[Senate Hearing 114-581]
[From the U.S. Government Publishing Office]
S. Hrg. 114-581
MENTAL HEALTH IN AMERICA:
WHERE ARE WE NOW?
=======================================================================
HEARING
before the
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
APRIL 28, 2016
__________
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______
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COMMITTEE ON FINANCE
ORRIN G. HATCH, Utah, Chairman
CHUCK GRASSLEY, Iowa RON WYDEN, Oregon
MIKE CRAPO, Idaho CHARLES E. SCHUMER, New York
PAT ROBERTS, Kansas DEBBIE STABENOW, Michigan
MICHAEL B. ENZI, Wyoming MARIA CANTWELL, Washington
JOHN CORNYN, Texas BILL NELSON, Florida
JOHN THUNE, South Dakota ROBERT MENENDEZ, New Jersey
RICHARD BURR, North Carolina THOMAS R. CARPER, Delaware
JOHNNY ISAKSON, Georgia BENJAMIN L. CARDIN, Maryland
ROB PORTMAN, Ohio SHERROD BROWN, Ohio
PATRICK J. TOOMEY, Pennsylvania MICHAEL F. BENNET, Colorado
DANIEL COATS, Indiana ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada MARK R. WARNER, Virginia
TIM SCOTT, South Carolina
Chris Campbell, Staff Director
Joshua Sheinkman, Democratic Staff Director
(ii)
C O N T E N T S
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OPENING STATEMENTS
Page
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman,
Committee on Finance........................................... 1
Wyden, Hon. Ron, a U.S. Senator from Oregon...................... 3
WITNESSES
Marshall, Brandon, executive chairman and co-founder, Project
375, Chicago, IL............................................... 6
Bennington-Davis, Margaret, M.D., chief medical officer, Health
Share of Oregon, Tualatin, OR.................................. 8
Thomas, Doug, Director, Division of Substance Abuse and Mental
Health, State of Utah, Salt Lake City, UT...................... 10
Rosenberg, Linda, MSW, president and CEO, National Council for
Behavioral Health, Washington, DC.............................. 12
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Bennington-Davis, Margaret, M.D.:
Testimony.................................................... 8
Prepared statement........................................... 33
Hatch, Hon. Orrin G.:
Opening statement............................................ 1
Prepared statement........................................... 39
Marshall, Brandon:
Testimony.................................................... 6
Prepared statement........................................... 40
Rosenberg, Linda, MSW:
Testimony.................................................... 12
Prepared statement........................................... 42
Thomas, Doug:
Testimony.................................................... 10
Prepared statement........................................... 45
Wyden, Hon. Ron:
Opening statement............................................ 3
Prepared statement........................................... 46
Communications
American Academy of PAs (AAPA)................................... 49
American Association for Geriatric Psychiatry (AAGP)............. 51
Boronow, John, M.D............................................... 52
Burton, Evelyn................................................... 53
Clinical Social Work Association (CSWA).......................... 54
Healing Minds NOLA............................................... 55
Jones, Nancy..................................................... 56
Martin, Marilyn.................................................. 57
Mental Illness Policy Org........................................ 59
National Alliance to End Homelessness............................ 69
National Alliance on Mental Illness (NAMI) and National
Association of Psychiatric Health Systems (NAPHS).............. 70
National Association of Anorexia Nervosa and Associated Disorders
(ANAD)......................................................... 72
Nunez Daw, Christina, MPH, Ph.D.................................. 73
Ranney, Patricia................................................. 74
The Trevor Project............................................... 74
MENTAL HEALTH IN AMERICA:
WHERE ARE WE NOW?
----------
THURSDAY, APRIL 28, 2016
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 2:31 p.m.,
in room SD-215, Dirksen Senate Office Building, Hon. Orrin G.
Hatch (chairman of the committee) presiding.
Present: Senators Crapo, Roberts, Cornyn, Thune, Scott,
Wyden, Stabenow, Cantwell, Carper, Cardin, Bennet, and Casey.
Also present: Republican Staff: Kimberly Brandt, Chief
Health-care Investigative Counsel; Chris Campbell, Staff
Director; and Jill Wright, Detailee. Democratic Staff: Ann
Dwyer, Health-care Counsel; Michael Evans, General Counsel;
Elizabeth Jurinka, Chief Health Policy Advisor; Joshua
Sheinkman, Staff Director; and Beth Vrable, Senior Health-care
Counsel.
OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM
UTAH, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. The committee will come to order.
I apologize for being late. We had to finish up some
Judiciary work, and Senator Grassley asked me to chair that
matter. It is a pleasure to see everyone here this afternoon.
Today's hearing will focus on mental health issues in
America and the role the Medicaid and Medicare programs play in
addressing the needs of those with behavioral and mental health
issues. Together, Medicare and Medicaid financed nearly 45
percent of mental health spending in the United States, which
amounted to more than $75 billion--that is with a ``b''--in
2014 alone.
As the Senate committee with jurisdiction over these
programs, it is our responsibility to better understand the
drivers behind the growing needs for and the costs of these
services and to work together to develop better solutions for
identifying and treating these issues. A report issued by the
Medicaid and CHIP Payment and Access Commission in June 2015
indicated that the majority of Federal spending on mental
health comes out of Medicaid. That same study found that
Medicaid is the single largest payer in the United States for
all behavioral health services, including mental health and
substance abuse. In fact, Medicaid accounted for 25 percent of
nationwide spending on behavioral health in 2009, the year with
the most recent data.
One of the many difficulties we face in addressing these
issues is that Medicaid enrollees with behavioral health
diagnoses have varied physical and behavioral health needs.
Patients often range from young children who need screening,
referral, and treatment for autism or depression to chronically
homeless adults with numerous diagnoses involving severe mental
illness. In 2011, only one in five Medicaid beneficiaries had a
behavioral health diagnosis, but they accounted for almost half
of total Medicaid expenditures.
Needless to say, these types of behavioral health issues
can seriously impair a patient's quality of life, cause
disability, and significantly decrease life expectancy. These
types of issues are associated with significantly higher rates
of chronic disease, substance use disorders, and inpatient
hospitalization among Medicare beneficiaries.
In Medicaid, patients with behavioral or mental health
diagnoses are more than twice as likely to be hospitalized as
those without such diagnoses. The number is drastically higher
if the patient also has a substance use disorder. These high
hospitalization rates are major drivers in the cost of our
Federal health programs. However, what is more unfortunate is
that all too often, people with mental or behavioral health
issues get no care at all.
According to the 2012 National Survey on Drug Use and
Health, nearly 40 percent of adults diagnosed with severe
mental illness, such as schizophrenia or bipolar disorder,
received no treatment for their illness in the previous year.
When you broaden that scope to include all adults with any
mental or behavioral illness, 60 percent went untreated for the
prior year.
It gets worse. Every year, suicide claims the lives of
38,000 Americans, more than car accidents, prostate cancer, or
homicides, and about 90 percent of suicides are related to
mental illness, according to the National Institute of Mental
Health.
Utah is not immune from this preventable tragedy. Suicide
has been the greatest threat to our young people in recent
years, and it is time for everyone to take notice. This is
absolutely tragic. However, the tragic pattern expands beyond
the suicide rate, as overall, people with serious mental
illness have an average life expectancy that is 23 years
shorter than the nationwide average.
Patients and their advocates say the country's mental
health system has been drowning for a long time--not from flood
waters, but from neglect. As we talk about solutions, we need
to note that the distinction between mental health, mental
illness, and severe mental illness is crucial, because each
group requires different clinical and policy prescriptions. For
example, the current system, proportionately speaking, provides
far more support for mental health than severe mental illness.
We need to review these priorities and find an equitable
solution to ensure that all needs are being met.
Today's panel will give us an opportunity to hear from
witnesses who can speak to these issues from almost every
perspective. We have an advocate who has suffered with these
issues firsthand. We also have experienced professionals who
will share their experiences providing care at the local,
State, and Federal levels and who can speak to the successes
and limitations of providing care in each of those
environments.
I look forward to hearing the testimony of today's
witnesses and beginning a dialogue with my colleagues on these
important issues that hopefully will lead to better solutions.
With that, I am going to turn to our ranking member, Senator
Wyden, for his opening statement.
[The prepared statement of Chairman Hatch appears in the
appendix.]
OPENING STATEMENT OF HON. RON WYDEN,
A U.S. SENATOR FROM OREGON
Senator Wyden. Thank you very much, Mr. Chairman, and thank
you for scheduling this important hearing.
The Finance Committee is responsible for the programs--
Medicare and Medicaid--that spend more on mental health than
any others in America. That is why this committee, working in
conjunction with other Senate committees--the Health,
Education, Labor, and Pensions Committee and the Judiciary
Committee--now have to develop a fresh approach for protecting
and caring for Americans with mental illness. The focus of that
approach should be breaking health care, social service
programs, and law enforcement out of their individual silos and
bringing them together in a coordinated system that deploys
their strengths to help people dealing with mental health
issues.
The Wyden family knows a little bit about this subject. My
brother struggled with schizophrenia for decades, and he had a
lot of his health-care bills covered by Medicaid. In and out of
halfway houses, confrontations with law enforcement officers,
problems securing funds for services or treatments--it was
certainly something that has confronted millions of families
and demonstrates the need for a fresh approach to helping those
with mental illness. Like so many families across the country,
you went to bed at night constantly thinking that your loved
one might the next day hurt themselves or somebody else.
Because of the lack of appropriate places to meet the needs
of those with these mental health challenges, we so often have
patients boarded in emergency rooms or in fights with police,
sometimes deadly, winding up in prison, where more than half of
all inmates suffer from mental health problems and minorities
are vastly overrepresented.
Now, I would be the first to say that mental health is not
an issue that falls neatly and precisely under just one Senate
committee's jurisdiction. A lot of different members with
different areas of expertise are going to have to pull the same
end of the rope to make progress on this front.
Now, fortunately, Senator Stabenow is here. She has been a
champion on these mental health issues. She is our leader here
on the Finance Committee, working to build a bipartisan
approach. We so appreciate her leadership. Senator Murray, the
Democratic leader on the HELP Committee, is also right at the
forefront.
In my view, the biggest challenge on mental health is to
focus on three priorities. First, there needs to be a sharp new
focus on preventing--preventing--mental illness. Patients need
better care earlier on to keep the illnesses from escalating.
Furthermore, there are nearly 2 million low-income,
uninsured Americans suffering from mental health or addiction
in States that have not expanded their Medicaid programs. Those
are 2 million Americans who, without treatment or help, are far
more likely to go homeless, far more likely to be incarcerated,
far more likely to face addictions, far more likely to commit
suicide. The choice to expand Medicaid and give new hope to
those 2 million individuals and their families, in my view,
ought to be an easy one to make.
Second, services from health care to social work need to be
better coordinated. It does not make much sense to tell a
person struggling with an illness that they are on their own
managing treatments, figuring out what specialist to see,
scheduling appointments, and handling medications.
Even outside the doctor's office, there are a lot of areas
where people with mental illness often need help that they are
not getting today: paying the bills, making it to appointments,
maintaining a home. Taxpayer dollars need to reach deeper into
our communities and improve the coordination of mental health
services to help those whom today the system largely overlooks.
Third and finally, there needs to be a better link between
mental health and law enforcement. In many cases, that is going
to mean more training on what to do when responding to a person
with mental illness. Too many individuals who should be in
proper health-care facilities are winding up in jail cells
instead.
In my hometown, Portland, the police bureau has recently
put a lot of work into building a team of specially trained
officers to handle these challenges safely. And I can tell you,
in my hometown, at least in the early going, this is paying off
big. In my view, more agencies around the country ought to pick
up on some of these Oregon lessons with respect to law
enforcement.
Of course, and I will close with this, the big challenge is
funding. Each year, mental illnesses cost the United States
$450 billion, only a third of which is actually spent on
medical care, with roughly $75 billion, combined from Medicare
and Medicaid, making up the biggest portion of the pie.
Those are huge numbers, and a lot of the overall total goes
to emergency room visits and jail time. In my view, if you can
begin to shift some of that funding to the three priorities I
have mentioned--preventing mental illness, better coordination
of services, and linking law enforcement with mental health--
you will see many more Americans being in a position to manage
their mental illness and living healthier lives. Big challenge.
Once again, as you and I have talked about, Mr. Chairman,
with our colleagues, this is going to take bipartisan teamwork,
the kind of bipartisan approach that Senator Stabenow is
working on. But I think that the members here want to come
together. We have been talking about this for a long time, and
it is time to move forward and actually put in place these new
priorities.
I thank you, Mr. Chairman. I also want to welcome all our
witnesses and thank them very much for being here.
[The prepared statement of Senator Wyden appears in the
appendix.]
The Chairman. Thank you, Senator.
I have to say that Senator Stabenow and the Senator from
Missouri, Roy Blunt, have met with us this morning on precisely
these issues, and we are going to see what we can do.
But before we begin this very serious discussion, I would
like to bring to everybody's attention that May 3rd is our
distinguished ranking member's birthday. Now, I personally hate
birthdays, because when I was a kid, they never had a birthday
party for me, and all the other neighborhood kids--we were so
poor, we could not afford one, and I just blow them out of
mind. It affects me even to this day, although I am getting
over it. [Laughter.]
But we just want to mention that Oregon's soccer team, the
Timbers, were national champions in 2015 [handing Senator Wyden
a wrapped gift box]. [Applause.]
Senator Wyden. Mr. Chairman, thank you.
The Chairman. That is a soccer ball.
Senator Wyden. I can tell. [Laughter.]
The Chairman. I know you would not know what it is. He only
played basketball. But it is a signed soccer ball from the
Timbers on your birthday, and we hope you have many more really
great birthdays.
Senator Wyden. Mr. Chairman, thank you. This is above and
beyond, and I look forward to coming to your office and
throwing the ball around with you. [Laughter.]
The Chairman. His wife owns the leading bookstore in the
country, so I let him get away with anything. [Laughter.]
Let me take a few minutes here to introduce our witnesses.
I am very pleased to introduce our first witness, Mr. Brandon
Marshall, an all-pro and six-time Pro Bowl receiver with the
New York Jets.
In 2011, Brandon was diagnosed with Borderline Personality
Disorder and spent 3 months in intensive treatment after
struggling with his mental health for years. Since then, he has
become a dedicated advocate for mental health issues. His main
platform is an organization called Project 375, which he
founded to bring awareness to mental illness and to eradicate
the stigma.
Brandon regularly produces PSAs, gives interviews and
speeches, and partners with other organizations that are
dedicated to improving mental health. The list of organizations
that he has worked with includes the National Alliance on
Mental Illness, Glenn Close's Bring Change 2 Mind, the Kennedy
Forum, the National Council for Behavioral Health, and the
Linehan Institute, just to mention a few. In addition to
speaking arrangements through those organizations and his own,
he has given interviews on his mental illnesses on national
networks, including CBS, NBC, MSNBC, ESPN, and Fox.
I think I speak for all of us when I say you are an
inspiration, Brandon--an inspiration to everyone with mental
illness and to all of us here today. I am just very grateful to
have you here, and we look forward to hearing your testimony.
Our second witness will be Dr. Margaret Bennington-Davis,
the chief medical officer at Health Share of Oregon, which
coordinates physical, dental, and mental health benefits for
240,000 Medicaid-enrolled Oregonians.
Prior to coming to Health Share, Dr. Bennington-Davis
served as the chief medical and operating officer at Cascadia
Behavioral Healthcare, Oregon's largest mental health and
addictions provider. Before that, she served as psychiatry
medical director for Salem Hospital, as well as the hospital-
wide chief of staff.
Dr. Bennington-Davis also served as faculty for the
Sanctuary Institute. She has coauthored a book, published
articles and chapters, and has done numerous consultations and
presentations regarding organizational change, trauma-informed
engaging environments, and leadership.
Dr. Bennington-Davis completed her M.D. and psychiatry
residency at Oregon Health Sciences University, where she
remains on faculty, and received her master's of medical
management degree at Tulane University School of Public Health.
Next, we will hear from Mr. Doug Thomas, the Director of
the Division of Substance Abuse and Mental Health for the State
of Utah. We are grateful to have Mr. Thomas here. He also
serves on the board of directors of the National Association of
State Alcohol and Drug Abuse Directors, as well as the Utah
Substance Abuse Advisory Council.
Additionally, Mr. Thomas serves as a member of the Utah
Commission on Criminal and Juvenile Justice. He has worked in
the mental health and substance abuse disorder field for over
20 years as a direct service provider and administrator. Mr.
Thomas has worked in both urban and rural settings and
previously oversaw county services, implementing evidence-based
service delivery models.
Mr. Thomas graduated from Brigham Young University, my own
alma mater, with a bachelor of science in psychology, and from
the University of Utah with a master's degree in social work.
Finally, we will hear from Ms. Linda Rosenberg, the
president and CEO of the National Council for Behavioral
Health. The National Council for Behavioral Health represents
and serves 10 million adults, children, and families served by
the National Council's 2,700-member organization.
Prior to joining the council, Ms. Rosenberg was the Senior
Deputy Commissioner of the New York State Office of Mental
Health. She has over 30 years of experience in designing and
operating hospitals, community and housing programs, and
implementing New York's first mental health court.
Ms. Rosenberg serves on an array of boards of directors and
is a really valued person in this area and a member of the
executive committee of the National Alliance for Suicide
Prevention.
I want to thank all of you for coming. I just want to
mention that each of your experiences and perspectives is
incredibly important on these sensitive issues--or set of
issues, I think we should say. We will hear the witness
testimonies in the order they were introduced.
So, Mr. Marshall, if you will, we will have you proceed
with your opening statement. We look forward to hearing from
you.
STATEMENT OF BRANDON MARSHALL, EXECUTIVE CHAIRMAN AND CO-
FOUNDER, PROJECT 375, CHICAGO, IL
Mr. Marshall. Thank you, Mr. Chairman. Ranking Member
Wyden, happy birthday.
Senator Wyden. Thank you.
Mr. Marshall. I am grateful and thankful that you guys
invited me out to speak before the U.S. Senate and the Finance
Committee.
My name is Brandon Marshall, wide receiver for the New York
Jets, and I just finished up my 10th year in the National
Football League. In 2011, I was diagnosed with Borderline
Personality Disorder. The best way to describe it is, it is an
emotional disorder. Some people do not have the skills and
tools to be able to cope and deal with some of the day-to-day
stress of just life. So I had to spend 3 months in an
outpatient program at McLean Hospital learning those tools. I
sat in groups and dialectal behavioral therapy, learning those
tools and skills; cognitive behavior therapy, where we studied
the frontal lobe and tried to understand how to live a healthy
and effective life; also, mentalization therapy, self-
assessment.
But it was at McLean Hospital where I found my purpose. A
lot of times, athletes think that their purpose is to catch a
ball, shoot a basket, run fast, but I think we are here for
something better. And it was at McLean Hospital where I learned
that my purpose is to help bridge the gap in the mental health
community.
At McLean Hospital, I was walking out of self-assessment,
and one young lady was self-harming herself. Another young lady
tried to commit suicide the night before. Another young lady,
the week before, in the 3East program, named Sasha, from
Canada, committed suicide.
I walked out of that group very sad, and I walked into a
parking lot to go to Reebok's headquarters to work out and I
saw 200 cars. I looked at those cars as patients. I asked
myself, how many more people out there are suffering or
suffering in silence and do not even know it?
It cost me $150,000 to get the treatment that I needed, and
3 months. Reimbursement, it was so bad that I did not even
bother to deal with the insurance. My mother, a recovering
alcoholic--and she gave me permission to tell her story--also
deals with some things. It cost us $30,000 a month to get my
mom the help that she needs. She is now 4 years sober, an
amazing woman.
My sister--the same story. My younger brother, who is
facing 30 years in prison, actually goes to court on the 28th,
it cost us $150,000 to send him to Yellowbrick in Evanston, IL.
I say that because I truly believe that where we are at
today is where the cancer and HIV community was 20-25 years
ago, and it is time for us to galvanize the community, stand
together, and make a change.
My wife and I, in 2011, also founded Project Prevent.
Project 375 is our foundation project. Prevent is a program
where we are trying to put on-site behavioral health-care
services in our schools to also be preventative and intervene
early, because we think that is the key.
I noticed, when I first got my diagnosis at McLean
Hospital, I was 50 percent better. I was able to be in group
and be validated by people who understood what I was going
through. The other 50 percent came from the work.
The call to action is, we need to develop and support
programs that are affordable, accessible, and scalable. We need
to reimburse mental ailments the same way we do physical. I
also think our call to action should be to adopt technology.
There are 320 million Americans, and over 100 million are
affected by mental illness. We need technology to be able to
stand in the gap to help our professionals, our doctors, our
government to get the people the help they need.
Last, this is the last great stigma in our country, and it
is a civil rights issue.
Thank you.
[The prepared statement of Mr. Marshall appears in the
appendix.]
The Chairman. Thank you, Mr. Marshall. That means a lot to
us, and we appreciate you taking time to come see us.
Mr. Marshall. Thank you.
The Chairman. Dr. Bennington-Davis?
STATEMENT OF MARGARET BENNINGTON-DAVIS, M.D., CHIEF MEDICAL
OFFICER, HEALTH SHARE OF OREGON, TUALATIN, OR
Dr. Bennington-Davis. Chairman Hatch, Ranking Member Wy-
den, honorable members of the committee, thank you for this
opportunity to offer testimony on the state of mental health
services, particularly those provided in the Medicaid program.
For the record, I am Dr. Maggie Bennington-Davis, an Oregon
psychiatrist and chief medical officer of Health Share of
Oregon.
Before I begin, I would like to thank you, Mr. Marshall,
for your remarks about your own experience. Your presence here
today is more important than you know.
I would like to begin by describing Oregon's recent
innovations in Medicaid. Health Share is the State's largest
Medicaid Coordinated Care Organization, or CCO, serving
approximately a quarter of Oregon's Medicaid enrollees as the
backbone in a collective impact organization of local health
plans, health systems, providers, and community organizations.
CCOs were created through a Medicaid waiver in 2012, with
the basic premise being that we would coordinate all Medicaid
benefits for our members--physical health, mental health,
dental health, addictions, even transportation--using a fixed,
global budget.
The model is showing early signs of success both in holding
down costs and in improving care. As a mental health provider
myself, I can tell you this model of collaboration with other
parts of the health-care system and even outside the health-
care system that are serving the same individuals is
remarkable. For the first time, we are able to work across
systems of care and address the problems of having thought and
planned and built services in silos. What is more, Oregon is
predicted to save the Federal Government $1.4 billion over the
first 5 years of implementation of the CCO model.
Oregon's CCO design has brought new attention to and
appreciation of the roles of mental illness and addictions in
costs and in poor health outcomes. I think of it as us finally
discovering the neck--that there is, indeed, a link between the
brain and the body.
People with serious mental illness die, on average, nearly
a
quarter-century sooner than the general public. That statistic
is even worse in Oregon, where people with serious mental
illness and addictions die, on average, in their mid-40s. These
early deaths are almost always because of chronic physical
illnesses that are modifiable with the right supports.
The financial impact is also striking. People with chronic
physical conditions and mental health and substance use
disorders have triple the cost of people with the same physical
health conditions, but without mental illness or substance use.
The CCO model compels us to do a much more thorough job of
connecting the brain and the body. Much of mental illness, like
physical illnesses, is preventable, and the CCO model
encourages us to look upstream toward prevention.
Trauma and chronic stress play an important role in all of
our lives, in our society, and certainly in the context of the
other social disparities of health and poverty in people who
are Medicaid members. When Health Share of Oregon first
analyzed the people who use the most services and were the
highest-cost members, we asked them to describe what had
happened to them throughout their lives. The results caught our
attention. Often, these folks were born as a result of
unintended pregnancy into unstable housing and chaotic
families.
Some had been in and out of the foster child system early
in life. Many had been neglected or sexually or physically
abused as children. Most did not have the kind of childhoods
that helped them to develop the emotional regulation skills to
prepare them to be successful in school. Most had various
erratic behaviors or depression or suicidal tendencies that led
them to require services in specialty mental health, if they
could get access, or in jails or hospitals if they could not.
That is exactly what the Adverse Childhood Experiences Study,
published in 1998 by Drs. Felitti and Anda, showed: that
adversity and toxic stress during childhood led to
significantly more physical and emotional problems in
adulthood.
Knowing that mental illness and substance use disorders,
along with other ill effects of childhood trauma, can be
prevented, Health Share of Oregon felt we had to move upstream
in our efforts to improve health. We are focusing on helping
our members avoid unwanted pregnancies; get social, physical,
and mental health supports during pregnancy; have basic needs
met in order to successfully be able to attach to their new
babies; and get the support and guidance they need to be
effective parents.
My last example is Health Share's foster child initiative.
We know from our own data, which mirror national data, that
children in the foster child system have a much higher
incidence of asthma, Attention Deficit Disorder, obesity, Post-
Traumatic Stress Disorder, even hypertension and schizophrenia.
What was news to us, though, was that these differences persist
and are even higher in children who are no longer in the foster
child system, but were once upon a time. So we at Health Share
are developing coordination among mental health, physical
health, and dental health providers to describe what are the
right supports for these children in these health arenas.
Community mental health services, where I spent much of my
career, have traditionally focused on people who have already
developed chronic and severe mental illness. By adding emphasis
to early childhood supports and the social disparities of
health, by partnering with early intervention programs in
schools, and by paying attention to the mental health supports
within a community, all things CCOs can do, perhaps we can
mitigate the tragic long-term effects of the toxic stress
described in the Adverse Childhood Experiences Study.
In closing, thank you for this honor and opportunity to
comment on our work in Oregon to bring attention to mental
health and its inseparability from physical health and overall
health, and to emphasize the importance of raising our children
in safe and nurturing communities. CCOs are an early promising
model for integrating and coordinating care, drawing attention
to the health and economic impacts of mental illness and
addictions, and clearly point to the need for mental health to
include better awareness of the impact of toxic stress in
childhood.
Thank you.
[The prepared statement of Dr. Bennington-Davis appears in
the appendix.]
The Chairman. Thank you.
Mr. Thomas, we will take your testimony.
STATEMENT OF DOUG THOMAS, DIRECTOR, DIVISION OF SUBSTANCE ABUSE
AND MENTAL HEALTH, STATE OF UTAH, SALT LAKE CITY, UT
Mr. Thomas. Chairman Hatch, Ranking Member Wyden, and
members of the committee, my name is Doug Thomas. I am the
Director of the Division of Substance Abuse and Mental Health
in the State of Utah, and I am honored to be here with you
today along with these distinguished guests.
Medicaid saves lives and is the backbone of the public
mental health system in Utah and throughout the United States.
It provides the infrastructure and economy of scale necessary
for States to standardize evidence-based practices to provide
high-quality care to individuals with serious mental health
needs.
The various Medicaid waivers and alternative benefit plans
available to States allow them needed flexibility to customize
plans to fit the unique challenges, needs, and resources of
each State. Case management, peer support services for
individuals and families, psychosocial rehabilitation, and
respite services are all great examples of Medicaid
reimbursable services that help people stay in their homes and
communities despite serious illness and allow people the
opportunity to reintegrate in place of being alienated from
their families and communities of origin.
In 2009, the Institute of Medicine, IOM, issued a lengthy
publication about the prevention and early intervention of
mental, emotional, and behavioral disorders. The report
highlights that almost one in five young people has such a
disorder at any given time and that among adults in the United
States, half of all these disorders were first diagnosed by age
14 and three-fourths by age 24.
The first symptoms usually precede a disorder by 2 to 4
years, giving us a window of opportunity. Narrowing the gap
between the onset of symptoms and evidence-based intervention
is critical, as the research is showing us that this early
intervention preserves executive functioning and allows people,
especially young people and people suffering from the first
episode of illness, to recover more quickly with less life
disruption. This allows them to accomplish and maintain
important developmental tasks, such as establishing healthy
interpersonal relationships, succeeding in school, and making
their way into and succeeding in the workforce.
For people with Medicaid, we are able to intervene early
with positive outcomes, showing that people can and do recover
from mental illness. Treating a person's mental illness
improves physical health outcomes and reduces overall health-
care costs as well.
There have been various Medicaid and other health-system
studies which show that collaborative physical and mental
health care lowers costs and improves health outcomes.
Prevention and early intervention can help us get upstream and
bend the cost curve.
In Utah, 3 years ago, with a new State legislative
appropriation and county matching funds, we began to act on the
IOM report with what we call Mental Health Early Intervention.
This consists of three programs: school-based behavioral
health, Mobile Crisis Outreach Teams for Youth in four of our
five most populous counties, and Family Resource Facilitation
With Wrap-Around to Fidelity, which is a peer support program.
Over the last 3 years, we have increased services to almost
5,000 additional youth, the majority with Medicaid funding.
Office disciplinary referrals are down, literacy scores are up,
symptoms of mental illness are being reduced, often to the
community norm, and families are receiving the supports they
need to keep their children safely at home, in their own
school, and enhancing their family's natural support system
through peer support.
Utah recently passed limited Medicaid expansion, designed
to target people with the lowest income and the greatest need:
parents with dependent children already on Medicaid, people who
are chronically homeless, people with mental illness and
substance use disorders involved in the criminal justice
system, and people with mental illness and substance use
disorders.
We must have Medicaid work with us to find a way to approve
a waiver allowing Utah to extend Medicaid coverage to those
people in need. People want to be served in the safest, least
restrictive environment, and providers want to provide these
types of services.
Sometimes children and adults need care beyond what can be
provided appropriately in an outpatient or home-like setting.
Allowing Medicaid residential services the ability to bill and
be paid for room and board would be a great step in the right
direction. Room and board is covered during a more costly
inpatient hospital stay, but not covered during a more
economical residential stay. This disincentivizes lower-cost,
short-term residential services in lieu of more costly
inpatient hospital care.
With the Patient Protection and Affordable Care Act, the
Mental Health Parity and Addiction Equity Act, and more
integrated care being provided, there is a need to modernize
the Medicaid Institutes for Mental Disease (IMD) Exclusion.
I applaud the efforts of the Substance Abuse and Mental
Health Services Administration, Centers for Medicare and
Medicaid Services, and the Department of Health and Human
Services to modernize this rule, including the option of State
waivers around the IMD exclusion.
It must be done cautiously and systematically to ensure we
are not re-institutionalizing people but that we are providing
a short-term crisis intervention meant to help people stabilize
and rejoin us in our communities where we all work and play and
live.
Thank you for the opportunity to testify before you today.
[The prepared statement of Mr. Thomas appears in the
appendix.]
The Chairman. Thank you for your testimony.
Ms. Rosenberg, we will take yours now.
STATEMENT OF LINDA ROSENBERG, MSW, PRESIDENT AND CEO, NATIONAL
COUNCIL FOR BEHAVIORAL HEALTH, WASHINGTON, DC
Ms. Rosenberg. Thank you, Chairman Hatch, Ranking Member
Wyden, and members of the committee. I am honored to be here
with my very eloquent colleagues.
There is attention to mental illnesses and addictions
everywhere we look, from presidential elections to the New York
Times feature on the Portland police; from the 600,000
Americans who have taken a mental health first-aid course to
last week's CDC data showing a 25-percent increase in suicides
in the last 15 years.
But attention is not enough. It is not enough for the more
than 28,000 who die from an opioid overdose. It is not enough
for the more than 41,000 who committed suicide, and it is
certainly not enough for their families.
It is not enough--and not because we do not know what
works. It is not enough because of the limited availability of
what works.
Respectfully, the question before you is not, where are we
now but, where do we need to be? If we are serious about moving
from pockets of excellence that you heard about from my
colleagues to the widespread availability of effective
interventions, we need to stop depending upon grants and then
wondering why good practices do not spread.
When we have cancer or heart disease, getting access to
chemotherapy or a stent does not depend upon a local clinic
having a grant. Why are mental illnesses and addictions
different?
The answer to where we need to be is the Excellence in
Mental Health Act demonstration, a bipartisan initiative led by
Senator Stabenow and Senator Blunt. The Act enables and
sustains treatment systems that increase access, deliver
evidence-based care, and integrate services.
Discussions of access often focus only on increasing beds.
Beds can never be effective in a vacuum. Only community-based
services prevent readmissions. At a time of Accountable Care
Organizations and medical homes, beds alone are not enough.
Neither, for that matter, is crisis care. Standing alone, it
just is not enough.
The Excellence Act establishes criteria for Certified
Community Behavioral Health Clinics, CCBHCs, that provide
mental health and substance use services and primary care
screening. CCBHCs deliver 24-hour crisis services, coordinating
with law enforcement, criminal justice, and veterans'
organizations.
But it is not just access. We need uniformly high-quality
services. Unfortunately, the adoption of research-based
practice is limited. An example is the successful NIMH RAISE
study that improved outcomes for youth experiencing a first
psychotic episode.
Most communities will be unable to implement this program.
Block grant funds and philanthropic grants will not be enough,
and thousands of young adults will be relegated to a life of
disability.
CCBHCs can move the needle. They are required to offer
evidence-based practices and are paid a rate inclusive of these
activities. With outcome tracking and quality bonus payments,
clinics will be held accountable for patient progress, a step
in our move to value-based purchasing.
A key challenge to delivering science-based services is our
shortage of professionals. Clinics all over the country
struggle to recruit and retain staff. The fundamental barrier
is that most clinics cannot afford skilled staff or investments
in technology to extend staff's reach.
Those of you who have ever run a business know this is
unsustainable. The Excellence Act offers certified clinics
Medicaid payments based on the cost of treatment. They can hire
critical staff and leverage new technologies, and even those
historically opposed to prospective payments, like the National
Association of Medicaid Directors, acknowledge there is not a
better solution.
The average age of death, as we have heard, for Americans
with serious mental illness is 53. The culprits are heart
disease, lung disease, and cancer. And people with chronic
physical illnesses, as you have heard, often have co-morbid
depression and anxiety.
CCBHCs represent a foundational opportunity to advance the
way care is integrated and coordinated. Shining a spotlight
into the shadows of mental illnesses and addictions is not
enough. The Excellence in Mental Health Act is where behavioral
health needs to be.
Twenty-four States are now planning their participation in
the demonstration, yet the law sets an 8-State limit. Every
State that wishes to create and sustain quality systems should
be able to do so. We urge you to allow all 24 States to
participate and to open the planning process to the remaining
26 States. CCBHCs will transform services in this country, and
that is what I call reform.
Thank you.
[The prepared statement of Ms. Rosenberg appears in the
appendix.]
The Chairman. Thanks to all of you. This has been
compelling testimony. I am very grateful to you.
Mr. Marshall, the stigma around mental health is very, very
important. I want to thank you for sharing your personal story
and perspective on living with Borderline Personality Disorder,
and I want to also thank you for your courage in taking a
leadership role to end the stigma surrounding mental illness.
You have spoken at length about the importance of proper
treatment for all people, regardless of whether they are a
parent in the suburbs of Salt Lake City, a single adult trying
to make ends meet, or a wide receiver in the NFL who is admired
by millions.
Can you expand on your work through your organization,
Project 375, to end the stigma around mental health?
Mr. Marshall. Yes. First, like I said in my testimony,
where we are at today is where the cancer and HIV community was
20-25 years ago. One of the first things they did was, they
galvanized the community. They came together, they changed the
narrative in the media, they broke down the stigma. Back in the
day, it was called the Big C. So that is where we find
ourselves.
So we spend a lot of our time telling stories, similar to
what Glenn Close does. I think it is important for influencers
in our country to stand up and say, ``This is who I am, and
this is what I have been dealing with.'' It could be them or it
could be a loved one.
So that is number one: breaking down the stigma. And I
think it is important, because there are a lot of people out
there suffering--and suffering in silence. Some people do not
even know that they are suffering. That is their norm.
The second thing, which I always call the tangible, is
preventative and intervention work. We want to put onsite
behavioral health-care services into every single school. But
to be honest with you, I am now realizing that that is really
hard to do. So that is why I mentioned one of the calls to
action is adopting technology to not replace, but help our
professionals, our government, our doctors, stand in the gap.
And so we are fighting hard for that, and we are looking for
your support in any way we can get it.
The Chairman. Thank you. I am very proud of you for being
willing to stand up on these issues.
I want to thank each of you witnesses for your work in this
very important area. To the extent that each of you is involved
in developing policies to address mental illness, what factors
do you consider for changes to the mental health delivery
system? If you would, I would like you to highlight any
successes you have seen in mental health delivery as well.
We can start with you again, Mr. Marshall, and go from
there.
Mr. Marshall. I will pass it to you, Doctor.
The Chairman. That would be fine. Let us start with you.
Dr. Bennington-Davis. Thank you, Mr. Chairman.
I would like to mention a very particular initiative that
Health Share of Oregon is partnering in with several delivery
system parts in Portland, called Project Nurture.
Project Nurture is a program that is specific for women in
Medicaid who are pregnant and who are addicted. This program
encourages women to seek prenatal care as early as possible. We
have a partnership with the Department of Human Services to
make sure that there is an understanding that we are, in fact,
giving the woman the support she needs to successfully get
through the pregnancy. And during the prenatal period, the
woman is also getting addictions treatment, she is getting peer
support, and she is getting therapy, and her baby is also being
taken good care of.
The program has staff who stay with the woman throughout
the delivery period and then even postpartum to help her attach
to her baby and learn the right parenting skills to give that
baby a good start, all the while getting addiction treatment.
It is that kind of coordination and collaboration across
mental health and physical health and that kind of
multidisciplinary approach that I think is going to change
outcomes, reduce mental illness, reduce addictions, and give
people a better start, and we can do that because of our
Coordinated Care Organization structure.
The Chairman. Thank you.
Mr. Thomas, let me just ask you this. The mental health
workforce is an issue about which I care deeply. You have
dedicated a great deal of your career to increasing peer
support services in the State of Utah. Could you please share
the impact of that model and ways in which it has spread to
different States to make meaningful local impacts?
Mr. Thomas. Having peer support is important,
paraprofessionals--they are people who have lived experience,
who have had a mental illness or a substance use disorder and
are in recovery--and/or family members who can go in and do the
same thing for families who are struggling with a child, who
have been through the child welfare system or the juvenile
justice system.
And they go in and they--just like Mr. Marshall--bring a
lot of credibility with them. They are someone who has been
through the system and has recovered and flourished. And so
what they do is, they help other peers and are able to link
them to services. But also, I think the main ingredient is,
they give them hope. They give them hope and a vision of a
better future, and many times, people really struggle to
maintain that hope.
So we have done that in Utah and had great success. We now
have family resource facilitators in some of our juvenile
courts, in child welfare with the 4(e) waiver that is happening
in Utah, which we appreciate your work on in that regard as
well, to provide more home and community-based services in lieu
of residential and in-patient. It means a lot and makes a big
difference in people's lives.
The Chairman. Thank you.
My time is up. Senator Wyden?
Senator Wyden. Thank you very much, Mr. Chairman.
Just for you, Mr. Marshall, your work to deal with the
stigma associated with mental health is appreciated. I have
been really struck by how negative perceptions about serious
mental illnesses are actually growing and that one in three
people say that they would not want their kid to be friends
with another child who is diagnosed with depression. So a big,
big thanks. I think that is enormously valuable work that you
are doing to highlight the stigma issue.
My first question will be for you, Dr. Bennington-Davis. We
are so proud of the work that you all are doing at home.
I want to focus on a group that is really getting left out
in this debate, and that is kids. Children suffering from
mental illness often are sort of given short shrift here, and
research shows that half of all lifetime cases of mental
illness begin by age 14.
So it would seem to me that screening and treating mental
health disorders is especially critical for children. Again,
this just seems to be an area that is being missed, and it is
not some partisan thing, it is just being missed.
If you could make one recommendation with respect to
children with mental illness, what would it be? I think my
first choice, again, is that prevention issue that Mr. Marshall
has highlighted and I have been interested in, which is
screening and treatment.
What do you think would be your top priority in terms of
trying to get kids help early?
Dr. Bennington-Davis. You stole my answer, Ranking Member
Wyden. One of the pushes that we have in the Coordinated Care
Organization setup in Oregon is to meet certain incentive
metrics--so outcomes that are incentivized by the program--and
one of those incentive metrics is to ensure that children get
developmental screenings at the correct times.
Another one in the foster child system is to coordinate
physical health and mental health--and dental, for that
matter--screening as soon as the child enters DHS custody.
I think things like that that actually structure, require,
and then incentivize and reward the provider system for doing
the right things at the right times, are going to make a big
difference in the lives of our kids as they go through the
system.
Senator Wyden. Let me bring our other panel members into
the next question.
We are obviously not the Judiciary Committee, and that is
why I indicated that several committees are going to have to be
involved here. But there are several pieces to this issue.
There is prevention, better coordinating the services, and
obviously--again, in Oregon, we have tried to highlight the
relationship between law enforcement and mental health
services, and it is surely about time.
Of people who were shot and killed by police officers in
2015, 25 percent displayed signs of mental illness, and more
than half of all prison and jail inmates have a mental health
problem. So in Oregon, we sought to try to break some new
ground here in terms of trying to define different
relationships between law enforcement and mental health.
I would be curious--maybe we will work our way the other
way. We can start with you, if we might, Ms. Rosenberg.
What would be your top priority in building a new, better
coordinated relationship between mental health practitioners on
the health side and law enforcement?
Ms. Rosenberg. I think one of the biggest problems you will
hear from law enforcement is, what do they do with someone who
clearly has a mental illness? I hear that over and over again.
When you read my bio, you talked about my being involved
actually in the first mental health court in New York City. I
think they get someone clearly having a problem, maybe picked
up on the street, maybe the family calls, there is nowhere to
go, and I think that is one of the reasons we are so interested
in fundamental change and ensuring that everybody knows where
to go.
Those services are available 24/7. People who are
professionally trained can intervene and the police are not
left alone, and that is before anyone gets either booked or
arraigned.
Senator Wyden. Mr. Thomas, do you want to take a crack at
that?
Mr. Thomas. Sure. Crisis intervention training for police
officers, mental health, first aid for first responders, are
great models on the law enforcement side. And we have had a
great justice reinvestment initiative in Utah with help from
the Pew Foundation, building it based on risk, needs, and
responsivity and having it very clear what the criminogenic
risks are and then what the substance use and mental health
needs are, and then targeting programs that help people who are
low criminogenic risk, who have high mental health or high
substance use disorder needs, and getting them into treatment
programs that work and that keep them from the recidivism
cycle.
Senator Wyden. I am going to have to be on the floor in a
few minutes, but I want to thank all of you. You have just been
a superb panel.
Senator Stabenow, who, of course, has championed this cause
for us here, will serve as our ranking minority member.
Mr. Chairman, I very much look forward to working with you
and our colleagues.
The Chairman. Thank you so much.
Senator Roberts, you are next.
Senator Roberts. Well, thank you. Before Senator Wyden
leaves, a special happy birthday to you, sir.
Senator Wyden. Thank you.
Senator Roberts. We have worked together for quite a few
years. I used to give you every extra 5 minutes that you needed
on the Intelligence Committee.
Senator Wyden. Always. [Laughter.] And we are Kansans.
Senator Roberts. Yes, we are both Kansans. I had the
feeling that if you took that soccer ball and kicked it over to
Ms. Rosenberg, Brandon would leap across there and catch it----
Ms. Rosenberg. You have no faith in me----
Senator Roberts [continuing]. Laying out. [Laughter.]
The Chairman. Could I interrupt you for just a second? I
have to leave for a few minutes. So the next one will be
Senator Stabenow and then Senator Cornyn. So if you will follow
up yourselves, I have to go speak to a group, and I will be
right back.
Senator Roberts. So you are not leaving me in charge, is
that right?
It is a coup. All right.
Mr. Chairman and Senator Wyden, thank you for holding this
hearing. It is our committee's commitment to reviewing and
finding ways to improve our mental health system.
Mr. Marshall, I did not know when we were having a good
discussion back in the back room here that you held the record
for most receptions, 21, in an NFL game. I thought that was Art
Monk of the Redskins. [Laughter.]
One of five players in NFL history to have at least 100
receptions in three seasons--I thought that was probably Lynn
Swann of Pittsburgh, whom you are familiar with. The NFL record
for most receiving touchdowns in a single Pro Bowl game, I
thought that was Jerry Rice. But that is you.
Mr. Marshall. Yes, sir.
Senator Roberts. And it is you who is sitting there who has
really provided a beacon of hope for an awful lot of people.
That is really special. That is even more special than going
over the middle and getting popped by a linebacker and still
holding onto the ball.
I really appreciate your testimony, and on the back page,
if I can find it, you say, ``As an NFL wide receiver, I have
caught hundreds of passes during my career. Today, I am
throwing one to you.'' ``You'' is us.
I still have good hands. I will not fumble it. [Laughter.]
I have a little bit different kind of questioning here.
Last month, the Center for Medicare and Medicaid Innovation,
CMMI--it is a brand new outfit, and we already have a brand new
acronym--they proposed sweeping changes to how we pay for
prescription drugs under Medicare Part B. This is under the
heading, ``we need to do good things on behalf of mental
health, but we have to also prevent bad things from
happening,'' and I am concerned about this center.
I know many of my colleagues on this committee share my
concerns with how this demonstration, quote, ``could affect
patients' quality of and access to care.''
As the president of the Kansas Medical Society described to
me in a letter just yesterday, this demonstration, quote,
``will force Kansas Medicare beneficiaries with serious,
sometimes life-threatening conditions to participate in a CMS
innovation initiative, disrupt their treatment processes, and
impede their access to needed medications, with no evidence of
improved health outcomes or financial gains for the Medicare
system.''
Most concerning for the purpose of our hearing today is the
proposal's impact on those suffering from severe mental
illness: schizophrenia, schizoaffective disorder, or bipolar
disorder with psychosis. It is often extremely difficult for
patients with these conditions to adhere to oral medications,
and, as a result, many rely on long-
acting injectable antipsychotics, which would fall under
Medicare Part B.
Phase one of the demonstration would reduce reimbursements
for all new second-generation long-acting injectables. Let me
repeat that: it would reduce reimbursements. In phase two, CMS
could decide--probably would decide--some of these medications
are now deemed, quote, ``high-value'' and limit access to them.
This could result in the patient going to a hospital, which
could be a lot further away, especially in rural Kansas, Texas,
or Michigan, where we may end up paying more for the same
treatment, or these patients could be switched to products that
are less effective or have more side effects, which is where I
get particularly concerned about the government coming between
you and your doctor. This is particularly concerning for a
patient with schizophrenia, as switching treatments impacts the
likelihood of relapse, increasing the debilitating and lasting
adverse effects on a progressive condition.
So my question to all of you on the panel would be this.
Have you heard about this proposed demonstration, number one?
Do you share these concerns about access to appropriate
medications for those with mental illness?
We will start with you, Doctor. Pardon me--Ms. Rosenberg.
Ms. Rosenberg. Yes. Thank you for promoting me. It feels
very nice.
Senator Roberts. I just bestowed that upon you.
Ms. Rosenberg. But I do feel strongly about this,
particularly about reducing the price or the payment for
injectables. As a country, we use less injectables than any
other place in the world.
It is a highly effective treatment. Patients and their
families are interested in it, and it is harder to administer
than giving someone a script.
So the minute you make reimbursement lower, you are going
to lower utilization even further. That is a very big mistake.
Senator Roberts. Mr. Thomas?
Mr. Thomas. Before I became the State Director, I was the
lead on a team that worked with people who struggled with
schizophrenia and bipolar disorder--in and out of the hospital
and State hospital for many years--and we did a lot of outreach
to them in their homes and watched them take their medication
to help them, because often that was one of their major things
that led to their hospitalizations.
When the long-acting injectables, the new generation, came
along with much less side effects than the old injectables, it
was a godsend for a lot of people. They were able to get their
shot and then not worry about it for a month and not have the
daily reminder or the daily struggle to take the medication.
For me, this is deeply personal, and I think anything that
gets in the way of that is dangerous for people.
Senator Roberts. Dr. Bennington-Davis?
Dr. Bennington-Davis. Senator Roberts, Health Share, the
company I work for, does not deal with Medicare, and I was
unaware of the proposal. So I have learned from you today.
Thank you.
Senator Roberts. Brandon Marshall?
Mr. Marshall. Yes. This is my first time hearing it, but I
will say that I agree with Ms. Rosenberg and Mr. Thomas.
I speak a lot from experience. My first charity event after
relaunch, after I spoke and said that I was diagnosed with
borderline personality disorder and I spent 3 months at McLean
Hospital, we had a charity event soon after, and there was a
young lady and her family who came in, and we stayed in contact
over the years.
Last year, she introduced me to injectables, and her
experience is night and day. She was someone who was heavily
sedated with medication, and this past year, she has just been
amazing.
Senator Roberts. I appreciate that. I apologize to my
colleagues for going way over my time. Let me just point out
that over 300 organizations are asking that this rule be
withdrawn. I agree.
This is another case of rationing health care. There are
four rationers. This is one. My fears are coming home to roost,
because we have a proposal which, if implemented by CMS, could
ration health care.
That is where we fumble the ball, Brandon.
I recognize the distinguished Senator, my colleague and
friend, Senator Stabenow.
Senator Stabenow. Thank you very much. Thank you, Senator
Roberts. I share your concern about this issue and have written
a letter, as well, expressing concern about this policy.
Welcome to all of you. It is terrific to have each of you
here and share your experiences, and thank you for what you are
doing.
I do want to make note that the last Finance Committee
hearing on mental health was in 1999. So we are overdue.
I think it is also important to stress that President
Kennedy signed the last law he ever signed on October 31, 1963,
when he signed the Community Mental Health Act, and we have yet
to fully implement the vision of the law that was enacted in
1963.
For me personally, in 1963, I was the eldest child in a
family where my dad was suffering with mental illness. All of
us have in one way or another been affected by mental illness.
Mr. Marshall, I can tell you that I am so grateful that you
are here. I understand what it is like with the stigma for a
family in a small rural town in northern Michigan, where folks
do not understand, even though my mom was a nurse and it was a
medical family, trying to understand what was happening with my
dad: misdiagnoses, lack of services.
I also know what happens when you get the right diagnosis.
At the time, my dad was diagnosed as a lot of things, but
finally, accurately, manic depressive, which we now call
bipolar, which is a chemical imbalance in the brain. He finally
got the services he needed, the medication he needed, and lived
the rest of his life healthy and productive.
So that is what fuels my commitment to this, both from a
family as well as from a professional standpoint.
We also know that one out of five adults has mental
illness--I hear one out of five, I hear one out of four; we are
all affected by this--and 60 percent of them do not get the
treatment they need in a year now, today. So you fast-forward
from what happened to my father.
It is also, I think, interesting to note that the Cook
County jail and the Cook County sheriff has hired a
psychiatrist to be the head of the jail, and he said, ``This is
not surprising, because over a third of the people I house have
mental illnesses.''
So we know the impacts of this, whether it is a hospital
emergency room, whether it is the jail. What we need is people
to get the services that you have described today, and get them
when they need them, get them early and be able to go on and
have productive lives.
So I have worn a lot of different hats on this one,
chairing at the State level in Michigan the mental health
committee, and I have seen what works and what does not work. I
have lived what works and does not work.
I am very excited about the fact that we have a moment now
where we have wonderful bipartisan interest in behavioral
health, mental health, and substance abuse. They are all
connected. We have wonderful work going on in a bipartisan way,
and it is time to seize this to be able to structurally change
what we do so that, as Ms. Rosenberg has said, we are not
depending on grants that come and go.
We do not depend on that if you have heart disease or
kidney disease or you have a broken back. We do not go, well,
you know, the grant ran out this year, so you will have to
wait.
But yet, if it is a disease above the neck, if it is a
disease in your brain, we have a very different system. And
that is the challenge, I think: to integrate our health-care
system so that brain diseases do not rely on grants when every
other kind of disease relies on a health-care system with full
reimbursement. That is why I am so grateful to all of you. I am
always saying that health care above the neck needs to be the
same as health care below the neck.
Before asking a question, I do want to just say that we
have begun that process. The exciting thing is, 2 years ago, on
the last SGR patch that we did, we passed something that
Senator Blunt and I worked on for some time to set up a
requirement for quality behavioral health standards, 24-hour
psychiatric emergency care, integrated care with primary care,
help for families, all the things--substance abuse, mental
health.
So we have these standards now and know what it looks like.
We need to fund it, and we were able to get funding for eight
States to be able to meet that, and 24 States stepped up. Now
we are saying we need to provide the opportunity for every
State that meets quality standards to be able to receive the
funding and get the reimbursement, and I am very grateful for
Senator Blunt's working with me so closely on this for so long
now.
So I want to start with Dr. Bennington-Davis. I know Oregon
is one of the States that has received a planning grant, one of
the 24 States. Could you talk a little bit about why you
applied for the planning grant and what you would hope for if
you were able to fully provide services, quality services, and
get reimbursed for it? What would that mean?
Dr. Bennington-Davis. Thank you, Senator Stabenow. I just
have to remark that I think your legislation is the most
important legislation to emerge regarding mental health since
President Kennedy signed that act. So thank you very much for
your efforts along those lines, and I am really excited about
it.
For 10 years, I worked for a community mental health
provider agency, and we served about 15,000 people a year, most
with serious and persistent mental illness, and the one thing
that was missing was, as you said, the below-the-neck part.
Even though so many of the people that we served had very
serious chronic physical conditions, they either could not or
would not get access around their primary care needs.
In the agency where I was, we were not set up to provide
those services. So the CCBHC gives us an opportunity to really
up our game and to connect the brain and the body and to
understand the person as a whole person.
Ever since becoming an M.D., I have understood that that is
the big gap. You cannot be a psychiatrist without thinking
about the whole person, and certainly you cannot be a person in
community mental health services without worrying about the
rest of your health. They just impact each other so constantly.
So it was a no-brainer to apply for the CCBHC grant. I am
thrilled that Oregon got it. It fits very nicely into the
context of all of the other innovative things we are interested
in in terms of integration. We need to integrate both ways,
though, not just behavioral health into primary care; we have
to integrate primary care into community behavioral health
services.
Thank you again.
Senator Stabenow. Thank you.
I would just ask one quick question of Ms. Rosenberg. There
are lots of things that I would love to ask all of you, but you
touched on helping veterans. And one of the things we worked on
as we looked at integrated care is integrating with veterans
who may not live near a VA facility but maybe someplace in the
community around their State.
We know that 22 veterans commit suicide every day. We know
all the numbers. More than 25 percent of veterans have a
psychiatric diagnosis.
How does providing fundamental reimbursement for community
care make a difference for veterans?
Ms. Rosenberg. It is going to make a tremendous difference
for veterans and for their families. You know, one of the
things we sometimes forget is, when someone comes home from
service and comes home with a disability--traumatic brain
injury, PTSD--it affects not only their spouse, but their
children.
So we are going to create opportunities for treatment in
every community, with your leadership, and we thank you so very
much. It will make a tremendous difference.
Once someone is no longer involved in the VA, now is
working with their families, those problems do not go away, and
now they will have community capacity, and people will know
where to go.
I think that is the other issue. Brandon Marshall--and, of
course, I am a hero now to my grandson because I am sitting at
this table with him--in addition to that, has brought attention
to this. Now for people who are telling their story, it is,
``Where do I go?''
The calls I get personally are from family members and from
friends across the country who have someone with a mental
illness, a child, an adult, and they really do not know where
to go.
We have to create that vision you described from 1963, that
there is a place in your community you can go and that, if your
primary care physician who has someone on their staff who is a
behavioral health specialist, if they feel you need more than
they can provide, they have someplace to send you.
So I think we want to be a community resource. We know what
to do. It is not that we do not. The grants have been very
successful. They have proven it. Now, it is about how we
systematize it so that every community has the resources they
need, including the substance use resources.
Let me also say that both Mr. Thomas and Dr. Bennington-
Davis worked in the past at member organizations of the
National Council. It is no surprise they are in the positions
they are in now. They were stars then.
Senator Stabenow. Thank you very much.
I think I am turning to Senator Cornyn.
Senator Cornyn. Thanks to each of you for being here today,
and I appreciate your contribution to the discussion.
Actually, there has been a discussion going on for a while
now, and I applaud Senator Stabenow and Senator Blunt, whom I
know work very closely together bringing mental health services
to the community, Federally Qualified Heath Centers, which I
have always been a supporter of. But recognizing that these are
existing health-care facilities, if we are able to enhance
access to mental health services at those existing facilities,
that is a pretty efficient and pretty effective way of dealing
with this issue.
I come at this from a law enforcement perspective, as a
recovering judge and Attorney General, but principally what I
have been struck by is the successes at local levels in dealing
with things like--Senator Wyden talked about training for law
enforcement to deescalate confrontations between police and a
person who is suffering a mental health crisis, but that takes
training to know how to deal with it.
Also, our jails often become the mental health provider of
first resort, or maybe it is of last resort. I actually met the
other day through a friend of mine--the sheriff of Barrett
County, San Antonio, TX--someone she introduced to me as the
largest mental health provider in America. Meet the sheriff of
the Los Angeles County jail.
So that speaks volumes for what our law enforcement
community needs to do in order to become better-informed and
better-trained. And I think there are some great models at the
local level, and we need to identify those best practices and
then scale those up and make those available across the
country.
Here is an interesting statistic, or it was to me. The
Federal Government provides $2 billion a year, $2 billion a
year, in assistance to State and local law enforcement, but
less than 1 percent of that is directed toward mental health
issues. To me, that just seems like it cannot possibly be
right. Since the Federal Government does not have limitless
access to resources and we are going to have to find ways to
pay and live within our means, it just seems to me that if we
are already spending $2 billion a year, that maybe, just maybe,
we ought to look at the allocation of some of those funds and
direct them toward training and other things that the Federal
Government can do in terms of highlighting best practices that
already exist across the country.
The other thing is, I was struck by Pete Earley's book,
``Crazy,'' and had the honor of meeting Pete. Pete has been
courageous to talk about his family's experience, Mr. Marshall.
He had a son who had a mental illness, but the biggest problem
he had, his family had, is his son simply would not cooperate
with his health-care treatment, would not take his medication,
for example, and ended up in jail.
As we have seen, that is where many people end up, either
that or homeless, living on the street. One of the biggest
problems, it seems to me, is not about reimbursement, it is not
about access to the best drugs necessarily, but it is, how does
a family member get the cooperation of a loved one who happens
to be mentally ill?
I think about somebody like Adam Lanza's mother in
Connecticut, the shooter at Sandy Hook. His mother knew he was
mentally ill and he kept getting sicker and sicker and sicker,
and she did not know what to do. She could have had him
involuntarily committed, but that is not forever. That is just
for a short-order treatment. You can imagine the tension and
friction in their relationship if she were to get an order for
him for involuntary commitment.
So there are a lot of really interesting things that are
happening, as I have said, across the country, including things
like assisted outpatient treatment, which does not require an
involuntary commitment, but it is a civil court order requiring
people to comply with their doctor's orders.
Right now, the courts have the authority of probation, or
parole even, and the control that comes along with that, but
unless you have those tools, unless you are a drug court or
some other judicial office, you do not really have the
resources to require people to comply with their doctor's
orders and take their meds.
My understanding is that a lot of what we see happening
resulting in people ending up in jail, living on the street, or
crowding our emergency rooms--if we could just do a little bit
better in terms of getting people not only access, but ensuring
better compliance with their doctor's orders, they could do a
lot.
We have an effort that I know of. In addition to what
Senator Stabenow and Senator Blunt have been doing, Senator
Alexander and Senator Murray in the HELP Committee--Health,
Education, Labor, and Pensions Committee--have a bill. Dr. Bill
Cassidy I know is working with the Senate version of the House
bill, along with Chris Murphy, on the larger mental health
package that Tim Murphy has been proselytizing on quite a bit.
I have a bill called the Mental Health and Safe Communities Act
bill, which is from the Judiciary Committee jurisdiction.
So to the ranking member's point, we have all these
different committees, and because of the silos we create here
in terms of how we look at things, I think what we need is a
better-coordinated effort, even internally within the Senate,
to try to come up with a consensus package that we can actually
act on, because I think there is a lot we can do in this area.
Mr. Marshall, I think you are right. This seems to be kind
of a magic moment when people finally realize this is pretty
important and we need to act on it.
So thanks, all of you, for being here. We look forward to
continuing to work with you, and we ask for your continued
advice and support.
Thank you.
Senator Stabenow. Senator Casey?
Senator Casey. Thank you very much. I want to thank the
chairman and ranking member for calling the hearing, and I also
want to commend you, Senator Stabenow, for your work on this
legislation over time.
I want to thank the panel. This is a panel that brings a
lot of personal and professional expertise to this, and I am
grateful to Brandon for being here. He has roots in Pittsburgh
and I wanted to note that for the record.
Folks in New York and around the country know Brandon well,
but he does have roots in Pittsburgh. I want to make sure--you
grew up in East Liberty?
Mr. Marshall. East Liberty, yes.
Senator Casey. Sometimes they pronounce it as one word in
Pittsburgh.
Mr. Marshall. Correct.
Senator Casey. But we are so grateful. I wanted to thank
Brandon Marshall for his testimony, and I will excerpt just a
few lines from his written testimony, talking about accepting
mental illness as a disease, saying, number one, that it needs
better research, better screening, better funding. You also say
that we need to have better recognition of new therapeutic
treatments proven to work. I guess if I were making a list, I
would say number five would be education in schools.
So you have given us an assignment--to use your words:
throwing us a pass. So we have an obligation to catch it and do
our best to run with it. So I want to thank you for that.
I want to start with, and I may only have time for one
broader question, but, Dr. Bennington-Davis, so much research,
which is part of your testimony, shows the connection between
childhood poverty and outcomes as adults. One of the ways to
thwart that or prevent it from happening is early intervention.
I guess one kind of broad question--and you may have
addressed this more broadly in your written testimony. But we
know that early intervention works. I guess it is a corollary
to ``good treatment works,'' and we are having a lot of
discussion on the opioid crisis. But we know that in this
context, early intervention works.
What can you tell us about, in your professional opinion,
the best method of early intervention? Is there one strategy
that works, or two, or is it more than that?
Dr. Bennington-Davis. Well, thank you for the question,
Senator Casey. I think it has to be a complex answer because it
is a complex set of issues, and poverty is complex, and the
stresses that go along with poverty are complex, and the social
disparities of health that are part and parcel of people's
lives are extremely complex. But if I were to try to boil down
what I think scientifically we are aiming at, I think what we
are aiming at is to decrease the overall toxic stress that a
young brain is experiencing both before birth and after birth.
If we can figure out how to decrease the overall stress,
the adversity, if a child can be in a safe and nurturing
relationship with a caretaker, in a safe and nurturing home,
and in interactions that help that child's brain develop
robustly, then I think humans are incredibly resilient and can
overcome most things.
So I would aim at that, and there are a lot of ways to do
that. There are parent supports, there are community supports,
there certainly are programs in schools and so forth, but that
would be the thought in my head as I set about trying to think
of an array of programs.
Senator Casey. I guess not to put too fine a point on it,
the earlier we do early intervention, the better.
Dr. Bennington-Davis. Yes. I think James Heckman, the Nobel
Prize economist, says the earlier you intervene, the way more
payoff that there is, and I think we in health care have to
grasp that concept as well.
Senator Casey. I may just have one more question.
Ms. Rosenberg--I could call you all doctors; you have a lot
of experience. Psychological services in our State are not
covered by Medicaid, and that is, obviously, a hurdle we have
to overcome. What is the best way to expand that kind of
access, access to mental health services generally?
Ms. Rosenberg. CCBHCs are excellent. Actually, your State
is a grantee. It just so happens that the chairman of our board
is from Pennsylvania. Her name is Susan Blue. We have members
all over your State, a very active association, and I think
they are very committed to it.
I think what we need is a standard that does not exist now
in terms of competence. That includes psychological treatment.
I think right now what has happened is, for most community-
based behavioral health organizations, they cannot afford
skilled staff, believe it or not. So you have a physician who
can do many things sitting and writing scripts all day. You
have peers who do many important things. But in between, you
really lack staff that can deliver cognitive behavioral
therapies that are very effective for both depression as well
as for more serious severe depression and other illnesses.
So I think we have to raise the floor, and this is your
opportunity. And that is why we are so grateful that you have
so many committees interested in this, and that is why, if
there was one thing I could ask based upon my years of
experience, it would be: do something that is systematic.
We do not necessarily need more grant programs. We know
they work. There are great things going on out there. You heard
it from the panelists. Now, it is about taking it to scale.
Senator Casey. Great. Thank you very much.
The Chairman. Thank you.
Senator Thune?
Senator Thune. Thank you, Mr. Chairman. And thank you to
the panel for all your great insights today.
I just want to ask, Mr. Thomas, according to the Utah
Department of Human Services' website, suicide was the leading
cause of preventable death in Utah in fiscal year 2014. As you
may know, South Dakota has experienced high rates of suicide,
particularly among young people, and particularly on our
reservations and in our tribal communities.
So my question is, what strategies has your department
employed in order to reduce the high suicide rate in your
State, and what are some of the other traits that you have
noticed in successful suicide prevention programs? And maybe,
if you could, talk a little bit about tele-health as an early
intervention technique that might help or if it has been used
in your success out there.
Mr. Thomas. Thank you, Senator Thune.
We have a State Coalition for Suicide Prevention, and what
we have done is, we have taken that State coalition and we have
built up some of the substance use disorder prevention
coalitions and had them add in suicide prevention as one of the
things that they are addressing at the local level.
So we have over 40 coalitions that are attacking this
problem at the local level throughout our State. We have had
people from Zero Suicide, which is a national effort to lower
the suicide rate and to have us look at comprehensive care; we
have had experts come in. We have done surveys and studies with
our workforce to find out gaps in their knowledge.
We have brought in training for them. Many people even in
our field do not have the training that they need to address
suicide specifically. So we have brought in evidence-based
training to our State to target suicide-specific actions,
behaviors, thoughts.
Another thing that we have done is, we have worked with all
of our health-care providers, our health-care system, as well
as our local mental health and substance abuse authorities, to
have a standardized language and a standardized screening and
risk assessment process.
So we are using the Columbia Suicide Severity Rating Scale.
IHC, Intermountain Healthcare, our largest provider, has
already implemented that into their health-care record, their
electronic health record, as well as in their emergency room,
crisis, and outpatient settings.
Then our local authorities--they are also the county
providers--are implementing that. So everyone will be talking
about risk the same way. Our crisis lines, they are doing the
same training, and then we are also using the same safety plan,
the Stanley Brown safety plan, which is top-of-the-line and
really gets at five different factors to try to keep people
safe. We have done a lot of campaigns and had a lot of
legislators, local legislators, who have helped us pass some
bills to target this issue as well, and we feel like we are
making progress.
As you have said, we have had a really high suicide rate,
along with the other intermountain States, and for the first
year, a year ago, our data showed that we have actually dropped
that rate a little bit. One person dying from suicide is too
many, which is why we are part of the Zero Suicide initiative,
and I feel strongly and passionately about this issue.
Tele-health for rural Utah--we have two counties that are
over 7,000 square miles. One has 15,000 people, another has
60,000 people in it. Tele-health is definitely part of the
solution, part of the answer, but we need to develop local
resources as well, and have local trained staff to be able to
help families and communities.
It does not always have to be professionals, but we do need
professionals involved in the care, and tele-health has been
used in our State to try to address this. It is not to scale.
It needs more infrastructure, but it is definitely something
that is part of the solution.
I believe it is good in South Dakota, and your Health and
Human Services has been a great partner in this. We have had a
Region 8 meeting with all of the States in our region to
discuss suicide prevention because of the high rates in our
region.
Senator Thune. Thank you.
Mr. Marshall. Can I add to that?
Senator Thune. Yes. Yes, please.
Mr. Marshall. I think Ms. Rosenberg was right when she said
it needs to be systematic. Sometimes we do too much. As a
patient and going through it and now on being a provider, so to
speak, one thing I know for sure is, if we start the
conversation early--we are talking about intervention in our
adolescence--one thing I know for sure is, if we have this
conversation in our schools, 50 percent of our problems would
go away, because what happens is two things.
One, we have an invalidating environment, and, two, our
professionals, our teachers, our parents, they do not know how
to identify and deal with it. So that is the first step: being
able to start the conversation early and being able to equip
our professionals with the things they need to be able to
identify it.
You talk about tele-health. There are companies out there,
like Lantern and Enjoyables and the X2AIs, where you can deploy
resources to those neighborhoods that may not have
professionals or a clinic, where we all have telephones. How
cool would it be if we are in school and we may not have
counselors, because we do not have the budget for it anymore,
or a professional, but you can do CBT with a clinician or
dialectal behavior therapy or just self-
assessment, where you are just talking about a day, instead of
invalidating a kid and putting him in isolation, which turns to
suicide.
Senator Thune. I appreciate that perspective on that. I
wanted, by the way, to say, Mr. Marshall, as a recognizable
professional athlete, how much we appreciate your advocacy for
people who struggle with mental illness, and especially for
those who have not yet sought treatment.
Since you are a high-profile individual who is known for
successfully pursuing treatment for mental illness, if you were
going to suggest for somebody where they should start if they
need help, particularly young people in some of those examples
that you just mentioned where you have kids whose parents do
not know how to identify it and teachers do not, where would
you suggest they go?
Mr. Marshall. Mr. Thomas hit it. They have a program, Peer-
to-Peer. The first place our children go to is their friends.
So that is why we need to start the conversation, because when
my son goes there--he is in elementary School--if he is having
issues, if his friend is having an issue, they go to each
other. Then what happens?
So I think there are many solutions, but one of the things
that I always talk about is educating our kids. Project 375, we
are working with this three-tiered program where we are
teaching our children how to identify and how to talk about it,
because that is what happens.
Even when you go to our young adults, the first outbreak is
from the age of 18 to 24. That is on campus. That is peer-to-
peer. The first person you go to is a friend or a loved one.
So that would be my answer. It is to start with the
conversation. We threw around mental health first aid. I think
that is really important not only in our school systems, but
also when we talk about our police departments. How do we
identify it? How do we deal with it? That is the first step.
Senator Thune. Thank you for sharing your story. Thank all
of you. By the way, we will be optimistic and say that when you
play the Packers in the Super Bowl next year, take it easy on
their secondary. [Laughter.]
Thank you.
Mr. Marshall. Thank you.
The Chairman. Senator Scott?
Senator Scott. Thank you, Mr. Chairman.
The Chairman. Senator, I have a whole office-full down
there that has been after me, and I have been interrupted a few
times. I apologize to you, because this is personally a very,
very important hearing, and I definitely will pay attention to
everything you have said.
I just want you to know this committee takes it seriously,
and we are going to do some things here this year that
hopefully will get us down the road a bit more. But I am fully
aware of how much we need to do.
So we are going to turn it over to the last questioner,
unless somebody else walks down, and if you will shut down the
committee, I would appreciate it.
If I can just wave to you guys and just say how deeply
appreciative I am that you could be here. I am sorry I have had
so many conflicts, but the testimony I have heard has been just
great.
Senator Scott?
Senator Scott [presiding]. Thank you, Mr. Chairman.
Thank you to all the panelists for being here this
afternoon. It certainly is a very important issue that we are
seeing, and there is a steady increase in interest around the
country, which I think is really good news.
In South Carolina, we really have been on the cutting edge
in the use of tele-psychiatry in our State. We have had, since
2009, about 27,800 mental health consultations that occurred
using tele-
psychiatry.
We think it is the future, frankly, in a number of areas in
the medicine field, especially as you look throughout the
States like South Carolina where the rural opportunities for
access to health care and to mental health services are
dwindling. They sometimes seems to be nonexistent.
I would love for the panelists to perhaps comment on the
success and the opportunity for more innovation and creativity
in the tele-health field, but specifically tele-psychiatry.
When you think about the fact that--my understanding is,
when you are looking at it from an emergency standpoint, that
the price point is about $3,000 less per episode, which is an
important part of a State's consideration. When you think about
the individual, there is no doubt that providing access to
quality health care when the person needs it the most,
especially if you are living in a rural area, is so important
that you need to think about tele-medicine.
So I would love to hear your comments on the use of tele-
psychiatry and using the whole next iteration of the
opportunities from a mental health and a health-care
perspective.
Mr. Marshall. Well, it is funny, because Tuesday I actually
spoke at Collision in New Orleans. It is a tech conference, one
of the largest out there. And a couple weeks ago, I spent some
time in San Francisco really trying to study this market,
because I have been pounding the pavement for a couple years--
and I know you guys have been working longer than me--but I
have been really frustrated, because my goal is to put a
clinician in every single school in America, but now I am
finally realizing that that is almost impossible.
So a few mentors of mine have been telling me for a few
years that we have to adopt technology. I will say this. It is
not to replace, but to assist and also help stand in the gap.
There is some amazing technology out there, and I think the
reason why it is the solution, part of the solution, a big part
of the solution, is because it is accessible, affordable, and
scalable.
When you look at our problems now, we are having problems
just getting our youth to take up psychology in school. So it
would be impossible for us to take one human being and take on
a workload of 200 patients, where we can take one tool--and I
love what you just threw out there and what you guys are doing
in South Carolina--but you can take one tool and that one tool
can treat or assist 2,000.
Senator Scott. Thank you. Are there any other comments?
Then I have a couple more questions and only about 2 minutes
left, according to--no longer according to the chairman, but
according to the clock. Thoughts?
Dr. Bennington-Davis. Senator Scott, I just would echo what
Mr. Marshall said. I really like the way that he said assist,
not replace. There is something about a human-to-human
interaction that, in psychiatry, is particularly powerful.
That said, there are tremendous uses of tele-health. We are
seeing it in dermatology, we have seen it in radiology for a
long time, and it turns out that the next generation of people
really like interacting through technology. So I think we are
just seeing the tip of the iceberg.
Senator Scott. Thank you. I am going to move on to my next
question to try to stay somewhat close to my 5-minute limit.
I would say that one of the areas where we are seeing a lot
of emphasis is on our veterans. We have so many men and women
who have donned the uniform, willing to sacrifice their lives
on behalf of this country, on behalf of freedom, and sometimes
they get back and it feels like our VA is failing so many of
our veterans.
I know that at home, Scott Isaacks, who runs the Ralph
Johnson VA location, has been one of the outliers, frankly,
from my perspective. He has done a really good job of using
tele-medicine and tele-psychiatry in a positive and powerful
way to treat so many of our veterans.
Both of my brothers have served in the military, and my
older brother, the unattractive one, has 32 years, has just
retired from the Army, a command sergeant major, and focused on
the war transition process.
Have you seen a collaboration between the VA and States on
addressing some of the issues that our veterans have?
Ms. Rosenberg?
Ms. Rosenberg. I was hoping you would not ask me.
Senator Scott. I am going to ask Mr. Thomas as well. So you
can decide who goes first.
Ms. Rosenberg. I will start. It is complicated.
Senator Scott. Yes, ma'am.
Ms. Rosenberg. Is that a good way to say it? I think the VA
often gets a bad rap. I think they do some very excellent
things and some very fine work. Often, people are interested in
the VA money more than they are interested in veterans,
unfortunately. I am being very honest and very direct.
But that said, the VA is also a single-payer system and
likes to keep control. So I think collaborations are difficult
for them. I think they have made tremendous headway, and I
think community organizations have worked very hard to create
those partnerships.
I have seen some very good evidence, particularly in the
area of the treatment of addictions, where there are some very
good partnerships.
Senator Scott. Mr. Thomas?
Mr. Thomas. With our VA, we also have Hill Air Force Base
and then a large National Guard contingent in our State. We
have worked with all three really well around, in particular,
suicide prevention and peer support and outreach.
Those have been the areas where we seem to be able to share
a lot of the same ideological and policy directions with them.
Our VA, the folks that we interact with, try hard to get--there
is some of the stigma that Mr. Marshall talked about in that
system, and if I say that I have a problem and get my services
through the VA, what will that do to my career?
So I think the clinics that they have started out in the
communities, where it does not go on your record, have been
really helpful and a step in the right direction.
Senator Scott. Perhaps not for right now, but perhaps you
can submit it for the record, if you have any shining examples
of States where you believe that that coordination is occurring
in the most effective way, I would love to hear from you. If
you want to respond now, you can, but if you do not mind
including that in perhaps a follow-up later, that would be
wonderful.
My final question for the panel would be one of the
economic impact of the untreated person. I think so often we
think about the cost associated with care, the cost associated
with treatment. Too often, I believe that we forget that there
is a cost to not treating.
I am not quite sure how we monetize and/or figure out how
to effectively figure out that cost, but I think we would be
remiss if we did not spend a few minutes on the fact that
without treatment, the human cost is incredible, and without
treatment, the economic cost is measurable, but it is pretty
dismal.
Final thoughts?
Dr. Bennington-Davis. I will chime in, Senator Scott. We
have already mentioned today the early death of people who have
mental illness and substance use disorders. I would add the
school dropout rates and the tremendous economic and human
impact of not being able to be successful in school, and I
think those are probably a good start.
Ms. Rosenberg. I would add to that. If you look at children
who have been diagnosed with a serious emotional disturbance,
what you see is up to 25 percent of them wind up in jails and
prisons. So we then have that cost.
I think additional to that, if you look at Social Security
Disability and SSI, the biggest driver is mental illness. So
you have lost income, lost taxes, lost wages.
I think it is quantifiable. Lack of treatment does cost us
a lot of money as a country.
Senator Scott. Yes, ma'am.
Mr. Thomas?
Mr. Thomas. I would just add, I think those are all the big
economic costs, but I think the biggest cost is the tear in the
fabric of our families and society, that that is the
devastation that occurs when a family member loses someone,
whether it is to jail or suicide or early death because of not
getting treatment.
Senator Scott. Absolutely. Well, thank you.
Mr. Marshall. I was going to say Mr. Thomas took all of my
words verbatim.
Senator Scott. Excellent. I would add that coming out of
South Carolina, approximately 38 percent of those between the
ages of 18 and 20 are unemployed and 53 percent between 21 and
64 are unemployed. So the impact of mental challenges, mental
health and mental illnesses, when you quantify it, it is
drastic.
Thank you all for being here and participating in the
process of engaging members of Congress, as well as the public,
on such an important issue. I want to thank you all for taking
the time. As we have heard, this is an incredibly important
topic, and frankly, one that we need to spend more time on.
I will continue to work with our colleagues on and off of
this committee to address mental illness.
As for our witnesses, once again, please keep us informed
on the great work that you all are doing. Thank you for the
courage and the commitment to making a difference not only in
our own lives and the lives of your community, but of our
Nation. We thank you for that.
I would ask that any questions for the record be submitted
by Thursday, May 12, 2016.
With that, this hearing is adjourned.
[Whereupon, at 4:20 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Margaret Bennington-Davis, M.D.,
Chief Medical Officer, Health Share of Oregon
Chairman Hatch, Ranking Member Wyden, honorable members of the
committee, thank you for this opportunity to offer testimony on mental
health services provided through the Medicaid program and Oregon's
innovations in service delivery.
I have spent the better part of 30 years as a leader in the mental
health services provider community in Oregon and abroad. I have worked
as a mental health provider in the community and hospital settings, as
a program administrator, and as a leader in organizational change. I
have performed hundreds of consultations, both nationally and
internationally, on trauma-informed care and the elimination of
seclusion and restraints in psychiatric care settings. What I have
learned in this time is that behavioral health--stable mental health
and freedom from substance use disorders--is simply health. In other
words, ``health'' requires not merely the absence of physical disease
but a state of wellbeing in physical, dental, social, and mental
health.
Currently, I serve as Chief Medical Officer for Health Share of
Oregon, the State's largest Coordinated Care Organization (CCO). Health
Share is a transformative model of Medicaid managed care that brings
together local health plan, provider, and community organizations to
coordinate physical, dental, mental health, and substance use disorder
benefits for more than 25 percent of Oregon's Medicaid enrollees.
The CCO model was created by a Medicaid 1115 Demonstration Waiver 4
years ago, and Health Share was a new organization created specifically
to fit that model. Even in this short time, the CCO model, which
provides financial incentives for improving health care delivery, has
allowed us to uncover data to support a simple truth about the
population we serve: the most frequent and costly utilizers of Medicaid
services are adults who experienced childhood trauma.
This discovery, and the CCO model in general, has brought new
attention to and appreciation of the roles of mental illness and
addictions in costs and poor health outcomes. As a result, there are
initiatives in communities across the State to increase access to
mental health and addictions services, integrate behavioral specialists
into primary care, and ensure better primary care supports to people
with serious mental illness.
In this testimony, I will: explore the promise of the CCO model;
describe the impetus of Health Share of Oregon's decision to focus on
access to services and promotion of early life health; provide examples
of upstream interventions that Health Share believes will bend the cost
curve in the long-term; describe the extant mental health system
challenges that communities are addressing in Oregon and across the
country; and comment on Federal policy challenges in the mental health
and substance use disorder space.
medicaid coordinated care organizations:
the promise of oregon's health system transformation
Oregon's CCOs are regional Medicaid managed care contractors, each
with a governance model that reflects its community and health services
marketplace. Each CCO has at least one Community Advisory Council that
is made up of a majority of CCO enrollees. All 16 CCOs have 2 things in
common: they are all different because they each reflect the community
they serve, and they share the goals of better care, smarter spending
and healthier people. There are a number of programs and incentives
designed to help CCOs obtain those goals, including but not limited to:
Integration of physical health, mental health, oral health,
non-emergency medical transportation, addiction residential
services, and children's wrap around services into each CCO;
Withholding 5 percent of CCO budgets to be paid based on
performance on robust set of incentive metrics;
Requiring development of alternative payment methodologies
and hosting ``learning collaboratives'' to spread successful
models;
Requiring CCOs to cover some ``flexible services,'' which
are non-covered services that may be more cost effective
alternatives to covered services (e.g., vacuums for families
whose children suffer from severe asthma; healthy meal
vouchers); and
Requiring CCOs to conduct regular community health needs
assessments and implement community health improvement plans.
The CCO model is already showing signs of success. This program is
expected to save the State and Federal governments $1.7 billion on
Oregon's Medicaid program over the first 5-year demonstration.
Oregon made a significant promise to CMS when it signed the current
Medicaid waiver agreement--that through the CCO model, our State would
decrease the expected Medicaid spending trend by 2 percent over 5
years, not by cutting the number of individuals served or reducing
provider payment rates, but by improving the way Medicaid services are
delivered. CCOs did not have much time to make good on this promise, so
we began with addressing the highest utilizing and most costly members.
the need to work upstream: what we learned from
the adverse childhood experiences study (aces)
When Health Share analyzed those among our 240,000 members who used
the most services and led to the highest costs, we began by asking them
to describe their lives. The results were compelling. Very often these
members were born into unstable housing and chaotic families, and to
parents who did not intend to have children and were not ready or able
to parent. Some had been in and out of the foster child system early in
life; many had been sexually or physically abused. Most did not have
childhoods that prepared them to be successful in school. There was
often drug use and other high-risk behavior during adolescence. Often
their drug use had led to brushes with the criminal justice system.
Many became parents themselves when they were not yet ready or able to
parent. Most had various erratic behaviors, depression, or suicidal
tendencies that led them to require services in specialty mental health
if they could get access, or to jails or hospitals if they could not.
Many had never finished school, and many had more than one chronic
physical condition.
This is exactly what the Adverse Childhood Experiences Study
(ACES), published in 1998, revealed: there is a powerful relationship
between adversity and toxic stress during childhood and our physical
and mental health as adults, as well as the major causes of adult
mortality in the United Stated.
We know that almost half of children in the United States grow up
in poverty, which is an important social determinant of health and
contributes to child health and developmental disparities. Growing up
in a stable and healthy home, in a language rich environment, and
having access to quality preschool and regular well visits to a medical
home are all critical for developing social and emotional competencies
in children as they prepare to enter school. Evidence also shows that
kindergarten readiness and success is linked with later educational
success, which in turn is associated with better health and economic
outcomes.\1\ In other words, if children are prepared mentally,
emotionally, and physically for kindergarten, they are more likely to
be healthy adults. To be effective parents, adults need to be healthy
themselves. To be healthy, they need access to physical, mental, and
dental services. The cycle of poverty is one that we, in the health
care community, have a role in ending.
---------------------------------------------------------------------------
\1\ Jones, D, et al. (2015). Early Social-Emotional Functioning and
Public Health: The Relationship between Kindergarten Social Competence
and Future Wellness. American Journal of Public Health. Vol. 105, No.
11, pp. 2283-2290.
Health Share of Oregon, in the face of such evidence, determined
that if we are to move the dial on curbing Medicaid costs, we needed to
move ``upstream'' in our efforts to improve health. We needed to build
systems and communities that create effective parents and healthy,
stable environments for children. To that end, Health Share is focused
on helping our members: avoid unwanted pregnancies; access social,
physical, and mental health supports during pregnancy; have their basic
needs met in order to successfully be able to attach to their new
babies; and get the support and guidance they need to be effective
parents.
what the decision to move upstream means for mental health services
Community mental health services have traditionally focused on
people who have already developed chronic and severe mental illness. By
adding emphasis to early childhood supports and the social determinants
of health, focusing on early intervention, partnering with schools, and
paying attention to the availability of mental health supports within a
community, perhaps we can mitigate the tragic long term effects of the
toxic stress described in the ACE study.
Nationally, people with serious mental illness die on average 25
years sooner than the general public; \2\ this statistic has been even
more severe in Oregon.\3\ These early deaths are almost always because
of chronic physical illnesses that are modifiable, with the right
supports. Oregon's CCOs are working hard to identify those ``right
supports.''
---------------------------------------------------------------------------
\2\ Parks, J., et al. (2006). Morbidity and Mortality in People
with Serious Mental Illness. Alexandria, VA: National Association of
State Mental Health Program Directors (NASMHPD) Medical Directors
Council.
\3\ (2008). Measuring Premature Mortality Among Oregonians. Salem,
OR: Oregon Department of Human Services Addictions and Mental Health
Division.
Senator Stabenow's Excellence in Mental Health Act is key to
identifying those ``right supports'' and is, in my view, one of the
most important legislative initiatives addressing mental health since
the 1960s. This legislation builds on the original Community Mental
Health Act, which described the continuum of services required to move
from institutional care for people with serious mental illness to the
community. Senator Stabenow's legislation now brings us to the
important recognition that community mental health services also need
to be providing or coordinating primary care because people with
serious mental illness may not get health care anywhere else. Oregon is
one of the eight pilot States, and improving care in community mental
health centers fits in very well with the overall CCO model.
moving upstream for special populations: creating medical models for
children in foster care and addicted mothers
Designing Health Care Systems That Work for Children in Foster Care
Through analysis of our population data, which mirror national
data, we know that children ages 0-6 in the foster care system have a
much higher incidence of asthma, attention deficit disorder, PTSD, and
obesity than children in Medicaid who are not in the foster care
system. These differences persist in older children, with the addition
of much higher incidence of depression, and by late teens/early
adulthood, the addition of higher incidence of schizophrenia and
hypertension. The most surprising finding for us was that these
differences persist, and are even higher, in children who were in the
foster care system at one time but are no longer involved in the child
welfare system. In other words, the experience in the foster care
system was not healing, and did not provide a safe way to ensure
healthy development, either physically or emotionally. We as a society
need to address the root of this issue by ensuring the right supports
to parents in the first place, so they keep their children in safe and
nurturing families. In the meantime, we at Health Share are also
focusing on developing coordination among mental health, dental health,
and physical health providers for these kids, and describing what the
right supports are for them in those health care arenas.
In October 2015, Health Share launched the Foster Care Advanced
Primary Care Collaborative with seven of our area's clinics and clinic
systems. The Foster Care APC is a year-long learning collaborative to
explore and implement Foster Care Medical Home Models and interventions
to better support the health needs of foster children. The
collaborative consists of six half-day learning sessions held every
other month that are focused on key population dynamics, such as
identifying children in foster care, working with victims of abuse,
neglect and trauma, understanding child welfare systems and processes,
working with foster parents and biological families, coordinating with
the mental health system of care, and more. Teams of four to eight
staff from each clinic participate in each learning session. On the off
months between learning sessions, a Steering Committee meets to help
tailor the next session topic to meet needs identified by the clinics
as they implement their models. The Steering Committee includes one
representative from each clinic system along with a small group of
local clinical and population champions from various organizations.
These seven clinic systems together provide primary care to more than
1,000 foster children in Health Share's three counties and look to play
an integral role in developing a system of care that meets the unique
needs of this vulnerable population.
Project Nurture: Serving Pregnant Women With Substance Use Disorders
Another example of a special population that requires our immediate
attention if we want to improve the health of future generations is
pregnant women with substance use disorders. There are obvious fetal
development risks involved with pregnant women battling addictions.
These risks can be mitigated with proper treatment, but these women
need to feel safe accessing appropriate medical care. To that end,
Health Share funded the development of, and continues to support, a
program called Project Nurture.
Project Nurture provides prenatal care, inpatient maternity care,
and postpartum care for women who struggle with addictions, as well as
pediatric care for their infants. Women who are enrolled also receive
Level 1 outpatient addiction treatment by certified alcohol and drug
counselors (CADCs), and Medication Assisted Therapy (MAT) using
methadone or buprenorphine when indicated. Project Nurture's model is
to engage women in prenatal care and drug treatment as early in
pregnancy as possible, provide inpatient care for their delivery and
follow them and their infants for a year postpartum providing case
management and advocacy services throughout. Women who participate in
Project Nurture are informed of policies regarding Child Welfare
reporting and we believe that this transparency facilitates a trusting
relationship with providers and allows us to advocate for women and
their families whenever possible.
the importance of health coverage to improving mental health in america
Oregon was also an early adopter of Medicaid expansion under the
Affordable Care Act (ACA). This was crucial for people with serious
mental illness in our State. Without insurance coverage, people could
not access community mental health services except for crisis, ERs, and
hospitals--the least efficient and effective times and ways to aid
recovery, and the most expensive. Nearly everyone in Oregon now has
better access to services, and sooner. Things are looking up for people
best served in community mental health settings, but we still have a
long way to go.
mental health system issues: levels of care and workforce challenges
One Size Does Not Fit All: Levels of Care in Community Mental Health
Even with nearly universal health coverage in Oregon, access to
specialty mental health services is still not necessarily smooth or
easy, and the array of services are not as broad and varied as is
necessary for optimal health. A contributing factor is glaring holes in
availability of certain types of mental health services along the
spectrum of levels of care for people with mental illness.
Most community mental health services are office-based outpatient
programs. Many people with serious mental illness need more intensive
supports initially, and then episodically thereafter.
Intensive outpatient and assertive community treatment (ACT) models
offer to literally meet the person where they are, at whatever hour
works best for them (a lot of people served in community mental health
centers are homeless or without transportation). ACT teams, sorely
lacking in many States, including Oregon, are multidisciplinary teams
that are on call to the individual 24/7, and help with myriad social
supports in addition to psychiatric support. Although these teams
require significant up-front investment, it is clear that they are
extremely effective and ultimately cost-saving for people who otherwise
cannot engage in traditionally administered clinic-based services, and
who end up using the most expensive settings--EDs, jails, and
hospitals--as their default service systems. Health Share is proud to
have funded for our community what we believe to be the first forensic
ACT team in the United States--designed specifically for people with
high engagement with the criminal justice system.
Independent housing, supportive housing, supported education, and
supported employment are also key components of a highly functioning
community mental health system. The CCO model was intended to allow
Medicaid managed care entities to expand payment for these types of
services, which are not traditionally covered health care services.
Oregon's CCOs are still learning how to best provide access to these
necessary services without reducing payment rates that are largely
based on utilization of traditional medical services.
Provider Workforce Challenges
There is a shortage of psychiatrists nationally, including in
Oregon; 59 percent of psychiatrists are 55 or older, and not enough
physicians are being trained. Federal health authorities have
designated 4,000 areas in the United States as having insufficient
access to psychiatry--areas with more than 30,000 people per
psychiatrist. We need to train more psychiatrists.
In community mental health, workers are often entry-level and
overworked. Once experienced, they move on to private practices or
hospital settings for better pay and better working conditions. We need
to make community mental health more attractive workplaces.
In addition to training more psychiatrists and improving working
conditions in community mental health centers, we need to broaden our
idea of who provides care (including peers and community health
workers) and what that care looks like. The mental health provider
community is only just beginning to understand the tremendous power of
peer supports in mental health treatment. People with lived experience
of mental illness and recovery are often the best coaches and system
navigators; they expand the workforce, give relief to over-taxed
professional teams, and are extremely effective and well-liked by those
they serve. Our systems are working to integrate peers into treatment
settings and teams, but there is work to do. Specifically, CCOs and
other payers need to develop payment models to support these types of
workers.
One program that Health Share has implemented in an attempt to
address workforce challenges is Project ECHO. This is a tremendously
successful ``tele-mentoring'' model developed by Sanjeev Arora, M.D. at
the University of New Mexico to upskill primary care providers to be
able to provide treatment to people with Hepatitis-C. Health Share, in
cooperation with one of our founding organizations, Oregon Health and
Science University (OHSU), brought the ECHO model to Oregon. Instead of
using the model to train PCPs in treatment of HCV, we began by using
the technology to train PCPs in psychiatric medication management.
Oregon, as noted above, suffers from a shortage of psychiatrists. We
used the ECHO model to bring teaching and consultation from
psychiatrists to PCPs serving our members and, eventually, across the
State. Building on that success, we started a second ECHO model this
year, which is upskilling PCPs in developmental pediatrics, teaching
them to screen for and treat developmental issues, such as trauma, ADHD
or autism.
medicaid payment and policy issues: the imd exclusion,
mental health parity, and 42 cfr part 2
IMD Exclusion
Experts agree that limiting institutionalization is an important
policy goal. Oregon remains a national leader in providing long-term
care services in home and community settings. However, it seems that
the ``IMD Exclusion''--the part of the Medicaid rules that prohibits
use of Medicaid dollars for adult stays in ``institutes for mental
disease''--has lost its utility, at least in the context of limiting
institutionalization.
The Supreme Court decision in Olmstead v. L.C. makes it clear that
under the Americans with Disabilities Act (ADA), States are generally
required to provide care in a community-based setting provided that the
``State's treatment professionals have determined that community
placement is appropriate, the transfer from institutional care to a
less restrictive setting is not opposed by the affected individual, and
the placement can be reasonably accommodated, taking into account the
resources available to the State and the needs of others with mental
disabilities.'' Repeal of the IMD Exclusion would not be expected to
adversely impact efforts to establish community based care for, but
rather to assure appropriate treatment for, those individuals needing
care in an IMD.
In its recently released final Medicaid managed care rules, CMS
partially lifted the exclusion for certain brief lengths of stay (15
days within a calendar month, up to 30 consecutive days over 2 months).
CMS reasons the increased flexibility is warranted by a decline in the
number of inpatient psychiatric care facilities and concerns about
access issues for those who need inpatient care, and psychiatric
boarding in emergency rooms. The limited length of stay, CMS reasons,
would preclude the use of IMDs for long-term care, indicating that
Medicaid is trying to balance the need for inpatient psychiatric beds
with a desire to limit institutionalization.
For consumers, this provides more options if hospital-based care is
needed. For provider organizations, this change would offer the
opportunity for acute care programs with 16 or more beds to participate
in the Medicaid program--and to offer more robust crisis response
programs and alternatives to hospitalization.
A full reversal of the IMD exclusion is likely not fiscally
practical, but revising the law even further could give providers
better incentives to ensure access to the right level of care at the
right time.
Allowing States to apply for waiver authority to exclude substance
use disorders facilities from the IMD exclusion was a step in the right
direction. The length of stay in an acute setting that is necessary for
effective treatment of substance use disorders is typically longer than
that needed for treatment of mental illness in an acute setting.
Allowing Medicaid payments for IMDs with average inpatient stays
that exceed the current 15 day limit, such as 30 or 60 days, would be a
stepwise approach to ensuring better access for Medicaid enrollees.
Congress could also narrow the definition of IMDs to facilities with
more than 30 or more psychiatric beds. These approaches would leave the
IMD exclusion itself in place while making access to short-term
inpatient care more accessible.
Mental Health Parity
Oregon was very early to ensure parity in access to mental health
benefits. Part of what makes Oregon's Medicaid program unique is that
in times of economic hardship for the State, rather than limiting the
number of eligible Oregonians Medicaid can serve, we choose to use a
public, deliberative, and evidence-based process to limit the benefit
package, which we call the Prioritized List of Services. For more than
20 years, mental health conditions have been ranked amongst physical
health conditions on the prioritized list. However, there are still
non-quantifiable issues of parity--the need to be quite advanced in
symptoms before getting access to specialty mental health and a high
threshold for Medicaid enrollees to access hospitalization (dangerous
to self or others). Truly effective parity still needs definition.
42 CFR Part 2: Privacy Protection and Sharing Information in a
Coordinated Care Environment
Sharing pertinent health care information about our members is
fundamental to providing truly coordinated care. We appreciate the
concerns that lingering stigma about behavioral health issues, and
substance use disorders in particular, raises for our members.
Patients' trust is fundamental to their acceptance of treatment, so
privacy is a particular concern for people receiving treatment for
addictions. That said, SAMSHA's regulation, 42 CFR Part 2, which
prohibits providers and health plans from sharing information about
substance use disorder diagnoses and treatment plans with each other--
and goes well beyond the privacy protections afforded to other health
services through the Health Insurance Portability and Accountability
Act (HIPAA)--restricts the sharing of information in a way that is
detrimental to thepeople receiving treatment. As the greater health
care community has shown through HIPAA, we are capable of limiting the
sharing of information to what is absolutely necessary to provide the
best possible care. We are encouraged by SAMHSA's current proposed
regulations and hope to move to a regulatory environment where
substance use disorder diagnosis and treatment information is treated
like any other personal health information.
the future of mental health in america looks bright,
but we have work to do
I am proud of what we have already accomplished at Health Share of
Oregon, and I believe that this regional, collective impact model could
work in any community and with other health care payer types. Looking
upstream to social determinants of health, including poverty, and
preventing trauma and chronic stress in childhood will reduce the
incidence of all illness--both physical and mental. I encourage
Congress to continue to support the kind of flexibility in the Medicaid
program that allows States like Oregon to improve the health of our
population and lower costs by focusing on prevention rather than the
volume of services used to treat people once they are already ill.
______
Prepared Statement of Hon. Orrin G. Hatch,
a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah)
today delivered the following opening statement at a hearing to examine
various options on how to address mental health issues in the American
health care system:
It is a pleasure to see everyone here today.
Today's hearing will focus on mental health issues in America and
the role the Medicaid and Medicare programs play in addressing the
needs of those with behavioral and mental health issues. Together,
Medicare and Medicaid finance nearly 45 percent of mental health
spending in the United States, which amounted to more than $75 billion
in 2014 alone.
As the Senate committee with jurisdiction over these programs, it
is our responsibility to better understand the drivers behind the
growing needs for and costs of these services and to work together to
develop better solutions for identifying and treating these issues.
A report issued by the Medicaid and CHIP Payment and Access
Commission in June 2015 indicated that the majority of Federal spending
on mental health comes out of Medicaid. That same study found that
Medicaid is the single largest payer in the United States for all
behavioral health services, including mental health and substance
abuse. In fact, Medicaid accounted for 26 percent of nationwide
spending on behavioral health in 2009, the year with the most recent
data.
One of the many difficulties we face in addressing these issues is
that Medicaid enrollees with behavioral health diagnoses have varied
physical and behavioral health needs. Patients often range from young
children who need screening, referral, and treatment for autism or
depression to chronically homeless adults with numerous diagnoses
including severe mental illness.
In 2011, only one in five Medicaid beneficiaries had a behavioral
health diagnoses, but they accounted for almost half of total Medicaid
expenditures.
Needless to say, these types of behavioral health issues can
seriously impair a patient's quality of life, cause disability, and
significantly decrease life expectancy. These types of issues are
associated with significantly higher rates of chronic disease,
substance use disorders, and inpatient hospitalization among Medicare
beneficiaries.
And, in Medicaid, patients with behavioral or mental health
diagnoses are more than twice as likely to be hospitalized as those
without such diagnoses. The number is drastically higher if the patient
also has a substance use disorder.
These high hospitalization rates are major drivers in the cost of
our Federal health programs. However, what is more unfortunate is that
all too often people with mental or behavioral health issues get no
care at all.
According to the 2012 National Survey on Drug Use and Health,
nearly 40 percent of adults diagnosed with severe mental illness--such
as schizophrenia or bipolar disorder--received no treatment for their
illness in the previous year. When you broaden that scope to include
all adults with any mental or behavioral illness, 60 percent went
untreated for the prior year.
It gets worse.
Every year, suicide claims the lives of 38,000 Americans--more than
car accidents, prostate cancer, or homicides. And, about 90 percent of
suicides are related to mental illness, according to the National
Institute of Mental Health. Utah is not immune from this preventable
tragedy. Suicide has been the greatest threat to our young people in
recent years, and it is time for everyone to take notice.
This is absolutely tragic. However, the tragic pattern expands
beyond the suicide rate as, overall, people with serious mental illness
have an average life expectancy that is 23 years shorter than the
nationwide average.
Patients and their advocates say the country's mental health system
has been drowning for a long time--not from floodwaters but from
neglect.
As we talk about solutions, we need to note that the distinction
between mental health, mental illness, and severe mental illness is
crucial, because each group requires different clinical and policy
prescriptions. For example, the current system, proportionally
speaking, provides far more support for mental health than severe
mental illness. We need to review these priorities and find an
equitable solution to ensure that all needs are being met.
Today's panel will give us an opportunity to hear from witnesses
who can speak to these issues from almost every perspective. We have an
advocate who has suffered with these issues firsthand. We also have
experienced professionals who will share their experiences providing
care at the local, State, and Federal levels and who can speak to the
successes and limitations of providing care in each of those
environments.
I look forward to hearing the testimony of today's witnesses and
beginning a dialogue with my colleagues on these important issues that,
hopefully, will lead to better solutions.
______
Prepared Statement of Brandon Marshall, Executive Chairman
and Co-Founder, Project 375
Thank you, Mr. Chairman, Ranking Member Wyden, and members of the
committee. I'm grateful for the opportunity to speak before the U.S.
Senate Finance Committee on an issue which not only affects me, but
millions of people across America: the impact of stigma in the mental
health community, and the critical need to make it easier for people to
get assessed and treated and be able to lead a normal, fulfilled life.
My name is Brandon Marshall--father, husband, son, friend, a man of
faith, wide receiver in the NFL, and co-founder with my wife Michi
Marshall of the nonprofit Project 375. Our mission is to end the stigma
surrounding mental illness, fostering open dialogue that encourages
people to recognize symptoms and seek help.
As a public figure, my actions have been in the spotlight for
years, both on the gridiron and off. I was diagnosed with Borderline
Personality Disorder in 2011. Before then, as many people may know, my
life was a living hell. Yet I didn't know why. It was hard to control
my emotions and manage my life effectively, and the situation was only
magnified by the tough-it-up culture of football.
For me, the tipping point came when I became so isolated and
depressed that I stopped talking to my wife and family. I descended
further and further, but it simply felt like the new normal. What the
tabloid headlines said wasn't the true reality of my suffering--the
isolation and depression were.
Finally, I was persuaded to visit McLean Hospital near Boston and
got evaluated in a supportive environment where I felt people actually
understood me. Just getting the diagnosis made me feel 50 percent
better. And getting the right treatment plan transformed my life.
Why did it take so long to get help? The biggest factor was the
stigma surrounding mental illness. I saw how ashamed others felt. This
was what motivated me and my wife to launch Project 375. The journey I
went through was difficult. I wanted to help others take that first
step, the hardest one to take. By many accounts, I am the first public
figure to stand up and publicly admit to the world a diagnosis of BPD.
Going public was hard. It's no less hard for others struggling with
undiagnosed mental illness.
In football, there's stats--lots of them. People obsess over the
stats. My fans can rattle off mine. Here are three:
I hold the record for most receptions--21--in an NFL game.
I'm one of only five players in NFL history to have at least
100 receptions in three seasons.
I hold the NFL record for most receiving touchdowns in a
single Pro Bowl game.
In the realm of football, those numbers are impressive. But there
are other stats that should make more of an impression on everyone here
today. Here are 10 of them:
1 in 3 people will experience a psychiatric disease in their
lifetime.
Over 60 million Americans are afflicted by mental illness
during any one year.
The suicide rate has risen over 24 percent since 1999,
making mental illness one of the only illnesses that has seen
an increase in mortality rates.
An estimated 17 million youth in the U.S. live with a
psychiatric disorder, more than the number of children with
cancer, diabetes and AIDS combined.
Anxiety disorders are the most common mental illness,
affecting close to 18 percent of adults in the U.S.
Among the 20 million American adults who experience a
substance use disorder, more than 50 percent have a co-
occurring mental illness.
Nearly 8 percent of Americans will experience PTSD at some
point in their lives. People who suffer from PTSD are nine
times more likely to experience issues of drug and alcohol
abuse and dependence.
Mental illness is associated with increased occurrence of
chronic diseases such as cardiovascular disease, diabetes,
obesity, asthma, epilepsy, and cancer.
According to the American Psychiatric Association, while
awareness of mental illness is increasing in the United States,
there is a worsening shortage of psychiatrists.
One silver lining: Many Americans do not understand that
common mental illnesses can be successfully treated most of the
time, including a 70 to 80 percent success rate for treatment
of depression.
The prevalence of mental illness in the United States is reflected
across society: from homelessness to incarceration to suicide. Often it
goes unreported, or simply unnoticed, until it claims the life of a
well-known figure, such as Robin Williams. The stigma surrounding
mental health issues is our last great fight on this frontier.
Ask yourself: would you feel ashamed being diagnosed with cancer?
No, of course not. With the first symptoms you'd get diagnosed and
treated, whether through surgery, radiation or chemotherapy. Would you
be afraid you'd be fired from your job if you were diagnosed with HIV/
AIDS? We've conquered that frontier--the answer is no. However, many
people still wonder: Are you sure you won't be fired if you're
diagnosed with Bipolar II or BPD? Would your child be invited to a
birthday party or sleepover if he or she is diagnosed with anxiety
disorder, OCD, or maybe schizophrenia?
A staggering 75 percent of those who need help do not seek it
because of the stigma. Because they fear what others may think, and how
it may negatively impact them. Without help and treatment the
consequences are dire--unemployment, incarceration, substance abuse,
and even death. According to Dr. Scott Rauch of McLean hospital and a
board member of Project 375, people are still hiding in corners,
avoiding treatment, fearful of being labeled, afraid of losing their
jobs.
I founded Project 375 with my wife out of our shared pain--and an
understanding that millions of others could be helped by my stepping
into the light. Talking about my BPD was liberating, but it was also
scary--because of the stigma, I could have lost everything. Every time
we release a video, send a tweet or publish a post, we hear from people
who were inspired to finally take that step forward, to seek help, and
to share their story.
We need to provide health coverage for brain Illnesses in the same
way we would any other physical illness or, in other words, treat the
brain like we would any other organ in the body, making ``Check Up from
the Neck Up'' part of routine exams, so we normalize treatment of
mental health and addiction. We must accept mental illness as a
disease, and like any other disease, it needs better research,
screening and funding. We need better recognition of new therapeutic
treatments that are proven to work. We need more robust education in
schools, the enlightened support of news and entertainment media, and
the advocacy of high-profile figures, like myself, willing to step
forward. None of this happens if we still remain silent about these
issues!
As an NFL wide receiver, I've caught hundreds of passes during my
career. Today, I'm throwing one, to you. Thank you.
______
Prepared Statement of Linda Rosenberg, MSW, President and CEO,
National Council for Behavioral Health
Thank you to the members of the committee for inviting me to be
with you today. On behalf of the National Council for Behavioral
Health, I appreciate the opportunity to talk with you about the
challenges and opportunities facing our mental health system.
Last week, the Centers for Disease Control and Prevention released
data showing a steady growth in suicide rates in the United States each
year since 1999, increasing by 25 percent in the last 15 years. Deaths
by suicide are rising among adolescents and youth . . . among middle-
aged Americans . . . and among older adults.
This news was especially difficult for me because I serve on the
Executive Committee of the Action Alliance for Suicide Prevention.
Despite growing attention to the issue of suicide prevention, our
Nation hasn't been able to move the needle. Shining the spotlight of
public attention into the shadows of mental illness is not enough.
There is rising public attention everywhere we look. This week, the
New York Times featured a story about the Portland Police Department's
efforts to improve how they handle crises. As Portland's police chief
put it, ``we are working in the backdrop of a fractured mental health
system that has gotten worse and worse.''
Talk of mental health and addictions has reached the presidential
campaign trail, where candidates are making the issue a major platform
of their campaigns. Governor Kasich, whose brother has been diagnosed
with schizoaffective disorder and whose home State of Ohio saw more
than 2,700 residents die of a drug overdose in 2014, has called for
more services. And on the other side of the aisle, Hillary Clinton has
released a comprehensive plan to address treatment and recovery.
Six hundred thousand Americans have taken a Mental Health First Aid
course. The public is hungry to learn how to recognize the signs of
mental illness, to be able to respond in an emergency, and to know
where you can get help. Teachers, first responders, veterans, clergy,
construction crews--the demand continues to grow.
So, yes, everyone--from Portland cops, to the candidates for
President, to friends and colleagues--is talking about mental health
and addictions. But as the numbers show, it is not enough. It's not
enough for the more than 41,000 Americans who died by suicide last
year. It's not enough for the more than 28,000 who died from an opioid
overdose.
It's not enough, but not because of stigma, and not because we
don't know what works in preventing these tragic deaths. It's because
of how rarely those interventions are available--across settings--to
reach people in their moment of need.
Life-saving treatments are too often delivered through Federal,
State or local grants. When patients have cancer or heart disease,
getting access to chemotherapy or a stent doesn't depend on their local
clinic having a grant that targets those conditions. Treatment for
mental illness and addiction should be no different.
Today, Congress has the opportunity to change the course of
millions of lives. The question before you is not, ``where are we
now?'' but ``where do we need to be?'' To get there, we need to move
from talk to action: from raising awareness to connecting people with
help. Here's how we can do it:
Access: Expand access to a full continuum of services
delivered in the context of robust and sustainable community-
based delivery systems.
Science-based care: Invest in evidence-based services,
delivered by a skilled workforce that leverages technology and
is held accountable for outcomes.
Integration: Ensure mental and physical health care is
integrated, services are coordinated, and high-need, high-cost
populations are targeted.
Access. To answer the question of ``where do we need to be?'' let
me begin with the issue of the shortage of psychiatric hospital and
residential beds. Currently, the Medicaid Institutes for Mental Disease
(IMD) exclusion makes it difficult for inpatient and residential
facilities to expand. This has led to proposals to eliminate the IMD
exclusion entirely or raise the permitted number of beds.
In some communities there is a need for more beds, and these
inpatient facilities represent an important part of the spectrum of
care. However, at their core, these services are designed to help
people experiencing a sudden and severe deterioration of their health.
Inpatient services will never be fully effective in a vacuum. Instead,
they must be delivered in the context of a continuum of care. Only
community-based services can prevent re-admissions, trauma, and
disruptions to home and work. At a time when we are growing Accountable
Care Organizations and Medical Homes, beds aren't enough.
That's why the National Council is so proud to support the
Excellence in Mental Health Act, which enables and sustains quality
community treatment systems, and facilitates the coordination of care
across health care settings.
The Excellence Act demonstration established criteria for Certified
Community Behavioral Health Clinics (CCBHCs) that provide mental health
and substance use services and primary care screening--along with care
coordination. When care in a different setting is needed, CCBHCs
coordinate with that facility to ensure seamless transition into and
out of care. CCBHCs must also collaborate with schools and justice
systems to keep individuals out of jail, at work, and in school. In
turn, organizations that meet the criteria to be a CCBHC qualify for a
Medicaid reimbursement rate that supports expanding services, serving
new populations, and engaging patients and families outside the four
walls of their clinics.
The comprehensive array of services envisioned under the Excellence
Act includes crisis services. There has been talk in policy circles
about investing in crisis services, and for good reason: timely access
to high-quality crisis care can be the difference between an individual
getting the intervention they need and that same individual ending up
in the emergency room, jail, or worse.
This is not the first time crisis services have gained prominence
in our policy debates--they were also touted in the 1980s as a way to
alleviate the burden on overcrowded, understaffed hospitals. Crisis
respite centers opened but many, funded by grants, struggled to
survive. And, just as with psychiatric hospitals and residential
facilities, standing alone, they were not enough.
The integration of crisis care into broader community-based
delivery systems is a cornerstone of the Excellence Act, with CCBHCs
required to directly delivery 24-hour crisis care (including mobile
teams). CCBHCs must also coordinate with law enforcement and criminal
justice agencies to ensure they're supporting public safety officers
who too often are first responders to a psychiatric crisis.
Importantly, CCBHCs must also coordinate with veterans-serving
agencies. As members of our armed forces return from Iraq and
Afghanistan, rates of post-
traumatic stress disorder and traumatic brain injury are on the rise.
Unfortunately, too many veterans cannot access the services they need,
in some cases because VA facilities are overburdened or simply
inaccessible. CCBHCs are tasked with providing culturally competent
care to veterans and members of the armed forces, and are responsible
for coordinating that care with other agencies that serve veterans.
The integration of crisis care with community-based care envisioned
in the Excellence Act could transform the way people access crisis
services in this country--it could quite literally save lives.
Unfortunately, it won't be available to all Americans.
Under the Excellence Act demonstration, 24 States are currently
planning the comprehensive mental health service reforms that will
allow them to certify, pay, and monitor CCBHCs. Yet, the law sets an 8-
State limit on those who may ultimately participate--meaning that two-
thirds of the planning States will have to stop in their tracks. Every
State that wishes to create and sustain quality service systems should
be able to do so, and that's why the National Council urges you to
allow all 24 States to participate in the demonstration.
Science-based care delivered by a skilled workforce with the
support of technology. To get our Nation's mental health and addiction
services to where they need to be, it's not enough to expand access--we
must ensure that services are high-quality, evidence-based and
delivered in a way that both enables us to measure what's working (or
what isn't) and holds us accountable for outcomes.
Unfortunately, the adoption of practices based upon the best
available research is limited by a reliance on grants. For example,
recent data from the NIMH Recovery After an Initial Schizophrenia
Episode (RAISE) study showed the effectiveness of a multi-pronged
intervention for individuals experiencing their first episode of
psychosis. The intervention included evidence-based practices such as
cognitive behavioral therapy along with medication, family
psychoeducation, case management, supported education and employment.
Despite research here in the United States and around the world, and
the allocation of block grant funding, it's not enough. Most
communities will be unable to implement the requisite interventions and
tens of thousands of young people will be relegated to a life of
disability.
Certified Community Behavioral Health Clinics hold the promise of
expanding Americans' access to science-based care. CCBHCs are required
to offer evidence-based services to meet the specific needs of their
communities--and they can be paid a rate inclusive of these activities.
Through data tracking andoutcome monitoring, clinics will be held
accountable not just for delivering these services, but for measuring
patients' progress and adjusting course when treatments aren't working
as hoped. Clinics that do well will be rewarded with quality bonus
payments, another step in our Nation's move toward linking payment with
performance, toward much discussed value-based purchasing.
But a key challenge to delivering timely, high-quality services
lies in our Nation's shortage of mental health and addiction treatment
professionals. The behavioral health workforce needs additional
capacity and support to fully meet Americans' need for services. Texas,
Iowa, Indiana, Idaho, Nevada, and Wyoming all have fewer than 6
practicing psychiatrists per 100,000 people--in fact, a mere 34
psychiatrists practice in the entire State of Wyoming. Just last week,
I spoke with a medical director at a clinic in Texas who has been
trying for more than 3 years to recruit a child psychiatrist. His
situation isn't unique. Clinics all over the country struggle to
recruit and retain staff.
One way Congress can help is by permitting licensed mental health
counselors and marriage and family therapists to directly bill Medicare
for their services. Technology can also help, playing a crucial role in
extending the workforce. Using state-of-the-art streaming video
technology, staff can connect with patients to adjust medications,
deliver cognitive therapies, and educate and support children and
parents. Online treatment platforms such as myStrength help patients
manage in their daily life. Mental health and addiction organizations
can be helped to adopt electronic health records--a proposal that has
received strong bipartisan support--to better track patient outcomes,
facilitate the exchange of health information, and coordinate care.
But the fundamental limitation underlying all discussions on the
workforce is that most clinics cannot afford skilled staff or the
necessary ongoing investments in technology. Those of you on this panel
who have ever run a business know this is unsustainable--and it's no
way to successfully treat Americans with mental illness and addictions.
If we are ever going to alleviate the workforce shortage, we need
clinics to be able to afford to hire the right staff and pay them what
they deserve. And we need sustainable financing mechanisms that
reimburse providers at a rate inclusive of technology costs.
The Excellence Act demonstration offers certified clinics a
Medicaid payment rate that bears a rational relationship to the costs
they incur. Under the Excellence Act, clinics will be able to hire
critical staff--including psychiatrists, midlevel professionals and
peers--and leverage new technologies to further extend the reach of
those clinicians. They will be to do this because they will receive a
sound, predictable and sustainable payment rate that--unlike grant
funding--supports the full array of activities of a high-performing
clinic and does so in a way that will continue into the future.
Integration. Data show that individuals with serious mental illness
have an average age of death at 53, the same as the U.S. life
expectancy in 1917. The primary drivers of that early mortality are
preventable and/or treatable chronic conditions like heart disease,
lung disease, and cancer. Data also tells us that people with chronic
physical illnesses often have co-morbid mental illnesses, especially
depression and anxiety, that lead to poor health outcomes. Integrated
care improves outcomes for both groups.
Earlier this month I had a first-hand experience with integrated
care. On a Sunday, I went to an urgent care clinic. Unbeknownst to me,
that urgent care clinic was part of an Accountable Care Organization
that also included my primary care physician--which I discovered upon
showing up at her office on Monday andfinding out that they already
knew all about the problem that had brought me to urgent care! They had
access to my electronic health record and knew what treatment I had
received. When my primary care doctor ordered a sonogram, the ACO
followed up with a phone call asking if I'd like to use their sonogram
provider. That's smart business AND it's good care. The two can, in
fact, go together.
Unfortunately, my experience is still all too rare. Far too few
health care organizations are equipped to fully coordinate and
integrate care in such a way that every patient could reap the benefits
I did. But behavioral health is aware of the need to better integrate
care, and we are at a tipping point. The Excellence in Mental Health
Act, through its creation of CCBHCs, represents a foundational
opportunity in the behavioral health safety net to advance the way care
is integrated and coordinated.
CCBHCs are required to provide basic primary care screening and
monitoring to all their patients, with referrals to and coordination
with local primary care providers. In this way, they help reverse the
trend of early mortality due to preventable causes among people with
serious mental illness; and help primary care providers better address
their own patients' ongoing mental health needs.
We know through the SAMHSA Primary Care-Behavioral Health
Integration program, which has been funded by Congress since 2009 and
has served over 70,000 Americans, that investing in integrated care
improves health and reduces costs. For example, after one year in the
PBHCI program, results from one grantee site in Travis County, Texas
indicated patients had 618 fewer emergency room visits and spent 155
fewer days hospitalized. These outcomes resulted in $1,193,000 saved in
a year.
These results were from one clinic operating under a time-limited
grant. Just imagine what we'll see when the Excellence Act
demonstration's CCBHCs start their operations in January of next year.
Conclusion. The question before you is not, ``where are we now?''
but ``where do we need to be?'' Shining the spotlight of public
attention into the shadows of mental illness is not enough. We need to
move from talk to action and from pockets of excellence to the
widespread availability of effective interventions.
The Excellence in Mental Health Act--CCBHCs--is where our mental
health system needs to be--financially sustainable continuums of
evidence-based treatments supported by and integrated with primary
care, 24/7 high-quality crisis services, and a revitalized behavioral
health workforce. That's what we can call reform.
______
Prepared Statement of Doug Thomas, Director,
Division of Substance Abuse and Mental Health, State of Utah
Chairman Hatch, Ranking Member Wyden, and members of the committee,
my name is Doug Thomas; I am the Director of the Division of Substance
Abuse and Mental Health in the State of Utah and I am honored to be
here with you today along with these distinguished guests.
Medicaid is the backbone of the public mental health system in Utah
and throughout the United States. It provides the infrastructure and
economy of scale necessary for States to standardize evidenced based
practices to provide high quality care to individuals with serious
mental health needs. The various Medicaid waivers and alternative
benefit plans available to States allow them needed flexibility to
customize plans to fit the unique challenges, needs, and resources of
each State. Case Management, Peer Support Services for individuals and
families, Psychosocial Rehabilitation and Respite services are great
examples of Medicaid reimbursable services that help people stay in
their communities despite serious illness and allow people the
opportunity to reintegrate in place of being alienated from their
families and communities of origin.
In 2009 the Institute of Medicine (IOM) issued a lengthy
publication about the prevention and early intervention of mental,
emotional and behavioral (MEB) disorders. The report highlights that
almost one in five young people have a MEB disorder at any given time
and that ``among adults in the United States, half of all of these
disorders were first diagnosed by age 14 and three-fourths by age 24.''
First symptoms usually precede a disorder by 2 to 4 years giving us a
window of opportunity. Narrowing the gap between the onset of symptoms
and evidenced based intervention is critical as the research is showing
us that this early intervention preserves executive functioning and
allows people, especially young people and people suffering from the
first-episode of illness to recover more quickly with less life
disruption. This allows them to accomplish and maintain important
developmental tasks, such as ``establishing healthy interpersonal
relationships, succeeding in school, and making their way (into and
succeeding) in the workforce.'' For young people with Medicaid we are
able to intervene early with positive outcomes showing that people can
and do recover from mental illness. Treating a person's mental illness
improves physical health outcomes and reduces overall healthcare costs
as well. There have been various Medicaid and other Health systems
studies which show that collaborative physical and mental health care
lowers costs and improves health outcomes. In Utah 3 years ago with a
new State Legislative Appropriation and County matching funds we began
to act on the IOM report with what we call Mental Health Early
Intervention. This consists of three programs, School Based Behavioral
Health, Mobile Crisis Outreach Teams for Youth in four of our five most
populous Counties and Family Resource Facilitation With Wrap-Around to
Fidelity. Over the last 3 years we have increased services to almost
5,000 more youth, the majority with Medicaid funding. Office
Disciplinary Referrals are down, Literacy scores are up, symptoms of
mental illness are being reduced often to the community norm, and
families are receiving the supports they need to keep their children
safely at home, in their own school, and enhancing their family's
natural support system through Peer Support.
Utah recently passed a limited Medicaid expansion designed to
target people with the lowest income in the greatest need, parents with
dependent children already on Medicaid, people who are chronically
homeless, people with mental illness and substance use disorders
involved in the criminal justice system and people with mental illness
and substance use disorders. We must have Medicaid work with us to find
a way to approve a waiver allowing Utah to extend Medicaid coverage to
these additional people in need.
People want to be served in the safest, least restrictive
environment and providers want to provide these types of services.
Sometimes children and adults need care beyond what can be provided
appropriately in an outpatient or home like setting. Allowing Medicaid
residential services the ability to bill and be paid for room and board
would be a great step in the right direction. Room and board is covered
during a more costly inpatient hospital stay, but not covered during a
more economical residential stay. This disincetivizes local, lower
cost, short term residential services in lieu of more costly inpatient
hospital care.
With the Patient Protection and Affordable Care Act, The Mental
Health Parity and Addiction Equity Act and more integrated care being
provided there is a need to modernize the Medicaid Institutes for
Mental Diseases (IMD) Exclusion. I applaud the efforts of the Substance
Abuse and Mental Health Services Administration, Centers for Medicare
and Medicaid Services and the Department of Health and Human Services
to modernize rule, including the option of State waivers around the IMD
exclusion. It must be done cautiously and systematically to ensure we
are not re-institutionalizing people but that we are providing a short-
term crisis intervention meant to help people stabilize and rejoin us
in our communities where we all work and play and live.
Thank you for the opportunity to testify before you today. If there
are any questions I would be happy to respond.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator from Oregon
The Finance Committee is responsible for the programs--Medicare and
Medicaid--that spend more on mental health than any others in America.
That's why this committee, working in conjunction with others including
HELP and Judiciary, must develop a fresh approach for protecting and
caring for Americans with mental illness. The focus of that approach
should be breaking health care, social service programs, and law
enforcement out of their individual silos and bringing them together in
a coordinated system that deploys their strengths to help people
dealing with mental health issues.
The Wyden family knows a little bit about this subject. My brother
struggled with schizophrenia for decades, and he had a lot of health
care bills covered by Medicaid. In and out of halfway houses,
confrontations with law enforcement officers, problems securing funds
for services or treatments--it was certainly something that has
confronted millions of families and demonstrates the need for a fresh
approach to helping those with mental illnesses.
Instead, because of the lack of appropriate places to go, patients
who deal with a lot of the same issues Jeff Wyden did have been boarded
in emergency rooms. They've been in fights with police, sometimes
deadly. Or they've wound up in prison, where more than half of all
inmates suffer from mental health problems, and minorities are vastly
overrepresented.
I'll be the first to say that mental health is not an issue that
falls neatly under any one Senate committee's jurisdiction. A lot of
different members with different areas of expertise will have to pull
the same end of the rope to make progress on this front. Senator
Stabenow, right on this committee, is a champion of mental health.
Senator Murray, the Democratic leader on the HELP Committee is also
right at the forefront.
In my view, our efforts on mental health have to be concentrated on
three priorities. First, there needs to be a sharp new focus on
preventing mental illness. People need better care earlier on to keep
illnesses from escalating. And furthermore, there are nearly 2 million
low-income, uninsured Americans suffering from mental illness or
addiction in States that have not expanded their Medicaid programs.
That's 2 million Americans who, without treatment or help, are far more
likely to fall into homelessness, far more likely to be incarcerated,
far more likely to suffer from addiction, far more likely to commit
suicide. The choice to expand Medicaid and give new hope to those 2
million individuals and their families, in my view, should be an easy
one to make.
Second, services from health care to social work need to be better
coordinated. It doesn't make much sense to tell a person struggling
with an illness that they're on their own managing treatments, figuring
out what specialists to see, scheduling appointments and handling
medications. Even outside the doctor's office there are a lot of areas
where people with mental illnesses often need help they're not getting
today. Paying the bills. Making it to appointments. Maintaining a home.
Taxpayer dollars need to reach deeper into our communities and improve
coordination to help people who the system today overlooks.
Third, there needs to be a better link between mental health and
law enforcement. In a lot of cases that's going to mean more training
on what to do when responding to a person with mental illness. Too many
people who should be in proper health care facilities are winding up in
jail cells instead. In Portland, the Police Bureau has recently put a
lot of work into building a team of specially-trained officers to
handle these challenges safely, and it's paying big dividends in the
early going. In my view, more agencies around the country ought to
follow suit.
The big hurdle in all of this is funding. Each year, mental illness
costs the U.S. $450 billion, only a third of which is actually spent on
medical care. At roughly $75 billion combined, Medicare and Medicaid
make up the biggest slice of the pie. Those are huge numbers, and a lot
of the overall total goes to emergency room visits and jail time. In my
judgement, if you can shift some of that funding to the three
priorities I talked about--preventing mental illness, better
coordinating care and services, and linking law enforcement with mental
health--you'll see a lot more people successfully managing their mental
illnesses and living healthier lives.
This is a tough challenge, and it's going to require a lot of
bipartisan teamwork. But I'm optimistic that members will come together
to make real progress, and I look forward to today's hearing.
______
Communications
----------
American Academy of PAs (AAPA)
22318 Mill Road, Suite 1300
Alexandria, Virginia 22314
www.aapa.org
On behalf of the more than 108,500 nationally certified PAs (physician
assistants) represented by the American Academy of PAs (AAPA), we
appreciate the Senate Finance Committee's interest in the state of the
American mental healthcare system. While there are numerous policy
challenges in this area, the most pressing may be the current shortage
of mental healthcare providers. In light of the historical use of PAs
to alleviate healthcare provider shortages, the increased number of PAs
practicing in psychiatry, and the growing movement towards the
integration of primary care and specialty care, AAPA believes that PAs
should be--and are well-equipped to be--better utilized in the
provision of mental healthcare.
According to the Substance Abuse and Mental Health Services
Administration (SAMHSA), an estimated 43.6 million Americans
experienced some type of mental health issue in 2014. While the
Affordable Care Act (ACA) attempted to make mental healthcare more
accessible, many individuals who suffer from mental illnesses continue
to go without treatment. For instance, SAMHSA's National Survey on Drug
Use and Health found that in 2014, more than 15 million adults reported
having a major depressive episode in the previous year. Yet, one third
of those individuals did not seek the assistance of a mental healthcare
provider. Although a variety of factors likely account for this
disparity, the U.S. Department of Health and Human Services recently
estimated 90 million people lack access to mental health and addiction
medicine providers. Many of these individuals live in rural and
medically underserved areas, where there are little or no options for
public transportation and the nearest mental healthcare provider may be
hours away. It is clear that more must be done to make treatment for
mental illnesses more accessible for this population, as well as the
public at large.
While early intervention for suspected mental illness is essential to
ensuring positive mental and physical health outcomes for all patients,
it is particularly important in the populations served by Medicare,
Medicaid, and the Children's Health Insurance Program (CHIP), as they
are typically less likely to have access to comprehensive and
coordinated healthcare. SAMHSA has found that half of adults who have
mental illnesses began showing symptoms by age 14. In 2014, more than
11% of youth between ages 12 and 17 had experienced a major depressive
episode in the prior year. However, fewer than half of them received
treatment or counseling. When combined with the everyday struggles of
many families who rely on Medicaid or CHIP, it is easy to see why early
intervention in mental healthcare issues within this population is
essential.
At the same time, SAMHSA has estimated that 25% of older Americans have
reported some kind of mental health problem, and 6.5 million seniors
have been diagnosed with depression. As in younger populations,
treatment for mental health issues in the Medicare population is
necessary to ensure better healthcare outcomes across the board. Yet,
an ongoing shortage of mental healthcare providers combined with
continued struggles to better coordinate healthcare for all populations
has meant that many individuals who are in the highest-need
demographics are falling through the cracks. While there are many
factors involved in creating a better mental healthcare system, AAPA
believes better utilization of PAs in federal healthcare programs is
essential to solving the overall access problem.
PA Education and Practice
PAs receive a broad education over approximately 27 months which
consists of two parts. The didactic phase includes coursework in
anatomy, physiology, biochemistry, pharmacology, physical diagnosis,
behavioral sciences, and medical ethics. This is followed by the
clinical phase, which includes rotations in medical and surgical
disciplines such as family medicine, internal medicine, general
surgery, pediatrics, obstetrics and gynecology, emergency medicine, and
psychiatry. Due to these demanding rotation requirements, PA students
will have completed at last 2,000 hours of supervised clinical practice
in various settings and locations by graduation.
The majority of PA programs award a master's degree. PAs must pass the
Physician Assistant National Certifying Examination and be licensed by
a state in order to practice. The PA profession is the only medical
profession that requires a practitioner to periodically take and pass a
high-stakes comprehensive exam to remain certified, which PAs must do
every 10 years. To maintain their certification, PAs must also complete
100 hours of continuing medical education (CME) every 2 years.
PAs practice and prescribe medication in all 50 states, the District of
Columbia, and all U.S. territories with the exception of Puerto Rico.
They manage the full scope of patient care, often handling patients
with multiple comorbidities. In their normal course of work, PAs
conduct physical exams, order and interpret tests, diagnose and treat
illnesses, assist in surgery, and counsel on preventative healthcare.
The rigorous education and clinical training of PAs enables them to be
fully qualified and equipped to manage the treatment of patients who
present with both physical and mental illnesses.
PAs and Mental Healthcare
PAs are recognized along with physicians and nurse practitioners under
Medicare, ACA, and other federal healthcare programs as one of the
three types of primary care providers. Overlap between primary care and
mental healthcare has traditionally existed, particularly in settings
which provide care for the medically underserved like hospitals,
community health centers, rural health clinics, free clinics, and jails
and prisons. This is largely due to the fact that many of these
facilities' patients suffer from both physical and mental ailments and
have little ability to obtain either primary or mental healthcare. In
these situations, providers will often work to treat the whole patient.
The interface between primary care and mental healthcare is becoming
more common due to the growth of alternative payment models within
Medicare, as well as efforts to better coordinate patient care at the
federal level. As a result, primary care providers in all settings are
beginning to offer mental health screenings, arrange ``warm handoffs''
to a mental health specialist, or work in tandem with a specialist via
telemedicine or other means.
Many of the mental healthcare bills currently before Congress
acknowledge the interface between primary healthcare and mental
healthcare. Today, there are approximately 30,000 PAs practicing as
primary care providers who are on the ``front lines'' of care. This
means even if they do not specialize in mental healthcare, a
significant number of PAs care for patients who reside in medically
underserved areas and present with complex or comorbid conditions
affecting both their physical and mental health. According to data
collected by AAPA in 2015, 10% of all patients cared for by PAs suffer
from depression. An additional 5% suffer from behavioral or other
psychiatric conditions other than depression. PAs who practice in
primary care are qualified to provide a full spectrum of healthcare
services for these patients, including conducting patient histories and
examinations, performing psychiatric evaluations and assessments,
ordering and interpreting diagnostic tests, establishing and managing
treatment plans, prescribing medications, and ordering referrals as
appropriate, and they should be fully utilized as members of the care
team.
At the same time, it is important to note that a growing number of PAs
are receiving additional education to specialize in psychiatry. While
Medicare recognizes these PAs as reimbursable mental healthcare
providers, they are not always included in legislation as mental health
professionals along with psychiatrists, psychologists, clinical social
workers, and psychiatric nurse practitioners. PAs in psychiatry work in
behavioral health facilities, jails and prisons, and psychiatric units
of rural and public hospitals. These PAs are credentialed and
privileged affiliate members of the medical staff who provide both
initial and ongoing care to patients. Given the current shortage of
providers in this field, it is critical that PAs in psychiatry be fully
included as part of the mental healthcare team.
Recent Legislative and Administrative Actions
There have been some notable efforts in recent proposals by both
Congress and the administration to better integrate PAs into mental
healthcare. In March, the Senate Committee on Health, Education, Labor
and Pensions (HELP) favorably reported S. 2680, the Mental Health
Reform Act of 2016, a comprehensive bill directed at improving access
to mental healthcare. AAPA supports this legislation because it
acknowledges the role of primary care providers in assisting patients
with mental illnesses, aims to increase coordination of care for
patients needing primary and mental health care, and includes PAs in
psychiatry among the specialty providers listed in the bill.
Additionally, the Health Resources and Services Administration (HRSA)
recently acknowledged the role of PAs in mental healthcare and
addiction medicine in its FY17 budget request by including them in the
definition of ``behavioral health workforce.'' AAPA is pleased by this
recognition, and we support HRSA's efforts to further integrate primary
care providers like PAs into mental healthcare by encouraging the use
of screenings, referrals, and telemedicine to connect patients with
mental health specialists when appropriate, all of which have been
shown to improve patient outcomes and mitigate gaps in coverage caused
by too few providers.
AAPA Legislative Recommendations
As the Committee works on solutions to the mental healthcare access
problem, AAPA hopes you will consider the following recommendations:
(1) Affirmatively including PAs in mental healthcare legislation
as members of the healthcare team. This inclusion is important for all
types of healthcare legislation, but it is especially important in
mental healthcare given the critical level of provider shortages in
this field. Moreover, as the Committee works on continuing to integrate
primary care into mental healthcare, PAs should continue to be counted
among primary care providers who may assist their patients in receiving
mental healthcare when it is appropriate.
(2) Including ``PAs in psychiatry'' as mental healthcare
providers. Mental health legislation has historically included a number
of specified mental healthcare providers, but left out PAs who
specialize in psychiatry. There is a growing number of PAs who receive
additional education to specialize in this field, and they work in
behavioral healthcare centers and other high-need facilities. These PAs
should be included in any definition of mental healthcare provider as a
result of their qualifications and experience. S. 2680, the Mental
Health Reform Act, is an example of how PAs can be included as part of
the solution to mental healthcare provider shortages.
AAPA looks forward to working with the Committee as you move forward on
these important issues. Please do not hesitate to have your staff
contact Sandy Harding, AAPA Senior Director of Federal Advocacy, at
571-319-4338 or [email protected] should you have any questions.
______
American Association for Geriatric Psychiatry (AAGP)
The American Association for Geriatric Psychiatry (AAGP) appreciates
this opportunity to comment on the status of Mental Health in America.
AAGP is a professional membership organization dedicated to promoting
the mental health and well being of older Americans and improving the
care of those with late-life mental disorders. AAGP's membership
consists of geriatric psychiatrists as well as other health
professionals who focus on the mental health problems faced by aging
adults. Thus AAGP brings a unique perspective to the consideration of
unmet mental health needs that plague our public healthcare services.
We would like to take this opportunity to highlight the geriatric
mental health workforce crisis that has crossed our nation's doorstep.
The 2012 Institute of Medicine (IOM) report ``The Mental Health and
Substance Use Workforce for Older Adults: In Whose Hands?'' clearly
highlights that our current and future capacity to manage the complex
medical needs of older adults with mental health or substance use
conditions is grossly insufficient.
The aging of the baby boomer generation will result in an increase in
the proportion of persons over 65 from 12.7 percent currently, to 20
percent in 2030, with the fastest growing segment of the population
consisting of people age 85 and older. During the same period, the
number of older adults with major psychiatric illnesses will more than
double, from an estimated 7 million to 15 million individuals, meeting
or exceeding the number of consumers in discrete, younger age groups.
In addition, 8 million Americans are estimated to have Alzheimer's
disease by 2030, nearly all of who will have neuropsychiatric or
behavioral symptoms that will require expertise in geriatric mental
health from all clinical disciplines.
Virtually all health care providers need to be fully prepared to manage
the common medical and mental health problems of old age. In addition,
the number of geriatric health specialists, including mental health
providers, needs to be increased to provide evidence-based care for
those older adults with the most complex issues and to support and
train the rest of the workforce as partners in collaborative care.
Unfortunately, workforce estimates for geriatric mental health do not
look promising. By 2030, it is estimated there will be only 1,500
geriatric psychiatrists across the country, compared to the 4,000 to
5,000 needed based on estimates from the National Institute on Aging.
Current rates of training geriatricians (175 fellows per year) lag far
behind what is needed (1,200 fellows per year) to reach the goal of
having 30,000 trained and providing care to our elders in 2030.
Geriatric training is also rare among other common members of the
geriatric mental health care team. For example, only 1% of Nurses,
Pharmacists and Physician Assistants; 2.6% of Advanced Practice
Nurses; and 4% of Social Workers have geriatric certification. Only 3%
of Psychologists work primarily in elder care.
The 2012 IOM report recommended Congress appropriate funds that
authorize training, scholarship, and loan forgiveness for individuals
who work with or are preparing to work with older adults who have
mental health or substance use conditions. We strongly encourage the
Committee to ensure funding opportunities prioritize mental health
training that focuses on the needs of vulnerable groups across the life
span, including older adults.
Supporting training for geriatric mental health will improve access to
evidence-based, high quality health care for our elders and will ensure
recruitment and retention of top professionals into geriatric mental
health practice. The well-being and dignity of our elders requires
action now to ensure the workforce is prepared.
Submitted by:
Christopher Wood
Executive Director
American Association for Geriatric Psychiatry
6728 Old Mclean Village Drive
Mclean, VA 22101
(703) 556-9222
______
Statement Submitted by John Boronow, M.D.
I am a practicing psychiatrist who has lived in Maryland for 35 years.
I specialize in the treatment of schizophrenia and other ``severe and
persistent'' mental disorders. I worked at Sheppard Pratt back in the
days of the IMD exclusion, when there were no Medicaid adults. Later
came the waiver, and since then, the State of Maryland has supported
Medicaid patients until last autumn. I have treated Medicaid inpatients
for nearly 20 years, in addition to the Medicaid outpatients I have
always treated since opening my practice. I also am an Associate
Clinical Professor of Psychiatry at the University of Maryland and
teach residents and medical students daily about public policy toward
this patient population.
The IMD exclusion is simply another example of an historical
anachronism that has lingered on well beyond its original intended life
span. It was created in an era before deinstitutionalization, when
asylums and private hospitals ran a parallel existence and when there
were virtually no psychiatric inpatient units in general medical
hospitals. Medicaid was invented right alongside the Community Mental
Health Act in the mid 1960s to transform the delivery of behavioral
healthcare. The intent of the IMD exclusion was to prevent state
hospitals from gobbling up new Federal dollars to maintain an otherwise
dying model of care, and to prevent rich private hospitals from
accessing funds for institutions that frankly did not need them.
When Sheppard Pratt first treated our Medicaid adults in the late
1990s, we had already started to build a continuum of care including
day hospitals, crisis residential care, and residential rehabilitation
programs in suburban apartment complexes. For us, access to Medicaid
enabled us to treat thousands of severely and persistently ill mental
patients who were in Maryland emergency rooms. What we brought to the
table was expertise: a small 20 bed general psychiatric unit has to
treat all comers, and it is impossible to be expert at all things. But
a large IMD with great depth is able to do more than just do crisis
intervention, and can actually successfully treat complex cases which
would otherwise be overwhelming to small programs.
It is time to end the IMD exclusion. Deinstitutionalization is done,
and it was done so poorly that in fact we have transinstitutionialized
patients from state hospitals to the criminal justice system. We need
now to finish the work: to deinstitutionalize the laws (which limit
commitment to bricks and mortar facilities instead of to a system of
care in the community) and to update the funding rules like the IMD
exclusion, which exclude patients from centers of excellence that can
actually solve difficult clinical challenges instead of just kicking
them down the road in the endless cycle of ``revolving door''
hospitalizations. IMDs are now part of the solution, they have changed
with the times, and the funding should now finally follow suit.
______
Statement Submitted by Evelyn Burton
Thank you for allowing this opportunity for public input on how the
Finance Committee can improve the Mental Health System.
Limited Medicaid funds need to be targeted more to treatment of those
with Serious Mental Illness who are at high risk for homelessness,
incarceration, victimization, and suicides. This will save both lives
and money.
I urge the repeal of the discriminatory Medicaid Institutions for
Mental Diseases (IMD) exclusion which denies medically necessary
appropriate psychiatric hospital care to adults with severe mental
illness. For no other conditions are Medicaid services excluded in
certain medical institutions.
If you decide to limit the number of days authorized in an IMD, I urge
you to allow at least 30 consecutive days, regardless to the month. The
proposed rule of allowing 15 days per month in an IMD is unworkable
from a medical prospective. If the intent is to allow 30 days to a
patient who enters an IMD on the 15th of the month, why should others
who require a 30 day stay and enter an IMD on the first of the month be
kicked out after 15 days? Will patients be encouraged to wait in the ER
until the 15th of the month or told by their doctor to wait 15 days and
increase the risk of criminalization, or suicide? Will the IMD try to
discharge them to a general hospital for one day and then readmit them?
This type of rule encourages high risk game playing with the lives of
the seriously mentally ill.
The IMD exclusion policy of Medicaid is a barrier to hospital treatment
and stabilization, and also reduces the incentive for expansion of
hospital beds.
I have personally seen individuals, with schizophrenia and bipolar
disorder, in many families, that cycle continually between Community
Hospital, homelessness, and jail, because they are never adequately
stabilized in the very short hospitalizations provided by most general
hospitals, Those lucky enough to have private insurance that pays for a
longer stay in an IMD have been better stabilized and are less likely
to be quickly rehospitalized or incarcerated.
I even know of one family that withdrew their family member from
Medicaid so that they could pay privately for a 6 week stay at an IMD,
to achieve stabilization and stop the frequent hospitalizations. It was
very successful. That individual has not been hospitalized now for over
10 years, thus saving Medicaid millions of dollars. Those on Medicaid
should have the same opportunity for stabilization.
The IMD exclusion is a disincentive for expansion of critically needed
hospital beds and has contributed to a shortage of hospital beds
nationwide. This results in Emergency Room boarding and driving vast
numbers of those with serious mental illness into the criminal justice
system. In Maryland over 90% of the state hospital beds are now taken
by forensic patients, and there is no availability for non-forensic
patients. Also those in my County jail may wait for weeks for a
hospital bed, denying their right to proper medical treatment.
The IMD Waiver Demonstration Program for hospitals has shown reduced
costs with the use of IMDs. It is past time to act on those results,
stop discrimination against those with serious mental illness, and save
lives.
The IMD exclusion for outpatient residential services is also highly
detrimental for those with serious mental illness and needs to be
repealed entirely or at a bare minimum, allow for much larger
facilities than 16 beds. Some with serious mental illness do NOT
recover to the point of being able to live independently or with part
time supervision. However they can live in the community with intensive
supervision and this is much less costly and more humane than frequent
hospitalizations or incarcerations. Allowing Medicaid payment for
outpatient residential treatment in facilities over 16 beds would allow
for the economic expansion of critically needed residential treatment
beds. Larger facilities do not mean that the residents would be
``institutionalized.'' Just like those living in Senior Communities, or
Assisted Living Facilities, those in a residential outpatient treatment
program can be engaged in community activities.
I also urge repeal of the discriminatory Medicare lifetime limit on
psychiatric hospital days. There is no lifetime hospital limit for any
other illness. It denies critical treatment to the most vulnerable of
our elderly population and contributes to the very high suicide rate in
the elderly.
Thank you for your consideration.
Sincerely,
Evelyn Burton, consumer and family advocate.
______
Clinical Social Work Association (CSWA)
P.O. Box 10 Garrisonville, Virginia 22463
(Office) 703-522-3866 (Fax) 703-522-9441
www.clinicalsocialworkassociation.org
The Clinical Social Work Association (CSWA) would like to thank you
for the opportunity to comment on this hearing. CSWA serves as the
Voice of Clinical Social Work, representing the 240,000 licensed
clinical social workers in the country, the largest single group of
independent mental health clinicians.
It is well documented that untreated or undertreated behavioral
health problems tend to become more severe, and often exacerbate other
medical conditions as well. That coverage for mental health conditions
continues to be less broad than what is offered for medical conditions
turns logic on its head, ultimately increasing overall health care
costs.
When the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 (MHPAEA) passed, licensed clinical social
workers and their patients were hopeful that the ways in which mental
health disorders were undertreated and under covered by insurers would
be resolved. Sadly, what we have seen instead are numerous coverage
restrictions on mental health treatment, imposed by insurers by means
of limits on ``acceptable'' diagnoses and/or treatment methods,
frequency of sessions, length of treatment, and patient access to out
of-network clinicians.
The lack of precise definitions for parity standards has been a
major failure of MHPAEA. This problem can be seen clearly in area of
``non-quantitative'' treatment limitations, where insurers restrict
treatment authorization on the basis of ``treatment progress'' when in
fact there is no absolute way to determine treatment progress except
when the patient has fewer hospitalizations, when the patient and
clinician agree the patient has less emotional suffering, has more
significant and continuing impact on improved mental health (Levy, et
al., ``The Efficacy of Psychotherapy,'' Psychodynamic Psychiatry, 42(3)
377-422, 2014). Additionally, the cross-discipline surveys done by
Consumer Reports (1995, 2004 and 2008) show that psychotherapy provided
by psychologists and licensed clinical social workers have widely
positive results in treating depression, anxiety, trauma-based
disorders, and even psychotic disorders.
Where in-patient mental health treatment is concerned, we
understand that budgetary consequences must be addressed--and decisions
based--on a realistic assessment of the costs of providing adequate
mental health and physical health care. However, we would be remiss if
we failed to point out two glaring gaps in mental health treatment for
chronic and severe conditions:
The limitation to 190 days of inpatient treatment for
psychiatric reasons. There is no such limitation on medical conditions,
and clearly this violates MHPAEA.
The lack of any coverage for Medicaid beneficiaries who need
inpatient mental health care in what are called Institutes for Mental
Disease. The IMD restrictions are unfair, and cause harm to those who
need inpatient care for mental health conditions.
We ask that the Task Force add these two coverage gaps--limitations
which have a devastating effect on individuals coping with chronic
mental health conditions (as well as their families and communities)--
to the range of issues under consideration.
On a more general level, CSWA would like to note the following
concerns:
As clinicians, we have long been aware of the inadequate
coverage of chronic mental health conditions on the inpatient and
outpatient level. We are concerned, as well, that the critically
important integration of medical/surgical care and mental health/
substance use care continues to be elusive.
Another area of CSWA concern is the general lack of attention to
diversity that we believe has been a major factor in the successful
delivery of health care and mental health treatment. Cultural
competence is not just basic to our clinical social work approach to
treatment, but fundamental to any health or mental health treatment.
Understanding of the patient's ethnicity, gender, sexual orientation,
economic levels, race, age, religion, and other areas of personal
identity is essential.
Finally, Accountable Care Organizations, with their goal of
creating delivery systems that would share profit and loss with
providers, have great potential for controlling overall healthcare
costs in America. However, mental health treatment is, at present,
seriously underfunded, and we fear that ACOs will not be viable as
health care delivery systems for treatment of chronic mental health
conditions without a significant increase in funding. The fiscal
targets that are to be met must be realistic or this form of funding
mental health treatment is likely to fail.
There is no question that mental health treatment is cost effective
in the long run, often preventing other health problems and/or more
severe mental health problems. We applaud the work of the Task Force in
reviewing the range of issues hindering parity in mental health and
substance use treatment, and look forward to your final report.
Thank you for the opportunity to make these comments.
Contacts:
Susanna Ward, LCSW, Ph.D., CSWA President and CEO
[email protected]
Laura Groshong, LICSW, CSWA Director, Policy and Practice
[email protected]
Margot Aronson, LICSW, CSWA Deputy Director, Policy and Practice
[email protected]
______
Healing Minds NOLA
2206 Soniat St.
New Orleans, LA 70115
[email protected]
(504) 274-6091
Statement Submitted for the Record by Janet Hays
Dear Chairman Hatch and respected members of the committee,
I am the wife of someone with a serious mental illness (SMI) as well as
an advocate for alternatives to incarceration, homelessness and death
for mentally ill people in my community.
As the director of Healing Minds NOLA, an organization I began last
year, I hear from many residents who struggle with the broken mental
healthcare system. The most tragic stories always involve the inability
of the caregiver to ensure that their loved ones with serious mental
illness are getting--and taking--medications necessary to manage their
illness. Funding should be directed to evidence-based programs and
services that provide support to that group of people.
Assisted Outpatient Treatment (AOT) is legal in almost every
State in the nation and avoids hospitalization. It's a compassionate
and creative approach to getting care to more difficult cases where a
person's disease has become more powerful than the person. AOT ensures
that a person follows their treatment plan in order that they can make
competent decisions for themselves. When a person is medication
compliant, it reduces conflicts that can escalate in families and
communities and helps to prevent incarceration for unacceptable
behavior. By keeping sick people out of corrections institutions, they
preserve their civil rights and right to self-determination and stay
out of the downward spiral that leads to further deterioration and
further costs to society. AOT should be funded and scaled up.
More inpatient beds are needed so eliminate the IMD Exclusion.
The case of my friend Eleanor Chapman's daughter demonstrates this
need. Post-Katrina, New Orleans went from 128 to virtually zero long-
term inpatient public psychiatric beds after the State shuttered
Charity Hospital. Due to bed shortages--(and HIPAA rules)--Eleanor was
unable to get her daughter Chelsea Thornton the care and treatment she
needed after having her involuntarily committed at least three times.
Consequently, Chelsea--who had a long history of mental illness--took
the lives of her two children one evening in a tragic psychotic
episode. To this day, Chelsea remains at the newly named ``Orleans
Justice Center'' (it's a jail) while she awaits trial.
Loosening HIPAA restrictions would have a major impact on
helping a mentally ill person be medication compliant by permitting
caregivers to know about a patient's treatment plan. It would not
require funding outside of what it costs to educate healthcare
providers about legislative changes.
Group homes should also be part of the recovery equation.
Personality disorders and intellectual disabilities and/or
developmental disorders make it challenging to live independently. Some
need daily help. When done properly and with proper oversight, group
homes can provide loving and caring environments that many people
cannot find elsewhere.
Stop funding stigma and use savings to treat SMI. A 2011 survey
by the SAMHSA Center for Behavioral Health Statistics and Quality found
stigma (mentioned by 7% of respondents) was low on the list of why
people with mental illness do not receive care, far behind cost (50%).
Stigma also came behind could handle problem without treatment, did not
know where to go, lack of time, belief that treatment wouldn't help,
anosognosia (did not feel need for treatment), and lack of insurance as
the reason people don't get care.
In a survey of Californians who had difficulty getting care for
mental illness, three times as many (63%) said cost was a reason,
versus that they were afraid or embarrassed to ask for help (21%). A
recent study in Psychological Medicine, ``What is the impact of mental
health-related stigma on help-seeking'' found stigma was only the
fourth highest reason people didn't seek care.
A 2011 study, ``Barriers to Mental Health Treatment'' found
``low perceived need for treatment'' was the primary barrier to
treatment with everything else--including stigma--far behind.
http://www.centerforhealthjournalism.org/2014/10/17/new-study-
stigma-not-major-barrier-treatment-people-mental-illness
We need to deal with 3 demographics. The population of people at the
epicenter of the crisis meaning those who are warehoused in jails and
prisons, those who are near incarceration, homelessness or death and
those people at the earliest stages of disease. Right now, our funding
priorities are backward. While there are more robust services for
mental wellness issues, there is little for people with mental illness.
We are now feeling the impacts of our neglect. Families know that if
they can keep their loved ones medication compliant, mental wellness
will follow but it doesn't work the other way around.
______
Letter Submitted by Nancy Jones
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Hello!
I write this as a parent, married 55 years. We were thrown into the
mental illness system, not by choice but for love and concern for our
seriously mentally ill son, now 48. My husband and I feel like we
failed or rather the broken mental illness non-care snake pit has
deserted us and most horribly our son and heartbroken two sons he has
been unable to care for.
In every instance of this painful journey of ours he has slipped
through the cracks from every entity out there that our taxes pay for
to bring needed medical care, hospitalization, and after-care for this
lifelong brain disease.
The saddest part of this nightmare is this could be a workable solution
to rendering the proper care and yet I blame the behavior health system
at hand for putting our son out homeless, hospitals and those in the
field of psychiatric care for outright malpractice for not treating our
son psychotic, delusional. Screaming at voices only he hears, so
pathetically unable to make decisions for himself or care for his
personal hygiene. He was immediately told he had rights to refuse
medical care, labeled a consumer, not a sick patient and when after all
loss of insight to his illness he was thrown to the streets.
As parents we were kept from helping him receive medical care. I was
told on many occasions by professionals that, ``he has a right to be
crazy if he chooses.'' This HIPAA law keeps family from being involved
being scolded that he isn't bad enough yet, he needs to be an imminent
danger to self/others to hospitalize. Police told me since after his
ranting and raving at imaginary Satan, for days, since he hadn't
injured either of us, they couldn't take him to a hospital. They left
two disabled senior parents to deal with him. I told them I'd let them
know when he tries to kill one of us believing we were the devil.
He has been incarcerated, without meds or psychiatric care, now in a
jail program some 2,000 miles from our home. The state psychiatric
hospital here in Illinois that would have treated him without Medicaid
while waiting the 2 years for SSI was closed by our state to save
money. Saving money, no way, loosing a productive life and sky high
taxes going into the legal, courts, jails and prison system. Treating
these very ill human beings is far more cost effective. Instead of
closing hospitals for the streets, we need more hospital beds with
trained medical personnel in the psychiatric field, not jail cells.
Our son doesn't have a behavior problem, he suffers a brain disease; he
should be put into an AOT program, ordered by a judge, not dropped from
a useless program because he didn't follow rules he signed in a
contract. Many uninformed preach, it's all about stigma. They're wrong,
it's all about non-treatment.
Treatment before tragedy is what we need, not yoga and art classes that
are wonderful for relaxation and enjoyment but do nothing in the needed
medical care for the sickest of the sick in this country right now.
Parents need to be able to take part in their adult child's commitment
and care, not even notified their loved one is in a psychiatric
hospital until after being released after the 72 hour hold and being
homeless because they have rights.
As our son is so ill he has a human right to medical care to be a
productive person again, hopefully. What some in power to make changes
in this broken system of ours don't realize is that some don't get
well, some untreated don't even live.
We need a workable bill to help families in mental illness crisis, not
a watered down one like those representing their own personal interests
here to keep their federal and state jobs are pushing for. They
callously don't want to believe our son has a medical disease and has a
right to treatment. H.R. 2646 offers all this to bring on reform.
Thank you for the opportunity,
Nancy J. Jones.
______
Statement Submitted by Marilyn Martin
1. There are three Federal laws that need to change, the first two
within your purview: (1) the IMD exclusion, which excludes Medicaid
patients from psychiatric facilities that have more than 16 beds, such
as Sheppard Pratt in Maryland. (2) The lifetime Medicare
hospitalization limit is discriminatory. There are no other limitations
on physical illnesses. My son's schizophrenia is a neurobiological
disease. (3) HIPAA laws that prevent caretaker families like mine from
knowing basic information that would be helpful in keeping our loved
ones in care. For example, I should have been notified that my son had
just fired his clinic provider a couple of weeks prior to his recent
assault on my husband. Since I had no HIPAA release (because my son had
lost insight to his illness), I was not notified. I later learned that
he had even run out of the pills that were no longer working, but they
did help him sleep. Lack of sleep is a trigger for psychosis.
2. Professional Shortages: We need more neuro-psychiatrists, and we
need for them to be better compensated--because treated SMI
(neurological brain diseases) can be extremely challenging, and often
dangerous. We also need more incentives for clinical licensed social
workers to treat the SMI rather than the ``worried well.'' My son was
able to find one therapist at his clinic who was effective for a few
months before she left the clinic to return to school. She was the only
therapist he was willing to see during the entire 8 years since his
first psychosis. These community clinics have high turnover and
difficulty in attracting highly qualified professional staff.
3. Beds. Maryland needs more beds for psychiatric disorders. This is
especially crucial for patients such as my son, who has had to wait for
a bed on several occasions.
4. Many disorders and diseases currently referred to as mental
illnesses are actually neurological disorders, according to NIH. My 32-
year-old son has schizophrenia. Although I believe that early treatment
provides better outcomes, I do not believe that the word,
``prevention'' has meaning for the families of those with serious
neurological brain diseases. (I believe in higher funding for brain
research would help with that.)
5. My son was recently placed on a new injectable antipsychotic that I
believe is effective. His SSDI and SSI payments are so low that he
would not be able to afford any increase in paying for them should
Medicare reduce reimbursement. He does not need another excuse for
opting out of his monthly injections. He's already done that in the
past. To save money, perhaps injectables could be administered by a
nurse rather than a doctor?
6. Limited funds need to be focused on the more serious brain
illnesses. One reason treatment is expensive is that many of our state-
level ``behavioral health'' treatment laws actually promote disability.
For example, my son recently spiraled into a serious psychosis after
decompensating on a medication that had stopped working--he had
developed a tolerance to it. Every time a person relapses like this,
the likelihood of his returning to his previous level of functioning is
lowered because he's lost grey matter. Many states, such as mine, will
only allow us to get our loved ones who lack insight back into
appropriate treatment when they become ``dangerous.'' States should be
rewarded for having more reasonable commitment standards. Hence, we had
to wait until my son became psychotic and assaulted my spouse. He is
now awaiting trial. States should be rewarded for having an Assisted
Outpatient Treatment statute. This way, those few with a history of
decompensating repeatedly could be kept out of the criminal justice
system before it is too late. If my son is fortunate enough to receive
long-term in-patient care rather than jail time, he should be able to
be stabilized enough to learn how to manage his chronic illness,
thereby staying appropriately medicated. An additional problem is that
my state's ``disabilities law center'' emphasizes getting out of the
hospital within 72 hours rather than focusing on keeping these patients
in treatment. Promoting very short stays places limits on stabilizating
on new medications. This is counterproductive for a patient with a
serious illness like schizophrenia, who would need at least 2-3 weeks
to stabilize on a new antipsychotic medication. My son has had at least
16 hospitalizations within the past 8 years, all very short. Mr. Cornyn
seems to have some understanding of the issues we have with
noncompliance. Thank you, Mr. Cornyn.
Thank you for your interest in mental health for which we have a good
system. I had no trouble finding good trauma therapy for PTSD after my
son's recent assault. However, for serious mental illness (brain
disorders) there is no reliable system, and family care givers are worn
out, stressed out, often fearful, and left out from useful information
from providers due to HIPAA. Please take action soon to help us save
lives, keep our loved ones out of prisons, or trying to survive as
homeless.
______
Mental Illness Policy Org.
Unbiased Information for Policymakers + Media
50 East 129 Street, PH7, New York, NY 10035
[email protected] http://mentalillnesspolicy.org
We thank Senator Hatch for his opening statement which identified the
single most important core issue:
As we talk about solutions, we need to note that the
distinction between mental health, mental illness, and severe
mental illness is crucial, because each group requires
different clinical and policy prescriptions. For example, the
current system, proportionally speaking, provides far more
support for mental health than severe mental illness. We need
to review these priorities and find an equitable solution to
ensure that all needs are being met.
One-hundred percent of Americans can have their mental health improved.
Twenty percent have a mental health diagnosis. These are often mild and
remit on own. But only 4% have a serious mental illness like those
suffered by the brother of Senator Wyden (schizophrenia) and father of
Senator Stabenow (bipolar disorder).\1\ Those serious mental illnesses
are not preventable or identifiable before the symptoms become manifest
which is usually in late teens and twenties. So elementary school age
interventions are not likely to bend the curve.
---------------------------------------------------------------------------
\1\ Substance Abuse and Mental Health Services Administration
(SAMHSA). ``NSDUH 2013 Report: Substance Use and Mental Health
Estimates from the 2013 National Survey on Drug Use and Health:
Overview of Findings.'' Rockville, MD, September 2014. Available at
http://store.samhsa.gov/shin/content/NSDUH14-0904/NSDUH14-0904.pdf.
It is seriously mentally ill adults, not children or the worried-well
who are most likely to become homeless, arrested, incarcerated,
suicidal, and dangerous to themselves or others. Congress should reject
pressure to move funds to younger groups, groups without mental
illness, and programs that promise ``prevention.'' Congress should keep
its eye on getting treatment to adults known to have serious mental
illness. Congress has tended to balkanize funding. It funds programs
for children, seniors, veterans, pregnant women, LGBT, high school
students, college students, African Americans, Native Americans,
immigrants and other special sub-populations. The mental health
industry has convinced funders that bad grades, single parent
households, unhappy marriages, underemployment, unemployment, sexual
confusion, criminal involvement, and other issues are ``risk-factors''
and diverted funding for them. For example, there are 5,500 suicides of
individuals under age 24 and Congress allocates $55 million to
preventing those. But there are 37,500 suicides in those over 24 and
Congress only allocates $2 million to them.\2\ Under pressure from the
mental health industry, Congress is spending where suicide is not,
rather than where it is. Creating these multiple priority populations,
leaves less for the elephant in the room: getting treatment to adults
known to have serious mental illness, what should be the core
population. But there are rarely programs targeted to them.
---------------------------------------------------------------------------
\2\ Testimony of SAMHSA Acting Director Kana Enomoto at House
Appropriation Hearing: Substance Abuse and Mental Health Services
Administration Budget, March 2, 2016. Available at https://
www.youtube.com/watch?v=Mke5HKRusMI.
Congress should ensure that both existing funds and incremental funds
are spent on interventions that meet these three criteria: have
independent evidence; improve a meaningful outcome like reducing
homelessness, arrest, incarceration, homelessness and hospitalization;
and reduce violence in people with serious mental illness.
Programs to eliminate
Virtually none of the programs funded by SAMHSA meet those three
criteria. We have documented SAMHSA's failure at http://
mentalillnesspolicy.org/samhsa.html. SAMHSA funds antipsychiatry and
pseudo-science. It declares non-evidence based practices to be evidence
based, encourages states to use mental health block grant funds
Congress appropriated for mental illness on people without mental
illness, refuses to focus on the seriously ill, refuses to focus on
improving meaningful outcomes, and wastes money. There is little
support for SAMHSA other than from those who receive funds from it.
Their own employees rated is the 319th worst federal agency and its
former top doc just wrote an op-ed explaining that she left SAMHSA
largely for the reasons I just explained. Congress should take funds
that go to CMHS unit of SAMHSA that don't help the seriously ill move
them to programs that do help. Any CMHS programs that are worthy of
continuing can be moved to NIMH, IOM, CDC, DOJ and other entities that
will use them more appropriately.
PAIMI. PAIMI has moved off its original purpose of preventing abuse of
the institutionalized mentally ill to preventing treatment of the
seriously ill. There is not a mental health director who has tried to
improve services for the seriously ill who has not found a PAIMI
advocate on the other side. PAIMI responsibilities can be moved to the
CRIPA unit within DOJ which is largely duplicative.
Programs to support
Programs that have independent evidence they improve a meaningful
outcome in people with serious mental illness and should be expanded
include:
Assisted Outpatient Treatment (AOT). We no longer have to make a
binary choice between the total removal of rights via incarceration and
involuntary commitment and unfettered freedom in the community. By
allowing judges to order a small group of the most seriously ill who
already have a history of violence, incarceration, or homelessness to
accept mandated and monitored treatment in the community, it reduces
homelessness, arrest, incarceration and violence in the 70% range. This
is all the more outstanding because AOT is only for the most seriously
ill who have not been helped by voluntary services. By replacing
expensive inpatient hospitalization and incarceration with less
expensive outpatient treatment, it cuts the cost to taxpayers in half.
A fact sheet is enclosed.
Access to hospitals. Eliminate the IMO Exclusion. As a result of the
IMO Exclusion, states lock the front door and open the back causing
incarceration of the seriously ill. There are 10 times as many mentally
ill incarcerated. Because IMO amelioration can be expensive (because
CBO does not score offsetting savings) we suggest starting with
providing IMD relief to non-forensic state hospital beds. There are
very few of those left, so the cost would not be excessive. Congress
could also raise the number of beds from 16 to say, 24 which would
allow IMO funds to go to the seriously ill without dramatically
increasing costs. Another approach would be to allow IMO relief for X
number of hospital days. CMMI issued regs that allow 15 days of
hospital care per month, but that only affects capitated patients.
Congress should mandate it for non-capitated ACA enrollees. A
Washington Post op-ed is enclosed.
Group Homes. Some of the most seriously mentally ill do not do well
in the independent supported housing currently being promoted. They are
now well enough to manage a household and drive-by case management is
not enough. They need on-site 24/7 support of the kind that can be
found in group homes.
Clubhouse Model programs. Congress should establish (or direct CMMI
to establish) a bundled Medicaid rate for clubhouse programs.
Clubhouses, like New York's Fountain House, are unique in that they
serve the most seriously ill. However, the unique model, whereby
several patients can be served at once does not neatly fit the Medicaid
model.
Finally, we urge Congress to give those of us who provide housing and
case management services to seriously mentally ill out of love, the
same access to information paid providers receive. HIPAA and FERPA
prevent the families of people from seriously ill from knowing the
diagnosis, treatment, medications and pending appointments. We are
therefore powerless to see prescriptions are filled and appointments
kept.
As Michael Biasotti, former President of the NYS Chiefs of Police told
a House Energy and Commerce Committee, ``We have two mental health
systems. The traditional mental health system helps those well enough
to volunteer for services. Those who are not well enough to volunteer
are turned over to criminal justice. The mental health system seems
unwilling to accept responsibility for this more symptomatic group.''
The main task of the Finance Committee should be to reorient services
back to the seriously ill. Thank you. Attached are fact sheets on some
of these issues.
Sincerely,
D.J. Jaffe
Executive Director
How the Federal Government Can Help the Most Seriously Mentally Ill
Focus on the 4% with serious mental illness,
not just the 18% with poor mental health.
Background: Some of the most seriously mentally ill (SMI), unlike
people with less severe ``mental health issues'' hallucinate, are
delusional, psychotic, and can't think straight (cognitive impairment).
Some need periodic hospital care, a small group will never recover, and
some as a result of cognitive impairments and anosognosia, are
unwilling or unable to stay in treatment even when available and
offered to them. Most mentally ill are not violent, but when the
seriously mentally ill go untreated, they are at higher risk of
violence.
Pretending these issues don't exist is causing massive homelessness and
incarceration of the seriously ill. Federal legislation tends to focus
on higher functioning, and/or less important issues. Following are
specific policies that would help persons with the most serious mental
illnesses. Prepared by Mental Illness Policy Org. http://
mentalillnesspolicy.org, May 14, 2015.
------------------------------------------------------------------------
Which seriously mentally ill
Policy does it help? How it helps
------------------------------------------------------------------------
Fund Assisted AOT helps a very small but Extensive replicated
Outpatient important group of the most research shows AOT
Treatment seriously ill who because of helps SMI stay in
inability or unwillingness to existing community
stay in treatment already treatment and avoid
accumulated multiple incidents expensive and rights-
of homelessness, arrest, depriving inpatient
violence, incarceration, or commitment and
hospitalization after being incarceration.
offered voluntary services 74% fewer
that were made available to participants
them. This small group, experienced
because of their known homelessness
history, is the most likely to 77% fewer
again become hospitalized, experienced
homeless, arrested, psychiatric
incarcerated and possibly hospitalization
violent. Note: AOT is not an 83% fewer
alternative to community experienced arrest
services. AOT is a way to help 87% fewer
the seriously ill access experienced
community services. http:// incarceration
mentalillnesspolicy.org/ 81% said AOT helped
national-studies/ao tworks.pdf them get and stay
well
Reduces
hospitalization/
incarceration costs
50%.
------------------------------------------------------------------------
Repeal IMO repeal would help a small Hospitals reduce
Institutes for group of the most seriously incarceration
Mental mentally ill who even if there America's mentally ill
Disease (IMD) were perfect community held in--
Reform services cannot survive safely Prison 2001: 600,000
in the community because Mental Hospitals
medications and other 2001: less than
treatments do not work for 50,000
them or they require the much
more intensive support than
the higher functioning. The
IMO Exclusion prevents
reimbursement for this care
and is federally sanctioned
discrimination against the
seriously ill. It affects no
other group and should be
eliminated. http://
mentalillnesspolicy.org/imd/
imd-nasmhpd. html
------------------------------------------------------------------------
Remove ``HIPAA HIPAA reform would help By giving Moms and
Handcuffs'' seriously mentally ill who Dads who provide care
have families willing to out of love the same
provide housing, case information that paid
management, and financial providers receive
support to them. But HIPAA parents can prevent
prevents families from being their relatives from
told the diagnosis, what becoming too
medications and rehabilitation psychotic to keep at
is needed, and therefore home and from
cannot see prescriptions are becoming a government
filled and transportation responsibility.
arranged. (http://
mentalillnesspolicy.org/
national-studies/
HIPAA_handcuffs.pdf )
------------------------------------------------------------------------
Eliminate or SAMHSA elimination would help SAMHSA elimination
Reform SAMHSA the most seriously ill who would free states of
need help based on the the SAMHSA-instituted
scientific ``medical model'' obligation to use
rather than the SAMHSA- Mental Health Block
invented ``recovery model'' Grants for people
which requires patients to without mental
self-direct their own care, illness and curtail
something some of the most SAMHSA funded
seriously ill cannot do. consumer trade
(http:// association from
mentalillnesspolicy.org/ lobbying against
samhsa. html) hospitals and other
treatments that help
the most seriously
ill. It would stop
SAMHSA funding
antipsychiatry, the
certification of
programs that do not
have independent
evidence, etc. This
would save taxpayers
money while helping
SM get care. The few
useful programs can
be transferred to
CDC, NIMH, IOM, etc.
------------------------------------------------------------------------
Require PAIMI Persons with serious mental PAIMI primarily
to focus on illness who have been focuses on
abuse and subjected to ``abuse or ``freeing'' the non-
neglect neglect.'' (http://mental seriously ill from
illnesspolicy.org/myths/ care, rather than
paimifails2011sam hsaevaluatio helping the seriously
n.html) ill access it. Threat
of suits prevents
states and hospitals
from helping the
seriously ill. Having
PAIMI focus on abuse
and neglect would
reduce both.
------------------------------------------------------------------------
______
[The Washington Post, December 30, 1999]
Federal Neglect of the Mentally Ill
By D.J. Jaffe and Mary T. Zdanowicz
The recently released Surgeon General's Report on Mental Health is the
equivalent of describing the maiden voyage of the Titanic without
mentioning the iceberg. While the report criticizes private insurance
companies for failing to provide ``parity'' in their coverage of mental
illnesses, it is totally silent on the failure to provide parity in
Medicaid, the federal government's insurance program.
For the most severely mentally ill, private insurance is essentially
meaningless. Because of their illnesses, most are indigent, and private
insurance is a luxury they cannot afford and are not in a position to
obtain through employment.
Many of these individuals do have insurance through Medicaid a federal
insurance program that covers their care, except for a single
exception--inpatient care in psychiatric hospitals. The federal
government's Institution for Mental Diseases (IMD) exclusion prohibits
Medicaid from reimbursing for most individuals who need care in a
psychiatric hospital. If you have a disease in your heart, liver or any
other organ and need treatment in a hospital, Medicaid contributes. But
if you have a disease in your brain and need care in a psychiatric
hospital, Medicaid does not.
As a result of this federally sanctioned discrimination, state
psychiatric hospitals are locking the front door and opening the back,
making it increasingly difficult for the most severely ill to get
inpatient treatment. They are discharging patients sicker and quicker
in a headlong dash to make them Medicaid eligible by ending their
inpatient residency.
There were about 470,000 individuals receiving inpatient psychiatric
care in state hospitals when the Medicaid program started in 1965,
compared with fewer than 60,000 today Hospital closures have actually
accelerated in recent years. Forty state hospitals shut their doors
between 1990 and 1997, nearly three times as many as during the entire
period from 1970 to 1990, and many more closings are planned.
Of the 3.5 million Americans with schizophrenia and manic-depression,
40 percent (1.4 million) are not being treated. Medicaid's denial of
coverage results in homelessness, incarceration, victimization and even
death for many people who are so ill they are unable to care for
themselves. By the Justice Department's own statistics, there are
currently about 283,800 mentally ill people locked up in the nation's
jails and prisons.
The Los Angeles County Jail and New York's Riker's Island are currently
the two largest ``treatment facilities'' for the mentally ill in the
country. Another 150,000 to 200,000 mentally ill are homeless, and 28
percent get at least some of their meals from garbage cans. More than
10 percent will die from suicide. Others will commit acts of violence
against family, friends, and total strangers.
Not only does federal discrimination hurt the mentally ill, it affects
the standard of living for everyone else, too. Many parks and public
libraries, once enjoyed by all, are now rendered nearly unusable to the
general community by the visions of lost, psychotic souls who need
inpatient care but are locked out by the discrimination embedded in
Medicaid law. Seemingly random acts of violence committed by
individuals with a history of mental illness are frequently reported on
the evening news. No amount of preaching by the Surgeon General against
``stigma'' will overcome the acts of a Russell Weston, a Ted Kaczynski
or an Andrew Goldstein, all persons with untreated schizophrenia.
The federal government must accept its share of criticism for a policy
that discriminates against individuals solely on a diagnosis of mental
illness. We must steer clear of the iceberg that sank our state
psychiatric hospital system and eliminate the Medicaid IMD exclusion.
D.J. Jaffe is Executive Director of Mental Illness Policy Org. Mary
Zdanowicz is (former) Executive Director of the Treatment Advocacy
Center.
______
All Studies Show Assisted Outpatient Treatment (AOT) Reduces
Homelessness
------------------------------------------------------------------------
AOT Study/Source Findings
------------------------------------------------------------------------
Substance Abuse and Mental Health- ``Although numerous AOT programs
Services Administration (SAMHSA) currently operate across the United
National Registry of Evidence States, it is clear that the
based Practices and Programs intervention is vastly
(NREPP) 2015. underutilized.''
------------------------------------------------------------------------
Agency for Healthcare Research and AOT ``programs improve adherence
Quality (AHRQ) U.S. Department of with outpatient treatment and have
Health and Human Services been shown to lead to significantly
Management Strategies To Reduce fewer emergency commitments,
Psychiatric Readmissions May hospital admissions, and hospital
2015. days as well as a reduction in
arrests and violent behavior.''
------------------------------------------------------------------------
Department of Justice ``Crime Assisted outpatient treatment is an
solutions: assisted outpatient effective crime prevention program.
treatment'' http://
www.crimesolutPions.gov/ 2012.
------------------------------------------------------------------------
Bruce Link, Matthew Epperson, ``For those who received AOT, the
Brian Perron, Dorothy Castille, odds of any arrest were 2.66 times
Lawrence Yang. ``Arrest outcomes greater (p<.01) and the odds of
associated with outpatient arrest for a violent offense 8.61
commitment in New York State.'' times greater (p<.05) before AOT
Psychiatric Services 62, no. 5 than they were in the period during
(2011): 504-508. and shortly after AOT. The group
never receiving AOT had nearly
double the odds (1.91, p<.05) of
arrest compared with the AOT group
in the period during and shortly
after assignment.''
------------------------------------------------------------------------
Allison Gilbert, Lorna Mower, ``The odds of arrest for
Richard Van Dorn, Jeffrey participants currently receiving
Swanson, Christine Wilder, Pamela AOT were nearly two-thirds lower
Clark Robbins, Karli Keator, (OR=.39, p<.01) than for
Henry Steadman, Marvin Swartz. individuals who had not yet
``Reductions in arrest under initiated AOT or signed a voluntary
assisted outpatient treatment in service agreement.''
New York,'' Psychiatric Services
61, no. 10 (2010): 996-999.
------------------------------------------------------------------------
Marvin Swartz, Christine Wilder, ``The likelihood of psychiatric
Jeffrey Swanson, Richard Van hospital admission was
Dorn, Pamela Clark Robbins, Henry significantly reduced by
Steadman, Lorna Moser, Allison approximately 25% during the
Gilbert, John Monahan. initial six-month court order . . .
``Assessing outcomes for and by over one-third during a
consumers in New York's assisted subsequent six-month renewal of the
outpatient treatment program.'' order. . . . Similar significant
Psychiatric Services 61, no. 10 reductions in days of
(2010): 976-981. hospitalization were evident during
initial court orders and subsequent
renewals. . . . Improvements were
also evident in receipt of
psychotropic medications and
intensive case management services.
Analysis of data from case manager
reports showed similar reductions
in hospital admissions and improved
engagement improved services.''
------------------------------------------------------------------------
Jo Phelan, Marilyn Sinkewicz, Kendra's Law has lowered risk of
Dorothy Castille, Steven Huz, violent behaviors, reduced thoughts
Bruce Link. ``Effectiveness and about suicide, and enhanced
outcomes of assisted outpatient capacity to function despite
treatment in New York State.'' problems with mental illness.
Psychiatric Services 61, no. 2 Patients given mandatory outpatient
(2010): 137-143. treatment--who were more violent to
begin with--were nevertheless four
times less likely than members of
the control group to perpetrate
serious violence after undergoing
treatment. Patients who underwent
mandatory treatment reported higher
social functioning and slightly
less stigma, rebutting claims that
mandatory outpatient care is a
threat to self-esteem.
------------------------------------------------------------------------
New York State Office of Mental Danger and violence reduced
Health, Kendra's Law: Final 55% fewer recipients engaged in
Report on the Status of Assisted suicide attempts or physical harm
Outpatient Treatment. Report to to self
Legislature, Albany: New York 47% fewer physically harmed others
State, 2005, 60. 46% fewer damaged or destroyed
property
43% fewer threatened physical harm
to others
Overall, the average decrease in
harmful behaviors was 44%
------------------------------------------------------------------------
Jeffrey Swanson, Richard Van Dorn, In New York City net costs declined
Marvin Swartz, Pamela Clark 50% in the first year after
Robbins, Henry Steadman, Thomas assisted outpatient treatment began
McGuire, John Monahan. ``The cost and an additional 13% in the second
of assisted outpatient treatment: year. In non-NYC counties, costs
can it save states money?'' declined 62% in the first year and
American Journal of Psychiatry an additional 27% in the second
170 (2013): 1423-1432 year. This was in spite of the fact
that psychotropic drug costs
increased during the first year
after initiation of assisted
outpatient treatment, by 40% and
44% in the city and five-county
samples, respectively. The
increased community-based mental
health costs were more than offset
by the reduction in inpatient and
incarceration costs. Cost declines
associated with assisted outpatient
treatment were about twice as large
as those for voluntary services.
------------------------------------------------------------------------
Marvin Swartz, Christine Wilder, ``We find that New York State's AOT
Jeffrey Swanson, Richard Van Program improves a range of
Dorn, Pamela Clark Robbins, Henry important outcomes for its
Steadman, Lorna Moser, Allison recipients, apparently without
Gilbert, John Monahan. feared negative consequences to
``Assessing outcomes for recipients.''
consumers in New York's assisted Racial neutrality: ``We find no
outpatient treatment program.'' evidence that the AOT Program is
Psychiatric Services 61, no. 10 disproportionately selecting
(2010): 976-981. African Americans for court orders,
Marvin Swartz, Jeffrey Swanson, nor is there evidence of a
Henry Steadman, Pamela Clark disproportionate effect on other
Robbins, John Monahan. ``New York minority populations. Our
State assisted outpatient interviews with key stakeholders
treatment program evaluation.'' across the state corroborate these
Duke University School of findings.''
Medicine, Durham, NC, 2009 AOT improves the likelihood that
providers will serve seriously
mentally ill: ``It is also
important to recognize that the AOT
order exerts a critical effect on
service providers stimulating their
efforts to prioritize care for AOT
recipients.''
AOT improves service engagement:
``After 12 months or more on AOT,
service engagement increased such
that AOT recipients were judged to
be more engaged than voluntary
patients. This suggests that after
12 months or more, when combined
with intensive services, AOT
increases service engagement
compared to voluntary treatment
alone.''
Consumers Approve: ``Despite being
under a court order to participate
in treatment, current AOT
recipients feel neither more
positive nor more negative about
their treatment experiences than
comparable individuals who are not
under AOT.''
------------------------------------------------------------------------
Michael Heggarty. ``The Nevada In Nevada County, CA, AOT (``Laura's
County Laura's Law experience.'' Law'') decreased the number of
Behavioral Health Department, Psychiatric Hospital Days 46.7%,
Nevada County, Nevada County, CA, the number of Incarceration Days
November 15. 2011 65.1%, the number of Homeless Days
61.9%, and the number of Emergency
Interventions 44.1%. Laura's Law
implementation saved $1.81-$.2.52
for every dollar spent, and
receiving services under Laura's
Law caused a ``reduction in actual
hospital costs of $213,300'' and a
``reduction in actual incarceration
costs of $75,6OO.''
------------------------------------------------------------------------
Marvin Southard. ``Assisted In Los Angeles, CA, the AOT pilot
Outpatient Treatment Program program reduced incarceration 78%,
Outcomes Report'' Department of hospitalization 86%,
Mental Health, Los Angeles hospitalization after discharge
County, Los Angeles, CA, February from the program 77%, and cut
24, 2011. taxpayer costs 40%.
------------------------------------------------------------------------
Virginia Hiday, and Teresa Scheid- In North Carolina, AOT reduced the
Cook. ``The North Carolina percentage of persons refusing
experience with outpatient medications to 30%, compared to 66%
commitment: a critical of patients not under AOT.
appraisal.'' International
Journal of Law and Psychiatry 10,
no. 3 (1987): 215-232.
------------------------------------------------------------------------
Mark Munetz, Thomas Grande, In Ohio, AOT increased attendance at
Jeffrey Kleist, Gregory Peterson. outpatient psychiatric appointments
``The effectiveness of outpatient from 5.7 to 13.0 per year. It
civil commitment.'' Psychiatric increased attendance at day
Services 47, no. 11 (1996) 1251- treatment sessions from 23 to 60
1253. per year. ``During the first 12
months of outpatient commitment,
patients experienced significant
reductions in visits to the
psychiatric emergency service,
hospital admissions, and lengths of
stay compared with the 12 months
before commitment.''
------------------------------------------------------------------------
Robert Van Putten, Jose Santiago, In Arizona, ``71% [of AOT patients]
Michael Berren ``Involuntary . . . voluntarily maintained
outpatient commitment in Arizona: treatment contacts six months after
a retrospective study.'' Hospital their orders expired'' compared
and Community Psychiatry 39, no. with ``almost no patients'' who
9 (1988): 953-958. were not court-ordered to
outpatient treatment.
------------------------------------------------------------------------
Barbara Rohland. ``The role of In Iowa ``it appears as though
outpatient commitment in the outpatient commitment promotes
management of persons with treatment compliance in about 80%
schizophrenia.'' Iowa Consortium of patients. . . . After commitment
for Mental Health Services, is terminated, about \3/4\ of that
Training andResearch, 1998. group remain in treatment on a
voluntary basis.''
------------------------------------------------------------------------
Treatment Advocacy Center. In New Jersey, Kim Veith, director
``Success of AOT in New Jersey of clinical services at Ocean
`Beyond Wildest Dreams.' '' Mental Health Services, noted the
Treatment Advocacy Center. AOT pilot program performed
September 2, 2014. ``beyond wildest dreams.'' AOT
reduced hospitalizations, shortened
inpatient stays, reduced crime and
incarceration, stabilized housing,
and reduced homelessness. Of
clients who were homeless, 20% are
now in supportive housing, 40% are
in boarding homes, and 20% are
living successfully with family
members.
------------------------------------------------------------------------
Virginia Hiday, Marvin Swartz, ``Subjects who were ordered to
Jeffrey Swanson, Randy Borum, H. outpatient commitment were less
Ryan Wagner. ``Impact of likely to be criminally victimized
outpatient commitment on than those who were released
victimization of people with without outpatient commitment.''
severe mental illness.'' American
Journal of Psychiatry 159, no. 8
(2002): 1403-1411.
------------------------------------------------------------------------
Jeffrey Swanson, Marvin Swartz, ``We found no evidence of racial
Richard Van Dorn, John Monahan, bias. Defining the target
Thomas McGuire, Henry Steadman, population as public-system clients
Pamela Clark Robbins. ``Racial with multiple hospitalizations, the
disparities in involuntary rate of application to white and
outpatient commitment: are they black clients approaches parity.''
real?'' Health Affairs 28, no. 3
(2009): 816-826.
------------------------------------------------------------------------
Some of the problems at the Substance Abuse and Mental Health
Services Administration (SAMHSA)
SUMMARY: Congress directed SAMHSA ``to target . . . mental health
services to the people most in need'' (Conference Committee May 19,
1992) (ADAMHA Reorganization Act 1992). Priority populations were
defined as adults with a serious mental illness and children with a
serious emotional disturbance (U.S. Congress n.d.). SAMHSA refuses to
focus on the most seriously ill and refuses to focus on the most
consequential issues like reducing violence, incarceration,
hospitalization, and homelessness.
In a 2015 survey of federal employees, SAMHSA was ranked 317th worst
government place to work out of 320 government agencies (Partnership
for Public Service 2015). Employees cited ineffective leadership as
biggest problem. A 2015 General Accountability Office audit found
SAMHSA fails to coordinate the nation's mental health policies, most of
its mental health programs don't serve the seriously ill, and most
programs that do serve the seriously ill go unevaluated (GAO 2015).
Former SAMHSA Administrator Pam Hyde told Congress on a scale of one to
ten, ``SAMHSA is a ten.''
SAMHSA's Strategic Plan ignores serious mental illness
SAMHSA's 2011-2014 strategic plan directed its mental health resources
toward ``creating a high-quality, self-directed, satisfying life
integrated in the community for all Americans'' (emphasis added)
(SAMHSA 2011). A top SAMHSA official told Time magazine: ``The
behavioral health of the entire population is a priority for SAMHSA''
(emphasis added) (Sanburn 2013). Of SAMHSA's six 2015-2018 ``strategic
initiatives'' only one mentions serious mental illness and that is
limited to preventing it. Serious mental illness cannot be prevented
(SAMHSA 2014).\3\
---------------------------------------------------------------------------
\3\ Of SAMHSA's eight 2011-2014 ``strategic initiatives,'' only one
involved getting treatment to adults with serious mental illness, and
that was limited to veterans (SAMHSA 2011).
---------------------------------------------------------------------------
SAMHSA replaced the scientific ``medical model'' with a SAMHSA-invented
``recovery model''
Instead of medical evidence, SAMHSA relies on popularity contests,
convening meetings of ``stakeholders'' and letting them vote on
priorities. SAMHSA stacks their meetings with high-functioning
consumers and mental ``health'' organizations and excludes police,
sheriffs, and others concerned about serious mental illness and issues
like hospitalization, arrest, violence, homelessness, and
incarceration. That's what SAMHSA did when it wanted to replace the
proven medical model of treating serious mental illness with a
politically correct ``Recovery Model.''
SAMHSA's Recovery Model includes ``10 Guiding Principles of
Recovery.'' The most important is that ``self-determination and self-
direction are the foundations for recovery.'' That makes the recovery
model dangerous to some as it makes no allowance for the fact that
there are individuals with severe mental illness who cannot self-direct
their care. ``Under the `recovery model,' John Hinckley was defining
his own life goal--the attention of Jodie Foster--when he shot
President Reagan'' (Torrey and Jaffe 2013).
SAMHSA claims it knows how to prevent serious mental illness and
diverts funds to it
As former NIMH Director Dr. Thomas Insel noted, we can't prevent
serious mental illness because ``we do not know the cause [and] we lack
a biomarker that is 100% accurate for diagnosis'' (Insel 2014). But
prevention is SAMHSA's number one strategic initiative: ``Prevention
Works'' is part of its motto, and a ``National Prevention Week'' is
held annually (SAMHSA 2011). SAMHSA-funded advocates parade the word
``prevention'' in front of legislators--along with spreadsheets showing
the alleged savings--in order to increase their own funding. SAMHSA
often quotes a 1994 Institute of Medicine (IOM) report (IOM 1994). But
the report said, ``To date, the definitions [of prevention] have been
so broad and flexible that almost everything has been labeled
prevention at one time or another. Thus the nation is spending billions
of dollars on programs whose effectiveness is not known.'' SAMHSA uses
the 2009 update to the 1994 IOM report to justify diverting funds to
prevention (IOM 2009). But that report focuses only on youth and
specifically excludes ``some rare but often severe disorders; for
example, schizophrenia and bipolar disorders.''
SAMHSA diverts millions to stigma in spite of their own research
showing it is not a major barrier to care
SAMHSA teaches the public and Congress that stigma is an important
reason people do not receive care and provides massive funding to this
tangential issue. But a 2011 survey by the SAMHSA Center for Behavioral
Health Statistics and Quality found stigma (mentioned by 7% of
respondents) was low on the list of why people with mental illness do
not receive care, far behind cost (50%). Stigma also came behind could
handle problem without treatment, did not know where to go for
services, lack of time, belief that treatment wouldn't help,
anosognosia (did not feel need for treatment), and lack of insurance.
SAMHSA does virtually nothing on these other issues, and focuses it's
resources on stigma.
SAMHSA knows peer support does not improve meaningful outcomes in
people with serious mental illness but diverts
funds to it
SAMHSA funds peer supporters, peer travel, peer conferences, peer
webinars, and peer support organizations and coerces states to use
mental health block grant funds for peer support. (Mental Illness
Policy Org. 2013) The Center for Mental Health Services (CMHS) is
headed by a peer and focuses on little else. Yet, SAMHSA's own research
shows: ``The literature [on peer support] that does exist tends to be
descriptive and lacks experimental rigor'' (SAMHSA-BRSS 2012). SAMHSA
``peer-run respite centers'' only accept those well enough to
volunteer.
SAMHSA refuses to certify programs that help the seriously mentally ill
and certifies programs that don't
SAMHSA encourages states to spend mental health block grants on
programs listed in their National Registry of Evidence-based Programs
and Practices. NREPP is a sham, little more than an assemblage of
privately developed workshops, training sessions, and courses. Little
of what's in it are actual treatments, serve the seriously ill, or
improve meaningful outcomes. The ``evidence'' SAMHSA uses to evaluate
the programs often comes straight from those who invent, sell, and
profit from the listed programs.
Mental Health First Aid (MHFA) ostensibly teaches people to
identify the symptoms of mental illness in others and connect them to
help. The three studies SAMHSA relied on to certify it were all done by
the owners/vendors of the program (SAMHSA-NREPP 2012). Their research
shows only that those who give and receive the training like it; they
do not show that it improves outcomes for people with mental illness.
There are studies that found no benefit for people with mental illness,
but they were not submitted by the vendors to SAMHSA and therefore were
ignored by SAMHSA (Mental Illness Policy Org. 2013).
Four of the five ``studies'' SAMHSA used to certify Triple-P
Positive Parenting, a program that teaches parents of misbehaving
children how to be better parents were conducted by the vendor of the
program, Prof. Matt Sanders (SAMHSA-NREPP 2014). Numerous independent
studies show it doesn't work (Coyne and Kwakkenbos 2013) (Wilson, et
al. 2012).
The two studies used to certify the Wellness Recovery Action
Plan (WRAP), which teaches people to develop a wellness plan were
conducted at least partially by Mary Ellen Copeland, the vendor of the
program. Like MHFA, WRAP is not proven to benefit the seriously
mentally ill who receive it (Mental Illness Policy Org. 2013). SAMHSA
recently gave Ms. Copeland a large grant.
SAMHSA certifies programs as being ``effective'' even when they don't
improve meaningful outcomes, such as reducing violence, arrest,
incarceration, suicide, homelessness, and hospitalization. Many
programs SAMHSA certifies as effective only improve soft outcomes, like
``satisfaction,'' ``feeling of wellness,'' ``empowerment,''
``hopefulness,'' and ``resiliency.''
SAMHSA refuses to evaluate programs that actually help improve
meaningful outcomes in people with serious mental illness including
Assertive Community Treatment (ACT) Teams, Intensive Case Managers
(ICM), Crisis Intervention Teams (CIT), Assisted Outpatient Treatment
(AOT) and Mental Health Courts.
SAMHSA prevents states from using block grant money to help people with
serious mental illness
The legislation establishing mental health block grants requires they
be used for ``adults with serious mental illness'' and ``children with
serious emotional disturbance'' and narrowly defines those terms (CMHS
1993). But the SAMHSA instructions and application process ignores that
direction and encourages states to use the funds for people without
mental illness. (Mental Illness Policy Org. 2013):
``The focus is about everyone, not just those with an illness
or disease, but the whole population'' (emphasis added) (SAMHSA
2012, SAMHSA 2014).
SAMHSA invented a new mental illness: trauma
SAMHSA invented a mental illness it calls ``trauma.'' No reputable
psychiatrist considers trauma an illness. Post-traumatic stress
disorder (PTSD) is an illness, and even that can run from mild to
severe. SAMHSA never exactly defined trauma, but declared ``Individual
trauma results from an event, series of events, or set of circumstances
that is experienced by an individual as physically or emotionally
harmful or threatening and that has lasting adverse effects on the
individual's functioning and physical, social, emotional, or spiritual
well-being'' (SAMHSA 2012). These definitions can therefore include
anyone who got divorced, found their spouse was cheating, knows someone
who died, was in a storm, or had any event they ``experienced as . . .
emotionally harmful'' if it affected their ``spiritual well-being.''
SAMHSA created a National Center for Trauma Informed Care and has
awarded major trauma grants to organizations like the National
Association of State Mental Health Program Directors (NASMHPD) (SAMHSA
2006). That is money going to preventing trauma rather than treating
serious mental illness.
SAMHSA funds antipsychiatry and antipsychiatrists
SAMHSA is responsible for distributing funds that Congress intended to
support programs of ``Regional and National Significance'' (OMB 2013).
Too much of it goes directly to antipsychiatry and other organizations
that oppose treatment. It is hard to find an antipsychiatry
organization that does not receive financial or PR support from SAMHSA.
SAMHSA's Mental Illness Awareness Week Guide suggests that schools
invite the MindFreedom, the Icarus Project, and the National Coalition
for Mental Health Recovery (NCMHR) into classrooms to teach children
about mental illness (SAMHSA October 2010). MindFreedom based in Oregon
believes ``mental illnesses are not brain diseases'' (MindFreedom
2008). The Icarus Project believes ``these experiences--commonly
diagnosed and labeled as psychiatric conditions--are mad gifts needing
cultivation and care, rather than diseases or disorders'' (Icarus
Project 2014). The National Coalition for Mental Health Recovery
(NCMHR), the umbrella group for SAMHSA funded peer-run non-profits
believes ``psychiatric labeling is a pseudoscientific practice of
limited value in helping people recover'' (NCMHR 2012).
SAMHSA's support of these individuals and organizations has enabled
them to prevent states from improving services for the seriously ill by
keeping hospitals open, implementing AOT, using ECT, housing seriously
mentally ill in congregate settings, hiring professionals in lieu of
peers, and has thereby made incarceration of many seriously mentally
ill people more likely.
SAMHSA wastes money intended to help people with serious mental illness
SAMHSA uses its budget to publish and distribute children's books, such
as Play Day in the Park for 3- and 4-year-olds; Look What I Can Do! for
5- and 6-year-olds; coloring books, such as Wally Bear and Friends; and
my favorite, The Lion and the Mouse sing-along (SAMHSA 2011). SAMHSA
has scores of free publications covering non-mental illness including
``What a Difference a Friend Makes'' and publications on oil spill
response, hurricane recovery, American Indian and Alaska native
culture, peer pressure, social marketing, employment services, and
health promotion. But SAMHSA has only a single publication on
schizophrenia, and it is out of stock (Torrey and Jaffe 2013). SAMHSA
commissioned a $22,500 painting of Native Americans by a Native
American artist, ``to help raise awareness about the roles of families
and the community in mental and substance abuse disorder prevention.''
It sits in SAMHSA's headquarters.\4\ SAMHSA spent $200,000 to put on a
party at Paramount Studies in Hollywood (Coburn 2013).
---------------------------------------------------------------------------
\4\ Until recently, SAMHSA also put on an annual in-house musical
to celebrate World AIDS Day.
SAMHSA recently led a ``National Wellness Week'' to encourage
``visiting a farmers' market, taking a class on nutritional cooking,
`drinking a veggie or fruit smoothie,' reading poetry, making a
collage, taking a walk, joining a song circle, taking a class on how to
make sacred drums, . . . and join[ing] the Line Dance for wellness . .
. because `dancing is a great stress reliever and also provides social
interaction' '' (Torrey, The Ridiculous ``National Wellness'' Week
2014).
SAMHSA downplays and minimizes violence thereby stymieing efforts to
reduce it
Violence is not associated with poor mental health but is associated
with serious mental illness that is allowed to go untreated. SAMHSA
refuses to admit to or address that.
SAMHSA promotes ``prevention'' knowing serious mental illness cannot be
prevented
NIMH had similar problems of mission-creep that were solved when its
previous director was replaced by Dr. Thomas Insel. The problem at
SAMHSA is not lack of money, it's having too much.
______
National Alliance to End Homelessness
May 12, 2016
The Honorable Orrin G. Hatch The Honorable Ron Wyden
Chairman Ranking Member
Finance Committee Finance Committee
U.S. Senate U.S. Senate
Washington, DC 20510 Washington, DC 20510
Chairman Hatch, Ranking Member Wyden, and members of the committee:
On behalf of the National Alliance to End Homelessness, we appreciate
the opportunity to submit a statement for the record. The Alliance is a
nonprofit, non-
partisan organization committed to preventing and ending homelessness
in the United States. By improving policy, building capacity, and
educating opinion leaders, the Alliance has become a leading voice on
this issue.
Evidence indicates that mental illness is a known risk factor for
homelessness, and data clearly shows that mental illness
disproportionately impacts homeless people. In 2014, almost 20 percent
of the adults in the United States experienced any mental illness
(AMI), and 4.1 percent had serious mental illness (SMI).\1\ In
contrast, 18.1 percent of people who experienced homelessness on a
single night in 2014 had SMI.\2\ Research has shown that integrated
treatment which incorporates housing components provides better
outcomes than usual care for people who are homeless.\3\
---------------------------------------------------------------------------
\1\ Center for Behavioral Health Statistics and Quality (2015).
Behavioral health trends in the United States: Results from the 2014
National Survey on Drug Use and Health (HHS Publication No. SMA 15-
4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/
data/.
\2\ https://www.hudexchange.info/resource/reportmanagement/
published/CoC_PopSub_NatlTe
rrDC_2015.pdf.
\3\ Hwang, S., Tolomiczenko, G., Kouyoumdjian, F., and Garner, R.
Interventions to improve the health of the homeless: a systematic
review. Am. J. Prev. Med. 2005 Nov; 29(4):311-9.
Therefore, we encourage the Committee to ensure that housing supports
are included in any legislation as a necessary component of mental
---------------------------------------------------------------------------
health treatment.
The following pending Senate legislation has been endorsed by the
Alliance and provides for comprehensive services to meet the needs of
people with mental illness who are experiencing homelessness:
S. 2525, Expand Excellence in Mental Health Act: This bill
authorizes the expansion of a 2014 demonstration of Certified Community
Behavioral Health Centers (CCBHs). CCBHs ensure availability and
accessibility of behavioral health services to vulnerable populations
including those experiencing homelessness. CCBHs are encouraged to
partner with homeless services providers or local continuums of care.
S. 2680, Mental Health Reform Act of 2016: This bill strengthens
mental health and substance abuse care and improve access to treatment.
The Act requires state plans for comprehensive community-based health
systems that include employment and housing services as well as other
supportive services that are essential to ending homelessness. The Act
also authorizes the use of funds to provide employment and housing
supports.
S. 524, Comprehensive Addiction and Recovery Act of 2016: This
bill encourages housing to be coordinated with medication assisted
treatments and behavioral health interventions for the treatment of
opioid use disorders.
We hope to continue to work with this Committee to effectively treat
mental illness and end homelessness, two national concerns that can be
solved.
Sincerely,
Nan Roman
President and CEO
______
National Alliance on Mental Illness (NAMI)
3803 N. Fairfax Drive, Suite 100, Arlington, VA 22203
703-524-7600
www.nami.org
National Association of Psychiatric Health Systems (NAPHS)
900 17th Street, NW, Suite 420, Washington, DC 20006
202-393-6700
www.naphs.org
April 28, 2016
The Honorable Orrin G. Hatch The Honorable Ron Wyden
Chairman Ranking Member
Senate Finance Committee Senate Finance Committee
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510-6200 Washington, DC 20510-6200
Dear Chairman Hatch and Ranking Member Wyden,
On behalf of the National Alliance on Mental Illness (NAMI) and the
National Association of Psychiatric Health Systems (NAPHS), we want to
thank you for convening today's important hearing on ``Mental Health in
America: Where Are We Now?'' We appreciate your focus on this vital
issue.
Mental Illnesses are the leading cause of disability and contribute to
premature death, yet millions of Americans face discrimination when
they need the help the most.
Medicaid is the single largest funding source for people living with
mental illnesses, but a little-known provision in the law called the
Medicaid Institutions for Mental Disease (IMD) Exclusion prevents adult
Medicaid beneficiaries (ages 21-64) from accessing short-term, acute
care in psychiatric hospitals.
The IMD Exclusion is discriminatory and for years has disadvantaged
Medicaid beneficiaries living with serious mental illness. People are
not getting the psychiatric hospital treatment they need, putting
families and communities at risk. In the end, this is--pure and
simple--a fairness issue. A Medicaid insurance card covers hospital
treatment for all other medical conditions, but adults with mental
illnesses cannot use their Medicaid insurance card for inpatient
psychiatric care in a psychiatric hospital. No other disorder limits
hospital choice in the way the IMD Exclusion does.
The Medicaid IMD Exclusion was part of the original Medicaid program in
1965 and was intended to ensure that the states (rather than the
federal government) would be primarily responsible for the costs
associated with inpatient psychiatric treatments. Long ago, in 1965,
the vast majority of inpatient psychiatric care was provided in state
mental hospitals and was primarily long-term, custodial care.
Of course, this is no longer the case. Today the vast majority of
inpatient psychiatric hospital care is provided in the community in
general hospital psychiatric units or freestanding, non-governmental
psychiatric hospitals. Inpatient stays today for psychiatric illnesses
are measured in days (on average less than 10 days), not in weeks or
months.
Over the past two decades, there has been a major decline in the number
of inpatient psychiatric beds throughout the country. This has resulted
in an increased number of individuals ending up in emergency rooms
where they stay for days (and sometimes weeks) before being able to get
the crisis inpatient hospital stabilization treatment they so
desperately need. A Government Accountability Office (GAO-09-347)
report on hospital emergency departments concluded difficulties in
transferring, admitting, or discharging psychiatric patients from
emergency departments were factors contributing to emergency department
overcrowding.
Community psychiatric hospitals could help relieve these backups if
Congress made a targeted, exception to the IMD Exclusion for short-
term, acute, psychiatric hospital treatment.
A question that is sometimes asked by policymakers and advocates is
whether modifying the IMD Exclusion would lead to more
institutionalization. The answer is that this is about people who are
in major crisis and need hospitalization to keep them safe. Hospital
stays in the community are short and focus on crisis stabilization,
helping people continue their recovery in the community.
Some also ask, why not invest in community care instead of hospitals?
This is not a question of ``either/or.'' What is needed is a
partnership in care. Hospitals are handling the most acute needs of
that person (so they don't hurt themselves or others), and then
hospitals work with their community partners to handle the next step.
This is not dissimilar to someone who has a heart attack, who needs
hospitalization to stabilize the situation and then moves onto a
rehabilitation facility and then home with continuing supports. What is
needed are reforms to the IMD Exclusion that expand access to acute
inpatient care and quality measures that ensure connection to
outpatient services after a short-term stay in a hospital. In addition,
reforms to the IMD Exclusion should also address the disparity that
currently excludes non-elderly adults with mental illness from
community services funded under state waiver programs.
There are many approaches that have been identified to address the
growing crisis of the shortage of inpatient psychiatric beds in this
country. And there is growing bipartisan support in both the House and
Senate to address the discriminatory and outmoded IMD Exclusion. There
are comprehensive mental health reforms bills that have been introduced
in the Senate and House, including the Mental Health Reform Act of 2016
introduced by Senators Bill Cassidy (R-LA) and Chris Murphy (D-CT)
which includes a targeted, exception to the IMD Exclusion to cover
short-term, psychiatric hospital treatment.
Making a change to the IMD Exclusion is the right thing to do and will
result in more timely access to life-saving inpatient treatment,
reduced emergency backlogs, and a more cost-effective system.
We look forward to continuing to work with the committee to address
this unfair and discriminatory policy, so that individuals living with
mental illnesses can get the right care at the right time.
Sincerely,
Mary Giliberti, J.D.
Chief Executive Officer
National Alliance on Mental Illness (NAMI)
Mark Covall
President and CEO
National Association of Psychiatric Health Systems (NAPHS)
______
National Association of Anorexia Nervosa and Associated Disorders
(ANAD)
750 E. Diehl Road #127
Naperville, IL 60563
May 9, 2016
Senator Orrin G. Hatch Senator Ron Wyden
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Hatch and Ranking Member Wyden:
Thank you for your commitment to improving our nation's mental health
care system and for holding a hearing on April 28 to examine the roles
that the Medicare and Medicaid programs play in addressing the needs of
those with behavioral and mental health issues.
I write today on behalf of the National Association of Anorexia Nervosa
and Associated Disorders (ANAD) and the patients we represent. Formed
in 1976, ANAD is a non-profit association dedicated to the prevention
and alleviation of eating disorders. We focus particularly on anorexia
nervosa, bulimia nervosa and binge eating disorder, and we advocate for
the development of healthy attitudes, bodies, and behaviors. ANAD
promotes eating disorder awareness, prevention and recovery through
supporting, educating, and connecting individuals, families and
professionals.
Eating disorders are common mental illnesses and can kill. Every 62
minutes at least one person dies as a direct result from an eating
disorder.
Anorexia is the third most common chronic illness among adolescents,
and it has the highest mortality rate among all mental illnesses--
between 10 and 20 percent of those who have the illness will die.
Further, eating disorders cause medical complications including cardiac
arrhythmia, cardiac arrest, brain damage, infertility and osteoporosis,
in addition to other mental health conditions such as anxiety and
depression.
Appropriate and timely diagnosis and treatment of an eating disorder is
absolutely crucial in achieving positive health outcomes for the
patient. Eating disorders can be successfully and fully treated but,
unfortunately, only about one third of people with an eating disorder
ever receive treatment.
Such treatment can often be lengthy--from months to years--but early
intervention and proper treatment improve a patient's prognosis and
chances of a full recovery. As such, ANAD advocates for the reduction
of barriers and obstacles to insurance benefits and discriminatory
medical management of those struggling with all eating disorders.
ANAD applauds the steps taken by Congress over the past decade to
improve mental health care access and coverage--including mental health
parity and related provisions in the Affordable Care Act (ACA). That
said, more can and must be done in order to ensure that those suffering
from eating disorders are not denied access to the care they need. In
particular, steps must be taken to ensure that low-income individuals
and families are able to receive coverage for eating disorders
treatments under the Medicaid program.
Improvements to Medicaid coverage are imperative to ensuring that all
patients have access to the eating disorder treatments that are needed
to save their lives. In addition, physicians and counselors in the
Medicaid program need the training that is imperative to successfully
treating an eating disorder. Skilled clinicians with specific eating
disorder expertise are essential for treatment, yet eating disorder
specialists are still not available in some communities.
Specifically, ANAD strongly supports the Anna Westin Act (S. 1865), a
bipartisan eating disorders bill that was introduced in July 2015 and
referred to the Senate Committee on Health, Education, Labor, and
Pensions (HELP). The bill is named after Anna Westin, a young
Minnesotan who committed suicide as a direct result of her battle with
anorexia in February 2000. Since that time, Anna's family has turned
their grief into something positive by founding the Anna Westin
Foundation and working to ensure that tragedies such as Anna's are
prevented in the future.
The Anna Westin Act is a comprehensive eating disorders bill that
focuses on both training and treatment measures, and it will help those
affected with eating disorders get the treatment they need and deserve.
Using current funds from the Department of Health and Human Services
(HHS), the bill would help train health professionals, school personnel
and the public on how to identify eating disorders and how to help
prevent the development of behaviors that may lead to eating disorders.
In addition, S. 1865 would clarify the mental health parity law to
include residential treatment service coverage--affording the same
protections as other illnesses.
The bipartisan Anna Westin Act has 12 cosponsors in the Senate, and its
House counterpart (H.R. 2515) has 82 cosponsors. Importantly, key
provisions of the bill were incorporated into the comprehensive mental
health bill that was approved by the HELP Committee on March 16.
ANAD applauds this bipartisan effort and sincerely hopes that as you
work with your HELP Committee colleagues to bring a full scale mental
health reform effort to the Senate floor, you will support these
provisions that are so important to those suffering from eating
disorders, as well as their families and loved ones.
Again, thank you for the opportunity to share our thoughts on the need
to improve our nation's mental health care system--particularly from
the perspective of treating and preventing eating disorders.
Should you have questions or need additional information, do not
hesitate to contact me directly at 630-577-1333 or
[email protected]. Additionally, do not hesitate to contact ANAD's
Washington Counsel at McDermott, Will, and Emery: Karen Sealander,
Partner, at 202-756-8024 or [email protected]; and Erica Stocker,
Public Policy Advisor, at 202-756-8334 or [email protected].
Sincerely,
Laura Zinger
Executive Director
______
Statement Submitted by Christina Nunez Daw, MPH, Ph.D.
While this hearing's agenda includes information about positive
efforts to integrate mental and physical health care delivery, address
suicide risk, and meet adolescent mental health needs, it is
disappointing that a long-standing barrier to psychiatric and substance
addiction treatment is not being discussed--the exclusion of federal
Medicaid funding for adult (age 21-64) treatment in IMDs (Institutions
for Mental Disease) with over 15 beds. I urge the Committee to support
the elimination of the IMD exclusion by ensuring that this provision is
restored to S. 2680, the mental health reform bill.
Rather than increasing health care costs, the elimination of the
IMD exclusion would save resources now spent in hospital emergency
rooms, jails, and prisons, and care for homeless mentally ill patients.
We are wasting precious resources in these non-treatment settings
because our nation is seriously short on inpatient mental health beds
and treatment. Unfortunately, the Congressional Budget Office issued a
cost estimate for this provision (eliminating the IMD exclusion) that
likely overstates the expenditures needed, while ignoring resulting
cost-saving in non-federal expenditures.
CBO estimated the cost of allowing federal funds for IMDs at
$40-$60 billion over 10 years.
Yet, in the multi-year Medicaid Emergency Psychiatric
Demonstration (MEPD), the cost of providing community inpatient mental
health treatment for individuals in acute mental illness crisis,
averaged $6,724 per admission; the 26 month demonstration covered over
11,500 admissions for just under $78 million (state and federal
dollars) in 12 states.\1\
---------------------------------------------------------------------------
\1\ Data as of November 10, 2015 presented by CMS at the MHA
Regional Policy Council.
Even assuming an admission volume of 25 times the number of
admissions in the 12-state MEPD demonstration, the total estimated
---------------------------------------------------------------------------
federal expenditure would likely be less than the CBO's estimate.
Moreover, if we provided treatment instead of jailing mentally
ill persons, we would save the $30,000-$50,000 per mentally inmate
currently incarcerated.
Hospital emergency room directors have long raised the concerns
that the lack of inpatient beds has forced them to board seriously
mentally ill persons in crisis, taking up beds in ERs and in wards
while delaying admissions of persons with other critical illnesses.
Moreover, the IMD exclusion is in clear conflict with mental health
parity laws, by discriminating against patients based on type of
illness and associated treatment.
The Senate mental health reform bill, S. 2680, lacks this crucial
component that was contained in S. 1945 and is still addressed in the
current House mental health reform bill. I urge the Finance Committee
to restore this provision in S. 2680 and ensure it is preserved in the
House-Senate legislative reconciliation process.
______
Statement Submitted by Patricia Ranney
URGENT NEED OF PARITY: MENTAL ILLNESS = MEDICAL ILLNESS:
As a concerned parent, grandmother, citizen and constituent, I urge
REPEAL OF DISCRIMINATORY IMD EXCLUSIONS. Medicaid denies payment to
psychiatric hospitals over 16 beds, for patients from 21 to 65 years
old . . . but doesn't do same with medical hospitals.
Also REPEAL LIFETIME LIMIT OF MEDICARE FOR TREATMENT OF MENTAL ILLNESS.
. . . JUST TREAT IT LIKE OTHER ILLNESS WITHOUT Restrictive CAP.
ABSOLUTE CRITICAL NEED FOR ADDICTION COUNSELORS, BEDS AND TREATMENT. .
. . Let's show our humanity by treating those in desperate need of
mental health services in a hospital, or rehab and NOT A JAIL CELL OR
THE STREETS.
Your shared concern is greatly appreciated.
Pat Ranney
______
The Trevor Project
Saving Young Lives
Los Angeles--8704 Santa Monica Blvd., Suite 200, West Hollywood, CA
90069
New York--575 8th Ave., #501, New York, NY 10012
DC--1200 New Hampshire Ave., NW, Suite 300, Washington, DC 20036
p 310-271-8845 | f 310-271-8846 www.thetrevorproject.org
May 12, 2016
The Hon. Orrin G. Hatch, Chairman
The Hon. Ron Wyden, Ranking Member
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
Dear Senators Hatch and Wyden:
The Trevor Project sincerely thanks you for recently holding a hearing
entitled ``Mental Health in America: Where Are We Now?'' and asks that
you immediately take steps to pass the Mental Health Reform Act (S.
2680). During the hearing it was very clear that our current mental
health system needs a thorough overhaul, and Congress has a great
opportunity to enact some of those key reforms by passing the Mental
Health Reform Act (MHRA) of 2016. Thankfully, the MHRA has already been
passed out of committee and is awaiting a vote on the floor of the
Senate. We strongly urge you to request that Senate Majority Leader
Mitch McConnell put the bill on the Senate agenda for a full vote as
soon as possible. The MHRA is a truly bipartisan bill that addresses
many current problems in the nation's mental health system and also
reauthorizes vitally important programs such as those created under the
Garrett Lee Smith Memorial Act (GLSMA).
The Trevor Project is the leading national, nonprofit organization
providing crisis intervention and suicide prevention services to
lesbian, gay, bisexual, transgender and questioning (LGBTQ) young
people through age 24. We work to save young lives through our
accredited free and confidential lifeline, secure instant messaging
services which provide live help and intervention, a social networking
community for LGBTQ youth, in-school workshops, educational materials,
online resources, and advocacy. Trevor is a leader and innovator in
suicide prevention, especially as we focus on an important, at-risk
population: LGBTQ youth.
When initially passed in 2004, the GLSMA created a suicide prevention
grant program to allow states/tribes and colleges to engage in
prevention efforts and allocated funding for the national Suicide
Prevention Resource Center. Although the inaugural version of the Act
expired in 2008, Congress has since continued to reauthorize the
measure in recognition of the importance of youth suicide prevention by
financially supporting Garrett Lee Smith programs.
The GLSMA currently needs to be reauthorized and is included in the
MHRA, providing critical funding for the Suicide Prevention Resource
Center ($6 million annually), Youth Suicide and Prevention Strategy
Grants to States and Tribes ($30 million annually), and Mental Health
and Substance Use Disorder Services and Outreach on campuses ($6.5
million annually). Its funding currently supports suicide prevention
programs in all 50 states, as well as the District of Columbia, and the
continuation of this funding is necessary to the maintenance of these
vital suicide prevention and mental health wellness services in schools
and communities nationwide. Through the GLSMA's administration by the
Substance Abuse and Mental Health Services Agency, its funding is
directed towards providing lifesaving services to individuals at risk
of suicide, whether that is through providing mental health counseling;
crisis intervention services; running a hotline; conducting a public
awareness campaign; or training individuals on how to recognize a
person in distress and to appropriately intervene.
Suicide is the second leading cause of death among children ages 10 to
24 in America, as well as the second leading cause of death on college
and university campuses.\1\ Lesbian, gay, bisexual, transgender, and
questioning (LGBTQ) youth are at an exceptionally heightened risk for
suicidal behavior: LGB youth are four times more likely, and
questioning youth three times more likely, to attempt suicide than
their heterosexual peers.\2\ Additionally, almost half of young
transgender people have seriously considered taking their lives, with
approximately 25% having made at least one suicide attempt.\3\ LGBTQ
youth who experience significant familial rejection are more than 8
times as likely to report at least one suicide attempt than their peers
who come from welcoming, accepting family situations.\4\
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\1\ Centers for Disease Control and Prevention. (2015). Web-based
Injury Statistics Query and Reporting System [Data file]. Retrieved
from www.cdc.gov/ncipc/wisqars.
\2\ Kann, L., O'Malley Olsen, E., McManus, T., Kinchecn, S., Chyen,
D., Harris, W.A., Wechsler, H. (2011). Sexual Identity, Sex of Sexual
Contracts, and Health-Risk Behaviors Among Students Grades 9-12--Youth
Risk Behavior Surveillance, Selected Sites, United States, 2001-2009,
Morbidity and Mortality Weekly Report 60(SS07), 1-133.
\3\ Grossman, A.H. and D'Augelli, A.R. (2007). Transgender youth
and life-threatening behaviors. Suicide and Life Threatening Behavior
37(5), 527. Retrieved from http://transformingfamily.org/pdfs/
Transgender%20Youth%20and%20Life%20Threatening%20Behaviors.pdf.
\4\ Family Acceptance ProjectTM. (2009). Family
rejection as a predictor of negative health outcomes in white and
Latino lesbian, gay, and bisexual young adults. Pediatrics. 123(1),
346-52.
These statistics are shocking and disheartening, but it is imperative
to remember that together we can work to prevent suicide--through
awareness and education, as provided by the GLSMA. Reauthorization of
the Garrett Lee Smith Memorial Act will preserve the necessary funds
for state and tribal organizations, as well as institutions of higher
education, in order to allow these programs to continue serving youth
in America who are at risk for suicidal ideation, behavior, and/or
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attempts.
With Congress's upcoming summer recess and its break for campaigning,
the bills that are going to pass this legislative session must
effectively be passed before the summer break, as we understand it is
unlikely for Congress to convene during the lame-duck period.
Therefore, we strongly urge you to request that Senate Majority Leader
Mitch McConnell put the MHRA on the Senate agenda for a full vote in
the next 2 weeks. The time has come for mental health reform and the
MHRA represents the best opportunity among the last three decades to do
just that.
Thank you for your time and consideration of supporting this critical
piece of legislation, and for your commitment to improving the mental
health of all Americans.
Sincerely,
Abbe Land
Executive Director and CEO
[all]