[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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