    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

     21ST CENTURY CURES IMPLEMENTATION: EXAMINING MENTAL HEALTH INITIATIVES

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JULY 19, 2018

                                   __________

                               Serial No. 115-154

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                   _________

                    U.S. GOVERNMENT PUBLISHING OFFICE

    35-691                   WASHINGTON : 2019

                        COMMITTEE ON ENERGY AND COMMERCE

                              GREG WALDEN, Oregon
                                     Chairman
    JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
      Vice Chairman                        Ranking Member
    FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
    JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
    MICHAEL C. BURGESS, Texas            ELIOT L. ENGEL, New York
    MARSHA BLACKBURN, Tennessee          GENE GREEN, Texas
    STEVE SCALISE, Louisiana             DIANA DeGETTE, Colorado
    ROBERT E. LATTA, Ohio                MICHAEL F. DOYLE, Pennsylvania
    CATHY McMORRIS RODGERS, Washington   JANICE D. SCHAKOWSKY, Illinois
    GREGG HARPER, Mississippi            G.K. BUTTERFIELD, North Carolina
    LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
    BRETT GUTHRIE, Kentucky              KATHY CASTOR, Florida
    PETE OLSON, Texas                    JOHN P. SARBANES, Maryland
    DAVID B. McKINLEY, West Virginia     JERRY McNERNEY, California
    ADAM KINZINGER, Illinois             PETER WELCH, Vermont
    H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
    GUS M. BILIRAKIS, Florida            PAUL TONKO, New York
    BILL JOHNSON, Ohio                   YVETTE D. CLARKE, New York
    BILLY LONG, Missouri                 DAVID LOEBSACK, Iowa
    LARRY BUCSHON, Indiana               KURT SCHRADER, Oregon
    BILL FLORES, Texas                   JOSEPH P. KENNEDY, III,
    SUSAN W. BROOKS, Indiana                 Massachusetts
    MARKWAYNE MULLIN, Oklahoma           TONY CARDENAS, California
    RICHARD HUDSON, North Carolina       RAUL RUIZ, California
    CHRIS COLLINS, New York              SCOTT H. PETERS, California
    KEVIN CRAMER, North Dakota           DEBBIE DINGELL, Michigan
    TIM WALBERG, Michigan
    MIMI WALTERS, California
    RYAN A. COSTELLO, Pennsylvania
    EARL L. ``BUDDY'' CARTER, Georgia
    JEFF DUNCAN, South Carolina
                             Subcommittee on Health

                           MICHAEL C. BURGESS, Texas
                                     Chairman
    BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
      Vice Chairman                        Ranking Member
    JOE BARTON, Texas                    ELIOT L. ENGEL, New York
    FRED UPTON, Michigan                 JANICE D. SCHAKOWSKY, Illinois
    JOHN SHIMKUS, Illinois               G.K. BUTTERFIELD, North Carolina
    MARSHA BLACKBURN, Tennessee          DORIS O. MATSUI, California
    ROBERT E. LATTA, Ohio                KATHY CASTOR, Florida
    CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
    LEONARD LANCE, New Jersey            BEN RAY LUJAN, New Mexico
    H. MORGAN GRIFFITH, Virginia         KURT SCHRADER, Oregon
    GUS M. BILIRAKIS, Florida            JOSEPH P. KENNEDY, III,
    BILLY LONG, Missouri                     Massachusetts
    LARRY BUCSHON, Indiana               TONY CARDENAS, California
    SUSAN W. BROOKS, Indiana             ANNA G. ESHOO, California
    MARKWAYNE MULLIN, Oklahoma           DIANA DeGETTE, Colorado
    RICHARD HUDSON, North Carolina       FRANK PALLONE, Jr., New Jersey (ex
    CHRIS COLLINS, New York                  officio)
    EARL L. ``BUDDY'' CARTER, Georgia
    GREG WALDEN, Oregon (ex officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, opening statement..............................     1
        Prepared statement...........................................     3
    Hon. Gene Green, a Representative in Congress from the State of
      Texas, opening statement.......................................     4
        Prepared statement...........................................     5
    Hon. Greg Walden, a Representative in Congress from the State of
      Oregon, opening statement......................................     6
        Prepared statement...........................................     8
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     9
        Prepared statement...........................................    10

                                   Witnesses

    Elinore McCance-Katz, Ph.D., Assistant Secretary for Mental
      Health and Substance Use, Substance Abuse and Mental Health
      Services Administration........................................    11
        Prepared statement...........................................    14
        Answers to submitted questions \1\...........................    58

                               Submitted Material

    Statement of Texas Tech University Health Sciences Center,
      submitted by Mr. Burgess.......................................    43
    Statement of the American Academy of Pediatrics, submitted by Mr.
      Green..........................................................    46
    Statement of the American Psychiatric Association, submitted by
      Mr. Green......................................................    47
    Statement of the American Psychological Association, submitted by
      Mr. Green......................................................    48
    Statement of the National Child Traumatic Stress Network,
      submitted by Mr. Green.........................................    46
    Article entitled, ``Nazis separated me from my parents as a
      child. The trauma lasts a lifetime,'' The Guardian, June 18,
      2018, submitted by Ms. Schakowsky..............................    51
    Statement of the Anti-Defamation League, submitted by Ms.
      Schakowsky.....................................................    54

    ----------
    \1\ The committee did not receive a response to Ms. McCance-
      Katz's submitted questions for the record by the time of
      printing.

     21ST CENTURY CURES IMPLEMENTATION: EXAMINING MENTAL HEALTH INITIATIVES

                                  ----------

                            THURSDAY, JULY 19, 2018

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:03 a.m., in
    room 2123, Rayburn House Office Building, Hon. Michael Burgess,
    M.D. (chairman of the subcommittee) presiding.
        Present: Representatives Burgess, Guthrie, Latta, Lance,
    Griffith, Bilirakis, Long, Bucshon, Brooks, Mullin, Hudson,
    Carter, Walden (ex officio), Green, Schakowsky, Matsui, Castor,
    Kennedy, DeGette, and Pallone (ex officio).
        Staff Present: Jennifer Barblan, Chief Counsel, Oversight
    and Investigations; Daniel Butler, Legislative Clerk, Health;
    Karen Christian, General Counsel; Adam Fromm, Director of
    Outreach and Coalitions; Ed Kim, Policy Coordinator, Health;
    Ryan Long, Deputy Staff Director; James Paluskiewicz,
    Professional Staff Member, Health; Kristen Shatynski,
    Professional Staff Member, Health; Jennifer Sherman, Press
    Secretary; Austin Stonebreaker, Press Assistant; Josh Trent,
    Chief Health Counsel, Health; Hamlin Wade, Special Advisor,
    External Affairs; Jacquelyn Bolen, Minority Professional Staff;
    Jeff Carrol, Minority Staff Director; Waverly Gordon, Minority
    Health Counsel: Tiffany Guarascio, Minority Deputy Staff
    Director and Chief Health Advisor; Samantha Satchell, Minority
    Senior Policy Analyst; Andrew Souvall, Minority Director of
    Communications, Outreach and Member Services; and C.J. Young,
    Minority Press Secretary.

    OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
                  IN CONGRESS FROM THE STATE OF TEXAS

        Mr. Burgess. The Subcommittee on Health will now come to
    order. The chair recognizes himself 5 minutes for the purpose
    of an opening statement.
        So today we convene and hold an oversight hearing on the
    mental health division of the 21st Century Cures Act which was
    signed into law in December 2016. On the anniversary of the
    House passage of 21st Century Cures, this subcommittee held a
    hearing on the sections of the law that the National Institute
    of Health and the Food and Drug Administration are
    implementing. Today we have Dr. Elinor McCance-Katz, the
    assistant secretary for Mental Health and Substance Use, here
    to testify before us about the work that the substance abuse
    and Mental Health Services Administration is doing to address
    our country's mental health needs.
        The mental health title of 21st Century Cures was based
    upon the Helping Families and Mental Health Crisis Reform Act
    of 2016 which passed the House by a vote of 422 to 2 prior to
    its inclusion in the Cures bill. This legislative effort
    represents the most significant reforms to the mental health
    system in more than a decade.
        The first provision within the mental health division
    strengthened the leadership and the accountability of SAMHSA
    including establishing the position that Dr. McCance-Katz now
    holds. One of her duties as the assistant secretary is to
    develop a strategic plan by the end of this fiscal year.
        Cures also strengthened existing programs, including
    SAMHSA's two biggest programs, the Community Mental Health
    Services Block Grant and the Substance Abuse Prevention and
    Treatment Block Grant. Given that each State and community is
    different, this law provides flexibility to States to address
    their unique mental health needs. Additionally, the law
    authorized the National Mental Health Policy Laboratory to
    carry out existing and new activities under the mental health
    policy umbrella including awarding grants for promising service
    delivery models and expanding evidence-based programs.
        Access to mental health and substance use disorder care is
    vital to the overall health of our Nation. According to the
    National Alliance on Mental Illness, approximately one in five
    adults in the United States experience mental illness per year.
    Of those adults suffering from mental illness, only a little
    more than 40 percent receive mental health services in the past
    year. Title 9 of the 21st Century Cures Act focused on
    promoting access to mental health and substance use disorder
    care.
        The programs included in this title authorized and
    strengthened several existing programs that previously had not
    been in statute. Some of these programs provide grants to
    eligible entries that provide mental health and substance use
    disorder services to homeless individuals and jail diversion
    programs. Additionally, the title authorized the program to
    further integrate primary care and behavioral health services
    through demonstration projects. Notably, the 21st Century Cures
    Act expanded the target population of this integration to
    include additional populations such as certain qualifying
    children and adolescents.
        The Centers for Disease Control and Prevention recently
    released a vital signs report that showed a rising suicide rate
    across the United States. In 2016, we lost nearly 45,000 lives
    to suicide. 21st Century Cures aimed to provide additional
    suicide prevention resources by codifying the National Suicide
    Prevention Hotline and authorizing the Garrett Lee Smith
    Suicide Prevention Resource Center and Youth Suicide Prevention
    State Grants.
        The existence of all of these programs would be far less
    impactful if we did not have an adequate work force to provide
    services. Therefore, there was an entire subtitle directed to
    strengthening the mental and behavioral healthcare workforce
    through training grants, demonstration programs, and other
    means.
        Cures established several new grant programs to address
    mental health needs in populations such as Mothers and
    Children. One program provides grants to support Statewide or
    regional pediatric mental health care telehealth access
    programs. Such programs could be especially helpful in early
    identification and treatment of mental health issues in school-
    age children. This is especially critical because 50 percent of
    all chronic mental illness begins by age 14.
        21st Century Cures made meaningful long-sought reforms to
    our mental health system and is the result of thoughtful
    bipartisan legislation created over the course of several
    years. While this law reflects on our diligence and our
    commitment to improving America's overall mental health, there
    is work that remains to be done.
        I will yield back the balance of my time and recognize the
    ranking member of the subcommittee, Mr. Green, 5 minutes for an
    opening statement, please.
        [The prepared statement of Mr. Burgess follows:]

                 Prepared statement of Hon. Michael C. Burgess

        Good morning. Today we convene to hold an oversight hearing
    on the mental health division of the 21st Century Cures Act,
    which was signed into law in December 2016. On the anniversary
    of House passage of 21st Century Cures, this Subcommittee held
    a hearing on the sections of the law that the National
    Institutes of Health and the Food and Drug Administration are
    implementing. Today, we have Dr. Elinore McCance-Katz, the
    Assistant Secretary for Mental Health and Substance Use, here
    to testify before us about the great work that the Substance
    Abuse and Mental Health Services Administration (SAMHSA) is
    doing to address our country's mental health needs.
        The mental health title of 21st Century Cures was based
    upon the Helping Families in Mental Health Crisis Reform Act of
    2016, whichpassed the House by a vote of 422-2 prior to its
    inclusion in Cures. This legislative effort represents the most
    significant reforms to the mental health system in more than a
    decade.
        The first provision within the mental health division
    strengthened the leadership and accountability at SAMHSA,
    including establishing Dr. McCance-Katz's position. One of her
    duties as the Assistant Secretary is to develop a strategic
    plan by the end of this fiscal year.
        Cures also strengthened existing programs, including
    SAMHSA's two biggest programs, the Community Mental Health
    Services Block Grant and the Substance Abuse Prevention and
    Treatment Block Grant. Given that each state and community is
    different, the law provides flexibility to states to address
    their unique mental health needs. Additionally, the law
    authorized the National Mental Health Policy Laboratory to
    carry out existing and new activities under the mental health
    policy umbrella, including awarding grants for promising
    service delivery models and expanding evidence-based programs.
        Access to mental health and substance use disorder care,
    especially in the midst of an opioid epidemic, is vital to the
    overall health of our nation. According to the National
    Alliance on Mental Illness, approximately one in five adults in
    the United States experience mental illness per year. Of those
    adults suffering from mental illness, only 41 percent received
    mental health services in the past year. Title IX of 21st
    Century Cures focused on promoting access to mental health and
    substance use disorder care.
        The programs included in this title authorized and
    strengthened several existing programs that had not been in
    statute. Some of these programs provide grants to eligible
    entities that provide mental health and substance use disorder
    services to homeless individuals and jail diversion programs.
    Additionally, the title authorized a program to further
    integrate primary care and behavioral health care services
    through demonstration projects. Notably, 21st Century Cures
    expanded the target population of this integration to include
    additional populations, such as certain qualifying children and
    adolescents.
        The Centers for Disease Control and Prevention recently
    released a Vital Signs report that showed rising suicide rates
    across the United States. In 2016, we lost nearly 45,000 lives
    to suicide. 21st Century Cures aimed to provide additional
    suicide prevention resources by codifying the National Suicide
    Prevention Hotline and authorizing the Garrett Lee Smith
    Suicide Prevention Resource Center and Youth Suicide Prevention
    State Grants.
        The existence of all of these programs would be far less
    impactful if we did not have an adequate workforce to provide
    services; therefore there was an entire subtitle dedicated to
    strengthening the mental and behavioral health care workforce
    through training grants, demonstration programs, and other
    means.
        Cures established several new grant programs to address
    mental health needs in populations, such as mothers and
    children. One program provides grants to support statewide or
    regional pediatric mental health care telehealth access
    programs. Such programs could be especially helpful in early
    identification and treatment of mental health issues in our
    school-aged children. This is especially critical because 50
    percent of all chronic mental illness begins by age 14. Another
    program awards grants to states for the purpose of screening
    and treating depression among women who are pregnant or who
    have given birth in the past year.
        21st Century Cures made meaningful, long-sought reforms to
    our mental health system, and is the result of thoughtful,
    bipartisan legislation crafted over the course of several
    years. While this law reflects our diligence and our commitment
    to improving America's overall mental health, there remains
    much work to be done.

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

        Mr. Green. Thank you, Mr. Chairman, for holding today's
    hearing on the implementation of the 21st Century Cures Act.
    Today we will be examining Division C of the law which focuses
    on mental health programs and activities administered by the
    Substance Abuse and Mental Health Service Administration,
    SAMHSA. I want to thank Dr. McCance-Katz, the assistant
    secretary for Mental Health and Substance Use of SAMHSA for
    joining us this morning.
        The enactment of the 21st Century Cures in December of 2016
    was a great achievement, particularly in a time of sharp
    partisanship and gridlock. But the work started long before
    2016 led by colleagues Fred Upton and Congresswoman Diane
    DeGette. But all of us on the committee were participants.
        In 2014, we set out on a mission to do something positive
    to boost medical research and innovation, accelerate the
    discovery and development of new cures and treatment, and
    improve public health.
        After countless hours devoted to roundtables, white papers,
    hearings, and drafts, Cures enjoyed bipartisan support and
    endorsements from over 700 organizations representing a full
    spectrum of the stakeholders. The investment and new
    authorities created by Cures are intended to go far in solving
    today's complex scientific problems giving new treatments from
    the lab table to the bedside and strengthening our nation's
    public health infrastructure.
        The Cures Act made several changes to mental health
    authorities and programs implemented by SAMHSA reauthorizing
    several existing mental health grant programs and creating new
    programs. For example. The Cures Act Established a chief
    medical officer within SAMHSA to assist in evaluating and
    organizing programs within the agency and promote best
    practices.
        The law thoroughly requires SAMHSA to develop a strategic
    plan every 4 years to identify priorities and including a
    strategy for improving the recruitment, training, and retention
    of a mental health workforce. The Cures Act also created a
    national mental health policy laboratory and an inter-
    department serious mental illness coordinating committee, which
    issued a report to Congress last December to address the needs
    of Americans suffering from serious mental illness and
    suffering emotional disturbance, across Federal agencies. One
    of the most important actions that the Federal Government can
    take to help Americans suffering from mental illness and
    emotional disturbance is ensuring they have the access to care.
        Medicaid is the single largest payer for mental health
    services in the United States. In 2015, Medicaid covered 21
    percent of adults with mental illness and 26 percent of adults
    with series mental health. I am concerned that actions taken by
    the Trump administration to make it more difficult to receive
    Medicaid and increase costs of health coverage more recently by
    suspending risk adjustment payments to insurers covering high-
    cost patients will make it more difficult for Americans
    suffering from mental illness and emotional disturbance to
    receive treatment they need to live in a full and healthy life.
        Before I close, I must note that on the ongoing mental
    health crisis created by the Trump administration regarding the
    separation of children from their parents. The American Academy
    of Pediatrics has emphasized that highly stressful experiences
    like family separation can cause irreparable harm disrupting a
    child's brain, architecture, and affecting his or her short-
    and long-term health. This type of prolonged exposure is
    serious stress known as toxic stress can lead to lifelong
    consequences for these children.
        Currently there are over 3,000 children who are forcibly
    separated from their parents by Federal authorities. We must
    hear how these family separations are impacting the mental and
    emotional health of these children and what action SAMHSA is
    taking to help these children recover from the trauma of family
    situation.
        Thank you, Mr. Chairman, and I would be glad to yield my
    last minute to someone who would like a minute.
        Nobody?
        Diane? I will yield to my colleague from Colorado.
        [The prepared statement of Mr. Green follows:]

                     Prepared statement of Hon. Gene Green

        Mr. Chairman, thank you for holding today's hearing on the
    implementation of the 21st Century Cures Act.
        Today, we will be examining Division C of the law, which
    focuses on mental health programs and activities administered
    by the Substance Abuse and Mental Health Services
    Administration (SAMHSA).
        I would like to thank Dr. McCance-Katz, the Assistant
    Secretary for Mental Health and Substance Use at SAMHSA for
    joining us this morning.
        The enactment of the 21st Century Cures Act in December
    2016 was a great achievement, particularly in a time of sharp
    partisanship and gridlock.
        But the work started long before 2016. In 2014, we set out
    on a mission: do something positive to boost medical research
    and innovation, accelerate the discovery, development and of
    new cures and treatment, and improve public health.
        After countless hours devoted to roundtables, whitepapers,
    hearings and drafts, Cures enjoyed bipartisan support and
    endorsements from over 700 organizations representing the full
    spectrum of stakeholders.
        The investment and new authorities created by Cures are
    intended to go far in solving today's complex scientific
    problems, getting new treatments from the lab table to the
    bedside and strengthening our nation's public health
    infrastructure.
        The Cures Act made several changes to mental health
    authorities and programs implemented by SAMHSA, reauthorized
    several existing mental health grant programs and created new
    programs.
        For example, the Cures Act established a Chief Medical
    Officer within SAMHSA to assist in evaluating and organizing
    programs within the agency and promote best practices.
        The law further requires SAMHSA to develop a strategic plan
    every four years to identify priorities, including a strategy
    for improving the recruitment, training, and retention of the
    mental health workforce.
        The Cures Act also created the National Mental Health
    Policy Laboratory and the Inter-Departmental Serious Mental
    Illness Coordinating Committee, which issued a report to
    Congress last December to address the needs of Americans
    suffering from serious mental illness and serious emotional
    disturbance across Federal agencies.
        One of the most important actions the Federal Government
    can take to help Americans suffering from mental illness and
    emotional disturbance is ensuring they have access to care.
        Medicaid is the single largest payer for mental health
    services in the United States. In 2015, Medicaid covered 21
    percent of adults with mental illness and 26 percent of adults
    with serious mental illness.
        I am concerned that actions taken by the Trump
    Administration to make it more difficult to receive Medicaid
    and the increase the cost of health coverage, most recently by
    suspending risk adjustment payments to insurers covering high-
    cost patients, will make it more difficult for Americans
    suffering from mental illness and emotional disturbance to
    receive the treatment they need to live a full and healthy
    life.
        Before I close, I must note the ongoing mental health
    crisis created by the Trump Administration regarding the
    separation of children from their parents.
        The American Academy of Pediatrics has emphasized that
    ``highly stressful experiences, like family separation, can
    cause irreparable harm, disrupting a child's brain architecture
    and effecting his or her short- and long-term health. This type
    of prolonged exposure to serious stress--known as toxic
    stress--can lead to lifelong consequences for children.''
        Currently, there are over 3,000 children who were forcibly
    separated from their parents by federal authorities.
        We must hear how these family separations are impacting the
    mental and emotional health of these children and what action
    SAMHSA is taking to help these children recover from the trauma
    of family separation.
        Thank you, Mr. Chairman, and I yield the remainder of my
    time.

        Ms. DeGette. Thank you very much.
        I just want to thank you, Doctor, for coming today. And I
    really look forward to hearing what SAMHSA is doing to
    implement the reforms in 21st Century Cures. This really,
    particularly the mental health aspects of the bill were issues
    that this committee worked on for many years trying to get it
    right. And I am not sure we yet have it right, but we are
    certainly working in that direction. So thank you.
        And I also want to echo what my colleagues are saying about
    these kids at the border. I think we are making progress
    reuniting them with their families, but we need to double our
    efforts down, and we also need to make sure they get adequate
    mental health counseling.
        I yield back.
        Mr. Burgess. The gentleman from Texas yields back.
        The chair notes there is a vote on the floor. But with the
    Committee's permission, we will finish with our opening
    statements before adjourning for the vote.
        And I will recognize the gentleman from Oregon, the
    chairman of the full committee, Mr. Walden, for his opening
    statement.

      OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
                   CONGRESS FROM THE STATE OF OREGON

        Mr. Walden. Well, thank you very much, Mr. Burgess. We
    appreciate that. And we appreciate your convening this hearing.
    It is really important that we do oversight on how 21st Century
    Cures and the wonderful bipartisan changes incorporated therein
    are now being implemented. I want to thank our colleagues on
    the committee who are here now, and certainly Dr. Tim Murphy
    who was a real leader in the Congress on mental health reform
    for his work on this as well. These policies were the result of
    multiyear, multimember bipartisan congressional effort, and
    they are based largely off the Helping Families in Mental
    Health Crisis Act which passed the House in July of 2016 by a
    sweeping vote of 422 to 2.
        It is also important, as an authorizing committee, that,
    once we pass legislation, we come back and review is it
    working? Where can we improve? What is not working? And that is
    why we are here today.
        These provisions were ultimately folded into Cures which
    was signed into law on December 13 of 2016. Division B of Cures
    authorized these landmark reforms to our nation's mental health
    laws, and they were long overdue.
        When our committee first took on this, there were 112
    Federal programs spread across eight Federal agencies designed
    to address mental illness. And they cost taxpayers $130 billion
    annually. So 112 programs, eight agencies, $130 billion. And
    many of the programs had not been updated or reauthorized in
    years.
        In Cures, under the leadership of Fred Upton, our chairman
    of the committee at the time, and Ms. DeGette and others, we
    streamlined these programs and brought them into the 21st
    century. We prioritized access to evidence-based programs and
    best practices to make them available to providers across the
    Nation. We granted States additional flexibility in
    administering mental health block grants to address the
    specific needs of their patient population. And we increased
    oversight, transparency, and accountability for these programs.
        Cures also made important progress in boosting resources
    for suicide prevention. Too many of us have friends who have
    lost loved ones to suicide. My dear friend and colleague,
    Senator Gordon Smith from Oregon, tragically lost his son
    Garrett Lee Smith to suicide 1 day before his son's 22nd
    birthday. I worked hard with Senator Smith to authorize the
    original Garrett Lee Smith Memorial Act which provides
    information and training for suicide prevention, surveillance,
    intervention, strategies for all ages. And I was proud to see
    this important program reauthorized in Cures.
        In a March funding bill which is now law, Congress provided
    critical funding for nearly 30 sections of the provisions
    within Cures, and these programs include the National Child
    Traumatic Stress Network, the National Child traumatic Stress
    Initiative, Mental and Behavioral Health Training Grants,
    Assisted Outpatient Treatment, and the National Suicide
    Prevention Lifeline. In addition, the bill also appropriated
    more than $2.3 billion in new funding for mental health
    programs and other training. These are resources that can mean
    the difference, literally, between life and death.
        It is also worth noting the promotion of integration of
    primary and behavioral health care included in Cures. In
    Wallowa County out the northeast part of my district and other
    areas across rural Oregon, I have heard the success stories of
    providers who have been able now to integrate their community
    health center and their behavioral health services. We know it
    works, but we also know there can be barriers to full
    integration. So I would appreciate hearing from our witness
    today about what you are seeing at the Federal level in this
    space of integration of service.
        Finally, I would like to note that the sections in Cures
    devoted to substance use disorder. And just last month the
    House passed H.R. 6, the Support for Patients in Communities
    Act. That is the biggest legislative package to address a drug
    crisis in American history. That bill started in this very
    subcommittee. And our work on substance use disorder, however,
    goes much further back, back to the lead up to the
    Comprehensive Addiction Recovery Acts, CARA, and the Cures
    legislation.
        So this intersection between mental health issues and
    substance abuse disorder is clearer now more than ever, and the
    grants and programs authorized by Cures have set the table for
    our work to combat the opioid crisis.
        So I would like to thank our witness for joining us today
    and the work that you are doing. Your position was created
    under the very law that we are examining today. And I know we
    are all eager to learn more about your work to coordinate
    critical mental health services and programs across the Federal
    Government.
        Mr. Chairman, I will yield back the balance of my time.
        [The prepared statement of Mr. Walden follows:]

                     Prepared statement of Hon. Greg Walden

        I'd like to thank Dr. Burgess for convening this hearing
    today to examine the meaningful mental health reforms enacted
    into law with the 21st Century Cures Act, or Cures. These
    policies were the result of a multi-year, multi-Congress
    effort. They are based largely off the Helping Families in
    Mental Health Crisis Act, which passed the House in July 2016
    by a sweeping vote of 422-2.
        The provisions were ultimately folded into Cures, which was
    signed into law on December 13, 2016. Division B of Cures
    authorized these landmark reforms to our nation's mental health
    system that were long overdue.
        When our committee first took this on, there were 112
    federal programs spread across eight federal agencies designed
    to address mental illness. They cost $130 billion annually, and
    many of these programs had not been updated or reauthorized in
    years.
        In Cures, we streamlined these programs and brought them
    into the 21st century. We prioritized access to evidence-based
    programs and best practices to make them available to providers
    across the country. We granted states additional flexibility in
    administering mental health block grants to address the
    specific needs of their patient population. And we increased
    oversight, transparency, and accountability for these programs.
        Cures also made important progress in boosting resources
    for suicide prevention. Too many of us have lost loved ones to
    suicide--my friend and colleague Senator Gordon Smith from
    Oregon tragically lost his son Garrett Lee Smith to suicide,
    one day before his 22nd birthday. I worked hard with Senator
    Smith to authorize the original Garrett Lee Smith Memorial Act,
    which provides information and training for suicide prevention,
    surveillance, and intervention strategies for all ages. I was
    proud to see this important program reauthorized in Cures.
        In a March funding bill which is now law, Congress provided
    critical funding for nearly 30 sections of provisions within
    Cures. These programs include: The National Child Traumatic
    Stress Network, The National Child Traumatic Stress Initiative,
    Mental and Behavioral Health Training Grants, Assisted
    Outpatient Treatment, and the National Suicide Prevention
    Lifeline. In addition, the bill also appropriated more than
    $2.3 billion in new funding for mental health programs and
    other training. These are resources than can mean the
    difference between life and death.
        It's also worth noting the promotion of integration of
    primary and behavior health care included in Cures. In Wallowa
    County and other areas of my district in Oregon, I've heard the
    success stories of providers who have integrated their
    community health center and behavioral health services. We know
    that works, but we also know there can be barriers to full
    integration and I'd love to hear from our witness about what
    you're seeing at the federal level in this space.
        Finally, I'd like to note the sections in Cures devoted to
    substance use disorder. Just last month the House passed H.R.
    6, the SUPPORT for Patients and Communities Act, the biggest
    legislative package to address a drug crisis in history. That
    bill started in this very subcommittee. Our work on substance
    use disorder, however, goes much further back--back to the
    leadup to the Comprehensive Addiction and Recovery Act (CARA)
    and Cures.
        The intersection between mental health issues and substance
    use disorder is clearer now more than ever, and the grants and
    programs authorized by Cures have set the table for our work to
    combat the opioid crisis.
        I'd like to thank our witness for joining us today. Her
    position was created under the very law we are examining today,
    and I know we are all eager to learn more about her work to
    coordinate critical mental health services and programs across
    the Federal Government.

        Mr. Burgess. The gentleman yields back. The chair thanks
    the gentleman.
        The chair recognizes the gentleman from New Jersey, the
    ranking member of the full committee, 5 minutes for an opening
    statement, please.

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

        Mr. Pallone. Thank you, Mr. Chairman.
        It is a critical function of this committee to conduct
    oversight and ensure that the legislation we pass is working as
    intended, and that is why I think it is important to hold
    hearings like these that allow us to learn directly from the
    administration how policies are being implemented.
        In December 2016, President Obama signed the landmark 21st
    Century Cures Act into law which was truly a product of the
    hard work of bipartisan members of this committee. And as we
    know, the Cures Act addressed a wide range of issues facing our
    healthcare system. However, today we will be focusing on the
    provisions related to mental health. And I would like to thank
    Dr. McCance-Katz for joining us today to testify on the
    important work happening at SAMHSA.
        The Helping Families and Mental Health Crisis Act, which
    was ultimately passed as part of the Cures Act, was an
    important step towards repairing our country's broken mental
    health system. And I would specifically like to highlight a
    provision that I worked hard with my colleagues to include in
    this legislation that expanded an important set of Medicaid
    benefits to children receiving inpatient psychiatric treatment.
    But despite what was accomplished through this law, I think we
    all agree our work on this issue is far from complete, and more
    needs to be done to improve access to affordable mental health
    treatment.
        Unfortunately, in the time since we passed the Cures Act
    the, Republican party has been fixated on repealing the
    Affordable Care Act and cutting Medicaid, which is the single
    largest payer of mental health services in the country. For
    many people, Medicaid provides the only chance they have of
    getting treatment for a mental health disorder, and I continue
    to believe that any progress made by the Helping Families and
    Mental Health Crisis Act would be completely reverse if the
    Republicans ever succeed in their radical plans to repeal the
    Affordable Care Act and drastically cut Medicaid benefits for
    low-income individuals. These actions could cause catastrophic
    harm to people with mental illness.
        And speaking of helping families in crisis, I am reminded
    that this committee has still not acted to help the thousands
    of families currently in crisis because of the Trump
    administration's cruel family separation policy. The
    administration recklessly moved ahead with this inhumane policy
    with little thought on how to address the long-term health
    implications for the children torn away from their parents or
    how to reunite them with their family. And this is a man-made
    disaster by the Trump administration.
        Public health advocates and healthcare providers have
    already warned how devastating forceable separation can be to a
    child's mental health and overall development. According to the
    American Academy of Pediatrics, ``highly stressful experiences
    like family separation can cause irreparable harm, disrupting a
    child's brain architecture, and affecting his or her short and
    long-term health. This type of prolonged exposure to serious
    stress--known as toxic stress--can lead to lifelong
    consequences for children.''
        And as I said at the outset of my remarks, oversight is a
    critical function of this committee. And so far Chairman Walden
    has not been willing to hold an oversight hearing on the family
    separation crisis, which I think we should have before we leave
    for the August recess. And that tells me that the Republican
    majority are really not as troubled by this crisis as some of
    them claim to be.
        So we must get to the bottom of how this happened so we can
    ensure it never happens again. We must reunite these families
    immediately. While we can't undue the trauma that these
    children have already endured, the administration must take
    every step possible to prevent further harm.
        And with that, I yield back, Mr. Chairman.
        [The prepared statement of Mr. Pallone follows:]

                 Prepared statement of Hon. Frank Pallone, Jr.

        It's a critical function of this committee to conduct
    oversight and ensure that the legislation we pass is working as
    intended. That's why I do think it's important to hold hearings
    like these that allow us to learn directly from the
    Administration how policies are being implemented.
        In December 2016, President Obama signed the landmark 21st
    Century Cures Act into law--which was truly a product of the
    hard work of bipartisan members of this committee. As we know,
    the Cures Act addressed a wide range of issues facing our
    health care system. However, today we'll be focusing on the
    provisions related to mental health-and I'd like to thank Dr.
    McCance-Katz for joining us today to testify on the important
    work happening at the Substance Abuse and Mental Health
    Services Administration (SAMHSA).
        The Helping Families in Mental Health Crisis Act, which was
    ultimately passed as part of the Cures Act, was an important
    step towards repairing our country's broken mental health
    system. I'd specifically like to highlight a provision I worked
    hard with my colleagues to include in the legislation that
    expanded an important set of Medicaid benefits to children
    receiving inpatient psychiatric treatment. But despite what was
    accomplished through this law, I think we'd all agree our work
    on this issue is far from complete and more needs to be done to
    improve access to affordable mental health treatment.
        Unfortunately, in the time since we've passed the Cures Act
    the Republican party has been fixated on repealing the
    Affordable Care Act and cutting Medicaid-which is the single
    largest payer of mental health services in the country. For
    many people, Medicaid provides the only chance they have at
    getting treatment for a mental health disorder. I continue to
    believe that any progress made by the Helping Families in
    Mental Health Crisis Act would be completely reversed if the
    Republicans ever succeed in their radical plans to repeal the
    Affordable Care Act and drastically cut Medicaid benefits for
    low income individuals. These actions would cause catastrophic
    harm to people with mental illness.
        And speaking of helping families in crisis, I'm reminded
    that this committee has still not acted to help the thousands
    of families currently in crisis because of the Trump
    Administration's cruel family separation policy. The
    Administration recklessly moved ahead with this inhumane policy
    with little thought on how to address the long-term health
    implications for the children torn away from their parents or
    how to reunite them with their family. This is a man-made
    disaster by the Trump Administration.
        Public health advocates and health care providers have
    already warned how devastating forcible separation can be to a
    child's mental health and overall development. According to the
    American Academy of Pediatrics, ``highly stressful experiences,
    like family separation, can cause irreparable harm, disrupting
    a child's brain architecture and effecting his or her short-
    and long-term health. This type of prolonged exposure to
    serious stress--known as toxic stress--can lead to lifelong
    consequences for children.''
        As I said at the outset of my remarks, oversight is a
    critical function of this committee and the fact that Chairman
    Walden refuses to hold an oversight hearing on the family
    separation crisis tells me that Chairman Walden and the
    Republican majority are simply not as troubled by this crisis
    as some of them claim to be--and I find that incredibly sad.
        We must get to the bottom of how this happened so we can
    ensure it never happens again. We must reunite these families
    immediately--and while we can't undo the trauma that these
    children have already endured--the Administration must take
    every step possible to prevent further harm.
        I yield back.

        Mr. Burgess. The chair thanks the gentleman. The gentleman
    yields back.
        The chair notes there are under 5 minutes left on this vote
    series. My understanding is there are four votes in this
    series. That should take us a little less than 1 hour to
    complete. And the committee will stand in recess until
    immediately after votes.
        [Recess.]
        Mr. Burgess. I call the committee back to order. As we
    recessed we had just concluded with member opening statements.
        The chair will remind members that pursuant to committee
    rules all member's opening statements will be part of the
    record. And we do want to thank our witness for being here
    today, and staying with us through votes, and taking time to
    testify before the subcommittee.
        Our witness will have the opportunity to give an opening
    statement followed by questions from members. And today we are
    going to hear from Dr. Elinore McCance-Katz, the Assistant
    Secretary for Mental Health and Substance Use, United States
    Department of Health and Human Services. We appreciate you
    being here with us today Dr. McCance-Katz and you are
    recognized for 5 minutes for an opening statement, please.

    STATEMENT OF ELINORE MCCANCE-KATZ, PHD, ASSISTANT SECRETARY FOR
      MENTAL HEALTH AND SUBSTANCE USE, SUBSTANCE ABUSE AND MENTAL
                     HEALTH SERVICES ADMINISTRATION

        Dr. McCance-Katz. Chairman Burgess, Ranking Member Green
    and members of the House Energy and Commerce Subcommittee on
    Health. Thank you for inviting me to testify at this important
    hearing.
        In December of 2016, the 21st Century Cures Act was signed
    into law. And I want to thank you for your vision and your
    leadership on addressing the needs of Americans living with
    mental and substance use disorders. We at the Substance Abuse
    and mental Health Services Administration, the Department of
    Health and Human Services have been actively implementing this
    law since its enactment.
        As the first Assistant Secretary for Mental Health and
    Substance Use, a position created by the Cures Act, I take
    seriously my duties outlined in Cures, including leadership and
    accountability for behavior health, evidence based program
    promotion and coordination across government. Part of
    strengthening leadership and accountability includes a strong
    clinical perspective at the agency. Cures codifies the role of
    the chief medical officer. And we have taken this further by
    establishing and expanding the Office of the Chief Medical
    Officer to include two additional psychiatrists, a clinical
    psychologist and a nurse practitioner.
        A new component of SAMHSA created by the Cures Act is the
    National Mental Health and Substance Use Policy laboratory. The
    policy lab promotes evidence based practices and service
    delivery through evaluation of models that would benefit from
    further development, expansion, or replication. The policy
    laboratory also provides leadership in identifying and
    coordinating policies and programs related to mental and
    substance use disorders, including needed policy changes.
        The Interdepartmental Serious Mental Illness Coordinating
    Committee, or ISMIC, was established by the Cures Act to ensure
    better coordination across the Federal Government to address
    the needs of adults with serious mental illness and children
    and youth with serious emotional disturbances and their
    families.
        The ISMIC has been working within five key areas of focus,
    strengthening Federal coordination to improve care, closing the
    gap between what works and what is offered, reducing justice
    involvement and improving care for those who are just as
    involved, making it easier to obtain evidence-based healthcare
    for mental and substance use disorders and developing finance
    strategies to increase availability and affordability of care.
        The Cures Act reauthorized the community mental health
    services block grant and codified the first episode psychosis
    set aside. If we can intervene early and with needed treatment
    in psychosocial services, individuals are better able to manage
    their serious mental illnesses similar to other chronic health
    conditions.
        In 2016, 44,965 Americans died by suicide. And according to
    SAMHSA's surveys on drug use and health statistics, over 1.3
    million Americans attempted suicide. The Cures Act authorized
    SAMHSA's existing national suicide prevention lifeline. Recent
    evaluation data showed that the majority of individuals served
    and then interview following use of life line purported that
    the intervention stopped them from completing suicide and
    helped to keep them safe. At the same time, the highest rate of
    suicide in America is among adults, aged 45 to 64 years old.
    SAMHSA is grateful to the authorization of the adult suicide
    prevention program and cures.
        The purpose of this program is to implement suicide
    prevention intervention programs focused on training of
    healthcare professionals, to ask about suicidal ideations, and
    to make safety plans and to assist people to treatment should
    they endorse thoughts of wanting to end their lives.
        One of SAMHSA's roles is it to oversee the implementation
    of 42 CFR Part 2, the regulation governing confidentiality of
    substance use disorder patient records. SAMHSA made substantive
    updates to these regulations in 2017 and 2018. In compliance
    with the Cures Act, SAMHSA held a listening session attend by
    over 1,200 people in January 2018 to obtain input about Part 2
    implementation. Themes included the need to align 42 CFR Part 2
    in HIPAA, the need for technical assistance and training, the
    importance of integrated care, and the use of electronic health
    records.
        The Cures Act also demonstrates Congress' commitment to
    addressing the opioids crisis. Through implementation of CURE's
    SAMHSA awarded $500 million in each of years 2017 and 2018. And
    the State targeted response grant funding to States and
    communities around the country. These funds support
    comprehensive approaches to addressing the opioids crisis
    through prevention, treatment and recovery services.
        I feel strongly that we need to ensure that the direction
    provided by Congress in Cures is followed with fidelity and the
    highest quality service delivery possible. In order to achieve
    this goal, I have reconfigured SAMHSA's technical assistance
    approach from a grantee-based approach to one which supports a
    robust national and regional technical assistance strategy
    emphasizing training on evidence based and effective practices
    to communities across the country.
        Much work has been undertaken at SAMHSA and across HHS to
    implement the Cures Act, but we know this work is far from
    over. I look forward to continuing a strong partnership with
    Congress, to help Americans living with mental and substance
    use disorders and their families.
        I am pleased to answer your questions today. Thank you.
        [The prepared statement of Dr. McCance-Katz follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. Thank you, Dr. McCance-Katz, and thank you for
    your testimony today. This concludes the witness opening
    statement portion of the hearing. We will move to member
    questions. I recognize myself 5 minutes for questions.
        And I want to begin by asking unanimous consent to place
    into the record a statement for the record by Dr. Billy Philips
    from Texas Tech University Health Sciences Center, the Hall
    Professor of Family Community Medicine, Professor of Public
    Health and Executive Vice President for Rural and Community
    Health at Texas Tech University describing their program of
    Telemedicine, Wellness, Intervention, Triage and Referral.
        Without objection so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Burgess. And Dr. McCance-Katz, I am submitting the
    whole statement for the record. Let me just pull a couple of
    pieces out of this. Dr. Philips tell us this program provides
    school based screening assessment and referral services to
    students that are typically struggling with behavioral and
    mental health issues and is currently active in 10 west Texas
    independent school districts.
        This project uses telemedicine technology to link remote
    rural schools that are without sufficient counselors,
    psychiatrists, and other mental health service providers. It
    also provides mental health recognition and training services
    to educators and school resource officers to promote a greater
    recognition and prompt referral.
        He then goes on to describe in some detail how the program
    runs and the coordination that occurs between their staff and
    the staff of the school. Interesting he provides some
    statistics. He says the impact area has an annual enrollment of
    42,000 students in ten mostly rural school districts
    surrounding Lubbock, Texas. They have created an environment
    where students are empowered to help create a safe learning
    environment and better morale.
        Of that number, only a small fraction, 414 total, have been
    referred by teachers. And we have been trained to recognize
    those who will need to be referred to the larger program, the
    team has screened out and triaged, by telemedicine, 215
    students and 25 of those have been removed from the school
    population, most by hospitalizations and a few by arrest. And
    they believe they have averted tragic outcomes and started
    others on a path towards healing.
        So a very interesting program that they have developed for
    school safety in their rural school districts in west Texas.
    And I would just be interested in your thoughts as to how this
    integrates with the work we did in Cures, and you are doing now
    with Cures implementation.
        Dr. McCance-Katz. Thank you for bringing that forward,
    because this is a very important part of not only of Cures Act
    but also a focus of the President's Federal school safety
    commission. And so we have had the opportunity to speak to a
    number of districts across the country, Texas being one of
    them. And these kinds of innovative programs are exactly what
    we need to better ensure--two things, one a safe environment
    for students, a nurturing environment where they can learn.
        And the second being one where we identify children early
    who may have emotional or mental health issues that need to be
    addressed and there are a number of ways to address those kinds
    of mental health service needs via either integration directly
    within the school system or through a close relationship with
    other types of programs.
        Some of the things that the Cures Act do that directly
    effect those kinds of programs is that Cures reauthorized
    several types of mental health programs that are oriented
    toward children. And SAMHSA continues to implement those
    programs.
        So things like Project Aware which provides for
    infrastructure of these types of services within schools in the
    States, and programs that teach about mental health
    psychological, mental health, and mental health first aid type
    programs to help to identify youth early so that we can get
    them the care and services that they need, Cures reauthorized
    those programs and we are in the process right now of making
    more awards through our granting system.
        In addition, when we start talking about integration of
    care, the certified community behavioral health centers that
    Congress established for us represent a model that can be used
    to provide those needed services to children who would be
    referred from the school systems.
        Mr. Burgess. Well, certainly I think use of that model will
    be important. As I understand this program has been funded
    entirely out of funds within Texas Tech University itself, but
    they have set up the telemedicine portals, and the secure
    connections, and the encrypting and all that is it necessary to
    have those secure connections.
        But I actually look forward to working with you and your
    office on this and perhaps the White House as well, because I
    do think they are on to something that is very, very important.
        I am going to yield back to you, Mr. Green, and recognize
    you for 5 minutes of questions.
        Mr. Green. Thank you, Mr. Chairman. And again welcome, Dr.
    McCance-Katz.
        The 21st Century Cures Act was a landmark law and included
    important provisions to strengthen mental and substance use
    disorder care for women, children and adolescents. In
    particular the Cures has reauthorized the National Child
    Traumatic Stress Initiative which supports a national network
    of child trauma centers and focuses on increasing access to
    affected trauma focused interventions.
        Can you explain how the National Child Traumatic Stress
    Network operates? And what impact it has on improving the lives
    of children impacted by traumatic stress.
        Dr. McCance-Katz. Yes, the National Child Traumatic Stress
    initiative is a program that is established in a large number
    of States, it provides national technical assistance services
    around issues of traumatic stress in children. This is a
    program that not only trains practitioners and providers of
    services, but also will do consultation within communities to
    help them to address traumatic issues. So this is a very highly
    regarded and valuable program.
        Mr. Green. Following the chairman, do you know of any
    grantees in the State of Texas off the top of your head?
        Dr. McCance-Katz. I don't have the grantees dedicated to
    memory. But I will tell you this we can get you that very
    quickly.
        Mr. Green. OK. Thank you. I appreciate it.
        If children that are impacted by traumatic stress receive
    early interventions and the trauma informed care they need, can
    the long-term health affects of trauma be mitigated in any way?
        Dr. McCance-Katz. Yes, they can. There is a fair amount of
    literature on this in terms of how trauma affects children and
    the ability to address those traumatic events in therapeutic
    environments can mitigate the affects later in life.
        Mr. Green. I am interested in how the National Child
    Traumatic Stress Network is responding to the recent events
    related to the family separations at the border as a result of
    the Trump administration's zero tolerance. Is the network being
    utilized to coordinate or facilitate services for children that
    have endured this trauma as a result of family separation
    policy?
        Dr. McCance-Katz. Well, what I would say, Congressman
    Green, is that SAMHSA itself is not involved in those issues.
    Those issues are being dealt with by a different part of HHS,
    the Administration for Children and Families and the Office for
    Refugee Resettlement. Any provider within a jurisdiction can go
    to a SAMHSA national program and ask for resources, but SAMHSA
    itself is not directly involved in that.
        Mr. Green. OK. Well, I was wondering, HHS is responsible
    for those children, if you happen to find any information on
    what is being done with HHS in the network for these children--
    my concern about the National Children Traumatic Stress has a
    document on its website that notes, children can recover from
    traumatic separation and other traumatic experiences with
    development of culturally and linguistically appropriate trauma
    services for these children and their families, including
    evidence based and trauma folks treatment. I would hope that
    would be part of the process and obviously SAMHSA in that
    effort.
        In the interdepartmental serious mental illness
    coordinating committee report that was released by SAMHSA last
    December it listed five areas of focus, including increasing
    availability and affordability of the care. Could a patient
    suffering from a serious mental illness, and SMI or a serious
    emotional disturbance, be denied health insurance--insurers as
    having a preexisting condition?
        Dr. McCance-Katz. So that is not my area of expertise. I
    really don't feel comfortable commenting on the details of
    health insurance. What I would say is that Medicaid is one of
    the largest providers of mental health services through their
    insurance program and they serve millions of Americans at this
    very moment.
        Mr. Green. Thank you, Mr. Chairman. I would also like to
    ask unanimous consent to place into the record a statement by
    the American Academy of Pediatrics opposing separation of
    children at the border, the American Psychiatric Association,
    opposing the separation of children from their parents. The
    American Psychological Association regarding the traumatic
    affects of separating families, and again the National Child
    Traumatic Stress Network and key points on the traumatic
    separation of refugee children and immigrant children.
        I ask unanimous consent to place into the record.
        Mr. Burgess. Without objection so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Burgess. The gentleman's time has expired.
        Mr. Green. I yield.
        Mr. Burgess. The gentleman yields back. The chair
    recognizes the gentleman from Kentucky, Mr. Guthrie, 5 minutes
    for questions.
        Mr. Guthrie. Thank you, Mr. Chairman and thanks for being
    here Dr. McCance-Katz.
        I have a question, the CDC has found that less than half of
    substance use disorder patients with multiple mental health
    issues have ever received treatment for their mental health
    issue. The commission suggests this is due to lack of access,
    fear of shame, and discrimination, and a lack of motivation to
    seek treatment. Would you discuss how you planned to encourage
    and work with States using the State targeted response opioid
    money to help patients with untreated mental health disorders?
        I am from Kentucky and as you know we have a very large
    population in need of these services, and the general public
    who just need education and awareness of these services.
        Dr. McCance-Katz. Yes, yes. Thank you for that question,
    because we are very much engaged on that issue. And so the
    State targeted response to opioids part of the Cures Act
    provides funding for technical assistance and training within
    the States. What we have now done at SAMHSA, what we have put
    in place in February was to have a grantee whose requirement
    was to establish teams within every State, multiple teams for
    States with larger geographic areas, but these teams had to
    have addiction experts and other types of mental health
    expertise and physical healthcare expertise available so that
    they could go into communities. Communities and providers
    within those communities let their States know what kinds of
    services, and training, and technical assistance, and these
    teams go in and provide that on the spot.
        And so we believe that that is going to be a way that we
    establish evidence-based practice. We know that the co-
    occurring rate of mental and substance use disorders is quite
    high. And so if somebody has a substance use disorder, they
    must be screened for mental health issues. We know that
    treating one and not treating the other and the person who has
    cooccurring disorders will not solve both problems. And these
    teams are professionals. They are licensed within their States
    and certified by their various regulatory boards to provide
    that kind of technical assistance and training as part of their
    own clinical practices and they are doing that in our
    communities now.
        Mr. Guthrie. OK thanks. And before my next question, I was
    watching I guess a new TV show that is out that Amy Adams the
    actress stars in. And several of the characters seem to have
    addictions so I can't really tell where the show is going yet.
    But at the very end of the show they had a public service
    announcement for SAMHSA. I don't know if you knew that or saw
    that. At the very end it says, if you have any issues or know
    people who have, please call. I don't know if you are getting
    any response from that, but I was pleased at the end of show
    they were trying to show people how to reach out that have
    addiction issues.
        So my next question is for guidance issued via the 21st
    Century Cures Act, SAMHSA has released extensive guidance for
    consumers on how they can report parity concerns as well as
    tools for health plans. Does SAMHSA have future plans to offer
    providers additional pathways for addressing potential--this is
    hard to say--offer providers additional pathways for addressing
    potential parity violations or concerns?
        Dr. McCance-Katz. So we are very pleased that we have a
    portal that consumers can use where they can report what they
    believe may by parity violations, difficulties they are having
    with getting coverage for their mental health or substance use
    problems. That portal will get them to the appropriate Federal
    agency, be it labor, be it CMS, be it Treasury, so we are
    pleased about that.
        We also provide guidance--SAMHSA last summer did a 30-State
    parity policy academy where we trained on issues related to
    parity and MHPAEA and how States can make sure that the
    appropriate attention is being paid so the people of their
    States can get the services that they need.
        Mr. Guthrie. Well thank you. And those are my two questions
    and I appreciate you being here.
        And I yield back.
        Mr. Burgess. The chair thanks the gentleman. The gentleman
    yields back. The chair now recognizes the gentleman from New
    Jersey, ranking member of the full committee, Mr. Pallone 5
    minutes for questioning.
        Mr. Pallone. Thank you, Mr. Chairman.
        Doctor, the Cures Act included provisions that specifically
    addressed child trauma. And as I noted in my opening statement
    I continue to have grave concerns about the children forcibly
    separated from their parents or guardians as a result of Trump
    administration's zero-tolerance policy.
        And I have sought information from the administration on
    whether children in the office of refugee's care may have
    experienced trauma. And my resolution of inquiry that was
    debated by the committee last week specifically requested
    documents on the long-term health implications of the family
    separation policy on the children in ORR's care.
        As HHS' leader on mental health issue, SAMHSA is uniquely
    qualified to speak to the impacts of trauma and the long-term
    health implications. So my questions are going to focus on
    this. And it is not just me that has raised concern about the
    health impacts of the family separation policy. This has been
    echoed by numerous pubic health organizations and child health
    advocates, including the American Academy of Pediatrics, the
    American Public Health Association, Trust for America's Health
    and the National Association of County and City Health
    Officials.
        So in fact the National Child Traumatic Stress Network,
    which is administered by SAMHSA, notes ``that separation from
    parents or primary caregivers is one of the most potent,
    traumatic stressors a child can experience, especially under
    frightening, sudden, chaotic or prolonged circumstances.'' What
    is traumatic or toxic stress basically, if you don't mind?
        Dr. McCance-Katz. Traumatic or toxic stress can be any of a
    number of things that an individual would experience as
    emotionally distressing and various individuals will have
    different types of responses to that. In fact, as you
    mentioned, one of them has been reported to be separation. But
    I would suggest to you that there are lots of stressors that
    these children have probably experienced in their travels to
    the United States.
        So not having seen any of these kids, not being able to
    attribute what their distress might be about, it is hard to say
    exactly what the etiology of any particular individual's
    problem might be.
        Mr. Pallone. So could you comment on how the circumstances
    of separation increase the likelihood of traumatic or toxic
    stress, could you comment on that?
        Dr. McCance-Katz. Very hard to say. What I will say is that
    if you were to look at the literature on traumatic stress, you
    would see somewhere depending on the study you look at up to 43
    percent of individuals will experience some type of traumatic
    stress in their lifetime, most of them do not go on to develop
    major mental disorders. And when you mitigate, when you relieve
    that stressor, they do recover.
        People have an amazing amount of resilience. That's why all
    of us who are exposed to some type of stress don't develop
    mental disorders, some do, we can't predict with reliability
    who will.
        Mr. Pallone. Then all the more reason why if you have had
    separation to try to get the kids back together with their
    parents, because then maybe they can recover.
        Dr. McCance-Katz. And our Department is working very hard
    on that. Our Secretary has spoken to that issue and they are
    addressing it every single day.
        Mr. Pallone. Well, I guess the problem that I have is that
    you mention that SAMHSA is not involved in the child separation
    issue that related from the zero-tolerance policy. But the
    problem is that the Cures Bill required SAMHSA to coordinate
    mental health services across the Federal Government. Do you
    think that SAMHSA as a leader of mental health care for our
    country should play a role in responding to this crisis at the
    border?
        Dr. McCance-Katz. SAMHSA has defined responsibilities. One
    of those, as you mentioned in the Cures Act, is the National
    Traumatic Child Stress Network and we do implement that and we
    work with our grantees to make sure that they are providing the
    services that are needed across this nation to serve Americans
    who may be experienced with traumatic stress and their
    children.
        It is also a decision by others as to what agencies are
    specifically involved in the day-to-day activities of any
    particular event. So SAMHSA does what it is required to do by
    the Cures Act and we stand ready to provide additional
    assistance if it were requested.
        Mr. Pallone. I don't want to put words in your mouth, but
    it sounds like you would be willing to help but maybe no one at
    the Department is asking you to. But you don't have to respond
    to that.
        I just think that it is clear that these families must be
    reunified immediately and ensure that these kids have access to
    the trauma informed prevention and mental health services in
    order to recover and mitigate the harm experienced as a result
    of this policy.
        And I will leave it at that, because my time has run out.
    Thank you.
        Mr. Burgess. The gentleman's time has expired. The
    gentleman yields back. The chair now recognizes the gentleman
    from Virginia 5 minutes for questions please.
        Mr. Griffith. Thank you very much. Mr. Chairman, thank you
    for being here today, very important topics, Cures and CARA and
    mental health are all so important. You have touched on a
    number of things.
        I am going to ask some questions that probably are not
    answerable in the 5 minutes that we have. And so I will give
    you an opportunity to answer, but recognize that I would like
    for you to think about them and come up with answers if you can
    and send them to us at a later date.
        Dr. McCance-Katz. Certainly.
        Mr. Griffith. So the first one is, in your testimony you
    discussed concerns brought up about the enforcement of parity
    protections, mental health, and other medicine or treatment. I
    was in a meeting with Secretary Acosta where he brought up
    similar concerns from the Department of Labor about the fact
    they have enforcement authority under ERISA plans, et cetera,
    but really have difficulty in the enforcement side of that. And
    so the question is what tools are necessary? What suggestions
    would you have for us about steps that we can take in the
    Federal law to ensure compliance with mental health parity and
    physical health parity? So the two are being treated the same
    in our various plans. And I will give you an opportunity, but I
    recognize that is probably an hour lecture as opposed to part
    of an answer in a 5-minute segment.
        Dr. McCance-Katz. So my quick answer to that would be that
    the question is quite an important one. It is one that I would
    want to seek legal counsel about.
        Mr. Griffith. Yes.
        Dr. McCance-Katz. And one that we will be happy to give a
    written answer to.
        Mr. Griffith. I appreciate that. And I would like an
    extended answer because these issues are all complex.
        Dr. McCance-Katz. Absolutely.
        Mr. Griffith. Switching gears, I am talking to a principal
    in one of my rural schools I represent a mostly rural district.
    And we are talking about school safety and mental health is
    obviously a major component in that. And he says look, we can
    identify a child that has some issues and send them off for
    evaluation, but because of the current state of privacy laws,
    they can't tell us what is going on. And we don't need to know
    everything that is going on in the child's life. But if there
    are some things that we need to know like are they violent, do
    they have a violent tendency, even if you don't expect them to
    do something now, is there a violent component in their
    emotional or mental issues. We can at least pay more attention,
    maybe have them checked by the office so we can look in their
    bookbag every day to see if they are bringing in contraband,
    guns or other weapons or issues that we maybe ought to be aware
    of.
        So we have got no ability to do that. And so the question
    is is there some way we can expand the knowledge base of folks?
    And we have passed some bills here to try to make it more like
    HIPAA, but that still wouldn't cover--that would be with drug
    abuse, but it still wouldn't cover the school personnel who may
    very well need to know what is going on. If you could get my
    some answers on that back, if you have something quick, that is
    great.
        Dr. McCance-Katz. So what I will tell you is this is a
    topic that is part of the Federal school safety commission that
    is one of the areas that the President has asked us to look at.
    And I will just go a little bit further, we will give you
    something in writing as well, but part of the big problem here
    is that providers, teachers, administrators don't understand
    when they can communicate. And if there is a threat already
    both HIPAA and FERPA allow communication, but this is not well
    understood. And so one of things that we really have to do is
    we have to work very hard to get that information out as to
    just what these laws allow and what they don't allow.
        Mr. Griffith. My time is running out, but I do want to jump
    in and say, so here is the dilemma you get, if there is a
    direct threat, yes, that is true or if you think they are going
    to be harmful to somebody else at that moment, but if you just
    detect that there may be a developing problem and that they may
    be a threat in the future I don't think it covers.
        Now we can certainly sit down and look at this. And so the
    school personnel would like to know what signs should we be
    looking for if this person might be starting to move further
    into their issues with mental illness that might--right now
    they are not a threat, but they have got some violent
    tendencies that we need to keep an eye on, what should we be
    looking for? They don't have a clue and they are with the child
    every day during the week, most weeks. And so they are probably
    the first people who could pick up on that.
        I am going to flip to one more, we don't have time for the
    answer, I apologize for that. And that is we did a lot of work
    here trying to figure out how we could deal with adult
    children, even if they are living in the home, have mental
    health issues, also medical issues, and how do the parents get
    to be interactive and I would love to help on that, I know Ms.
    DeGette of Colorado struggled with this at some time.
        Ms. DeGette. Yes.
        Mr. Griffith. If we can be of assistance or if there is
    something that you all have that we need to do in the code,
    this committee on a bipartisan basis wants to help. We want to
    fix the problem, but we don't want to give up all the privacy
    rights and balancing the two are tough.
        I yield back.
        Mr. Burgess. The chair thanks the gentleman. The gentleman
    yields back. The chair now recognizes the gentlelady from
    Illinois Ms. Schakowsky 5 minutes for questions.
        Ms. Schakowsky. Thank you, Mr. Chairman.
        Dr. McCance-Katz, I was going to--I guess I will ask this
    question to start, given SAMHSA's leadership on traumatic
    informed care and practice, has the Office of Refugee
    Resettlement worked with SAMHSA to ensure the children being
    held in their custody are receiving trauma informed care?
        Dr. McCance-Katz. So I can say two things about that. One
    is that the Office of Refugee Resettlement assures that these
    children are getting both physical healthcare and mental
    healthcare and they are getting that regularly. That is----
        Ms. Schakowsky. OK. And the reason I was going to say I am
    not going to ask you that because quite frankly I was pretty
    shocked by your attitude that well, we all have trauma in our
    life and most of us get over it. And they will probably get
    over. You may have heard Congressman Green enter into the
    record statements from a number of the professional health
    organizations, the American Psychiatric Association, the
    American Psychological Association, the American Public Health
    Association, the American Academy of Pediatrics. And the
    concern about the trauma.
        I want to add into the record too a couple of other
    articles of people and groups that actually weighed in that
    were victims of long ago atrocities about separation of
    children.
        So I ask unanimous consent to enter into the record two
    articles. The first from the Guardian: ``Nazis separated me
    from my parents as a child. The trauma lasts a lifetime.'' That
    is the one article.
        Mr. Burgess. Without objection.
        Ms. Schakowsky. On the second from the Anti-Defamation
    League, ``Hidden children of the Holocaust open up about border
    situation, saying policies separating migrant children from
    parents is unconscionable.'' And they have in this article
    talking about the lifelong affects which--so maybe it is fine
    that they didn't contact you about that.
        I wondered if you do have any----
        Mr. Bucshon. I object. I have an objection to submitting
    articles about the Nazis and comparing what the Nazis did to
    what the current U.S. Government's policy is in the United
    States. With clarification, I may remove my objection, but to
    compare Nazis to the United States of America is something I
    will object to and I won't allow those to be submitted to the
    record.
        Ms. Schakowsky. Well, then let me just comment on that in
    defense, particularly of the Anti-Defamation League today
    issued a statement on behalf of a group of hidden children of
    the Holocaust who felt strongly compelled to oppose the Trump
    administration's expanded ``zero tolerance'' policies.
        Mr. Bucshon. I Object, Mr. Chairman.
        Mr. Burgess. Objection is heard.
        Ms. Schakowsky. I am going to ask for the yeas and nays.
        Mr. Bucshon. We can resolve this if the gentlelady would
    recognize there is no comparison between the current United
    States Government and the Nazis.
        Ms. Schakowsky. I recognize that there isn't, but this is
    about a particular issue of separating children from their
    parents and the long-term affect.
        Mr. Bucshon. OK, I remove my objection thank you.
        [The information appears at the conclusion of the hearing.]
        Ms. Schakowsky. Thank you, I appreciate that.
        I wanted to ask you about no touching policies. I have had
    a hard time pinning down exactly what that is, if there is a
    policy, if this is being done by the particular staffs at
    particular places, because--it is unclear exactly if it is a
    firm policy. But I certainly have heard of places for example,
    and there have been articles, that a sister was not able to
    embrace her younger brother, that they were told the children
    may not touch each other, that staff may not come and hold
    children that are in great distress. I wondered what kind of
    trauma, if those decisions are trauma informed care?
        Dr. McCance-Katz. It is really not possible for me to
    comment on that, because I am not familiar with the details of
    it.
        Ms. Schakowsky. The issue of touching, are you not informed
    about the effects of touching or comforting physical touching
    when it comes to mental health?
        Dr. McCance-Katz. What I am not familiar with is the agency
    and its roles and----
        Ms. Schakowsky. No, I am asking a more general question.
    According to decades of psychological study, positive touch
    from adults cannot only lower stress levels in the most, but
    can have long-term beneficial affects if administered
    regularly. And relatedly, a consistent lack of positive touch
    has been shown to have detrimental affects on kids as they
    mature. Do you agree with that?
        Dr. McCance-Katz. I don't have an opinion on it, it is out
    of context.
        Ms. Schakowsky. Really? I am asking generally about an
    issue that you are supposedly an expert on. Trauma informed
    care. And this is not----
        Dr. McCance-Katz. Let me just tell you that touching can
    have all sorts of implications, good and bad. And so I----
        Ms. Schakowsky. Do you agree with the statement----
        Mr. Burgess. I think the witness has answered the question
    and the gentlelady's time has expired.
        I am going to go to Ms. Brooks from Indiana 5 minutes for
    questions please. Dr. Bucshon next? Dr. Bucshon 5 minutes for
    questions.
        Mr. Bucshon. All right. Thank you. Well first of all thanks
    for being here. I very much appreciate it.
        I just want to say that I am opposed to separating children
    from their families so I think all of us on both sides of the
    aisle are. But I also have serious concerns and I wasn't going
    to bring this subject up, but since it seems like my colleagues
    on the other side are staying on message on this and every one
    of them is going to talk about this, I feel that I will also. I
    am also concerned about the thousands children coming
    unaccompanied from and trekking thousands of miles across
    Mexico, being brought by coyotes and drug cartels,
    approximately 10,000.
        I have just been down there so this is information I know,
    many of whom have been sexually assaulted and abused. So I am
    concerned about them also. Just so everyone knows, we have
    about 12,000 children under our custody, 10,000 of which
    approximately are unaccompanied that came with no adult, no
    family member. It is a tragic circumstance.
        As well as the families who are coming in currently, adult
    males with children because they know that we don't have any
    beds for them in the United States and if they come, we are
    releasing with ankle bracelets into the United States, 200 to
    300 of these people per day. Again, that is not my opinion,
    that is what we are doing, because the cartels and coyotes know
    our laws and when we don't follow the law they exploit it--or
    when we do follow our law that needs to be changed and it is
    Congress' fault, when we need to adjust these things.
        But many of these people are coming in my view from the
    past failed policies most recently of the Obama administration
    on open borders and sanctuary cities and catch and release
    being encouraged to send their children thousands of miles by
    themselves. In fairness, their countries are in dire
    circumstances and I can't say what I would do, but I do know
    that the situation is much more complicated than is being
    portrayed.
        And I am also concerned about the millions of citizen
    children every day who are being abused, neglected and
    suffering traumatic problems. And we all know that that is a
    difficult circumstance, that is all I am going to say on that.
        Section 605 of Cures required SAMHSA to develop a strategic
    plan every 4 years identifying priorities, including a strategy
    for improving the mental health workforce. Additionally, your
    testimony mentions engaging subject matter experts from across
    the country, from academia hospitals, insurers, community
    providers, State governments consumers, and family to inform
    SAMHSA on the complex problems and it is a complex problem such
    as workforce challenges among other things.
        Can you expand a little bit on what SAMHSA is doing it
    address the workforce challenges, particularly in rural areas
    related to mental health? And let me just say this, I know
    because I was a healthcare provider before, one of the big
    challenges is financial support for this type of--these type of
    services.
        But can you expand on that a little bit?
        Dr. McCance-Katz. I can. And thank you for the question. So
    we have developed a new program that will be in place by
    September 30th so the end of this fiscal year that sets up both
    specialized programs around issues related to mental and
    substance use disorders. So things like the teens that I
    mentioned for the opioids crisis, we call it the State targeted
    response, we have one for veterans, we have the National Child
    Traumatic Stress initiative. We have a number of different
    types of topic-related special national programs.
        We have the new clinical support system for serious mental
    illness that will address issues around serious mental illness.
    We also are establishing technical assistance and training
    programs within each of the 10 HHS regions. Those again are
    focused on localized needs of communities because we know every
    community is different.
        We also recently have established a relationship with the
    Department of Agriculture that does a lot of rural work and so
    we are expanding our technical assistance through some of their
    initiatives into rural areas. Telehealth is a big issue for the
    Department of Health and Human Services. We have the behavioral
    health coordinating committee which includes the operating
    divisions and telehealth is a specific issue that we are
    working on to provide additional guidance to States to try to
    expand the reach of the practitioners that we have into rural
    areas.
        Mr. Bucshon. Thank you very much for that answer. Mr.
    Chairman, I yield back.
        Mr. Burgess. The chair thanks the gentleman. The gentleman
    yields back. The chair recognizes the gentlelady from
    California, Ms. Matsui for 5 minutes of questions please.
        Ms. Matsui. Thank you, Mr. Chairman.
        Dr. McCance-Katz, thank you very much it for joining us
    today. I am pleased we are hosting this hearing to discuss the
    mental health provisions in 21st Century Cures. I look forward
    to having oversight hearing of the final section of 21st
    Century Cures, including health IT and interoperability.
        Before I ask my questions about mental health and Cures, I
    have to make a comment about the mental health of thousands of
    children who have been separated their families due to
    President Trump's zero-tolerance policy. Public health, mental
    health, and pediatric experts, including the American Academy
    of Pediatrics, the American Nurses Association have voiced
    concerns about the harm caused through the stress and trauma
    incurred by children who have been forcibly separated from
    their parents. The stress and trauma not only has immediate
    harmful impact on these children, but is also damaging a long
    term impact, on a child's health and development.
        Dr. McCance-Katz, SAMHSA notes that the impact of childhood
    traumatic stress can last for far beyond childhood and that
    child trauma survivors are more likely to have long term health
    problems, including behavior health and substance use
    disorders. That is why this committee must act immediately to
    ensure that HHS is reuniting children with their parents and to
    ensure that HHS has long-term plans to mitigate the impact of
    trauma on these children.
        Now moving onto my legislative priorities for 21st Century
    Cures. I authored Title 11, the compassionate communication on
    HIPAA's section of the bill that passed into law, these
    provisions seek to clarify confusion about the HIPAA privacy
    rule as it applies in mental health scenarios. The confusion
    for patients, families, doctors, and even administrators and
    lawyers about what information can and cannot be shared
    remains.
        Cures requires that the HHS Office for Civil Rights to
    coordinate with SAMHSA and other relevant agencies to develop,
    disseminate, and periodically update model programs to train
    healthcare providers, lawyers, patients and the families on the
    permitted use and disclosure of protected health information of
    individuals seeking and receiving treatment from mental health
    or substance use disorders.
        Dr. McCance-Katz, as you know, HHS released additional
    guidance on this topic back in December. What progress has it
    made to develop model training programs?
        Dr. McCance-Katz. Well, I have a few things to tell you.
    One, is that we are working very hard with the office of civil
    rights to coordinate those efforts and one of things that we
    did just last week was to train attorneys, healthcare
    attorneys, on issues around both HIPAA and 42 CFR. In fact I
    brought a copy of the training and I will be happy to leave it
    if you would like to see it.
        Ms. Matsui. That would be great. Thank you.
        Dr. McCance-Katz. We had 1,000 attorneys on that webinar,
    that is the most you can have. And the American Bar Association
    which has possession of this now and is continuing to
    disseminate it, they said that they thought we would have 4,000
    could they have accommodated everybody that wanted to learn
    about this topic.
        We are also using this to develop something that I will
    just say is going to be in a little more simpler language for
    people like me, who are practitioners, to do special training
    for practitioners on the privacy issues. But the thing that I
    think is most exciting is that yesterday we were able to
    publish a funding announcement, we will have a national center
    on privacy. HIPAA and 42 CFR and I think that is going to make
    a huge difference.
        Ms. Matsui. How about the other stakeholders such as
    clinicians, are you going to be bringing them in too as you
    develop and disseminate these model training programs?
        Dr. McCance-Katz. Absolutely. So we will have a single
    grantee whose job it will be to train clinicians, to train
    administrators and often these will be lawyers that are
    involved in healthcare systems. But the other requirement that
    I put in that funding announcement is that we must put out
    materials for families and for patients.
        Ms. Matsui. That is really very important because many
    times this is merely misunderstood, even if we set up these
    programs, if we don't have a communication in essence to even
    have some patients come in and parents come in to understand
    what the process is, because when the family gets into a
    certain kind of situation, people don't know what to do.
        And I would hope that we would keep these training sessions
    going too, because just because we have a certain set trained,
    doesn't mean that it is all done.
        Dr. McCance-Katz. That is correct. And this will be a
    multiyear initiative.
        Ms. Matsui. OK well thank you. Yield back.
        Mr. Burgess. The chair thanks the gentlelady. The
    gentlelady yields back. The chair now recognizes the gentlelady
    from Indiana, Mrs. Brooks, for 5 minutes of questions please.
        Mrs. Brooks. Thank you, Mr. Chairman and thank you Dr.
    McCance-Katz. Thank you so much for being here as the first
    Assistant Secretary focused on these issues in this way and
    every answer you have given your portfolio is so large about so
    many issues that our constituents care about, I am having a
    hard time figuring out where to focus.
        I have to tell you as an attorney who practiced criminal
    defense in the courts. As former U.S. attorney, as someone who
    has been very involved in the criminal justice system. We know
    that 21st century Cures reauthorized and added some programs
    regarding revising the jail diversion grant programs for mental
    health in our jails. Our jails are often just overflowing, are
    often the largest institutions in many ways in counties that
    have those with mental illness.
        Can you give us any updates on these successes you have
    seen in the programs so far that we can help our local county
    jails and State prisons deal with this problem?
        Dr. McCance-Katz. Yes. And this is really a great benefit
    of the Cures Act that these kinds of resources are being made
    available.
        What we have done at SAMHSA is to fund mental health courts
    both for adults and for youth who are experiencing mental
    illness sometimes for the first time but it has involved them
    in the justice system. We also are starting programs that
    divert people prior to arrest. This is really very important
    because people who have serious mental illnesses suffer from a
    great deal of stigma. And these things when have you an arrest
    it makes it so much more difficult for you to be able to
    navigate in communities without problems.
        It makes it more difficult to get insurance. Makes it more
    difficult to get a job, makes it more difficult to get housing.
    So we like the idea of prediversion programs and we are funding
    some of those again through the abilities given to us in the
    Cures Act.
        Mrs. Brooks. And I applaud you from that, and I also think
    that what you just mentioned the National Center on Privacy and
    the fact that that many lawyers got on a call. I want to
    applaud the American Bar Association for encouraging that. And
    I believe that many, many lawyers will participate in that kind
    of training. And I want to encourage you getting the word out
    as well as my colleagues across the aisle.
        What is the best way for our constituents to learn about
    all of these grant opportunities? There just seems to be so
    many new grants, so many new programs and quite frankly we are
    having a hard time trying to help direct all of our
    constituents. We had a school shooting in my district on May
    25th. And when you talked about teachers and educators wanting
    to learn more, that is the one thing that I heard is that our
    teachers and educators are so concerned about learning more
    about whether it is the mental health first aid, whether it is
    about identifying as Congressman Griffith brought up.
        What can you share with us is the best mechanisms we can
    provide our constituents to be educated or to pursue grant
    programs, particularly for mental health in our schools, mental
    health in our communities, what are the best ways we should be
    communicating this, instead of just going to SAMHSA's website?
    And how can we have better access to the tools to provide our
    constituents?
        Dr. McCance-Katz. And so I would say that SAMHSA's website
    has that information and it is a resource.
        Mrs. Brooks. Extensive.
        Dr. McCance-Katz. It is. And we are working on how to
    simplify that and make it easier to find things. But we also
    are working on developing webinars on specific programs to talk
    to the public about what those programs are and about the
    funding opportunities that are available.
        The other thing that we will be using the system of
    regionalized training for is for these kinds of opportunities
    as well, to make it easier for those who are taking advantage
    of those regional programs to know more about what the
    opportunities are.
        So if you have an addiction transfer center for example in
    region one, the Northeast, that technology transfer center also
    can make it easier for the communities and individuals in those
    communities to find out what the resources are as it relates to
    addiction. We will have one for substance abuse prevention and
    we will also have one for mental health issues.
        We also are supplementing those mental health technology
    transfer centers to specifically work on issues related to
    schools and our children's needs. That will be happening in the
    next fiscal year and so we hope that by regionalizing the
    programs that we can get down to the community level and
    communicate better because you are so right it is very
    difficult.
        Mrs. Brooks. Thank you. I applaud all the work that your
    office is doing. It is so critically important. I look forward
    to helping you with that. I yield back.
        Mr. Burgess. The chair thanks the gentlelady. The
    gentlelady yields back.
        The chair recognizes the gentlelady from Florida, 5 minutes
    for questions, please.
        Ms. Castor. Thank you, Mr. Chairman.
        Dr. McCance-Katz, thank you for being here today. You have
    a very significant responsibility as Assistant Secretary for
    Mental Health and Substance Use, and I want to thank you for
    taking on this very important assignment. I have reviewed your
    bio. You have great experience and a number of degrees from
    outstanding institutions, so I think your expertise is needed
    here in this area.
        I want to ask you about the long-term mental health
    implications of child traumatic stress caused by the family
    separation policy. You have heard the concern from colleagues
    here today. And we are reflecting the concern that we are
    hearing back home all across the country.
        But I would like to ask you about child traumatic stress
    caused by the family separation policy on those children that
    have been forcibly separated from their families. I know you
    cannot get into specific cases. But based upon your extensive
    expertise, I would like you to comment in general.
        At this point, many public health organizations have
    stressed that ``the practice of separating children from their
    loved ones and caregivers for an extensive period of time is a
    threat to public health, inflicting serious trauma, and
    threatening long-term irreversible health effects.''
        Do you agree?
        Dr. McCance-Katz. This is a form of trauma.
        Ms. Castor. What are some of the serious long-term
    irreversible health effects that could result from family
    separation?
        Dr. McCance-Katz. So I can't speak to family separation per
    se. I don't know who might develop a mental disorder that will
    have long-term implications for them. None of us do.
        Ms. Castor. That kind of runs counter to everything we are
    hearing from organizations, the leading mental health
    organizations and public health organizations, from across the
    country.
        Dr. McCance-Katz. The President has directed that families
    not be separated further. Secretary Azar has made it very clear
    that our job is to reunite these families. We are working very
    hard at HHS to do that. These children are in a safe
    environment. The practitioners there are all licensed within
    the States that these facilities----
        Ms. Castor. You would not have recommended this policy at
    the outset, would you have?
        If they came to you as the Assistant Secretary, would you
    have recommended this policy? Were you asked? Were you
    consulted?
        Dr. McCance-Katz. There are a number of different policy
    implications there, and----
        Ms. Castor. I am not trying to play gotcha. I am curious. I
    know Secretary Azar, I believe he said he was not consulted.
    Were you asked as the Assistant Secretary for Substance Use
    Mental Health?
        Dr. McCance-Katz. Asked what?
        Ms. Castor. Before the family separation policy was
    implemented?
        Dr. McCance-Katz. I was not consulted about that.
        Ms. Castor. OK. We know that there is a significant body of
    evidence detailing the public health implications of adverse
    childhood experiences. Would you consider the forceable
    separation of children from their parents to be an adverse
    childhood experience?
        Dr. McCance-Katz. I would consider separation from parents
    to be an adverse experience. And I would also remind you that
    these children are getting physical healthcare and mental
    healthcare, and they are getting that very regularly.
        Ms. Castor. Thank you.
        It is likely that this forceable separation already
    compounds upon other adverse childhood experiences these
    children have faced in their home countries such as witnessing
    domestic violence or gun violence.
        Do these experiences have a cumulative effect?
        Dr. McCance-Katz. Depending on the individual, the reality
    is that most people have a great deal of resiliency. And when
    they can get their mental health issues addressed, and these
    children are getting mental healthcare in these facilities,
    then we hope that they will not go on to have any adverse
    affects.
        Ms. Castor. Well, the CDC and Kaiser Permanente adverse
    childhood experiences study found many long-term health impacts
    of adverse childhood experience, including the risk of
    disrupted neural development, social, emotional, and cognitive
    impairment, and heightened risk for disease, disability, and
    social problems.
        Can you explain some of the specific physical and mental
    health problems that can result from adverse childhood
    experience?
        Dr. McCance-Katz. There are a variety of different types of
    mental disorders that can be a result of adverse experiences.
        Ms. Castor. And there are risk factors for behavioral
    health and substance use disorders specifically, correct?
        Dr. McCance-Katz. That is true.
        Ms. Castor. There was a recent news report that said----
        Mr. Burgess. I believe the gentlelady's time has expired.
        Ms. Castor. Well, I would ask the courtesy most members
    have gotten an additional 30 seconds. I just want to ask about
    funding shifts at HHS, because there is a recent report that
    HHS has quietly dipped into tens of millions of dollars to pay
    for what has happened through family separation. The Department
    has burned through at least $40 million in the past 2 months.
        I am just wondering, has that impacted your shop at SAMHSA?
    Have you been asked to shift any moneys out that were
    previously directed towards SAMHSA?
        Dr. McCance-Katz. SAMHSA has not had any direct effect----
        Ms. Castor. Thank you very much Mr. Chairman.
        Mr. Burgess. That response is negative, and the gentlelady
    yields back.
        The chair recognizes the gentleman from Florida, 5 minutes,
    please.
        Mr. Bilirakis. OK. Thank you very much. I appreciate it,
    Mr. Chairman.
        Dr. McCance-Katz, in accordance with Section 13002 of
    Cures, I understand that SAMHSA last year convened a public
    listening session on mental health parity involving 15 in-
    person groups with an additional 40 comments submitted via
    email and in writing.
        Can you provide us with a high level summary of those
    comments? How were these comments addressed through SAMHSA's
    action plan? And do you plan to host another meeting with
    industry stakeholders?
        Dr. McCance-Katz. Yes, we did hold that listening session.
    And the comments that we received were around need for
    education around the Parity Act and how individuals who
    experience what they believe to be pari violations would get
    assistance that they need. And what are the responsibilities of
    States and insurers around these issues.
        SAMHSA is in the process of developing a guidance on that,
    and that should be out before the end of this calendar year is
    what I was told prior to this hearing. So I am giving you the
    information that I have available to me.
        Mr. Bilirakis. OK. Thank you very much.
        In your testimony, you mentioned that over 7.4 million
    children and youth in our nation have a serious mental health
    disorder while only 41 percent actually receive treatment
    leaving the vast majority untreated. The 41 percent are the
    ones that were identified, so it could be even more than that.
        So, as you know, it is a serious issue. And I am glad that
    the chairman is holding this hearing and we are taking this
    issue very seriously. It really is an epidemic.
        And In addition to supporting systems of care, how is
    SAMHSA working with industry to address workforce shortage
    issues?
        Dr. McCance-Katz. So when you think about what type of
    problem we have, we have an urgent problem, we have an urgent
    need to get more services to Americans who are living with
    these kinds of conditions. What is the fastest way to do that?
    By the way, it is not going to be by opening more medical
    schools. That is going to take too long.
        And so when I think about this, I have to think about how
    can I get services to Americans. I can do it by training and
    providing technical assistance that will prepare practitioners
    to intervene and to provide care and treatment for mental and
    substance use disorders. And that is why so much attention,
    since I have come to SAMHSA----
        Mr. Bilirakis. So when you talk about practitioners, are
    you talking about psychologists, psychiatrists, or primary care
    physicians who would get additional training?
        Dr. McCance-Katz. All of the above.
        Mr. Bilirakis. All of the above.
        Dr. McCance-Katz. All of the above. And so we are setting
    up programs of regional training and technical assistance. We
    also have speciality programs. We are working very hard to
    disseminate that information so that clinicians and
    practitioners, psychiatrists, psychologists, nurse
    practitioners, physician assistants, counselors, social
    workers, and primary care doctors would be able to take
    advantage of these kinds of trainings. That allows them to get
    specialized kinds of skills and provide that service to their
    clients.
        Now, the other thing that I would say is that we are
    working to set up programs through our grant-funded
    organizations that will provide ways that practical assistance
    can be provided. So, for example, in the State targeted
    response funds that Cures provided, the States can contract
    with providers that provide specialized opioid treatment
    services. We also have a grant program at SAMHSA. It is called
    MAT-PDOA, which just means medication assisted--it is a way to
    implement medication assisted treatment.
        Those programs provide practical experience. So we have the
    ability to provide didactic classroom style webinar, web-based
    training, but then the ability within regions of the country
    where people can go and see this in practice. And we think that
    that is a way to better assure that practitioners will feel
    confident enough and able to use a new skill set to provide
    care when Americans need it.
        We also continue to support programs called SBIRT,
    Screening, Brief Intervention, Referral to Treatment. We also
    encourage primary care to continue to----
        Mr. Bilirakis. How does that work now in the schools? How
    are we going to identify the kids that have these issues? And
    is the burden going to be always on the teacher? Where do you
    go next once they are diagnosed?
        I know it is very expensive. The treatment centers and a
    lot of the insurance companies do not cover.
        Mr. Burgess. And the gentlemen----
        Mr. Bilirakis. And even if they do, the co-pays are so very
    high and the deductibles.
        I am sorry, Doctor.
        Mr. Burgess. The gentleman's time has expired.
        Mr. Bilirakis. OK. All right.
        Mr. Burgess. The gentleman from Georgia has been waiting
    very, very patiently here all day. Perhaps that question could
    be responded to in writing.
        The gentleman from Georgia is recognized for 5 minutes.
        Mr. Carter. Thank you, Mr. Chairman.
        Dr. McCance-Katz, thank you for being here. And thank you
    for what you do for the children, particularly of our citizens.
    We appreciate that very much. I know a lot of this hearing has
    gotten a little bit off base, but I want you to know that we
    appreciate what you are doing for our citizens here.
        I am sorry to have to report to you that Georgia is not
    doing so good with mental health services. In fact, we rate
    about 47th out of 50. And that is one of the things that
    bothers me. And, in fact, it is estimated that we have less
    than 20 percent of the beds that we need for mental health
    services in the State of Georgia as well. Particularly when it
    comes to childhood mental health, we have got 159 counties in
    the State of Georgia, and only 76 of them have a licensed--or
    76 do not have a licensed psychologist. We have got, again, 159
    counties, 52 of them have no licensed social worker.
        All of these figures are alarming to us, and alarming to me
    in particular because of the fact that in the State of Georgia,
    for those children between the ages of 15 and 19, the second
    leading cause of death is suicide. And for those between 10 and
    14, the third leading cause of death is suicide.
        So all of that leads me to ask you, Cures reauthorized the
    children's mental health initiative, and that provided a lot of
    grants and a lot of assistance that we are very appreciative
    for. But I just wanted to ask you, particularly in the State of
    Georgia, we have a lot of rural areas, particularly in south
    Georgia, in my district, a lot of rural areas. And I am just
    wondering how do we get services to those areas? Any
    suggestions on how we can improve services there?
        Dr. McCance-Katz. So SAMHSA has supported two types of
    integrated care programs. One is where behavioral health
    providers would be able to be part of a team in a primary care
    program such as a federally qualified health center.
        The second way is through programs such as our certified
    community behavioral health clinics that bring primary care
    directly into a behavioral health setting. So that a person can
    easily access all the care and services that they need in one
    setting.
        SAMHSA, as you know, has limited funds. We do
    demonstrations. We work closely in terms of establishing those
    demonstrations and then doing more technical assistance in
    training and try to establish those programs on a national
    level. We talk with our colleagues at the Centers for Medicare
    and Medicaid Services.
        Mr. Carter. OK. What about telemedicine? Telehealth,
    telemedicine. Is that something that we should be focusing more
    on?
        Dr. McCance-Katz. Yes. And I was just about to get there.
        Mr. Carter. I am sorry.
        Dr. McCance-Katz. So, yes, telehealth is a very important
    piece of it, particularly for areas that have a lot of large
    rural communities.
        Mr. Carter. Right.
        Dr. McCance-Katz. Telehealth can really extend the reach of
    a practitioner who may be in a more urban area but can--and so
    the Department of Health and Human Services has a committee
    that is working on telehealth guidance for the States and, in
    addition to that, is working with, for example, the Drug
    Enforcement Administration around issues of prescribing so that
    we can utilize those telehealth providers to the very best
    extent.
        Mr. Carter. Great.
        Are there grants specifically for that, or are they just
    included in the regular grants that you can use it for that
    purpose?
        Dr. McCance-Katz. We have, at SAMHSA, part of a larger
    grant program that our telehealth services come from and I
    believe that other parts of HHS, such as HRSA, have specific
    funding for telehealth services.
        Mr. Carter. Great.
        Another thing I want to talk about real quickly is the
    opioid addiction and the funds that have been going there, the
    grants that have been going there. We have been very fortunate.
    The Georgia Department of Behavioral Health and Developmental
    Disabilities has gotten over almost $12 million. And I want to
    report back to you, because I have been a part of some of these
    programs. And it is working well, and it is been utilized well.
    In fact, one of the cities, and I want to give them a shout-
    out, the city of Pembroke, Georgia, in my district, in Bryan
    County, has been very active in this and has implemented a
    number of programs that have media campaigns, school
    partnerships. A number of programs that have been very
    successful.
        Can you elaborate just very quickly on what else we might
    be doing with that?
        Dr. McCance-Katz. So the opioids crisis is one of Secretary
    Azar's priorities.
        Mr. Carter. And this committee's priority.
        Dr. McCance-Katz. Yes. And we are very grateful to Congress
    for the increase in funding to address these issues.
        So what we have to do is to work very hard to integrate
    substance abuse treatment, opioid addiction treatment, into
    primary care settings in addition to having speciality care
    available. We know that people find it very difficult to access
    care, and so we want to broaden the number of providers that
    are willing to engage in the care and to use innovative
    practices, such as telehealth, this is why we are working with
    the Drug Enforcement Administration, to make it possible for a
    clinician to have a greater reach and to reach Americans in
    those rural areas that have such difficulty accessing.
        Mr. Carter. Great.
        And thank you again for your work.
        And I yield back.
        Mr. Burgess. The chair thanks the gentleman. The gentleman
    yields back.
        Seeing that all members have had the opportunity to ask
    questions, I want to again thank our witness for taking time to
    be here with us today.
        Pursuant to committee rules, I remind members they have 10
    business days to submit additional questions for the record.
    And I ask our witness to submit responses within 10 business
    days upon receipt of those questions.
        Without objection, the subcommittee is adjourned.
        [Whereupon, at 12:30 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

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