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

     EXAMINING H.R. 2646, THE HELPING FAMILIES IN MENTAL HEALTH CRISIS ACT

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 JUNE 16, 2015

                                   __________

                               Serial No. 114-55

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                   ___________

                             U.S. GOVERNMENT PUBLISHING OFFICE
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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 Health

                         JOSEPH R. PITTS, Pennsylvania
                                     Chairman
    BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
      Vice Chairman                        Ranking Member
    ED WHITFIELD, Kentucky               ELIOT L. ENGEL, New York
    JOHN SHIMKUS, Illinois               LOIS CAPPS, California
    TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
    MICHAEL C. BURGESS, Texas            G.K. BUTTERFIELD, North Carolina
    MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
    CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
    LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
    H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
    GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
    BILLY LONG, Missouri                 JOSEPH P. KENNEDY, III,
    RENEE L. ELLMERS, North Carolina         Massachusetts
    LARRY BUCSHON, Indiana               TONY CARDENAS, California
    SUSAN W. BROOKS, Indiana             FRANK PALLONE, Jr., New Jersey (ex
    CHRIS COLLINS, New York                  officio)
    JOE BARTON, Texas
    FRED UPTON, Michigan (ex officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Joseph R. Pitts, a Representative in Congress from the
      Commonwealth of Pennsylvania, opening statement................     1
        Prepared statement...........................................     2
    Hon. Gene Green, a Representative in Congress from the State of
      Texas, opening statement.......................................     4
    Hon. Fred Upton, a Representative in Congress from the State of
      Michigan, opening statement....................................     6
        Prepared statement...........................................     7
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     8

                                   Witnesses

    Creigh Deeds, Senator, Senate of Virginia........................    11
        Prepared statement...........................................    13
    Patrick J. Kennedy, Former U.S. Representative (RI), and Founder,
      Kennedy Forum..................................................    17
        Prepared statement...........................................    19
    Jeffrey A. Lieberman, M.D., Chairman, Department of Psychiatry,
      Columbia University College of Physicians and Surgeons.........    23
        Prepared statement...........................................    25
        Answers to submitted questions \1\...........................   135
    Paul Gionfriddo, President and CEO, Mental Health America........
        Prepared statement...........................................    38
    Steve Coe, Chief Executive Officer, Community Access.............    52
        Prepared statement...........................................    54
    Mary Jean Billingsley, Parent, National Disability Rights Network    66
        Prepared statement...........................................    68
    Harvey Rosenthal, Executive Director, New York Association of
      Psychiatric Rehabilitation Services............................    73
        Prepared statement...........................................    75
        Answers to submitted questions \2\...........................   137

                               Submitted Material

    H.R. 2646 \3\
    Congressional Research Service memorandum, submitted by Ms.
      Schakowsky.....................................................   116
    GAO Mental Health report entitled, ``HHS Leadership needed to
      Coordinate Federal Efforts Related to Serious Mental Illness,''
      submitted by Mr. Murphy \4\
    GAO Mental Health report entitled, ``Better Documentation Needed
      to Oversee Substance Abuse and Mental Health Services
      Administration Grantees,'' submitted by Mr. Murphy \5\
    Statement of the American Roundtable To Abolish Homelessness,
      submitted by Mr. Murphy........................................   118
    Statement of the American College of Emergency Physicians,
      submitted by Mr. Murphy........................................   121
    Statement of the National Alliance on Mental Illness, submitted
      by Mr. Murphy..................................................   123
    Statement of the American Psychological Association, submitted by
      Mr. Murphy.....................................................   124
    Statement of the American Academy of Child & Adolescent
      Psychiatry, submitted by Mr. Murphy............................   126
    S. 1299 \6\
    Article entitled, ``Fatal Police Shootings in 2015 Approaching
      400 Nationwide,'' Washington Post, May 30, 2015, submitted by
      Messrs. Tonko and Butterfield..................................   128

    ----------
    \1\ Mr. Lieberman did not respond to submitted questions by the
      time of printing.
    \2\ Mr. Rosenthal did not respond to submitted questions by the
      time of printing.
    \3\ Available at: http://docs.house.gov/meetings/if/if14/
      20150616/103615/bills-1142646ih.pdf.
    \4\ Available at:http://docs.house.gov/meetings/if/if14/20150616/
      103615/hhrg-114-if14-20150616-sd017.pdf.
    \5\ Available at:http://docs.house.gov/meetings/if/if14/20150616/
      103615/hhrg-114-if14-20150616-sd014.pdf.
    \6\ Available at:http://www.gpo.gov/fdsys/pkg/BILLS-114s1299is/
      pdf/BILLS-114s1299is.pdf.

     EXAMINING H.R. 2646, THE HELPING FAMILIES IN MENTAL HEALTH CRISIS ACT

                                  ----------

                             TUESDAY, JUNE 16, 2015

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:07 a.m., in
    room 2123 of the Rayburn House Office Building, Hon. Joseph R.
    Pitts (chairman of the subcommittee) presiding.
        Members present: Representatives Pitts, Guthrie, Shimkus,
    Murphy, Burgess, Blackburn, Lance, Griffith, Bilirakis, Long,
    Ellmers, Bucshon, Brooks, Collins, Upton (ex officio), Green,
    Engel, Capps, Schakowsky, Butterfield, Castor, Sarbanes,
    Matsui, Schrader, Kennedy, Cardenas, and Pallone (ex officio).
        Also present: Representatives Tonko and Loebsack.
        Staff present: Clay Alspach, Chief Counsel, Health; Gary
    Andres, Staff Director; Leighton Brown, Press Assistant; Karen
    Christian, General Counsel; Noelle Clemente, Press Secretary;
    Andy Duberstein, Deputy Press Secretary; Katie Novaria,
    Professional Staff Member, Health; Tim Pataki, Professional
    Staff Member; Graham Pittman, Legislative Clerk; Chris Santini,
    Policy Coordinator, Oversight and Investigations; Adrianna
    Simonelli, Legislative Associate, Health; Sam Spector, Counsel,
    Oversight; Traci Vitek, Detailee, Health; Dylan Vorbach, Staff
    Assistant; Greg Watson, Staff Assistant; Christine Brennan,
    Democratic Press Secretary; Jeff Carroll, Democratic Staff
    Director; Waverly Gordon, Democratic Professional Staff Member;
    Tiffany Guarascio, Democratic Deputy Staff Director and Chief
    Health Advisor; Una Lee, Democratic Chief Oversight Counsel;
    and Samantha Satchell, Democratic Policy Analyst.

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

        Mr. Pitts. The subcommittee will come to order. The
    chairman will recognize himself for an opening statement.
        Today's Health subcommittee hearing will examine the
    legislation authored by our colleague, Representative Tim
    Murphy, H.R. 2646, which is designed to help families
    struggling with crisis caused by mental health disorders. The
    bill makes available much-needed psychiatric, psychological,
    and supportive services for individuals with mental illness and
    families in crisis.
        With more than 11 million Americans who suffer with severe
    mental illness, such as schizophrenia, bipolar disorder, and
    major depression, many are going without treatment and often
    families struggle to find appropriate care for their loved
    ones. Since there is a patchwork of different programs and
    sometimes ineffective policies across numerous agencies, it is
    important for this committee to examine ways to fix the broken
    mental health system by focusing and coordinating programs and
    resources on psychiatric care for patients and families most in
    need of services.
        Over the past several years, Dr. Murphy, a practicing
    psychologist, has worked diligently to discern the most
    effective ways to research and treat these illnesses. As
    chairman of the Subcommittee on Oversight and Investigations,
    Chairman Murphy launched a review of the country's mental
    health system beginning in January of 2013. The investigation,
    which included public forums, hearings with expert witnesses,
    document and budget reviews, and GAO studies, revealed that the
    Federal Government's approach to mental health is a chaotic
    patchwork of antiquated programs and ineffective policies
    spread across numerous agencies with little to no coordination.
    The Helping Families in Mental Health Crisis Act of 2015, H.R.
    2646, aims to fix the Nation's broken mental health systems by
    refocusing programs, reforming grants, and removing barriers to
    care.
        I am pleased we are holding this hearing to hear from our
    witnesses and colleagues about their views on this pending
    legislation. And I look forward to the testimony from each of
    you today.
        [The prepared statement of Mr. Pitts follows:]

                   Prepared statement of Hon. Joseph R. Pitts

        The Subcommittee will come to order.
        The Chairman will recognize himself for an opening
    statement.
        Today's Health Subcommittee hearing will examine the
    legislation authored by our colleague, Rep. Tim Murphy, H.R.
    2646, which is designed to help families struggling with crisis
    caused by mental health disorders. The bill makes available
    much needed psychiatric, psychological, and supportive services
    for individuals with mental illness and families in crisis.
        With more than 11 million Americans who suffer with severe
    mental illness such as schizophrenia, bipolar disorder, and
    major depression, many are going without treatment and often
    families struggle to find appropriate care for their loved
    ones.
        Since there is a patchwork of different programs and
    sometimes ineffective policies across numerous agencies, it is
    important for this committee to examine ways to fix the broken
    mental health system by focusing and coordinating programs and
    resources on psychiatric care for patients and families most in
    need of services.
        Over the past several years, Dr. Murphy, a practicing
    psychologist, has worked diligently to discern the most
    effective ways to research and treat these illnesses. As
    Chairman of the Subcommittee on Oversight and Investigations,
    Chairman Murphy launched a review of the country's mental
    health system beginning in January 2013. The investigation,
    which included public forums, hearings with expert witnesses,
    document and budget reviews, and GAO studies revealed that the
    federal government's approach to mental health is a chaotic
    patchwork of antiquated programs and ineffective policies
    spread across numerous agencies with little to no coordination.
    The Helping Families in Mental Health Crisis Act of 2015, H.R.
    2646, aims to fix the nation's broken mental health system by
    refocusing programs, reforming grants, and removing barriers to
    care.
        I am pleased we are holding this hearing today to hear from
    our witnesses and colleagues about their views on this pending
    legislation.
        I look forward to the testimony today and yield the balance
    of my time to Dr. Murphy.

        [H.R. 2646 is available at: http://docs.house.gov/meetings/
    if/if14/20150616/103615/bills-1142646ih.pdf.]
        Mr. Pitts. And I yield the balance of my time to Dr. Murphy
    from Pennsylvania.
        Mr. Murphy. Thank you, Mr. Chairman. Thank you for holding
    this hearing.
        Our mental health system is broken. Badly broken. It is
    getting worse, and it has to be fixed. Same goes for our
    handling of substance abuse in this country. Forty thousand
    suicide deaths in this country last year, 42,000 drug overdose
    deaths, 60 million with a diagnosable mental illness, 10
    million with serious mental illness, like schizophrenia,
    bipolar, severe depression, 100,000 new cases a year.
        The General Accounting Office reviewed this for the
    committee, said we spend in the Federal Government $130 billion
    a year, over some 112 programs and agencies that don't work
    together, have little accountability, and in many cases, don't
    have very good results.
        I ask every member of the committee during this hearing,
    and as we work forward on this bill, to stop and think. Imagine
    you have a child who is hallucinating, schizophrenic, out on
    the streets, and you are told that the law says you have no
    right to know anything about your child's location, condition,
    or care. Others presume that having any information is harmful
    to your own child. Or if your child is brought before a judge
    with concerns for the symptoms and the inability to care for
    themselves, and the judge says it is not against the law to be
    crazy. I ask you to stop and think about that. Are we so
    lacking in compassion, and are we so ignorant of what serious
    mental illness is? Would we say it is not illegal to have a
    heart attack, and walk away from a person with chest pains? Or
    how about dealing with someone with Alzheimer's, would we say
    it is not illegal to have Alzheimer's, and wonder the streets
    in winter, barefoot?
        Look, here is the truth. Serious mental illness is a brain
    disorder, and we must come to terms with this critically
    important fact or else nothing else we do or say today will
    make any sense to anyone. Let me say this again. Mental
    illness, especially serious mental illness, is a brain
    disorder, and as such, has to be seen and treated for what it
    is. To believe otherwise is folly, anti-science, and an
    injustice to the person, denies them appropriate treatment, and
    sentence them to more imprisonment, homelessness,
    victimization, unemployment, and barriers to care.
        So I urge members to embrace this bill, and I thank all
    those members on both sides of the aisle who have worked with
    us, and the many agencies and organizations who have done this
    as well. This bill is comprehensive, it is a big first step,
    but it does not fix everything. I wish there was a way we could
    go even further to build even more comprehensive changes,
    especially in dealing with substance abuse disorders, but this
    bill makes substantive changes in that so those issues will be
    addressed. It sets the stage for more reform.
        I look forward to hearing from the witnesses, but I
    especially want to thank our witnesses today, and Senator
    Creigh Deeds, and others for coming out to tell your courageous
    stories. I thank Chairman Upton for helping us schedule this
    hearing and move this forward. Let's make sure we provide more
    help for folks, so we understand where there is help, there is
    hope.
        I yield back.
        Mr. Pitts. The chair thanks the gentleman.
        I am now pleased to recognize the ranking member of the
    subcommittee, Mr. Green of Texas, for his opening statement.
    Also to help welcome one of our former colleagues here.

       OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
                    CONGRESS FROM THE STATE OF TEXAS

        Mr. Green. Thank you, Mr. Chairman, for holding this
    hearing on mental health reform.
        I would like to recognize our former colleague, Patrick
    Kennedy. Good to see you, and thank you for your service and,
    of course, your family. And we keep it in the family. We have a
    relative on the committee.
        The Affordable Care Act made important changes in the field
    of mental and behavioral health. The law expanded access to
    mental and behavioral health services, advanced parity of
    coverage, and enabled states to expand their Medicaid programs
    so that millions of more Americans could access affordable
    quality coverage. While the ACA made great strides toward
    improving access to mental and behavioral health services, the
    mental health system is still in need of reform.
        In our efforts to advance reform, it is critical that the
    patient remain at the center of our focus. Approximately 10
    million Americans suffer from serious mental health illnesses,
    including major depression, schizophrenia, bipolar disorder,
    post-traumatic stress syndrome. The National Alliance on Mental
    Illness reports that between 70 and 90 percent of individuals
    have significant reduction of symptoms and improved quality of
    life with appropriate treatment and support. The numbers show
    that treatment works. Even though the overwhelming majority of
    individuals with mental and substance use disorders improved
    after receiving treatment, almost \1/2\ of all adults living
    with serious mental illness do not receive treatment in the
    past year. Given that the statistics show that treatment is
    effective, and that a considerable number of adults still go
    without treatment, our efforts to improve the mental health
    care system must empower patients and their caregivers with
    access to a range of treatment and support services. We must
    also remove barriers to that access.
        In today's hearing, we are considering several pieces of
    legislation that seek to reform and improve our mental health
    care system. They are H.R. 2646, the Helping Families in Mental
    Crisis Act, and H.R. 2690, the Including Families and Mental
    Health Recovery Act.
        I appreciate my colleague from Pennsylvania, Dr. Murphy's,
    endeavor to advance comprehensive mental health reform, and I
    particularly appreciate his relationship when we have been
    working on this for a few years, including during the
    Affordable Care Act. I do have some concerns about the
    legislation, that it may not adequately take into account the
    diversity and complexity of mental health needs that patients
    and their caregivers present. Comprehensive mental health
    reform must feature community-centered options that focus on
    recovery and prevention. We must ensure that reforms are
    patient-centered and address the full continuum of care.
        I look forward to hearing today more about this legislative
    proposal, and I also appreciate my colleague from California,
    Congresswoman Matsui, for her efforts to improve mental health
    care delivery and the Including Families in Mental Health
    Recovery Act. The legislation seeks to improve the
    understanding of providers, patients, and caregivers on how
    HIPAA requirements apply to the mental health space. It will
    clarify HIPAA privacy standards for the release of protected
    information to patients' families and caregivers, and increase
    education on this critical issue.
        I would also like to thank our witnesses here today and
    look forward to their perspectives.
        With that, I would like to yield 1 minute to my colleague,
    Congressman Kennedy, from Massachusetts.
        Mr. Kennedy of Massachusetts. I thank the ranking member,
    and I thank the committee for holding this important hearing.
    To all of the witnesses, thank you very, very much for your
    testimony, and look forward to your insight.
        There is a familiar face, as I think everybody recognizes.
    Patrick, it is wonderful to see you here. I think you will
    probably hear from your colleagues, it is like you have never
    left. And that is true because it actually really is true. I
    get at least once a day people come up to me and say, Patrick,
    it is great to see you again. I get introduced often on the
    House Floor as the gentleman from Rhode Island. I get often
    many of your colleagues relate to me how grateful they are for
    my leadership on these issues, as they thank me, Patrick, for
    all that I have done. Which, of course, you can imagine I say,
    you are very welcome, and take all of the credit for myself.
    And every now and again, I let you know that, but often I
    don't.
        But, Patrick, it is largely to your efforts in Congress
    that mental health parity is much closer to becoming a reality
    today than it was a decade ago, and that the Affordable Care
    Act has allowed 16.4 million previously uninsured people get
    the coverage that they need. But I think everyone here would
    agree that we still have a lot more word to do.
        A lack of access to care has had a heartbreaking
    consequence across our country. Just recently, I saw a report
    that stated over \1/2\ of youth battling severe mental illness
    receive absolutely no help at all. Allowing so many children to
    fall through the gaps in our system leads to substance abuse
    and addiction, crime, and violence. In Massachusetts, as you
    know, we are in the midst of an opioid abuse epidemic that cost
    over 1,000 lives last year alone. Lives of the rich and poor,
    young and old, male and female, black and white. Taunton, a
    city in my district, we have already tragically seen 10 people
    die just this year. It has been 7 years since the Paul
    Wellstone Act was signed into law by President Bush, and
    another year since those final rules went into effect. Lives
    cut short in every corner of our country serve as a stark
    reminder that true parity cannot wait another day.
        I look forward to hearing from each of our witnesses today
    about how the bills we are considering and other legislation
    can help ensure that loved ones battling mental illness and
    addiction not only have the access to care that they need, but
    that they can get those services without additional barriers.
        Patrick, thank you.
        Mr. Green. Mr. Chairman, whatever time I have left, which
    is nothing, I would like to yield to my colleague from New
    York, Congressman Tonko.
        Mr. Kennedy of Massachusetts. Sorry.
        Mr. Pitts. Recognized for 30 seconds.
        Mr. Tonko. I thank Representative Green and the chair for
    the opportunity.
        I am pleased we are holding this hearing on such an
    important topic, and I wanted to take a moment at the outset to
    acknowledge and welcome my constituent and my friend, Mr.
    Harvey Rosenthal, to the panel. Harvey and I have known each
    other for many years, and have long worked together to better
    the lives of individuals dealing with mental health challenges;
    most notably, with the passage of Timothy's Law, which brought
    mental health parity to New York State before even our federal
    parity protections, which are outstanding. As the executive
    director of the New York Association for Psychiatric
    Rehabilitation Services, Harvey's passion and advocacy for
    individuals struggling with mental illness for over 40 years is
    unparalleled.
        So welcome, Harvey. Welcome panelists. I greatly look
    forward to hearing your testimony today. And with that, I yield
    back the balance of my time.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the chairman of the full committee, Mr.
    Upton, 5 minutes for an opening statement.

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

        Mr. Upton. Thank you, Mr. Chairman.
        There is no question that mental illness affects millions
    of Americans and their families, yet sadly way too many are
    going without treatment and their families are certainly
    struggling to find care for loved ones. Following the tragic
    events of Newtown, Connecticut, this committee led a multiyear
    review of the federal mental health system. Ensuring treatments
    and resources are available and effectively used for those
    suffering with mental illnesses has remained the real priority
    of this committee throughout the past number of years.
        I particularly commend Oversight and Investigations
    Subcommittee Chair Tim Murphy who has led and spearheaded our
    thorough review of all federal mental health programs. This
    committee held a series of public forums, briefings, and
    investigative hearings to determine how federal dollars are
    being prioritized and spent on research and treatment,
    particularly for serious mental illness. To address the flaws
    discovered in the extensive and wide-ranging examination,
    Chairman Murphy introduced H.R. 3717, the Helping Families in
    Mental Health Crisis Act of 2013. And two major pieces of that
    bill became law in the last Congress, and today we continue our
    efforts and look upon building on that success.
        Dr. Murphy has reintroduced his bill in this Congress,
    building upon the previous bipartisan version while updating it
    to include new findings from the committee's continuing
    investigation. H.R. 2646, this year's bill, would remove
    federal barriers to care, clarify privacy standards for
    families and caregivers, reform outdated federal programs,
    expand parity accountability, invest in services for those with
    serious mental illness, and promote evidence-based care. Every
    community, every single one, has been impacted in some fashion,
    and literally every family as well. To our community leaders on
    the frontlines, in my district, folks like Jeff Patton, who
    runs the Kalamazoo Community Mental Health and Substance Abuse
    Services, we say thank you. And to those families who have been
    impacted by mental illness in some form, Congress is aware,
    yes, we are, of your plight, and we can and we must and we will
    do much better.
        I want to thank our witnesses for taking the time to
    testify before the subcommittee, particularly my friend, former
    colleague, Patrick Kennedy, Virginia State Senator Creigh
    Deeds. We have an all-star panel, that is for certain.
        And I yield the balance of my time to the vice chair of the
    subcommittee, Mrs. Blackburn.
        [The prepared statement of Mr. Upton follows:]

                     Prepared statement of Hon. Fred Upton

        Mental illness affects millions of Americans and their
    families, yet sadly many are going without treatment and
    families are struggling to find care for loved ones. Following
    the tragic events of Newtown, Connecticut, the Energy and
    Commerce Committee led a multiyear review of the federal mental
    health system. Ensuring treatments and resources are available
    and effectively used for those suffering with mental illness
    has remained a priority of this committee throughout the past
    several years.
        Oversight and Investigations Subcommittee Chairman Tim
    Murphy spearheaded our thorough review of all federal mental
    health programs. The committee held a series of public forums,
    briefings, and investigative hearings to determine how federal
    dollars are being prioritized and spent on research and
    treatment, particularly for serious mental illness. To address
    the flaws discovered in the extensive and wide-ranging
    examination, Chairman Murphy introduced H.R. 3717, the Helping
    Families in Mental Health Crisis Act of 2013. Two major pieces
    of that bill became law in the 113th Congress and today we
    continue our efforts and look to build upon that success.
        Dr. Murphy has reintroduced his bill this Congress,
    building upon the previous bipartisan version while updating it
    to include new findings from the Committee's continuing
    investigation. H.R. 2646 would remove federal barriers to care,
    clarify privacy standards for families and caregivers, reform
    outdated federal programs, expand parity accountability, invest
    in services for those with serious mental illness, and promote
    evidence-based care.
        Every community has been impacted in some fashion. To our
    community leaders on the frontlines, folks like Jeff Patton who
    runs the Kalamazoo Community Mental Health and Substance Abuse
    Services--we say thank you.
        And to those families who have been impacted by mental
    illness in some form--Congress is aware of your plight and we
    can and must do better.
        I'd like to thank the witnesses for taking the time to
    testify before the Subcommittee--in particular former
    Congressman Patrick Kennedy and Virginia State Senator Creigh
    Deeds. We have an all-star panel for sure. I yield the
    remainder of my time to --------------------------------------
    ----.

        Mrs. Blackburn. Thank you, Mr. Chairman. And to our
    witnesses, we do thank you so much for being here. We are
    deeply appreciative of the time, and we know Congressman
    Kennedy has had this as an issue close to his heart for a long
    time, so we appreciate that you are here to share.
        I think that Tim Murphy deserves a tremendous amount of
    credit for the work that he has put into working through this
    process for the past couple of years. You have 10 million
    Americans that are in need of services, and who suffer some
    form of severe mental illness. The Federal Government is
    spending $130 billion a year, and people are not getting the
    services that we need. And in our district, Centerstone is a
    group that we have worked with on these issues for a period of
    time. And we were looking at the homeless population, some of
    the figures related there, and the fact that so many of these
    individuals end up in our jails, and this is something that
    needs to be addressed. They are sick and they need care. And in
    Tennessee, there were a total of 21,246 inmates in fiscal year
    2013. Of those, 11 percent were diagnosed with a severe mental
    illness, another 21 percent were diagnosed with nonspecific
    mental illness, and 16 percent were prescribed at least one
    psychotropic medication.
        But, see, we have this gap on outcomes and what the
    deliverable would be. And we are so grateful to Chairman
    Murphy's leadership for helping us hone in on this to make
    certain that needs are addressed, that there is a process for
    care delivery, and there is a process for these individuals to
    have a quality of life.
        And so we are going to have questions for all of you today,
    and we thank you for your commitment and for your time.
        And, Mr. Chairman, I yield back.
        Mr. Pitts. The chair thanks the gentlelady.
        I now recognize the ranking member of the full committee,
    Mr. Pallone, 5 minutes for an opening statement.

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

        Mr. Pallone. Thank you, Mr. Chairman. I know that Patrick
    Kennedy, our colleague, has gotten all kinds of accolades, but
    I want to add to it because, I think many of you know, or maybe
    you don't, that he was dealing and urging us to pass the Mental
    Health Parity Bill long before we even had it included in the
    ACA, and then he advocated when we were passing the ACA to
    expand it, which is exactly what happened. And I also would
    mention that he is not only an advocate domestically but also
    internationally. I remember when you and I went to Armenia
    together, and you went there because of the Special Olympics
    and trying to set up the Special Olympics in Armenia. So thanks
    for all that you do, Patrick, and it is good to see you.
        Today's hearing gives us the opportunity to discuss an
    important public health issue. According to the National
    Alliance on Mental Illness, approximately 1 in 5 adults in the
    U.S., or 43.7 million, will experience mental illness in a
    given year. Of those people, approximately 10 million live with
    a serious mental illness, including major depression,
    schizophrenia, and bipolar disorder.
        We have taken significant steps forward in recent years.
    The Affordable Care Act's passage was quite literally the
    largest expansion of mental health and substance abuse disorder
    coverage in a generation. The ACA prohibits individuals from
    being denied coverage due to a preexisting mental health
    condition. It expands eligibility for Medicaid coverage, and
    requires most health plans, including Medicaid, to cover mental
    health and substance abuse services. Not only are services
    covered, but mental health parity now applies, protecting 62
    million more Americans. This means that no insurer can impose
    requirements that are more burdensome for mental health than
    they can for physical health.
        Despite these major advances, far too many individuals
    still go without the treatment they need to live long, healthy,
    and productive lives, and more must be done to ensure coverage
    translates into effective treatments, and actually meets parity
    standards. That is why I am interested in hearing from
    stakeholders on what is working, what is not working, before we
    move forward with extensive or comprehensive legislation. For
    instance, Parachute NYC is here to discuss an innovative new
    approach for respite care for the seriously mentally ill, and I
    believe we can learn valuable lessons from this project and
    others funded through the ACA.
        Mr. Chairman, unfortunately, like last Congress, the first
    Health Subcommittee hearing on mental health is once again a
    legislative hearing on the Helping Families in Mental Health
    Crisis Act. As a result, the subcommittee will focus on
    solutions as framed by this bill, instead of being framed by
    the needs of individuals with mental illness and the system
    that serves them.
        While I have concerns with this process, I want to
    recognize that there are provisions of H.R. 2646 that I
    strongly support, including the increased focus on workforce
    development and the parity enforcement reporting requirements.
    However, I am opposed to several provisions in the bill,
    including its changes to HIPAA that would weaken the privacy
    rights of individuals with diagnosed mental illness, the
    conditioning of community mental health block grant funding on
    the presence of state AOT laws or treatment standard laws, and
    cuts in funding to substance abuse programs to pay for new
    mental health programs. As we all know, too often substance
    abuse and mental health go hand in hand, and we have a crisis
    in both areas. So I hope that after this hearing we can work
    together and find common ground to move bipartisan legislation
    forward that further advances the mental health system in this
    country.
        I would like to yield the remainder of my time to
    Representative Matsui.
        Ms. Matsui. Thank you, Ranking Member. And I welcome all
    you panelists. And nice to see you, Patrick.
        All of us know that we need to reform our Nation's broken
    mental health system, and we should all care about this issue
    before, during, and after a crisis or an event that affects us
    personally. We shouldn't wait until a person is in an acute
    crisis to provide needed care and services, and we shouldn't
    abandon people once the immediate crisis has ended.
        There is a full spectrum of mental health and illness that
    our system needs to address, and a full spectrum of treatment
    options, tools, and services and supports that we need to make
    available. We should not prioritize funding only for the
    highest level of care, such as inpatient hospital beds, at the
    expense of funding the rest of the continuum of care.
        I believe in the power of prevention, and that we need to
    do more to catch many conditions, including mental illnesses,
    early before they progress. I know our current system is
    flawed, and I look forward to working with my colleagues to fix
    it. That is why I introduced the Including Families in Mental
    Health Recovery Act, which is one of the pieces of legislation
    that we are discussing today. Stories of patients and their
    families who suffer mental illness do affect me personally.
    Time and time again, including what will be in testimonies
    today, I have heard horror stories from patients, families, and
    providers about what happened when providers could not
    communicate with caregivers, and information wasn't shared. I
    hear from providers and families alike in the mantra; I
    couldn't share because of HIPAA. However, the language of the
    HIPAA law does not prevent information-sharing in 99 percent of
    the stories I hear. Rather, it is a vast misunderstanding,
    misinterpretation, and overly cautious application of the HIPAA
    law. This is important. There is a problem here, but HIPAA
    isn't the root cause of it, which means that changing HIPAA
    won't fix anything. The root problem is awareness of what is
    and isn't allowed under the law.
        The bill that I introduced would do 2 simple things. First,
    formalize HHS Office for Civil Rights Guidance which clearly
    outlines how providers can strike the right balance between
    sharing information with caregivers and protecting patients'
    privacy. Second, it requires the development and dissemination
    of a model training program to educate and train providers,
    administrators, and lawyers, and patients and families on what
    can and can't be shared under the law.
        I appreciate this hearing, and I look forward to working
    with all of you. Thank you, and I yield back.
        Mr. Pitts. The chair thanks the gentlelady.
        That concludes the opening statements of the members. As
    usual, the written opening statements from the members will be
    entered into the record.
        We will now go to our panel, and I will introduce them in
    the order of their presentations.
        First of all, the Honorable Creigh Deeds, Senator, Senator
    of Virginia. Welcome. And then our former colleague, the
    Honorable Patrick Kennedy, former U.S. Congressman from Rhode
    Island, founder of the Kennedy Forum. Jeffrey Lieberman, M.D.,
    Chairman, Department of Psychiatry, Columbia University College
    of Physicians and Surgeons. Welcome. Mr. Paul Gionfriddo,
    President and CEO, Mental Health America. Steve Coe, Chief
    Executive Officer of Community Access. Ms. Mary Jean
    Billingsley, Parent, National Disability Rights Network. And
    Harvey Rosenthal, Executive Director, New York Association of
    Psychiatric Rehabilitation Services. Thank you all for coming
    today and testifying on this very, very important subject. And
    your written testimony will be made part of the record, and you
    will each be given 5 minutes to summarize your testimony.
        So the chair at this point will recognize Senator Deeds 5
    minutes for your summary.

       STATEMENTS OF CREIGH DEEDS, SENATOR, SENATE OF VIRGINIA;
       PATRICK J. KENNEDY, FORMER U.S. REPRESENTATIVE (RI), AND
     FOUNDER, KENNEDY FORUM; JEFFREY A. LIEBERMAN, M.D., CHAIRMAN,
       DEPARTMENT OF PSYCHIATRY, COLUMBIA UNIVERSITY COLLEGE OF
     PHYSICIANS AND SURGEONS; PAUL GIONFRIDDO, PRESIDENT AND CEO,
      MENTAL HEALTH AMERICA; STEVE COE, CHIEF EXECUTIVE OFFICER,
       COMMUNITY ACCESS; MARY JEAN BILLINGSLEY, PARENT, NATIONAL
      DISABILITY RIGHTS NETWORK; AND HARVEY ROSENTHAL, EXECUTIVE
     DIRECTOR, NEW YORK ASSOCIATION OF PSYCHIATRIC REHABILITATION
                                SERVICES

                       STATEMENT OF CREIGH DEEDS

        Mr. Deeds. Thank you, Mr. Chair, and thank you, members of
    the committee, for giving me a couple of minutes. Thank you,
    Congressman Murphy, for making mental health issues--to
    bringing them to the forefront, to helping develop solutions to
    help families in crisis throughout the country.
        When formulating my thoughts about what I wanted to speak
    about today, how best to use my time, I thought about all the
    compelling stories that have been shared with me from
    Virginians and from people all throughout the United States.
    Honestly, I thought what could be more compelling than the loss
    of those innocent lives in Newtown, the moviegoers in Aurora,
    the bright emerging leaders of Virginia Tech, or the dedicated
    public servants at the Navy Yard.
        In Virginia, we tinkered around the edges of public policy
    following the tragedy, but the real reform and meaningful work
    remains. But if we did not act after all those unspeakable
    tragedies, what could I possibly say today to you to press upon
    you the importance of acting, the importance of coming together
    and finding solutions, many of which are here before you in
    H.R. 2646.
        In addition to each of those high-profile cases involving
    large losses of life, there are tragedies of smaller scales.
    You can read about Natasha, a woman with mental illness who
    ends up in jail instead of a mental health treatment facility
    that can properly care for someone with an illness. When the
    jail attempts to transfer her, six members of law enforcement
    in biohazard suits handcuff, shackle, and place a faceguard on
    her. When she refuses to bend her knees and sit in a transport
    chair, she is tazed multiple times. She dies. If she was in a
    mental health facility and needed to be sedated, the staff
    would have had appropriate options. I can only imagine what she
    was thinking and feeling when all of those men entered her cell
    in spacesuits, and I can only imagine how much grief and pain
    her family is enduring today.
        You can read about Christian, a 17-year-old boy with a
    knife, threatening suicide. Law enforcement was called to the
    scene, and when the boy made movements toward the officer, he
    was shot dead. I can only imagine the shock and horror of his
    friend who had called for help.
        Tragedies happen every day that involve someone in a mental
    health crisis. Most do not make the news. I have heard so many,
    and those stories serve to guide me in my review of the mental
    health system in Virginia. The heartbreak is unbearable. I hear
    these stories, I hear them every day. People reach out to me
    for help every day, and the sad truth is that in many ways,
    there is little I can do to help. The system is not set up in a
    way that encourages advocacy.
        One of the primary issues I see is HIPAA. We came together
    in a bipartisan way in Virginia to adopt meaningful reforms
    last year and to some extent during the 2015 Session, but
    nothing we do can circumvent HIPAA. I need, the states need,
    the Federal Government as a partner in reforming the mental
    health system. Government was not envisioned to work quickly,
    and we are geared toward incremental policy changes, but I am
    telling you, the time for action is now. Families are
    struggling. People are dying. People are grieving.
        While there is no panacea, there are things to be done to
    improve the lives of people with mental illness, promote better
    outcomes, and to help give some relief to families who are
    struggling every day. We can accomplish this without
    jeopardizing the civil liberties of those with mental illness.
        While I do not like to speak about my own situation, I will
    end briefly talking about Gus. No legislative action either
    here in the District of Columbia, nor in Virginia, will bring
    back my son, but hopefully it will help others keep their loved
    ones safe. I have four precious children. My three daughters
    make me prouder every day, but I have forever lost my son. I
    worked within the mental health system to help Gus when he
    began to show signs of mental illness. He was brilliant.
    Everyone in this room would envy his adeptness in picking up
    languages, his knowledge of religion, his ability to play any
    instrument he would pick up, and his kindness and gentleness to
    his fellow man. My world was shaken to its core when he began
    showing signs of delusional thinking and sporadic behavior. I
    was just not equipped with the knowledge or the information to
    help him. HIPAA prevented me from accessing the information I
    needed to keep him safe and help him towards recovery. Even
    though I was the one who cared for him, I was the one who fed
    him and housed him, transported him, insured him, I was not
    privy to any information that would clarify for me his
    behaviors, his treatment plan, his symptoms to be vigilant,
    not--I had no idea. I didn't know his diagnosis, his
    prescription changes, and necessary follow-up. I had sought to
    have him hospitalized earlier, so he was wary of my having any
    information. So I was in the dark as I tried to advocate for
    him in the best way I could with the best information I had.
    The last time I tried to hospitalize him, he was turned away.
    We ran out of time, and law enforcement had to release him.
        We have to do better. Not for me, not for the countless
    other families who have already buried their loved ones, but
    for those who struggle with mental illness and the families
    that struggle to help them. They are crying out for help. They
    are desperate, they are exhausted, and they need your
    leadership.
        Thank you.
        [The prepared statement of Mr. Deeds follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. The chair thanks the gentleman.
        Patrick, you are recognized 5 minutes for your opening
    statement.

                    STATEMENT OF PATRICK J. KENNEDY

        Mr. Kennedy of Massachusetts. Thank you, Mr. Chairman.
    First, I think I speak for all of us, Senator Deeds, when we
    say our hearts go out to you. I don't think there is a person
    in this country that wasn't moved by your tragedy, and what it
    speaks to all of us. And the notion that we have let all those
    tragedies go by, and as a nation, have failed to act is
    abominable. And I think what you have said is what we all need
    to hear over and over again; the time is now. And,
    Representative Murphy, thank you for stepping up. I know you
    have drawn a lot of criticism, and this bill isn't perfect, but
    you have had the fortitude to stick with it and to keep
    pressing. And you have listened to people and you have shaped
    legislation that moves us forward. Is it the answer, as you
    rightly said? No, it is just a piece of the answer. But as you
    said at the very start of your remarks, the essential message
    we need to come out of this hearing is that these are real
    physical illnesses, and they need to be treated with the same
    urgency that we would treat cancer or any other fatal or
    disability in this country.
        The notion that we treat these issues as moral issues as
    opposed to medical issues is really the central issue before
    this committee. And I am honored to have been honored to work
    with many of you to get the Mental Health Parity and Addiction
    Equity Act passed. And that bill, if implemented, and I have
    heard comments already from many of you including my cousin,
    Joe, will transform the system because if the liability is on
    payers, including the Federal Government, to treat brain
    illnesses like any other illness, then they will start to see
    that an ounce of prevention is worth a pound of cure, that
    investing in early identification and treatment and
    intervention is the answer. Just like with cancer, just like
    with diabetes, just like with cardiovascular disease. We don't
    wait until these illnesses become pathologized before we treat
    them. But with mental illness and addiction, what do we do? We
    wait until you are in crisis before our system ever starts to
    kick in. And then people blame the system as not working
    because somehow it doesn't take someone with stage 4 cancer and
    make them well.
        Are you kidding me? If we don't intervene early, these
    illnesses do become intractable. But we don't have to let it be
    that way. We can intervene early. We can save lives. But the
    basic premise to all this is just treat these like you would
    someone with cancer, and not wait around until the illness gets
    to become worse and in a crisis stage.
        So, Representative Murphy, I am sure we will have a chance
    to talk in great length about the details of this bill, but I
    just want to salute you for putting forth a number of issues
    that we can talk about and we can begin to explore as ways to
    improve the system. The system needs accountability. The system
    needs transparency. And you have been a champion of those
    things, and I think that they are--throughout your legislation,
    and it is why I am honored to be here to work with you and my
    democratic colleagues to make sure that this House passes
    something to answer what Senator Deeds put forward to us, and
    that is to act, and to act now.
        Thank you.
        [The prepared statement of Mr. Kennedy follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. The chair thanks the gentleman. Thank you for
    your leadership and your passion.
        Dr. Lieberman, you are recognized for 5 minutes for your
    opening statement.

                STATEMENT OF JEFFREY A. LIEBERMAN, M.D.

        Dr. Lieberman. Thank you, Chairman Pitts, Ranking Members
    Green and Pallone, and honorable committee members. I am
    pleased to be here attending this hearing. I also would like to
    thank Representatives Murphy and Johnson for their enlightened
    legislation, and express my gratitude to Representatives Upton
    and DeGette for the critical leadership on the 21st Century
    Cures.
        I am a Professor and Chair of Psychiatry at Columbia
    University, and Psychiatrist-in-Chief at New York Presbyterian
    Hospital, and have spent my career doing research on the
    neurobiology and psychopharmacology of psychotic disorders. In
    addition, I have, throughout my career, taken care of patients,
    both overseeing clinics with trainees, as well as having
    patients directly in my own practice. I am a member of the
    National Academy of Sciences, Institute of Medicine, and the
    past President of the American Psychiatric Association. I
    mention this simply to say that I believe that I am in an
    informed perspective to express knowledgeable opinions about
    the field of mental illness and mental health care.
        And in the course of my career, I can say that I have
    continuously borne witness to all that Senator Deeds and
    Congressman Kennedy have described to you. The stories are
    countless, enumerable, and appalling.
        But in the time I have, I would like to make 3 points.
    First, that psychiatry is a scientifically based profession. No
    different from cardiology, neurology, or ophthalmology,
    although in deference to Representatives Burgess and Bucshon,
    maybe not as advanced as obstetrics and gynecology and cardiac
    surgery. But the second is that, although we have an egregious
    chronic crisis in mental health care, this is solvable. You
    deal with a lot of problems that are not solvable. Alzheimer's
    Disease in the aging population, global warming, terrorism.
    This is a solvable problem. And the third is, I want to
    describe what providing quality and comprehensive mental health
    care will do for our country.
        When I was a medical student in third year in the mid-1970s
    at George Washington University, I told my advisor that I
    wanted to go into psychiatry. He exploded and said, what would
    you do a dumb thing like that for, and throw away a perfectly
    good career? Psychiatry was then, and still is, the Rodney
    Dangerfield of medicine. It doesn't get the respect it
    deserves. But that is because for the first 150 years of its
    existence, psychiatry had little to show for itself. No
    scientific information of mental illness, no effective
    treatments. It could do little to help people with mental
    illness, other than to institutionalize them, and those became
    appalling snake pits.
        But that was then and now is now, and everything has
    changed since the scientific revolution of the latter 20th
    century, beginning with the arrival of psychotropic drugs. And
    as a result, psychiatry has a strong scientific foundation, and
    an array of evidence-based treatments that are effective and
    safe.
        What this means is that we have the knowledge and the means
    to solve this crisis. To do this though, we have to provide a
    template of comprehensive evidence-based services to health
    providers at the state, county, and municipal levels, and align
    financing mechanisms to incentivize to providers to adopt
    these. In addition, and this is something that is not widely
    appreciated, we must dispel the stigma of mental illness, just
    like we have in our society for other things, such as racism,
    sexism, anti-Semitism. There still is prejudice against mental
    illness and psychiatry due to its inglorious past, but these
    anachronistic attitudes confuse people, create fear and
    mistrust of mental health care, and deter people from seeking
    and getting help.
        The Helping Families in Mental Health Crisis Act offers a
    transformative opportunity. If we are successful, and we can
    be, we will lessen the burden of illness and improve the
    quality of life of our citizens. It also alleviates some of the
    most disturbing and dispiriting problems in our society,
    including domestic violence, addiction, suicide, the mentally
    ill who are homeless and increasingly in prisons, the shocking
    rates of PTSD and suicide in military personnel, and the
    recurrent episodes of these civilian massacres and mass
    violence perpetrated by some people with untreated mental
    illness. As a bonus, comprehensive effective mental health care
    would also deter the massive inflation in health care costs
    driven by patients with comorbid mental disorders who receive
    repeated and unnecessary medical and surgical services.
        One final comment is that, it is imperative that in the
    process of revamping our mental health care system, that we be
    guided by scientific evidence and not ideology or opinion.
    Science guides cardiovascular medicine, oncology, orthopedics,
    neurology. It should guide mental health care as well.
        The 21st Century Cures, I hope, will address an egregious
    chronic underfunding of the biomedical research community,
    because ultimately, research is what drives the quality of
    care. We have the means to solve this crisis. We simply need to
    find the social and political role.
        I thank you for having me, and I await your comments and
    questions.
        [The prepared statement of Dr. Lieberman follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. The chair thanks the gentleman.
        I now recognize Mr. Gionfriddo for 5 minutes for an opening
    statement.

                      STATEMENT OF PAUL GIONFRIDDO

        Mr. Gionfriddo. Thank you. I want to applaud this
    subcommittee, and in particular, Congressman Tim Murphy and
    Congresswoman Eddie Bernice Johnson, for your leadership in
    this area.
        As a parent of an adult son with schizophrenia, I deeply
    appreciate this because for so many of us, this is not just a
    policy matter, this is our life.
        As a former state legislator in Connecticut, I know how
    difficult it can be to build consensus around mental health
    policy. I, therefore, also appreciate the effort of the
    sponsors to invite so much feedback during the past year to use
    it to shape the proposal before you today. In our view, H.R.
    2646 is an important start to making comprehensive mental
    health reform a reality in America.
        In these brief remarks, let me focus on some areas that are
    important to MHA. Its emphasis on moving upstream in the
    process, that is, on intervening before stage 4, is a critical
    step forward to treating mental illnesses like we treat every
    other chronic disease. It includes funds for screening, early
    intervention, and treatment programs. And let me share why this
    is so important. In the spring of 2014, MHA launched an online
    screening tool through our Web site at MHAscreening.org. To
    date, nearly \1/2\ million screens have been completed; nearly
    \1/2\ by people under the age of 25. Two thirds screen as
    positive or moderate to severe for the condition for which they
    have screened, but \2/3\ of those say they have never been
    diagnosed with a mental health condition. Screening is the
    doorway to services and treatment. H.R. 2646 makes screening,
    especially for children and young adults, a part of the
    innovation grants, the demonstration grants, the Youth Suicide
    Prevention Program, the Campus Mental Health Program, among
    others. And in legislation that emphasizes building on
    evidence-based programs, we note the importance of innovation,
    because today's evidence-based program is yesterday's well-
    evaluated innovation.
        In addition, it is our hope that you will look to expand
    the opportunities to integrate health and educational services
    for our children. My son, Tim, has schizophrenia. He is 30
    years old today, living mostly on the streets of San Francisco.
    He first showed signs of the disease when he was a young child.
    Throughout his school years, we sought special education
    services for him, and were frequently rebuffed. This is because
    those of us making policy a generation ago were not thinking
    about children like Tim as we implemented our modern special
    education laws. Today, only 362,000 children in the country
    receive special education services because of an SED label.
    That represents only 1 child in every 28 NIMH says has a
    serious mental health condition or concern. This represents too
    many tragedies waiting to happen.
        MHA endorses the empowerment and elevation of the lead
    federal agency in this legislation, and we hope you will
    consider adding two additional responsibilities to it. The
    first would be to establish a common standard, other than
    danger to self or others, as a trigger to involuntary treatment
    for SSI, because this is not a clinical standard. The second
    would be to develop a national plan that would result in an end
    to the incarceration of nonviolent people with serious mental
    illnesses. We also endorse the efforts to enhance the mental
    health workforce in this bill. At MHA, we have a special
    interest in the peer. And in this legislation, we see an
    opportunity to develop a properly credentialed peer workforce
    that could work competitively at competitive salaries in
    clinical settings.
        With respect to AOT, we support the approach in this
    legislation that it takes not to mandate it nationwide. We
    encourage the committee's review of language that may appear to
    be in conflict with the intent of the sponsors, and revise it
    if need be. And we also support changes to the privacy rules,
    because the current rules are an impediment to integrating
    health and behavioral health care. You can't fully integrate
    care with only \1/2\ a medical record. But as someone who has
    worked closely in the past in Austin, Texas, with community-
    based providers seeking to integrate care, I worry that meeting
    simultaneously the six conditions may be so difficult and time-
    consuming for providers that many will not try.
        Consider as an alternative this. Clarify the relevant law
    to eliminate the super authorization needed to share behavioral
    health information. This will promote integration without
    compromising an individual's right to manage the release of his
    or her protected health information. Finally, we understand the
    need to offset new expenditures with reductions in other areas,
    but worry that the offsets might come from existing community
    health programs. If you want to find offsets, please look
    towards jails and prisons. By sending so many of our children,
    like my son, Tim, to those 21st century asylums, that is where
    we sent the funding we need for mental health services today.
        In closing, for more than a century, MHA has argued, for
    more than a century, that it is well past time to address
    mental health issues in a comprehensive, thoughtful way, and
    this is a start. Let's work together to remove the stigma
    associated with seeking help for mental health concerns, and
    the discrimination that occurs against those who live with
    them. Let's put in place a mental health system that allows us
    all to move upstream, provide the behavioral health services
    individuals need and deserve early, and enforce parity in
    coverage. Let us address mental health concerns before stage 4.
        Thank you.
        [The prepared statement of Mr. Gionfriddo follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. The chair thanks the gentleman.
        I now recognize Mr. Coe 5 minutes for your opening
    statement.

                         STATEMENT OF STEVE COE

        Mr. Coe. Chairman Pitts, Congressman Murphy, thank you very
    much for inviting me to come today. It is a very important
    legislation, and I congratulate you for your vision.
        As you can see from my resume, I have worked as a CEO at
    the same agency, Community Access, for almost 36 years. I like
    to tell people I may have worked here a long time, but I have
    had the same job for only 1 day. For instance, I wasn't
    testifying before Congress yesterday. Next week, I will be at a
    conference in Norway, learning about assertive community
    outreach programs in Europe. And with hundreds of employees,
    and 11,000 tenants in 20 apartment buildings from the Bronx,
    Manhattan, and Brooklyn, something different is happening every
    day.
        Most of what happens at Community Access is inspiring,
    which is another reason I have worked here so long. As my
    submitted testimony describes, our organization was founded by
    family members, led by the brother of a woman who had spent
    years confined to psychiatric hospitals, and then more years
    cycling between squalid housing and more hospital wards. His
    name was Fred Hartman. Fred inspired me, when I met him as a
    graduate student, studying housing and service models that
    would break the revolving door cycle, common in the 1970s when
    states discharged thousands of patients into our communities
    without proper supports. Fred's day job was Editor of Natural
    History Magazine, but he was really an activist and an
    organizer. As a white New York City kid, he had gotten on a bus
    and went to help black Americans vote in the south. When faced
    with the human misery and injustice experienced by his own
    sister, he recruited friends and colleagues, and created a
    better mousetrap; an improved model of care that would give
    former patients a safe, stable, affordable home, and basic
    supports.
        Community Access started out renting apartments in rundown
    tenement buildings. Today, we build modern apartment buildings
    with amenities like free Wi-Fi, 24/7 front desk service. But
    the core elements remain the same. People choose their own
    apartments and who they want to live with. They sign leases,
    they are responsible for their own bills. And our buildings
    integrate affordable housing for families and children, with
    units for formerly homeless people recovering from mental
    illness, referred directly from the New York City shelter
    system. We even have a subsidy program to encourage pet
    ownership.
        Overall, I feel H.R. 2646 supports many of the principles
    we embrace; an emphasis on results and outcomes, recognizing
    the valuable role peers can play in the workforce, support for
    innovation and demonstration projects to test new ideas, and
    more. But while there is a lot to like in H.R. 2646, the
    principle vehicle offered to achieve these results, AOT, is not
    what Fred would do. He believed too strongly in human rights
    and social justice; passions that I share. We can all agree our
    system of care fails on many fronts, and nowhere more than in
    the provision of crisis services and supports. H.R. 26
    acknowledges this fact within the title of the bill, to make
    supportive services available to individuals and families in
    mental health crisis.
        H.R. 2646 doesn't spell out what these supports should look
    like, which makes potential supporters of reform legislation,
    like myself, extremely wary. AOT is not a defined service. I
    can mean anything, and not much at all. In New York City, for
    instance, an AOT-assigned individual is given priority access
    to supportive housing, which research shows is the most
    effective tool in promoting community stability, and is
    entirely absent in many places.
        What service is going to take its place if this person in
    crisis is homeless? A higher dosage of medication, a 15-minute
    visit to a psychiatrist, a hospital bed? Without standards, AOT
    can mean anything, including interventions that have no
    evidence-base whatsoever.
        If we want true reform, let's mandate specific
    interventions that we know work, and many of which are
    mentioned in H.R. 2646. Mobile crisis teams, crisis
    intervention training for first responders. Only 3,000 of the
    Nation's 18,000 police departments use this commonsense
    approach. Patient-centered treating planning, targeted case
    management, psychiatric rehabilitation services, which is
    evidence-based, peer support and counseling services. Adding a
    guaranteed housing subsidy, and there have been cutbacks
    continually in Section 8 at the federal level, 24/7 walk-in
    centers, peer-operated support lines, like we operate with the
    Parachute NYC Program, and reform to the Ticket to Work Program
    so it actually becomes a pathway to a job, would truly
    transform the lives of millions of Americans with mental
    illness.
        States are already mandated to provide many services,
    including public education and prisons. How fervently they have
    chosen to embrace these mandates and fund them varies widely,
    and there is no reason to expect a vaguely defined mandate for
    an AOT program would turn out any better.
        Health care reform, with an emphasis on preventive
    services, integrated physical and mental health care, and
    crisis supports to avoid costly and traumatic hospital care, is
    already driving reform efforts across the country. H.R. 2646
    should look to support what is already happening in the
    marketplace, and not place another unfunded mandate on our
    State governments.
        Thank you.
        [The prepared statement of Mr. Coe follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. The chair thanks the gentleman.
        I now recognize Ms. Billingsley 5 minutes for an opening
    statement.

                   STATEMENT OF MARY JEAN BILLINGSLEY

        Ms. Billingsley. Good morning, Chairman Pitts, Ranking
    Member Green. Thank you for the opportunity to testify today on
    this important topic that has touched me and my family
    personally.
        My name is Mary Jean Billingsley. I have a Master's Degree
    in Counseling and Personnel Services, but more importantly, I
    am the mother and co-guardian of Tim Costello. Tim is 22 years
    old and is dually diagnosed with both significant mental
    illness and developmental disabilities. Tim lives in Johnson
    County, Kansas. We are one of the families with a positive
    outcome that would not have been possible if the Helping
    Families in Mental Health Crisis Act of 2015 was law when my
    son encountered his problems. Several provisions of this
    legislation would have had a detrimental impact on the work of
    the Protection and Advocacy for Individuals with Mental
    Illness, the PAIMI program, in addressing Tim's needs. The
    changes to the PAIMI program in this bill would not help
    families, but would, in fact, harm families like ours.
        Tim's mental illness manifests itself with certain
    behaviors. Because of these behaviors, Tim was placed in a
    psychiatric institution in 2010. He was 17 at the time. In the
    summer of 2011, Tim was going to be discharged with no plan,
    and without proper supports in place. Without those supports,
    Tim's discharge was doomed to fail. We were devastated. Because
    Tim has both significant mental illness and a developmental
    disability, the different providers were trying to pawn Tim off
    to each other. Tim was always somebody else's problem. Without
    the right supports, Tim was going to continue to cycle in and
    out of institutions, at a high cost to both taxpayers and Tim's
    ability to recover.
        Tim wanted to live in the community. Our family wanted Tim
    to live in the community. This is a right granted under the
    Americans With Disabilities Act, allowing him to get needed
    treatment in the community instead of at an expensive
    psychiatric institution. We contacted the Disability Rights
    Center of Kansas, the federally mandated protection advocacy
    agency for people with disabilities, which operates the PAIMI
    program. Because of the PAIMI program, DRC was able to help Tim
    and my family with his complex situation. Sorry, I missed a
    page, excuse me.
        Every brick wall the system threw up against us, the PAIMI
    program gave DRC the authority to tear it down. Kansas policy
    made it impossible for young adults like Tim to transfer out of
    psychiatric institutions to community long-term care programs
    with needed supports. DRC was able to negotiate a change in
    this policy, allowing Tim to obtain services through the Money
    Follows the Person Program, and obtain the long-needed supports
    in order to live successfully in the community.
        This bill would prohibit PAIMI-funded programs from
    engaging in much-needed policy work, even using nonfederal
    dollars. Tim's civil and human rights under the ADA would not
    have been protected.
        Tim was living successfully in the community, and we
    thought our problems were over, but they were only beginning.
    Tim then faced discrimination simply because of his disability.
    Some local governments in Johnson County, Kansas, started using
    zoning and land use ordinances to attempt to close Tim's
    community group home, as well as others. A not-in-my-back-yard
    attitude prevailed, targeted against Tim and others, because
    some did not want those people living in their neighborhood.
    We, again, contacted DRC for help. After failed attempts to
    work with local governments, Tim and 16 similar individuals
    with disabilities urged DRC to file disability discrimination
    complaints with Housing and Urban Development, alleging
    violations of federal and state laws. The HUD case is currently
    pending.
        If this bill were law, the PAIMI program would have been
    prohibited from helping our son with legal advocacy in the
    housing discrimination case because it is not abuse and
    neglect. The current PAIMI law has no such limitation. Without
    the help of DRC and the PAIMI program, Tim would still be
    cycling in and out of institutions. The resolution of Tim's
    current discrimination case may require DRC to seek a change in
    policy through legislation or local ordinances, which they
    currently can do using nonfederal funds. H.R. 2646 will
    prohibit this, and severely limit the remedies available for
    Tim.
        Tim's case was complicated. The PAIMI program gave DRC the
    ability to engage in every aspect of protecting Tim's rights,
    including the flexibility to use nonfederal dollars to engage
    in needed policy change. Tim's prior institutionalization and
    current housing discrimination involves numerous disability
    rights issues, including unjust denial of Medicaid services,
    violation of rights under the ADA and housing discrimination.
    Often the issues faced by people with mental illness are not
    abuse and neglect, but the problem of human and civil rights.
        In closing, this bill would limit the authority of the
    PAIMI program to cases of abuse and neglect, making it far easy
    to discriminate against and violate the rights of people with
    mental illness. It would also eliminate advocacy for policy
    changes, even with nonfederal dollars, on behalf of persons
    with disabilities, including mental illness. Those provisions
    are bad for families and bad for my son, Tim.
        Thank you for the opportunity to testify.
        [The prepared statement of Ms. Billingsley follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. The chair thanks the gentlelady, and now
    recognizes Mr. Rosenthal 5 minutes for his opening statement.

                     STATEMENT OF HARVEY ROSENTHAL

        Mr. Rosenthal. Good morning, and thank you for this
    extraordinary opportunity to testify today.
        I am Harvey Rosenthal----
        Mr. Pitts. Is your mike on?
        Mr. Rosenthal. Yes.
        Mr. Pitts. Yes, go ahead.
        Mr. Rosenthal. Thank you. Sorry about that. A person in 43
    years of recovery from a bipolar disorder, with 40 years of
    experience working in the field, 18 in a hospital, clinic and
    rehab program, with 22 working as an advocate who has come to
    sit on New York's Medicaid Redesign Team, its Behavioral Health
    Workgroup, and our Most Integrated Setting Council.
        Thank you for including a recovering person here. I urge
    you to include more of us in these deliberations.
        My experience has told me that the best way to fix a broken
    system isn't by forcing people into the exact same services
    that have failed them in the past. It won't be achieved by
    reducing privacy protections, limiting access to personal and
    systemic advocacy, or by all of a sudden moving sharply to a
    medical biological bent in ways that could undo or jeopardize
    the extraordinary gains of the recovery and consumer-focused
    approaches that have taken us decades to develop.
        We are not working on my comments. They will tell you, in
    my written comments, they will explain my position.
        I woke up this morning and I felt like I had to use and
    focus on a word that has barely been discussed today, and that
    is recovery.
        And so as I said before, recovery, rehabilitation,
    consumer, and peer support movements have changed the face of
    service delivery to people with the most serious mental health
    conditions in this country and around the world. Before these
    movements took hold, our system told people they would never
    get well, never have intimate relationships, never get a job,
    and never be able to make most of their most personal
    decisions. I know because I saw it every day when I worked in
    the state hospital. We told people that they would never get a
    job, that they would be poor, idle, isolated, and segregated
    from society. They would be permanently disabled. The primary
    treatments of the day were medication and hospitalization. And
    I know we are talking a lot about that here in the bill, but we
    are not talking enough about recovery. We are talking a lot
    about meds and beds, but not enough about recovery.
        Our movements brought hope to people and their families,
    many for the first time. Hope was, and it is still not enough,
    a part of our toolkit. Even the sickest person can improve and
    get well. Although they are dissuaded from going to services if
    the service message is that you are sick, that you need to take
    medication, that you can't make decisions, that you will face
    coercion, that your privacy rights will be violated. It is not
    a way to engage people.
        I will tell you a way to engage people. We run a peer
    bridging program in the streets of New York City. We work with
    the hardest to serve; people that are very sick, and don't have
    good housing, who have addiction and trauma, and are, by
    definition, hard to find, victims of abuse, veterans. These are
    our greatest challenges. We developed a model of peer bridging
    that hits the streets. Too much of our system stays in the
    office and blames the patient. We hit the streets, and we go
    again and again and again to engage people. We work with
    families. We have helped hundreds of people in the city, reduce
    their relapses and their readmissions by 50 percent. Yet these
    services have not reached the standard of evidence-based
    practice. We are talking about research on brains. We have to
    also do research on peer services and recovery services because
    otherwise, we will undo them.
        When we talk about AOT, we are typically mandating people
    to take medicine in a hospital. When we talk about limiting
    what PNAs do, we are fearing that people will get off
    medications. When we are talking about the IMD exclusion, we
    are talking about more beds. We have come a long way to just
    talk about medications and beds.
        And, you know, when we talk about importing all of SAMHSA
    into the office of a new Assistant Secretary, we are gambling
    on the possibility that all of the work that has been done to
    transform and offer hope, recovery, wellness, employment,
    community integration, person-centered and self-directed care,
    might get lot in a large bureaucracy.
        There are some out here that believe the recovery movement
    is the enemy; that we are not interested in working with the
    sickest individuals. But I can tell you that we have helped
    tens of thousands of people stay out of jails and prisons and
    homeless shelters, and avoid suicide. We must absolutely be
    able to really focus in funding these programs. So we greatly
    need to offer the promise of recovery to people. You will see
    in my comments that we support a number of the things that
    Chairman Murphy--we laud him for his passion, but we really
    need to see a full range of recovery services, like Steve has
    talked about. There is not enough focus here in the bill, and
    it has to be said.
        Thank you.
        [The prepared statement of Mr. Rosenthal follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pitts. The chair thanks the gentleman. Thanks to all of
    our witnesses. That concludes the opening statements of our
    witnesses.
        We will now begin questioning, and I will recognize myself
    5 minutes for that purpose.
        Dr. Lieberman, we will start with you. Do you believe that
    the community mental health system, developed in the 1960s, was
    designed to serve the needs of individuals who experienced the
    most chronic and severe manifestations of mental illness, and
    if not, what are the consequences of this?
        Dr. Lieberman. Mr. Chairman, it may have been designed with
    that intent, but it was really woefully naive and ill-conceived
    and it failed miserably. I mean the idea was to humanize mental
    health care by being able to move patients from institutions
    into the community, and have them receive an array of support
    services, including housing, including case management,
    including medication and rehabilitation, but none of that was
    there, and they simply fell through the cracks. And we have
    never sort of regained traction on that program and that
    population since.
        Mr. Pitts. Mr. Gionfriddo, how has the
    deinstitutionalization of the mentally ill worked out over the
    past \1/2\ century? In your experience, why do so many mentally
    ill individuals pass through our criminal justice system or end
    up homeless, and are these individuals getting treatment while
    in prison or living on the streets?
        Mr. Gionfriddo. Those of us who were policymakers in the
    1970s and '80s really didn't understand two things about our
    system. One was that we were going to have to put front and
    center the kind of clinical services and support services that
    people would need when they were not in institutions. The
    second was we didn't understand that the pipeline was a
    pipeline of children, that these were illnesses that primarily
    affect initially children and young adults. And so as a result
    of that, what we have ended up doing with
    deinstitutionalization, the kind that we did in the '70s and
    '80s, was a reinstitutionalization of people into prisons. And
    those prisons and jails are not at all connected with the rest
    of the system, and that is a real tragedy.
        Mr. Pitts. Mr. Kennedy, at the present time, how does the
    IMD exclusion impact on the availability of clinically
    effective inpatient treatment options, particularly for
    Medicaid enrollees? How, if at all, would Title V of H.R. 2646
    go about fixing that?
        Mr. Kennedy of Massachusetts. Well, first of all, we have
    to understand that if we are going to treat these illnesses
    like all other illnesses, if the illness is critical and needs
    intensive inpatient treatment, you wouldn't limit that if it
    were the cancer patient, you wouldn't limit that if it was the
    cardiovascular patient, and you shouldn't limit that simply
    because the patient is someone with a psychiatric disorder.
        So I understand the derivation of this IMD exclusion. It
    came out of the days when people were warehoused, where care
    was substandard and horrifying, and yet we took a polar
    opposite approach by just not paying for any inpatient
    treatment as a result. Now we have progressed 5 decades, and we
    are stuck in the same mentality as 5 decades ago? No. We should
    follow the science, treat these illnesses as real illness, and
    in doing so, treat them if they need to be treated in inpatient
    settings, do so, and not preclude that as an option.
        Mr. Pitts. Senator Deeds, why is it important that we have
    enough hospital beds for the most seriously mentally ill who
    need hospitalization? Isn't a large part of the problem not
    just the lack of sufficient inpatient beds, but also the
    absence of any systematic way for the states to determine in a
    timely fashion where a vacant bed may be located?
        Mr. Deeds. That is a really good question. The reality is
    that when we moved to a community-based system, we reduced
    dramatically the number of beds we have all over the country.
    It is not just a national problem, it is not just a Virginia
    problem, it is everywhere in the country. And, as
    Representative Kennedy said, when a person has a heart attack,
    they are not turned away from an emergency room because the
    emergency room is full. It is just like when a person commits
    murder, they are not turned away from a jail because a jail is
    full. When a person has a mental health crisis, we have to find
    a bed.
        And in my view, hopefully, the larger number of people who
    need to be treated can be treated in the community, and we are
    not going to have to put them in an institution. But also in my
    view, we--and at this time, we have a shortage of beds
    nationally for those who have long-term mental health issues
    that need some period of institutionalization, sometimes 30
    days or more. We don't have the capacity in Virginia to provide
    that service to people.
        Mr. Pitts. Dr. Lieberman, you wanted to add something?
        Dr. Lieberman. If I could add something, Mr. Chairman. This
    is an egregious problem that is complicated but understandable.
    What happened was that the inpatient length of stay for most
    individuals with psychiatric illness in the 1960s and '70s was
    months, if not years. And they were either in state mental
    institutions, or they may have been receiving long-term
    psychotherapeutic treatment in the kind of euphemistically
    named institutions out in rural areas--typified by what the
    Menninger Clinic was. And when payers and the government found
    out the conditions in hospitals were terrible, and people
    weren't getting better and discharged, and psychotherapy and
    psychoanalytical treatment wasn't doing anything either for
    serious mental illness, they said, we are not going to pay for
    this stuff.
        The government health insured--Washington, D.C., when I
    went to medical school in the 1970s, had the highest
    concentration per capita of psychiatrists of any city in the
    country. Do you know why? Because GHI paid for psychoanalysis.
    That stopped pretty quick when there was no evidence to support
    it, and people started getting concerns of health care costs.
        So the kneejerk reaction was to go the other way and to
    limit length of stay, which plummeted down to now the single
    digit days as average length of stay.
        In my hospital, New York Presbyterian Hospital, the largest
    health provider in the New York metropolitan area, the average
    length of stay range--I mean the occupancy rate in the hospital
    in medical surgical services ranges from maybe 60 percent to 85
    percent, and in the psychiatry units it is 100 percent always,
    and the psych ED is the same thing. But the hospital, which is
    struggling for financial viability, will never give me another
    bed because it is not financially desirable to do so. And so we
    are caught in this quandary. As Senator Deeds said, if we had
    an effective mental health care system which could deter people
    coming into it by preventive care, which provided adequate
    ambulatory care to keep people from having to come into the
    hospital, we would decompress this, but it will take time.
        Mr. Pitts. The chair thanks the gentleman.
        My time has expired. The chair recognizes the ranking
    member, Mr. Green, 5 minutes for questions.
        Mr. Green. Thank you, Mr. Chairman. I want to thank all our
    panel.
        My experience outside of being a legislator is as a lawyer
    doing probate work in the 1980s in Houston, Harris County. I
    was so proud when we got a Harris County psychiatric center,
    managed by the University of Texas Health Science Center. But
    we have fewer beds there today than we did in 1988, and that is
    the frustration I think seen around the country.
        But when I was practicing law, I was so happy when I found
    somebody who actually was a veteran because I could get them
    into our veterans hospital that had real treatment, and we
    didn't have to wait for a bed. And that is our problem, and I
    know it is even worse today because of the growth in our
    population.
        My frustration back then was that very few insurance
    policies covered mental health. And I know the Affordable Care
    Act did much to advance mental health care largely by extending
    coverage for mental health and substance use disorders. It
    required new and small group insurance plans to cover these
    services as essential health benefits. In addition to advancing
    parity of coverage, the ACA authorized the Center for Medicare
    and Medicaid Innovation, the CMMIs, to test innovative models
    of care. The first round of health care innovation grants
    CMMI--10 were focused specifically on mental health.
        Mr. Coe, in your testimony you described the work Community
    Access has done to create programs that provide innovation and
    tailored services to people experiencing psychiatric episodes.
    I understand Community Access received the Health Care
    Innovation Grant from CMS to create Parachute NYC, or New York
    City.
        Mr. Coe. Right. Thank you, Congressman. That is correct.
    Community Access, in partnership with the City of New York,
    applied for a grant to create alternatives to hospital care,
    and the city called it Parachute NYC. It means a soft landing
    for people in a psychiatric crisis. Then the Parachute
    Program--it actually created four residences: one in Staten
    Island got left out again, but one in each borough, as well as
    enhancing the workforce by adding peers to mobile crisis teams,
    and creating a peer-run support line. So our residence opened
    first in January of 2013, so we have run it just for about 2
    years.
        We had almost no guests for the first 6 months. We had
    five, six guests. We had a capacity for seven. We had over 100
    people in the last 5 months. And 25 percent of those were self-
    referrals. So if you put a service out that is an experience
    that people appreciate, they will flock to it. People can come
    and go. People are encouraged to talk to staff. Our staff are
    all peers. We had 800 applicants for 14 positions. And then
    training people on how to talk and listen to people, and
    brought in evidence-based practice to do that.
        New York has made a deal with the Center for Medicaid and
    the Government to reduce actually the usage of hospital use by
    25 percent over the next 5 years, including Dr. Lieberman's
    hospital, which is part of the reform plan, by creating more
    respite services, mobile crisis teams. Our mobile crisis teams
    take 48 hours to go out. In Pierce County, Washington, they
    take 48 minutes to go out. And a family in crisis needs a
    response, it needs a place to call, and then they need somebody
    to respond when the call is made.
        So Parachute NYC was a package of improving mobile crisis,
    offering alternatives to hospitalization, offering support
    lines, and expanding the peer workforce.
        Mr. Green. Mr. Coe, do you think that program could be
    replicated around the country, although I know we have a lot of
    programs all over the country that actually may not be Federal
    Government funding, but actually coming from the community?
        Mr. Coe. It is a simple model. I think that the idea--and I
    think the resistance that we faced initially was that it wasn't
    going to be safe, that peers are going to be running it,
    therefore, it is not going to be a safe place for people to go.
    So we had open houses, we had cake sales, we had people come
    and meet the staff. The staff went out and did presentations to
    agencies so they could see who worked there. We also linked to
    medical facilities and health care. So we don't ignore that
    safety is first. So you take care of people when they come in
    the door, if you notice a problem, you can seek help, but it
    has to be a system, and it can't be just one thing. It has to
    be organized, system-wide. And there are very few places around
    the country where they have done that.
        The crisis intervention teams, and a lot of--Arlington,
    Virginia, has a great program. Mental health, police, drop-off
    centers. Very well organized, they meet monthly. That is the
    kind of comprehensive----
        Mr. Green. OK.
        Mr. Coe [continuing]. Service that you can put together.
    So, yes.
        Mr. Green. Thank you, Mr. Chairman. I know I am out of
    time. But, Ms. Billingsley, I wanted to ask you a question. I
    will submit it and we will get a response about the success
    with your job. So thank you.
        Mr. Pitts. The chair thanks the gentleman.
        Now recognize the vice chairman of the full committee, Mrs.
    Blackburn, 5 minutes for questions.
        Mrs. Blackburn. Thank you, Mr. Chairman. And thank you to
    each of you.
        I am going to come to Senator Deeds and Rep. Kennedy and
    Mr. Rosenthal. As I said, we have worked on this. Chairman
    Murphy has done such a tremendous job on this, and we want to
    have a piece of legislation that we can put in place, get
    signed into law, and then have that foundation that will work
    us toward parity.
        With that in mind, what I would like for the three of you
    that I have mentioned, and, Senator Deeds, let's start with
    you, to just talk to me, give me the two or three things that
    you think are best about the bill that will be most helpful,
    and then the couple of things that probably you think we need
    to go back to the drawing board on. And very quickly to the
    three of you, and then the others of our esteemed panelists, I
    would like for you to just submit that to us in writing.
        I think as we drill down, and as we get something ready to
    move forward, give me your thoughts. This is helpful to us as
    we plan forward.
        Mr. Deeds. And honestly, I was provided a summary of the
    bill, and that is what I read, and so I don't know that I have
    all the details to give you the answer to that question
    precisely. And maybe I can do that in writing later on.
        Mrs. Blackburn. That is acceptable.
        Mr. Deeds. The part of the bill that I really like are the
    changes to HIPAA. I hear from so many people--I mean since my
    son died, the last 19 months I get messages, I get e-mail, I
    get Facebook messages, I get contacted by people all over the
    country every day. Mothers and fathers, older brothers and
    older sisters who care for a loved one who has a mental
    illness, who can't get the information that they are in
    basically the same situation I am in, and I think----
        Mrs. Blackburn. OK. So for you, the number one would be the
    changes to the HIPAA laws.
        Mr. Deeds. HIPAA, yes.
        Mrs. Blackburn. You like that. That is something that would
    help you as a caregiver.
        Mr. Deeds. It----
        Mrs. Blackburn. OK.
        Mr. Deeds. I mean nothing is going to help me. I am done.
        Mrs. Blackburn. Yes, sir----
        Mr. Deeds. But it is going to help the next person.
        Mrs. Blackburn [continuing]. I understand, but I mean to
    that type situation.
        Mr. Deeds. Right.
        Mrs. Blackburn. And I appreciate that so very much. And I
    appreciate your willingness to work with us on this.
        Patrick?
        Mr. Kennedy of Massachusetts. Thank you, Representative
    Blackburn. I would say, obviously, we have all spoken about
    prevention as the main policy we should all adopt, but I don't
    want this hearing to end up becoming this false dichotomy that
    it is one or the other. Obviously, payers want to do it on the
    cheap. So if they can hire a bunch of peer support folks, they
    are going to do it. And if they can deny inpatient treatment,
    they are going to do it. So we just have to be mindful that one
    doesn't preclude the other.
        I like the recovery model. I am a beneficiary of the
    recovery model. But God forbid we use that as an excuse to
    preclude the medical treatment that people need when they are
    in crisis. This is not an either/or issue. We need both. And so
    I would say that. And I would finally say this. 42 C.F.R., if
    we are going to move forward in the 21st century, we need to
    have brain illnesses included in your medical record or else we
    are never going to get the comprehensive support that----
        Mrs. Blackburn. OK.
        Mr. Kennedy of Massachusetts [continuing]. Someone needs in
    their care. And I love that about----
        Mrs. Blackburn. OK, so we have HIPAA and we have a both-end
    approach, not an either/or.
        Mr. Kennedy of Massachusetts. Yes.
        Mrs. Blackburn. OK.
        Mr. Rosenthal?
        Mr. Rosenthal. Thank you. The parts of the bill that I like
    the best are the focus on integration of health care and mental
    health care, and the better coordination of criminal justice in
    mental health. There is no question that so many of our most
    vulnerable people really have all these issues, and the
    coordination is essential.
        In New York, thanks to the Affordable Care Act, they are
    implementing health homes which are linking all of these
    systems to work together. One staff person, one record, one
    plan.
        The second thing, and I am really just not sure how to read
    the bill, but it looked like something we had talked about,
    Congressman Murphy, about outreach and engagement. You have a
    section in the block grant section which appears to say that
    you must have a good outreach and engagement plan in order to
    get the block grant, and that the strategies there may or may
    not have to have AOT in them. So I think a lot of us believe
    that this really aggressive but not coercive outreach and
    engagement, relentless outreach and engagement, is critical,
    and it seems like you are very focused on that, and I think
    that is tremendous. It is on the front end that we are going to
    have to do the most work.
        And the third thing is the Interagency Serious Mental
    Illness Coordinating Committee. I think it really brings
    together all kinds of agencies and leads and expertise. The
    only thing I would say about that is it should include SAMHSA
    and the Centers of Medicaid and Medicare. It is the number one
    funding stream, Medicaid, is in America, and that is our best
    change. The outcomes associated with that, the incentives.
        Mrs. Blackburn. All right.
        Mr. Rosenthal. The things I like the least, well, assisted
    outpatient treatment really had its origins in New York in a
    very big way. I have been working in opposition of that for a
    very long time, and I do that because I don't believe it has
    been proven to be an effective strategy. There have been
    studies, first at Belleview, that gave everybody better
    services, and gave some court orders, and the study found it
    was the more and better services that got it done, not the
    court orders.
        The legislature was so concerned about that that they
    ordered a comparison between voluntary and involuntary--am I
    out of----
        Mrs. Blackburn. Mr. Rosenthal, I am sorry, my time has
    expired, and----
        Mr. Rosenthal. Sorry.
        Mrs. Blackburn [continuing]. If you can submit this----
        Mr. Rosenthal. I will write it to you.
        Mrs. Blackburn [continuing]. In writing. Thank you all so
    much.
        Yield back.
        Mr. Pitts. The chair thanks the gentlelady.
        I now recognize the ranking member of the full committee,
    Mr. Pallone 5 minutes for questions.
        Mr. Pallone. Thank you, Mr. Chairman.
        I wanted to ask my questions of Mr. Rosenthal. We can't
    talk about mental health coverage without talking about the
    Affordable Care Act's Medicaid expansion. Can you comment on
    how Medicaid expansion has expanded access to mental health and
    substance abuse services? And I ask that because, to put this
    in context, 22 states have declined to expand Medicaid at this
    time, leaving 3.7 million uninsured adults with serious mental
    illness unable to obtain coverage. And I hope those states will
    see both the economic and moral benefit of Medicaid expansion,
    sooner rather than later. And your answer to this question may
    provide some reason as to why they should do that.
        Mr. Rosenthal. Thank you. The Medicaid program of the past
    was a very rigid and limited program, very focused on illness
    and symptom management but not, as I said earlier, about all of
    the domains of recovery that are essential.
        We now have in this country a Medicaid Expansion Program
    and a greater use of Medicaid managed care, where the focus is
    on outcomes and improved services, and a diversity of services,
    including supports for even the social nutriments of health;
    housing, employment, things that really matter in peoples'
    lives. So the expansion, I think, really brings in people who
    currently are shut out, including people in addiction recovery
    and some of the programs that they require. So it is an
    extraordinary time to watch Medicaid reform and Medicaid
    expansion because I think millions and millions of Americans,
    without getting access to that, will be shut out and will be
    subject to poor care and poor treatment.
        Mr. Pallone. I mean is it fair to say that lack of
    insurance coverage is not only a significant barrier, but maybe
    the most significant barrier to someone receiving consistent
    care for a serious mental illness?
        Mr. Rosenthal. Absolutely.
        Mr. Pallone. OK.
        Mr. Rosenthal. And you know where that really turns up is
    people who are in jails and prisons who lose their Medicaid, it
    is shut off, and at that critical moment of discharge,
    planning, if the Medicaid is not in force, people fall within
    the cracks.
        I read somewhere that people in addiction, if they don't
    get help in 20 days, 30 percent of them die. It is a very
    strong figure. So Medicaid access is critical, and in that
    system in particular, people are leaving jails and prisons
    without the services they need, and that is why we get so much
    re-incarceration and tragedy.
        Mr. Pallone. All right, I wanted a second question about
    Programs of Regional and National Significance, the PRNS. H.R.
    2646 would create new grant programs that would be funded
    through a 20 percent cut on Programs of Regional and National
    Significance, and on SAMHSA's general funding authority. And I
    wanted to focus on the possible effect of a 20 percent
    reduction in funding for PRNS grant programs. SAMHSA's Center
    for Mental Health Services currently funds mental health first
    aid training for teachers and other adults who interact with
    youth. That training equips them with the tools needed to
    detect and respond to mental illness in children and young
    adults. That PRNS program received $15 million in fiscal year
    2014 and 2015 to provide grants to states and local education
    agencies.
        So, Mr. Rosenthal, if SAMHSA's PRNS authority was reduced
    by 20 percent, $3 million would potentially have to be cut from
    that program. In general, what would a 20 percent cut in grant
    funding for community programs mean to those existing programs?
        Mr. Rosenthal. Well, I think it would be a loss of access
    for many, many Americans in need. Certainly, the Mental Health
    First Aid Program has been so critical in educating the
    communities, the police, other important groups, and if that is
    cut, then that is that many communities and that many people
    and families who won't have the benefits of first aid.
        I am not familiar enough with all of the Programs of
    Regional and National Significance, but I reviewed them
    briefly, and there are a number of recovery programs that, if
    they were cut by 20 percent, again, where there is a real
    emphasis on AOT and not enough, I think, on the recovery side
    of things.
        Mr. Pallone. Well, in addition to cutting mental health
    programs, H.R. 2646 would cut substance abuse programs to pay
    for those new mental health programs. A program that could be
    cut is funding for states to enhance or expand their treatment
    services to increase capacity and access to evidence-based
    Medication Assistance Treatment, or MAT. And the fact is
    America is facing a public health crisis related to the misuse
    and abuse of opioids, and we should not be cutting, in my
    opinion, any funding for that or for other SAMHSA substance
    abuse programs.
        Thank you, Mr. Chairman.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the vice chair of the subcommittee, Mr.
    Guthrie, 5 minutes for questions.
        Mr. Guthrie. Thank you, Mr. Chairman.
        Senator Deeds, I used to serve in the Kentucky State
    Senate, and you mentioned in your testimony that you had
    bipartisan efforts at the state level. You didn't really
    elaborate on those. Can you just kind of--for a few minutes
    of--about a minute or so, what you did, and then how the
    Federal Government can help states doing what you want to do
    there?
        Mr. Deeds. At the state level, when I went back to the
    General Assembly just a few weeks after all of this happened,
    to me, my scars were red and my eyes were too. People there
    knew me because I have been in the General Assembly for a long
    time. I am a bipartisan guy. I am a partisan democrat, but I
    have friends on both sides of the aisle. They knew my son,
    because he had been on the campaign trail with me for years. So
    I was able to cobble folks together to get things done, but the
    reality is that funding is not as consistent as it needs to be
    across the board. We need federal organization. And what this
    bill does in many respects is it takes funding and reorganizes
    it in a way that makes more sense, I think, makes more sense
    for the states, makes more sense for the country.
        Mr. Guthrie. Well, thanks. And I was going to ask Mr.
    Kennedy, my friend, Patrick, this, but you mentioned HIPAA and
    how did HIPAA specifically block what you were hoping to do, or
    how did it affect your situation? I understand that as a
    caregiver, you can't get the information you need.
        Mr. Deeds. Well, I couldn't get psychiatrists to talk to me
    or to even return my calls. I couldn't get people in hospitals
    to tell me anything about what was going on with my son. And he
    was wary of me in the first place, so when I got him to go
    places, I tried for a long time to get him to sign a power of
    attorney or to sign a medical power of attorney to give me
    access to information. I tried to get him to give me that
    authority on some forms that other people had prepared for him,
    and he just wouldn't do it. And the providers wouldn't talk to
    me. I had one provider that sat down and talked to me, probably
    broke the HIPAA law, and maybe it is a lack of understanding of
    the law, but if it is, it is widespread.
        I got an anonymous letter just about 4 months ago from a
    person who told me that he or she had provided care for Gus,
    and had told me some things that touched my heart about their
    treatment of him. I just didn't have the information
    beforehand. It seems to me, let me just tell you. One woman
    called me, or she called my office. She tried to get her adult
    son committed through an involuntary process. She was
    successful. But in the hospital, they wouldn't tell her where
    her son was going.
        Mr. Guthrie. Yes.
        Mr. Deeds. So she couldn't get him his things, she couldn't
    talk to anybody there about his experience. That facility
    wouldn't even return her calls. They just put him on a bus and
    sent him home. How in the world is he going to be kept to
    schedule, is he going to take his medications, is he going to
    keep his appointments if somebody doesn't know it? That is----
        Mr. Guthrie. Understand.
        Mr. Deeds. That is what this legislation----
        Mr. Guthrie. Thanks. I have one more question--well, it is
    not really a question, but Ms. Billingsley brought up some
    concerns. And we want to solve problems, not raise more
    concerns. And talked about the PAIMI program, and if I could
    yield to my friend from Pennsylvania to address some of the
    concerns that you brought up, I would like to do so.
        Mr. Murphy. Well, let me just say this. With regard to some
    things on the protection advocacy issues, now, I can't say that
    there is much that this panel has said that I don't agree with,
    and it sounds like some clarification of wording. Our bill does
    not require assisted outpatient treatment. It does not, and
    that is a misnomer, and I see that in the minority memo, so
    let's make sure we are clear on that. We recognize it can be
    valuable for some people, particularly those who are cycling in
    and out of jail, those of have history of violence. We just saw
    that happen down in Dallas, Texas. I think it can help in some
    cases, but it is not a panacea. But I want to make sure that we
    are focusing on this, and worded this in such a way that people
    can get help and can get that advocacy. It is against federal
    law to use it for lobbying, and I don't intend to change that
    law, but I want to look at something that does need to change.
    And just to follow up on what you were saying to Senator Deeds
    about some individuals have claimed that with regarding to
    releasing any information under HIPAA, it has to be ``as
    necessary to prevent or lessen a serious and imminent threat to
    the health or safety of a person or the public.'' So that is
    the limitation. Do you agree with that kind of limitation?
        Mr. Deeds. I might take it a little broader, but I think
    that that protects a person's privacy. Somebody has to make a
    decision that it is necessary that the person doesn't
    understand what is in their best interests, and that the
    caregiver will provide for that.
        Mr. Murphy. Which is important, and that is where I think
    our bill tries to broaden that. If that person is not aware, to
    provide you with a diagnosis, treatment plan, time, and place
    of the next appointment----
        Mr. Deeds. That is right.
        Mr. Murphy [continuing]. Medications, that would be helpful
    to you as a parent?
        Mr. Deeds. That would be very helpful. Critical.
        Mr. Murphy. I will go back to my questioning later. Thank
    you.
        Mr. Guthrie. Thanks, and my time has expired. I yield back.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the gentlelady from California, Mrs. Capps,
    5 minutes for questions.
        Mrs. Capps. Thank you, Mr. Chairman. And thank you all for
    your amazing testimony.
        For too long, mental health has been left out of our
    discussions about health. I am happy that members of this
    committee on both sides of the aisle have a shared interest in
    addressing this important issue. My background is a public
    health nurse, worked in our community schools. This is an issue
    I know well. I have a brother who has a history of being
    bipolar. I know it personally very well.
        Thankfully, we have made great strides in recent years,
    most notably that all plans must now follow mental health
    parity rules. Many previously uninsured and underinsured
    individuals with mental illness now have access to insurance.
    This was the greatest expansion of mental health services in
    our history, but now one that needs to be built upon. And as
    written, I am concerned that my colleague, Mr. Murphy's, bill
    does not comprehensively advance this progress enough. We need
    to work together to do so, because it does little to address
    mental health issues before they reach that crisis level, help
    individuals after the crisis point has passed. It pits mental
    health and substance abuse services against each other, despite
    the fact that for so many individuals, these are intertwined
    ailments, and needlessly injects partisan politics into the
    mental health space by attaching extraneous abortion language.
    We don't need to be doing that here. It is not a way to move a
    bipartisan bill forward to make meaningful change. Our Nation
    has a history of reacting to mental health issues in a very
    erratic way, swinging from one extreme to another. We need to
    stop the swing, and enact thoughtful evidence-based policies if
    we really truly want to make progress.
        I am hopeful that today's hearing is going to help us look
    beyond a particular bill, and help us have that constructive
    dialogue to move in a positive way.
        Ms. Billingsley, at a previous hearing on this issue I was
    particularly moved by a woman's testimony where she described
    the abuse that took place in her group home, and how the
    protection and advocacy for individuals with mental health
    program, PAIMI----
        Ms. Billingsley. Yes.
        Mrs. Capps [continuing]. Helped shut it down and bring her
    and her housemates to justice. I will never forget her
    testimony. Similar to what you have talked about today. It is
    equally notable. But as you noted, the Murphy bill would tie
    some of the program's hands to protect these individuals from
    unlawful discrimination from educating policymakers like
    ourselves about the issues that these individuals face. I think
    that seems really shortsighted. If the PAIMI program is
    prohibited from advocating for the rights of an individual with
    mental illness, where will families turn to ensure the
    enforcement of laws and regulations?
        Ms. Billingsley. I don't know where they would turn, and
    quite honestly, I don't know where our family would be if we
    had not had their help. I can't even imagine where we would be.
    I often think, and coming here today has brought back quite a
    bit of this journey for our family, it is possible my son
    wouldn't be alive today. It is quite possible----
        Mrs. Capps. That bad.
        Ms. Billingsley [continuing]. Because of the downward
    spiral he was in, and we were no longer able to help him. So if
    that funding was not there, I don't know what we would have
    done.
        Mrs. Capps. Programs like PAIMI are so critical, and you
    said it, to ensuring that families and individuals with mental
    illness have advocates ensuring that their rights are
    protected. We don't want, as it seems to be the case in this
    bill, to tie their hands, and that is another indication in my
    mind that we can do better.
        One bill I am particularly interested in was written by my
    California colleague, Representative Matsui. Her bill, it is
    the Including Families in Mental Health Recovery Act of 2015,
    would clarify HIPAA privacy rules, and would educate providers,
    patients, and families about the law as well.
        Mr. Rosenthal, may I turn to you? Do you think health
    providers adequately understand what HIPAA permits if a patient
    is in a crisis situation? In other words, do we have a problem
    with provider education----
        Mr. Rosenthal. Absolutely.
        Mrs. Capps [continuing]. Or do we need fundamentally to
    rewrite our privacy laws?
        Mr. Rosenthal. I think education is critical. I think
    HIPAA, as I understand it, and also sort of codified, if we
    could codify OCR, the Office of Civil Rights, sort of guidance
    would make it even clearer, but I know that providers at
    minimum are confused or frightened, and at worse, are hiding
    behind HIPAA rather than really--they can listen to families
    now. They may not be able to disclose everything, and there are
    circumstances where they can and they should, and they don't.
    So I think--absolutely, I think education is critical. We can't
    do enough----
        Mrs. Capps. So that is an indication of the ways that we
    have to move past where we are today, even considering this
    bill.
        I am out of time. I will yield back.
        Mr. Pitts. The chair thanks the gentlelady.
        I now recognize the gentleman from Illinois, Mr. Shimkus, 5
    minutes for questions.
        Mr. Shimkus. Thank you, Mr. Chairman. And thank you all for
    being here, and for my colleagues for their great questions. I
    just would encourage my colleagues that if we want to have an
    opportunity to really move a bill, we are going to have to come
    together and be positive and just tweak the language and work
    this through. My colleague, Mr. Murphy, has worked real hard.
    Patrick, it is great to see you again. Senator Deeds and the
    folks' testimonies are just heartbreaking.
        And so the easy question, how many of you on the panel are
    parents? Raise your hand if you are parents. OK. Everyone is a
    parent. So my question is, when do we stop being a parent? I
    don't think we do.
        Ms. Billingsley. No, we never do.
        Mr. Shimkus. You know, my mom and dad, thankfully, are
    going to celebrate their 65th wedding anniversary, and if I do
    something wrong, they are in my face.
        So this HIPAA debate--I said that, didn't I? Dang. That is
    our secret. Don't tell anybody. But this HIPAA debate is very,
    very important, and I think we really need to get it right. I
    still have young--not young, but young men who, some of this
    onset comes at different times. And I fear the day where they
    need help and we can't get access to information. And so I am
    very encouraged by the talk and this whole debate because we
    want to be engaged.
        My question is to Dr. Lieberman on--asking you if you have
    any sense of what kind of clinical outcomes are associated with
    the emergency department overcrowding for patients requiring
    medical or psychiatric services?
        Dr. Lieberman. Well, the overcrowding and the increased
    demand relative to capacity simply sort of backs up people who
    are waiting to be seen, makes the health care personnel kind of
    rushed in the process of being able to do the evaluation, and
    then if the disposition is hospital admission, which it
    frequently is because there is a paucity of available beds,
    they must sit there. In New York State, there is a law that you
    have to make a disposition of somebody in an emergency room
    within 48 hours. It sounds long, but many people sit there for
    longer. We have had patients in the emergency room for as long
    as 6 months. That means they have to be fed, bathed. And the
    reason why this occurs is because if you have what is called an
    intellectual or developmental disability, autism, Fragile X,
    any of the genetic neurodevelopment disorders, and a
    complicating psychotic disorder, there is no place for you to
    go. So it is ridiculous.
        But it really prompts me to sort of comment on some of the
    discussion we have had here about the various programs,
    Community Access and so forth, Harvey Rosenthal's excellent
    work as a rehab director. We are not having a discussion about
    excluding programs, but this is all part of a comprehensive
    effort. Mental health care is disease management, it is not
    simply a doctor giving a pill, or a rehab counselor, finding
    housing or teaching a skill. But when you have cancer and you
    have to go--let's say you have breast cancer or prostate cancer
    or--you go and make a recommendation, surgery, possibly
    radiation and chemotherapy. If the surgery disrupts your
    musculature, you might need rehab. Oftentimes there is a
    psychiatric component to it. All of these things are a part--
    right now, we can't provide those because there is not a
    collocated availability of these services, and a revenue stream
    for financial reimbursement. So it is all fragmented, and as a
    result of this--and I appreciate the effort here because this--
    if anything can rise to be a bipartisan cause, this should be.
    This is not like we have to discover something new and
    mysterious. The expertise, the tools are available, we simply
    have to develop the policy to be able to orchestrate it. And
    what concerns me is that ideological issues are permeating and
    kind of diverting attention from the real issues. If you look
    at SAMHSA's Web site where they have a list of 360-plus
    interventions, there is no mention of medication. Now, I am not
    a cowboy doctor that is going to prescribe massive drugs and
    say, ``See me in a month,'' to people. That is not what
    physicians do, and it is certainly not what psychiatrists do.
    But how can you have a list of interventions with no
    medication? It is like if you are going to go--it is like
    Steven Jobs, he refused surgery because he wanted to try a
    naturopathic approach. It shouldn't be exclusionary. We need to
    have a big picture approach to this in order to be able to
    really deal with this problem. And how long is it going to take
    us to appreciate it? How many Newtowns, how many Aurora,
    Colorados, how many Jared Loughners, is it going to take for
    this to happen?
        Mr. Shimkus. My time has expired so thank you.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the gentlelady from Illinois, Ms.
    Schakowsky, 5 minutes for questions.
        Ms. Schakowsky. Thank you, Mr. Chairman. I apologize to the
    panel, there are concurrent hearings going on.
        I want to especially welcome my friend, Patrick Kennedy,
    for being here. And of all the ways that you have contributed,
    the many ways, I want to thank you for decreasing the stigma
    attached to mental health issues. Thank you for that, Patrick.
        Before I begin my questions, I want to first say I am very
    concerned that we are unnecessarily seeing antiabortion
    language included in this bill. We do not need to attach this
    kind of restrictive language on programs that help to prevent
    suicide and provide transitional housing for people with mental
    illness. And moreover, the language in this bill actually goes
    a step beyond the Hyde Amendment and restricts funds from being
    used to refer a woman to abortion services and, if anything, a
    provision that would probably guarantee increased mental
    anguish. Women deserve to have access to the full range of
    health services. At a minimum, have a right to know what
    services are available to them. So this language continues a
    dangerous precedent of attaching language restricting a woman's
    access to reproductive health services in bill that address
    different topics.
        But let me move on. I would also like to address the
    drastic changes H.R. 2646 would make to the Protection and
    Advocacy for Individuals with Mental Illness Program. In
    Illinois, our protect and advocacy organization, Equip for
    Equality, has worked tirelessly to advocate for individuals
    with disabilities for 30 years. Not only has Equip for Equality
    secured housing and services for individuals with mental
    illness, but they have also worked to affect public policy. For
    example, they worked with state officials to create an adult
    protective services system which works to prevent abuse,
    neglect, and exploitation of adults with disability. They also
    have advocated for the continuation of services that will allow
    medically fragile children to remain in their communities
    rather than in institutions, and yet this legislation would
    actually prevent Equip for Equality from doing this important
    work.
        So, Ms. Billingsley, I want to thank you so much for
    joining us today to share your personal story of your family
    and son, Tim. As important as it is for PAIMI to address abuse
    and neglect, many people like Tim face hardship due to their
    mental illness because of discrimination and navigating the
    complex mental health care system. Families are often not able
    to find the help their family member needs, regardless of how
    hard they try. I have actually experienced that in my own
    family.
        You said in your testimony that Tim is just 22 years old.
    Could you further elaborate in how Tim's illness manifests
    itself, and why it is important to Tim to be in the community?
        Ms. Billingsley. Tim is going to be 23 next month, so he is
    pretty excited about that. The way his mental illness manifests
    itself is that he is highly needing to have structure on a
    regular basis for him, and he is a very talkative person, and
    he is very social. And if he is isolated for very long, he acts
    out with that. That goes against what he wants to be around
    with--or be with people. He also has a seizure disorder, and I
    bring that up simply because he needs to have family and
    community around him to help take care of that issue if that
    were to come about, and we have had a few situations with that.
    He currently lives in a home with five other young men, and he
    is very hasty to tell me it is time for you to go, which took
    me a little getting used to, to be quite frank. But he has a
    full life without me, and he needs that community setting to
    live his life well beyond the time I am here.
        Ms. Schakowsky. So let me ask you this. Do you think you
    have would have been successful in securing Tim's right to stay
    in the community if the Disability Right Center of Kansas had
    not been allowed to advocate on his behalf?
        Ms. Billingsley. No, there is no way.
        Ms. Schakowsky. What would have happened then?
        Ms. Billingsley. It is kind of similar to what else has
    been shared here today. We wouldn't get phone calls returned.
    We wouldn't get responses when we asked about programs. We were
    on waiting lists for services during a time in which my son
    would become violent at home, and there were concerns with the
    safety of our own family. If we had not had their intervention,
    as has mentioned here within 48 hours, when we needed it, we
    would have to have been hospitalized, I am sure.
        Ms. Schakowsky. Thank you. I would like to ask unanimous
    consent to put into the congressional record, Congressional
    Research Service memorandum.
        Mr. Pitts. Without objection, ordered.
        [The information appears at the conclusion of the hearing.]
        Ms. Schakowsky. Thank you.
        Mr. Pitts. Gentlelady's time has expired.
        Ms. Schakowsky. Thank you very much, I yield----
        Mr. Pitts. The chair now recognizes the gentleman from
    Pennsylvania, prime sponsor of this legislation, Dr. Murphy, 5
    minutes for questions.
        Mr. Murphy. Mr. Chairman, before I start, I just want to
    ask that a couple of things be submitted to the record. One is
    the GAO report this committee requested called Mental Health
    HHS Leadership Needed to Coordinate Federal Efforts Related to
    Serious Mental Illness. \1\ Second is the GAO report requested
    by this committee called Mental Health Better Documentation
    Needed to Oversee Substance Abuse in the Mental Health Service
    Administration. \2\ Third is from the HHS Office of the
    Assistant Secretary for Planning and Evaluation, called
    Evidence-Based Treatment for Schizophrenia and Bipolar
    Disorders and State Medicaid Programs. And finally, a list of
    materials I would like to submit for the record, the statement
    from the American Roundtable to Abolish Homelessness, and
    letters of support from the American College of Emergency
    Physicians, the National Council for Behavioral Health, the
    National Alliance on Mental Illness, the American Psychiatric
    Association, the American Academy of Child and Adolescent
    Psychiatry, and the American Psychological Association.
        Mr. Pitts. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
    ---------------------------------------------------------------------------
        \1\ The report has been retained in committee files and is also
    available at:http://docs.house.gov/meetings/if/if14/20150616/103615/
    hhrg-114-if14-20150616-sd017.pdf.
        \2\ The report has been retained in committee files and is also
    available at:http://docs.house.gov/meetings/if/if14/20150616/103615/
    hhrg-114-if14-20150616-sd014.pdf.
    ---------------------------------------------------------------------------
        Mr. Murphy. Thank you.
        It is an amazing day that all of you are here, and Congress
    is gathered to talk about such a critically important subject.
    Let's not forget that. We have a massive amount of common
    ground here. We have to link arms together and do this. And I
    thank my colleagues for their thoughtful comments in this as
    well.
        Let me dig down in a couple of these things which I think
    are important in this bill. Mr. Gionfriddo, in this bill, we
    lay out a greater emphasis on secondary and tertiary
    prevention, and say you have to put some more dollars into
    child and adolescent areas rather than wait until later on.
    Could you describe why that is important to you, why you think
    it is important to focus on those areas?
        Mr. Gionfriddo. Well, I think it is critically important to
    focus in on children. The date are 50 percent of mental
    illnesses manifest by the age of 14; \3/4\ by 25. But for a lot
    of us the statistics don't matter. My son was 5 when he
    developed signs and symptoms of schizophrenia. And he got the
    10-year delays everybody else gets by the time he got his final
    diagnosis, 10 years that we lost opportunity after opportunity
    to change the trajectory of his life. That is one of the
    reasons he is homeless now, not by his choice, but by choices
    we made as policymakers to do that. It is critically important
    we move upstream. We have to arrest this at stage 1, 2, and 3.
    We can't keep waiting until stage 4. We can't keep waiting for
    crises to occur, we can't keep waiting post-crisis, we have to
    move upstream. That is why it is important to me.
        Mr. Murphy. Now, I might add for my colleagues, what I mean
    by primary prevention is what we tell everybody, secondary
    prevention is now you identify the high-risk group, and
    tertiary is someone who is with symptoms. And that is important
    because, as we go through in the grant programs what the GAO
    report said about SAMHSA is, quite frankly, they weren't
    documenting, they weren't evaluating, programs that got grants
    didn't stick to their grants, so it is important we have that
    oversight.
        I also want to note with regard to the issues with regard
    to Medicaid services here, that in this report from Office of
    the Assistant Secretary for Planning and Evaluation, it said
    only 45 percent of beneficiaries with schizophrenia, and 35
    percent with bipolar disorder, maintained a continuous supply
    of evidence-based medications, and received at least one
    psychosocial service during the year. In other words, these
    reports are saying our system is failing pretty bad in this.
        Patrick Kennedy, you and I have talked a great deal about
    this issue of an Assistant Secretary, and their role to get the
    Federal Government coordinated in these symptoms, to follow
    through on parity, and to report back to Congress. You have
    been here. You understand what it is like. What do you see the
    value of having someone go through these 112 federal agencies,
    get the data from the states, and keep Congress' feet to the
    fire in this? What do you see the value of that in moving
    forward in the long run?
        Mr. Kennedy of Massachusetts. Well, thank you,
    Representative Murphy. First, to your previous question to
    Paul, would say we could solve this crisis tomorrow if we
    intervene on first incidents of schizophrenia. There is no
    mystery in this country how to avoid the over-hospitalization
    and crisis management. We are picking up the pieces after
    people have fallen off the cliff. We know what to do. Intervene
    right away with first onset. Don't let the time lapse. And as
    Paul said, you permanently change the trajectory of those
    people. So for people who are interested in return on
    investment, your investment is a lifelong disability is averted
    if you do that wraparound services, first incident.
        So, Representative Murphy, I appreciate that being a major
    focus. The raise work that is being done now is the model.
    Naples is the model. The prodromal phase scientifically before
    symptoms is really what our Holy Grail should be. And we can do
    that with scientists like Jeff Lieberman.
        To the answer on accountability, we are in a new post-
    parity world. We have the legal infrastructure to appeal when
    people aren't being treated equitably under the parity law. And
    I appreciate the fact in this legislation you have a specific
    GAO report evaluating non-quantitative treatment limits. That
    is the secret way that insurance companies deny care. They keep
    it behind, of course, we have eliminated the quantitative
    treatment that sets premium discrimination, copay
    discrimination, lifetime limit--that is gone. So now where has
    the discrimination moved? It has moved to this non-quantitative
    treatment limit.
        If we expose that, which your bill, among many other things
    calls for greater transparency and accountability, I am telling
    you, you are going to see a sea change in the way that we move
    towards this problem, because we are not going to be waiting
    for it to become crisis. It is going to be evident to insurers
    that it is more cost-effective for them to intervene early. So
    I appreciate that. And the state reporting is key because, as
    you acknowledge in this bill, it is the states' mandate to
    continue to work in implementing this law. We need to have an
    accountability structure to see how they are doing, and I
    appreciate that also being in this legislation.
        Mr. Murphy. Thank you.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the gentlelady, Ms. Castor, 5 minutes for
    questions.
        Ms. Castor. Well, thank you, Mr. Chairman and Mr. Green,
    for calling this hearing today. And I want to thank the panel
    for relaying a sense of urgency for the Congress to act when it
    comes to mental health. And thank you for your expert
    recommendations on how to improve the bill today.
        And, Congressman Kennedy, it was great to see you a few
    months back at the Florida Mental Health Research Institute in
    Tampa, at the University of South Florida. They presented
    Congressman Kennedy with the Humanitarian Service Award that is
    very well-deserved. So it is great to see you.
        I want to keep the focus on implementation of the Mental
    Health Parity Act. There is an important provision in the draft
    bill that would require the Department of Labor to submit a
    report to Congress identifying federal investigations conducted
    or completed during the previous year regarding compliance with
    parity in mental health and substance abuse disorders under the
    Mental Health Parity Act. Remember, that Act enshrined in law
    that principle that mental health is equivalent to physical
    health. And the law required group health insurance plans
    covering mental health and substance abuse services to cover
    them at parity with physical health services.
        Then the Affordable Care Act extended this principle to the
    individual health plan market. It also requires that all
    expanded Medicaid programs, as well as individual and small
    group health insurance plans, cover mental health and substance
    abuse services as part of the essential health benefits
    package. That is critical. The ACA expanded these benefits and
    parity protections for 62 million Americans.
        But Congressman Kennedy, in the beginning of your testimony
    you referenced the difficulty with implementation. You are
    hearing about insurance companies' compliance or noncompliance
    with the parity requirements, is that accurate?
        Mr. Kennedy of Massachusetts. Absolutely accurate. And if
    members want to make a difference tomorrow on getting more
    people care than they have today, write a letter to Secretary
    Perez from the Department of Labor, because Secretary Perez can
    issue greater guidance on all ERISA plans, that is employers'
    insurance plans, that this should be a greater evaluation on
    whether they are complying with a federal law. He can issue
    guidance tomorrow. He needs to hear from you that you want him
    to do that, because 65 percent of the health market is that
    employer-sponsored health care. And our veterans, by the way,
    are going to depend on their health plans, if they are
    employed, having coverage for their signature wounds of war.
        Two, you could write a letter to Secretary Burwell from
    HHS. She has the authority today to issue greater disclosure
    requirements on all insurance companies so that we can better
    understand how they do medical management, because as you know,
    Representative Castor, the key to this is the utilization
    management, how they move those things around. We under parity,
    by necessity, need to know how to compare the way they do
    utilization management for the mental health patient, to the
    way they do utilization management for the stroke patient, for
    the cancer patient, for the diabetic. If we know how to draw
    those analogs, we can enforce parity because the law would
    require that they do something different than they are
    currently doing.
        Ms. Castor. Other panel members, are you hearing about
    difficulties with implementation of the important goals of
    mental health parity? Mr. Gionfriddo?
        Mr. Gionfriddo. Absolutely. I think that everybody
    understands that the law has changed, but the implementation
    law hasn't fully taken place yet. And we deal with this every
    single day at Mental Health America. We are hearing a lot about
    this, and strongly endorse efforts to try to make certain that
    we realize all the benefits of parity for all the people we
    care about.
        Ms. Castor. Mr. Rosenthal?
        Dr. Lieberman. I can----
        Ms. Castor. Yes, go ahead.
        Dr. Lieberman. I can add to that. When I was in my role as
    President of the American Psychiatric Association, we had to
    make decisions about which litigation to pursue against various
    insurance companies that were denying benefits or not complying
    with the parity law. And what it ultimately came down to was
    the fact that we had a very strong case in almost all
    instances, but there were such deep pockets on the side of the
    insurers that financially, they just drained us. And so it
    became a much more complicated sort of battle to fight, and I
    think we are still engaged in that battle.
        Ms. Castor. Well, I want to thank you all. Really, I think
    with Mr. Murphy's help, we can look at ways to improve this. If
    you all, when you are submitting comments back to the
    committee, would make some specific recommendations here. And I
    also appreciate Ranking Member Pallone bringing up the Medicaid
    expansion, the importance of it. The State of Florida,
    unfortunately, just last week, rejected a republican State
    Senate plan to expand Medicaid in Florida. That leaves about
    800,000 of my neighbors across the State of Florida in that
    gap, leaves billions of dollars of our taxpayer dollars here in
    Washington, rather than bringing them back home. So if you all
    can talk to policymakers in the State of Florida, please relate
    to them how important Medicaid expansion is for mental health
    services.
        Thank you.
        Mr. Pitts. The chair thanks the gentlelady.
        I now recognize the gentleman from Virginia, Mr. Griffith,
    5 minutes for questions.
        Mr. Griffith. Thank you very much, Mr. Chairman. Thank you,
    members of the panel, for being here this morning, particularly
    Senator Deeds. It is so great of you to be here. Your story is
    obviously very compelling, and when the incident occurred with
    your son, the entire region was affected by it. And we
    appreciate you being here.
        That being said, one of the reasons I asked to be on this
    particular subcommittee was so I could talk about rural health
    care issues. And how long have you been in the state
    legislature, 24 years?
        Mr. Deeds. Twenty-four years. Got there one term before
    you.
        Mr. Griffith. That is what I was thinking. And you live
    about, what, 9 or 10 miles outside of the 9th Congressional
    District?
        Mr. Deeds. I used to be one of only two members in the
    State Senate that was on the dirt road, off a dirt road caucus,
    but the other fellow retired, so I am the last one that lives
    on a dirt road, off a dirt road.
        Mr. Griffith. There you go.
        Mr. Deeds. It is about 9 miles out of the 9th District.
        Mr. Griffith. So that brings up the issue, you worked very
    hard and got some great legislation through in Virginia to make
    sure that there was a mental health bed registry available to
    the people of Virginia. But I noticed in an article late last
    year that Eastern State is getting a lot of patients because
    they are the location that has beds, and they are the beds of
    last resort. And I am wondering if we need to be thinking about
    encouraging the states to participate in a national bed
    registry, because you are also not far outside the 9th. How far
    are you from West Virginia----
        Mr. Deeds. I am not far from West Virginia at all, and I
    am----
        Mr. Griffith. Ten, 15 miles?
        Mr. Deeds. Probably a little bit further than that, but not
    very far. Twenty-five miles. And national registry might make
    some sense. It might make some sense, but as you know, and we
    in Virginia have also turned down the Medicaid dollars. They
    provide insurance to about 400,000 Virginians and about 162,000
    of them have serious mental illness. Pretty significant for us.
        Mr. Griffith. Yes. And mental--I will agree with you that
    mental health issues are things that we need to take a look at
    and be very serious about.
        I am also concerned about the HIPAA requirements that you
    weren't able to know. Whether it is a misunderstanding or not,
    we need to change the language to get rid of the
    misunderstanding----
        Mr. Deeds. Absolutely. Yes.
        Mr. Griffith [continuing]. To make it clearer. I think this
    bill does a lot of that. One of my concerns is, and I know you
    have only read the summary of the bill, is that in the sections
    on HIPAA, we get family members involved, which I think is
    great. My concern is the family member--and I know you have
    practiced in this area, or at least most rural lawyers have,
    where somebody has abandoned the family when somebody is a
    juvenile, and you think it might be helpful if we put language
    in there. We have excluded people who have a documented history
    of abuse, but do you think it might be helpful if we also
    excluded family members who have abandoned a juvenile----
        Mr. Deeds. That----
        Mr. Griffith [continuing]. Before the incident--obviously,
    as an adult, but when they were a juvenile, abandon them?
        Mr. Deeds. I think that language needs to be clear. The
    summary I read does make clear that there has to be some kind
    of caregiver relationship between the family that is going to
    have information and the person that is affected.
        Mr. Griffith. And I appreciate that.
        I have a little bit of time left. It is great to see you--
    --
        Mr. Deeds. Thank you very much.
        Mr. Griffith [continuing]. And appreciate you being here.
    Is there anything else that we haven't touched on that you
    wanted to touch on?
        Mr. Deeds. I think we have touched on a whole lot, yes.
    Thank you. Thank you for asking.
        Mr. Griffith. All right, and we have.
        Mr. Murphy. Gentleman would yield time, or----
        Mr. Griffith. Yes, well, I can. The gentleman from
    Pennsylvania is requesting my time, and I would like to yield
    to Mr. Murphy.
        Mr. Murphy. I thank the gentleman from Virginia.
        Dr. Lieberman, I want to clarify something about HIPAA,
    because I hear a lot of talk about it, but you are the only one
    on this panel, as I understand, who is a licensed provider who
    has to follow HIPAA laws in that sense as in your doctor role
    there. Is it just a matter of getting education out to other
    providers and saying if only you follow this, everything is
    going to be fine, or do you think there needs to be some
    changes in what you are allowed to tell loving, caring family
    members who are the provider? What do you think?
        Dr. Lieberman. Referring to in terms of the HIPAA----
        Mr. Murphy. In terms of HIPAA----
        Dr. Lieberman [continuing]. HIPAA discretions?
        Mr. Murphy [continuing]. I mean the restrictions at HIPAA
    now, what you are allowed to tell someone, is it just educating
    them or do we really need some changes?
        Dr. Lieberman. Right, it is certainly more than education
    because there is a medical-legal aspect to it that health care
    institutions are cognizant of, and doctors have the fear of God
    placed in them by not just their hospital CEOs but also the
    personal injury lawyers.
        Mr. Murphy. So right now then, and along those lines, if
    you were seeing Creigh Deeds, and he says, can you tell me
    about my son, can you just tell me what is his diagnosis, when
    is his next appointment, where is he, I want to get in there.
    Would you be allowed to say that as existing law is now?
        Dr. Lieberman. Right. Strictly speaking, no. If he is an
    adult, if he is overage, but if you did it, you would be doing
    it at your own risk because you could be sort of challenged.
    Doctors often do that, but I don't want to get into that
    because it is the commonsense thing to do.
        Mr. Murphy. OK, thank you.
        Mr. Griffith. I yield back.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the gentlelady from California, Ms. Matsui,
    5 minutes for questions.
        Ms. Matsui. Thank you, Mr. Chairman. And I want to thank
    all of you for being here today. Your testimonies have been
    very compelling, the full range of mental health.
        And first of all, let me just say I agree with Congressman
    Kennedy about the continuum of care. We should not allow
    prevention, intervention to go against the serious mental
    illness. It is just a continuum of care. This is what we are
    talking about today. And the emphasis should be on the mental
    health of an individual. And I believe in prevention and
    intervention at the early end, and all of the services that
    have to be provided, and that has been my history. I have
    always been feeling that way. And I think that what is really
    important here to look at too is the fact that we have been
    focusing many times here on serious mental illness, because we
    know how tragic that is. Whether or not it ends tragically, I
    know in my family, I have a sister who has been severely
    mentally ill for a long time, and during that time, she really
    did not have the care because it was a long time ago. I think
    today she would probably be functioning much better, much like
    your son, Ms. Billingsley. But I would have to say this. I have
    been affected very much by the tragedies that have occurred. I
    have a couple of friends who have adult children who have, they
    felt, been limited by not being able to assist them. And
    listening to you, Senator Deeds, I feel that pain again. And I
    thought that the importance of this bill, because it covers
    such a broad range, and HIPAA has come up so very often, and I
    think that HIPAA should be not looked at as an enemy here, and
    we can't use it as an excuse either. I think we really need to
    figure out what can we do with HIPAA. And I have spent a lot of
    time thinking about this, and also asked myself what can we do
    about these situations when it feels like there is no
    communication and no one to turn to. And I really thank you for
    working with me to answer that question, specifically for these
    issues about sharing information and communications between
    providers and caregivers. We have to walk a fine line here. We
    must protect the patient's right to privacy, and protect them
    from those who don't have their best interests at heart, but we
    must also empower families and loved ones to be able to help.
        I think my bill strikes that balance. It is not a wholesale
    change. I don't believe we can do that because HIPAA should
    cover both mental and physical illnesses. It just can't be one
    versus the other. This bill is really supported by mental
    health advocates that really fall on both sides of the mental
    health policy issues, as well as groups in between. Groups like
    the American Psychiatric Association, the Bazelon Center for
    Mental Health Law, the Mental Health Association of California.
    And additionally, I thank Congressman Kennedy and the Kennedy
    Forum for recognizing the importance of this bill. I thank
    NAMI, the Treatment Advocacy Center, the National Council for
    Behavioral Health, the American Psychologic Association, and
    others for their help. I really feel that this is something
    where we just can't just say we are going to change it. We have
    to look at it to find out how we can change it, and I believe
    that this bill strikes the right balance.
        And, Congressman Murphy, I also believe that your bill is
    something we can work with, and I would like to work with you
    on it. And I think you have heard from people on my side of the
    aisle that they feel that there are really good points to this,
    and there are adjustments that have to be made, and I think
    people on the panel have expressed the same also. So I feel
    strictly that today we should feel heartened that we are
    actually drilling down and trying to find some solutions to
    this, and that to me is probably the most important outcome of
    this because, as we move forward, we pledge to do something
    here that makes real sense.
        And just to comment on my bill here. Mr. Rosenthal, can you
    describe any situations where it would be important to protect
    the patient's right to privacy?
        Mr. Rosenthal. I am struggling for a little bit here, I was
    caught off guard. Sorry. I think that patients really want to
    feel a sense of integrity and choice, and I think if they
    really are already feeling fearful, don't want to feel like
    their caregivers and the therapists are talking whenever
    possible about them without them.
        Ms. Matsui. OK. Can you think on the other side of this
    situation, when it would be appropriate and even necessary for
    a provider to communicate or share information with a patient's
    family?
        Mr. Rosenthal. When somebody's health and welfare and
    safety are at risk, the person or someone else, I think that is
    critical. So I think those are critical sort of----
        Ms. Matsui. OK.
        Mr. Rosenthal [continuing]. Considerations.
        Ms. Matsui. All right. I yield back. Thank you.
        Mr. Pitts. The chair thanks the gentlelady.
        The chair recognizes Dr. Murphy for a unanimous consent
    request.
        Mr. Murphy. Mr. Chairman, just to correct the record on the
    misrepresentation or perhaps misunderstanding about abortion. I
    ask that S. 1299, the Garrett Lee Smith Memorial
    Reauthorization Act, authored by Senator Jack Reed of Rhode
    Island, be introduced into the hearing record. It is Senator
    Reed's legislation, endorsed by the American Foundation for
    Suicide Prevention, which is identical to the language of H.R.
    2646, the Helping Families in Mental Health Crisis Act on
    Suicide Prevention.
        Mr. Pitts. Without objection, so ordered.
        [H.R. 2646 is available at:http://www.gpo.gov/fdsys/pkg/
    BILLS-114s1299is/pdf/BILLS-114s1299is.pdf.]
        Mr. Pitts. The chair recognizes the gentleman from Florida,
    Mr. Bilirakis, 5 minutes for questions.
        Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it
    very much. And thank you for holding this hearing. Very
    important hearing.
        Last December, I had the pleasure of hosting Congressman
    Murphy in Florida for a mental health roundtable with
    stakeholders from the community. I commend him for the
    extensive amount of time he put into addressing mental health
    and substance abuse disorders. I also serve on the Veterans
    Affairs Committee, where we have extensively focused on mental
    health issues plaguing our veterans, our true American heroes.
    In 2012, Time magazine wrote that more U.S. military personnel
    sadly have died by suicide since the war in Afghanistan began
    than have died fighting there. Mental health is an important
    issue, and I am glad we are addressing it. Thank you,
    Congressman Murphy.
        A question for Dr. Lieberman. Dr. Lieberman, training for
    law enforcement that addresses how officers can best approach
    individuals with mental health or substance abuse issues has
    been extremely important in my community. Training programs
    that establish a partnership between law enforcement and mental
    health groups have effectively been implemented in my district.
    Since this legislation provides the creation of such programs,
    can you provide some insight about what effective training
    might entail, what should law enforcement be aware of when
    encountering individuals with mental health or substance abuse
    disorders in the line of duty, how could a lack of training
    cause an escalation in these encounters?
        Dr. Lieberman. Thank you for that question. This really is
    a very important but also unfortunate situation that has arisen
    in which the law enforcement and criminal justice system has
    become so intertwined with mental illness and mental health
    care. Every time I see a terrible story about a mentally
    disturbed individual being subdued and possibly injured or
    killed by police, I am thinking why are the police called upon
    to be first responders? That is really not their training. And
    similarly, in correctional officers in jails or prisons,
    because of the increasing number, that is not their training,
    and even if they do have some in-service training about this,
    it really is not sufficient.
        So I think both criminal--and it is interesting you ask
    that because just this past Friday, I was speaking to 500
    attorneys in the Manhattan District Attorney's Office. They
    asked me to come down to speak to them about mental illness,
    what the nature of it was, what it looked like, and also how
    could they try and adapt so that they could better manage the
    process of judicially reviewing cases of individuals who
    clearly have mental illness. So this is a growing problem.
        I think training is important, both for the police as well
    as for the criminal justice system, but frankly, if we are
    going to basically launder our mentally ill through the
    criminal justice system, both juvenile and adult, we probably
    need to have mental health professionals embedded with the
    police and more present within the prisons, in the jails. This
    is the new normal or the new reality, and we need to provide
    care where it is required.
        I was having a conversation with individuals at that
    meeting on Friday where I offered the observation that, in
    adult prisons, you have people principally who are adults, who
    are either psychotic, with schizophrenia, bipolar disorder,
    possibly psychotic depression, and substance abusing.
    Predominant diagnoses. In the juvenile detentions, it is kids
    who have what are regarded as antisocial behaviors and conduct,
    but in many respects, I would even venture to say it is the
    majority, these individuals start out as individuals who have
    learning disabilities or what is scientifically called
    pediatric cognitive disorders. They have dyslexia, they have
    ADHD, they have nonverbal learning disabilities, and they can't
    connect with the world socially, educationally, and because
    they aren't succeeding, they are getting kind of negative
    feedback, they react to it in an obstreperous or disobedient
    way, and that leads them down this path and they end up in
    prisons. So it gets to what Patrick was saying about, we are
    sort of addressing this downstream, closing the barn door after
    the horses have left. But either we give a modicum of training
    to our law enforcement and correctional people, or we embed
    mental health professionals or we really go for the big
    solution which is preempting the flow of individuals into the
    legal system to begin with.
        Mr. Bilirakis. Thank you. Thank you very much. I will yield
    back. I don't have any more time. Thank you, Mr. Chairman.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the gentleman from Maryland, Mr. Sarbanes,
    5 minutes for questions.
        Mr. Sarbanes. I thank you, Mr. Chairman. I want to thank
    the panel. Patrick, welcome back. It is great to see you. I was
    talking to Dr. Nancy Grasmick the other day when I was working
    with you on brain research affecting early childhood, and she
    is incredibly excited about the work that you all are doing
    together. And I worked for her for 8 years, so I can tell you
    if she is excited, it has to be good stuff. So congratulations
    on that, and thank you for your testimony here today.
        There is no question that we still live in a world where,
    when we see physical pain, our impulse is to treat it, and
    unfortunately, when we see mental pain, our collective impulse
    often is to look in the other direction. And the first step
    towards remedying that, a critical step, obviously, is to make
    sure that our health care system acts with the kind of parity
    that Patrick Kennedy and others fought so hard for, and is now
    embedded in the Affordable Care Act.
        There is this tension as we think about how to distribute
    resources across a health care system that is more sensitive to
    issues of mental health between, sort of where along the
    spectrum do you place the resources to maximize the positive
    impact you can have. When you are talking about people that are
    on that spectrum of illness, intervening in an earlier stage
    may be intervening when the illness is less acute, more
    moderate. And so that is something that I know we are trying to
    sort out in the deliberations over this bill and other
    proposals that have come forward.
        It occurred to me that a lot of the debate over what kind
    of information can be made available to parents, for example,
    or family members of people that are suffering from mental
    illness, occurs because those suffering are of adult age, and
    that is when these protections kick in, which, to my mind, just
    emphasizes the importance of early intervention, because
    presumably early intervention, intervention at first instance,
    as Patrick indicated, would oftentimes be intervention that
    occurs before the individual reaches the age of majority and
    these protections kick in. So if we could promote more of that,
    we are not going to be diffusing all the situations where you
    have these kind of competing considerations between privacy and
    delivering care, but we will be addressing a significant number
    of them. And also presumably, just promoting a broader and more
    open and more candid conversation among all the affected people
    in the equation so that you begin to build a relationship and a
    communication, a conversation, that can help support that
    individual as they move forward. One that includes family
    members and includes caregivers, and so forth.
        And finally, early intervention, I presume, has to promote
    parity. And we talk about sort of legal parity and health
    insurance coverage parity, but the greatest challenge we face,
    obviously, is achieving parity in a judgment that society
    delivers upon one kind of illness versus another. And I think
    that we all want to get to a place where our reflexive response
    to someone who is suffering from mental illness is on par with
    the way we respond to those who are experiencing a physical
    trauma, kind of in the traditional sense.
        I am committed to this ongoing conversation. I thank
    Representative Murphy for putting this in front of us for
    discussion. I thank Representative Matsui for her important
    contribution to the conversation. It is something we have to
    continue going forward.
        And I don't really have any questions, just to thank you
    all for your testimony today. And I will yield back.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the gentleman from New York, Mr. Collins, 5
    minutes for questions.
        Mr. Collins. Thank you, Mr. Chairman.
        Before I get started, I just need to go out of my way to
    thank Congressman Murphy for his tireless work on the important
    issue we are here talking about. As a cosponsor of this bill
    last Congress, I am pleased to see this moving forward. This is
    certainly one step in that process. But I want to particularly
    thank Congressman Murphy for adding into this bill Section
    207(d), a version of the Ensuring Children's Access to
    Specialty Care Act, which I introduced earlier this year with
    Congressman Joe Courtney. This provision adds child and
    adolescent psychiatrists to the loan repayment program in the
    National Health Service Corps, or NHSC, for those doctors who
    practice in underserved areas. I believe this is an important
    step forward in getting mental health treatment to children,
    and I will continue to work to ensure that all pediatric
    subspecialties are covered in the NHSC program.
        I think we have covered a lot of the details today, but I
    did hear, Mr. Rosenthal, you mentioned, and I know you are a
    supporter of Obamacare, and we can all agree to disagree on
    certain things, you certainly let it hang out there that
    because of Obamacare, in the Medicaid expansion in those states
    that have accepted Medicaid expansion, they are offering
    significantly better different programs in mental health than
    the states that did not accept expansion. And I guess in the
    category of you don't know what you don't know is always--it
    has been my impression that with one minor exception, which is
    an optional minor demonstration program dealing with
    reimbursement for emergency inpatient psychiatric care, with
    the exception of that, the main thing that the Medicaid
    expansion did was change the income guidelines under which
    patients would qualify for Medicaid. States that accepted the
    expansion were able to get people in at a higher income level
    than states that didn't. But I wasn't aware that there was this
    wide area of different programming, et cetera, et cetera, going
    on. So I guess all I can do is say I kind of take issue with
    that piece of it which is kind of hung out there. But also I
    just want to bring up, we had under Chairman Murphy, a hearing
    on SAMHSA, and in that clearly, this committee was generally
    not happy with some of the outcomes, the expenditures of money,
    and so forth. And I know I--correct me if I am wrong, but I
    think the majority of your funding comes from SAMHSA, so you
    are--doesn't. But I am assuming you are well versed in what
    SAMHSA does.
        Mr. Rosenthal. I would say 3 percent of my funding----
        Mr. Collins. OK.
        Mr. Rosenthal [continuing]. Comes from----
        Mr. Collins. But I know you do deal with SAMHSA and get----
        Mr. Rosenthal. Yes.
        Mr. Collins. OK. So I guess kind of as a pick-up on that
    particular hearing, I believe this committee would like more
    local control of dollars, good reporting coming back, because
    SAMHSA is a funding mechanism to get grants out. Could you
    share with us here your thoughts on SAMHSA and how we might
    have the taxpayer dollars go to better use with that funneling
    mechanism, have you got any recommendations? I don't know that
    it belongs in this bill or not, but we would just be interested
    in your observations there.
        Mr. Rosenthal. Well, as I said earlier, I think SAMHSA
    really helped birth the recovery consumer movement, and my
    experience with them in the contracts that I am working on is
    really focused on peer support, health care integration,
    employment, things that are noncontroversial and very important
    and significant. I think that arguments have been made that
    SAMHSA needs to be more balanced, but I think that the solution
    of eliminating it is not the way to go. We will lose an
    important resource and decades----
        Mr. Collins. Yes, I don't think that has been suggested,
    but like some government agencies, I think at some point more
    accountability, more metrics----
        Mr. Rosenthal. I don't disagree with that, Congressman. I
    think----
        Mr. Collins. OK.
        Mr. Rosenthal [continuing]. SAMHSA needs more
    accountability.
        Mr. Collins. Yes. Well, I appreciate all of your--you would
    like to make a comment?
        Dr. Lieberman. Yes, I mean SAMHSA----
        Mr. Collins. You only have about 30 seconds, but----
        Dr. Lieberman. SAMHSA's budget is $3.6 billion. The NIMH's
    budget is $1.2 billion. SAMHSA's efforts to try and provide and
    innovate mental health care from the perspective of the
    academic psychiatric community has been a disaster. They have
    not had a psychiatrist in a significant position of leadership
    in that in a decade. There is an ideological bias which
    pervades the organization. In fact, I would go so far as to say
    that SAMHSA is a proxy agency for the antimedical,
    antipsychiatry approach to mental health care.
        Mr. Collins. I can appreciate those comments, and certainly
    we continue to look to Chairman Murphy to lead our discussion
    in many of these areas based on his expertise. And while I
    don't think anyone would suggest SAMHSA go out of existence, I
    think we want to see our taxpayer dollars go where they should,
    and perhaps a rebalancing might be appropriate as we move
    forward, and we would certainly appreciate your input on that.
        My time has expired, Mr. Chairman. I yield back.
        Mr. Pitts. The chair thanks the gentleman.
        I don't see any other Health Subcommittee members present,
    so without objection, we will go to--do we have----
        Voice. It is full committee.
        Mr. Pitts. Full committee members. Mr. Tonko, you are
    recognized 5 minutes for questions.
        Mr. Tonko. Thank you, Mr. Chair.
        I think we need to identify for the record whether or not
    we eliminate the SAMHSA role with the creation of a new
    structure within the Secretary's position.
        Mr. Pitts. Do you want to respond, Dr. Murphy?
        Mr. Murphy. What we do is we elevate SAMHSA from an agency
    to having Assistant Secretary of Mental Health and Substance
    Use be the head of that. And so it is not eliminated at all. It
    is elevated in terms of the authority of that. As you know,
    with these 112 federal agencies out there, someone needs to
    have enough strength behind their name and title to actually
    coordinate many aspects of this.
        Mr. Tonko. OK. I think it certainly warrants further
    discussion. And Representative Butterfield had to leave. He has
    asked that I request that this article, Fatal Police Shootings
    in 2015 Approaching 400 Nationwide, be submitted to the record.
        Mr. Pitts. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Tonko. And I thank you, Mr. Chair. And thank you as
    well to my colleagues. Certainly, Representative Murphy and
    Representative Matsui have been doing great work to introduce
    legislation that continues the conversation on how we can best
    address the needs of those struggling with mental illness.
        While I continue to have a number of concerns with the
    Helping Families in Mental Health Crisis Act, I believe that it
    is a thoughtful and earnest endeavor, and it is my hope that we
    can all come together to move forward, address these concerns,
    strengthen the legislation, and produce a final product. I
    think it is very important that we do that, and that need has
    been expressed by several on the panel here this morning.
        That being said, Mr. Gionfriddo, in your testimony you
    touched upon the issue of funding for the new programs included
    in this legislation, stating that it is emphatically the
    position of Mental Health America that any offsets should not
    come from existing community mental health programs. One of my
    concerns with this legislation as it currently is written is
    that it is ambiguous on the funding mechanisms of many of these
    programs, and where it does speak to funding specific programs,
    it often reauthorizes them at lower levels than currently
    funded. As the authorizing committee, it is our job to ensure
    that we put our money where our mouth indeed is, and provide
    clear and unambiguous funding instructions to the
    Appropriations Committee so that together, we can make the
    strong bipartisan case that more funding is needed for mental
    health and substance use programs----
        Mr. Gionfriddo. Yes.
        Mr. Tonko [continuing]. And can you please comment on this
    and, more generally, the need for this legislation to support
    not supplant existing funding for mental health and substance
    use programs?
        Mr. Gionfriddo. Yes, I would be happy to. The first thing
    is that I would certainly encourage the committee to not make
    any doubt about the fact, or have any doubt about the fact that
    those dollars ought to come from someplace else. And, of
    course, I said in my testimony I think they ought to come from
    the jails and prisons. I think that is the place to get them
    from because that is the place they have been sent to.
        Too many dollars have been cut. The states cut $4.6 billion
    from mental health agencies between 2009 to 2013, and here we
    hear that we only put the federal level $1.2 billion into IMH,
    and then SAMHSA only put $1.2 billion into the mental health
    side. That is \1/2\ of what the states have cut is the total
    federal amount. So we can't continue to live with that. If the
    states aren't going to do their jobs, and they haven't been
    doing their jobs in this area, they just haven't, the Federal
    Government has to step in and figure out how to give them the
    guidance to make sure that they invest this way, and make sure
    they continue to invest early on in the process.
        Mr. Tonko. Thank you very much.
        And can I ask our other panelists to comment on that same
    question about supporting, nor supplanting existing funding?
    Senator Deeds?
        Mr. Deeds. Sure. I don't claim any expertise. I know about
    the Virginia system, but from my perspective, the system
    overall is not working. I don't think it hurts anything to
    examine the way you spend money and see if you can spend it
    more efficiently. I have been in the state legislature 24
    years, I have never believed that you solve problems just by
    throwing money at them. But it is clear to me that in some
    cases, more funding is needed, but we have to make sure we are
    spending money as efficiently as we can right now, and I don't
    think we are.
        Mr. Tonko. OK. Congressman Kennedy, great to see you. Thank
    you for your hard work.
        Mr. Kennedy of Massachusetts. Well, thank you,
    Representative Tonko. You in New York passed the parity in New
    York. We acknowledge that.
        I would say that we have to see the forest for the trees.
    And the forest says that if we employ a whole new system,
    instead of the emergency rooms, instead of the jails, we could
    give better care to people and it will cost us less money. And
    talk about a bipartisan plan that would get through Congress.
    So we need to talk about with GAO and OMB new mechanisms to
    think about mental health in a systemic way so that we are not
    trimming along the edges, because right now, Representative
    Murphy's statement that we are fiddling while Rome burns is
    true. We need to look at the more fundamental issues of where
    the funding is coming overall, and align them in between
    committees of jurisdiction, because a lot of people hear about
    the housing issues which need to be supported, the Department
    of Labor issues, the job training and support, none of that is
    aligned in our budgets and that is what hobbles our ability to
    have a comprehensive solution to this challenge.
        Mr. Tonko. Thank you very much. Dr. Lieberman?
        Dr. Lieberman. I completely agree. I think it is not a
    matter of reducing funding, but it is a matter of--I think
    SAMHSA needs to be basically rehabilitated, and there is a
    mechanism in this bill which really elevates the stature and
    importance of mental health care which had been under the
    rubric of SAMHSA. I remember, my career goes back to when there
    was ADAMHA which was the combination of the NIMH and what is
    now SAMHSA, and there was effective oversight and direction
    then, but for a variety of reasons I don't claim to be privy
    to, they were separated. The NIMH went back into the NIH, and
    SAMHSA went off on its own, and it has been a complete waste
    ever since.
        Mr. Pitts. The gentleman's time has expired.
        The chair now recognizes Mr. Loebsack 5 minutes for
    questions.
        Mr. Loebsack. Thank you, Mr. Chair and Ranking Member.
    Thank you for letting me be an interloper here today. I am not
    a member of this subcommittee, and so it is a great opportunity
    for me to speak to some of these issues, and ask a couple of
    questions.
        First thing I should say, as so many of the folks in this
    body, I have personal experience with this issue. My mom, as I
    was growing up, and as long as I can remember, as long as she
    lived, she struggled with mental illness. That leads me to the
    issue of stigma, and I am really glad that Ms. Schakowsky
    talked about that. I know that you folks are very aware of
    that. And, Congressman Kennedy, I mean we have talked about
    this while you were here, and you have been such a great
    champion on these issues. When I was on the Education and Labor
    Committee, we had a lengthy hearing, we had Rosalynn Carter
    come in and talk about this. I tell people often as a Member of
    Congress, if I don't succeed at anything else on the mental
    illness front, I am going to be very successful in talking
    about this issue and doing everything I can to remove the
    stigma from this issue and those folks who are struggling with
    this issue. And if that is all I succeed then I will have at
    least done something while I am here.
        On the policy front, I do thank my friend, Congressman
    Murphy, for his attempts to do what he can on this front. I
    know we can do better. He knows we can do better. And I have
    talked to him at great length about how we can hopefully work
    together to resolve some of these issues.
        My big issue today that I just want to mention briefly has
    to do with children, has to do with rural areas, and there are
    a number of us on this panel who are from rural areas. Clearly,
    children are best served by providers that are trained to meet
    their needs. There is no question about that. That may mean a
    child psychiatrist where one is available, and that is the big
    issue in many ways, but it should also involve pediatricians, I
    would argue, that have well-established relationships with
    families and that serve as a medical home for children. But in
    Iowa, there are only 53 child and adolescent psychiatrists.
    Now, we only have 3 million people, but only 53. And these
    providers are concentrated in 14 counties. That leaves 85 more
    rural counties without a single provider. Also, the provider on
    average is 52 years old. So the demographics are there as well.
    You know this very well, Dr. Lieberman.
        I am going to be introducing legislation soon that would
    tackle this issue by supporting innovative programs that
    operate in more than \1/2\ of all states, including my own,
    Iowa, to provide mental health consultation by child
    psychiatrists, or pediatric primary care practices, often
    called child psychiatry access programs, to enable the
    pediatrician to treat a child in his or her office, or refer to
    a specialist if that is necessary. These programs, I think,
    show a lot of promise. They are being well received by
    pediatricians and by child psychiatrists alike. So I guess I
    would like to--Mr. Gionfriddo, and perhaps Dr. Lieberman as
    well, and anyone else, talk to me about these issues if you
    would, about the need for early childhood intervention and
    treatment programs, and about how the needs of children are
    different than the needs of adults, and how child psychiatrists
    are uniquely qualified, if you will, to help this population,
    and integrating that as well, as I have suggested.
        Mr. Gionfriddo. Well, starting from a nonclinical
    perspective, and mostly sort of a parental perspective about
    this----
        Mr. Loebsack. That is important.
        Mr. Gionfriddo [continuing]. It was absolutely essential
    that my son, at a relatively early age, had access to a good
    child psychiatrist. He had access to a good child psychologist
    as well, and they together really helped develop a plan. Now,
    it didn't work out all that well because we couldn't integrate
    what the schools were doing, and that is a whole other issue we
    all need to talk about----
        Mr. Loebsack. Right.
        Mr. Gionfriddo [continuing]. How we do that with kids. But
    it is absolutely essential that we get those perspectives
    working with parents and the parents' pediatricians, as you
    point out, right from the start, because together, all of those
    four parties, if you will, and the social workers who assist,
    and others too, can put together the kind of plans that can
    change trajectories of lives. And that is what we have to think
    about here. We don't just have these two populations, all these
    people are going to get better on their own, or those other
    people we have to wait until disaster occurs to treat, 99.9
    percent of the people like my son, somewhere in the vast middle
    of this, and we can do so much for them if we all work
    together, just like you are going to do so much for us by all
    working together this year.
        Mr. Loebsack. That is right. Hey, we have done some of that
    on this committee already, and I think we have already set some
    good examples.
        Yes, Dr. Lieberman?
        Dr. Lieberman. I couldn't agree with you more. If you talk
    to any primary care doctor, whether it is a pediatrician, a
    family medicine doctor, or an internist, they will tell you
    that 40 percent of their practice or more is psychiatric. And
    there aren't enough child psychiatrists, there aren't enough
    adult psychiatrists, to go around, and we need to have really
    teams of mental health care providers which include all the
    disciplines--psychology, social work, nurse practitioners--that
    have defined roles and responsibilities. But the frontier, the
    line of first defense, needs to be in the primary care system.
        Mr. Loebsack. OK.
        Dr. Lieberman. And so mental health education needs to be
    part of all the primary care system. That includes pediatrics,
    OB/GYN, and family medicine.
        Mr. Kennedy of Massachusetts. And I would just add
    collaborative care models have been validated through 80-plus
    randomized control trials. So this notion of building this has
    been demonstrated to be cost-effective in outcomes, and why we
    don't have insurance companies reimbursing for something that
    is in their self-interest in terms of better financial interest
    and better health, is something we still have to work on. But
    you are right on target with trying to bridge this gap in the
    workforce shortage by having more collaborative care models.
        Mr. Loebsack. Thanks to all of you. And thank you, Mr.
    Chair. Thank you.
        Mr. Pitts. The chair thanks the gentleman.
        I now recognize the gentleman from Indiana, Dr. Bucshon, 5
    minutes for questions.
        Mr. Bucshon. Mr. Chairman, I yield my time to Mr. Murphy
    from Pennsylvania.
        Mr. Murphy. I thank the gentleman from Indiana. And just a
    couple of quick questions here.
        Dr. Lieberman, is there anything we can do to really
    totally prevent schizophrenia and bipolar right now?
        Dr. Lieberman. I think that these conditions are
    preventable in the sense that we can't cure them, but we can
    stop them from starting. And the way to do that has really
    already been--a template has been created in the area of
    cardiovascular disease. In 1955, President Eisenhower had a
    heart attack and, I think it is known that he loved to play
    golf, he was a chain-smoker, he was obviously in high stress,
    he had a heart attack. And he went in the hospital for 4 weeks,
    he rested, afterwards they told him to take it easy for another
    4, 6 weeks and then come back to work. And he sort of resumed
    the same lifestyle, and some years later, from a recurrent
    heart attack, he died. But that stimulated public attention and
    galvanized research in the medical community and the NIH
    funding. And 50 years later, the morbidity and mortality of
    cardiovascular--arteriosclerotic heart disease is 60 percent
    less, 60 percent less. But apart from that, it transformed the
    way cardiovascular disease was managed. It is no longer wait
    until somebody gets sick and then put them in the hospital or
    treat them with something, it is when you are born, you know
    what risk factors you have. You may have a family history. As
    you grow, you have to watch your weight. Your family may want
    you to watch your diet. You can have your cholesterol measured.
    There are now gene panels that assess risk for cardiovascular
    disease. So preemptively, these are being addressed. But if you
    do get into a point where you are short of breath and you have
    chests pain or something, you can have a thallium scan, you can
    have a stress EKG, you can have various tests with pre-
    morbidly, that is your secondary prevention----
        Mr. Murphy. Are we getting to some of those, so one comment
    Mr. Rosenthal said by fostering a sharp swing to a more medical
    biological approach to mental health, we shouldn't be doing
    that necessarily, but I mean--but yet last summer they
    identified 108 genetic--genomic markers of schizophrenia. I see
    that as a breakthrough. I hope we can get there to do these
    things.
        And let me give a couple of concluding comments. I think I
    am the last person to question here.
        Senator, I feel like I have made a new friend today, and I
    thank you for that. I thank you for your courage and your
    tenacity as well. If every state had someone like you for our
    Nation, more people like you, we would get this done. Patrick,
    also a dear friend, thank you for your voice on these issues.
    It is powerful. We have to keep that up. Keep it motivated.
    Jeff Lieberman, I know you are dedicated to these things. You
    are a great voice in saying we can solve these problems, and we
    will do that. Paul, we developed a good friendship over this
    too, and understand we have common grounds here. We have to
    work on these prevention issues. It is your work that made
    substantial changes in this bill. I thank you for that. We will
    keep working on that. And, Mr. Coe and Ms. Billingsley and
    Rosenthal, as I said earlier, there is a lot you said I totally
    agree with, and what we have to do is find the right wording to
    make sure we have that in there. You have heard a joint
    commitment here as we go through with Ms. Matsui, Mr. Tonko,
    and others here. We have more conversations of this on the
    floor than--of course, the media would never report, but you
    know what, we are actually working together. And maybe that is
    the news. But because we have been so involved in mental health
    for a long time, I began some 40 years ago at this too, but I
    think of that when we are all fresh and wet behind the ears,
    dealing with the mental health field. One of the things that
    oftentimes struck me is why do we do it this way? Why can't we
    just help these families? Why can't we just talk to people? Why
    can't we use evidence-based care? And oftentimes we were told,
    well, we can't do it that way because, and it shouldn't be that
    way. I say psychiatry and psychology are the only areas of
    medicine that are defined by lawyers, and we need to make then
    defined by the patients' needs, by the consumers' needs, and
    get involved in a model that says really, yes, we can, and not
    only yes, we can, but we have to.
        Now, with regard to funding on these things, look, I am
    first in line to nag the Appropriations Committee. And now, the
    Senate may have some different rules they can follow, but we
    have to put a bill through that is budget-neutral. We are
    working hard to find some offsets on this. I look forward to
    working with my colleagues on this. I--look, I have no doubt
    that this equal, equal passion for changing these things, and
    we will do these things together.
        And I ask along those lines if all the members of this
    panel, all the witnesses, all the members of this subcommittee
    and others, we will keep working together. You have given us
    some great ideas today about what we have to do about the
    wording for this. But for all those people who we have lost
    this year and lost in other years, let's not make their lives
    lost a lost cause. Let's join together and recognize that we
    have to make sure that those disappearance of their lives
    shouldn't be a disappearance of our passion and our dedication
    to this. We can make this happen. I fear greatly for this
    Nation if we do not make this the year that we make these
    significant and substantial reforms in this. Let's use our
    voices together. We will not be silenced. We will make some
    changes here.
        And with that, Mr. Chairman, I thank you for your
    leadership in this as well. We can get this done. Hopefully,
    next time we get together will be for a Markup, or as a group,
    but with my colleagues, we will work together on some wording
    of these things for their concerns.
        And I--with that, I yield back.
        Mr. Pitts. The chair thanks Dr. Murphy. Thank you for that
    excellent summary of our hearing today.
        And the chair would like to thank all of the witnesses for
    your patience, for your testimony, your expertise. It has been
    a very important hearing in this whole path that we are
    traveling on this issue, and the committee will act on this
    legislation.
        Members who were not here will have questions, I am sure.
    Some of us may have follow-up questions. We will submit those
    to you in writing. We ask that you please respond promptly.
        I remind members that they have 10 business days to submit
    questions for the record. That means they should submit their
    questions by the close of business on Tuesday, June 30.
        Without objection, the subcommittee is adjourned.
        [Whereupon, at 12:48 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]
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