[Senate Hearing 115-707]
[From the U.S. Government Publishing Office]
S. Hrg. 115-707
IMPLEMENTATION OF
THE 21ST CENTURY CURES ACT:
RESPONDING TO MENTAL HEALTH NEEDS
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING IMPLEMENTATION OF THE 21ST CENTURY CURES ACT, FOCUSING ON
RESPONDING TO MENTAL HEALTH NEEDS
__________
DECEMBER 13, 2017
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Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
27-981 PDF WASHINGTON : 2019
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky AL FRANKEN, Minnesota
SUSAN M. COLLINS, Maine MICHAEL F. BENNET, Colorado
BILL CASSIDY, M.D., Louisiana SHELDON WHITEHOUSE, Rhode Island
TODD YOUNG, Indiana TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas ELIZABETH WARREN, Massachusetts
LISA MURKOWSKI, Alaska TIM KAINE, Virginia
TIM SCOTT, South Carolina MAGGIE WOOD HASSAN, New Hampshire
David P. Cleary, Republican Staff Director
Lindsey Ward Seidman, Republican Deputy Staff Director
Evan Schatz, Democratic Staff Director
John Righter, Democratic Deputy Staff Director
(ii)
C O N T E N T S
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STATEMENTS
WEDNESDAY, DECEMBER 13, 2017
Page
Committee Members
Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor, and Pensions, opening statement......................... 1
Murphy, Hon. Christopher, a U.S. Senator from the State of
Connecticut, opening statement................................. 3
Murray, Hon. Patty, Ranking Member, Committee on Health,
Education, Labor, and Pensions, prepared statement............. 5
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana,
opening statement.............................................. 6
Witnesses
McCance-Katz, Elinore F., M.D., Ph.D., Assistant Secretary for
Mental Health and Substance Use, Substance Abuse and Mental
Health Services Administration, Rockville, MD.................. 7
Prepared statement........................................... 9
IMPLEMENTATION OF
THE 21ST CENTURY CURES ACT:
RESPONDING TO MENTAL HEALTH NEEDS
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Wednesday, December 13, 2017
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:03 a.m. in
room SD-430, Dirksen Senate Office Building, Hon. Lamar
Alexander, Chairman of the Committee, presiding.
Present: Senators Alexander [presiding], Cassidy, Young,
Casey, Franken, Bennet, Whitehouse, Murphy, Warren, Kaine, and
Hassan.
Opening Statement of Senator Alexander
The Chairman. The Senate Committee on Health, Education,
Labor, and Pensions will please come to order.
This morning, we are holding a hearing entitled ``The
Implementation of the 21st Century Cures Act: Responding to
Mental Health Needs.''
Senators Cassidy and Murphy were the leaders in this
Committee on mental health reform and in the Senate, and those
reforms were included in our 21st Century Cures Act.
Senator Murray is not here today, so she has asked Senator
Murphy to fill in for her.
I have asked Senator Cassidy to chair most of this hearing,
or at least until 11:45. I will come back and attend it, but I
think it is appropriate that Senators Cassidy and Murphy chair
the hearing, especially given their extensive work in the area,
and their leadership in enacting the legislation last year.
After our witness testifies, Senators will have 5 minutes
of questions.
Sean Lester is, by all accounts, a typical busy Nashville
young adult with a full time job, who also attends college.
In June 2014, 2 days before his 25th birthday, he
experienced his first schizophrenic experience. Since then,
Sean has been admitted to the Vanderbilt Psychiatric Hospital
five times, spending 10 weeks receiving psychiatric treatment.
Sean recently wrote me saying, ``This may seem slightly
depressing, but my story does not end there. The doctors and
staff I encountered at the hospital and the Centerstone Clinic
taught me to live productively again in society. I have been
free of the hospital for a whole year now. During that time, I
have taken medication, returned to work, and even paid off a
car. I am currently enrolled in Tennessee State University as a
junior pursuing a degree in psychology.''
Sean is one person out of nearly 10 million in the United
States with a serious mental health condition. Without this
treatment, his story could have had a very different outcome.
In Tennessee, about 1 in 5 adults have a mental illness,
according to the Tennessee Department of Mental Health and
Substance Abuse. That is more than 1 million Tennesseans. Over
230,000 of them have what is considered a serious mental
illness.
Over the past few years, this Committee has worked in a
bipartisan way to update parts of the Federal mental health
system including programs at the Substance Abuse and Mental
Health Services Administration, which we call SAMHSA, for the
first time in over a decade.
As I said at the beginning, this effort was championed by
Senators Cassidy and Murphy, as well as Senator Collins and
other Members of this Committee.
The reforms were part of the Mental Health Reform Act,
which passed this Committee on March 16, 2016 and were included
in the 21st Century Cures Act, which Majority Leader McConnell
called, ``The most important legislation Congress passed last
year.''
Today marks the third hearing on the implementation of the
Cures legislation. We hope the updates in this law will help
more Americans access quality, evidence-based mental health
care.
As I said when we began hearings on the Every Student
Succeeds Act, a law is not worth the paper it is printed on if
it is not implemented properly, and I intend to ensure that the
21st Century Cures Act is fully and properly implemented as
well.
Our focus today is to hear how SAMHSA is implementing the
mental health provisions in Cures. Of the 10 million Americans
with a serious mental health illness--and that includes severe
schizophrenia, bipolar disorder, and major depression--millions
go without treatment as families struggle to find care for
loved ones.
Most of the services and treatments for people with mental
illness are provided by the private sector such as Vanderbilt,
or through programs run by the states. The largest role in the
Federal Government is the amount of money spent through
Medicaid in partnership with the states.
The Federal Government also plays a role through SAMHSA
which, while relatively small compared to Medicaid and the
responsibility states have, is critically important to
improving the availability and quality of prevention
screenings, early intervention and treatment programs, and
recovery services.
Tennessee received over $80 million in SAMHSA grants last
year.
Prior to our work on Cures, Federal mental health programs
had not been updated in over a decade, and the coordination
between Federal agencies was not as effective as it could have
been. I hope today we will learn more about how implementation
of those provisions is going. How has coordination improved
among Federal agencies on the best way to assist those with
mental illness?
For example, we hope that promising research into early
intervention programs at the National Institutes of Health
would translate into clinical applications for patients.
We also included updates to the SAMHSA block grants to
states to ensure that funding is best meeting the needs of
those suffering from mental illness.
In addition to improve the care patients receive, we
encouraged the adoption of proven scientific approaches to
treatment. So I would like also to hear how the agency started
to incorporate more evidence-based approaches for treating
mental health.
We also hope the reforms would help increase integration
between primary care and mental health care, ensure that
insurance coverage for mental health disorders is comparable to
insurance coverage for other medical conditions, and strengthen
suicide prevention efforts.
Dr. McCance-Katz, our witness today, serves as the first
Assistant Secretary for Mental Health and Substance Use, a
position we created in the 21st Century Cures Act.
She has new authorities through Cures to work with states
and Federal agencies, and help more Americans receive the
treatment they need.
I look forward to hearing about the progress being made to
ensure more people can receive the help they need, and have
positive outcomes like Sean.
I would now like to turn the chairing of this hearing over
to Senator Cassidy. Senator Murphy will make an opening
statement, then Senator Cassidy will make a statement, and then
Senator Cassidy, you can take it from there.
Thank you very much.
Senator Cassidy [presiding]. Thank you.
Opening Statement of Senator Murphy
Senator Murphy. Thank you very much, Chairman Alexander.
Thank you to both you and Ranking Member Murray for holding
this important hearing. Thank you to Senator Murray for
allowing me to sit in her place and to Senator Cassidy for
years of our partnership on this issue.
It is indeed fitting that we are holding this hearing on
the 1-year anniversary of President Obama signing the
legislation that established this new position at the
Department of Health and Human Services.
Dr. McCance-Katz is the first-ever Assistant Secretary for
Mental Health and Substance Use, a position that is long
overdue.
It is also almost 5 years to the day since the terrible
tragedy at Sandy Hook Elementary School, when a young man, with
serious mental illness, killed 20 first graders and 6 adults.
Now, let us be clear, there is no inherent connection
between mental illness and violence. America has no more mental
illness than any other country, and yet, we have a gun violence
rate that is 20 times higher than comparable nations. But we
also know that when people fall through the cracks of our
fractured mental health system, it can have a devastating
impact.
In the aftermath of that tragedy, Republicans and Democrats
were able to come together to pass the Mental Health Reform
Act, which was part of the 21st Century Cures Act. It
represents the first comprehensive overhaul and reauthorization
of our Nation's mental health laws in a generation.
It was supported by the mental health community. It
garnered equal support from both parties, and it could not have
happened without the bipartisanship of this Committee, which
is, of course, a testament to Chairman Alexander and Ranking
Member Murray.
I think the legislation's most important provision is the
part that built upon the Mental Health Parity and Addiction
Equity Act by strengthening enforcement of that law and making
it more transparent for Americans.
Still, there are two recent reports that illustrate how far
we still need to go to fully achieve that vision of parity.
A couple of weeks ago, NAMI released its third nationwide
parity report, which found that more than 1 out of 3
respondents with private insurance had difficulty finding a
mental health therapist, compared with only 13 percent
reporting difficulty finding a medical specialist.
Similarly, Milliman released a study that found that
insurers pay primary care providers 20 percent more for the
same types of care that they pay addiction and mental health
specialists, including psychiatrists. In many states, the
disparities in payment rates were two to three times greater,
rates higher for medical doctors for people practicing medicine
below the neck than those who are practicing medicine above the
neck.
Fortunately, the 21st Century Cures Law provides additional
authority to the Trump administration on parity, and I hope
that we will begin to see these provisions implemented soon.
The law also created the position of the Assistant
Secretary, as I mentioned. This was an important step to make
sure that there was one person at the top of the leadership of
the department who is solely focused on these issues. We also
codified the role of the Chief Medical Officer within SAMHSA to
work closely with you.
Other provisions include several grant programs to improve
coordination of mental health treatment, the creation of the
first-ever infant and early childhood mental health grants.
There is a section of the bill that promotes workforce
development.
After hearing from consumers and providers about how there
was confusion around HIPAA and when it was allowable to share
personal health information, we included new authorization for
HHS to develop educational materials to help patients, and
clinicians, and family members better understand when these
disclosures can take place.
There are other elements of the bill that will likely come
up today, but we have to remember that none of the programs
that we authorized in this bill matter if we do not fund them.
Congress has an awful habit of talking a really good game
on mental health and addiction, but then never being willing to
actually meet our rhetoric with resources. The current Labor-
HHS appropriations bill does not yet include funding for the
new programs in the bill we passed last year.
Even worse, the health repeal bill, that Republicans tried
to push through the Senate earlier this year, would have cut
Medicaid funding over time by $800 billion. Medicaid, of
course, is the Nation's primary payer for mental health
treatment.
But the legislation that we passed as part of the 21st
Century Cures Act is still groundbreaking. If properly funded,
it will save lives.
I am deeply thankful, again, to the Committee for their
work in making this bill possible and for calling this hearing.
Last, I would just like to ask unanimous consent that
Ranking Member Murray's opening statement be placed in the
record.
Senator Cassidy. Without objection.
Senator Murphy. Thank you.
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Opening Statement of Senator Murray
Chairman Alexander, thank you. And thank you to all our colleagues
for joining us this morning.
One year ago today, President Obama signed into law the 21st
Century Cures Act. This was an important bipartisan step forward.
Together, we took significant action to improve the lives of patients
and families.
We made progress to advance life-saving medical research and
innovative products; tackle some of our hardest-to-treat diseases, like
cancer and Alzheimer's; and address a truly urgent health threat facing
our country today: the opioid epidemic--a crisis that each year kills
tens of thousands and that continues to worsen each day.
Like all my colleagues, I've heard from far too many people in my
home State of Washington--of all ages and background--about the ways
substance use disorders, including opioid use disorder, are ruining
lives and tearing families apart. And I've heard from countless of
local, state, and national health leaders about the impact addiction
has had on an already overtaxed mental health system and what that
means for patients suffering from serious mental illnesses.
As I've said before, these are issues that do not discriminate.
They are issues that can reach anyone--and they can reach anywhere. And
so I want to touch on a couple key points.
As Democrats have made clear, when it comes to combating the opioid
crisis improving policy isn't enough. We need new investments and
resources--and we need them as quickly as possible.
While we must do more, I am proud that Cures took an important
first step and dedicated $1 billion in new funding--above and beyond
the budget caps--to help states and communities fight back against this
opioid crisis. And that we secured important changes to ensure this
money went directly to states critically in need.
Along with this new funding, Cures advanced important bipartisan
mental health reforms. For one, we prioritized expanding access to
quality care for mental illness and substance use disorders. We
strengthened coordination between local and Federal agencies engaged in
crisis intervention. And we invested more resources to strengthen our
behavioral health workforce.
Now, these efforts are already making a real difference for so many
nationwide--that much is certain. But as I have long said, a law is
only as good as its implementation, and so we need strong congressional
oversight of Cures to ensure its full potential is realized.
I am glad to have Dr. McCance-Katz from the Substance Abuse and
Mental Health Services Administration here with us today. I'm looking
forward to your updates on implementing many of the mental health and
substance use disorder provisions in Cures, and I am interested in your
thoughts on what more is needed.
As you know, I am very concerned with President Trump's failure to
meaningfully respond to the opioid crisis. Again, what's needed to make
a real difference in the lives of patients and families struggling from
addiction are real, immediate resources to fight this battle on the
ground. But so far, and despite their own analysis pointing to its
urgent need, the Trump administration has repeatedly failed to identify
any additional funding to battle the epidemic.
I want to hear more from you about that, as well your views on
resources for addressing all mental health and substance use disorders;
what more we can do to protect the civil rights of individuals with
serious mental illness; and your thoughts on improving training for law
enforcement and others to better understand individuals with substance
use and mental health challenges.
I am proud of the steps we took in Cures when it comes to mental
health and substance use disorders. And I believe we can say with
confidence that our work is having a real impact for patients and
families, and that we are moving in the right direction when it comes
to the law's implementation.
One year later, I would urge all our colleagues to remain mindful
that many of the public health challenges we sought to address with
Cures--particularly substance abuse and misuse--are only growing more
urgent. And so it is not only important that we get implementation
right, but that we also keep pushing to do more in the near-and long-
term.
Thank you.
______
Statement of Senator Cassidy
Senator Cassidy. As many of you know, I am a physician who
worked for 25 years in Louisiana's charity hospital system, and
I learned a couple of lessons.
One, that when the patient has the power, the system lines
up to serve the patient where she or he gets the need that she
or he needs.
But what I have also observed is that those with serious
mental illness have no power. Their ability to act upon the
resources that are available is lost by the disorder which is
in their mind.
Now, this is not just an experience for a fellow who has
worked in a public hospital for the uninsured. It is the
experience of us all, whether it is a family member, an
associate, someone we went to high school with. We all know
someone who seemed to have such promise and that promise was
snuffed out by serious mental illness. And their ability to
execute power totally lost because of that.
Now, Government has a role and Government has a role at its
best to help those who are most vulnerable. There has been a
tangle of efforts by Government to attempt to help those who
have serious mental illness.
I was so privileged to work with Senator Murphy and others
on this Committee for the Mental Health Bill of 2016. We
created the position that Dr. McCance-Katz is the first to hold
to create the authority to untangle this mess. To somehow take
this whole mishmash--some effective, some not, some would be
effective if coordinated--of Government programs and line them
up to help those with serious mental illness.
We are now about the 1-year anniversary of that bill's
signing and this is a hearing to look at the effectiveness of
this. And let me say, sometimes these committees are
confrontative. This is about collaboration and cooperation. How
do we work together with this newly created position so that we
can better serve those folks who have lost their power for
almost anything because of serious mental illness?
My goal is that when that 24-year-old has her first
psychotic episode, it is her last psychotic episode. And when
she is 50 years old, she does not look back upon that single
event as a life-defining event leading up to the breakup of her
marriage, loss of her children, loss of her health. But rather,
she looks back upon it as a distant memory from which she grew
and actually became a better person.
That is the goal of all of us. We look forward to your
testimony today, Dr. McCance-Katz, as to how ultimately we
restore wholeness and return power to that patient.
So thank you for being here, and now I will make your
introduction.
I am very pleased to welcome Dr. Elinore McCance-Katz to
today's hearing. Dr. McCance-Katz is the Assistant Secretary
for Mental Health and Substance Use at the Substance Abuse and
Mental Health Services Administration.
The 21st Century Cures Act created the office of Assistant
Secretary for Mental Health and Substance Use, replacing the
role of SAMHSA Administrator.
Dr. McCance-Katz formerly served as the Chief Medical
Officer for the Rhode Island Department of Behavioral Health
Care, Developmental Disabilities, and Hospitals. Before that,
she served as Chief Medical Officer for SAMHSA.
Welcome, again, Dr. McCance-Katz.
You have 5 minutes to give your testimony and we shall hear
from you now.
STATEMENT OF ELINORE F. MCCANCE-KATZ, M.D., PH.D., ASSISTANT
SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION, ROCKVILLE, MD
Dr. McCance-Katz. Thank you so much, Senator Cassidy,
Senator Murphy, and Members of the Health, Education, Labor,
and Pensions Committee.
Thank you for inviting me to testify at this important
hearing today.
One year ago today, the 21st Century Cures Act was signed
into law, and the Substance Abuse and Mental Health Services
Administration has been actively implementing its provisions in
concert with our colleagues of the Department of Health and
Human Services, state and local governments, tribal entities,
and other key stakeholders.
For over 25 years, I have served people with serious mental
illness and serious substance use disorders. It is such a
privilege for me, and an honor for me to serve as the first
Assistant Secretary for Mental Health and Substance Use.
As the Assistant Secretary, I take my duties seriously. The
Cures Act has asked that the Assistant Secretary look at
disseminating research findings and evidence-based programs to
improve prevention and treatment services, ensure that grants
are subject to performance and outcome evaluations, consult
with stakeholders to improve mental health services for those
with serious mental illness, and children with serious
emotional disturbances. And we, and I, work actively on that.
Part of strengthening leadership and accountability at
SAMHSA includes a strong clinical perspective at the agency.
The Cures Act codifies the role of the Chief Medical
Officer and we have taken this further by expanding the office
of the Chief Medical Officer to include two additional
psychiatrists 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 will promote evidence-based practices and service
delivery models through evaluating models that would benefit
from further development and through expanding, replicating, or
scaling evidence-based practices across a wider area.
The Interdepartmental Serious Mental Illness Coordinating
Committee, what we call ISMICC, was established by the Cures
Act to ensure better coordination across the Federal Government
to address the needs of individuals with serious mental illness
and serious emotional disturbances, as well as their families.
I was pleased to chair the first meeting of the ISMICC in
last August, which was attended by key leaders in Federal
Government, as well as 14 highly qualified, non-Federal
members. The ISMICC 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 justice-
involved; Making it easier to obtain evidence-based behavioral
healthcare, and; Developing finance strategies to increase
availability and affordability of care.
As required by the Cures Act, the ISMICC Report will be
delivered to Congress today. I just show you this. We are very
pleased to bring it to Congress on time and I hope that you
will be pleased with it.
The Cures Act reauthorized the Community Mental Health
Services Block Grant and codified the first episode of
psychosis set-aside. The set-aside is vitally important to
ensuring that individuals developing SMR receive timely and
appropriate treatment if we can intervene early with needed
treatment in psychosocial services, people are better able to
live with their illnesses similar to other chronic health
conditions.
I strongly support the reauthorization in the Cures Act of
Assisted Outpatient Treatment or the AOT program. In Fiscal
Year 2016, SAMHSA implemented an AOT grant program and awarded
17 grants.
SAMHSA has partnered with the Assistant Secretary for
Planning and evaluation to implement a cross site evaluation,
which will assess the effectiveness and impact of this program.
One very important area that the Cures Act addressed was
suicide prevention. In 2015, over 44,000 Americans died by
suicide and there are over 1.1 million suicide attempts
annually in the United States.
The Cures Act authorized SAMHSA existing National Suicide
Prevention Lifeline. In 2017, the Lifeline has already answered
over 1.67 million calls, surpassing by 100,000 those recorded
for all of 2016, and we are not done with 2017 yet.
Suicide remains the second leading cause of death for
individuals 15 to 24 years old. The Cures Act reauthorized the
Garrett Lee Smith Memorial Act, which provides grants to states
and tribes to reduce youth suicide and suicide attempts.
At the same time, the highest rate of suicide in America is
among adults 45 to 64 years old. Prior to the Cures Act, there
was no authorized suicide prevention program for adults at
SAMHSA. We are grateful for the authorization of the Adult
Suicide Prevention Program in Cures, and for Congress's funding
of the program in Fiscal Year 2017. As a result, we have
awarded grants for Zero Suicide, which is a program that
implements suicide prevention and intervention programs within
health systems.
Ensuring children and adolescents at risk for, and living
with, behavioral health conditions receive services and support
they need was a key element of the Cures Act.
The National Child Traumatic Stress Initiative was
reauthorized by the Cures Act and has provided resources to
communities and individuals impacted by natural disasters and
other traumatic events impacting the mental health of all
Americans.
As directed by the Cures Act, SAMHSA is working
collaboratively with the HHS Office of Civil Rights on guidance
that will clarify permitted uses and disclosures of protected
health information by healthcare professionals under HIPAA to
improve communication with caregivers of adults with serious
mental illness in order to facilitate treatment.
With the passage of the Cures Act, we continue to recognize
the critical role of behavioral health parity in ensuring
equitable, high quality health and behavioral healthcare for
all Americans.
SAMHSA has conducted two Parity Policy Academies to improve
parity implementation in the commercial insurance market,
Medicaid, and the Children's Health Insurance Program.
The HHS Parity Website has been updated to include
information from a public listening session, as has the
Insurance Parity Portal, which provides information for
individuals who may have experienced a parity violation.
Much work has been undertaken at SAMHSA and across HHS to
implement the Cures Act, but we know this work is far from
over. There are many more individuals and families struggling
with mental and substance use disorders that need help.
I look forward to continuing a strong partnership with
Congress to help these people and their families, and to
answering your questions.
[The prepared statement of Dr. McCance-Katz follows:]
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Prepared Statement of Elinore F. McCance-Katz
Chairman Alexander, Ranking Member Murray, and Members of the
Senate Health, Education, Labor, and Pensions Committee, thank you for
inviting me to testify at this important hearing. One year ago today,
the 21st Century Cures Act (Cures Act) was signed into law, and the
Substance Abuse and Mental Health Services Administration (SAMHSA) has
been actively implementing many of the provisions in coordination with
our colleagues at the Department of Health and Human Services (HHS),
State and local governments, tribal entities, and other key
stakeholders.
The Cures Act touches on so many important issues. The Act
strengthens leadership and accountability for behavioral health at the
Federal level \1\, ensures mental health and substance use disorder
prevention, treatment, and recovery programs keep pace with science and
technology \2\, supports State prevention activities and responses to
mental health and substance use disorder needs \3\, promotes access to
mental health and substance use disorder care, and strengthens mental
and substance use disorder care for children and adolescents \4\. We at
SAMHSA appreciate your leadership and dedication in enacting new
authorities to reduce the impact of substance abuse and mental illness
on America's communities.
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\1\ 21st Century Cures Act, Pub. L. No. 114-255, Title VI, 130
Stat. 1033 (2016).
\2\ Id. at Title VII.
\3\ Id. at Title VIII.
\4\ Id. at Title X.
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In my testimony, I will highlight how SAMHSA is implementing some
of the key provisions of the Cures Act and how it is benefiting the
behavioral health community and, most importantly, individuals living
with mental illness and/or addiction and their families.
Strengthening Leadership and Accountability
I am humbled and honored to serve, thanks to the Cures Act, as the
first Assistant Secretary for Mental Health and Substance Use. As the
Assistant Secretary, I take seriously my duties as outlined in the
Cures Act such as maintaining a system to disseminate research findings
and evidence-based programs to service providers to improve prevention
and treatment services; ensuring that grants are subject to performance
and outcome evaluations; consulting with stakeholders to improve
community-based and other mental health services including for adults
with serious mental illness (SMI) and children with serious emotional
disturbances (SED); collaborating with other departments (such as the
Department of Veterans Affairs, Department of Defense, the Department
of Housing and Urban Development (HUD), and the Department of Labor
(DOL)) to improve care to veterans and service members and support
programs to address chronic homelessness; and working with stakeholders
to improve the recruitment and retention of mental health and substance
use disorder professionals \5\. SAMHSA is a small agency with a small
budget, but it has a very important mission. We must use our resources
wisely and focus on the most pressing issues: those of SMI and the
opioid crisis.
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\5\ Id. at Sec. 6002.
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Strengthening leadership and accountability at SAMHSA includes
ensuring a strong clinical perspective at the agency. The Cures Act
codifies the role of the Chief Medical Officer and we have taken this
further by expanding the Office of the Chief Medical Officer to include
two additional psychiatrists and a nurse practitioner. The Office of
the Chief Medical Officer responsibilities include:
Serving as a liaison between SAMHSA and providers;
Assisting the Assistant Secretary in evaluation,
organization, integration, and coordination of SAMHSA programs;
Promoting evidence-based and promising practices; and
Coordinating internally and externally to assess the
use and ensure the utilization of appropriate performance
metrics.
The Office of the Chief Medical Officer is strategically positioned
within SAMHSA to facilitate the development of policy, practice, and
programs that comport with best practices and current trends in
contemporary health care.
The Cures Act codified the Center for Behavioral Health Statistics
and Quality, which serves as the Federal Government's lead agency for
behavioral health statistics. The Center for Behavioral Health
Statistics and Quality conducts national surveys tracking population-
level behavioral health issues, and a new Office of Evaluation will be
responsible for conducting SAMHSA's program evaluations. For example,
the Center for Behavioral Health Statistics and Quality data collection
efforts include the National Survey on Drug Use and Health and the
Treatment Episode Data Set. The Center for Behavioral Health Statistics
and Quality also is responsible for collecting Government Performance
and Results Act data from our grantees. The Center for Behavioral
Health Statistics and Quality will also be developing a standardized
evaluation with specific questions related to each program that will
inform us about the functioning of programs, and help us to determine
whether programs are meeting stated goals in serving Americans living
with behavioral health disorders and their families.
The Interdepartmental Serious Mental Illness Coordinating Committee
was required by the Cures Act to ensure better coordination across the
entire Federal Government related to addressing the needs of
individuals with SMI and SED and their families. I was pleased to chair
the first meeting of the Interdepartmental Serious Mental Illness
Coordinating Committee in late August which was also attended by
Secretary Carson of HUD and many other key leaders in the Federal
Government as well as 14 non-Federal members. The Interdepartmental
Serious Mental Illness Coordinating Committee has been working within
five workgroups that focus on:
1. Strengthening Federal coordination to improve
care;
2. Closing the gap between what works and what is
offered;
3. Reducing justice involvement and improving care
for those who are justice involved;
4. Making it easier to obtain evidence-based
behavioral health; and
5. Developing finance strategies to increase
availability and affordability of care.
Tomorrow morning, December 14, we will be holding a press event to
release the first Interdepartmental Serious Mental Illness Coordinating
Committee Report to Congress which will be followed by the second
public meeting of the Interdepartmental Serious Mental Illness
Coordinating Committee. The report includes recommendations from the
non-Federal members of the Committee and sets the stage for intensive
work by the Interdepartmental Serious Mental Illness Coordinating
Committee in the years ahead. The meeting will focus on next steps for
the Committee. HHS leadership and staff look forward to working with
the other Federal departments represented on the Committee, as well as
the non-Federal public members of the Committee and Congress, in order
to improve Federal coordination and the systems that serve people
living with SMI.
Ensuring Mental Health and Substance Use Disorder Prevention, Treatment
and Recovery Programs Keep Pace with Science and Technology \6\
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\6\ Id. at Title VII.
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The Cures Act created the National Mental Health and Substance Use
Policy Laboratory (Policy Lab). The Policy Lab will promote evidence
based practices and service delivery models through evaluating models
that would benefit from further development and expansion. In
particular, the Policy Lab will focus on schizophrenia and
schizoaffective disorder, as well as other SMI. It will also focus on
evidence-based practices and services for addiction with focus on
opioids.
The responsibilities of the Policy Lab include: to identify,
coordinate, and facilitate the implementation of policy changes likely
to have a significant effect on mental health and mental illness; to
work with the Center for Behavioral Health Statistics and Quality to
collect information from grantees under programs operated by the
Administration in order to evaluate and disseminate information on
evidence-based practices, including culturally and linguistically
appropriate services and service delivery models; to provide leadership
in identifying and coordinating policies and programs, including
evidence-based programs, related to mental illness and substance use
disorders \7\; to periodically review programs and activities operated
by the Administration relating to the diagnosis or prevention of,
treatment for, and recovery from, mental illness and substance use
disorders, including identifying any such programs or activities that
are duplicative and are not evidence-based, effective, or efficient.
---------------------------------------------------------------------------
\7\ Id. at Sec. 7001.
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Supporting State Prevention Activities and Responses to Mental Health
and Substance Use Disorder Needs \8\
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\8\ Id. at Title VIII.
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The Cures Act reauthorized the Community Mental Health Services
Block Grant and codified the first episode psychosis set-aside. This
set-aside is vitally important to ensuring that people with SMI receive
appropriate treatment. If we can intervene early and provide needed
treatment and psycho-social services, people are able to manage their
SMI as chronic health conditions. I want to share with you one success
story from the first episode psychosis program.
Jesse (whose name has been changed to protect privacy), is a 26
year old African American male. Jesse experienced his first
episode of psychosis during his senior year of college. He was
able to graduate, but was hospitalized shortly thereafter.
Jesse's symptoms were primarily delusional in nature and
centered on his beliefs that various people and influential
groups were trying to surveil him, harm him, and ultimately
ruin his future. This challenging combination of symptoms
resulted in Jesse suffering through four hospitalizations over
the course of 6 months before being referred to the first
episode psychosis program. Jesse's challenges with accepting
his illness and allowing treatment to proceed as recommended
complicated his situation. For example, Jesse stopped taking
medications frequently, particularly early in treatment.
As Jesse began to develop trust with the team of providers, he
opened up to the idea of medications and other treatments. As
time passed he began to increase his participation in all
aspects of the program, and a significant improvement was
observed. This progress was interrupted when Jesse opted to
stop medications half-way through his time in the program. This
discontinuation resulted in a hospitalization. Since that
hospitalization Jesse has started a long acting injectable
antipsychotic medication in order to improve his follow through
and maintain his functioning. Jesse is now approaching the end
of 2 years in the program and things have changed significantly
for him. He recently accepted his first full time job with
competitive pay and benefits.
Promoting Access to Mental Health and Substance Use Disorder Care \9\
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\9\ Id. at Title IX.
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The Cures Act reauthorized many critical programs at SAMHSA such as
Projects for Assistance in Transition from Homelessness. The Projects
for Assistance in Transition from Homelessness program funds services
for people with SMI experiencing homelessness. These include outreach,
screening, and referral services to get people with mental health and
substance abuse issues off the streets and into housing, as well as the
primary healthcare, mental health and substance abuse treatment, job
training and other services to help them be successful in staying
housed.
The Cures Act reauthorized the Assisted Outpatient Treatment
program. Assisted outpatient treatment programs are court-supervised
treatment that take place in the community, sometimes referred to as
``(involuntary) outpatient commitment.'' In fiscal year 2016, SAMHSA
implemented an Assisted Outpatient Treatment grant program and awarded
17 grants through the program. A variety of program types are eligible
for these grants, including, county and city mental health systems,
mental health courts, and any other entities with authority under the
law of the State in which the grantee is located to mandate Assisted
Outpatient Treatment. This 4-year pilot program is intended to
implement and evaluate new Assisted Outpatient Treatment programs and
identify evidence-based practices in order to reduce the incidence and
duration of psychiatric hospitalization, homelessness, incarcerations,
and interactions with the criminal justice system, while improving the
health and social outcomes of individuals with an SMI. This program is
designed to work with families and courts to allow these individuals to
obtain treatment while continuing to live in the community and their
homes. Grants were awarded to applicants that have not previously
implemented an Assisted Outpatient Treatment program. SAMHSA has
partnered with the Assistant Secretary for Planning and Evaluation and
the National Institute of Mental Health (NIMH), a component of the
National Institutes of Health, to implement a cross-site evaluation
that will assess the effectiveness and impact of the Assisted
Outpatient Treatment grant program. Additional program outcomes to be
evaluated will include the rates of incarceration, employment,
healthcare utilization, mortality, suicide, substance use,
hospitalization, homelessness, and use of services. SAMHSA continues to
consult with NIMH, the Attorney General, and the Administration for
Community Living on this pilot program. In addition, SAMHSA is working
with families and courts in the implementation of this program.
Assertive Community Treatment is another important program for
people with SMI, and SAMHSA is grateful that the Cures Act authorized a
program for Assertive Community Treatment. SAMHSA's fiscal year 2018
Budget requested $5 million dollars for the Assertive Community
Treatment program. Assertive Community Treatment is an evidence-based
practice considered one of the most effective approaches to delivering
services to people with SMI and has been disseminated by SAMHSA for
widespread use through its Evidence-Based Toolkit series beginning in
2008. Assertive Community Treatment was developed to reduce re-
hospitalization and improve outcomes on discharge. Assertive Community
Treatment is designed as a coordinated care approach to provide a
comprehensive array of services, including medication management and
other supportive services, directly rather than through referrals. An
Assertive Community Treatment team is composed of 10-12
transdisciplinary behavioral health staff--including psychiatrists,
nurses, peer specialists and others--working together to deliver a mix
of individualized, recovery oriented services to approximately 100
people with SMI to help them to integrate into the community. Assertive
Community Treatment caseloads are approximately one staff to every 10
individuals served. The services are provided 24 hours, 7 days a week
and as long as needed, wherever they are needed. Teams often find they
can anticipate and avoid crises. If funded in the final appropriations
bill, in fiscal year 2018 SAMHSA will award grants, to states,
counties, cities, tribes and tribal organizations, mental health
systems, healthcare facilities, and other clinical entities to
establish, maintain or expand Assertive Community Treatment programs.
Special consideration will be given to applicants that serve those
adults with SMI who are high utilizers of healthcare and social
services including homeless and justice involved populations. In
addition, technical assistance and a program evaluation will be
supported. The program evaluation will include public health outcomes
inclusive of mortality, suicide, substance use, hospitalization; rates
of homelessness and involvement with the criminal justice system;
patient and family satisfaction with program participation, and;
service utilization and cost.
One important area that the Cures Act addressed is suicide
prevention. In 2015, 44,193 Americans died by suicide; according to
National Survey on Drug Use and Health statistics, there were
approximately 1,104,825 suicide attempts in the United States annually.
The Cures Act authorized SAMHSA's existing National Suicide Prevention
Lifeline (Lifeline). In 2017, the Lifeline has already answered
1,670,118 calls, surpassing by over 100,000 calls those recorded for
2016. The Lifeline projects that over 2 million calls will be answered
by the end of the calendar year. Last month, we received the following
comment on the Lifeline website:
I just wanted to message you guys to let you know that you
saved my life--quite literally--and I need to thank you. I
believe I looked up your number what will be 2 years ago in
exactly a week. I had a plan to take my own life, and I was
going to go through with it. For some reason, there was a small
part of me that wanted to live, but I couldn't figure out why
so I called you. For the life of me, I cannot remember the
woman's name, but she was the kindest, most empathetic person
I've ever had the privilege to talk to. I don't even remember
what we talked about, really. I don't think it was anything
important. But she reminded me that I was a living, breathing
person who had thousands of opportunities ahead of me. Of
course, it took me a long time after this to completely regain
my dedication to life, but I'm well on my way there. I do have
ups and downs, of course, but I am still moving forward every
day. I am so sorry that I can't remember this woman's name, but
whoever you are, thank you. And thank you all for saving my
life. I'm now going to my dream school, studying things that I
love, and I could not be happier.
Suicide remains the second leading cause of death for individuals
15-24 years old. The Cures Act reauthorized the Garrett Lee Smith
Memorial Act, which provides grants to states and tribes to reduce
youth suicide and suicide attempts. At the same time, the highest rate
of suicide in America is among adults 45-64 years old. Prior to the
Cures Act, there was no authorized suicide prevention program for
adults at SAMHSA. SAMHSA is grateful for the authorization of the adult
suicide prevention program in Cures and for Congress' funding of the
program in Fiscal Year (FY) 2017. In fiscal year 2017, SAMHSA awarded
three grants for the Zero Suicide program. The purpose of this program
is to implement suicide prevention and intervention programs within
health systems for people who are 25 years of age or older. The
comprehensive, multi-setting approach will raise awareness of suicide,
establish referral processes, and improve care and outcomes for
individuals who are at risk for suicide. The program funds three
grantees (The New York State Office of Mental Health, the Choctaw
Nation of Oklahoma, and the University Health System in San Antonio,
Texas) at a total cost of $7.5 million. SAMHSA also provided five
grants under the Cooperative Agreements to Implement the National
Strategy for Suicide Prevention program. The purpose of this program is
to support states in implementing the 2012 National Strategy for
Suicide Prevention goals and objectives focused on preventing suicide
and suicide attempts among adults, ages 25 and older, to reduce the
overall suicide rate and number of suicides in the United States. This
$7 million program supports five grantees (University of Central
Florida--supporting the Florida Implementation of the National Strategy
for Suicide Prevention, Massachusetts State Department of Mental
Health, Maine Department of Health and Human Services, Tennessee State
Department of Mental Health and Substance Abuse Services, and the Utah
Department of Human Services).
Strengthening Mental and Substance Use Disorder Care for Children and
Adolescents \10\
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\10\ Id. at Title X.
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Ensuring children and adolescents at risk for and living with
behavioral health conditions receive the services and supports they
need was a key element of the Cures Act, and SAMHSA is implementing
many of these elements. Since the Cures Act passed, our Nation has
faced several natural disasters and man-made traumatic events that have
impacted the mental health of all Americans, but especially children
and adolescents. The National Child Traumatic Stress Initiative was
reauthorized by the Cures Act and has provided resources to communities
and individuals impacted by these tragedies. As one example, the
National Child Traumatic Stress Initiative conducted a Psychological
First Aid Train the Trainer course for the State of Texas in response
to Hurricane Harvey. Participants were selected from HHS-contracted
behavioral health providers, giving priority to those regions most
impacted by Hurricane Harvey.
SAMHSA has also been working with the Health Resources and Services
Administration and stakeholders to advance screening and treatment for
maternal depression. In alignment with the Cures Act, SAMHSA continues
to fund screening for depression in specific grant programs (e.g.,
Pregnant and Postpartum Women, Project Linking Actions for Unmet Needs
in Children's Health (LAUNCH)), and participates in Federal interagency
collaborations providing expertise regarding depression screening in
federally supported family services programs (e.g., Department of
Agriculture/Women, Infants and Children program; Health Resources and
Services Administration /Maternal and Child Health Bureau Home Visiting
Programs). SAMHSA's toolkit, ``Depression in Mothers: More Than the
Blues,'' (available in English and Spanish) has garnered widespread
interest and uptake among family service providers. In August 2017,
SAMHSA consulted with researchers, practitioners, consumers and family
members to determine priority areas for practice and policy related to
maternal depression, with a particular focus on low-income women; to
identify best practices in screening, treatment, and innovative,
technology-based interventions; to more broadly integrate this issue in
medical settings, particularly among obstetricians/gynecologists,
family practice, and pediatric medicine; and to identify gaps in
training and workforce development. A guidance document is being
prepared based on suggestions from this feedback.
It is estimated that over 7.4 million children and youth in the
United States have a serious mental disorder. Unfortunately, only 41
percent of those in need of mental health services actually receive
treatment. Created in 1992, SAMHSA's Children's Mental Health
Initiative addresses this gap by supporting ``systems of care'' for
children and youth with SED and their families, in order to increase
their access to evidence-based treatment and supports. The Cures Act
reauthorized the Children's Mental Health Initiative which provides
grants to assist states, local governments, tribes, and territories in
their efforts to deliver services and supports to meet the needs of
children and youth with SED.
The Children's Mental Health Initiative supports the development,
implementation, expansion, and sustainability of comprehensive,
community-based services that use the systems of care approach. Systems
of care is a strategic approach to the delivery of services and
supports that incorporates family driven, strength-based, and
culturally and linguistically competent care in order to meet the
physical, intellectual, emotional, cultural, and social needs of
children and youth throughout the United States. The systems of care
approach helps prepare children and youth for successful transition to
adulthood and assumption of adult roles and responsibilities. Services
are delivered in the least restrictive environment with evidence-
supported treatments and interventions. Individualized care management
ensures that planned services and supports are delivered with an
appropriate, effective, and youth-guided approach. This approach has
demonstrated improved outcomes for children at home, at school, and in
their communities. For example, Children's Mental Health Initiative
grantee data show that suicide attempt rates fell over 38 percent
within 12 months after children and youth accessed Children's Mental
Health Initiative--related systems of care services. In addition,
school suspensions/expulsions fell over 42 percent and unlawful
behavior fell over 40 percent within 18 months of children and youth
beginning systems of care related services and supports.
SAMHSA's fiscal year 2018 Budget requested that Congress allow
SAMHSA the ability to develop and implement a services research
demonstration effort as part of the Children's Mental Health Initiative
based on the North American Prodrome Longitudinal Study funded by NIMH.
During the prodrome phase, a disease process has begun but is not yet
diagnosable or, or potentially, inevitable. The demonstration will
address whether community-based intervention during this phase can
prevent the further development of SED and ultimately SMI. The project
will examine the extent to which evidence-based early intervention for
young people at clinical high risk for psychosis can be scaled up to
mitigate or delay the progression of mental illness, reduce disability,
and/or maximize recovery. The new effort would be funded from a 10
percent set-aside of the base program and would focus on youth and
young adults who are identified to be at clinical high risk for
developing a first episode of psychosis. If funded, the grantees would
focus on this population in order to support the development and
implementation of evidence-based programs providing community outreach
and psychosocial interventions for youth and young adults in the
prodrome phase of psychotic illness.
Other Priority Implementation Activities
As discussed in the hearing held by this Committee on October 5th
regarding the Federal response to the opioid crisis, SAMHSA continues
to work closely with states on their implementation of State Targeted
Response (STR) grants. On October 30, 2017, notification was sent to
all Governors indicating that the fiscal year 2018 funding allocation
for the program will remain the same as it was in the first year of the
program. On November 17, 2017, SAMHSA announced the availability of $1
million in supplemental funding for 1 year to enhance STR activities in
areas of the greatest need, as determined by the highest rates of
overdose deaths in 2015 according to the Centers for Disease Control
and Prevention data.
As directed by the Cures Act, SAMHSA is working collaboratively
with the HHS Office for Civil Rights on guidance that will clarify
existing permitted uses and disclosures of health information under the
Health Insurance Portability and Accountability Act of 1996 by
healthcare professionals to improve communication with caregivers of
adults with SMI in order to facilitate treatment. In January 2017,
SAMHSA issued a final rule related to Confidentiality of Substance Use
Treatment Records and a Supplemental Notice of Proposed Rulemaking. The
final rule facilitates the sharing of patient data for research
purposes; increases patient choice to disclose more broadly, such as in
integrated healthcare settings; updates the rule to be more compatible
with electronic health records; and clarifies requirements for audits.
The Supplemental Notice of Proposed Rulemaking sought public input
related to the role of contractors, subcontractors, and legal
representatives in the healthcare system with respect to payment and
healthcare operations. Since the final rule was issued, SAMHSA has been
providing technical assistance, developing a final rule related to the
Supplemental Notice of Proposed Rulemaking, and working on additional
guidance documents to help patients better understand their choices. In
line with the Cures Act, SAMHSA will be convening relevant stakeholders
early next year to determine the effect of the regulation on patient
care, health outcomes and patient privacy.
With the passage of the Cures Act, specifically section 13002,
Congress recognized the critical role behavioral health parity plays in
ensuring equitable, high-quality health and behavioral healthcare for
all Americans. Section 13002 called for the convening of a public
listening session and the creation of a parity action plan for
increased enforcement of behavioral health parity.
The listening session was held on July 27th, 2017. More than 15
groups provided public comment in person and a total of 40 comments
were received via email or in writing. The Public Listening Session was
concurrently webcast and attended in person by more than 75
individuals. All comments are available on the HHS website at, https://
www.hhs.gov/programs/topic-sites/mental-health-parity/achieving-parity/
cures-act-parity-listening-session/comments/index.html in addition to a
recording of the event https://www.youtube.com/watch'v=BcA-JS3fOj8.
Comments were received from various stakeholder groups including
insurance representatives, employers, behavioral health providers, and
patients or their advocates. The most common concerns cited by
commenters were the need for more guidance from Federal agencies,
transparency from insurance companies as to parity analysis and
coverage decisions, and enforcement of parity protections. The
forthcoming Action Plan will include strategies and action steps to
address these comments.
In March and April 2017, in collaboration with DOL, HHS's Center
for Consumer Information & Insurance Oversight and HHS's Center for
Medicaid and CHIP services, SAMHSA conducted two parity policy
academies to provide technical assistance for improved parity
implementation in the commercial insurance market, the Medicaid program
and the Children's Health Insurance Program programs. In addition, the
HHS parity website has been updated to include information from the
Public Listening Session as well as the Parity Portal which provides
information for individuals who may have experienced a parity
violation.
Conclusion
Much work has been undertaken at SAMHSA and across HHS to implement
the Cures Act, but we know this work is far from over. There are many
more people and their families struggling with mental illness and
addiction that need help. I look forward to continuing a strong
partnership with Congress to help these Americans. The Cures Act has
served to focus attention and resources on the needs of Americans
living with SMI and addiction, and their families. Congress has
provided a blueprint for addressing these needs, and we at SAMHSA
greatly appreciate their efforts.
______
Senator Cassidy. Senator Murphy, would you like to go
first?
Senator Murphy. Thank you, Mr. Chairman.
Thank you, Dr. McCance-Katz. We are very excited that you
are doing fantastic work in this position. You have a lot on
your plate, but we are excited about some of the early
deliverables.
I wanted to maybe first ask you to talk a little bit more
about this question of integration, and you referenced it in
your testimony.
But I would like you to talk a little bit more about the
work that can be done at HHS and through CMS to try to bring
together our behavioral health system and the rest of our
healthcare system. Whether the proper ways to do that are
working through state governments, whether there are new
payment mechanisms that we could develop through CMS to try to
marry together these systems.
It is an anachronism, the idea that we have one system of
healthcare for your neck down and then you have to walk across
town to find somebody that will treat the rest of your body. It
is a slow progression to fix that, in part, because of the way
that we fund mental health and mental health services.
So there is at least one grant program at SAMHSA that is
designed to take this on, but tell me what you have been doing
since you have been on the job to try to promote integration.
Dr. McCance-Katz. Yes, so thank you for that question
because I think we are doing a fair amount.
We have funded programs that are bidirectional and that was
through the Cures Act so that behavioral healthcare can be put
into primary care settings, and primary care into behavioral
health settings.
We also have a program that, again, Congress brought into
being a couple of years ago and is now in the process of
implementation and that is for the Certified Community
Behavioral Health Centers.
These are programs that are focused on behavioral
healthcare, but require that both serious mental illness
treatment and substance use disorder treatment, as well as
physical healthcare, can be in the same setting for individuals
primarily diagnosed with mental disorders. So that is very
important.
We work collaboratively with CMS. We are talking with them
about what kinds of innovations they might be able to look at
in terms of ongoing funding.
I will personally advocate for the continuation of CCBHC,
the Certified Community Behavioral Health Center program,
because even though we have an evaluation out, we know that
FQHC's work very well and they work very well because they
integrate care, and they pay for that care. And that is the
other thing about the CCBHC's.
We have CMS that is providing the payment for services. I
think that is going to be very important to establishing these
kinds of Centers.
We also work collaboratively at SAMHSA with other operating
divisions that provide direct care including HRSA, which is a
much larger organization than we are, but we provide a lot of
technical assistance and opportunities for training for their
providers on behavioral health issues; same with the Indian
Health Service.
I have also, since I started, had my Chief Medical Officer
establish a relationship both with HRSA and the Indian Health
Service to make sure that these things move forward.
Senator Murphy. Often states regulate behavioral healthcare
centers, and their primary care of federally Qualified
Healthcare Centers, through different agencies.
When they try to combine, they often have some just simple
regulatory hurdles, like the numbers of fire drills are
different in the two different locations. So when they go onto
one site, they often are being overregulated.
I hope that is something that you will help states try to
overcome.
One final question on HIPAA, I mentioned it in my
testimony. A lot of confusion out there in the community as to
what clinicians can share with family members and with
caregivers. We gave you the ability to develop some new
guidance to try to make it clearer, I think, mostly to
providers about when they are actually able to share
information with a mom, or a dad, or a caregiver.
I know you are working with the Office of Civil Rights
within HHS on guidance, but I just wanted you to give us an
update on when we might be seeing that come forward. I think it
would be really helpful to everybody in the community.
Dr. McCance-Katz. Yes, I can definitely comment on that.
For one thing, I think, today you will get a series of
informational documents from the Office of Civil Rights that
further clarify when information can be shared. We spoke about
that, I spoke with them, actually, yesterday at HHS about it.
So they told me that would be delivered to Congress today just
as our ISMICC Report is coming to you today.
A few weeks ago, the Office of Civil Rights put out
guidance to practitioners about what can be shared in emergency
settings.
So one of the big sources of confusion has been when a
person comes into an emergency department, for example, with an
opioid overdose, can that information be shared with
caregivers, with loved ones? And often, it has not been shared
because, mistakenly, practitioners think this is covered by 42
CFR, the Federal confidentiality statutes related to substance
abuse treatment.
This is not substance abuse treatment. This is treatment of
a medical emergency and under HIPAA, we are able to share that.
But also, it is also true that there are exceptions under 42
CFR.
We have had one guidance go out to practitioners about what
they can share under emergency situations. That went out in
November.
We are working on another document that will further
clarify both HIPAA and 42 CFR in the same document. I like
these to be short and easily digested by practitioners.
I can tell you, just last week, I was at a national meeting
of substance abuse treatment providers and the issue of sharing
information was one of their main issues. And so I am really
grateful to Congress for the direction on this.
Senator Murphy. Thank you for taking it so seriously.
Thank you.
Senator Cassidy. Dr. McCance-Katz, I am going to ask you to
be very kind of tight with your answers because I have a lot to
ask you.
Let me just follow-up quickly with what Senator Murphy just
asked you about. That is great that you are coming out with
this HIPAA guidance.
Now, is there any plan, do you have the ability to turn
this into a Continuing Medical Education credit, or a legal
credit, or a nursing credit? Because I find those sorts of
things can be trees fallen in the forest, but if you make it a
CEU right before the end of the year, and everybody has to get
their credits in, it has a little bit more bang.
Dr. McCance-Katz. Exactly.
We have a number of different types of training programs at
SAMHSA. They address a wide variety of topics and the issue of
sharing information.
Senator Cassidy. But will these specifically be in
continuing education credits?
Dr. McCance-Katz. Absolutely.
Senator Cassidy. Wonderful.
Dr. McCance-Katz. So our programs offer this at no cost to
providers. We have the Provider's Clinical Support System
oriented toward physicians, nurse practitioners, and P.A.'s
mainly. We have the Addiction Technology Transfer Center.
Senator Cassidy. But you also have to get your continuing
legal credits, I will just say that, because it is going to be
the lawyer that they are calling in the middle of the night
saying, ``Hey, listen. Can I share information?'' And if the
lawyer says no, they are not going to do it.
Dr. McCance-Katz. So you are exactly right about that, and
as somebody who has worked in a hospital setting, I can tell
you that they can be a very big barrier to sharing information.
Senator Cassidy. Lawyers a problem? I cannot imagine, but
anyway.
Dr. McCance-Katz. But actually, our Chief Medical Officer,
one of the things that she is working on is developing a
network with hospitals and the National Hospital Associations
to exactly address these kinds of issues.
Senator Cassidy. Okay. Let me, then, go on.
In our legislation, collectively ours, we have reporting
requirements. And clearly, you just have to measure or else
this could be money which is wasted.
So first, has SAMHSA put those state plan requirements in
place for the Fiscal Year 2018 block grants? How are you
measuring compliance by the states in terms of reporting? And
how does SAMHSA take into consideration compliance with the
reporting section and how well states are performing when they
decide to award a grant?
Dr. McCance-Katz. So we have a required Government
reporting system that is used by all of our grantees, including
the states, in the block grant funding.
I will tell you that I am not satisfied with the data as it
is currently collected. I think that we could do a much better
job of getting information, and that requires a certain set of
steps that we need to go through.
But I will tell you since I have started, we have made good
progress on that, and we will be approaching the OMB to further
hone those questions that will be more informative about
programs.
Senator Cassidy. Now, let me ask as well, because I have
actually spoken to colleagues about this.
Medicaid is not required to robustly report data. I
understand when it comes to mental health, it is called
braiding of SAMHSA block grants with Medicaid dollars, with
Medicare dollars, et cetera. And it is all put together for a
package.
CMS has one set of reporting requirements and SAMHSA has
another.
Has there been any initiative between SAMHSA and CMS to
somehow coordinate these reporting requirements, perhaps to
unlock some of what CMS holds, but SAMHSA could use?
You see where I am going with this?
Dr. McCance-Katz. I do see where you are going with it, and
what I can tell you is this.
Part of the role of the Assistant Secretary position is to
reach out to other divisions, other agencies, other
departments. And so, I have asked for a meeting with CMS. That
will be happening soon and this is one of several topic areas
that we will be addressing.
I have talked to folks at SAMHSA about this. They say this
is a big hurdle. That they do not know a way that we could,
right now, pair those data, because I do understand what you
are getting at. But I will be talking with CMS about that and
see if we cannot bring people together to look at that.
Senator Cassidy. Let me just also say, again, as I said in
the beginning, this is about collaboration and cooperation.
I suspect Senator Murphy, but certainly my staff, would
love to meet with your staff as to how we facilitate that.
Because right now, we are paying a lot of money as the Federal
Government for Medicaid and we have some pretty poor outcomes
in Medicaid. When you control for everything, you still have
poor outcomes.
And so, we need to have better reporting requirements and
if it takes a statute to make that happen or some sort of
oversight, sometimes that just makes it work better.
Do you want to work on that?
Senator Murphy. Okay.
Senator Cassidy. So at least Murphy's and Cassidy's staffs
would like to meet with your staff regarding that.
Dr. McCance-Katz. Got it.
Senator Cassidy. Okay?
I have some other questions, but I am almost out of time.
So now, I think I go to Senator Franken.
Senator Franken. Thank you, Mr. Chairman.
Good to see you again, doctor.
When I meet with people in Minnesota who are struggling
with mental illness and substance use disorders, I often hear
about the stigma people experience. Mental illnesses are often
not regarded as physical conditions. Rather sometimes seen as
moral failings, and we all know that is just not the case.
My predecessor, Senator Paul Wellstone, made it his life's
work to fight for people with mental illness, pushing
ceaselessly for mental health parity. One of my greatest
honors, as Senator from Minnesota, has been to carry forward
his work on mental health and championing policies that promote
parity.
I am proud that the Affordable Care Act expanded parity
protections to people who do not have employer sponsored
coverage and seek care through the individual market. And the
21st Century Cures Bill extends these efforts by calling on the
Federal Government, and other key stakeholders, to generate an
action plan to improve enforcement of mental health parity
laws.
Dr. McCance-Katz, in your testimony, you referred to the
listening session that the Administration held this past July.
Patients, advocates, and providers explained that many times,
people cannot find in-network providers, face high out of
pocket costs, and have to fight with insurance companies just
to get services covered.
Stakeholders called for more enforcement, transparency from
insurance companies, and agency guidance.
The actions the Administration has taken thus far fall
short of these demands.
What will you commit to doing in your new role to improve
transparency from insurance companies and transform the Parity
Portal into a meaningful resource for consumers?
Dr. McCance-Katz. Yes, thank you, Senator Franken.
I will tell you, that is a work in progress.
One of the reasons that I agreed to come back into Federal
service is because I want to advocate for people living with
mental and substance use disorders. And so, I am going to be an
advocate for as long as I am in this position.
One of the things that, I think, is very important is for
people to be able to get access to care, and when they have
barriers that are put in place by arbitrary insurer limits, it
is unfair.
So I am working with people at HHS around this Parity
Portal to try to make it something that will be more functional
for consumers.
Right now, it has been updated, so that at least people
will be shunted to either social or to the Department of Labor,
depending on what their problem is.
But I would like to see this be something much greater and
something that consumers can actually use to get information.
Senator Franken. Okay.
Dr. McCance-Katz. But it will take time.
Senator Franken. I am so glad to hear you say that.
For years, we have heard a growing and urgent cry for help
from clinicians and tribal leaders about the opioid epidemic
and, in particular, its impact on Indian country.
That is why in the Indian Affairs Committee, I asked Indian
Health Service Acting Director, Admiral Weahkee, how the
Administration could address this issue and the opioid epidemic
in Indian country more broadly.
He recommended that we first bring Tribes to the table, and
second, consider community and culturally specific drug abuse
prevention and treatment programs.
I pushed for language in the 21st Century Cures Act to
ensure the leaders at SAMHSA consider the unique needs and
circumstances of vulnerable subpopulations, including Native
Americans, in their programs.
What are you doing to support and expand culturally based
treatment programs for individuals living in Indian country,
especially those suffering with opioid addiction and other
substance disorders? And as part of your answer, can you
describe how you are engaging with tribal communities and
working to develop and implement these culturally specific
programs?
Dr. McCance-Katz. Yes. We actually have an Office of Tribal
Affairs at SAMHSA. We have ongoing meetings with tribal
leadership.
When I came to SAMHSA, I learned that one of the Addiction
Technology Transfer centers that was specifically put in place
to assist tribal nations was going to end. That has now been
funded. There is a funding announcement out.
Senator Franken. Very good.
Dr. McCance-Katz. We will choose a grantee who will work
with Tribes and meet their cultural needs as well as their
substance abuse needs.
We also work, as I mentioned, with the Indian Health
Service. Our Chief Medical Officer is meeting with theirs and
working with them around what kinds of technical assistance and
training needs do they recognize and that SAMHSA can help them
with.
We have, and I will not take a lot of time, but we have a
lot of training programs that really are quite good.
Senator Franken. Yes, thank you, because I am out of time.
Before the hearing, I spoke to you about supportive
housing.
Dr. McCance-Katz. Yes.
Senator Franken. I want to continue that conversation with
you even as I leave this body because, I think, that is very
important that people with mental health disorders, and with
addiction, get supportive housing and wraparound services.
So thank you for engaging in that conversation before the
hearing.
Dr. McCance-Katz. Thank you, sir.
Senator Franken. Thank you, Mr. Chairman.
Senator Cassidy. Senator Whitehouse.
Senator Whitehouse. Thank you, Chairman. Appreciate it.
Dr. McCance-Katz, welcome. Good to see you again before the
Committee.
Dr. McCance-Katz. Thank you.
Senator Whitehouse. We, in the negotiations around CARA and
the Cures Act, got a bipartisan commitment for an extra billion
dollars to be spent on opioid treatment.
The first half of that was already distributed and we hope,
and expect, that the second half of it will come through in the
end of this year's funding measure, whatever that ends up
looking like. We are very much counting on that.
In the last one, the measure by which the funding was
distributed to states did not correlate to the rate of the
opioid epidemic; the intensity and severity of the opioid
epidemic in that state. Nor did it connect to the recently
passed CARA bill.
I am hoping that, as we move forward on this, you will be
in a position to structure the grant process for that second
half billion in such a way that it more accurately addresses
the high impact states and that it better connects to the CARA
Bill. I think you can probably do that in the terms of the
grant application request that you structure from SAMHSA.
I just wanted to hear from you where you plan to go with
that, because the high impact states kind of got not treated so
well.
Dr. McCance-Katz. So my understanding of this situation is
that if we make any kind of changes to the previous funding
announcement, then all states would have to reapply for the
money.
I can just tell you that we have been hearing from lots of
states about their concerns in having to reapply for the money,
and the decision was made to not have any substantive changes
in the second year of funding for that 2 years, that billion
dollars.
Senator Whitehouse. Yes.
Dr. McCance-Katz. Five hundred million each year.
Senator Whitehouse. For the sake of the process convenience
for all, the high intensity states are going to pay the price.
Dr. McCance-Katz. I would say a couple of things.
One, when that decision was made, I did go back, and we
looked very hard, and we did find money, and we put a new
funding announcement out that does prioritize those states that
have been hardest hit by the opioid epidemic.
Senator Whitehouse. Yes.
Dr. McCance-Katz. I will continue to do that.
In addition, the other thing that I have been able to do is
to reallocate funding so that we are building a new Technical
Assistance Program that will be individualized to every state.
So those states that are hardest hit, that have certain
types of special needs, we will have local, technical
assistance available to them that, we think, will be important
to helping them implement as efficiently and effectively as
possible.
Going forward from that 2 years of funding, whatever
Congress and the President decide upon, we will look at that
and we will be very much aware of the kinds of issues you have
just raised.
Senator Whitehouse. Please, also, be an advocate for
additional spending in this area in the CARA programs in
particular. I think we were able to get $170 million in the
last funding measure.
Dr. McCance-Katz. Yes.
Senator Whitehouse. That is 2 percent of the $8.6 billion
that the pharmaceutical industry makes selling just the
prescribed opioid products, setting aside the illicit stuff
that comes over the border.
So 2 percent up against the devastation that we are seeing
in the context of a multibillion dollar industry, I would
consider a beachhead, not a victory.
I hope you agree.
Dr. McCance-Katz. Yes, sir.
Senator Whitehouse. Last quick thing, this is a Rhode
Island specific thing.
The Health Insurance Commissioner, as you know, in Rhode
Island is taking a look at the mental health parity compliance
of the insurance companies in Rhode Island, and I know you are
looking at that at the national level.
Can I just make sure that you have somebody on your staff
coordinating with Rhode Island to make sure that you are
supporting their work and everybody is pulling smoothly
together on parity disclosure and enforcement?
Dr. McCance-Katz. Yes, so two things.
One, SAMHSA has developed a parity toolkit for insurance
commissioners that we have made available to all the states.
Two, we have an office around healthcare reform issues, and
we have a person who works individually with the states and
with insurance commissioners within the states.
Senator Whitehouse. Terrific.
Dr. McCance-Katz. So we will make sure that happens.
Senator Whitehouse. Time is up.
Thank you. Appreciate it.
Senator Cassidy. Chairman Alexander.
The Chairman. Thank you.
Dr. McCance-Katz, welcome.
I want to follow-up Senator Whitehouse's question because,
if I remember right, it was his language that we put into the
Cures Act to try to make sure that the money distributed took
into account high impact states.
Am I not correct about that? At least I remember you
talking about it.
Senator Whitehouse. The problem is that it was based, as I
understand it, on the number of opioid deaths among other.
The Chairman. Right, but we did put language in.
Senator Whitehouse. And if it is a big state, you obviously
are going to have a big number, but it does not necessarily
mean that is a big impact.
The Chairman. Right.
So our intention, Dr. McCance-Katz, was to distribute money
to high impact states. That was our intention and I believe
Senator Whitehouse----
Senator Whitehouse. I think the intention was not
accomplished.
The Chairman. Yes.
What do we need to do to accomplish our intention?
You are saying that it would be impractical to cause all
the states to reapply again. I can see that. But there will be
more money coming for opioids. We do not know yet when, or
where, or how much.
But is it the language about the difference between high
impact states? I mean, the number of total deaths and the
number of per capita deaths, is that the issue?
What kind of language would you recommend that we include
in any new funding so that we direct money with a particular
sensitivity to high impact states?
Dr. McCance-Katz. Senator Alexander, I was not here in the
previous administration when the decision was made.
The Chairman. Yes.
Dr. McCance-Katz. However, my guess would be that they were
trying to implement as Congress directed.
The Chairman. Right.
Dr. McCance-Katz. And I do not know that the----
The Chairman. Well, what would be a better way to do it? I
am not trying to criticize them.
I am just trying to say if you were doing it today, how
would you do it?
Dr. McCance-Katz. Yes, and so for the new funding
announcement that we just put out, what we said was, what we
were looking at was the rate of opioid overdose deaths within
the state and the rate of increase year over year. That tells
you how hard a state is being hit.
The Chairman. Okay.
Is that going to affect the second round of funding?
Dr. McCance-Katz. When the second round of funding comes
forward, absolutely, we would be looking at different funding
formulas.
The Chairman. I see. That does not require reapplication by
all the states.
Dr. McCance-Katz. If it is a new source of funding? No.
Everybody would have to apply for that funding and then we
have----
The Chairman. Wait a minute. But the second round of
funding, the other half.
Dr. McCance-Katz. I am sorry. The second, yes.
The Chairman. The second half billion dollars.
Dr. McCance-Katz. Sorry.
The Chairman. Does what you just described apply to that
second half billion dollars?
Dr. McCance-Katz. So, no. We cannot----
The Chairman. But you would recommend that it, what you
just said would apply to any new money.
Dr. McCance-Katz. Exactly.
The Chairman. Would you work with our staff so that if we
write that properly--and if our intention is to recognize high
impact states--that we do it in a correct way, and so we do not
get surprised by it?
Dr. McCance-Katz. I absolutely will do that. Yes.
The Chairman. Okay, now let me ask you this. In 2014,
Congress required states--I remember the discussion with
Senator Whitehouse, and I wanted to see that his--we tried to
implement his intention and we can keep working on that.
Senator Whitehouse. Well, I am just so grateful that you
followed up that way, Chairman.
The Chairman. Yes.
Senator Whitehouse. I appreciate it.
The Chairman. Yes.
In 2014, Congress required states to set aside 5 percent of
community mental health block grant funds for serious mental
illness. The Cures Act increased that required to 10 percent.
Now, that sounds good, but that reduces the flexibility
that states have to address what might be different in Rhode
Island and California.
What is your opinion about the increase from 5 to 10
percent? Does that help or hurt the ability of states to
respond to the needs of those with serious mental illness?
Dr. McCance-Katz. The vast majority of payments for the
services delivered to people with serious mental illness is not
from SAMHSA.
The block grant having that increase of 10 percent causes a
focus on something that is extremely important, and that is
early identification of first episode psychosis.
We know that the longer a person goes without having their
psychotic thinking detected and treated, the more refractory
their illness becomes over time. And so, that 10 percent and
that block grant do a tremendous amount of good in terms of
raising awareness of this important issue.
The Chairman. Well, how does that encourage early
prevention, if the language is just to focus on serious mental
illness, is it not or does it say something about ``early''?
Dr. McCance-Katz. It talks about early identification of
serious mental illness.
The Chairman. Early identification of serious mental
illness.
Dr. McCance-Katz. Yes.
The Chairman. So it is not the ``serious,'' it is the
``early'' that is the key, really, to effective treatment.
Dr. McCance-Katz. But we consider psychosis to be serious.
The Chairman. Right.
Dr. McCance-Katz. To be indicative of serious mental
illness.
The Chairman. So you think the 10 percent helps.
Dr. McCance-Katz. I absolutely do.
The Chairman. Because of the push toward early
identification----
Dr. McCance-Katz. Yes.
The Chairman ----of serious mental illness.
Dr. McCance-Katz. Yes, and we know that the onset of most
psychotic disorders is in adolescent and transitional age
youth. So this is really very important to the lives that these
folks will be able to live going forward.
The Chairman. Thank you, Mr. Chairman.
Senator Cassidy. Senator Hassan.
Senator Hassan. Thank you very much, Senator Cassidy.
Mr. Chairman, thank you for holding this hearing.
Dr. McCance-Katz, thank you so much for being here and for
the work you do.
I want to follow-up on the conversation we were just having
about funding for those of us who are from states that have
been incredibly, disproportionally impacted by a horrible
epidemic that is taking lives, obviously, across our country.
But in New Hampshire, our Fentanyl, heroin, and opioid
epidemic is referred that way because it is Fentanyl that is
killing people in my state at one of the highest, if not the
highest, per capita death rates in the country. And we have
been targeted by Fentanyl dealers.
I was at a funeral Saturday where a family buried their
second daughter from an overdose. A woman who had been in
recovery and had been working really hard at it, and this
disease is taking all of our efforts.
I am very, very grateful to everybody on this Committee.
But I will add my concerns and frustrations to what you heard
from Senator Whitehouse.
I have expressed them directly to the Secretary. I think
the fact that states were uncomfortable about reapplying is not
an excuse in terms of the decision that was made with the
second round of this funding.
Toward that end, Senator Alexander, Senators Capito, Coons,
myself, and Senator Manchin have a bill in called the Targeted
Opioid Funding Act that would change the formula and make clear
what kind of priority we should give to per capita death rates.
And I would love the Committee's attention and collaboration on
the bill.
But even if we fix this formula under the Cures Act, we
know that the Cures Act money right now is only for 2 years,
and we know that there is no quick fix for this epidemic.
We desperately need funds to fight this epidemic. We need
the Administration to tell us what supplemental resources it is
proposing to turn the tide.
I was appreciative of being at the White House in October
when the President declared this a public health emergency. But
so far, we have not seen any follow-up to that declaration, and
we have seen no proposal from the Administration for the funds
that we need to tackle this epidemic everywhere in our country.
An epidemic that is not only taking lives, but in New
Hampshire, I think the year was 2014 or 2015, cost us over $2
billion in our economy.
So Dr. McCance-Katz, have you had conversations about the
need for additional funding with HHS and the White House? Why
has this Administration not called for additional funding or
proposed additional funding so we can get the dollars and the
resources to the frontlines where it is so needed?
Dr. McCance-Katz. Senator Hassan, I think that there are
many conversations going on about what the needs are and lots
of efforts to look at the data that is available, the
information that is available.
It is my understanding that the Administration is very
interested in working with Congress on developing those ideas
that might be something that both the President and Congress
can agree upon to bring more resources to bear.
Senator Hassan. Well, this Congress has made very clear
that we support additional funding to fight this, but we really
need a partner in the Administration to stop talking and start
funding.
I would look forward to continuing those conversations.
I also wanted to follow-up with another question, because
we know how complex the opioid use disorder is. It is often
accompanied by a variety of mental health disorders including,
for example, Posttraumatic Stress Disorder.
This leads to complex and sometimes very dangerous
outcomes. Veterans and other populations with PTSD and co-
occurring pain conditions are often prescribed higher doses of
opioids, putting them at a greater risk for accidental overdose
and deaths.
Treating one disorder, obviously, does not address symptoms
of the other. It is imperative that we work to ensure that
patients have access to comprehensive treatment to address both
substance use disorders and mental health needs.
Doctor, have the mental health provisions in the 21st
Century Cures Act helped SAMHSA enhance the availability of
evidence-based treatment programs for dual diagnosis of mental
health disorders and opioid use disorder?
Dr. McCance-Katz. Yes, I believe they have. And
specifically, I can speak to the issue around the Department of
Defense and Veterans Affairs which Cures addressed, and which
has developed into a very strong relationship where SAMHSA
works collaboratively in an ongoing way.
We specifically address the issues of mental disorders and
the opioid epidemic, as well as suicide. Those are the big
issues that we are working on right now.
We also can use the information that we learn from the
V.A., which actually does a lot of research of its own.
Senator Hassan. Right.
Dr. McCance-Katz. We share this, and we promulgate it to
communities.
Senator Hassan. Well, I thank you for that, and I thank you
for the vision of the integrated healthcare in this area.
I am most concerned that we are delaying some of our work
that would be made possible with extra funding because of the
stigma attached, as many of the other Senators have referenced,
and I appreciate very much your efforts.
Dr. McCance-Katz. Thank you.
Senator Cassidy. Senator Young.
Senator Young. Doctor, good to see you.
I read a book some months ago by Sebastian Junger. It is a
small, little book called, ``Tribe,'' and he discusses in the
book the challenges our veterans face as they try and
reintegrate back into society.
He makes the point that from an evolutionary standpoint, we
are more comfortable in tribal societies, like military
platoons embedded in a military structure, than we are in the
current atomized society where people tend to feel lonely. And
so, there are challenges of reintegration and adaptation.
So he turns on its head the challenges our veterans are
facing. The problem is not, per se, with the veteran, but it
may be with the broader society. It is a really interesting
read.
When I lay that line of argument, that analysis, on top of
the study, the ``Deaths of Despair'' study that indicates we
see increasing rates of morbidity among middle aged men, white
men in this country. And the reason for the deaths is
heightened suicide, alcohol use, and so forth. I start to think
that loneliness is really driving so many of the mental health
issues in our country.
Could you just give me your assessment of that, perhaps,
popular reading of the literature?
Dr. McCance-Katz. So I do think that those are important
points.
I actually think that there is research data that says that
people who are isolated, who will endure loneliness and feeling
ostracized within their communities die at much younger ages.
So that is an important issue.
Senator Young. It is a driver, is what I am hearing, a
driver of some of our mental health challenges.
Are there evidence-based approaches to intervening in this
problem; if not solving it, then mitigating the challenges? And
if so, what is that evidence base? What interventions work?
Dr. McCance-Katz. Yes.
Senator Young, I think that this is a topic in evolution,
but I do think there is some accumulating evidence for the
value of recovery supports as they relate, not only to
substance use disorders, but to mental disorders.
One of the things that I am working on, and this is one of
my priorities, actually, is to bring psychiatric medicine into
closer contact and collaboration with community recovery
supports.
It is not enough to just provide medical care as
psychiatric medical care. People need those recovery supports
in their communities. They can be veteran-based. They can be
faith-based.
Senator Young. Right.
Dr. McCance-Katz. Yes, so you get where I am going with
that.
Senator Young. Yes.
Dr. McCance-Katz. I think that will go a long way toward
assisting people to live the fullest life they can.
Senator Young. It just seems consistent with common sense
that there is more needed than medicating these problems away.
People need genuine human contact. They need relationships
that are meaningful to them. They need to feel like they are
part of a broader community, a meaningful part.
I just have a couple of minutes left. If we could turn to
how the Federal Government incorporates, or fails to
incorporate, feedback loops in terms of addressing mental
health and the policies we have.
There was a recent ``Governing'' magazine article on this
written by a health economics professional at Harvard Medical
School, and a former Obama administration official.
The authors advocate for including a tiered evidence
approach with Cures dollars to allow for scaling up of
evidence-based approaches, while concurrently supporting field-
generated innovations.
Have you considered including a tiered evidence approach in
some of your programs, say, the National Mental Health
Substance Use Policy Lab?
Dr. McCance-Katz. Thank you for that question, Senator. And
I think we spoke a little bit about this when I was going
through the confirmation process.
Senator Young. But I want to publicly speak about it.
Dr. McCance-Katz. Yes, and so, the answer to your question
is yes, we are.
I am very happy to be able to tell you that the Policy Lab
is being stood up now. We have hired a Director who is, I
think, a very experienced and knowledgeable person who is going
to do exactly that kind of work.
Senator Young. Well, great. I continue, of course, to have
great interest in this and we will be following up with you,
and your staff, to see how it might be supported from a
legislative standpoint.
Dr. McCance-Katz. Thank you.
Senator Young. Thank you, Chairman.
Senator Cassidy. Senator Franken.
Senator Franken. Thank you, Mr. Chairman.
I was glad to hear you talk about recovery supports. We had
Rebecca Boss from Rhode Island. I know you are from Rhode
Island.
Dr. McCance-Katz. I used to work for her.
Senator Franken. Yes, and she was doing unbelievable work.
Dr. McCance-Katz. Right.
Senator Franken. I know she talked in Rhode Island, they
have recovery coaches.
Dr. McCance-Katz. Yes.
Senator Franken. That is what they are called and do
exactly what you are talking about in getting into the
community.
One of the things that we put in 21st Century, into the
Cures Act, is more crisis intervention training for police.
We talked before the hearing about Judge Leifman, Steven
Leifman in Miami Dade has implemented a system where people
with mental illness and substance abuse who get arrested.
Instead of going to jail--which they used to do and which costs
a tremendous amount of money or going to emergency rooms, which
also costs a lot of money--is getting them housing and getting
them wraparound services.
That is something that, I know Senator Young and I have
talked about housing as a way. We have done this in Hennepin
County in Minnesota as well.
But that is something that I want Senator Young and others
on this Committee to keep advocating for and keep thinking
about. I will be bugging you even from outside.
I want to talk about Indian country again and Senator
Hassan talked about PTSD and talked about trauma. We see a
tremendous amount of trauma in Indian country, not just the
historical trauma, but the trauma of extreme poverty, of
domestic violence, of drugs, and sexual abuse, and all of those
things. And so that is why we see such high incidents of opioid
deaths in Indian country.
I went to a rehab for teenagers in North Minnesota a couple
of years ago. I have visited a number of rehabs and I had never
seen such, kind of hopelessness from these in rehab. Usually
when you go to rehab, there are people feeling hope at a
certain point.
What I really got was that these kids, most of them, it
started with use with their parents. And the hopelessness that
I saw was what they were going back to. And this is true also
outside Indian country.
I was in Rochester, Minnesota where we had a roundtable on
opioids, and a woman whose daughter had got treatment, went
back, fell in with the old crowd, and is now gone.
One of the things that I was thinking of, again with
housing, is a model of, and maybe piloting this, of a sober
living housing in Indian country where, instead of going back
to the home where you were living, going to a facility that has
people like you. And it can be very close to the Reservation or
on the Reservation.
But where you are getting continuous support, and you are
being tested, and you are going, and you have a fellowship of
the people there who are living sober too. Because especially
opioids, this is a long, long, long term thing. It is not,
what, 5 days of detox and then 28 days. It is a much longer
thing than that.
That is something that I would really like to advocate for
going forward.
One last thing about culturally specific in Indian county.
I think it is very important, but I did a roundtable in
Minneapolis and one of the providers there, one of the
counselors said to me. I said, ``What does that mean,
culturally specific?'' And she said, ``When an Indian woman
sees me as her counselor, because I am Indian, she knows that I
know what she has been through.''
I think that culturally specific means more than just a
cultural thing. I think it means, actually, in Indian country
making sure that we train the providers.
Thank you.
Dr. McCance-Katz. Yes, and I agree with you. Yes, you are
quite right.
Senator Franken. Thank you, Doctor.
Senator Cassidy. Senator Warren.
Senator Warren. Thank you, Mr. Chairman.
Dr. McCance-Katz, one of the most important things we did
in Cures was to create an Office of the Assistant Secretary of
Mental Health and Substance Use, which is now what you have
been nominated to head up.
We need to ramp up our response to the opioid epidemic, and
that means using every single tool in the toolbox. And one tool
is to put more resources into mental health.
Can I ask you to tell us why it is so important that we
address mental health if we want to beat back the opioid
crisis?
Dr. McCance-Katz. Yes, and thank you for that question,
because there is such a very high rate of co-occurring mental
disorders with substance use disorders. And the genesis of
these mental disorders often predates the substance use
disorder itself. We also know that if we do not address both
disorders--treating one does not treat both.
Senator Warren. Good. That is a very succinct way to put
it, and I appreciate that.
It is clear that making progress on the opioid crisis means
putting resources into treating mental health disorders.
Medicaid is the largest funding source for mental health
services, but SAMHSA has a number of other programs that help
fund services that are not covered through public or private
insurance.
The mental health services block grant, and a group of
other grant programs called the Programs of Regional and
National Significance, are SAMHSA's main mental health programs
providing funding for all 50 states and supporting the work of
mental health agencies of local government and of nonprofits
who are working in this area.
These programs are absolutely critical to improving mental
health in this country and they serve millions of Americans.
But let me ask you, Dr. McCance-Katz.
Is everyone who needs mental health care able to get that
help right now?
Dr. McCance-Katz. I would say the short answer to that is
no.
Senator Warren. No? And why not?
Dr. McCance-Katz. There are a variety of reasons.
One thing we know is that a lot of people, who we would say
need this kind of assistance, do not want it. But then there
are also barriers that prevent people from getting the care and
treatment that they need. It can be very difficult to access
care.
Senator Warren. Right. Do you have an estimate on how many
people need mental health treatment who are not able to get it?
Dr. McCance-Katz. I think our NSDUH data told us somewhere
about 12 to 13 million people.
Senator Warren. Yes, that is really a stunning, stunning
number.
Now, the Mental Health Services Block Grant, and the
Programs of Regional and National Significance, are SAMHSA's
two largest mental health programs. Combined, we spend less
than a billion dollars a year on those programs. So let me ask
you.
The White House Counsel of Economic Advisors released a
report last month estimating the cost of the opioid crisis to
this country.
Do you know what figure they came up with?
Dr. McCance-Katz. I am guessing it was pretty high.
Senator Warren. It was pretty high, $504 billion.
Think about that. The cost to this country annually of the
opioid crisis is more than half a trillion dollars. That is in
2015 alone. That is where we have the most recent data.
We are investing only one-fifth of 1 percent of that amount
in helping SAMHSA tackle the mental health piece of this
problem.
I think we need to do more and that is why I have called
for an additional billion dollars of funding in next year's
budget. That would double SAMHSA's budget and let them double
what they put into the two largest mental health programs.
Yesterday, the National Council, which represents 2,900
mental illness and addiction organizations, wrote me a letter
and I just want to quote what they said. They said, ``Now is
the time to support the highest possible levels of funding for
healthcare programs in the Federal budget.''
Today, this morning, the Massachusetts Association for
Behavioral Health Care sent me a separate letter requesting
that Congress double these funds.
I could not agree more that doubling the funds for these
mental health programs would give millions more Americans
access to the treatments that they need and it would start
making a dent in the astronomical costs that the opioid crisis
is imposing on our country.
Thank you for being here.
Thank you, Mr. Chairman.
Senator Cassidy. Senator Kaine.
Senator Kaine. Thank you, Mr. Chair.
It is good to have you with us, Dr. McCance-Katz.
I want to ask about the issue that I hear about all the
time in Virginia from my law enforcement community and that is
the intersection between mental health and people who are in
jails and prisons who should not be.
I have a lot of tough sheriffs, tough law enforcement
sheriffs and police chiefs who lament the fact that their jails
are filled with people who have diagnosed, but untreated, or
sometimes never diagnosed, mental health conditions.
They feel that these people should not even be in jail, but
if they are not treated, they are going to do something to harm
themselves or others, they will end up in jail.
They feel like they are being asked to be the mental health
provider for a society that does not fund mental health
services. And they feel both sort of a compassionate anger
about that, but also a resource challenge that makes it harder
for them to do their job. And so, I really want to ask about
that.
I also talk to police chiefs sometimes after high profile
incidents, a police shooting of somebody, for example. And they
will say, ``At bottom, some of this was the police approach.
Somebody had a mental health need and we are not completely
trained on that.'' And then it spiraled into something worse,
and then that can often become a flashpoint for community
anger.
But at the bottom of it, there was an untreated mental
health issue. So that is what I want to talk to you about.
The 21st Century Cures Act has some important provisions
around mental health and the criminal justice system including
an Interdepartmental Serious Mental Illness Coordination
Committee; that is a long acronym. And a provision that called
for the Attorney General to establish a pilot program to
determine the effectiveness of diverting eligible offenders
from the Federal court system, Federal courts and prisons, into
drug and mental health courts.
Can you tell us a little bit about work the Coordinating
Committee is doing in conjunction with the criminal justice
system? And has the Attorney General, and the Department of
Justice, been supportive in these efforts?
Dr. McCance-Katz. So a lot of questions there, but yes.
So ISMICC, we call it the ISMICC, the Interdepartmental
Serious Mental Illness Coordination Committee includes the
Department of Justice. They have been good partners with us and
we expect that to continue.
As you know, this is a 5-year process. You will be getting
that Report from the Committee today.
Senator Kaine. Right.
Dr. McCance-Katz. And the issues around the interface
between serious mental illness and the justice system are one
of the primary areas of focus within that Report.
I will just tell you also that we have programs at SAMHSA
that are dedicated to diversion and mental health courts. We
have programs for offender reentry so that they do not get lost
through the cracks.
Because my own experience--having run the state hospital
system in Rhode Island, where we worked with the Department of
Corrections--was that we frequently would get folks back
because they did not get into appropriate outpatient care at
the time they were leaving.
Senator Kaine. Right.
Dr. McCance-Katz. Even though we might provide treatment to
them, while they were incarcerated, that stopped.
So the ISMICC has addressed this. I hope you will be
pleased with some of the recommendations that we will be
working on.
Senator Kaine. I very much look forward to reading it. The
thing that I am sort of most familiar with at the state level
is the use of mental health courts, which are significant.
Can you talk a little bit about how the mental health court
system is working at the Federal level, some of the things that
we might be reading in the ISMICC Report about that?
Dr. McCance-Katz. Well, what you will be reading is that we
need more, more of these types of programs. And these programs
are very effective in diverting people away from incarceration
and into treatment, appropriate care, including medication
because a lot of these individuals need medication have not
gotten it and do not continue to get it.
That is also part of what the ISMICC committee has
recommended that the issues around civil commitment laws be
looked at to try to maintain a person in care once they leave.
Also, the other thing that we talk about in the Report is
the Crisis Center, the use of a crisis center that is
specifically geared to the treatment of people who have
substance use and mental disorders, rather than going to an
emergency department, which is not an appropriate placement and
where law enforcement often gets stuck.
Senator Kaine. Right.
Dr. McCance-Katz. These kinds of interventions can be very
helpful in freeing up law enforcement and getting people the
care they need.
Senator Kaine. Right.
Mr. Chair, I have one more question, if I could ask. I am
near the end of my time, if others want to jump ahead for a
second round. Should I just go ahead?
I want to ask you about co-prescription of Naloxone. I know
many of the questions you have been asked have been about
opioid issues.
I have worked with colleagues to introduce a Co-Prescribing
Save Lives Act which was incorporated, partially, into the
CARA. I was pleased to see that was a very bipartisan effort.
How much progress has been made in terms of making Naloxone
more available to at-risk populations? Can you speak to the
availability of prescribing guidelines?
Dr. McCance-Katz. Prescribing guidelines, we have at SAMHSA
an Opioid Overdose Prevention Toolkit that speaks to the use of
all of the available formulations of Naloxone.
That is in the process of being updated right now because
there have been some recent FDA approved formulations. So that
is available.
We also encourage co-prescribing. We train on co-
prescribing and we have, through CARA and through Cures, we
have programs available that train first responders and also
provides for funding for purchase of Naloxone and distribution
of Naloxone.
Senator Kaine. Thank you, Mr. Chair.
Senator Cassidy. Yes.
Dr. McCance-Katz, I have kind of a follow-up. It is a
follow-up, not only to what I asked earlier, but actually to a
previous hearing where you were talking about opioids.
In my previous line of questioning, I was asking about, how
do we monitor outcomes? The last Committee hearing I asked, how
do we monitor a specific program?
If we have Treatment Program A and Treatment Program B, and
Treatment Program A has a high recidivism rate with a lot of
folks being, perhaps, overdosing in an emergency room 2 weeks
after discharge. We have Program B where they have a more
effective approach and we do not see that sort of thing on
billing data or however.
I had asked you last time if SAMHSA was instituting those
kinds of review processes. I think the answer I got, ``Great
idea, but probably not at this point.''
In relation to what I asked earlier, is it possible for
SAMHSA to do that without a cooperative agreement with CMS to
look at billing data, to see if there is some marker of
recidivism?
For example, a billing for an emergency room visit a week
after discharge. You follow what I am saying.
What I am really trying to get at is how do we effectively
look at programs that are treating folks for addiction to know
whether or not those programs are effective and the taxpayer
gets the best deal for her dollar, but more importantly or as
importantly, the patient gets the best outcome relative to
recovering from their addiction?
Thoughts?
Dr. McCance-Katz. The issue around CMS and their billing
data is one that we have to work on, but yes.
I am reviewing all of SAMHSA's data collection programs
right now, and we are going to be making that data more
available publicly. So it is not just a matter of do programs--
--
These would be our programs that we are funding. But it is
not just a matter of collecting that data so that we can see
whether the programs are good, but making it available to the
public.
We are working with our Center for Behavioral Health
Statistics and Quality to look at means by which we can make
that data more available.
The other thing that we do is I will tell that you for the
STR program, I am a clinician.
Senator Cassidy. STR is?
Dr. McCance-Katz. STR is, I am sorry, it is the State
Targeted Response. It is the $500 million a year for each of 2
years.
I am a clinical and I love clinical work. I am meeting with
my staff about every single grantee. We are looking at every
single program to see how the states are using their money.
They are all doing it differently.
Senator Cassidy. So let me ask.
Dr. McCance-Katz. Yes.
Senator Cassidy. In follow-up, if states are doing it
differently, is there a common way that you can say, ``This is
how we wish you to evaluate''?
Because really, absent billing data that apparently is only
available from CMS, it seems like it can be very difficult to
evaluate recidivism rates. Is somebody moving to another
locale? Many of these treatment programs are at a geographic
distance from the place where the patient began. Right?
If there is a way to evaluate without billing data, one,
does it exist? Two, is CMS promulgating this? As, ``Listen. We
want you to evaluate and this is how we wish you to do so.''
Dr. McCance-Katz. Yes. The answer to your question is we
have several evaluations of this program ongoing. We are
monitoring the states to make sure that they are using
evidence-based practices.
We have one evaluation that is being done by CDC. We have
another that is being done by a contractor. That data will be
made available publicly. So that is an ongoing project for
SAMHSA.
Senator Cassidy. By the way, I do not personally think the
data should be used punitively. It could be also total quality
management.
Dr. McCance-Katz. The other thing that we do is that
because we are working so closely with the states--and because
we have a new program of technical assistance--we will also be
asking the states to bring forward data on their programs
because they have the ability to see whether their programs are
working.
Senator Cassidy. When will this data be available for the
general public or for Congress to review, the first set of it?
Dr. McCance-Katz. I do not know the exact answer to that,
but I will find out and get to you about that.
Senator Cassidy. Fantastic.
Senator Murphy.
Senator Murphy. Thank you very much.
A few follow-up questions I wanted to ask too on the
challenge of broadening our mental health workforce.
Senator Kaine accurately talked about diverting individuals
out of the criminal justice system. Often, your first
interaction with the criminal justice system happens at school.
Many kids with mental illness will misbehave at school,
will run into a police officer, and be sucked into the criminal
justice system never to emerge.
We talk a lot about mental health first aid training.
To the extent that schools have police officers onsite,
should not every single school-based resource officer have some
basic training in identifying mental illness so that they can
divert kids away from jails and into treatment if they present
with symptoms?
Dr. McCance-Katz. Yes, and without endorsing a particular
program.
Senator Murphy. Right.
Dr. McCance-Katz. Yes, I believe that is the best way to
approach that issue. Absolutely.
Senator Murphy. Then, tell me about SAMHSA's work to
develop more peer capacity.
Peers occupy a very specific and useful role in treatment,
lots of emerging data telling us that for many people in
recovery that peer connection is what matters most.
Give me an initiative that SAMHSA is working on now to try
to broaden and improve the quality of peers on our system
today.
Dr. McCance-Katz. So SAMHSA has had a pretty substantial
role in the development of the peer workforce.
However, it is my view that no Government agency should be
in the business of trying to figure out how to accredit a
particular type of workforce.
What we are doing is we have an office for consumers and
families that is working with some national organizations on
developing criteria for accreditation of peers. The states are
all different. They do it differently, but we are working with
states and with the stakeholders to move that process along.
I believe that peers need to be integrated into the
healthcare team because it is so important to not just give
medical care, but also the recovery services.
That is what we are working toward.
Senator Murphy. One last question, follow-up on a
conversation you were having with Senator Cassidy.
You mentioned that you were not satisfied with the data
that you are receiving from states. I think that is in relation
to the block grants.
Can you just tell us why you are not satisfied with the
data that you are getting? Is it the amount of data or the
quality of data? What is the problem that you are seeing?
Dr. McCance-Katz. Because the data does not tell us
anything about diagnoses and it does not tell us anything about
really basic standard of care issues, like, did a person get
medication-assisted treatment?
How do I know if a program is working if I do not even know
if they got the standard of care? We are changing that.
Senator Murphy. So what are you getting right now?
Dr. McCance-Katz. We get the number of people served. We
get things that approximate certain types of diagnoses. Did you
feel sad? Do you use certain substances?
But that is not enough to tell us what these programs are
doing for whom, and what does and does not work.
Senator Murphy. Thank you for your focus on data. I agree
with Senator Cassidy that to the extent we can avoid
duplication in requirements to the states on this, it is
something we should work together on.
Senator Cassidy. I would echo that and I thank the
Administration for appointing you, because you seem as
irritated about some things that I am irritated about, and they
are good things to be irritated about.
I want to finish by thanking Senators Alexander, Murray,
and Murphy for calling, convening, and participating in this.
I also thank you, Dr. McCance-Katz, for an excellent
testimony.
The hearing record will remain open for 10 days. Members
may submit additional information for the record within that
time, if they would like.
Senator Cassidy. Thank you for being here today.
The Committee stands adjourned.
[Whereupon, at 11:28 a.m., the hearing was adjourned.]
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