[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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            Printed for the use of the Committee on Finance
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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

                              ----------                              

                           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

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                     American Academy of PAs (AAPA)

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                              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\
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
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

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