minutes.
    Mr. Griffith. Thank you very much.
    And I don't think I will be quite as emotional this time as 
I was on the first round of questioning, but I do appreciate 
you all being here, and hope that you understand that even when 
we get a little excited and emotional about the issue, it is 
because we are trying to move the Government in the right 
direction, and there is sometimes frustration, but we are all, 
I think, everybody, you all included on the panel, trying to 
work into the right direction.
    Dr. Kohn, in 2013, the GAO issued a report finding that the 
Office of National Drug Control Policy could better identify 
opportunities to increase program coordination. GAO recommended 
that ONDCP assess the extent of overlap and the potential for 
duplication across Federal programs engaged in drug abuse 
prevention and treatment activities, and identify opportunities 
for increased coordination. It is my understanding that ONDCP 
concurred with this recommendation, am I correct in that?
    Ms. Kohn. Yes, they did.
    Mr. Griffith. And did the fact that ONDCP concurred with 
GAO's recommendation mean that ONDCP totally agreed with GAO's 
analysis, such as the overlap of Federal programs, always being 
a negative?
    Ms. Kohn. No, they identified that sometimes there are 
benefits to overlaps, such as reinforcing messages, that some 
of the goals, if the data were cut different ways, showed 
different----
    Mr. Griffith. So they didn't----
    Ms. Kohn [continuing]. Results.
    Mr. Griffith. They didn't agree completely.
    Ms. Kohn. No.
    Mr. Griffith. But they did, as I understand it, state that 
they were willing to work with the agencies administering these 
programs to further enhance coordination even if it meant not 
eliminating complete overlaps, is that correct?
    Ms. Kohn. That is correct, and in our recommendation 
follow-up, that has been implemented.
    Mr. Griffith. And I guess the question then comes, and that 
was the lead-in, Dr. Frank, so here we have a different agency 
reaction to a similar report. Couldn't HHS have concurred with 
the GAO recommendation even while expressing differences on 
some of GAO's analysis, just like the ONDCP did?
    Mr. Frank. I think the issue here is--well, first of all, I 
understand your emotion and your commitment, and I only respect 
and admire it and that of the whole committee, so thank you for 
that. But I think the problem we had was, when you count 
programs and you count evaluations, and you do so selectively 
and you don't go in behind, so what was in the evaluation, what 
are we really doing with the program, what are you really doing 
over here in Medicaid, we feel like you haven't told the story 
and that is what made us uncomfortable, that we agree. 
Coordination is something that both Administrator Hyde and I 
have spent our careers working on. In fact, the way I met her 
was through a project to coordinate care for people with, at 
that time, chronic mental illness. And that was in 1986.
    Mr. Griffith. All right. We will get to one more point, and 
then I hope I have enough time to make one statement. In a talk 
you delivered in March of 2013, you indicated, and it is on 
YouTube, and at about the 28 minute mark you spoke about the 
dangers of mission creep where the aim of targeting 
particularly high-risk groups becomes diluted to reach lower-
risk populations as well. And you noted at that time that the 
mission creep could have disastrous results. Do you think you 
have your guard up, do you think it is possible that SAMHSA may 
be subject to similar pressures to engage in mission creep, and 
how does this impact their ability to support individuals with 
the most high-risk and severe mental illnesses?
    Mr. Frank. I still believe the admonition, and I think it 
is a question that we have to constantly ask ourselves. Every 
time we make a sort of program decision, a budget decision, and 
a policy decision, we have to ask ourselves are we working for 
the customers that are most important. And I think that is your 
question, and I think that we constantly have to ask ourselves 
that question, and we try to.
    Mr. Griffith. And I appreciate that, and appreciate the 
self-examination is always a good thing even when it is 
sometimes painful.
    Part of your mission is to coordinate and to make sure 
things are efficient. Might I recommend, and maybe you are 
already doing this, and if so, please tell me, that you get a 
few street lawyers out there and it is probably not the right 
term, Mr. Chairman, but street clinicians, but people who are 
out there on the frontlines who might be able to help you 
figure out what is working and what isn't working, particularly 
on making sure that folks know what programs are available. So 
that would be my suggestion to you.
    Mr. Frank. Thank you for that suggestion. Just to remind 
ourselves, to give you an idea, a bunch of us, the deputy 
secretary, myself, our principal deputy, we went out on a 
homeless count the other night and we kind of walked the 
streets just because of that kind of inclination, and we try to 
visit programs, and I know Administrator Hyde does it all the 
time, and I think it is important because otherwise you forget.
    Mr. Griffith. Well, and sometimes it is good to have the 
folks that are out there day in and day out because when it is 
somebody new or different, and it is human nature, they are 
going to whip out the spick and span and make everything look a 
little bit better, but when you have folks who deal with it day 
in and day out and over the course of years, they can give you 
an unvarnished or an un-cleaned up, spic-and-span type view of 
what is happening in the real world. But thank you.
    I yield back.
    Mr. Frank. Thank you.
    Mr. Murphy. Thank you.
    I am going to recognize myself again for 5 minutes.
    Dr. Kohn, when you reviewed the various agencies, did you 
see in there any review between agencies, for example, what we 
hear from states increasing instances of incarceration of the 
mentally ill, did you see that anybody is doing that 
investigation?
    Ms. Kohn. We did not identify that.
    Mr. Murphy. Dr. Frank, or, Ms. Hyde, if you don't, just let 
me know, so it is kind of yes or no or we don't know. Are your 
agencies involved with looking at sort of a state-by-state 
report to the Nation, because we are hearing anecdotally, I am 
hearing from a lot of governors and secretaries who handle 
incarceration that they see increasing rates of people in 
state, county and local jails of people with serious mental 
illness. Is HHS conducting any study of this to give a report?
    Mr. Frank. I will take that one. Yes, a couple of things. 
My agency, ASPE, is conducting a study right now on mental 
illness and violence, mental illness and criminal justice, 
exactly because we have been hearing the same thing you are.
    Mr. Murphy. Do you know when that will be completed? Any 
idea? Within this year?
    Mr. Frank. Within this year.
    Mr. Murphy. Obviously, we would love to see that.
    Mr. Frank. We would be delighted to share it. Also, 
Administrator Hyde and I are actively involved in the Re-entry 
Council, which is an interagency council that is run by the 
Attorney General----
    Mr. Murphy. OK.
    Mr. Frank [continuing]. That focuses on re-entry, and a 
disproportionate share of people that have serious mental 
illnesses.
    Mr. Murphy. Let me raise another question here. With the 
Affordable Care Act, part of this is there is supposed to be 
parity for access. And, you know, we passed a parity bill here 
6 years ago. It took 5 years, I think, for HHS to get us the 
regulations. I am still hearing a lot of concerns that parity 
is not taking place. Is HHS preparing any state-by-state 
evaluation of what states are doing with regard to meeting 
parity guidelines with the insurance companies that operate 
within the states? Is there anything happening with those that 
you know of?
    Mr. Frank. CMS and ASPE sit on that group as well, 
continuously work with insurance commissioners to, A, do more 
technical assistance, and also find out what is going on and 
help them resolve complaints as they come in from consumer 
groups.
    Mr. Murphy. OK. Another thing with this too is that with 
the ACA, a lot of people are finding themselves--they have a 
very high deductible, and I am hearing from a lot of 
psychiatrists, psychologists, social workers that people just 
aren't coming in for their appointments because they say if I 
have a $5,000 deductible for me, or a 10 or 12 or $13,000 
deductible for my family, they are just not coming in for care. 
Is that something that HHS is also investigating to find out 
what those numbers are, and what impact that is having upon 
care?
    Mr. Frank. Yes. We are conducting several sets of analyses. 
One set of analyses we have been monitoring the trends and 
deductibles in private insurance broadly, and we are also 
looking at just the design of the benefit, both in the bronze 
and the silver plans within the ACA.
    Mr. Murphy. But you know what I am saying, is----
    Mr. Frank. Absolutely.
    Mr. Murphy [continuing]. It is very important. I think this 
committee----
    Mr. Frank. And it is very important----
    Mr. Murphy [continuing]. Would like to have that 
information.
    Ms. Hyde, you talked about, when you talked about this, in 
families in serious mental health crisis, you want to engage 
the family. One of the problems we consistently heard also is 
the families said we want to be engaged but HIPAA laws keep us 
from doing that. We keep hearing stories of someone who has 
suffered because a doctor says I can't talk to you. And the 
families say, look, all they want to know is what medication is 
he on so I can follow up. When is the next appointment so I can 
get him there? I know in the past HHS has given us some 
clarification and said doctors can listen to family members, 
they are allowed to do that, but they can't kind of in a cold 
basis if someone calls over the phone and give information. I 
get that. We should protect that. And nor should we release all 
the records. But is this something that we can be addressing to 
say how do we at least get that information when, in absence of 
that information, that person becomes gravely disabled and it 
is necessary for treatment, how are we going to deal with that?
    Ms. Hyde. We worked with the Office for Civil Rights who 
actually was taking the lead on providing the clarification to 
practitioners about what you just said, Mr. Murphy, that 
practitioners can, in fact, listen and they can, in fact, get 
lots of information that can help them with treatment. I think 
there are a lot of clinicians who it is just easier to say I 
can't talk at all.
    Mr. Murphy. But it is that other part about----
    Ms. Hyde. Part of what we are----
    Mr. Murphy [continuing]. Giving information. This is 
something I think we really have to address.
    Ms. Hyde. Yes. Part of what we are trying to do is develop 
some training and some ability to help practitioners understand 
what they can and cannot do, and also to see how----
    Mr. Murphy. This is----
    Ms. Hyde [continuing]. They can utilize existing state laws 
to get at the issue of when someone cannot make a decision for 
themselves.
    Mr. Murphy. I have a couple more questions. I will go to 
Ms. DeGette.
    Ms. DeGette. I am sorry, I have already done my second 
round.
    Mr. Murphy. Well, I am doing a third and a fourth.
    Ms. DeGette. I need to go, so----
    Mr. Murphy. OK.
    Ms. DeGette [continuing]. I would suggest----
    Mr. Murphy. All right. Let me just say this. Dr. Frank, you 
have suggested that GAO has, to paraphrase you, missed the boat 
in its analysis of the coordination between Federal agencies by 
failing to coordinate with, among others, the Medicaid program. 
Now, this kind of goes into the struggle we are having at the 
Federal level, but let me ask you how you coordinate it on the 
ground, as you state. For example, I understand this morning 
the state of Kansas is debating removal of many mental health 
medications from its Medicaid program. Are you even aware that 
Kansas is proposing to remove these drugs? Apparently, the 
Federal Government pays 55 percent of the cost of that program, 
but here is the Kansas proposal to even remove those. Are you 
aware of that?
    Mr. Frank. I am not aware of that specific proposal. We 
have been concerned with the placement of psychiatric drugs on 
formularies generally, and have been examining that pretty 
carefully.
    Mr. Murphy. OK. What was that one other thing I wanted to 
ask? One other question I want to ask about the----
    Mr. Frank. Mr. Chairman.
    Mr. Murphy. Yes?
    Mr. Frank. I would never say that Dr. Kohn missed the boat. 
I have known her for too long----
    Mr. Murphy. OK.
    Mr. Frank [continuing]. To think that.
    Mr. Murphy. All right. Thank you. We don't want to have any 
aspersions about boats or sailors too.
    Another thing, Dr. Frank, in your 2006 book, which we are 
promoting here, Better Not Well----
    Mr. Frank. Yes.
    Mr. Murphy [continuing]. One of the things you suggest is 
this creation of a new Federal agency or authority, it doesn't 
have to be a new agency, with budgetary oversight over all the 
programs that serve people with mental illness. Do you still 
think that is a good idea to give someone that authority so 
they can really, I guess I will use the word mojo, have to go 
to all these agencies and have to answer to someone and say is 
it working, is it not working, is it interacting well, are you 
meeting your targets, do you still believe that?
    Mr. Frank. Well, at the time I wrote that in 2005 the world 
was a somewhat different place, and that was the--you got the 
rationale for why we were proposing that right. What has 
changed since is, for example, the Congress has done a variety 
of legislative things to sort of force some of that on the 
ground. The Melville 811 Act, for example, forces housing and 
Medicaid to come together. And we have added so many 
institutions that now are coordinating better on the ground, 
that what I would like to do is see how that works out before 
adding another level of bureaucracy.
    Mr. Murphy. Well, I am not talking about adding another 
level of bureaucracy, I am talking about someone who really has 
the authority to call for these things that people have to 
respond to.
    Mr. Frank. Yes.
    Mr. Murphy. Because my concern is that, what we are hearing 
from Dr. Kohn's report is it is not being coordinated. I am 
pleased that some action just immediately took place, and that 
some of these agencies have not been meeting in 5 years, so we 
need someone who is singularly accountable to be that pivot 
point. I mean I say in my bill there should be an Assistant 
Secretary of Mental Health, which means someone within this 
agency that has that power and authority to go to DoD and VA 
and HUD and Education and Labor and saying we are going to sit 
down, we are going to hash this out, because somehow having at 
least 112 programs isn't working when we look at the outcome 
measures and all those things to say that. So----
    Mr. Frank. Yes, as you can imagine, I am sympathetic to the 
view, but I really do think that we have changed--the idea that 
we had was in service of making sure that the dollars got 
funneled to the right place, to the right people, at the right 
time. And we are trying a different way right now to do that, 
and I would like to see whether it is successful, because, in 
fact, I have also seen a lot of programs where we tried to 
coordinate the bureaucracies up here, nothing happened on the 
ground. And so I would like to--this time start at the ground 
and then work my way up, and then see what happens. But it is a 
hard problem and I am interested in seeing how our efforts work 
out because I really think they are serious and they are 
important.
    Mr. Murphy. All right. Well, I thank you for those things. 
I also know, Ms. DeGette, I am sure you also support the idea. 
We will work with getting SAMHSA those documents, and she is 
absolutely supportive. And that is the way we are. We want 
those documents we requested a year ago, and get the other 
responses here quickly.
    I thank all of you for being here. This has been a very 
revealing report. Dr. Kohn, thank you so much. I do recognize a 
lot of work has to be done. You have heard that from Members 
here. And I think the best thing here is approach us with 
humility and honesty and saying, you know what, when we look at 
what has happened with mental health in America, it really is 
not good. From the thousands and thousands of families we hear, 
from the frustrations I hear from providers, from consumers, so 
many people saying this isn't working. We have to change this. 
And so let us ease up on saying everything is fine, and let us 
really look at how we have to change this. And if it takes 
legislative changes, we are going to push those, and I am going 
to continue to push that.
    So I ask unanimous consent that the Members' written 
opening statements be introduced into the record. And without 
objection, the documents will be entered into the record.
    And in conclusion, again, I thank all the witnesses and 
Members that participated in today's hearing. I remind Members 
they have 10 business days to submit questions for the record, 
and I ask the witnesses all agree to respond promptly to the 
questions.
    And with that, this committee is adjourned.
    [Whereupon, at 12:29 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                 Prepared statement of Hon. Fred Upton

    Today we continue our examination of federal efforts to 
combat our nation's mental health crisis. This hearing is a 
natural outgrowth of the committee's investigation into the 
federal mental health system. Our work began following the 
heartbreaking December 2012 tragedy in Newtown, Connecticut, 
and we remain committed to addressing the problems that 
contributed to that tragedy.
    Severe mental illness is, and should be, a top priority for 
U.S. public health spending. Unfortunately, the $130 billion a 
year being spent on mental health surveillance, research, 
prevention, and treatment activities, income support and other 
social services has not solved the problem. In Southwest 
Michigan, I've met with my local public health officials and 
local law enforcement and they agree that more needs to be done 
to grapple with these difficult issues.
    Today we gather to discuss how we can better prioritize our 
taxpayer dollars to address the threat of untreated severe 
mental illness.
    Thanks to the bipartisan efforts of this committee, and the 
nonpartisan expertise of Government Accountability Office, we 
now have some answers. GAO reports that there are at least two 
significant problems facing our federal agencies and their 
spending that addresses mental health. First, high-level 
interagency coordination for programs supporting individuals 
with serious mental illness is lacking, and SAMHSA, which is 
charged with promoting coordination on these matters across the 
federal government, seems largely to blame. Second, agency 
evaluations of programs specifically targeting individuals with 
serious mental illness are too few in number and often lacking 
in quality or completeness.
    Although the Department of Defense and the Department of 
Veterans Affairs graciously accepted the GAO recommendation 
targeting their shortcomings, as identified by this report, HHS 
has explicitly rejected both of GAO's recommendations. GAO 
stands by its recommendations, and we're going to hear about 
those recommendations today.
    We are looking for answers. In light of the seriousness of 
the GAO's findings, we must ask: why do HHS and SAMHSA think 
that there is no room for improvement in the areas identified 
by the nonpartisan government watchdog?
    The untold suffering of the families and individuals 
impacted by the programs discussed in this report is simply too 
great, and the cost to the federal purse is too high, to allow 
us to continue on our present path. Lives are at stake, and we 
can and must do better. I thank Chairman Murphy for his 
dedication to this important matter that hits so close to home 
for millions of American families.
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