[Senate Hearing 115-]
[From the U.S. Government Publishing Office]





 
  DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND 
          RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2018

                              ----------                              


                      WEDNESDAY, FEBRUARY 15, 2017

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:40 a.m., in room SD-138, Dirksen 
Senate Office Building, Hon. Roy Blunt (chairman) presiding.
    Present: Senators Blunt, Alexander, Moran, Kennedy, Rubio, 
Murray, and Shaheen.

                          MENTAL HEALTH CARE:
                   EXAMINING TREATMENTS AND SERVICES


                 opening statement of senator roy blunt


    Senator Blunt. Welcome to this hearing of the Subcommittee 
on Labor, Health and Human Services, and Education. We are 
certainly glad to have our four witnesses here today: Dr. Joe 
Parks, the Medical Director for the National Council of 
Behavioral Health, also a great asset to our office in his past 
job as a mental health leader in our State and as a professor 
and current job, professor at the University of Missouri; Dr. 
David Johnson, CEO of Navos Mental Health Solutions in Seattle, 
Washington; Dr. Dennis Freeman, CEO of the Cherokee Health 
System in Knoxville, Tennessee; and Chief Don De Lucca, the 
president of the International Association of Chiefs of Police.
    A lot is going on this morning, including a couple of votes 
that we didn't anticipate at 10:30 a.m. So members will come 
and go, and questions will probably be repeated because the 
questions we don't hear, we don't know for sure are asked, and 
I assume you are like me--used to answering the same question 
over and over again anyway. So this hopefully shouldn't be too 
big an imposition on our guests today.
    I am going to submit my full remarks for the record.
    This is clearly an issue that the Congress has taken real 
attention to in the last couple of years, more than maybe in 
the time before that, an understanding of how many Americans 
and how many families are impacted by mental health issues and, 
I believe, a renewed commitment to do more about it.
    So we are glad all of you are here. Senator Murray will be 
here soon. I think she is going to vote first and then come 
over, but I think in the interest of everybody's time, we are 
going to start with Dr. Parks for your opening statement. And 
as much as you can, the more time we have for questions, the 
better we all like it, but we would like a summary or whatever 
you want to do, Joe, of your opening remarks, and then we will 
just go in the order that I introduced everybody for your 
opening statements.
    [The statement follows:]
                Prepared Statement of Senator Roy Blunt
    Good morning. I want to thank the witnesses for appearing before 
the Subcommittee today to discuss a critical public health issue that 
too often goes untreated in our health system: mental illness.
    Nearly one in five Americans has a mental or behavioral health 
issue that is both diagnosable and treatable. Yet only a fraction of 
these Americans receive the help they need.
    According to the Substance Abuse and Mental Health Services 
Administration, among the 43 million adults with any mental illness in 
2015, less than half--only 43 percent--received mental health 
treatment. That same year, only 50 percent of children, aged 8-15, with 
a mental illness received the services they need.
    Those suffering from serious mental illness often only seek 
treatment when in crisis and can end up in the emergency room because 
they have no other option. This lack of access is a problem regardless 
of whether an individual has health insurance coverage because, 
unfortunately, benefits do not automatically translate into treatment.
    Over the past several years, Congress has worked to help mental 
health centers gain equal footing with traditional health centers by 
improving quality standards and offering patients services like 24-hour 
crisis care and counseling.
    But until our healthcare system treats mental illness like it would 
treat any other physical illness, it will be difficult to reach parity. 
That's why today's healthcare system must do more to adequately treat 
mental illness.
    Through the Labor/HHS bill, last year this Committee provided 
nearly $3 billion in dedicated mental health resources distributed to 
every State in the Nation. These critical resources provide 
infrastructure and support for communities to help treat mental illness 
and improve access to mental health services.
    This funding continues research into better understanding and 
treating mental illness. And, it invests in capacity building to 
prevent youth suicide. We must continue to expand these efforts to 
create better access and comprehensive treatment for those suffering 
with mental illness in our country.
    Mental health is not a partisan issue. I know Senator Murray agrees 
that ensuring access to mental healthcare is critical and an ongoing 
challenge for us to tackle together.
    Today's witnesses have a broad range of experience in mental health 
and I welcome the opportunity to hear from them as we highlight this 
important issue. I hope our discussion today focuses on how we can 
improve access to care and treatment, learn what programs our experts 
think are most valuable, and better understand how resources should be 
directed to ensure that we effectively support States, communities, and 
individuals who are dealing with mental illness.
    Thank you.
STATEMENT OF JOSEPH PARKS, PH.D., MEDICAL DIRECTOR, 
            NATIONAL COUNCIL FOR BEHAVIORAL HEALTH, 
            DISTINGUISHED PROFESSOR OF SCIENCE, 
            MISSOURI INSTITUTE FOR MENTAL HEALTH, 
            UNIVERSITY OF MISSOURI-ST. LOUIS
    Dr. Parks. Thank you, Mr. Chairman. And I want to thank you 
for the opportunity to testify.
    Just to give a little of my background, for 30 years, I 
have been doing behavioral healthcare services in several 
States, Illinois and Ohio, prior to Missouri. I have been 
medical director of the Department of Mental Health in Missouri 
for 30 years, and for 3 years, I was the division director for 
mental health services. The last 3 years, I have been the 
Medicaid director in Missouri.
    During that time, I have also practiced psychiatry at a 
Federally Qualified Health Center and continue to do so. And I 
have three family members that have behavioral health 
disorders, both mental illness and substance use disorders. So 
the perspective I bring is of somebody that has managed large 
healthcare budgets and delivery systems that include behavioral 
health services, somebody that actually delivers healthcare, 
behavioral healthcare as well as regulating it, and a family 
member of people that depend on access to effective services to 
stay functional and healthy.
    Behavioral health treatment has come into more demand in 
recent years as stigma has gone down and as the knowledge of 
how effective the treatments are has gone up. And this is 
appropriate, especially since we are facing national epidemics 
of both opiate addiction and suicide.
    Depression is the leading cause of disability in the U.S. 
for people between the age of 15 and 54, and suicide is the 
second most common cause of death between ages 15 and 34.
    Behavioral health conditions increase the cost of other 
healthcare. People with behavioral health conditions cost two 
to three times as much for the care of their diabetes, 
hypertension, and heart disease.
    And we have not kept up. We have not had the kind of 
workforce, we have not had the kind of funding arrangements and 
the innovations in our healthcare delivery system that we need 
to make sure that services are available, are effective, and 
prompt. This is demonstrated by the fact that only about half 
of people with serious mental illness are getting the 
behavioral healthcare services they need.
    A lot more progress could be made. Some of the 
recommendations I want to give the committee is to continue to 
assure that future changes in healthcare delivery continue to 
expand and promote parity. The parity laws that have been in 
several acts have been a great step forward and need to be 
expanded and protected.
    The future changes in healthcare delivery need to assure 
that rates are adequate to support the costs of care. I want to 
thank Senator Blunt and also Senators Stabenow, Matsui, and 
Lance for sponsoring the Excellence in Mental Health Act 
demonstration project, enacted as Section 223 of Protecting 
Medicaid Act. The prospective payment, which is also essential 
to Federally Qualified Health Centers, is a major step of 
making sure that rates are adequate to support the actual costs 
of services.
    It would be useful to extend the Emergency Psychiatric IMD 
demonstration. In Missouri, it demonstrated increased access 
and reduced costs, reducing costs and reducing ER crowding. It 
would be important to extend the IMD waiver to residential 
substance abuse treatment facilities. Treating substance use 
disorders in hospitals or in small facilities of less than 16 
beds is inefficient and more expensive than necessary.
    It would be important to continue funding SAMHSA (Substance 
Abuse and Mental Health Services Administration) grants to 
integrate primary care and behavioral healthcare in Community 
Mental Health Centers. This has been previously called the 
PBHCI initiative. People served in our Community Mental Health 
Centers have higher rates of chronic medical illness like 
diabetes and heart disease than people in general medical 
clinics. And these initiatives save lives and reduce healthcare 
costs.
    It will be important to continue funding Mental Health 
First Aid. I want to thank the committee for providing $15 
million in funding for Mental Health First Aid for the last 3 
years, and I want to strongly recommend that that funding be 
extended to first responders. Our police, our ambulance crews, 
our firefighters see a lot of people with behavioral health 
problems and in distress and would benefit from this funding.
    It would be very helpful to change confidentiality 
requirements so that they are not different and more strict for 
substance use disorders. The separate requirements reduce the 
quality and effectiveness of treatment, they promote stigma, 
and they keep treatment fragmented. I don't believe that 
separate is never equal. We need to treat this information the 
same.
    Finally, many of the healthcare reform initiatives 
initiated over the last several years have left out behavioral 
healthcare. They have not provided the same support for 
increasing workforce capacity, modernizing electronic medical 
records, and implementing payment and innovation changes that 
have gone to primary care and general medical care.
    I would urge the committee to increase SAMHSA's block grant 
funding in specific areas where behavioral health was left 
behind. This would include implementing and enhancing 
electronic medical records, training for behavioral health 
workforce, implementing payment and system delivery innovations 
like expanding the Excellence in Mental Health Act so more 
States can participate, and funding treatment facility 
replacements and renovations. FQHCs (Federally Qualified Health 
Centers) have availability and so do hospitals of Federal 
assistance to renovate their facilities. CMHCs (Community 
Mental Health Centers) have not had these.
    In closing, I would like to thank the committee for the 
opportunity to testify, and I am happy to answer questions or 
assist any way I can. Thank you.
    [The statement follows:]
                Prepared Statement of Joseph Parks M.D.
    Thank You for the Opportunity to Testify.
    My name is Joseph Parks. Over the past 30 years I've been 
responsible for the delivery of behavioral health services in Ohio, 
Illinois, and Missouri. For 20 years, I was the Medical Director for 
the Missouri Department of Mental Health and for three of those years I 
was director of the division responsible for mental health services. 
For the past 3 years, until this January, I was Missouri's Medicaid 
Director. During my 24 years of service in Missouri I was also and 
continue to be a practicing psychiatrist seeing patients at a federally 
qualified health center in Columbia, Missouri. Three of my immediate 
family members either have or are receiving treatment for behavioral 
health disorders. So the perspective I bring you today is that of 
someone who's been responsible for managing large healthcare budgets 
and delivery systems that include behavioral healthcare, regulating 
behavioral healthcare services, directly providing behavioral 
healthcare myself, and as a family member of persons dependent upon 
those services being accessible and effective.
    Behavioral health conditions (both substance use disorders and 
mental illness) have come into increasing demand as treatments have 
become more effective and receiving treatment has become more 
acceptable. This change in demand is appropriate and necessary since we 
are in the midst of two epidemics--opiate addiction and suicide. 
Depression is the leading cause of disability in the US for persons 
between the ages of 15 and 54, and for those individuals ages 15 to 34 
suicide is the second most common cause of death. Behavioral health 
conditions increase the cost of general medical care. The cost of 
treating general medical conditions like diabetes and heart disease are 
2 to 3 times higher when a person also has a behavioral health 
condition. Unfortunately, our current healthcare delivery system, 
workforce, and funding arrangements are not adequate to keep up with 
the demand and maintain reasonably prompt access to good quality, 
effective behavioral health treatment services--as demonstrated by the 
fact that we serve only about half of people with serious mental 
illnesses in the United States.
    Much progress could be made by:
  --Assuring that future changes to healthcare delivery continue to 
        require and promote parity of coverage for treatment of mental 
        illness and substance use disorders compared to general medical 
        care
  --Assuring that future changes to healthcare delivery result in rates 
        that are adequate to support the cost of care provided. I want 
        to thank Senators Roy Blunt (R-MO) and Debbie Stabenow (D-MI), 
        and Reps. Doris Matsui (D-CA) and Leonard Lance (R-NJ) for 
        sponsoring the Excellence in Mental Health Act demonstration 
        program enacted as: Section 223 of the Protecting Access to 
        Medicare Act, which is an excellent step in this direction.
  --Extending The Emergency Psychiatric Services IMD Demonstration, 
        which demonstrated increased access and reduced costs in my 
        home State of Missouri. Waiver of the IMD exclusion should be 
        extended to substance abuse residential treatment facilities. 
        Treating sub use disorders in hospitals or in residential 
        facilities of less than 16 beds is inefficient and expensive.
  --Continuing funding for SAMHSA grants to integrate primary care and 
        behavioral healthcare within community mental health centers, 
        also known as the PBHCI initiative. People served in Community 
        Mental Health Centers have higher rates of chronic medical 
        illnesses like diabetes and heart disease than persons going to 
        general primary care clinics. These initiatives save lives and 
        reduce healthcare costs.
  --Assuring the communities are ready to offer assistance and support 
        to persons experiencing immediate distress due to their 
        behavioral health disorder. I want thank this committee for 
        providing $15 million in funding for Mental Health First Aid 
        each of the last three fiscal years and urge you to continue 
        funding this important community safety net intervention.
  --An ongoing commitment to covering pre-existing conditions is 
        essential for persons with behavioral health disorders. 
        However, equally important is to continue to require that 
        persons are not charged more for coverage when they have 
        chronic illnesses. A return to charging people more for 
        coverage because they have a chronic illness will decrease 
        access for persons with behavioral health disorders.
  --The confidentiality requirements for sharing treatment information 
        to coordinate and improve care should not be different for 
        behavioral health disorders than general medical disorders. 
        Separate requirements reduce the quality and effectiveness of 
        treatment and promote stigma and fragmented care. Separate is 
        never equal.
  --The healthcare reform initiatives initiated over the past years 
        have not provided behavioral health with the same support for 
        increasing workforce capacity, adopting modern electronic 
        medical records, and implementing payment and delivery system 
        innovations that were made available to primary care and 
        general medical care. I urge the committee to increase SAMHA's 
        Block Grant funding in the specific areas where behavioral 
        health was left behind:
    --implementing and enhancing electronic medical records
    --training for behavioral health workforce
    --implementing payment and delivery system innovations and
    --funding for treatment facility replacement and renovations
    This would also serve to demonstrate how Block Grant funding can be 
transformative in improving care.
    The National Council Medical Director Institute convened an expert 
panel last October to develop recommendations for Improving Access to 
Services and will provide this committee with a report with detailed, 
specific policy options next month.
    I want to close by again thanking the committee for this 
opportunity to testify. I would be pleased to be of any assistance I 
can in your efforts to improve access and quality of behavioral health 
services.

    Senator Blunt. Dr. Johnson.
STATEMENT OF DAVID M. JOHNSON, ED.D., LMHC, CHIEF 
            EXECUTIVE OFFICER, NAVOS MENTAL HEALTH 
            SOLUTIONS
    Dr. Johnson. I am David Johnson, the CEO of Navos Mental 
Health, and we are one of the largest behavioral health 
organizations in the State of Washington.
    Each year, we serve thousands of people ranging in of all 
ages, from 5 weeks old in our infant mental health program 
through people over 100 years old. We help them be resilient 
over the challenges of mental illnesses, emotional 
disturbances, and serious addictions.
    The Affordable Care Act has dramatically improved millions 
of lives. And one of the benefits of the expansion of Medicaid 
is that adults are able to find coverage based on income, not 
just on disability. And this smart change has resulted in early 
intervention, catching developing disease processes before they 
become expensive and dangerous. It is more prudent and more 
humane to address mental illnesses and substance use disorders 
before someone escalates systems to a crisis state that 
requires costly hospitalization, incarceration, and 
institutionalization.
    Since the launch of Medicaid expansion, people in 
Washington who couldn't previously hope for access to treatment 
have become eligible for healthcare, and they have used it very 
effectively. Upon receiving healthcare, they have also tapped 
into assistance with other social determinants of health that 
affect wellness, such as housing, employment, and care 
coordination.
    We have been impressed with the improvement in the 
functioning of families when parents at last have an 
opportunity to deal with their own healthcare needs as well as 
those of their children. The health and vitality of the parent 
is important to the parent-child relationship.
    Navos has also been grateful that as we discharge people 
from our 70-bed involuntary commitment psychiatric hospital 
that we have witnessed, with Medicaid expansion, significantly 
increased ability to enroll clients quickly into outpatient 
care, to obtain appropriate medications, and to refer people on 
for supported housing. Before Medicaid expansion, the process 
was slow, complicated, and unpredictable. The risk of 
recidivism back into the hospital was higher when many people 
had no outpatient services to follow up for inpatient care.
    Mental illness and addiction can happen in any family at 
any time, and untreated behavioral health conditions are costly 
to individuals, families, and communities. And when people 
don't get the behavioral health they need, they become 
expensive, and at times, they become dangerous.
    But treatment works. People can recover when we use 
evidence-based best practices, when we track outcomes, and when 
we are quick to change treatment plans when progress isn't 
happening soon enough.
    Wellness has increased, quality of life has improved, and 
enrollment has been successful in decreasing the number of 
people without insurance. There has been a decrease from 14 
percent of uninsured people in the State of Washington to 5.8 
percent between 2013 and 2016. And by 2016, 750,000 more people 
in Washington now have health insurance.
    We are also better at addressing issues of equity in 
healthcare. Before the ACA (Affordable Care Act), more than a 
quarter of the African-American population in the Seattle/King 
County area were uninsured, a quarter. Today, it is less than 1 
in 10.
    Also, rural and poor counties are some of the biggest 
winners with the Affordable Care Act benefits. One county in 
the State of Washington now has 50 percent of its residents 
enrolled in healthcare that didn't receive it before.
    We are also becoming better at addressing the problems of 
the working poor. More than 600,000 Washingtonians, lower 
income, mostly working people, have gained coverage through 
Medicaid expansion.
    We are also making progress in upstream interventions, 
addressing wellness needs and general functioning before they 
become more serious and more expensive. And we are better able 
to target services for the opioid addiction epidemic and other 
substance use disorders. In 2015 alone, 30,000 new adult 
Medicaid enrollees in Washington received substance use 
disorder treatment services.
    The total cost, the total cost of care per person decreases 
with integrated care between primary care and behavioral 
healthcare. There has been a 35 percent reduction in the total 
cost of care to managed care companies for those who were seen 
at the Navos Mental Health and Wellness Center.
    If resources are decreased, fewer will receive treatment, 
wellness will decrease, and the ultimate costs will be 
transferred. There will be increased costs, and they will be 
transferred to emergency care, long-term care, management of 
increased homelessness, and an increased demand for 
incarceration and institutionalization.
    Thank you.
    [The statement follows:]
           Prepared Statement of David M. Johnson, Ed.D, LMHC
    I am David Johnson, CEO of Navos. Our organization is one of the 
largest providers of community mental health services in Washington 
State. Through our inpatient, outpatient and residential treatment 
programs each year we serve thousands of people of all ages, from five 
weeks old in our infant and early childhood mental health program to 
people over 100 years old in our older adult program. We help them be 
resilient over the challenges of emotional and mental illnesses and 
substance use disorders.
    The Affordable Care Act (ACA) has dramatically improved millions of 
lives. One benefit of the expansion of Medicaid is that it allows 
adults coverage based on income, not only based on disability. This 
smart change has resulted in early intervention, catching developing 
disease processes before they reach dangerous and expensive 
proportions. It is more prudent and humane to address mental illness 
and substance use disorders before someone escalates symptoms to a 
crisis state that requires costly hospitalization, incarceration or 
institutionalization.
    Since the launch of Medicaid expansion, people in Washington who 
previously couldn't hope for access to treatment for physical, mental 
health and substance use disorders became eligible for healthcare and 
they have used it effectively. Upon receiving physical and behavioral 
healthcare they have also tapped into assistance with other social 
determinants of health affecting wellness: housing, employment, and 
care coordination.
    Service providers are now able to serve many more children and 
adults. We have assessed, diagnosed and treated developing health 
conditions that would otherwise not have emerged until they became 
costly in both dollars and human suffering.
    We have been repeatedly impressed with the dramatic improvement in 
the functioning of families when parents at last have a way to address 
their own healthcare needs as well as those of their children. The 
health and vitality of the parent is crucial in the parent/child 
relationship.
    Navos has also been grateful that as we discharge patients from our 
70 bed involuntary commitment psychiatric hospital we have witnessed, 
with Medicaid expansion, significantly increased ability to enroll 
clients quickly into outpatient behavioral health treatment, to obtain 
appropriate medications, and to refer folks to supported housing. 
Before Medicaid expansion the process was slow, complicated and 
unpredictable. The risk of recidivism back into the hospital was higher 
when many people were discharged from the hospital without ready access 
to outpatient services.
    Mental illness and addiction can happen in any family at any time. 
It would be expensive and tragic to have to go back to a time when so 
many went without care until they became deeply disabled and required 
expensive crisis care.
    Untreated behavioral health conditions are costly to individuals, 
families and communities. When people don't get the behavioral health 
services they need, they become expensive and at times they can become 
dangerous. We can do better and the ACA has been a critical part of our 
progress.
  --Behavioral health professionals working in collaboration with 
        primary care professionals substantially improve outcomes and 
        produce savings for payers.\1\
  --Researchers at Washington State's Department of Social and Health 
        Services established that mental illness is by far the most 
        prevalent primary disabling condition among working- age SSI 
        recipients in Washington State. Under healthcare reform there 
        is a financial incentive to invest in mental health treatment 
        for non-disabled adults to prevent disability.\2\
  --The managed care companies that I appreciate working with truly 
        believe and champion this kind of collaboration and have joined 
        with providers in being assertive to establish ways we can work 
        together and leverage the benefits of addressing behavioral 
        health needs in order to promote physical wellness as well. The 
        logic of including behavioral healthcare in the Essential 
        Benefits package has now been acknowledged to be wise and good 
        practice, not just a requirement.
    Treatment works. People can recover when we use evidence based 
practice, measure progress and change treatment plans when we are not 
seeing enough progress soon enough.
  --An estimated 20 percent of non-elderly adults had a mental illness 
        in the past year, and 10 percent had a substance use disorder. 
        These conditions are more prevalent among people with low 
        incomes and often go untreated in people who are uninsured. For 
        example, a low-income person with a serious mental illness is 
        30 percent more likely to get treatment if enrolled in Medicaid 
        than otherwise. (nami.org)
  --The ACA provided those States that opted to expand Medicaid a 
        critical resource for addressing the mental health and 
        substance abuse challenges, particularly the opioid epidemic.
  --Medicaid expansion has significantly benefitted individuals with 
        mental health and substance use disorders by providing access 
        to basic care such as screenings, assessments, behavioral 
        health treatment, and prescription medication assisted 
        treatment to address psychiatric symptoms and substance use 
        disorders.
    With the ACA exchange plans and Medicaid expansion, hundreds of 
thousands in Washington State now have medical insurance with some 
parity guarantees and have had access to effective treatment. Wellness 
has increased. Quality of life has improved.
    Enrollment has been successful in decreasing the number of 
uninsured:
  --The ACA, coupled with the Mental Health Parity Act of 2008, 
        expanded mental healthcare, including treatment for substance 
        abuse disorders, to 62 million Americans nationwide.
  --The expansion of access to mental and behavioral health prevention 
        and treatment under the ACA has been historic; while 
        approximately 22 million gained access to health coverage 
        through the Marketplaces and Medicaid expansion.\3\ HHS 
        estimates an even larger group--(62 million Americans in all) 
        gained expanded mental health and substance use disorder 
        benefits and Federal parity protections through the individual, 
        small group, and employer sponsored markets and Medicaid \4\ 
        closing treatment gaps that had left millions of Americans 
        without access to treatments for mental health and substance 
        use disorders.\5\
  --There has been a decrease from 14 percent to 5.8 percent in the 
        percent of uninsured in Washington from 2013 to 2015.
  --By 2016, 750,000 more people in Washington now have health 
        insurance and care including the expansion population Medicaid 
        and others purchasing through the Healthcare Exchange.
  --The 2017 enrollment is up by 25 thousand individuals over last 
        year.
    We are becoming better at addressing equity in healthcare:
  --Before the ACA more than a quarter of African Americans in Seattle/
        King County were uninsured. Now it is less than one in ten.
  --There has been a disproportionate benefit to rural Washingtonians. 
        An average of 19 percent of the residents of Washington's 30 
        rural counties are Medicaid expansion enrollees under the ACA.
    --In Garfield County, a small Southeast Washington community and 
            the State's least populous county, 72 percent of 19-24 year 
            olds are enrolled under Medicaid expansion.
    --In rural Adams County, 50 percent of the population is covered by 
            the Affordable Care Act, either through Medicaid expansion 
            or through plans sold on the Exchange. This is higher than 
            any other county and is more than twice the rate of King 
            County.
  --For rural healthcare it can be more expensive to hire staff, 
        implement telehealth, spread care over great distances, and 
        engaging patients in different ways such as frequent phone 
        contact. The expansion of Medicaid funding has helped rural 
        health clinics and hospitals.
    We are becoming better at addressing the problems of the working 
poor:
  --The ACA included mental health and substance use disorder services 
        on its list of Ten Essential Health Benefits and required 
        individual plans and small-group plans offered on the exchanges 
        as well as Medicaid expansion plans to provide a mental health/
        substance use disorder benefit that meet parity with medical/
        surgical benefits.
  --More than 600,000 lower-income mostly working Washingtonians have 
        gained coverage through Medicaid expansion.
    We are making progress in ``upstream interventions'' addressing 
wellness needs and general functioning before they become more serious 
and expensive:
  --The populations who have become eligible for healthcare coverage 
        have a variety of needs that have been addressed well through 
        integrated care among behavioral health and primary care 
        clinics, and medication assisted treatment for substance use 
        disorders.
  --We have seen a reduction from 15.5 percent to 11.1 percent for 
        those who needed to see a doctor but could not because of 
        cost.\6\
  --A disproportionate (approximately 29 percent) share of individuals 
        in the Medicaid expansion population have a mental health or 
        substance use disorder need. For Washington State, this 
        represents approximately 174,000 individuals who now have 
        access to treatment for mental illness and/or addictions.\7\ If 
        we address that need it keeps them off long-term disability 
        (SSI or SSA) in the future, saving Federal money and supporting 
        individual dignity.
  --It is particularly important to get young men at risk for prison 
        and substance use disorders into care in the right setting now 
        that they have access
  --We assessed several years ago that 70 percent of people needing 
        assessment for involuntary commitment have never had contact 
        with our behavioral health system. Medicaid Expansion has 
        allowed us to find and treat people upstream, before escalating 
        into crisis.
    We are better able to target services for the opioid addiction 
epidemic and other substance use disorders:
  --The ACA has expanded the number of people receiving substance use 
        disorder treatment services, with 30,000 newly eligible 
        enrollees accessing services across Washington. Without the 
        Affordable Care Act, the system would be far less able to serve 
        this at-risk population.
  --The ACA has also played a vital role in how we treat the growing 
        opioid addiction epidemic in Washington State. The challenge is 
        huge: we have seen a tremendous increase in heroin- related 
        overdoses. In Seattle/King County, fatal overdoses linked to 
        heroin jumped 58 percent between 2014 and 2015, the largest 
        rise in 17 years.
  --In addition to expanded coverage, through the ACA HHS has provided 
        specifically earmarked funds to help provide opioid treatment 
        in Washington, with $3 million going to community health 
        centers in 2016, both urban and rural areas to provide opioid-
        related services. In 2015 alone, almost 30,000 new adult 
        Medicaid enrollees received substance use disorder treatment 
        services.
    The total cost of all medical care per person is decreased with 
integrated care, a cornerstone of the ACA and Parity.
  --There has been a reduction in total healthcare expense to managed 
        care for those served at Navos' community behavioral health 
        center (28 percent) and especially those seen at the integrated 
        healthcare clinic at Navos (35 percent).
  --Medicaid expansion not only improved access to care, it is also 
        saving States millions in their behavioral health programs. For 
        example, Michigan saved $190 million in fiscal year 2015 after 
        enrollees in a State-funded program providing services to 
        people with mental illnesses were transitioned into Medicaid. 
        Kentucky saved $30 million in its state mental and behavioral 
        health programs in the first 18 months of expansion. (cbpp.org)
  --In Washington the average annual premium increases have dropped 
        since the ACA passed and became law, from 18.5 percent to 6.7 
        percent average annual increase and drop in Health Care CPI 
        average increase from 3.1 percent to 1.4 percent.\8\
    If resources are decreased, fewer will receive treatment. Wellness 
will decrease and the ultimate increased costs will be transferred to 
emergency care, long term care, management of homelessness, and 
increased demand for incarceration and institutionalization.
  --Eliminating the ACA will cripple national and Washington State 
        efforts to address the opioid epidemic and treat serious mental 
        health conditions. It will make treatment on demand unlikely 
        and jeopardize the infrastructure improvements we have 
        instituted during the era of Medicaid Expansion.
  --Eliminating the ACA would strip health insurance from an estimated 
        30 million Americans, and nearly 800,000 Washingtonians, 
        including coverage for services that help some of the one in 
        five Americans with a mental health condition. (Urban 
        Institute)
  --Repealing the ACA and its behavioral health provisions would have 
        stark effects on those with behavioral health illnesses. 
        Harvard/NYU estimate that approximately 1,253,000 people with 
        serious mental disorders and about 2.8 million Americans with a 
        substance use disorder, many of whom have an opioid disorder 
        would lose some or all of their insurance coverage.\9\

Citations:
    \1\ Medicare Payment for Behavioral Health Integration. The new 
England Journal of Medicine, February 2, 2017.
    \2\ Disability Caseload Trends and Mental Illness: Incentives under 
Health Care Reform to Invest in Mental Health Treatment for Non-
Disabled Adults. David Mancuso, PhD et. al. Washington State DSHS 
Planning, Performance and Accountability, Research and Data Analysis 
Division.
    \3\ Health Reform Repeal Would Double the Number of People Without 
Insurance in 2019, Center on Budget and Policy Priorities: http://
www.cbpp.org/sites/default/files/atoms/files/12-7-16health-factsheets-
us.pdf.
    \4\ Washington Healthcare Exchange: https://www.mentalhealth.gov/
get-help/health-insurance/.
    \5\ Repealing the ACA Could Worsen the Opioid Epidemic: http://
healthaffairs.org/blog/2017/01/30/repealing-the-aca-could-worsen-the-
opioid-epidemic/.
    \6\ The Affordable Care Act Post 2016: What's at Stake for 
Washington State? Updated January 4, 2017 Chart #11.
    \7\ CBHQS Report, SAMSHA National Survey on Drug Use and Health, 
November 18, 2015.
    \8\ The Affordable Care Act Post 2016: What's at Stake for 
Washington State? Updated January 4, 2017 Chart #20.
    \9\ Keep Obamacare to Keep Progress on Treating Opioid Disorders: 
http://thehill.com/blogs/pundits-blog/healthcare/313672-keep-obamacare-
to-keep-progress-on-treating-opioid-disorders.

Attached Documents:
  --The Affordable Care Act Post 2016: What's at Stake for Washington 
        State? Updated January 4, 2017.
  --Disability Caseload Trends and Mental Illness: Incentives under 
        Health Care Reform to Invest in Mental Health Treatment for 
        Non-Disabled Adults.
  --Medicare Payment for Behavioral Health Integration. The New England 
        Journal of Medicine, February 2, 2017.
  --Covered: 1.8 million people are insured through Washington Apple 
        Health or private insurance offered through Washington 
        Healthplanfinder: www.1in4WA.com
  --Repealing the ACA could worsen the Opioid Epidemic: http://
        healthaffairs.org/blog/2017/01/30/repealing-the-aca-could-
        worsen-the-opioid-epidemic/.
  --Medicaid's Future: What Might ACA Repeal Mean? http://
        www.commonwealthfund.org/publications/issue-briefs/2017/jan/
        medicaids-future-aca-repeal.
  --Addiction Treatment Grew Under Health Law. Now What? https://
        mobile.nytimes.com/2017/02/10/health/addiction-treatment-
        opiods-aca-obamacare.html?--r=0&referer=https://
        www.google.com/.

Links of Interest:
  --The Affordable Care Act Post 2016: What's at Stake for Washington 
        State? http://ofm.wa.gov/healthcare/ACA_impact.pdf.
  --Heroin epidemic, painkiller abuse targeted by new Federal money for 
        treatment: http://www.seattletimes.com/seattle-news/health/
        heroin-epidemic-painkiller-abuse-targeted-by-new-Federal-money-
        for-treatment/.
  --Heroin deaths spike by 58 percent in Seattle area: http://
        www.seattletimes.com/seattle-news/health/heroin-deaths-spike-
        nearly-60-percent-in-seattle-area/.

    Senator Moran [presiding]. Dr. Freeman.
STATEMENT OF DENNIS S. FREEMAN, PH.D., CHIEF EXECUTIVE 
            OFFICER, CHEROKEE HEALTH SYSTEMS
    Dr. Freeman. I am Dennis Freeman. I am a psychologist and 
chief executive officer of Cherokee Health Systems, a 
community-based healthcare organization in Tennessee.
    Cherokee is both a federally Qualified Health Center and a 
Community Mental Health Center. We provide care in 24 locations 
spread across East Tennessee and in inner city Memphis. Last 
year we saw over 73,000 patients. So today, I really speak for 
them. I am their advocate.
    Before sharing my perspective on today's topic, I want to 
acknowledge the support of this subcommittee for community 
health centers. Thanks to that support, today 1,400 health 
center organizations serve more than 25 million patients in 
nearly 10,000 communities nationwide. The investment this 
committee has made continues to have a profound impact on our 
patients, on our communities, and on the healthcare system as a 
whole, and we are truly grateful for that support.
    At Cherokee, we have blended behavioral health services 
into our primary care model for many years. Today, I will share 
some insights gleaned from that experience in providing 
integrated care, a comprehensive approach to care that is 
rapidly gaining traction across the country. I have submitted 
written testimony which expands on these comments, and I hope 
that you will read the written testimony and consider me a 
resource with these topics in the future.
    Without question, access to appropriate and timely care is 
the greatest challenge facing the behavioral health sector 
today. The behavioral healthcare system as presently configured 
struggles to accommodate the demand of those who present for 
care, let alone addressing the need that exists in our 
communities. We really need new models. We really need new 
approaches.
    In our experience at Cherokee, providing access to 
behavioral health within primary care goes a long ways towards 
reducing the access barrier to behavioral healthcare, which is 
so prevalent across the country. Primary care is the front door 
to the healthcare system. It is the primary access point for 
all healthcare concerns, including behavioral health issues.
    In addition to the frequent presentation of psychiatric 
conditions and substance use disorders in primary care, 
personal health habits, history of trauma, how one deals with 
stress all influence the response to treatment and health 
outcomes. Behavioral health then is a factor in every primary 
care visit.
    At Cherokee, we have embraced the patient-centered medical 
home model, and we have enhanced it by blending behavioral 
health professionals into that primary care team. These 
behavioral consultants provide assessment and intervention with 
patients. They also consult with primary care visits. When the 
primary care patient comes, it is all part of the primary care 
visit.
    When indicated, psychiatric consultation is available in 
real-time to this team, generally through our telehealth 
service. Primary care is an effective and efficient platform 
for the delivery of primary care.
    Some patients present conditions which require a creative 
response. For example, the current epidemic of opioid disorders 
has prompted us to really create a complex care team to care 
for these folks. So we are the healthcare home for these 
patients just as we are the healthcare home for patients living 
with diagnoses of serious mental illness. The integrated 
medical home is really the ideal place for care for patients 
with challenging and complex conditions.
    Finally, I would like to highlight a couple of policy 
priorities under discussion this year which are really critical 
to the successful delivery of integrated care.
    As you are aware, congressional action is necessary before 
September 30 of this year in order to save the health center 
funding. There will be a 70 percent reduction in grants due to 
the expiration of the health centers fund. Nationally, HHS 
projects this reduction would lead to the closure of 2,800 
health center sites and would create a loss of care for 9 
million Americans.
    At Cherokee, we project that this would limit our care by 
reducing our patient base by about 10,000, and 80 staff 
positions would be in jeopardy. So, on behalf of my health 
center colleagues, I ask this committee to work in concert with 
other committees of jurisdiction, with the House, with the 
administration to avert the health center funding cliff.
    Secondly, for patients served by safety net providers like 
FQHCs, like Community Mental Health Centers, the Medicaid 
program, the importance of it cannot be overstated. Nearly 40 
percent of our patients at Cherokee are receiving Medicaid; 46 
percent of our revenue comes from the Medicaid program.
    Once again, I am truly honored to have had this 
opportunity. I look forward to your questions.
    Thank you.
    [The statement follows:]
              Prepared Statement of Dennis Freeman, Ph.D.
    Chairman Blunt, Ranking Member Murray, my Senator Lamar Alexander 
and Members of the Subcommittee: It is an honor to be asked to share my 
views on behavioral health service delivery with you today. I am Dennis 
Freeman, a psychologist and Chief Executive Officer of Cherokee Health 
Systems, a community health organization in Tennessee. Cherokee is both 
a federally qualified health center and a community mental health 
center, and in 2016 we served more than 73,000 patients in 24 locations 
spanning 13 counties and inner city Memphis.

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    Before I share my perspective on today's topic, I briefly want to 
acknowledge and recognize the depth of support that has been shown by 
this Subcommittee, on a bipartisan basis, for community health centers. 
Thanks to that support, today some 1,400 health center organizations 
serve more than 25 million patients in nearly 10,000 communities 
nationwide. The investments you've made have had a profound impact on 
the patients and communities we serve, not to mention the healthcare 
system as a whole, and for that we are truly grateful.
    At Cherokee we have blended behavioral health services into our 
primary care clinical model and embedded behavioral health 
professionals in our primary care teams for many years. This approach 
to care is known, of course, as integrated care. Today, I hope to share 
insights gleaned from our experience in providing integrated care, a 
model of care that is rapidly gaining traction across the country.
    Without question access to appropriate and timely care is the 
greatest challenge facing the mental health and substance misuse 
treatment sectors of the Nation's healthcare system. In our experience 
providing access to behavioral health assessment and intervention 
within primary care goes a long way toward reducing the access barrier 
to behavioral healthcare so prevalent across the country. Many 
federally Qualified Health Centers, as well as other primary care 
practices, have developed or are beginning to develop integrated 
practice. Health Centers, who provide primary care for Americans who 
reside in underserved urban and rural communities, provided 8.3 million 
behavioral health visits in 2015, almost a threefold increase over a 
10-year period.
The Expansion of Integrated Care
    Primary care is the front door to the healthcare system. It's the 
primary access point for all healthcare concerns and medical 
conditions, including behavioral health issues. In addition to the 
frequent presentation of psychiatric conditions and substance use 
disorders in primary care, the personality and the lifestyle of the 
patient are always factors in a patient's healthcare outcomes. Personal 
health habits, a history of trauma and resiliency in response to stress 
all influence the etiology, the response to treatment and the prognosis 
of all medical conditions presented in primary care. The patient's 
behavioral health is a factor in every primary care patient visit. This 
is especially true for patients coping with chronic medical conditions. 
Encouraging these patients to adopt appropriate health behaviors is the 
key to the medical management of patients with complex and chronic 
conditions.
    Cherokee's integrated care model developed from efforts initiated 
over 40 years ago to reach out and bring mental healthcare to residents 
of the southern Appalachian Mountains in east Tennessee. Circuit riding 
mental health professionals established a beachhead in rural primary 
care practices and began sharing care with primary care colleagues. The 
benefits of this collaboration of professionals was immediately 
apparent. The experience was profoundly eye opening. It was apparent 
that the nature of primary care practice was, in large part, 
behavioral. We learned that most folks turn to their PCP in times of 
trouble. We watched our physician colleagues counsel their patients 
through the difficult times in their lives. We observed the impact 
patients' behaviors had on the outcomes of their chronic medical 
conditions. A different model of behavioral healthcare began to take 
shape, behavioral care provided within the context of primary care. In 
addition, the presence of behavioral health professionals within the 
primary care setting brought a clearer focus on addressing the 
psychosocial factors which influence health status. This new integrated 
care strategy broadened the scope of primary care and enhanced the 
effectiveness and efficiency of primary care practice.
Description of Cherokee's Integrated Care Clinical Model
    Over the past few years the Patient-Centered Medical Home (PCMH) 
model has come to be considered the best practice when it comes to 
primary care delivery. At Cherokee we have embraced this model and have 
enhanced it by embedding uniquely skilled behavioral health 
professionals, referred to as Behavioral Health Consultants (BHC), in 
the primary care team. BHCs are available to their primary care 
colleagues for consultation at the point of care. They provide 
assessment and intervention with patients during their primary care 
visit. When indicated, psychiatric consultation is also available, in 
real time, to the primary care team. Psychiatric consultation is one of 
the telehealth services Cherokee makes available across its network of 
clinics.

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    BHC's have a broad scope of practice within primary care. Not only 
are they the experts on the team with respect to psychiatric disorders, 
they also help address the general health concerns of patients. They 
help patients improve their self-management of chronic medical 
conditions like diabetes, hypertension and asthma. They also engage 
patients in adopting healthy lifestyle habits including exercise 
regimen, diet and sleep hygiene. They help patients stop smoking, 
manage stress and curb overuse of alcohol and the misuse of other 
drugs. And when psychiatric emergencies present in primary care, as 
they did so frequently do, BHC's help manage crises and triage patients 
into more intensive levels of care when indicated.

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    When a patient sees a BHC during a primary care visit at Cherokee 
they generally do not perceive their time with the BHC as a separate 
session with the behavioral health professional. Much as lab and x-ray 
are expected components of a primary care visit so is a consultation 
with the BHC or psychiatrist an expected part of a primary care visit 
at Cherokee. These embedded behavioral health professionals do not 
carry an independent caseload. Their caseload is the combined panel of 
the PCPs with whom they are working on a daily basis. All providers on 
the team share an electronic health record, treatment planning and the 
responsibility for the overall care of all the patients on the panel.
    The core elements of the clinical model described above have been 
in place at Cherokee since the early circuit riding days of nearly 40 
years ago but the role of the BHC has evolved significantly over time. 
Currently BHCs utilize well-developed clinical protocols and behavior 
change strategies, developed over years of practice, to assess and 
provide therapeutic interventions with patients across the lifespan and 
with a wide range of medical and behavioral disorders. Like their 
primary care colleagues, they are prepared to work with anyone who 
enters primary care. Yet, despite this generalist orientation, there 
are certain subpopulations of patients with conditions that need a 
special focus and attention by the team.
    For example, the current epidemic of opioid abuse has prompted 
Cherokee to form a complex care team to serve these patients. We have 
developed a team-based model to care for women who are pregnant and 
abusing alcohol and drugs. We seek to become the healthcare home for 
these patients, just as we are the medical home for patients enduring 
diagnoses of serious mental illness and other chronic conditions. The 
integrated medical home is ideal for the care of patients with these 
challenging and complex conditions.
    Cherokee Health Systems has utilized this model of integrated care 
in our clinics since 1984. It has enabled our organization to thrive 
through good economic times as well as more challenging times. We have 
expanded our footprint across east Tennessee and last June added 3 
clinics in inner city Memphis. We operate 24 clinic locations and have 
an additional 24 School-Based Health Clinics where Cherokee primary 
care providers teleconference in to treat ailing students. Last year we 
provided care to 73, 965 Tennesseans. 49 percent of our patients saw a 
behavioral health professional as part of their care. All benefited 
from a care team that has incorporated behavioral principles into the 
pattern of practice. Our patients appreciate the comprehensiveness of 
the integrated care model. Our primary care providers are enthralled 
with the support behavioral staff provide them. The integrated care 
team lightens the individual burden of primary care providers and 
enhances their satisfaction with their work. Insurance companies are 
pleased because the overall cost of care declines. Best of all patient 
outcomes improve.

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    The claims cited above are supported by Cherokee's performance 
data, however, they are not unique to Cherokee. We hear about similar 
improvement in outcomes when the integrated model is deployed from 
colleague organizations who attend our Integrated Care Training 
Academies. The professional literature provides abundant support for 
integrated care. The Agency for Healthcare Research and Quality (AHRQ) 
began taking a keen interest in integrated care a decade ago. In 
addition to reviewing the research support for integrated care AHRQ has 
produced a definition of integrated care and supported a study of the 
best practice of integrated care.

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Policy Recommendations
    The system of providing behavioral healthcare, especially truly 
integrated care, is complex. It varies State to State, and community to 
community. Still, there are several areas of policy--both within the 
Subcommittee's jurisdiction and related to it--that I want to 
highlight.
    The Federal Health Centers Program has been instrumental to efforts 
to support and expand care integration at community health centers 
nationwide. In recent years, with funds allocated by this Subcommittee 
and the mandatory Health Centers Fund, HRSA has made important, 
targeted investments to expand the health center system of care. At 
your direction, these funds have not only gone to fund new health 
center sites, but to expand services, with a particular focus on mental 
health and substance use disorder treatment.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    One of the most impactful recent investments has been the funding 
provided in the last fiscal year to expand health centers' response to 
the opioid epidemic. These funds have helped establish and support the 
dedicated care team I described earlier, focused on patients struggling 
with opioid use.
    As members are aware, without Congressional action by September 
30th of this year, Health Centers nationwide face a 70 percent cut in 
grant funding with the scheduled expiration of the Health Centers Fund, 
which was extended for 2 years in 2015 on a bipartisan basis. 
Nationally, HHS projects that a reduction of this magnitude would mean 
the closure of more than 2,800 health center sites, loss of some 50,000 
jobs, and most importantly, a loss of access to care for some 9 million 
patients in need. At Cherokee we project we would be able to care for 
10,00 fewer patients and 80 staff positions would be in jeopardy. While 
I recognize that members of this Subcommittee only allocate a portion 
of CHCs' overall funding, I ask that you work in concert with the other 
Committees of jurisdiction, with the House and with the Administration 
to avert this cliff and indeed to make strategic new investments in 
health centers.
    One additional challenge that faces organizations like mine across 
the country is the ability to train, recruit and retain a clinical 
workforce. We grapple not only with the issue of shortages in both 
primary care and behavioral health professionals, but with finding 
those professionals who are prepared and eager to practice in a truly 
integrated care environment. For this reason, I do want to highlight 
the importance of two smaller programs--the Graduate Psychology 
Education Program and the National Health Service Corps program. The 
GPE Program supports the inter-professional training of doctoral-level 
psychology interns and postdoctoral fellows while also providing 
behavioral health services to underserved populations such as older 
adults, rural populations, children, those suffering from chronic 
illness, veterans, victims of trauma and abuse. The Corps creates a 
vital incentive for clinicians--including behavioral health 
professionals--to enter primary care and to practice in rural and 
underserved areas. Nationally, more than half of NHSC clinicians 
practice in health centers. Cherokee has benefitted greatly from both 
of these vital programs.
    While grant funding, whether it be operational support or targeted 
support for recruitment or training, is critical, I do want to 
underscore that grants alone cannot create or sustain the systems of 
care we need in order to properly serve our patients. For the patients 
served by safety net providers like FQHCs--and CMHCs--the importance of 
the Medicaid program cannot be overstated. Nearly 40 percent of the 
patients we see at Cherokee are covered by Medicaid--nationally, 
Medicaid covers nearly half of all health center patients. Unlike many 
other forms of public and private coverage, Medicaid typically covers 
important behavioral health services, further driving the move toward 
integrated care. And because Medicaid was designed to work with health 
centers through a unique prospective payment system, health centers in 
particular can leverage Medicaid resources effectively into patient 
care that saves the taxpayer resources long-term.
    Not only does Medicaid provide value for health centers, but we 
strongly feel that by delivering primary and preventive care before it 
becomes more acute, health centers also deliver enormous value to 
Medicaid, and, by extension, to the Federal taxpayer. A recent study 
showed that when compared to patients who received their primary care 
in other settings, health center Medicaid patients had 24 percent lower 
total costs of care. Nationally, health centers serve one in six 
Medicaid beneficiaries for less than 2 percent of the overall Medicaid 
budget.
Conclusion
    I commend the Subcommittee for today's examination of mental health 
services and treatment, and the impact that these services have on 
patients, communities and the entire health system. As you continue 
your work, I urge you continue to support primary care as an efficient 
and effective platform for the delivery of behavioral health services. 
Our experience at Cherokee, and similar experiences around the country, 
have demonstrated that this model works. In supporting this work, I 
urge you to look beyond mere co-location of behavioral health and 
primary care, but to focus your support on driving truly integrated 
practice.
    I recognize that you have difficult decisions to make, competing 
priorities and a difficult budget environment. As you examine these 
choices in the year ahead, please continue to prioritize investment in 
operational capacity, workforce development and meaningful coverage--
all of these components are necessary to build a truly integrated 
system worthy of our patients and their diverse needs.

    Senator Moran. Doctor, thank you very much.
    I apologize to the witnesses that you have an audience, at 
least up here, of only one Senator. Votes are ongoing, and 
perhaps that was explained, and my colleagues have gone to 
vote. I have cast the first vote. They are going to vote their 
first and second, and then I will be replaced.
    But we appreciate your testimony, and I look forward to the 
questions that will come from--while I am particularly 
apologetic to you, Dr. Freeman, that the Senator from Tennessee 
was absent during your testimony.
    Chief De Lucca, welcome.
STATEMENT OF CHIEF DONALD W. DE LUCCA, PRESIDENT, 
            INTERNATIONAL ASSOCIATION OF CHIEFS OF 
            POLICE
    Mr. De Lucca: Thank you.
    Good morning. Thank you for the opportunity to speak to you 
today about an issue of critical concern to the law enforcement 
profession--how to best help those individuals affected by 
mental illness.
    I am currently the chief of police in Doral, Florida, and I 
am also the president of the International Association of 
Chiefs of Police, a law enforcement association of leaders that 
includes 27,000-plus members.
    At the IACP (International Association of Chiefs of 
Police), we have long been hearing from our members about the 
challenges they face when responding to calls of mental 
illness. In fact, in 2016, the IACP conducted a series of 
critical issue forums in eight locations throughout the United 
States and Canada. We met with more than 450 law enforcement 
officials, and a top concern at each listening session was law 
enforcement's interaction with persons affected by mental 
illness. Participants stressed that the lack of mental health 
treatment options or mental health centers has left law 
enforcement officers as the de facto mental health providers in 
their communities.
    Let me assure you that our organization fully understands 
and supports change, changes to address the much bigger picture 
of what we can clearly see as a mental health crisis across our 
country.
    The four most urgent concerns that we have are as follows: 
One, the sheer volume of the problem. One in five adults 
experiences a mental health problem of some kind in any given 
year. That is 43.8 million people, or 18.5 percent of our total 
population.
    Two, ironically, even with the stunning numbers, the stigma 
attached to mental illness continues to hold strong, and 
affected individuals are having to struggle with both their 
illness and how others perceive that illness.
    Three, the individuals that our officers come into contact 
with are often suffering from mental illness, and at the same 
time, the use of addiction to drugs, alcohol, or both. Sorting 
out these overlapping problems and providing smart, cost-
effective, and easily accessible solutions to address them 
present a huge problem for our program infrastructure.
    And four, we know from our officers on the street that 
mental health program availability for those individuals they 
encounter is often not available or those--that waiting period 
to access those programs is so long that it renders the service 
useless.
    While these four issues are each troubling and not easily 
addressed, IACP stands firmly in its intent to continue to call 
for and support improvements in these overarching problem 
areas.
    Legislative and funding support is absolutely essential to 
the success of local efforts to build safer communities by 
enhancing law enforcement response to persons with mental 
illness. Communities must have adequate resources for 
treatment, housing, and other support services so that law 
enforcement officers can help prevent the criminalization of 
mental illness by diverting eligible individuals to the non-
justice alternatives. Funding assistance in the way of 
training, equipment, grants, or innovative approaches to help 
encourage partnerships in mental health courts.
    Finally, I would like to take my remaining time to address 
how the IACP is changing the way our officers handle these 
encounters. The IACP recently launched a campaign to improve 
officer response to persons suffering from a mental health or 
other crisis event. That program is called the One Mind 
Campaign.
    This initiative was designed and launched with several 
significant partners, including the Substance Abuse and Mental 
Health Services Administration, National Alliance on Mental 
Illness, the U.S. Department of Justice (BJA), the American 
Psychiatric Association, CIT International, and the Mental 
Health First Aid.
    Law enforcement agencies are asked to commit to four steps 
to enhance officer encounters with those affected by mental 
illness or in crisis: one, establish a clearly defined and 
sustainable relationship with a local community mental health 
organization; two, develop and implement a written policy 
addressing law enforcement response to persons affected by 
mental illness; three, demonstrate that 100 percent of sworn 
officers receive training in Mental Health First Aid; four, 
demonstrate that a minimum of 20 percent of all sworn officers 
are trained in Crisis Intervention Team training. Taken 
together, these four steps can profoundly change the way our 
officers respond, increasing the likelihood of positive 
outcomes.
    We are also exploring even more innovative and potentially 
useful approaches. One example is in Springfield, Missouri. 
Through a pilot program in partnership with Burrell Behavioral 
Health, selected Springfield officers can, at the point of 
encounter with a person in crisis, offer the opportunity for 
that person to speak via Skype using iPad technology with an 
on-call mental health professional. This can help calm the 
situation and lets the officer consider diverting the 
individual to a mental health resource instead of making an 
arrest.
    Another example of a successful diversion program is 
Diversion First in Fairfax County, Virginia. The government, 
law enforcement, and the mental health community work together.
    The program is designed to reduce the number of people 
affected by mental illness in the county jail by diverting low-
risk offenders experiencing a mental health crisis to treatment 
rather than jail. As part of Diversion First, the Merrifield 
Crisis Response Center opened, as assessment site where 
officers can transfer custody of nonviolent offenders seeking 
mental health services to a CIT-trained officer assigned to the 
center.
    On behalf of the IACP, I conclude by thanking you again for 
the opportunity to discuss this critical problem. I would be 
happy to answer any questions you may have.
    [The statement follows:]
             Prepared Statement of Chief Donald W. De Lucca
    Good Morning Chairman Blunt, Ranking Member Murray, and Members of 
the Subcommittee: Thank you for the opportunity to speak to you today 
about an issue of critical concern to the law enforcement profession--
how to best help those individuals affected by mental illness.
    I am currently the chief of police for the Doral, Florida, Police 
Department. I am also the president of the International Association of 
Chiefs of Police (IACP). The IACP is the world's largest association of 
law enforcement leaders, with more than 27,000 members in 136 different 
countries.
    At the IACP, we have long been hearing from our members about the 
challenges they face when responding to 9-1-1 calls that involve a 
person affected by mental illness. In fact, in late August and early 
September 2016, the IACP conducted a series of critical issue forums in 
eight locations throughout the United States with a cross-border 
session involving a number of Canadian agencies. The purpose of these 
sessions was to meet with and listen to police leaders to gain a better 
understanding of the distinctive challenges they are facing within 
their communities and agencies, as well as to discuss and examine the 
vast array of challenges currently confronting the law enforcement 
profession as a whole. We met with more than 450 law enforcement 
officials, and a top concern at each listening session was law 
enforcement's interaction with persons affected by mental illness. 
Participants stressed that the lack of mental health treatment options 
or mental health centers has left law enforcement officers as the de 
facto mental health providers in their communities.
    Before I elaborate further into the steps being taken, let me 
assure you that our organization fully understands and supports changes 
to address the much bigger picture of what we can clearly see as mental 
health crisis across our country. And on a personal note, I too 
understand the challenges. My county, Miami-Dade County is home to the 
largest percentage of people with serious mental illnesses of any urban 
community in the United States.
    The four most urgent concerns we have are as follows:
    1)  The sheer volume of the problem--one in five adults experience 
        a mental health problem of some kind in any given year--that's 
        43.8 million people or 18.5 percent of our total population 
        Given these numbers, our attention to this issue should be at 
        the top of the list of priorities for Federal, State, and 
        county governments and yet that's often not the case.\1\ 
        Looking deeper, a recent study by SAMHSA reported that 50--70 
        percent of youth in the juvenile justice system met the 
        criteria for a mental health disorder.
---------------------------------------------------------------------------
    \1\ American Psychological Association, ``Data on Behavioral Health 
in the United States,'' http://www.apa.org/helpcenter/data-behavioral-
health.aspx.
---------------------------------------------------------------------------
    2)  Ironically, even with these stunning numbers, the stigma 
        attached to mental illness continues to hold strong with 
        affected individuals having to struggle with both their illness 
        and how others perceive that illness, if it is even 
        acknowledged. This culture of silence without doubt reduces the 
        chances that the almost 44 million people facing this problem 
        will seek the help they need.
    3)  The individuals that our officers come in contact with are 
        often suffering from mental illness and, at the same time, the 
        use of or addiction to drugs, alcohol, or both. Sorting out 
        these overlapping problems and providing smart, cost-effective, 
        and easily accessible solutions to address them presents a huge 
        problem for our program infrastructure.
    4)  When those affected individuals do seek the help they need, the 
        mental health services infrastructure in our country is not in 
        any way sufficient to meet these current and future mental 
        health needs. We know from our officers on the street that 
        mental health program availability for those individuals they 
        encounter is often not available or that the waiting period to 
        access those programs is so long that it renders the service 
        useless during the moment of crisis.
    While these four issues are each troubling and not easily 
addressed, IACP stands firm in its intent to continue to call for and 
support improvements in these overarching problem areas as much as we 
promote innovative responses by our officers at first contact.
    Legislative and funding support is absolutely essential to the 
success of local efforts to build safer communities by enhancing law 
enforcement response to persons with mental illness. Communities must 
have adequate resources for treatment, housing, and other support 
services so that law enforcement officers can help prevent the 
criminalization of mental illness by diverting eligible individuals to 
these non-justice alternatives. Today, in my home State of Florida, the 
county jail serves as the largest psychiatric institution housing more 
than half as many individuals with mental illnesses as all State 
psychiatric hospitals combined.\2\
---------------------------------------------------------------------------
    \2\ Http://www.dcf.state.fl.us/admin/publications/docs/
quickfacts.pdf.
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    Law enforcement and other justice system agencies also must have 
sufficient resources to expand and sustain their collaborative efforts 
to improve their crisis responses and decision- making about persons 
affected by mental illness, and that support needs to come in the form 
of funding for training, equipment, grants for innovative approaches to 
help encourage partnerships, and mental health courts.
    Laws and policies that regulate access to Medicaid, Medicare, and 
Social Security should be carefully crafted to ensure that persons with 
mental illness can readily access benefits to which they are entitled, 
both before and after incarceration. Regulations that protect 
consumers' privacy and dignity of choice should also permit necessary 
and appropriate information sharing across agencies when it can 
positively affect intervention outcomes. These and other policy issues 
must be addressed with assistance from national organizations with 
expertise in relevant areas.
    Finally, I would like to take my remaining time to speak to you 
about how we're changing the way our officers handle encounters with 
persons affected by mental illness.
    Just 5 months ago, the IACP launched an aggressive campaign to 
improve officer response to 9-1-1 calls involving someone suffering a 
mental health or other crisis event. That program is called the One 
Mind Campaign. The One Mind Campaign was designed and launched with 
several significant partner experts in the mental health arena, 
including the Substance Abuse and Mental Health Services Administration 
(SAMHSA), National Alliance on Mental Illness (NAMI), the U.S. 
Department of Justice (BJA), the American Psychiatric Association, CIT 
International, and Mental Health First Aid (MHFA). Driving this work 
was the knowledge, that at least 25 percent (and likely more) of 
individuals who died during an encounter with the police in 2016 were 
persons with mental illness, according to the Washington Post Fatal 
Force Database.
    The campaign asks every one of our 18,000 law enforcement agencies 
in the United States to commit to four basic, but critical, steps to 
improve officer encounters with those affected by mental illness or in 
crises: (1) Establish a clearly defined and sustainable relationship 
with a local community mental health organization; (2) develop and 
implement a written policy addressing law enforcement response to 
persons affected by mental illness; (3) demonstrate that 100 percent of 
sworn officers receive training in Mental Health First Aid; and (4) 
demonstrate that a minimum of 20 percent of all sworn officers are 
trained in Crisis Intervention Team (CIT) approaches. Taken together, 
these four steps can profoundly change the way officers respond, 
increasing the likelihood of positive outcomes to those calls.
    Looking beyond these four essential steps, we are also exploring 
even more innovative and potentially useful approaches during 9-1-1 
responses. One shining example of this is happening right now in the 
Springfield, Missouri, Police Department with the leadership of Chief 
Paul Williams. Through a pilot program begun in 2013 in partnership 
with Burrell Behavioral Health, selected Springfield officers can--at 
point of encounter with a person in crisis--offer the opportunity for 
that person to speak via Skype, using iPad technology, with an on-call 
mental health professional. This action can allow for a calming of the 
situation that then lets the officer consider diverting the individual 
to a mental health resource, instead of making an arrest. Ideas like 
these, once fully evaluated, can become models for adoption nationally. 
IACP One Mind Campaign is in direct contact with SPD and Burrell staff 
to learn more and monitor progress.
    Another example of a successful diversion program--one specifically 
targeting persons affected by mental illness--is Diversion First, a 
collaborative effort between Fairfax County, Virginia, government 
executives, law enforcement, and the mental health community. The 
program is designed to reduce the number of people affected by mental 
illness in the county jail by diverting low-risk offenders experiencing 
a mental health crisis to treatment rather than bringing them to 
jail.\3\ As part of Diversion First, Fairfax County also has opened the 
Merrifield Crisis Response Center (MCRC), an assessment site where law 
enforcement officers can transfer custody of nonviolent offenders 
seeking mental health services to a CIT-trained officer assigned to the 
center. The MCRC is staffed 21.5 hours a day, seven days a week, in 
order to accept custody of individuals experiencing a mental health 
crisis, allowing officers to quickly return to answering calls for 
service.
---------------------------------------------------------------------------
    \3\ Fairfax County Government, ``Diversion Fist,'' http://
www.fairfaxcounty.gov/diversionfirst.
---------------------------------------------------------------------------
    On behalf of the IACP, I conclude by thanking you again for the 
opportunity to discuss this critical problem. I think it's clear that 
the only effective solutions to the problem must be systemic in nature, 
addressing the entire continuum from police encounters to a mental 
health infrastructure in this country that can address mental health 
issues at the same level of success as we now address our physical 
health. We stand ready to help in any way we can as you work toward 
this goal. I would be happy to answer any questions you may have.

    Senator Moran. Chief, thank you very much. I have the great 
opportunity now to ask the experts the questions, and I want to 
take full advantage of that.

                          WORKFORCE RETENTION

    Let me, first of all, say that Kansas is a State that has 
some diversity in the sense of urban and suburban areas and a 
lot of expanse in which the population is pretty small. And it 
is a challenge to provide mental health services really in any 
of those settings, but perhaps more difficult in the rural 
environment. And one of the greatest challenges we face is 
attracting, retaining, educating the workforce professionals 
necessary to provide that care and treatment.
    Have there been any successful programs that we ought to 
role model ourselves, promote in regard to that education, 
training, and hiring of professionals across the spectrum of 
that geography?
    Dr. Parks. I think one opportunity would be of investment 
in State-based workforce training centers. Nebraska, just north 
of you, has done a long-term investment in mapping out its 
behavioral health workforce, which has allowed them to identify 
strategies to improve it.
    Iowa is not that far from Missouri or Kansas, has invested 
in doing a training program for physician's assistants to 
specialize in psychiatric services. There are also some--it 
would also be helpful to increase the postgraduate training 
funds for both--for psychiatry and for other mental health 
professionals.
    In particular, currently there are better GME reimbursement 
ratios for obstetricians and primary care than psychiatry. That 
was done when it was felt there was a shortage of primary care 
and obstetricians. Clearly, there is a stronger feeling about 
shortage of psychiatry, and their funding ratio should be made 
equal to the obstetricians and primary care.
    Finally, it might make sense to--in the Conrad 30 program, 
which does payments for--which lets you let in foreign medical 
graduates, probably it would be helpful if behavioral health 
professionals did not count towards the 30 per State cap under 
the Conrad 30 and say, well, if you get more of those we are 
not going to count that to your 30 because we know you need 
more.

                  MENTAL HEALTH WORKFORCE RECRUITMENT

    Senator Moran. Well, Doctor, there is a wide array of 
mental health professionals. And I don't want to put them in 
any category, but we have psychiatrists, Ph.Ds. We have 
physicians, social workers, family and marriage therapists, 
just a wide--is there a way to focus on what is most needed?
    It may be more challenging to recruit a psychiatrist to a 
rural community. Are there other professionals that can assist 
in filling that gap that are more easily acquired?
    Dr. Parks. Certainly there are, and there are a lot of 
psychiatric extenders being used. Advanced practice nurses have 
gone up dramatically in their numbers, and additional funding 
for their training programs would be helpful. As I mentioned, 
physician assistants are seeing growth.
    On the nonprescribing side, there are rate problems also 
with psychologists. Many of the commercial and the governmental 
reimbursement rates for psychology are below their actual cost, 
as they are for psychiatry. Right now, most Community Mental 
Health Centers actually lose money on their licensed 
professionals, and they have to make up that loss on their 
support service, their nonlicensed people.
    One important part that was mentioned earlier, one 
advantage that federally Qualified Health Centers have is their 
prospective payment, which is also part of the Certified 
Community Behavioral Health Centers, where the payment is 
designed so it must be adequate to support the cost of care. 
Even if you have the workforce, if the business is going to 
lose money every time it gives the service, they have to limit 
that service.
    Senator Moran. Thank you very much.

                      MENTAL HEALTH REIMBURSEMENT

    Let me ask Dr. Freeman. In regard to compensation, is there 
a difference for a healthcare professional that works at a 
community mental health center versus a community health 
center? Is the way the financing of those organizations matter 
in their ability to attract and retain and pay adequate 
compensation?
    Dr. Freeman. Yes. These days, with so much of Medicaid 
being managed-care, some of those issues are kind of washed 
out.
    Senator Moran. Okay.
    Dr. Freeman. I mean, there is some fee-for-service that is 
still kind of the base of those contracts, but more and more 
contracts are going to value-based payment, so we are being 
paid so much for taking care of a population. So that is 
becoming less and less of an issue.
    While Joe was talking, there were a couple of manpower 
workforce programs that I wanted to mention that are already in 
existence that are already funded. There is a very small 
program called the Graduate Psychology Education Program. It is 
a HRSA (Health Resources and Services Administration) program. 
There are just a few of these grants across the country. We 
have been fortunate enough to have one of those.
    And it really is training the workforce to work--behavioral 
health workforce to work within primary care with underserved 
populations. So we are training and delivering care at the same 
time.
    We have found, having received one of those grants, that 
almost all of those recipients stay with us, even if they are 
in rural, underserved areas, if they are in inner city areas. 
Once people get the opportunity to work within a system, they 
will often stay.
    The other program is much larger, and that is the National 
Health Service Corps. And over the years, that has been a 
wonderful resource for workforce for safety net providers, 
Community Mental Health Centers and FQHCs. So we probably have 
had 200 recipients of that program over the years. About 25 
currently are receiving loan repayment. And a high percentage 
of those--for us, it is over 80 percent of the folks that 
receive those training funds to work within our system for a 
few years will end up staying in our system.

               MENTAL HEALTH AND COMMUNITY HEALTH CENTERS

    Senator Moran. What is the relationship between a community 
mental health center and a community health center?
    Dr. Freeman. Yes.
    Senator Moran. How do they work together, or do they serve 
a different population, or are they just available in some 
places and not in others?
    Dr. Freeman. You know, these days they are really working 
closely together across the country. Often, they do, you know, 
serve the same population. You know, so there is a lot of 
collaboration back and forth, a lot of referral back and forth, 
good collegial relationships back and forth.
    I think there is a clear trend, you know, to kind of bring 
these services together in the same setting, and that is kind 
of what our model is all about. So we are both FQHC and a CMHC.
    I know in Joe's State, in Missouri, there has been a lot of 
collaboration between these two sectors. So it is really a 
healthy thing for the population that we are all trying to 
serve.

                FEDERAL RESPONSIBILITY IN MENTAL HEALTH

    Senator Moran. How do we divide the responsibilities 
between the Federal Government and State government in meeting 
the needs for those who need mental health services?
    And let me say it this way. I often think that many of 
these issues are State and local, but there is a significant 
component, a role that we play. You have named, you have 
outlined a long list of things that Congress, the Federal 
Government is involved in in supporting those efforts, but does 
the primary responsibility for providing mental health services 
to those in need rest with Kansas and Missouri and Tennessee?
    Dr. Parks. This is a very old issue that actually got 
played out in the 1800s under President Pierce, I believe, who 
wanted to make it an issue for the States. De facto, it is an 
equally shared version these days with the matching, with both 
State funds funding both Medicare and Medicaid and often 
funding both sides of education. I think it needs to be seen as 
a shared responsibility.
    In terms of who leads, I think the national--the Federal 
can set the priorities for broad movement, but I think in the 
nuts and bolts, implementation in a locale is the 
responsibility of the State.
    To mention one approach on integrating federally Qualified 
Health Centers, community health centers, and CMHCs, in 
Missouri we did some State-funded grants that could only be 
given out if it was applied for by an FQH--community health 
center and a CMHC together. They both got an equal amount of 
money that they could only use to buy services from each other. 
And it was really a grant that funded more integration so they 
would do more work directly and understand each other's 
business better. That might be, a model that will work well 
elsewhere.
    Senator Moran. Thank you very much, Dr. Parks. It is 
unusual for a Kansan to listen to a Missourian, but I am happy 
to do so this morning.
    [Laughter.]
    Dr. Parks. I think we are modeling speaking well to each 
other.
    Senator Moran. We are. If we can overcome our differences, 
maybe Republicans and Democrats can do the same.
    [Laughter.]
    Senator Moran. Chief, I appreciate what you had to say. It 
is a common conversation with law enforcement officials, county 
officials, county commissioners, those who fund law 
enforcement, mayors, and city councils. The tremendous 
financial burden that now accrues for, in a sense, housing 
those who really need to be cared for in a mental health 
setting end up in our county jails and our city jails. And it 
is a financial burden that many counties and cities, 
particularly rural, are simply unable to meet.
    In Kansas, and I have recently visited both, we have two 
institutions, two mental health hospitals, one in Osawatomie, 
one in Larned. I visited both. Certification has been an issue 
really in both hospitals, but most recently at Osawatomie. And 
that then creates--because of closure of beds within that 
facility--creates an even greater burden on local officials. 
There is no place to take someone who is arrested for 
treatment.
    I served in the State Senate for--now a long time ago--and 
chaired the appropriations committee that was responsible at 
the time for funding mental health centers. And we were going 
through the community-based decisions versus institutional or 
hospital care. And in my view, it takes both. And the promise 
was made as we moved more toward community-based services that 
the money would flow from the hospitals to the community-based 
services.
    And in too many instances and after a short period of time, 
that seemingly promise was failed to be kept, and now we pay 
the price for what is happening in the institutional setting, 
the hospital setting. And yet, the community-based services 
don't have the money either. And so, we have really, in a 
sense, hopefully unintentionally, but the consequence has been 
the burden, financial and otherwise, falls to local units of 
government to pick up the tab where the Federal or State is 
failing.

                  THE VA'S ROLE IN MENTAL HEALTH CARE

    Let me--with Senator Alexander returning, I am going to go 
vote, but a question I did want to ask is we pay a lot of 
attention to veterans. And it is one of the places, in my view, 
that the VA (Veterans Affairs) is failing many. Way too many 
veterans who have mental health conditions are slipping through 
the cracks.
    And we have worked trying to get the VA for a long time to 
contract with Community Mental Health Centers. It is the one 
thing we do have across Kansas. There is still distance 
involved in many instances, but there is a community health 
center that serves every county, every citizen of our State.
    The VA is outside of Kansas City in Leavenworth. It is in 
Topeka, and it is in Wichita. The congressional district I used 
to represent in Western Kansas is larger than the State of 
Illinois. There is no VA facility there. So the distances are 
tremendous. And we have yet to achieve what I think--I think we 
have just failed miserably in getting the VA to contract with 
mental health centers to provide services to their veterans 
where they happen to live.
    We now have under the--in the Department of Veterans 
Affairs, something called Choice. It says if you are a veteran 
who lives more than 40 miles from a VA facility or it takes the 
VA more than 30 days to provide the services that you need, 
then at your choice, the veteran's choice, you can receive 
those services at home.
    It highlights to me that, one, we need greater effort on 
the part of the VA to contract and to enter into those 
agreements; but two, we need the resources to attract and 
retain the professionals. It is one thing to say that the VA 
can contract with someone in a rural community to provide the 
services, but the services are not always there.
    So I just wondered if there is a role model out there, if 
you have seen any evidence that the VA is making changes that 
would benefit all of our citizens. But particularly, one of the 
things that if a veteran is using his or her choice in a 
community, then the dollars that that presents to the provider 
benefits the infrastructure for everyone. It helps us keep a 
mental health center going financially if we are caring for 
veterans at home.
    Any evidence that there is a role model or that the VA is 
doing what it should do in regard to utilizing your services in 
a community setting?
    Dr. Johnson. I will say in the State of Washington, in 
Seattle, there is good cooperation between the VA center there 
and the hospitals and the outpatient clinics. This era of 
healthcare is all about multiple partnerships. And one of the 
things that I am finding most exciting across the Nation is 
when different systems like the VA, the Community Mental Health 
System, and the FQHCs do partner together, and so I am finding 
reason for hope.
    I am also very impressed that the Veterans Administration 
has picked up on the importance of trauma-informed care and 
approaching treatment with that in mind. And so, I am finding 
reason for encouragement at this time.
    Senator Moran. Good to hear.
    Mr. Chairman, thank you.
    Senator Blunt [presiding]. Thank you, Senator Moran, for 
standing in so we could all go vote.
    Senator Alexander.
    Senator Alexander. Thanks, Mr. Chairman.

                     BEHAVIORAL HEALTH INTEGRATION

    Dr. Freeman, about a year and a half ago I hosted a 
roundtable in Knoxville, where you are from, with a lot of 
people who dealt with the opioid abuse. Dr. Tom Frieden with 
the Centers for Disease Control and Prevention came. Maybe it 
was 2 years ago. Dr. Frieden's work is really putting the 
spotlight on epidemics that threaten the American people, and 
he was doing that then.
    We made some changes in the law, as a result of some of the 
suggestions actually made at that roundtable in Knoxville. But 
I know you have been a leader in behavioral health integration. 
What have you been doing at your center to deal with opioid 
abuse in the East Tennessee region?
    Dr. Freeman. Yes. Well, I appreciate that meeting in 
Knoxville. We had a number of staff who were there and 
appreciate the changes that have taken place.
    We have really targeted that population. It fits 
beautifully with the integrated model because these folks need 
medical care. They need psychological care. So we deal with the 
population with a complex care team that has a physician 
primary care prescriber, a psychiatrist, a psychologist, and 
they work with this population.
    We have to think of this really as a long-term problem. You 
know, there are no short-term solutions for this problem, and 
so our task is really to engage these patients in this model 
and stick with them. We have targeted certain subpopulations 
within that. We have a group that is working especially with 
pregnant women, who have addictions, and it is a tough, tough 
challenge, but I think we have got to mobilize the care teams 
that have the sufficient depth and breadth to take care of a 
tough problem.

                       OPIOID PRESCRIBING HABITS

    Senator Alexander. Were you a part of the discussion we had 
at the roundtable about the physician satisfaction survey and 
the effect it might be having on prescribing opioids? Do you 
remember that issue?
    Dr. Freeman. I do, yes. We have talked a lot about that. I 
think that if we look at this practice across the country, the 
medication-assisted treatment practice, there are a lot of docs 
that are trying to kind of do this on their own.
    And we think it is a much more complex problem than that. 
You know, I think if you look at satisfaction surveys of 
physicians, if they have a care team around them, you know, if 
they have behavioral health support, if they have nurses that 
are working up to the maximum of their license, that really 
creates a much more favorable environment for physicians, and 
they will stay in the workforce much longer.
    Senator Alexander. What are the biggest challenges you face 
in this work you just described?
    Dr. Freeman. Well, there is a long list.
    Senator Alexander. Well, the top one or two. What are 
those?
    Dr. Freeman. Yes. I think workforce is just a constant 
issue, to find enough providers who are well trained, who want 
to work with underserved populations.
    And we were talking earlier, before you came in, that there 
are a couple of programs that are already funded by the 
Government that have been great support for us. One is the 
Graduate Psychology Education Program, where one of those 
grantees--there are just a couple of dozen maybe around the 
country, and we train behaviorists to work in this integrated 
care setting.

              REPLICATION OF INTEGRATED MENTAL HEALTH CARE

    Senator Alexander. Do you believe that your successful 
model at Cherokee Health Systems could be replicated in other 
community health centers around the country?
    Dr. Freeman. Oh, I think it is being replicated. I mean, it 
is--what is happening in these guys' States, very similar. We 
do training academies. We have had people from every State in 
the country and three foreign countries. When people come in, 
they are often pretty far along in developing this kind of 
program. So I think integration is really becoming a model that 
folks are looking to and following.
    Senator Alexander. Thanks, Dr. Freeman. Thank you, Mr. 
Chairman.
    Senator Blunt. Thank you, Senator Alexander.
    Glad to be joined by the ranking member of the committee 
who I have worked together with on these issues a lot. And 
Senator Murray, if you have both an opening statement you want 
to make and questions to ask, we will go to you right now.
    Senator Murray. Well, thank you very much, Mr. Chairman, 
for calling a hearing on such an important topic. I do want to 
thank all of our witnesses for traveling here today, and I am 
sorry that I can't remain here for the hearing. There is a lot 
going on.
    So, given the limited amount of time, I would just ask that 
my opening statement be a part of the record, and I will go 
directly to my questions.
    [The statement follows:]
               Prepared Statement of Senator Patty Murray
    Thank you, Mr. Chairman for calling this hearing on such an 
important topic.
    I would also like thank our witnesses for traveling to be here 
today, and am sorry I will not be able to remain for the full hearing 
as planned.
    Given the limited time, I have just a few comments and ask that my 
full statement be entered in the record.
    We all know that mental health is one of the country's most 
pressing healthcare needs.
    The good news is that prevention and treatment work, and I am 
pleased the Subcommittee supports several important programs that help 
people with mental illness.
    But let's be very clear--the investments in the Labor H bill will 
mean very little if Republicans continue with their efforts to repeal 
the Affordable Care Act.
    Building on the Mental Health Parity Act of 2008, the ACA has 
helped 62 million Americans gain access to behavioral healthcare 
services by, first of all, expanding Medicaid. Medicaid is by far the 
largest source of Federal financing for mental health services.
    The ACA also ensures that health plans can no longer deny or 
discourage those with mental health issues from getting the treatment 
they need.
    Now, however, all of this is at risk. The President and my 
colleagues on the other side of the aisle are looking for ways to erode 
the ACA.
    I hope that won't happen.
    I ask my Republican colleagues to drop this harmful repeal effort 
once and for all, and start working with us to build on the progress 
made to help families and communities get the mental healthcare they 
need.
    Thank you, Mr. Chairman.

    Senator Murray. And Dr. Johnson, good to see you.
    Dr. Johnson. Thank you.

            AFFORDABLE CARE ACT'S ROLE IN MENTAL HEALTH CARE

    Senator Murray. Thank you for coming out here. And as you 
noted in your remarks, the ACA expanded access to mental health 
and substance use disorder services for over 68 million 
Americans by making mental health services an essential health 
benefit and by expanding parity protections. We also know that 
because of the ACA, hospitals have seen their uncompensated 
care burden drop by $10 billion.
    So I wanted to ask you, as the CEO of one of Washington's 
largest community mental health providers and as a clinician, 
you have been on the front lines of behavioral healthcare for 
over 30 years now. Can you talk a little bit about how the ACA 
and then particularly the expansion of Medicaid have impacted 
your practice and access to mental healthcare?
    Dr. Johnson. Sure. Now that we have almost 800,000 more 
people insured in the State of Washington, I think one of the 
happiest effects of that is that people who never thought they 
would have access to care have, indeed, gotten evaluations, 
gotten assessment, and we have found mental illnesses, 
substance use disorders that were in development, and we have 
been able to intervene early. And it is so much better to 
intervene early rather than to have somebody become 
involuntarily committable, suicidal, deeply anxious, and so on. 
So that has been an excellent byproduct.
    Also, I am very appreciative that the Affordable Care Act 
has created accountable communities of health throughout the 
State. We have nine accountable communities of health where 
people from business, higher education, inpatient and 
outpatient services, and so on, get together to strategize ways 
to increase the wellness of the population in general. And we 
are doing some wonderful work to address everything from food 
deserts to inequity in access to care based on some of the 
social determinants of health. So that has been a great 
byproduct.
    Also, as we broaden the eligibility criteria, we are 
serving people we couldn't serve before. There are many young 
families who are participating in our infant and early 
childhood mental health program making a tremendous difference 
in those lives who wouldn't be in care because of the previous 
eligibility criteria.
    And we know for every dollar we spend on taking care of a 
young child, we save $17 down the line that would have been 
spent with school failure, incarceration, institutionalization, 
homelessness, and so on. So many lives are better because of 
this.

                       AFFORDABLE CARE ACT REPEAL

    Senator Murray. So how damaging would it be to your 
patients that you treat if there was the efforts here to repeal 
the ACA occurred?
    Dr. Johnson. Well, the very first thing that comes to mind 
is my concern for people in rural counties and poor counties in 
the State of Washington. And particular----
    Senator Murray. Rural counties?
    Dr. Johnson. Yes, the rural counties, and particularly, men 
with less education. They are the ones who have become eligible 
for services. And if we roll back, once again, we are going to 
be putting uneducated men who live in poor rural communities 
behind. And so, that concerns me.
    Also, I am concerned about the loss that would happen in 
the work that we are doing not only with children, but the 
Affordable Care Act has allowed me to place my staff, to embed 
my staff in 50 schools, for example. We are able to go where it 
is convenient for people to get services and for kids who 
couldn't get to a mental health center to do that, and so there 
are losses all along the way.
    It will become more expensive. Because behavioral health 
services decrease total healthcare costs by 35 percent, if we 
were to roll back the gains made, it is going to cost us a lot 
more, and there will be many lives badly affected.

                         MEDICAID MANAGED CARE

    Senator Murray. Well, I appreciate that. And there is talk 
as well of repealing the Medicaid expansion as part of that and 
converting it to a per capita allotment or a block grant, as we 
hear so often here. I know that Washington State's expanded 
Medicaid program has really strengthened our State's safety net 
by covering the lowest income individuals, including those with 
homelessness you mentioned a moment ago, mental health 
conditions, substance abuse, so much of that. How is Navos 
working now with Medicaid managed care organization to reduce 
costs while addressing behavioral health?
    Dr. Johnson. You know it used to be that the managed care 
companies were the adversaries of healthcare providers. They 
were the ones that said, no, you can't do services that we felt 
were needed. That is not the case today. Some of my best 
colleagues are the managed care companies because they 
understand that if we do effective behavioral health treatment, 
it is going to save them on all sorts of physical health 
hospitalizations and diseases that advance too far, cancers 
that happen and diabetes that goes out of control.
    And so, we are working together in very, very practical 
ways. There are initiatives where we are funding peer support 
specialists to become care coordinators and care navigators. We 
are offering wellness classes, wellness groups. We are doing 
combined treatment. We are doing treatment in the home. And I 
am finding that the managed care companies are eager to help 
provide the smartphones, the apps for the phones, and step up 
to share the savings that they are making through helping us 
purchase care coordination staff.
    Senator Murray. Okay, very good. My time is up, but I do 
have other questions that I will submit for the record, and 
again, apologizing for just having a short amount of time here.
    Senator Blunt. Thank you, Senator Murray.
    Senator Kennedy, welcome to the Appropriations Committee 
and welcome to this subcommittee.
    Senator Kennedy. Thank you, Mr. Chairman. Thank you, 
gentlemen.

                            MEDICAID SAVINGS

    I want to talk to you just for--excuse me--a few minutes 
about Medicaid. In my State, we have about 4.6 million people. 
We have got about 1.8, 1.9 million on Medicaid. We spend 41 
percent of our budget on Medicaid. Every year we spend more and 
more money on Medicaid, and we use that money to treat people 
who keep getting sick faster and faster.
    In terms of the State dollars, our State match has gone up 
in the last 9 years about 9 percent a year, and the funding is 
crowding out other needs like--excuse me--higher education and 
roads. I don't know anybody that wants to deny healthcare to 
people who need it. I reject the implication of some that if 
you are not for every social program you are somehow an evil 
person.
    You know, American people, shoot, if you are hungry, we 
will feed you. If you are homeless, we will house you. If you 
are too poor to be sick, we will pay for your doctor. But I 
think most right-thinking people are concerned about the cost 
because most people have to work for their money.
    So here is my question. You have all had experience, most 
of you, with Medicaid. How can we save money on Medicaid?
    Dr. Parks. We have saved money in Medicaid in Missouri by 
mostly focusing on giving more efficient treatments and using 
data to target care gaps. So instead of focusing on people who 
go to the ER a lot, we focus on the conditions that cause them 
to go to the ER a lot and try to get impact on it upstream.
    One example was making sure people with asthma are on the 
proper inhaler that prevents you from starting to wheeze. So 
instead of intercepting them at the ER, it is important to have 
programs in the community that get the illness early. The 
other----
    Senator Kennedy. I am going to interrupt you, Doctor----
    Dr. Parks. Yes.
    Senator Kennedy [continuing]. Because I have only got 5 
minutes. And I am not trying to be rude, but I really want to 
get down to specifics here. I think you are talking about 
chronic disease management, which I appreciate, but let us talk 
about emergency rooms.
    Dr. Parks. Okay.

                          EMERGENCY ROOM CARE

    Senator Kennedy. Last year in Louisiana we had 900,000 
taxpayer-funded visits to emergency rooms for routine care. We 
have got people going to be treated for acne, to have a fever 
blister looked at, to get obesity counseling. I talked to one 
ER doc that tells me about a couple that drop their grandmother 
off every Saturday night at the ER because they don't want to 
pay for a babysitter. Now, how do we stop that?
    Dr. Johnson. Could I speak to that?
    Senator Kennedy. Yes, please.
    Dr. Johnson. You know, the use of a peer support 
specialist, somebody who has the lived experience of having a 
mental illness or substance use disorder, who has recovered and 
has taken training, they are far less expensive than an 
emergency room doctor. And we find that when we couple peer 
support specialists in working with people on changing how they 
live, they stop going to the emergency department.
    If somebody can come into your home and help you make sure 
that you have got food, help you make sure that you are doing 
whatever needs to be done to the home to prevent an asthma 
outbreak, it is far less expensive and a far better quality of 
life for people.

               LIMITATION OF SERVICES AT EMERGENCY ROOMS

    Senator Kennedy. Why can't we do what the Governor of 
Washington State, hardly a bastion of conservatism, tried to do 
a few years ago? He about got his head taken off for it, but he 
published a list of different illnesses, if you will, that 
Medicaid was going to no longer pay for. I mean, and it was 
common sensical stuff, you know, fever blister. I mean, if you 
come in with a headache, that wasn't on the list. You could 
have just a headache, or you might have a concussion. But if 
you have a fever blister, no, we are not going to treat you in 
our ER.
    Dr. Parks. So a number of States and this is something we 
are in the process of implementing in Missouri do give much 
lower reimbursement for non-emergency medical conditions. So we 
will only pay--Georgia has put this in place already. In this 
kind of situation if somebody comes in for something that isn't 
an emergency, the hospital is only paid for the triage 
evaluation. They are required to look at you and make sure it 
is not something bad, but they just pay for the triage.
    Senator Kennedy. But does it have to be a doctor to do the 
triage?
    Dr. Parks. Not in every case, no.
    Senator Kennedy. That is right.
    Dr. Parks. Sometimes hospitals choose that because they 
fear liability, but that is not a requirement. That is driven 
by liability fears.
    Senator Kennedy. Right. You can station a paraprofessional 
at the entrance, and if somebody comes in with a fever blister, 
they can be told, ``Look, you know, you don't want to wait 4 
hours here, and it is not fair to taxpayers and the people who 
are really sick. We will help you get an appointment with a 
private--with a primary care physician,'' but come on.
    Dr. Parks. Now some of the things that has helped reduce ER 
usage in the health homes that is being wider in the Certified 
Community Behavior Health Centers under the Excellence Acts is 
people, we actually track when they go to the ER, and if you go 
when you shouldn't we call you up and say, ``Why the heck 
didn't you call me first?''
    Senator Kennedy. Sure.
    Dr. Parks. ``And next time I want you to call me first.'' 
And people respond to that personal touch. That is the kind of 
peer----
    Senator Kennedy. That is a good point.
    Dr. Parks. Yes. But you need a relationship.

                         EMERGENCY ROOM COPAYS

    Senator Kennedy. I have got 36 seconds. Do copays work in 
the ER?
    Dr. Parks. For some people, not for everybody. The low 
copays in Medicaid are not much of a deterrent right now. They 
could be more. For some people, they still would not work. Some 
of these people really don't have two nickels to rub together, 
and you couldn't get them out of them anyway.
    Senator Kennedy. Okay. No, I have a minute, don't I? I am 
done, huh?
    Voice: Once it goes to zero, that starts the other time.
    Senator Kennedy. Oh.
    Voice: The 30 seconds----
    Senator Blunt. Thirty-six seconds quickly became 56 
seconds.
    Senator Kennedy. No, I am done. I am sorry.
    Senator Blunt. But we will have a second round of questions 
if you have time and want to wait.
    Senator Kennedy. Sure.

                      EXCELLENCE IN MENTAL HEALTH

    Senator Blunt: I think a couple more members are on the 
way. But again, thanks to all of you for coming. This is an 
issue that we are way behind on and trying to get caught up.
    Senator Stabenow and I went to the floor the last day of 
October of 2013, which was the 50th anniversary of President 
Kennedy signing the Community Mental Health Act. And when you 
talk your way through that act and read your way through that 
act, a lot of facilities got closed, as the act anticipated. 
However, the new alternatives didn't get opened and we're 
trying to do that now. Dr. Parks, as you know, we have eight 
States that are the pilot States in Excellence in Mental 
Health.
    And I think, Dr. Johnson, I will come to you on this in a 
minute, and maybe others as well, I think what those eight 
States will generally find out is that treating mental health 
like all other health actually in the greater context of 
healthcare doesn't cost anything, but because the other 
healthcare issues that the mental health community may have are 
so much more effectively and easily dealt with.
    But, Dr. Parks, would you talk just a little bit about the 
plan you put together and how that plan in our State or other 
States could be implemented so that these pilots work in the 
best possible way?
    Dr. Parks. Part of the power of the Certified Community 
Behavioral Health Center to reduce healthcare costs is that the 
Community Mental Health Center is not responsible just for 
behavioral costs, but for overseeing and coordinating all the 
medical treatment. So our Community Mental Health Centers in 
Missouri are monitoring people for their blood sugar control, 
for their blood pressure control, and that will expand and 
continue under the Excellence Act Certified Community 
Behavioral Health Centers.
    We have seen better control through the--as good a control 
of blood sugar through CMHCs as we see through the community 
health centers, the primary care clinics. And the Community 
Mental Health Centers have 30 percent people with diabetes as 
opposed to the primary care clinics, only 15 percent. This is 
because people with serious mental illness have many more 
chronic medical conditions than the general population.
    They are required to have the whole range of services. So 
if you don't get better with just med visits and therapy, you 
don't just automatically go inpatient. You can get intensive 
day treatment. You can get partial hospitalization. You get 
assistance with transportation to get you in there with a 
cheaper ride than an ambulance ride to the ER.
    They are required to have afterhours. They have to be open 
on some weekends, some evening hours so people can get-- if 
they are working some jobs, they can get in when it doesn't 
interfere with their work.
    And most of all, they don't have a disincentive to provide 
just supports and not provide treatment. Many CMHC 
reimbursements right now pay a better rate for supports than 
they do for treatment professionals, so Community Mental Health 
Centers don't have enough psychologists, don't have enough 
psychiatrists, don't have enough licensed therapists because 
they lose money on those. And the prospective payment rate 
system will be essential to making sure that treatment is as 
big a part to get them better as supports to help them get 
through with their disability.

                   FEDERALLY QUALIFIED HEALTH CENTERS

    Senator Blunt. And the prospective payment rate system 
largely analogous to what happens now with Federally Qualified 
Health Centers?
    Dr. Parks. Exactly. It is almost completely identical, and 
it is what allows Federally Qualified Health Centers to be able 
to get the staff mix they need instead of going with staff that 
are cheaper, and therefore, don't have the proper mix of 
skills. You don't want your business model driving the clinical 
decision of who is the best person to treat you.
    Senator Blunt. The National Institutes of Health says that 
1 out of 4 Americans has a diagnosable and almost always 
treatable mental health challenge. I asked our NIH 
representatives at a hearing last year about this issue and 
they said that 1 out of 9 adult Americans has a mental health 
issue that impacts how they live every single day.
    So this is not an isolated group of Americans. This is now 
something that every family in one way or another is likely to 
be dealing with with some member of their family. But, Dr. 
Johnson, you mentioned a percentage of, I think, 35 percent of 
other healthcare costs go down?
    Dr. Johnson. Yes. Right. When we have the proper health 
home, and for people with very serious and persistent mental 
illnesses, often the mental health center is the best place to 
have the health home. And that is because we have--for 
instance, we offer hundreds of supported living houses and 
residential treatment options.
    But we find that if we take care of those problems well 
enough and quickly enough that people don't go on to have out 
of control diabetes. They don't have repeated hospitalizations. 
They don't have repeated visits to the emergency department.
    And Senator Kennedy, I want to echo your concern about 
lifetime care. I believe even with serious and persistent 
illnesses, we should be thinking of episodes of care and 
helping people recover well enough so that they can have 
periods of independence or independence further on. We are 
doing this now. It is working.
    And I appreciate, Senator Blunt, how articulate you were 
about how the total healthcare cost doesn't increase. It 
actually goes down when we include effective behavioral health 
treatment.

                          MENTAL HEALTH PARITY

    Senator Blunt. Do you have--you know, there are some big 
county studies--no statewide studies that I am aware of--and 
maybe you are, and I am not. There are some studies in bigger 
counties in the country that in, I believe, all cases have 
wound up that when they treat mental health like all other 
health, they save money beyond what they were spending in a 
previous year on when they weren't treating mental health like 
all other health. Would that surprise anybody here?
    Dr. Johnson. No, and I will give an example of that. And 
this goes back, again, to Senator Kennedy's concerns about two 
expensive people doing work. We couple peer support specialists 
who are in our--folks who are in our psychiatric hospital for 
about a 14-day stay, we find if we develop a relationship with 
a peer support specialist who then goes into the community with 
them for the next 90 days, that they don't come back into the 
hospital.
    We have documented millions and millions of dollars of 
savings in the Seattle/King County area alone in the past few 
years because we find that if we make sure we deal with that 
arrest warrant that is frightening the person in the hospital, 
if we can get that dismissed, if we can get them to their first 
appointment with the doctor and their first appointment at the 
mental health center, they don't go back into the hospital. 
Those are the three touch points, a very inexpensive 
intervention with a tremendous payoff.
    Senator Blunt. Well, I think how we look at these eight 
pilots and how we analyze the results will make a big 
difference in what a pilot is supposed to show. And Dr. 
Freeman, I may come to you on the second round of questions of 
any of your thoughts on that very same area of overall 
healthcare cost when you treat mental health like other 
healthcare.
    But we are going to go now to Senator Shaheen. And with her 
encouragement, this committee, this Appropriations Committee, 
actually got a year's start on the national discussion about 
opioids, and Senator Shaheen understands that issue, has been 
an advocate for it and the mental health issues that either 
develops when you have an opioid problem or lead to an opioid 
problem.
    Senator Shaheen.
    Senator Shaheen. Thank you very much, Mr. Chairman, and 
thank you for those remarks. And that is exactly what I would 
like to discuss with the panel this morning.

          SUBSTANCE ABUSE AND CO-EXISTING MENTAL HEALTH ISSUES

    In New Hampshire, we have the second-highest percentage of 
overdose death rates from substance use disorders. And as I 
have talked to specialists, to treatment providers, what I have 
heard is that the co-occurrence of mental health issues with 
people who are using substances--whether it be alcohol, heroin, 
opioids--is dramatic. So I wonder if the doctors here could 
speak to whether that is what you have seen, in fact, and is 
there a ratio? What I have heard is about 40 percent of those 
with substance use disorder problems also have co-occurring 
mental health issues.
    Dr. Johnson. We need to think through a trauma-informed 
lens when we consider this question. Very often people who go 
on to have significant psychiatric issues or substance use 
disorder issues have histories of sexual and physical abuse.
    We also have learned from our 21st century wars that when 
we send even our best and our brightest in harm's way, too 
frequently every single one of us, regardless of our genetic 
predisposition for schizophrenia or bipolar, every single one 
of us has that tipping point where under enough stress we 
become depressed, we become anxious, we become suicidal, we 
become impulsive.
    And so, yes, we are finding that kind of overlap. The areas 
of the brain impacted by psychiatric symptoms and addictions, 
you know, there is a tremendous overlap.
    So when we think in terms of what has happened in 
somebody's life to activate a predisposition to addiction--to 
self-anesthesia, frankly--we need to have a multiple-pronged 
effort to address it.
    Think of the people who got their first Hydrocodone from a 
dentist appointment, from an oral surgery, or from injuries at 
war. We need to think of the responsibility we need to take for 
having introduced that into people's lives. And then we know 
that through partnership and through many different avenues, 
whether it is education and treatment and medication-assisted 
treatment, we can make a difference.

                           MEDICAID EXPANSION

    Senator Shaheen. Can I--I just want to follow up on that, 
if I could, because what we have seen in New Hampshire is 
because of coverage under the Affordable Care Act, because of 
expanded Medicaid, we now have people who can get treatment who 
could never get treatment before. Last year, we had 48,000 
Medicaid applications to address substance use treatment for 
various people in the State.
    So can you speak to what--what I have heard is that without 
that, without those resources, treatment is going to be very 
hard to come by. So can you speak to--any of you speak to what 
happens if we eliminate those options for treatment and the 
resources to help people get that treatment?
    I don't know, Dr. Freeman, if you were about to comment.
    Dr. Freeman. Well, I am from Tennessee. You probably know 
we did not expand Medicaid in Tennessee. Thirty percent of our 
patients are uninsured, you know, and we see everyone that 
wants to come. And it is truly a challenge to take care of that 
population, but we do find a way.
    And I think, you know, what you are saying about the co-
occurrence of psychiatric conditions and substance misuse, very 
common, but it really goes beyond that, too, because many of 
these folks have not received adequate medical care, and many 
of these folks really are kind of living on the edge of 
society. They have huge social needs, housing, any kind of 
income, employment. So really it does take a complex team to 
take care of these folks adequately.
    And I think, you know, we do that as both an FQHC and a 
CMHC, and that may be the ideal setting because we have the 
medical. We have the behavioral. We also have persons who go 
out into the field, community health workers who can help 
folks.
    Senator Shaheen. Sure. We also have that in New Hampshire, 
and they have been very good at partnering on so they can 
address the substance use disorders as well as do the rest of 
the treatment for patients.

                        SUBSTANCE USE DISORDERS

    Chief, I want to go to you because one of the things that 
we are doing much better, I think, in New Hampshire and in many 
places across the country is recognizing that substance use 
disorders are a disease and that we are not going to jail our 
way out of dealing with this problem, and what we need to do is 
make sure that people can get treatment.
    We have a number of safe station programs in the State of 
New Hampshire where if you go into a fire station, they will 
make sure that you get treatment. We also have that in my local 
area where the police departments have teamed up with community 
health centers, with other treatment providers to make sure 
that people can get treatment when they come in, when they are 
ready for that treatment. Can you speak to why you think that 
is so important from a law enforcement perspective?
    Mr. De Lucca. Well, law enforcement as a whole, realizing 
there are 18,000 agencies in the United States, diversion is 
important. You know, to arrest, incarcerate only leads to 
recidivism if there is nothing done upfront. So we are training 
officers across America in Crisis Intervention Team, Mental 
Health First Aid to prepare them for this. The last thing we 
want to do is tie up our jails, our hospitals without another 
option. So I think it is very viable.
    Senator Shaheen. Thank you very much. Thank you all for 
being here.
    Senator Blunt. Thank you, Senator. Senator Rubio.
    Senator Rubio. Thank you all for being here. Thank you, 
Chief. Good to see you.
    Along the lines of what you are doing now across the 
country as part of the association, but also your experience 
working in South Florida, Miami Beach, and now in Doral, as you 
recall, we had an issue many, many years ago with police 
departments and law enforcement interacting with people that 
suffer from mental illness, and we saw some incidents, you 
know, where the police had to use strong measures to restrain 
someone. And so there was this dichotomy between traditional 
police training and how to appropriately handle someone who was 
mentally ill. Those procedures have changed over the years in 
South Florida and I believe through much of the country.

              LAW ENFORCEMENT'S ROLE IN MENTAL HEALTH CARE

    So the first thing I would ask is how in that training have 
we seen improvements in the way law enforcement can now 
identify someone who is just being belligerent and someone who 
is exhibiting signs of mental illness, and as a result, the 
approach to arresting and protecting them would be different 
than in somebody else?
    Mr. De Lucca. Absolutely. I would like to talk about the 
11th Circuit Criminal Justice Mental Health Project that is 
going on in South Florida, which is really spearheaded by Judge 
Leifman.
    Senator Rubio. Correct.
    Mr. De Lucca. Way back in 2000, the period that you are 
talking about, where we realized we are loading up our jails 
with mentally ill people. At the peak of this, there were 7,200 
people in our Dade County jails. And today, because of the 
proper training, we are down to about 4,000. We have been able 
to close a facility, save about 25,000 beds a year, which makes 
a big impact.
    So, in 2000, to divert individuals with serious mental 
illnesses who do not pose significant public safety risks away 
from the criminal justice system into community-based treatment 
and support services. There were two components--pre-booking 
diversion, where we trained our officers and Crisis 
Intervention Team. In South Florida, we have trained about 
5,000 law enforcement officers. And also there is post-booking 
diversion serving individuals who are in jail or awaiting 
adjudication, who are at a lower risk who can get into 
programs.
    We have seen that the rate of recidivism has dropped 75 
percent on those individuals with the collaborative work of so 
many work groups who have really bought into this. I think an 
important note for me to talk about two of our large agencies. 
From 2010 to 2016, Miami Dade Police and the City of Miami had 
almost 68,000 interactions with mental illness persons. There 
were 14,000 diversions made and only 127 arrests. I think that 
speaks volumes of the front-end training for officers to 
identify is a person in crisis, are they mentally ill, what 
steps do I take using de-escalation, and where to go next.
    So I think those are some of the important steps that we 
are talking about today and how we can get there in the future 
by supporting funding, supporting the IACP and other 
associations, and pushing out our One Mind Campaign to continue 
to build on this.
    Senator Rubio. And what the chief is referring to, for 
those that obviously may not be familiar with it because they 
are not from South Florida, we had a couple of floors at the 
county jail, for example, that were a house of horrors in the 
early 2000 to 2005 period. I happened to be Speaker of the 
House during some period of time and toured it. And you 
basically had mentally ill people being held in a traditional 
jail setting that was not prepared, and it was horrifying, the 
conditions they were in and so forth.
    And that is where Judge Leifman, who has truly done a 
phenomenal job, began to interact with this program. And we 
still have some issues, but we certainly have come a long way 
from where were.
    You discussed the importance of these programs and how 
these solutions are beginning to change the way we approach it. 
Obviously, this is a committee that appropriates money. And so 
is there anything else that you would point to that this 
committee needs to know that we should consider as we move 
forward on future appropriations bills, the kind of projects we 
should be looking to fund? What is the takeaway from this when 
it comes to our function in appropriating Federal funds?
    Mr. De Lucca. Well, first, we must realize the problem is 
very real. When we went on our eight-city tour, the IACP, this 
is universal in the United States. This is one of the front 
pressing issues when you are talking about mental illness or 
homelessness, it coexists.
    I think understanding that funding training for law 
enforcement in the academies or in an association that will 
push out Crisis Intervention Team training or Mental Health 
First Aid, technology for agencies that are being progressive 
that are using technology in the way of getting the first line 
to social services. Instead of having somebody bring them into 
a jail or a social service, to divert them the right way is 
paramount at this time.
    But I think also important, if I may, is the IACP has been 
asking for a long time for a National Criminal Justice 
Commission to look at not only mental illness, but all the 
things that are taking place because there is no one fix 
anymore. Everything is bleeding into other society issues, and 
we have become the de facto stop for so many.
    You know, I hear the doctors, and so many of these things 
sound so great. But to that officer on the street who is trying 
to do de-escalation and make the right decision, we are usually 
the first interaction.
    Senator Blunt. Senator Rubio, if you want to ask a couple 
more questions, I am going to do a second round here. So go 
ahead.
    Senator Rubio. Am I--oh, you are in the second round?
    Senator Blunt. Right.
    Senator Rubio. So I get to double up? Oh, this is a good 
thing.
    Senator Blunt. You get to double up.
    Senator Rubio. I didn't know that. It is my first time on 
this committee. I just got on this committee, and I like the 
rules in this committee. So----
    [Laughter.]
    Senator Blunt. Very good. We call them the ``Rubio rules.''
    [Laughter.]

                          DE-ESCALATION MODEL

    Senator Rubio. Good. It is pretty good to have things named 
after you most of the time. So just to continue to talk about 
what--I won't need the full 5 minutes, but you keep using the 
term ``de-escalation,'' and I know that you primarily are 
involved with law enforcement at the local level, and that is 
what you represent. But that is not the only people that 
interact with people that are suffering from mental illness in 
the community. That interaction is occurring in our schools, in 
our prison system, at airports.
    Do you think there is an opportunity here to take the de-
escalation model beyond the traditional local law enforcement? 
What other agencies in society--because you talked about this 
bleeding over into other aspects of our society. What other 
agencies or instruments in our society are interacting with 
this problem, and in your view, could benefit from the better 
training on how to handle, how to identify these problems?
    Mr. De Lucca. Yes. Well, the range of age that is impacted 
starts at a very young age. I saw so many at our own station 
last week, 10 years old, mental illness dealing with issues. So 
I think schools would be important for them to understand what 
they are confronted with, the early signs to help prevent 
things in the future.
    You mentioned the airport. We saw a horrific act take place 
in Fort Lauderdale International Airport. In jails, absolutely 
another great place, our prisons. Anybody who is in the front 
line that has an opportunity to make a decision to change 
somebody's life I think would be important.
    Dr. Johnson. Senator Rubio, can I say one more thing about 
that? I think the more people we have in America who are 
trained in Mental Health First Aid, the better it will be. If 
we can have family members, schools, librarians, any place 
people go, if the people they run into there are able to 
recognize warning signs and expedite getting people help, we 
would see far less crisis.

                                SUICIDE

    Senator Rubio. And I think interrelated to all of this--and 
this will be my last question--is what some are calling an 
epidemic, the numbers are certainly startling, about the 
suicide rates in America among young people. We saw a horrific 
incident about 2 weeks ago in South Florida where a young woman 
committed suicide live on Facebook. This is obviously 
interrelated into all of this.
    As part of the de-escalation process and so forth, how are 
we--how is the front-line law enforcement officer in America 
trained if, in fact, they get a call of someone who is either 
threatening to kill themselves or perhaps attempting to commit 
suicide?
    How--obviously every--there are so many different law 
enforcement agencies across the country, but how well prepared 
are we as a Nation in terms of the first responders to the 
scene of either a suicide or an attempted suicide to de-
escalate that, to, you know, talk them off it and bring them 
back down from it, or does that involve specialized units that 
sometimes can't deploy in time and in some instances may not be 
available in some communities?
    Mr. De Lucca. That is a challenge in itself for anybody 
that has been trained in law enforcement. You go through a 
police academy. You are given the basic skills, but because of 
funding, different police departments are definitely at 
different levels. I am fortunate to be in a place, the City of 
Doral, where we can afford funding, training, and ongoing 
training, but that is not universal.
    The other concern you just talked about is something is 
suicide, but there is also an issue called suicide by cop, 
where people put themselves in a high-risk situation, wanting 
an officer to take their lives. Also, you know, the mentally 
ill persons, a report was done in 2015 by The Washington Post 
where it has talked about how many people are killed by 
officers by mental illness, and it is about 25 percent of our 
police shootings involve mentally ill persons.
    I think the de-escalation training or anything that we can 
have ongoing is the answer to this question. Some of those 
decisions, as you know, are split-second decisions, and you try 
to make the right one. The capacity is really, at that time, 
hoping to have enough officers in the field who are CIT trained 
or Mental Health First Aid trained.
    So I am hoping that, you know, we talk about the One Mind 
Campaign in South Florida and across the United States, and 
Senator Blunt, even in my great State, Springfield, Missouri, 
they are engaged. We have got to get this message pushed out. I 
think the support of this room and appropriations will help us 
get there.

                       CRISIS INTERVENTION TEAMS

    Senator Blunt: Thank you, Senator, and thank you, Chief.
    You know, Chief, I have--both in Kansas City and in 
Springfield, which is my hometown,--ridden with Crisis 
Intervention Teams to see how they do what they do. And my 
impression always was having some alternative that somebody 
could go to that might turn into a more long-term situation 
than just, ``Let us take them to the jail or let us take them 
to the emergency room and control them for tonight,'' seemed to 
make a big difference in how that officer was able to react. 
Would you talk about that just a little bit?
    Mr. De Lucca. Absolutely. I think when options are 
available--and policing has changed. It has continued to 
evolve. You know, I am here today talking about this. I can 
tell you tomorrow I will be in Seattle with another panel 
talking about mental health. This is an ongoing topic, and what 
we have to do is prepare our officers on the front line.
    And the more officers you have who are CIT trained or 
Mental Health First gives an option. You know, you are more 
empathetic. You are more understanding. And then there is an 
option of not pushing somebody into jail, which leads to 
ongoing incarceration and then back into the cycle that never 
ends.
    What I think is important and I hear my colleagues talk 
about is if there is things that could be done upfront where if 
somebody ever engages in the criminal justice system, I think 
the greater our success is going to be at our first 
interaction.

                    TELEHEALTH IN MENTAL HEALTH CARE

    Senator Blunt. I would say in Springfield and I believe in 
St. Louis County they're moving toward trying to have an iPad 
linkup with a 24/7 provider. And in one of those instances I 
saw, it did seem to me that, actually, as good as the crisis 
intervention officer was, and I am sure they didn't have me 
riding around with their worst officer. He was very good. But 
actually, the person he was dealing with seemed much more 
comfortable talking to the person on the iPad than they did the 
person right there in the moment with him, which I thought was 
interesting. So I want to also ask a little about telemedicine 
in mental health.
    Mr. De Lucca. I think the Springfield model that you are 
talking about is very innovative. It takes the onus off 
somebody in uniform communicating with somebody who might be in 
crisis at that time and gives them comfort to talk to somebody 
they might understand, but understands the crisis much better 
than we ever will.
    Because, remember, we are getting a limited amount of 
training, and these are professionals. But I think this option 
and funding options like this with the iPad technology and 
future technology is important.
    And if I may, just talk about technology for a second. 
There are private sector programs like Smart 911 that is used 
in 1,500 municipalities. And the State of Michigan itself has 
pushed it out through all their law enforcement agencies where 
persons, home members, can provide information on family 
members that might have issues, health issues. So if a 911 call 
goes out of somebody living at the house, we will know that it 
is a child who might not be taking their medication and how to 
best respond and have who to respond, but I think my colleagues 
here might be able to expand on that, you know?
    Senator Blunt. Telemedicine, Dr. Johnson, then Dr. Parks, 
and Dr. Freeman.
    Dr. Johnson. Just briefly, in Seattle, Washington, we had, 
at the University of Washington, a team of mental health 
professionals and psychiatrists. Any primary care provider 
anywhere in the State can call that team and get immediate 
consultation on how to deal with complex cases that involve 
psychiatric issues, addictions issues, as well as primary care 
issues.
    How terrific is it to have the smartest people available to 
everybody in the State through a Skype or a telephone call?
    Senator Blunt. And what about the direct interaction of a 
patient with their doctor who is not in the room?
    Dr. Johnson. We are finding that is just not an issue. I 
mean, that we are starting to do mental health court now 
through tele-hookups because we are finding with the latest 
technology where even eye contact can be made, there simply 
isn't what we might have expected to be a discomfort.
    Senator Blunt. Dr. Parks.
    Dr. Parks. Actually, some patients, many patients, are more 
comfortable without being in the same room, particularly people 
that have been traumatized. I am still in practice. I treat a 
number of women who have been traumatized by men, and at times, 
we discuss that it is not always easy for them to sit in the 
room with me. Probably it would be easier for them to see me 
over telepsychiatry, and I am increasing that part of my 
practice.
    It saves travel time. Why do you want to have a physician 
or a therapist or anybody using their time riding around in a 
car to get to the clinic when they could be in immediate 
contact?
    Senator Kennedy was asking about and was reflecting on 
people going to the ER. Well, they like the ER because it is 
kind of like the Wal-Mart of healthcare. You can go anytime and 
get whatever you want. It is too simple and too easy. And an 
iPad and telemedicine, teletherapy, can go a long way to 
meeting that need where people can get that immediate need 
almost on demand. That is what the patients want, and it would 
be a good thing for them.
    I think what could be done on the Federal side is there are 
some regulations that make that difficult. We have an expert 
panel through our Medical Directors Institute at the National 
Council, and I will get your staff some specific regulatory 
points that might be changed.
    The second thing is payment. And this goes again to the 
importance of payment systems that cover actual cost like the 
prospective payment and Excellence in Mental Health. You are 
doing it under a grant right now, but grants always run out. A 
prospective payment system like the Community Mental Health 
Center gets can build this kind of service in and cover that 
ongoing, which in the long-run is a lower cost.
    Senator Blunt. Dr. Freeman.
    Dr. Freeman. Yes. We have used telehealth applications for 
two decades. About a quarter of our psychiatry visits are 
telepsychiatry. We have monitored no-show rates very closely. 
We have a higher show rate with telehealth than we have face-
to-face. That may say something about the capabilities of a 
nurse to establish rapport compared with a provider.
    We have a child and adolescent psychiatrist who lives in 
South Georgia who practices in East Tennessee every day through 
telehealth. Our director of primary care lives in Lexington, 
Kentucky, sees patients in Tennessee every day.
    We have a network of school-based health clinics in a 
school where we have two nurse practitioners who are centrally 
located. They beam into 25 school systems. Nurses triage 
patients. They can see the provider very effectively, very 
efficiently.
    We have some connections that kind of interface with some 
of the things the chief was talking about. We do mobile crisis 
work, and we have places in hospitals where police can bring 
folks and our telehealth providers can interview that way. So 
we use telehealth extensively.
    Senator Blunt. Well, I think on mental health, particularly 
based on the three things you just added, or the four things 
you have just added, that telehealth may turn out to be a more 
than an acceptable alternative for remote populations, for 
rural populations.
    And another committee I am on, the Commerce Committee, 
makes it even more important that we assure that people have 
access to those broadband services, but healthcare is one of 
them.

                   FEDERALLY QUALIFIED HEALTH CENTERS

    Now, Dr. Freeman, I haven't forgotten my other opportunity 
to ask you about treating mental health, and particularly, you 
do that in your federally qualified health center that also is 
a community behavioral center. What do you see in terms of the 
overall cost of treating, when you are treating mental health 
in that same facility as you are treating other health?
    Dr. Freeman. There is really good data. Our data came from 
an insurance company that said, basically, the cost was reduced 
by about 25 percent, very, very, very efficient. You know, 
access is the huge issue in behavioral health, and most 
everybody goes to primary care. You know, probably three times 
as many patients actually try to find behavioral health 
assistance in primary care rather than from a specialty 
provider.
    So with this model, we treat about 85 percent of folks with 
psychiatric conditions in the primary care setting. Seeing--
patient comes in, sees both a behaviorist and a primary care 
provider. So it is a very, very cost-efficient model.
    Senator Blunt. Well, you know if you feel better about 
yourself, taking your medicine, eating better, sleeping better, 
your other health problems have to be easier to deal with, and 
hopefully, we can put even more information out there for 
States and communities to look at that make that case.
    Does anybody have any final comments you want to make?
    Dr. Johnson.
    Dr. Johnson. Yes. Just one more piece on this. We embedded 
a seven-exam room primary healthcare clinic inside our behavior 
health center, and I actually studied the floor plans from Dr. 
Freeman's Tennessee facility as I designed mine because he has 
been so successful at this. But we did that because people who 
felt safer coming to a behavioral health center, we felt an 
obligation to bring primary care to them.
    And we found that when you have--with the person that is 
looking to quit smoking, if their doctor, their therapist, 
their vocational rehabilitation specialist, and their housing 
support person, if everybody know that, everybody can be 
working their angle to promote that good change in the person's 
health. And so I just--any time we have a multidisciplinary 
team working to better--working together people do better.
    Senator Blunt. Well, I would say also that coverage is 
important, and we heard some discussion of that today. But 
coverage without access is not solving the problem. I mean, we 
have had mental health parity since 2008 for employee-based 
plans, for Medicare, for Medicaid. That doesn't mean that the 
reimbursement rate is adequate, but more importantly, it 
doesn't mean you have places to go.
    And I think access continues to be one of the major 
challenges here and how we create that access and how we create 
access to the kind of care people need as opposed to the kind 
of care that maybe somebody has decided they want to pay for, 
which are two different things.
    Anybody else have anything? Dr. Parks.
    Dr. Parks. Well, one way to increase access is treatment 
facilities, Community Mental Health Centers, and community 
health centers often are approached by training programs 
wanting to place people in internships or preceptorships, which 
are the final requirement in training before you can do your 
work alone, and there is costs associated with that. It takes 
staff time to supervise them. Often the training program wants 
you to pay the person a stipend of some kind.
    And one thing within the discretionary scope of this 
committee would be some funding to Community Mental Health 
Centers, to federally Qualified Health Centers to cover some of 
those agency costs of taking in students and training them. 
That gets more people trained. It gets them trained in the 
safety net settings as opposed to academic settings. And those 
are people that are usually the first to be recruited once they 
are fully licensed.
    So I think some grants to cover the preceptorship cost, the 
stipend cost of interns, preceptors, social workers coming out 
of training, substance abuse counselors could really help the 
workforce issue.
    Senator Blunt. All right. Dr. Freeman.
    Dr. Freeman. Yes. Change is obviously in the air. And you 
know, I would ask you to remember the safety net; you know how 
important Medicaid is to the safety net, how the funding of 
health centers, you know, is at risk. So please remember the 
safety net.
    Senator Blunt. Well, and you know, the safety net, in all 
likelihood, needs to be there, whatever we do. If you will 
recall, the first draft of the ACA had health centers going off 
a cliff financially because everybody was going to have 
insurance, and that didn't turn out to be----
    Dr. Freeman. Did not turn out.
    Senator Blunt [continuing]. What happened at all.
    Chief, anything you want to say?
    Mr. De Lucca. First, thank you for the opportunity for 
letting policing have a voice. We really are at the front line 
of this situation every day, and having the support, the 
funding to ongoing programs like CIT and Mental Health First 
Aid is paramount to our success in getting people into the 
right programs and keeping them out of jail and recidivism. So 
thank you for this opportunity.
    Senator Blunt. Well, thank all of you.
    The record will stay open for 1 week.

                          SUBCOMMITTEE RECESS

    We appreciate the time that all four of you and some of 
your team have taken to be here today. This hearing is closed.
    [Whereupon, at 12:07 p.m., Wednesday, February 15, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]


 
              MATERIAL SUBMITTED SUBSEQUENT TO THE HEARING

    [Clerk's Note.--The following outside witness testimonies 
were received subsequent to the hearing for inclusion in the 
record.]

         Prepared Statement of the American Gaming Association

    Dear Chairman Blunt and Ranking Member Murray:
    As Congress considers the repeal and replacement of the 
Affordable Care Act (ACA), the American Gaming Association 
(AGA)--which represents commercial and tribal casino operators, 
suppliers and other entities affiliated with the U.S. casino 
gaming industry--urges you to recognize gambling disorders as a 
public health issue that merits inclusion in any replacement 
for the healthcare law.
    Today, gambling disorders are recognized under the ACA's 
essential health benefits, in the categories of ``mental health 
and substance use disorders'' and ``behavioral health 
treatment.'' This is aligned with the American Psychiatric 
Association's (APA) fifth edition of the Diagnostic and 
Statistical Manual of Mental Disorders (DSM--5), which 
recognizes ``gambling disorder'' as a diagnosable condition. We 
believe this recognition, which did not exist prior to the 
passage of ACA, is critical not only to enable adequate funding 
for research, but also to ensure necessary resources and 
treatment facilities are available for those struggling with 
problem gambling disorders.
    We would be concerned with any paring back of essential 
health benefits that eliminates ``gambling disorders.'' 
Inclusion of behavioral health is critical to ensuring 
integrated and comprehensive healthcare in the United States, 
and this approach has increased access to treatment for 
gambling disorders.\1\
---------------------------------------------------------------------------
    \1\ National Council on Problem Gambling, Problem Gambling in the 
21st Century Healthcare System (July 2014), http://www.ncpgambling.org/
wp-content/uploads/2014/07/ACA-brief-web-layout-publication.pdf.
---------------------------------------------------------------------------
    The casino gaming industry takes extraordinary measures to 
ensure customers enjoy the entertainment experience we provide 
in a responsible manner. AGA member companies, which encompass 
90 percent of the $240 billion U.S. gaming industry, abide by a 
robust code of conduct that outlines measures every casino must 
take to prevent and address responsible gaming, including 
extensive employee training. Additionally, the industry makes 
significant investments in peer-reviewed research focused on 
effective treatment and prevention methods through the National 
Center for Responsible Gaming.
    Even as dozens of new casinos have opened nationwide over 
the last 20 years, the prevalence rate of problem gambling-- 
about one percent-- has not increased. While research shows 
that the majority of patrons set a budget of under $200 when 
they visit a casino, those who struggle with a gambling 
disorder deserve access to treatment.
    For these reasons, we urge you to ensure that any ACA 
replacement legislation continues to recognize gambling 
disorders as a public health issue and is included as an 
essential benefit. We welcome the opportunity to further 
discuss this important issue with you and your staff.
    Sincerely.

    [This statement was submitted by Geoff Freeman, President 
and CEO, American Gaming Association.]
                                ------                                


             Prepared Statement of Lielah Ann Leighton MSW

    Until recently, I have worked as a social worker in 
Clackamas County, Oregon, for Lifeworks NW, providing mental 
healthcare for rural young adults and youth who have serious 
and persistent mental illness. The Affordable Care Act, 
Medicaid expansion and the Substance Abuse and Mental Health 
Services Administration (SAMHSA) grants that improve community 
mental health services are a game changer in the lives of 
Americans with mental health and substance use disorders. A 
continuation of Medicaid expansion and the new demonstration 
program for community mental health centers is vital.
    In 2015, the Medicaid expansion under the Affordable Care 
Act gave 14 million Americans (546,400 Oregonians) the chance 
to see a doctor, get medications for chronic conditions and 
gain access to mental healthcare. One out of three persons 
covered through Medicaid expansion live with mental health or 
substance abuse conditions. Medicaid expansion offers them the 
foundation to get treatment, and access services they need to 
build resilience and foster recovery from addiction, trauma, 
and a history of mental conditions that has impaired their 
ability to function.
    Medicaid expansion is especially important because it 
covers single adults with mental illness who may easily fall 
through the cracks in our healthcare system. Mr. S. at age 19, 
was one of my clients who prior to Medicaid expansion would 
have likely fallen through the cracks in the healthcare system. 
He met the clinical criteria for PTSD (Post-traumatic Stress 
Disorder) and bipolar disorder. In addition, he suffered from a 
long history of profound trauma and violence, and poor foster 
care placements. However, his presentation as an adult would 
not have been severe enough to access developmentally 
appropriate community-based mental health services. He was not 
picked up by the police chronically, regularly present in the 
emergency room, or have persistent active suicide ideation. 
However, in time, without treatment, his functioning and mental 
health would have likely deteriorated to require a much more 
intense level of care, such as inpatient care, or acute care.
    Because Oregon expanded Medicaid, my community mental 
health center has been able to offer a program designed to help 
young people, like Mr. S., transition from the services they 
receive as children to adult services. Under 18 years of age, 
he was able to access clinical care and supportive services 24 
hours a day when needed. Once 18 years of age, he would be seen 
in an office outpatient setting once every six weeks. That 
dramatic cliff and drop in treatment and services is fraught 
with negative outcomes for these young people, such as 
addiction, incarceration, homelessness and suicide. The TAY 
Program (Transition Age Youth Program) allowed me to provide 
Mr. S. with in-home treatment once a week. Over the course of 
my work with Mr. S., he developed and expanded his self-
awareness and skills. He was able to begin to make healthy and 
developmentally appropriate self-determinations about his 
future. Medicaid continues to be his coverage. He would be at a 
tragic disadvantage in life if Congress repealed the Medicaid 
expansion.
    As a clinician, I am passionate about mental health; it is 
my calling. Like Mr. S., the vast majority of my clients have 
suffered a long history of trauma, abuse, neglect, violence, 
addiction and homelessness that would scar any soul deeply. To 
recover and tap into their own strengths and resilience 
requires a level of services and integrative care that most 
community healthcare systems are not designed to deliver. Most 
community mental health centers are staffed at insufficient 
levels, which allow staff to provide clients with only symptom 
management. Community mental health centers need to be staffed 
to allow clinicians to engage regularly in the deeper, more 
transformative work that is required for mental health and 
addiction recovery.
    I have seen indications that some structural change is 
possible. Four sites at Lifeworks NW plan to implement a 
program to deliver more integrative care, combining primary 
care services and mental healthcare. They will be part of 
Oregon's 2-year demonstration grant under the Excellence in 
Mental Health Act. The focus is to provide better care by 
increasing clinical staff, streamlining services and improving 
working conditions. In these locations, clients will benefit 
from a cohort of well-resourced professional staff not just one 
social worker because of criteria to establish Certified 
Community Behavioral Health Clinics (CCBHC). Clients will have 
additional support in developing basic life skills and have a 
better chance of overcoming the many barriers they face. For 
these structural changes to spread and become the norm, 
Medicaid expansion must remain the foundation for the SAMSHA 
grants to build on and further improve community mental health 
services.
    Social workers and other behavioral health staff must have 
a voice in the workplace. Our work is not just a job. It is a 
steadfast commitment that is largely unsung. Like others in the 
field, our days often start early and end late. This work 
matters because it means something to make a community better, 
to help someone who has seen horrible trauma find that they 
already possess the courage to move forward on his or her own 
terms, and to support someone on the path of recovery. In fact, 
it means everything.
    The work by every person in a community mental health 
center deserves respect because we are working to sustain our 
communities. We see how social, economic, and racial inequities 
affect overall mental health and well-being. I urge you not to 
repeal the current Medicaid expansion. I also urge you to 
provide SAMSHA with multiyear and mandatory funding to support 
additional grants to reduce community mental health center 
caseloads.
    AFSCME (American Federation of State, County and Municipal 
Employees ) is the Nation's largest and fastest growing public 
services employees' union with more than 1.6 million working 
and retired members, including 50,000 behavioral health 
workers. Oregon AFSCME is an affiliate of AFSCME and represents 
25,000 workers, including 1,000 in the behavioral health 
industry.
                                ------                                

             Prepared Statement of Solve ME/CFS Initiative
    Dear Chairman Blunt and Ranking Member Murray:
    On behalf of the Solve ME/CFS Initiative (SMCI) and as a patient 
with myalgic encephalomyelitis (ME), I am writing to applaud your 
leadership at today's hearing to examine treatments and services in 
America's mental healthcare system. One area in particular that I 
request you further examine is the current Center for Disease Control 
(CDC) recommendations including Cognitive Behavioral Therapy (CBT) and 
Graded Exercise Therapy (GET) for patients with myalgic 
encephalomyelitis (ME), commonly known as chronic fatigue syndrome 
(CFS) which is a biological illness yet misdirected into mental health.
    ME/CFS is a complex disease with an array of debilitating symptoms 
including extreme exhaustion, orthostatic intolerance, unrefreshing 
sleep, memory loss, joint pain, inflamed lymph nodes, severe headache, 
sore throat, neurological abnormalities, and even complete organ system 
shutdown. The cause of ME/CFS is unknown, and there is no existing cure 
nor FDA-approved treatment for the disease. It is estimated that the 
burden of ME/CFS costs our economy up to $24 billion a year.
    I bring these items to your attention because ``many healthcare 
providers are skeptical about the seriousness of ME/CFS and mistake it 
for a mental health condition,'' \1\ despite definitive scientific 
evidence that ME/CFS is a biological disease. In 2006, Dr. Anthony 
Komaroff, a senior physician at Brigham and Women's Hospital and 
professor of medicine at Harvard Medical School observed:
---------------------------------------------------------------------------
    \1\ ``Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: 
Redefining an Illness,'' Institute of Medicine of the National 
Academies Final report brief, May 2015, http://
www.nationalacademies.org/hmd//media/Files/Report%20Files/2015/MECFS/
MECFS_Report
Brief.pdf.

    ``There are now over 4,000 published studies that show underlying 
        biological abnormalities in patients with this illness (ME/
        CFS). It's not an illness that people can simply imagine that 
        they have and it's not a psychological illness. In my view, 
        that debate, which was waged for 20 years, should now be 
---------------------------------------------------------------------------
        over.'' \2\

    \2\ Professor Anthony Komaroff, MD. ``Chronic Fatigue Syndrome 
Awareness Campaign.'' Center for Disease Control Press Briefing, 
November 3, 2006, The National Press Club, Washington DC. Press 
Conference.
---------------------------------------------------------------------------
    Yet over 10 years later, practicing physicians and even information 
provided by government agencies misdirects patients with ME/CFS into 
the mental healthcare system.
    The CDC website recommends treatment options for this illness 
including Cognitive Behavioral Therapy (CBT), despite numerous concerns 
expressed by the patient and medical communities. While we are 
encouraged by the CDC's efforts (such as the technical development 
working group) to address these concerns, these inappropriate CBT 
references persist even after the Agency for Healthcare Research and 
Quality (AHRQ) downgraded CBT in an addendum published in July 2016.\3\
---------------------------------------------------------------------------
    \3\ ``Diagnosis and Treatment of Myalgic Encephalomyelitis/Chronic 
Fatigue Syndrome'' Agency for Healthcare Research and Quality Evidence 
Report/Technology Assessment #219, Addendum July 2016.
---------------------------------------------------------------------------
    As a result of this information being communicated by the CDC, 
between 1 million and 2.5 million patients \4\ with ME/CFS are being 
encouraged to seek mental health treatment options that are unlikely to 
assist their condition and could even potentially cause harm. This 
influx of misdirected patients creates additional strain on our mental 
healthcare system which is already struggling to accommodate patient 
needs. It would save our country billions of dollars if patients with 
ME/CFS were correctly and promptly diagnosed by fully-educated medical 
professionals and directed into appropriate and robust systems of care 
instead of into our heavily impacted mental healthcare system.
---------------------------------------------------------------------------
    \4\ ``Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: 
Redefining an Illness,'' Institute of Medicine of the National 
Academies Final report brief, May 2015, http://
www.nationalacademies.org/hmd//media/Files/Report%20Files/2015/MECFS/
MECFS_Report
Brief.pdf.
---------------------------------------------------------------------------
    As you examine the treatments and services available in the 
American mental healthcare system today, please keep in mind the 
patients with ME/CFS and how a small correction at the CDC can ease the 
burden on our existing mental healthcare treatment system.
    I hope this information and insight into the lives of those with 
ME/CFS has been helpful. Please feel free to contact myself or my staff 
if have any questions or if there is any additional information we can 
provide. I look forward to continuing to work with you and your 
colleagues to improve the lives of patients with ME/CFS in the future.
    Sincerely.

    [This statement was submitted by Carol Head, President and CEO, 
Solve ME/CFS Initiative.]