[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

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

                                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

                               __________

 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
        
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                    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

                              ----------                              

                               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

                              ----------                              


                      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.
                                ------                                


                  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:]
                                ------                                


             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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \5\  Id. at Sec. 6002.
---------------------------------------------------------------------------
    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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