[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                  THE TRUMP ADMINISTRATION'S RESPONSE
                      TO THE DRUG CRISIS, PART II

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


                                HEARING

                               BEFORE THE

                              COMMITTEE ON
                          OVERSIGHT AND REFORM
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 9, 2019

                               __________

                           Serial No. 116-21

                               __________

      Printed for the use of the Committee on Oversight and Reform

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                  Available on: http://www.govinfo.gov
                     http://www.oversight.house.gov
                        http://www.docs.house.gov
                        
                        
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
36-437 PDF                  WASHINGTON : 2020                     
          
--------------------------------------------------------------------------------------
                       
                        
                   COMMITTEE ON OVERSIGHT AND REFORM

                 ELIJAH E. CUMMINGS, Maryland, Chairman

Carolyn B. Maloney, New York         Jim Jordan, Ohio, Ranking Minority 
Eleanor Holmes Norton, District of       Member
    Columbia                         Justin Amash, Michigan
Wm. Lacy Clay, Missouri              Paul A. Gosar, Arizona
Stephen F. Lynch, Massachusetts      Virginia Foxx, North Carolina
Jim Cooper, Tennessee                Thomas Massie, Kentucky
Gerald E. Connolly, Virginia         Mark Meadows, North Carolina
Raja Krishnamoorthi, Illinois        Jody B. Hice, Georgia
Jamie Raskin, Maryland               Glenn Grothman, Wisconsin
Harley Rouda, California             James Comer, Kentucky
Katie Hill, California               Michael Cloud, Texas
Debbie Wasserman Schultz, Florida    Bob Gibbs, Ohio
John P. Sarbanes, Maryland           Ralph Norman, South Carolina
Peter Welch, Vermont                 Clay Higgins, Louisiana
Jackie Speier, California            Chip Roy, Texas
Robin L. Kelly, Illinois             Carol D. Miller, West Virginia
Mark DeSaulnier, California          Mark E. Green, Tennessee
Brenda L. Lawrence, Michigan         Kelly Armstrong, North Dakota
Stacey E. Plaskett, Virgin Islands   W. Gregory Steube, Florida
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan

                     David Rapallo, Staff Director
                        Lucinda Lessley, Counsel
                           Laura Rush, Clerk

               Christopher Hixon, Minority Staff Director

                      Contact Number: 202-225-5051
                         
                         
                         C  O  N  T  E  N  T  S

                              ----------                              
                                                                   Page
Hearing held on May 9, 2019......................................     1

                               Witnesses

The Honorable James W. Carroll Jr., Director, Office of National 
  Drug Control Policy
    Oral Statement...............................................     5
Ms. Triana McNeil, Acting Director, Homeland Security and 
  Justice, Government Accountability Office
    Oral Statement...............................................     6
Ms. Karyl Thomas Rattay, M.D., M.S., Director, Delaware Division 
  of Public Health
    Oral Statement...............................................     7
Mr. Wayne Ivey, Sheriff, Brevard County, Florida
    Oral Statement...............................................     9

Written statements for witnesses are available at: https://
  docs.house.gov.

                           INDEX OF DOCUMENTS

                              ----------                              

The documents listed below are available at: https://
  docs.house.gov.

  * ACA article; submitted by Rep. Hill.

  * Fentanyl article and charts; submitted by Mr. Roy.

  * CNN articles on fentanyl; submitted by Mr. Hice.

  * Roundtable Statement; submitted by Ms. Shauntia White.

  * Statement for the Record; submitted by Mr. Bill Sternberg.

 
                  THE TRUMP ADMINISTRATION'S RESPONSE.
                      TO THE DRUG CRISIS, PART II

                              ----------                              


                         Thursday, May 9, 2019

                   House of Representatives
                          Committee on Oversight and Reform
                                                   Washington, D.C.

    The committee met, pursuant to notice, at 11:06 a.m., in 
room 2154, Rayburn House Office Building, Hon. Gerry Connolly 
presiding.
    Present: Representatives Connolly, Maloney, Norton, 
Krishnamoorthi, Raskin, Rouda, Hill, Sarbanes, Welch, Speier, 
Kelly, DeSaulnier, Plaskett, Khanna, Ocasio-Cortez, Pressley, 
Tlaib, Jordan, Amash, Massie, Meadows, Hice, Grothman, Comer, 
Cloud, Gibbs, Higgins, Roy, Miller, Green, Armstrong, and 
Steube.
    Mr. Connolly. The committee will come to order.
    The Chair is authorized to declare a recess of the 
committee at any time.
    The full committee hearing is convening to continue our 
review of the Administration's response to the drug crisis. We 
previously held a hearing on March 7. This hearing is a 
followup continuing our examination of ONDCP's coordination of 
national drug control efforts, including efforts to expand 
access to treatment.
    I now recognize myself for five minutes to give an opening 
statement.
    Earlier today, members of our committee had the very 
important opportunity to meet with four extraordinary 
individuals who have lost loved ones to our Nation's crippling 
substance abuse problem. We heard from Mr. Kevin Simmers, Ms. 
Shauntia White, Mr. Bill Sternberg, and Mr. Mike Cannon. They 
told us about the challenges their families endured while 
trying to get help for their loved ones in their hours of 
greatest need. They turned their unbearable pain into an 
inspiring passion to help save other lives and spare other 
families from the terrible ordeal that they went through.
    They are all here with us now, and I would like to ask each 
of them to stand and be recognized for their courage.
    [Applause.]
    Mr. Connolly. Thank you so much. Thank you.
    On behalf of this entire committee, we thank you for 
sharing your stories and for bringing the commitment you have 
and your dedication to this very important battle that affects 
all too many families across America.
    I know your determination and urgency are shared by 
countless other families also struggling to help their loved 
ones, and thank you again for everything you have done and 
continue to do.
    Today, the committee is holding our second hearing on the 
Trump Administration's response to the opioid crisis. At our 
first hearing in March, we heard testimony about the Trump 
Administration's failure to issue a national drug control 
strategy for two years while tens of thousands of people 
succumbed.
    We also examined the unsatisfactory strategy that the 
Administration finally issued earlier this year in January, and 
we heard the Government Accountability Office testify that this 
strategy is deficient; in fact, did not really add up to a 
strategy, and does not comply with the basic legal requirements 
Congress has set.
    The strategy or so-called strategy lacked enough detail for 
the committee or GAO to exercise even minimal oversight or to 
ensure accountability for the tens of billions of dollars we 
spend annually on national drug control efforts.
    For these reasons, we told the Office of National Drug 
Control Policy they had to do better, and we told them that we 
would have them back today to gauge that progress since our 
earlier hearing.
    The good news is that there have been some improvements. In 
response to the committee, ONDCP has now provided several 
supplements to the paper it issued earlier this year. These 
materials are certainly more useful than what we saw in 
January, and I thank Director Carroll and the dedicated public 
servants at ONDCP for the progress they have made.
    Unfortunately, the goals in these documents are, to use the 
most charitable description, all too modest, especially in 
light of what we heard this morning at the roundtable. For 
example, there were approximately 70,000 overdose deaths in 
2017. But the Administration's plan seeks to reduce overdose 
deaths by only 15 percent over five years. At that pace, more 
than 200,000 Americans will lose their lives between 2019 and 
2022, even if ONDCP meets all of its goals. That is a 
frightening projection and one, I think, on a bipartisan basis, 
we cannot accept.
    Here is another one. Right now, only about 10 percent of 
people who need addiction treatment can get access to it across 
the country. The Administration does have some ideas here. Its 
plan says, ``Evidence-based addiction treatment, including 
medication-assisted treatment for opioid addiction, is now more 
accessible nationwide.'' But when you look at the details, the 
Administration's plan is to have only 20 percent of specialty 
treatment facilities provide this type of medication-assisted 
treatment by 2022. In fact, we know that most rehab facilities, 
in fact, are not medication-assisted treatment facilities, even 
though we know medication-assisted treatment is the only 
efficacious treatment for opioid addiction.
    We must do better. We have to fight harder. The opioid 
crisis is the most devastating health emergency our Nation has 
faced in over a generation, and we need a bold strategy to meet 
this challenge head on.
    That is why every Democratic member of the committee joined 
together yesterday to introduce the CARE Act, which stands for 
the Comprehensive Addiction Resources Emergency Act. This 
landmark bill would finally provide stable and sustained 
resources to expand treatment for those who so desperately need 
it.
    The CARE Act has now been endorsed by more than 200 
organizations, including the American Medical Association, the 
American Society of Addiction Medicine, the National Nurses 
United, the National Association of Counties, the March of 
Dimes, the American College of Physicians, and the AFL-CIO. It 
is supported by doctors, nurses, mental health experts, 
organized labor, local governments, public health experts, and 
tribal organizations.
    The CARE Act will finally start treating the opioid 
epidemic like the public health emergency it is, and it will 
help people in red states, blue states, and purple states who 
are suffering without adequate access to treatment.
    Opioid addiction does not know partisanship. These include 
people just like the loved ones and the family members who were 
lost by Mr. Simmers, Ms. White, Mr. Sternberg, and Mr. Cannon.
    I want to thank you all again for being here, and we all 
look forward to what we hope is a more productive session this 
morning.
    I now turn to the Ranking Member for his opening statement, 
Mr. Jordan.
    Mr. Jordan. Thank you, Mr. Chairman.
    I, too, want to thank our guests and Director Carroll for 
coming back as well for a second time here.
    Our country is a country that values community and civic 
engagement. It is now being devastated by drug dependency. It 
is a crisis that hits close to home for every single family, 
and it has hit especially hard for Americans like Ms. White, 
Mr. Simmers and Cannon and Sternberg, who are joining us today 
in the audience. I, like the Chairman, want to thank you for 
your story. The last hour we just spent upstairs hearing your 
story was so compelling. Thank you for bravely sharing your 
compelling experiences with us this morning, your stories about 
your loved ones, and all too similar stories felt by an Ohio 
family, the Riggs family, who lost their young daughter to 
heroin use at the age of 20. In the face of such grief, Ms. 
Riggs speaks with students and their families about her 
daughter's struggle to bring awareness and shatter stigma in 
hopes of preventing such devastation to other families.
    Our home state of Ohio, over the course of a single year, 
witnessed almost 5,000 fatal drug overdoses, nearly 14 deaths 
in a single day. But this crisis does not strike each community 
in the same way. What prevention, treatment, or enforcement 
efforts may be effective in one area may not work in another. 
This is not a problem that funding alone can solve, even $100 
billion. We need to thoughtfully empower each community to 
address its unique need to reduce drug supply, prevent illicit 
drug use and, most importantly, get the needed treatment for 
these individuals.
    Sheriff Wayne Ivey is with us today from Brevard County, 
Florida. He is making great strides for his community. Sheriff 
Ivey, who relies on ONDCP for standardized and timely data 
about drug trends and emerging threats, recently led the arrest 
of nearly 100 traffickers of meth and nearly three pounds of 
fentanyl. That is enough fentanyl to kill every single person 
in this country.
    But it was something else about Sheriff Ivey that struck 
me. Sheriff Ivey has recognized an important aspect of this 
cyclical crisis. When those battling substance abuse disorders 
are climbing out of despair, they are in need of support; 
treatment, yes, but also purpose. Sheriff Wayne connects his 
inmates in jail for drug use with training and jobs on release 
into the community. Now the cycle might have a chance of being 
broken.
    Under the Trump Administration, the strength of our economy 
is creating tons and tons of new jobs, good-paying, dignified 
jobs that can be filled by those who may have struggled with 
the drug problem. Lifting every single member of a community 
and giving them a job, responsibility, and accountability gives 
them purpose.
    I look forward to hearing from Director Carroll, who leads 
the Office of National Drug Control Policy, a recently 
revitalized office that is playing a newly enhanced role in 
coordinating this effort. Director Carroll, the Chairman and I 
want your office to succeed. I look forward to hearing from you 
on the progress of ONDCP and the Trump Administration, and I 
remain optimistic about the support of the committee for 
continued progress.
    I also look forward to hearing from the experts on the 
ground who battle this problem daily. Thank you all for taking 
the time to be here this morning to discuss this office and 
help us all find solutions to the public health crisis of our 
time.
    With that, Mr. Chairman, I yield back.
    Mr. Connolly. Thank you, Mr. Jordan, and thank you for 
sharing that data on Ohio. It is gripping and disturbing and, 
unfortunately, not unique.
    Mr. Jordan. Not unique.
    Mr. Connolly. I know we have an opportunity in this 
committee, on a bipartisan basis, to move forward, and I 
certainly commit to you in wanting to do that.
    Now we want to welcome back ONDCP Director James Carroll, 
as well as Triana McNeil, the Acting Director of Homeland 
Security and Justice of the Government Accountability Office. 
She is accompanied by Mary Denigan-Macauley, the Acting 
Director of Health Care at GAO. And I would also like to 
welcome Dr. Karyl Thomas Rattay--am I pronouncing that 
correctly?--the Director of the Delaware Division of Public 
Health and Safety; and Sheriff Wayne Ivey of Brevard County, 
Florida. I want to thank them all for participating in today's 
hearing.
    It is our custom to swear in witnesses. So, if you would 
all rise and raise your right hand?
    [Witnesses sworn.]
    Mr. Connolly. Thank you. You may be seated.
    Let the record show that the witnesses answered in the 
affirmative.
    The microphones are sensitive, so I would ask each of you 
to please speak directly into them when you turn on the button.
    Without objection, your written statement will be made part 
of the record.
    With that, Director Carroll, you are now recognized to give 
an oral presentation.

    STATEMENT OF JAMES W. CARROLL, JR., DIRECTOR, OFFICE OF 
                  NATIONAL DRUG CONTROL POLICY

    Director Carroll. Thank you, Chairman Connolly, Ranking 
Member Jordan, and members of the committee. Thank you for the 
opportunity to appear before you again to discuss the critical 
work the Office of National Drug Control Policy has been doing 
to address the challenges America faces from the opioid 
epidemic and the broader addiction crisis.
    I want to especially thank the committee for their 
leadership on this issue, and I appreciate the invitation to 
return and have the opportunity to talk with you all about the 
work that has been going on since we last met.
    It has been my pleasure since our last hearing on March 7 
to bring the GAO into ONDCP to see the great work my team has 
been doing and making them familiar with our critical role. 
Moreover, I ensured GAO has received all of the supplementary 
information they requested from ONDCP, including 1,501 pages of 
documentation, in response to the additional request from GAO. 
I am incredibly proud of my team, and I believe our GAO 
colleagues have gained a great deal from the time they spent 
with the most senior members of my staff in meetings on at 
least 10 different occasions since our last hearing.
    I would also like to thank the committee staff for joining 
us for several routine interagency engagements over the past 
month, which I hope gave them additional context for a few of 
the issues that were raised at the hearing.
    The time since my last hearing has given us the opportunity 
to continue issuing the supplementary materials of the National 
Drug Control Strategy, as planned, that fulfill our statutory 
requirements. As we continue the process of formally 
implementing the 2019 Strategy, several of our interagency 
partners have provided us valuable positive feedback on its 
clarity, focus, and utility as the right framework to guide 
broad control activities in the years ahead.
    In addition to the main Strategy document, its three 
companion documents provide valuable context on today's drug 
trafficking and use environment, and the means to measure our 
progress and effectiveness as we advance the Strategy going 
forward. These include the Budget and Performance Summary, 
which provides details on the drug control budget that supports 
the implementation of the Strategy and provides performance 
metrics for each drug control program agency; the Data 
Supplement, which provides more than 150 tables presenting data 
on which ONDCP relies to formulate, implement, and assess 
progress toward achieving the goals and objectives of the 
Strategy; the Performance Reporting System, which provides the 
goals and objectives for the Strategy; plus the two-and five-
year targets and metrics for tracking progress and achieving 
them. All of these documents are the constituent parts of the 
National Drug Control Policy Strategy, and they have been 
submitted to Congress and posted on ONDCP's website.
    I am proud to say that during this entire period, my team 
has been focused on delivering tangible results for the 
American people. We are tackling the addiction crisis head-on, 
and we are beginning to see results.
    Since the beginning of this Administration, the total 
number of opioid prescriptions has declined 34 percent. The 
number of naloxone prescriptions has increased by 484 percent. 
Twenty percent more people who have a substance use disorder 
are now receiving treatment.
    ONDCP's ad campaign, ``The Treatment Box,'' just this week 
won a daytime Emmy for compellingly bringing adults face to 
face with the opioid addiction. More importantly, the campaign 
has over 1.4 billion impressions from 18-to-24-year-olds, and 
has 92 million total online views.
    As a result of all of these efforts and others, preliminary 
data suggests that the total number of drug-involved deaths has 
stabilized and for the first time in decades might be beginning 
to decline.
    As I discussed with you before, I have made saving lives 
the central focus of our efforts, and it is the true measure of 
success not only for the agency but for the American Government 
as a whole. Every one of us at ONDCP knows that saving lives is 
the only criterion that really matters, and we will continue to 
advance that mission as we go forward every day.
    I appreciate the committee's ongoing interest in working 
with ONDCP on this issue, and I look forward to answering your 
questions today.
    Mr. Connolly. Thank you, Mr. Carroll.
    Ms. McNeil?

STATEMENT OF TRIANA MCNEIL, ACTING DIRECTOR, HOMELAND SECURITY 
         AND JUSTICE, GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. McNeil. Chairman Connolly, Ranking Member Jordan, and 
members of the committee, I am pleased to be here today to 
discuss GAO's ongoing work on ONDCP's strategies and programs, 
as well as our prior work on treatment for people who misuse 
opioids.
    When I was here in March, I made some key points.
    One, in 2017, 70,000 people died from drug overdoses.
    My next set of points related to ONDCP's 2019 strategy. 
Based on our preliminary observations, it did not include a 
number of requirements such as a performance measurement system 
to track progress and specific assessments to provide a 
baseline of illicit drug use.
    Since that time, ONDCP staff have met with us without delay 
and provided some previously requested materials. ONDCP staff 
also met with other GAO staff to obtain information on best 
practices related to strategic planning and coordination. We 
have also met with a number of drug control agencies during the 
past few months, in addition to White House counsel, to discuss 
the opioid cabinet.
    Moving forward, we will continue to conduct a thorough 
assessment of the documents that ONDCP recently published that 
they said, in combination with the Strategy, comport with the 
provisions of the 2006 statutory requirements. These documents 
include the 2019 Data Supplement, the 2019 Performance 
Reporting System, and the 2019 Budget and Performance Summary.
    Can GAO say that these three documents, plus the Strategy, 
adhere to the 2006 statutory requirements? Not at this time. 
But we will include a thorough assessment and our own 
conclusion in our upcoming report. We are working to finalize 
our design and begin to draft our report. Before we do that, we 
still need some key pieces of information to ensure we can 
answer questions from the Congress.
    For example, we have asked for the budget funding guidance 
that ONDCP provided to drug control agencies. We need this to 
understand how they certified budgets when there was no 
strategy.
    We also have a forward-looking aspect to our work, and we 
will continue to look at how ONDCP plans to address the 
requirements set forth in the Support Act.
    This is a two-part statement. So, the other part of GAO's 
statement focuses on prior work that we have done on MAT, 
medication-assisted treatment, for opioid addiction. It is a 
combination of therapy and medications. GAO has issued two 
reports on this, one in 2016, one in 2017.
    In 2016, we reported that several factors, including the 
availability of qualified providers, could affect patient 
access to this treatment. In 2017, we found that HHS needed to 
establish measures to better determine progress toward goals. 
HHS has partially implemented this recommendation. Moreover, 
further action to measure the capacity of providers would help 
HHS determine whether patient needs can be met.
    My colleague, Mary Denigan-Macauley, from GAO's health care 
team, is here to answer any questions that you have related to 
this treatment, and I can provide any further information on 
our ongoing work looking at ONDCP's efforts.
    Chairman Connolly, Ranking Member Jordan, and members of 
the committee, this concludes my prepared Statement.
    Mr. Connolly. Thank you, Ms. McNeil.
    Dr. Rattay?

    STATEMENT OF KARYL THOMAS RATTAY, M.D., M.S., DIRECTOR, 
               DELAWARE DIVISION OF PUBLIC HEALTH

    Dr. Rattay. Chairman Connolly, Ranking Member Jordan, and 
distinguished committee members, thank you for the opportunity 
to appear before the committee today.
    State, territory, and local health agencies are on the 
front lines responding to the current addiction crisis. As 
Delaware's state health official for the past decade, and as a 
pediatrician and epidemiologist, I have witnessed many facets 
of this devastating, complicated, and evolving crisis.
    We first sounded the alarm and declared our epidemic in 
Delaware in 2011. Our data showed a steady incline over the 
previous two decades, going from five overdose deaths in 1990 
to 100 in 2009. Importantly, the epidemic is evolving. In 2009, 
nearly all our overdose deaths were due to prescription drugs. 
Now, illicit fentanyl and other synthetic opioids are the major 
driver of overdose deaths, causing 72 percent of the 400 deaths 
we experienced in our state this past year.
    And behind these data are real people whose lives are 
forever changed because of this epidemic. Opioid addiction 
affects a wide array of individuals, from high school athletes 
to blue-collar workers and highly educated professionals. Yet 
stereotypes about those afflicted with addiction still exist, 
and one of the greatest barriers to treatment is the stigma 
experienced by individuals with opioid use disorder. We must 
view addiction as a chronic health disease that affects the 
brain, and just like asthma or diabetes, if we apply 
appropriate evidence-based strategies, addiction is both 
preventable and treatable.
    For example, in my state we have had the pleasure of 
getting to know Alyssa, who was struggling with opioid 
addiction. However, she accepted help when her baby was born. 
She has received treatment and recovery services and has been 
successful with the use of buprenorphine.
    Also, through our home visiting program, we were able to 
provide the necessary supports so she could appropriately care 
for her newborn baby. Alyssa and her now three-year-old 
daughter are thriving.
    Although we would all love an easy fix to address this 
problem, no single public health tactic or policy will end the 
opioid crisis. The complex nature of this epidemic and its 
broad, pervasive, and substantial impact on communities and 
society at-large justify a multi-pronged set of strategies and 
solutions. Preventing and identifying addiction, connecting 
people to evidence-based treatment and recovery services, as 
well as reducing harm are critical pieces to the multifaceted 
response required.
    With that in mind, I would like to emphasize three key 
points today. Federal, state, and local governments must take a 
comprehensive and sustained approach to not only address the 
current crisis but we must focus upstream to prevent 
individuals from becoming addicted in the first place. We 
strongly encourage the committee to include primary prevention 
as a core component of opioid-related legislation moving 
forward. Any resources going to public health should not cap 
primary prevention efforts. We must have the ability to have 
flexible resources to meet the needs of our communities and the 
populations we serve.
    No. 2, it is crucial for the Federal and state, working 
with local governments, to continue expanding access to 
evidence-based treatment. The ideal system is engaging, 
comprehensive, coordinated, high-quality, and person-centered. 
It meets people where they are in their communities and 
provides an immediate connection to treatment when they are 
ready, no matter the setting. It addresses mental and physical 
health, as well as social needs like housing and occupational 
skill development. It is constantly improving, using real-time 
data and evaluation to drive decisionmaking.
    As it relates to treatment that will lead to recovery, I 
strongly urge Congress to approve legislation to modify the 
three-day rule. As an example, under the current rule a non-ex-
waivered emergency physician who is providing care for an 
individual who has overdosed can only administer and not 
prescribe buprenorphine one day at a time for the purpose of 
relieving acute withdrawal symptoms while a person is awaiting 
admission into treatment.
    The Association of State and Territorial Health Officials 
is deeply concerned that the requirements of the three-day rule 
are preventing providers from appropriately managing 
withdrawal, and we are missing opportunities to successfully 
engage people into treatment. Our members have explored many 
alternative options, but we are told by Federal officials that 
the only way to address this is through legislation. I implore 
the committee to address this immediately.
    In closing, we work tirelessly to save lives, but we must 
also work to improve the lives of people who are impacted by 
the disease of addiction, and we must do all we can to prevent 
addiction.
    Thank you again for the opportunity to speak today.
    Mr. Connolly. Perfect timing. Dr. Rattay, thank you very 
much.
    Sheriff Ivey?

   STATEMENT OF WAYNE IVEY, SHERIFF, BREVARD COUNTY, FLORIDA

    Sheriff Ivey. Mr. Chairman, Ranking Member Jordan, and 
members of the committee, my name is Wayne Ivey, and I have the 
honor of serving as the Sheriff of Brevard County, Florida. We 
have a population of almost 600,000 citizens and are blessed to 
be called the gateway to space, as we are home to the Kennedy 
Space Center.
    I would like to personally thank you for allowing me to 
speak to this committee today in furtherance of our national 
strategy to combat the opioid epidemic.
    Government's one and only responsibility is to protect its 
citizens, and this epidemic is without question the most 
impacting challenge law enforcement has faced for decades. For 
those that have been in this business for a while, we remember 
thinking that crack cocaine was the worst thing we had ever 
faced. Sadly, we were mistaken. This epidemic far exceeds those 
realities and without question will destroy our communities if 
we do not aggressively intervene without delay.
    As has already been said, this epidemic has no boundaries 
and does not discriminate. This nationwide epidemic is having 
devastating effects on individuals, families, and entire 
communities. In fact, in my county alone, we have felt the 
devastation at levels that none of us believed possible.
    Brevard County is one of three counties leading the state 
of Florida in overdose deaths. In the past 24 months, my 
community has lost 172 dads, moms, sons, daughters, husbands, 
and wives to opioid deaths. That is 172 members of our 
community who were taken from us way too soon.
    As if that were not bad enough, that number grows to 300 in 
the past 48 months, and sadly over 650 in the past 10 years.
    In addition to those we have lost to death, we have also 
had to consider the impact on families who now have a family 
member in jail because they targeted the addictions of others 
for their own greed.
    Opioids are also coming at an enormous financial cost. In 
fact, the financial impact does not stop at government. It 
extends to entire communities, including a significant impact 
on health care and employment. Communities like ours are not 
only losing friends, family, and loved ones, which is the 
ultimate loss, but we have suffered a great financial burden 
due to this epidemic. The rising cost of medical treatment for 
those suffering addiction and overdoses, for newborns born 
dependent on opioids, for counseling and rehabilitation, and 
for law enforcement and first responders, the cost of 
combatting this abuse, distribution, and death caused by this 
epidemic is significantly increasing every day.
    As an example of that statement, I would offer to this 
committee that in 2018, the Brevard County jail had 3,737 
inmates who required medical detox treatment while incarcerated 
in our facility for opioid addictions. In addition, my agency 
alone has expended well over $200,000 this past year in Narcan 
deployment and investigative costs relating to investigations 
of deaths and crimes. Just last week, our agency culminated one 
of the most significant single drug investigations in the 
history of our community, resulting in the issuance of over 100 
arrest warrants for dealers of fentanyl, heroin, and 
methamphetamine. These killers known as white powder, brown 
powder, China white or black tar, are historically manufactured 
and refined in Europe, Mexico, and China, laced with fentanyl, 
and floated into the streets of our communities. The drugs in 
our investigation were being delivered to the organization from 
California, Las Vegas, and Georgia by car couriers and U.S. 
Mail.
    As a result of that investigation, our agents, in 
partnership with the Drug Enforcement Administration, Central 
Florida HIDTA, the United States Attorney's Office, the Brevard 
State Attorney, and our Florida Attorney General, seized 
kilogram quantities of fentanyl, heroin, and methamphetamine. 
As our committee members are aware, fentanyl can be a threat to 
anyone who comes into contact with it, as it can be absorbed 
through the skin, eyes, or accidentally inhaled. It is 50 to 
100 times more potent than morphine, and 30 to 50 times more 
potent than heroin.
    The Drug Enforcement Administration estimates that there 
are approximately 500,000 lethal doses in a single kilogram of 
fentanyl. The Drug Enforcement Administration further estimates 
that a 2-milligram dose is lethal for most people.
    Using that formula, the amount of fentanyl seized in our 
investigation was enough to kill every single resident of 
Brevard County. This epidemic is not isolated to Brevard but 
instead is impacting communities in the same fashion across our 
great Nation. That is exactly why we must address this epidemic 
collectively at the local, state, and Federal levels, as well 
as in partnerships with our health care providers and 
lawmakers.
    Based upon my experience as a 39-year veteran of law 
enforcement, I believe that we have to take a multi-dimension 
approach to stabilizing and eradicating this epidemic. To truly 
protect our citizens, we must shield them with a bulletproof 
vest that is designed to protect each citizen. If you know 
anything about a bulletproof vest, it is layer after layer of 
material that, when woven together, becomes so strong it will 
stop a bullet or edged weapon. If one layer fails, the next 
layer is standing ready to intervene. This type of strategy 
will be paramount in ending this deadly threat to our Nation. 
If we take a single-dimension approach to this issue, we will 
not be successful. And let there be no doubt, we must execute 
our plan right now, before another citizen is taken from us. We 
cannot delay or we will be effectively writing off a generation 
eliminated by addiction, prison, and death.
    As such, I believe that we should construct our bulletproof 
vest with the following layers: education and awareness; 
aggressive enforcement; partnership enhancement; enhanced 
prosecution and sentencing; life-saving tools; and 
compassionate care and rehabilitation.
    In the interest of time, I included the substance of each 
of those areas in my written statement, and if you would like, 
I would be glad to share more detail.
    Mr. Connolly. Thank you, Sheriff Ivey. We know you and your 
colleagues are in the front lines of this battle as well. Thank 
you so much for your service.
    The Chair now recognizes himself for five minutes of 
questioning.
    Mr. Carroll, Director Carroll, the Trump Administration's 
Drug Control Strategy says addiction is a chronic medical 
condition that affects the brain by causing distinct cognitive, 
behavioral, and physiological changes; correct?
    Director Carroll. Yes, sir.
    Mr. Connolly. And the Strategy goes on to state, quote, 
``Increasing the availability of treatment services for 
substance use disorder will lead to a greater number of 
Americans achieving sustained recovery and reduce the size of 
the illicit drug market and demand in the United States.'' 
Correct?
    Director Carroll. Yes, sir.
    Mr. Connolly. And yet there is a significant unmet need, is 
there not, for treatment in the United States? According to the 
Strategy issued in January, your office points out in 2017 an 
estimated 20.7 million Americans age 12 or older needed 
treatment for substance use disorder, but only 4 million of 
those 20.7 million received any kind of treatment, and only 2.5 
million received that treatment at a specialty facility. And, 
of course, we could add to that that many of those so-called 
``specialty facilities'' with respect to opioids are not 
appropriate, the treatment is not efficacious. So, that number 
even overstates how many people got efficacious treatment, and 
that is from your report, which is really stunning data in 
terms of capacity and cost apparently being such important 
factors in people getting treatment.
    Director Carroll. Yes, sir. Thank you for the question. I 
think it is important to note a few things at the outset. 
Undoubtedly, there are millions of people--as we said, the 
estimates are 18 to 20 million people who have an addiction. 
Sadly, not all of them, only a few percent that actually 
recognize and accept the fact, and we heard about it this 
morning, are willing to go get treatment. That is the estimate 
that we talked about of the people who are willing to get 
treatment.
    So, certainly, one of the things that we need to do is 
decrease the stigma to make sure that more people are willing 
to get treatment. Right now, the estimates are 10 percent or so 
of that 20 million even seek treatment. So, first off, we need 
to increase the number that are accessing treatment. That is 
one of the things that we have successfully been able to do.
    You talked about effective treatment, and as I said in my 
opening statement, I am very happy to report to the public and 
to the committee the number of people seeking treatment in the 
last year-and-a-half or two years has gone dramatically up. But 
you are right, it is not up as high as we need.
    And the types of treatment--and we heard a little bit this 
morning from one of the parents--every individual is different. 
We have to recognize the relationship between a patient and a 
provider, and one of the goals of the National Drug Control 
Strategy is to increase the number of treatment centers that 
offer medication-assisted treatment, MAT, by 100 percent. At 
the same time, we do have to recognize, as we heard this 
morning, some people who have this addiction do want to go to a 
facility where it is total sobriety----
    Mr. Connolly. I am going to have to interrupt because my 
time is limited, but thank you, good point. If you read 
Dopesick, by Beth Macy, she points out that two-thirds of all 
the treatment centers for opioid addiction in the United States 
still do not allow medical treatment, other drugs to take you 
down. That is a sure-fire recipe for getting on heroin or 
something worse. It just does not work. The success rate is in 
the single digits with that kind of treatment.
    What we do know is that the AA approach, go cold turkey, 
absolutely is life-threatening when it comes to opioid 
addiction. It might work for alcohol; it does not work for 
opioids. And that is why----
    Director Carroll. And--I am so sorry.
    Mr. Connolly. No, go ahead.
    Director Carroll. I mean, I could not agree more, but there 
are many patients who are suffering from an addiction to 
opioids who have found that MAT does not work, and they want to 
go to a 12-step method. We should just make sure that we do not 
force MAT on a patient. I think the doctor would understand 
this, and we heard this morning from a father. Again, let's 
find the right treatment for them.
    Mr. Connolly. We want to stay flexible, but we also have 
data.
    Director Carroll. Absolutely.
    Mr. Connolly. And we know that MAT works three or four 
times better than cold turkey, and there are real risks with 
cold turkey.
    Real quickly, Dr. Rattay, you talked about people in your 
state, which has a little more than half the population of my 
home county, having 6,000 people who are not receiving 
treatment. Given the size of Delaware, that is a pretty 
stunning statistic in terms of what we are talking about here 
in terms of people being able to get treatment, having access 
to clinics and rehab facilities that are efficacious.
    Dr. Rattay. Correct. Although we have been able to increase 
the treatment capacity in our state, we know we are not where 
we need to be yet with treatment capacity.
    But also, as the Director mentioned, engaging individuals 
into treatment is also incredibly important. So, one of our 
focuses in our state is using what we call reachable moments 
such as when somebody has overdosed, when somebody is involved 
in the criminal justice system, or when a mother has had a baby 
as three prime examples of when individuals are most ready to 
become engaged into treatment, and then engage them very 
quickly into a system that really meets their own personal 
needs.
    Mr. Connolly. Thank you. I hope we have a chance to pursue 
that.
    Final question. My time is up.
    Director Carroll, I understand you had a conversation with 
the Chairman of this committee, Mr. Cummings. Have you had a 
chance to look at the CARE Act being introduced recently, and 
any reactions to it you want to share with us?
    Director Carroll. First off, I would like to appreciate the 
bill itself in that it is very clear that we share a mutual 
goal of saving lives, and I think the bill speaks to that, and 
I would love to be able to work with you, Chairman Cummings, 
and the rest of the committee to make sure that we are doing so 
in a way that is the most effective and efficient way to get 
help to people. So, I commend the heart and spirit of this 
bill.
    Mr. Connolly. Well, I just want to say I hope we can work 
on this on a bipartisan basis, Mr. Jordan, because this affects 
every one of our states. The stories, tragically, are the same. 
It knows no socioeconomic boundaries. It respects none, and we 
have got to save lives. We have got to try to get quick, 
effective treatment and try to turn this around. So, it has to 
be done on a bipartisan basis, and it has to be done with the 
cooperation of the Administration. So, thank you for that 
reaction.
    I now call upon the Ranking Member, Mr. Jordan. I think you 
want me to recognize the gentle lady from West Virginia. The 
gentle lady is recognized for five minutes.
    Mrs. Miller. Thank you, Mr. Chairman.
    I would like to thank all of you all for being here today, 
and I particularly want to thank the families who came and 
talked to us during the roundtable. My heart goes out to all of 
you.
    I also hazard a guess that there is not an individual in 
this room who has not been affected by addiction. If you are 
standing in the line at the grocery store, sitting in a pew at 
church praying with someone, a family member, we are all 
touched by addiction.
    I have spoken to this committee before about the opioid 
crisis and the devastating effect it has had on my community. 
My hometown of Huntington, West Virginia is considered the 
epicenter of the crisis, and I must give out my respect and 
heartfelt gratitude to my mayor, my fire chief, my police 
chief, all of those first responders, the faith community, and 
anyone who is in recovery, because we are all working together 
to solve this problem.
    I have visited hospitals and centers where babies are 
treated because they have been exposed to addiction. They are 
not considered addicted. They are exposed to drugs. I have seen 
them laying inconsolable, writhing in pain and crying. It is a 
terrible thing. I have sat with their mothers who are being 
treated while they are trying to restart their lives. I have 
talked to teachers and principals who are now dealing with 
young people in school who are the result of the opioid 
addiction, and we are learning that teachers have more issues 
that they have to deal with with these children.
    Addiction is heart-wrenching. It is a minute by minute, 
hour by hour struggle for those who have lived with it and face 
it every day.
    I was pleased recently that the Huntington Police 
Department reported that they saw a drop of 60 percent in the 
heroin seizures between 2017 and 2018.
    What is alarming to me is recently what we have seen is 
that the seizures of meth are up. They were up 366 percent. 
That number is alarming. Regardless of how many grams are 
seized, we have to recognize that trend is going on and that 
meth is also on the rise.
    Huntington as a community has come together and has 
implemented some amazing programs to help those struggling with 
addiction, to assist their families and respond quickly to the 
overdoses. There is no silver bullet. We need to focus on 
treatment for those who are struggling with addiction and stop 
the flow of drugs once and for all.
    Director Carroll, the Justice Department recently charged 
60 doctors, pharmacists, and others in opioids pushing through 
Appalachia. The case involved more than 350,000 prescriptions, 
encompassing more than 32 million pills.
    This is unacceptable. How can we work together to prevent 
problems like this?
    Director Carroll. Thank you very much. I do want to commend 
you and the work that is going on in Huntington. You mentioned 
the mayor and the fire chief, and it is hard not to ask people 
to watch the documentary on Huntington of ``Heroine,'' with an 
``e'' on the end. It is a very compelling story to watch.
    In terms of the prescriptions, we have, working hard with 
HHS, cut down on the number of prescriptions. But importantly, 
one of the things that we are developing is a National 
Prescription Data Plan to make sure that there is insight not 
only for physicians when they write prescriptions but also for 
law enforcement when they are out there, to make sure that they 
can see spikes and trends in terms of where a particular 
community is seeing a sudden spike in the increase of 
prescriptions being written and making sure that that does not 
trigger a red flag that we might have one of those 60 
physicians or health care providers.
    In reading the charging documents for those 60 individuals, 
it is horrifying. These are the people that we talk about who 
are preying on people with an addiction, asking them to do 
horrific things, knowing that they need the medication to 
sustain their addiction. So, I was very happy to work with DEA, 
as well as the state and local members of our High-Intensity 
Drug Task Force that participated in making sure that we are 
getting help to people through appropriate physicians, but we 
are not hurting them either. Thank you.
    Mrs. Miller. Mr. Chairman, may I ask for a few more 
minutes, please?
    Mr. Connolly. The gentle lady's time has expired. It may be 
possible when we come back that somebody could yield you some 
time.
    I now call upon the gentle lady from the District of 
Columbia, Ms. Norton, for five minutes.
    Ms. Norton. Thank you very much, Mr. Chairman.
    I want to thank all of the witnesses. This is critical 
testimony, especially after the roundtable we had. We just held 
a hearing with families of victims.
    On the one hand I must say, Director Carroll, I am pleased 
that the Administration, after two years without a specific 
strategy, has developed since January a strategy so that the 
budget will enable a strategy.
    So, if you look at first glance, the President's budget 
appears to put a priority on public health priorities. But if 
you take a second look, and you had better take a second look 
very quickly, you see that the President has very inconsistent 
policies here. He is gutting the very programs that are 
critical to the objectives of confronting the opioid epidemic. 
I say that because so many of those caught in the opioid 
epidemic depend upon Medicaid, four in ten adults struggling 
with this addiction. Indeed, we find that those struggling with 
this addiction are more likely to be on Medicaid than on 
private insurance.
    So, I am trying to find the real deal on the resources that 
are committed to this program, and you have $1.5 trillion in 
Medicaid cuts over the next 10 years.
    So, let me ask you, because I noticed something in your 
testimony, Dr. Rattay, in which you said that Medicaid had been 
critical to allowing individuals to get access to treatment, 
and that the expansion allowed the state--and I am quoting here 
from your testimony--``to free up treatment dollars to increase 
treatment capacity, including wrap-around services.''
    So, I would like to ask you, since we only look at one part 
of the policy without looking at what we are actually doing, 
let me ask you, Dr. Rattay, what would it mean in your own 
state if Medicaid expansion were repealed? How would this 
affect your ability, the ability of your state, to respond to 
the opioid epidemic?
    Dr. Rattay. Thank you for that question, Congresswoman. 
Having access to effective treatment is so critical to turning 
this crisis around. And as you mentioned, in our state 
expanding Medicaid has been, we believe, a critical piece to 
not only increasing access to individuals who are Medicaid 
recipients but also allowing us to use those additional state 
dollars to be able to expand capacity or support wrap-around 
services, as well as paying for peer recovery coaches, which is 
also an important piece to addressing treatment as an 
individual. Additionally, Medicaid has been at the forefront 
for allowing naloxone and buprenorphine to be available in our 
state.
    So, going backward and reversing the expansion I believe 
would be incredibly detrimental, and probably we would--I 
should not say ``probably.'' We would lose lives because of 
that.
    Ms. Norton. What if the Medicaid program were converted to 
a block grant with a per-capita cap? How would that affect what 
you are doing now, and what would be the effect in Delaware?
    Dr. Rattay. I do not oversee the Medicaid program in our 
state, and I do not want to answer for our Medicaid director, 
and I would say it really depends on the amount in that block 
grant. Flexibility can be a good thing, but if from a dollar 
perspective that limited----
    Ms. Norton. What about a per-capita cap?
    Dr. Rattay. Again, it depends on the amount. If the amount 
is too low----
    Ms. Norton. So, you have no cap now. There is no cap now to 
what you can spend with someone who has this addiction.
    Dr. Rattay. Right. I mean, we do all we can to take a 
person-centered approach, and since everyone's journey is 
different, some individuals do great on outpatient therapy, 
some require more intensive treatment. So, a cap could be very 
detrimental to appropriate treatment.
    Ms. Norton. Thank you, Mr. Chairman. I just want to say 
that you cannot begin to help somebody and then say, ``I'm 
sorry, we have reached the limit of what we can spend on your 
addiction.'' Thank you very much.
    Mr. Connolly. Well, I would also just note your question 
about block grants. It depends on the size of the state. 
Delaware has three counties. My state has 95, and the suburban/
urban counties in a block grant system that goes to the state 
capital always get the short end of the stick. So, it really 
depends on how big the state is, maybe, how you view block 
grants.
    The gentleman from Kentucky is recognized for five minutes, 
the other gentleman from Kentucky.
    Mr. Massie. Thank you, Mr. Chairman. I am going to yield my 
time to the gentle lady from West Virginia, who represents 
Huntington, West Virginia, the city where I was born and where 
a lot of my family reside.
    Mr. Connolly. The gentle lady is recognized, and I would 
just say to the gentle lady I am sorry I could not accommodate 
her request, because I know she was on a line of questioning, 
and we will restore the full five minutes to the gentle lady 
from West Virginia.
    Mrs. Miller. Thank you, Mr. Chairman. And I thank the 
gentleman from Kentucky.
    Director Carroll, quickly, how is the approach to tackling 
the rise in meth in the United States different from addressing 
heroin or opioids?
    Director Carroll. One of the things, I think, it is 
important to remember as we were talking at the beginning of 
this hearing about medication-assisted treatment, I think we 
need to put the marker out there that, sadly, right now there 
is no MAT for people who have a meth addiction. And some 
states--when I was in Oklahoma a few weeks ago, Oklahoma has 
just been ravaged by meth. California is also hit particularly 
hard. There are a lot of rural places where methamphetamine 
really is on the rise. So, MAT does not work for those 
individuals.
    One of the things that we need to do is to stop the flow of 
meth coming into this country, and it is all coming in from 
Mexico. The vast majority used to be made here in the United 
States. Through our law enforcement efforts such as Sheriff 
Ivey and the Drug Enforcement Agency, they have done a great 
job in stamping out the meth that was being made here. Since 
that time, it has been moved to Mexico. The purity of meth 
coming across the border is at an all-time high, 90-some 
percent. And meanwhile, because it is flowing into the country, 
it is less than half the price.
    Mrs. Miller. Okay. Thank you very much.
    Sheriff Ivey, in my state we have had great success working 
with HIDTA, and I would like you to speak on your experience in 
working with the ONDCP and its program. How is it working in 
your county?
    Sheriff Ivey. It is working very well. We have a great 
relationship with the Central Florida HIDTA Task Force. In 
fact, they were deeply embedded in this last investigation that 
we just conducted.
    One of the things that I think makes that task force work 
so well is that the governing committee of the HIDTA Task Force 
is people such as myself that sit there and understand what is 
happening in that particular region. The data that we 
continually get from ONDCP is paramount in us being able to do 
what we do, understanding the trends that are taking place, 
understanding the intelligence from other aspects or other 
areas of the country.
    So, everything, where we sit right now versus where we 
previously were on this epidemic, I think, is working, 
certainly in partnerships. I am a big believer--I always tell 
everybody there are all sorts of ships in the ocean, but 
nothing calms rough seas like partnerships. We have a great 
partnership with HIDTA. We have a great partnership with ONDCP. 
We could not do what we are doing, boots on the ground, without 
them.
    Mrs. Miller. Is there more that you see that they could be 
helping you with?
    Sheriff Ivey. At the surface, not for us. We are getting 
everything we need. Obviously, all of us would like to have 
more fiscal input to help us with these issues and combatting 
it because of the investigative cost. But from an intel 
perspective, from a resource perspective, even to the 
relationship we have with the United States Attorney's Office 
in prosecuting these cases and making sure that we are keeping 
those who are preying on the addictions of others off the 
street where they cannot do that, it is working.
    Mrs. Miller. Thank you very much.
    Mr. Chairman, I yield back the rest of my time to the 
gentleman from Kentucky.
    Mr. Massie. Thank you, Ms. Miller. Thank you for being a 
leader on this issue. Thank you for representing my family 
there in West Virginia, and for taking this issue up for our 
region. As somebody who represents eastern Kentucky, we are all 
interconnected there in southern Ohio and West Virginia. So, I 
appreciate very much what you are doing on this, and I yield 
back the balance of my time.
    Ms. Hill.[presiding] Thank you so much.
    I would like to recognize Mr. Sarbanes for five minutes.
    Mr. Sarbanes. Thank you, Madam Chair.
    I want to thank the panel for being here, and I want to 
also thank those who came and spoke at the roundtable earlier 
for sharing your stories, which I think had a tremendous impact 
on us.
    Mr. Carroll, I want to thank you for coming and thank you 
for your Office putting forth the nine priorities now in terms 
of the goals for addressing the opioid crisis. Among them is 
the goal of increasing the percentage of Federal prescribers 
who undergo continuing medical education on prescribing 
practices, getting that up to 50 percent by the year 2022, 
which I think is a good goal. Certainly, those providers need 
to be informed on the most up-to-date education information, so 
their practices are safety-driven and evidence-based.
    We should be nearing those safety standards, I think, as 
well in other aspects of our Federally-driven policy when it 
comes to the opioid crisis, and I am concerned that is not 
happening with respect to these high-dosage opioids. So, I 
wanted to discuss that with you for a moment.
    The CDC's 2018 guidelines for prescribing opioids state 
that clinicians should avoid increasing dosage to what is 
called 90 morphine milligram equivalents, MME, a day, or over. 
So, that is the standard, 90. Despite that, FDA has approved 
opioids that exceed this limit. Let me give you an example. 
Oxycodone, the generic version of OxyContin, is available in 
immediate-release 30-milligram tablets. This form is FDA-
approved for use every four to six hours. So, in other words, 
the FDA has approved a frequency of dosage which, in 
combination with what that dosage is, means that a patient 
following that prescription and taking four of those tablets a 
day is actually consuming 180 MME per day, morphine milligram 
equivalents per day, which is double what the CDC is 
recommending.
    So, I guess the question is, as we are warning prescribers 
to avoid prescribing over these limits, does it not make sense 
that we also kind of look at what is happening at FDA in terms 
of that approval and whether that approval needs to be 
revisited with respect to these high-dose opioids?
    Director Carroll. Thank you for the question. Quite 
frankly, you are absolutely right. We need to take a hard look 
at what is allowable and recommended in terms of what we know 
about the impact it can have. We know that opioid prescription 
for someone who is taking a high dose in a week or less can 
become addicted. So, when we are going forward and making these 
prescriptions, or going forward and talking to doctors about 
this, we have to work with the health care experts to determine 
what is the right amount of dosage.
    One thing, though, I want to make sure we keep in mind, and 
I hear it from the community quite a bit, are those people who 
are suffering from chronic pain. We want to make sure that they 
continue to have access, whether it is for a physical 
condition, or whether it is for cancer or some other life-
threatening disease. We want to make sure that we are not 
stigmatizing them or making it harder for them to get their 
pain medication.
    But you are right, we are trying to work together to make 
sure, and we are evaluating the pain management actually as we 
speak.
    Mr. Sarbanes. I appreciate that answer, and I do take your 
point that we need to strike the right balance. We want to make 
sure that there is the opportunity for physicians to prescribe 
pain medication in those instances where that is really the 
alternative option that is available to deal with that chronic 
pain situation. But I think there is going to be emerging 
evidence, as we look harder at this question of the high-dosage 
opioids, that the availability of that in combination with what 
the FDA prescribing limits are can create situations and 
potentially frequent situations where the dosage that that 
patient or that consumer is taking is well beyond what is 
actually needed to address the particular pain and make sure 
that that therapy is working.
    So, I am very interested in pursuing better alignment of 
the CDC guidelines with respect to what is considered safe in 
dosage over a 24-hour period, aligning that with what the 
currently FDA-approved prescribing and dosage levels are. So, 
we hope to work with your office on that going forward.
    Director Carroll. I am happy to, and I am happy to have 
some of our pain experts and health care professionals work 
with you and the committee staff going forward.
    Mr. Sarbanes. Thank you.
    I yield back.
    Ms. Hill. Thank you.
    I recognize Mr. Roy for five minutes.
    Mr. Roy. Thank you, Madam Chair.
    I appreciate you all taking the time to be here and 
visiting with this committee, and for all the work that you all 
do to address this particular problem. I appreciate everybody 
who is coming here and people who have been affected by this 
dreaded crisis that we face in dealing with the opioid 
epidemic.
    A question for Director Carroll. I have a study here in the 
Journal of American Physicians and Surgeons from the spring of 
2018, so a year ago, estimating the actual death rate caused by 
prescription opioid medication and illicit fentanyl. What the 
author, John Lilly, posits is that, from his closing: ``As more 
constraints are placed on legal prescriptions, it appears that 
market competition is driving opioid misusers from prescription 
opioid medication to illicit fentanyl because of its high 
potency and the variability of dosing of legally obtained 
drugs. Illicit fentanyl is far more likely to result in 
death.''
    Would you agree with that characterization?
    Director Carroll. Thank you for the question. I think we do 
have a careful balancing here. One of the things that we need 
to do to address it is to make sure that we are not starting 
down that path of prescribing opioids when a patient does not 
need it. That is one of the goals, to reduce opioid 
prescriptions. The goal was a third by four years. We are 
actually already ahead of schedule on that.
    The other thing that we do need to keep in mind is the 
education that we are doing in the communities through our 
Drug-Free Communities and with our partners to make sure that 
we are getting the message out to people----
    Mr. Roy. But would you agree that a significant amount of 
the problem right now is illicit fentanyl?
    Director Carroll. Is illicit fentanyl? Absolutely.
    Mr. Roy. Yes, illegally obtained illicit fentanyl.
    Director Carroll. It is terrifying. HIDTA last year alone 
removed a ton-and-a-half of fentanyl alone, which we heard how 
deadly it is.
    Mr. Roy. So, without objection, I will ask that this report 
be introduced in the record.
    Ms. Hill. So, ordered.
    Mr. Roy. A graph that is in there is hard to see because I 
have not put it up, but you will see if you look at this, the 
blue being the prescription opioids and the red being the 
illicit fentanyl. This is only through 2016. You will see some 
pencil chicken scratch on the right, my numbers looking at 
2017. This shows upwards of--these numbers here take you to 
35,000 almost total deaths as a result of overdose. That red 
number, that red being the illicit fentanyl, seeing the spike 
that we are seeing from 2013 to 2016, that number is 
progressing. Would you agree with that?
    Director Carroll. It is progressing and it is terrifying. 
That is one of the reasons the President has made it a goal to 
stop the flow of fentanyl from China. We got an agreement from 
the President. Now we have to enforce it and we have to make 
sure it is not coming through the mail or across the border.
    Mr. Roy. Great. Would you, Director Carroll, or maybe 
Sheriff Ivey could jump in, would these data points make sense 
to you? According to Border Patrol's most recent data through 
the end of April, they have seized 136.09 pounds of fentanyl 
between ports of entry since October, 98.9 percent of that 
being seized on our southwest border. Does that sound like an 
accurate statistic to you?
    Director Carroll. Could you repeat the number again? I am 
just looking to my page.
    Mr. Roy. Sure. This is data released for April, 136.09 
pounds of fentanyl between the ports of entry since October. 
This is according to CBP yesterday.
    Director Carroll. That is correct, essentially what I have. 
I do not have April, but I have March.
    Mr. Roy. Through March, okay, sure, 98.9 percent of which 
was seized on our southwest border. Does that sound correct?
    Director Carroll. Absolutely.
    Mr. Roy. In Fiscal Year 2018, the United States Border 
Patrol seized 388 pounds of fentanyl, and this year's numbers 
are following a similar trend. Fentanyl is a powerful opioid, 
as you know. It is 50 to 100 times more potent than morphine. 
Is the flow across our southern border a significant portion of 
the problem that we are dealing with with narcotics in our 
country?
    Director Carroll. Absolutely, positively, without question. 
And I think all you have to do is actually go back to the data 
from 2017.
    Mr. Roy. Right.
    Director Carroll. It was 181. Now in 2018, in the data we 
have for 2018, it is right, as you said, at 388. It is 
doubling. It doubled in a year. This is where it is coming from 
in terms of Mexico, and it is coming from China either directly 
from Mexico or through the mail. But the southwest border 
between the ports of entry is terrifying.
    Mr. Roy. And are we aware that a significant reason that 
this is happening is because of the influence of cartels at our 
border? They are profiting by moving people and moving 
narcotics; true?
    Director Carroll. Absolutely. I will try to be quick. The 
drug cartels, they are an incredibly dynamic, organized group. 
These are not individual people out there. If you go down to 
the border, you will see forward scouts on the Mexican side 
with binoculars. They see where CBP is, they flood the zone 
with immigrants until CBP is preoccupied with individuals. Once 
they know CBP is over here with these immigrants, they flood 
the zone with the drug trafficker.
    Mr. Roy. And I have 12 seconds left. Would the opioid 
epidemic be further enhanced in our country, improved, if we 
were to target cartels and stop the flow across the border and 
secure our southern border?
    Director Carroll. We absolutely--that has to be one of our 
many, but has to be one of the priorities.
    Mr. Roy. Thank you.
    Ms. Hill. Thank you.
    I recognize Ms. Tlaib for five minutes.
    Ms. Tlaib. Thank you so much, Chairwoman.
    I wanted to personally thank the families from this 
morning. It was incredibly powerful to hear what the human 
impact of doing nothing looks like. I talk about that a lot, 
and I talked to Mike Cannon, Kevin Simmers, Bill Sternberg, and 
Shauntia White. Thank you again so much for sharing. I heard 
this sense of urgency from all of you of really having us do 
something.
    So, Director Carroll, you have been very clear that we 
cannot end the epidemic without expanding treatment to those 
individuals suffering from the disease of addiction, and the 
National Drug Control Strategy recognizes, quote, ``Addiction 
is a chronic medical condition.''
    I could not agree more, and what I heard this morning, it 
really was a testament that they do not want any more talk. 
They want to talk about the need for treatment and that we must 
dedicate resources to expanding those treatments. And then we 
have to make sure that it is actually working.
    The Performance Reporting Supplement recognizes that in 
2017 only 10 percent of specialty treatment providers offered 
medication-assisted treatment. However, the Administration sets 
a very modest goal of doubling the number of specialty 
treatment facilities within five years. Even if we reach that 
goal by 2022, only one in five specialty treatment providers 
would offer the medication-assisted treatment, and the vast 
majority still would not.
    Director Carroll, how was this goal chosen? Why did your 
agency aim for only 20 percent when 70,000 Americans are dying 
each year from overdoses?
    Director Carroll. Thank you, Congresswoman. I would love to 
have that number be 100 percent. I think you would, too. And I 
think that is what the American people deserve. But what we are 
trying to do is--and we could put that in the strategy 
document, but what we have to do is set aggressive goals that 
we think we can actually meet once we have an understanding of 
what is going on.
    This crisis, sadly, took us years to get here. There is a 
recent Washington Post article that talked about how long and 
how many years we could see this coming. I think we have to be 
realistic with people to say how long it is going to take to 
get us out of this crisis. That is why we have to rely not only 
on----
    Ms. Tlaib. But it takes a strategy, Director, and----
    Director Carroll. We have a strategy. Yes, ma'am.
    Ms. Tlaib. I know. Well, then tell me how many more people 
with opioid use disorder will be receiving medication-assisted 
treatment.
    Director Carroll. What we want to be able to do is double 
that number as quickly as possible.
    Ms. Tlaib. What is that number?
    Director Carroll. Right now, the number of people receiving 
treatment is about 10 percent of the 20 million who had it. We 
do not have it broken down by specialized treatment. That is 
not the way HHS tracks the number in terms of facilities that 
provide MAT, but I am happy to try to work with you to get that 
HHS number, if they provide specialized treatment.
    Ms. Tlaib. We know that addiction is a chronic disease, 
like diabetes. If only one in five diabetes clinics offered 
treatment with insulin, would that be acceptable?
    Director Carroll. I am not a health care professional, so I 
cannot tell you about diabetes.
    Ms. Tlaib. But the point is, right, Director, that----
    Director Carroll. The point is that people are individuals, 
and we have to treat them as that and not raw numbers.
    Ms. Tlaib. But we already know medication-assisted 
treatment is one of those elements that needs to be fully 
funded and the resources available to the families that need 
this.
    Director Carroll. I could not agree more.
    Ms. Tlaib. So, I want to turn for a minute to the 
President's budget, because we cannot reach these goals without 
dedicated Federal resources. For my colleagues, it always will 
take resources, no matter how much we try to fix border issues. 
It is here now, and we cannot fix it without resources.
    So, Director Carroll, what resources are needed to reach 
the Administration's stated goal of doubling specialty 
treatment centers offering, again, medication-assisted 
treatment within five years?
    Director Carroll. The President's budget included an 
additional $6 million last year, and I appreciate Congress' and 
this committee's support of getting additional treatment. The 
total budget that we spend on this issue is about $35 billion. 
And everyone--maybe not everyone, but a lot of people have the 
misconception that the vast majority of that goes to law 
enforcement interdiction attempts. It is patently untrue. It is 
almost a dead-even split of half of that money going toward law 
enforcement and interdiction, and the other half going to 
prevention and treatment, with 90 percent of that $18 billion 
going for treatment alone.
    I appreciate the committee's interest in making sure that 
those treatment centers have the resources to get help to 
people.
    Ms. Tlaib. So, as a member, and a new member, which agency 
is going to be responsible for achieving this objective?
    Director Carroll. That is part of the implementation 
process now, to work with the agencies. Obviously, at the end 
of the day, HHS on the treatment side has the largest part of 
that. But one of the things that we also have to remember is we 
have to have fewer people addicted in the first place to make 
sure we are cutting down on the availability of prescriptions, 
illicit drugs, and God willing we will have fewer people that 
are addicted. So, it really is--we cannot look at this too much 
in isolation, but obviously on the treatment side alone, the 
key partner for that will be HHS.
    Ms. Hill. Thank you. Your time is up. Sorry.
    I would like to recognize Mr. Higgins for five minutes.
    Mr. Higgins. Thank you, Madam Chairwoman.
    Ladies and gentlemen, thank you for appearing today.
    I believe we face a cultural crisis in our country, and one 
of the major impacts of that crisis is an opioid challenge. A 
cultural crisis requires a cultural response, so let's talk 
about the genesis and the direction of this epidemic.
    A decade ago, as a patrol officer, part of my job in 
communicating with the citizens that I served was greeting new 
residents, and I will briefly advise of one story that ended 
tragically because of prescription opioid addiction.
    A lady moved into the neighborhood with her daughter, a 
young adult who had a child. So, the lady, her daughter, her 
grandchild moved in, were very happy. They were greeted by the 
community, and over the course of one year I watched this life 
deteriorate. The daughter left. The lady went from being very 
friendly to being rather mean and very aggressive, continually 
had her lights turned off, complaints from neighbors, et 
cetera, constant interaction from law enforcement, and my 
observations were that she was addicted to Lortabs.
    We warned her. I told her. I said one night I am going to 
get a call here and you are going to be gone, from your 
daughter, your granddaughter. And indeed, that is exactly what 
happened. About a year after they had moved in, we got a call 
from the daughter that she had not talked to her mom in a 
couple of days. She had moved out some time before but she was 
worried; would I go check? I went and found the lady deceased 
with empty bottles of Lortabs next to her.
    The Nation responded to this by restricting easy access to 
Lortab prescriptions and other opioid prescriptions, cracking 
down on doctor shops, et cetera, and this was largely 
effective. At the same time, our Nation was dealing with 
crystal meth. You remember, Sheriff, we had crystal meth labs, 
shake and bake labs, home labs all over the place. The Nation 
responded by restricting access to the primary ingredients of 
crystal meth, Sudafed, et cetera, took it off of the shelf and 
the aisles. You had to document who was buying this stuff.
    So, the Chinese created fentanyl. A decade ago we were not 
dealing with fentanyl; now we are.
    So, my concern is that this body looks beyond our actions 
and stays ahead of the curve of what can happen with the drug 
trade and the consumption of dangerous narcotics by our 
citizenry.
    The flow of drugs across the southern border, to me the 
biggest thing we can do to fix this thing is to secure our 
southern border. With all due respect to my colleagues that 
have alternate opinions, I respect their opinions, but as a 
former cop I am going to ask you, Sheriff, if you would share 
with us, what would your jurisdictional authority look like? 
How would it impact Florida if we could just stop the flow of 
illegal drugs across the border with aggressive law enforcement 
and change in our laws?
    Sheriff Ivey. Well, I do not think there is any doubt that 
securing our borders is going to not only impact this in 
controlling this epidemic but also impact us in the gangs, in 
the gun running, everything else that goes along with that. We 
work very closely with our partners from ICE and just recently 
partnered with the 287(g) Program in Brevard County to be able 
to help in that aspect.
    I can tell you that in working closely with them, we see 
the information, the data that Director Carroll was talking 
about earlier, the massive amount that is flooding into our 
country and that ultimately floods to communities like mine. It 
lands in communities where you are from, and that----
    Mr. Higgins. Regarding those numbers, not to interrupt but 
my time is short, did 400 or 500 pounds of fentanyl last year, 
100-something pounds thus far this year--I think those numbers 
are light, don't you?
    Sheriff Ivey. I do. I believe those numbers are--the 
numbers that we actually----
    Mr. Higgins. In my remaining time, would you respond, sir? 
Would there be positive ancillary impact if we could stem the 
tide, if we could hold this--would there be positive ancillary 
impact by being able to devote your assets to other services 
for your community, as opposed to----
    Sheriff Ivey. Without question it would do that, it would 
have that major impact, and it would give us the ability to 
further our investigations in other areas.
    Ms. Hill. The gentleman's time has expired.
    Mr. Higgins. Mr. Carroll, yes or no, is the President 
serious about this?
    Director Carroll. Yes, sir.
    Ms. Hill. The gentleman's time has expired.
    Without objection, a study from the American Journal of 
Public Health, entitled ``The Affordable Care Act: 
Transformation of Substance Use Disorder Treatment,'' is 
entered into the hearing record.
    Ms. Hill. And I would like to recognize Mr. DeSaulnier for 
five minutes.
    Mr. DeSaulnier. Thank you, Madam Chair and Ranking Member. 
Thanks for having this hearing.
    I would like to ask my questions from the perspective, 
given that all of us participated in the amazing testimony--I 
believe all of us. Maybe, Ms. McNeil, you were not there; maybe 
you were--of Mr. Steinberg, Ms. Simmers, Ms. White, and Mr. 
Cannon, all of who are still here.
    So, both professionally and personally, having heard what 
they said and having negotiated similar personal issues and 
tried to see them from a professional standpoint at the county 
and state level in California, and now at the Federal level, 
for multiple generations in my family, I have watched AA and 
now neuroscience and behavioral health, and I am going to 
direct the question first to Dr. Rattay.
    But for family members, and we heard this from a 
journalist, a police officer, someone who struggled with the 
social service safety net, it very much resonates with me. So, 
I have heard family members take the approach to parents, to 
children, siblings, you need to do this, you shall do this, 
sort of the hierarchical ``We can just say no.''
    Well, we know the neuroscience, we know the behavioral 
health, and that is not the right way to get a return on 
investment, and it is nice to hear a bipartisan ``let's do 
evidence-based research and have really good outcomes,'' and 
the GAO, I think, has done a marvelous job at trying to 
establish that. I am reminded of that quote often used, 
supposedly attributed to Einstein, that the definition of 
insanity is approaching a difficult-to-solve problem the same 
way and expecting different results. This, to me, is the 
epitome of it.
    So, why can we not be more client-based, taking the 
evidence-based research--I do not know why we do not just give 
this to the Centers for Disease Control. This is what they do, 
with all due respect to Mr. Carroll. We had this conversation 
last time. To be perfectly honest, Kaiser in my area, in Walnut 
Creek, California, has an opening for substance abuse director. 
They have over 400,000 clients in my county. You would not 
qualify from a paper standpoint. So, I appreciate your passion. 
The National Institute for the study of cancer--I am a survivor 
of cancer. The NIH's evidence-based research to develop the 
directors.
    So, my point is client-based, but then have professionals 
develop the evidence-based research.
    In your experience, do family members in Delaware go 
through what family members in California and what we heard 
this morning? And how can we help the family members get the 
resources they need given the urgency? I think the testimony by 
the police officer was amazing. I mean, how many times does a 
family have to spend that kind of emotional and mental strain 
to get through the bureaucratic process?
    Dr. Rattay. Thank you for that question. We agree 
completely. The system was in no way at all ready for a crisis 
like this. This experience has certainly led us to rethink all 
of how we provide these services for individuals, as well as 
supporting families.
    Treatment must be evidence-based. That is why access to 
medication-assisted treatment is so critically important, and 
we see at times where families really want their loved ones to 
try treatments that are not evidence-based, so there is 
education for everyone. Taking the stigma away from MAT is 
really important.
    But then also that person-centered approach, as you 
mentioned, really is so important because everybody's journey 
is so different. One person may really want to do outpatient 
treatment, which works very well, so they can continue their 
job. Other individuals may really need residential----
    Mr. DeSaulnier. Doctor, if I could stop you there. But as a 
family member, the challenge is we rely on the professionals to 
say that. I have had family members go into residential 
treatment and be outpatient. I expect the experts to make the 
assessment based on evidence-based research, and I want to 
support them. But my personal experience, like our witnesses 
today, from very divergent backgrounds, they have all had the 
same problem. The point of entry does not support you.
    I just want to switch because I have very little time.
    Ms. McNeil, we have to change the process. So, how could 
you look at not just performance standards for outcomes, which, 
Director Carroll, I appreciate you making a very real effort, 
but how can we look at what we did for cancer, for instance, to 
have the professionals do the work, but then what we missed in 
cancer is exactly what the families are having a problem with.
    And last, it would be wonderful if GAO looked at our 
policies in the Federal Government and the state government 
that have reinforced the stigma and have put up obstacles, so 
that we do not just spend money on it and give it to someone 
else. This committee should look and evaluate the policies we 
have enacted that reinforced the system we currently have, 
whether it is HIPAA or anything else.
    Ms. McNeil?
    Ms. Hill. The gentleman's time has expired.
    You can answer, briefly.
    Mr. DeSaulnier. Thank you, Madam Chair.
    Ms. McNeil. GAO would agree that evidence-based 
policymaking and decisionmaking is key. So, in the work that we 
have that we will be starting up soon, I think that is one of 
the things that we will consider - looking at programs that 
have worked well and bringing that to bear and making sure that 
that information is provided to you all.
    Ms. Hill. Thank you.
    I recognize Mr. Hice for five minutes.
    Director Carroll. Madam Chairwoman, I know I do not get to 
reclaim 30 seconds, but for the sake of parents and family 
members out there, may I just make sure that they are aware of 
a website where they can go for treatment?
    Ms. Hill. Yes, please.
    Director Carroll. Thank you.
    In working with HHS, ONDCP did put out a website for 
parents to go and find a locator, so thank you for that. For 
any parents or individuals who have an addiction, they can go 
to www.samhsa.gov/findtreatment, so they can find centers.
    Thank you. I apologize.
    Ms. Hill. Thank you.
    Mr. Hice?
    Mr. Hice. Thank you, Madam Chair.
    I would ask unanimous consent to have submitted into the 
record a CNN article about how the Trump Administration won a 
major policy shift from the Chinese on fentanyl.
    Ms. Hill. So, ordered.
    Mr. Hice. Thank you very much, Madam Chair.
    Director Carroll, from what I am hearing, is it accurate to 
say that you are continuing to track the increases of fentanyl 
coming across the southern border? Is that correct?
    Director Carroll. Yes, sir. We have to.
    Mr. Hice. And you described it as frightening.
    Director Carroll. Yes, sir. Scary for the parents and the 
kids out there.
    Mr. Hice. Absolutely, for our entire Nation.
    Now, the flow that is coming across the southern border is 
not by any stretch limited to our ports of entry; correct?
    Director Carroll. Absolutely not, not at all.
    Mr. Hice. Okay. So, there is no question while we are 
seizing a significant number of illegal drugs at our ports of 
entry; correct?
    Director Carroll. Yes. We are seizing it all along the 
border.
    Mr. Hice. All right. But a lot of it at the ports of entry, 
I would assume, primarily, because we have the resources there, 
the manpower, the dogs, those types of resources and others?
    Director Carroll. We are able to concentrate law 
enforcement at those areas, at the POEs.
    Mr. Hice. That is right, and just because we have those 
types of resources there, it is safe to assume that we have 
tons of illegal drugs coming in-between our ports of entry.
    Director Carroll. Absolutely. I think it is key to note 
that seizures do not indicate flow, and we know from the flow 
that we are able to capture between the ports of entry that 
that is a fraction of what is coming across.
    Mr. Hice. That is right, and that is because we do not have 
the resources in-between the ports of entry, or the manpower; 
correct?
    Director Carroll. That is correct.
    Mr. Hice. All right. So, besides your conversation with Mr. 
Roy a while ago talking about the importance of addressing the 
cartel issue between the ports of entry primarily, would you 
also agree that securing the border, the entire southern 
border, would stem the flow of illegal narcotics?
    Director Carroll. We have to secure the country, and that 
starts with securing the southwest border.
    Mr. Hice. Now, you mentioned also that fentanyl is coming 
largely into this country from China, that they are a major 
producer, I think 160,000 chemical companies in China, and they 
are going to Mexico or whatever, and then across our southern 
border. How important is the article? I do not know if you saw 
the article that I just had submitted, but China now referring 
to fentanyl as a controlled substance, how significant is that?
    Director Carroll. What we have to do is make sure that 
China understands that they are about to become the drug dealer 
of the world, and we have to make sure that they are 
aggressively enforcing the class scheduling that became 
effective May 1. Both on the intel side in the classified 
setting, as well as in the public space, we are going to be 
able to track what China is doing to actually live up to their 
agreement. We have to.
    Mr. Hice. And what kind of impact will that have?
    Director Carroll. I think it is going to have a significant 
impact. Congressman Roy held up the map or the graph that 
showed the amount of fentanyl. While we are here today talking 
about American lives, this is really a global problem. If you 
were to see the graph for Canada, which was just put out 
publicly this week, it is almost the exact same. I mean, this 
is becoming a worldwide problem. We have to take care of 
Americans, but China has got to stop.
    Mr. Hice. I could not agree with you more.
    Sheriff Ivey, let me go to you with this same question. 
What kind of impact do you think the Chinese now referring to 
fentanyl as a controlled substance, what kind of impact will 
that have on you?
    Sheriff Ivey. I would go back to what you were saying 
earlier about the ability to deploy resources in other 
capacities. Right now, fighting this opioid epidemic is 
draining my resources. My team, for example, just in one case 
was committed for six months to this lengthy investigation. So, 
being able to stop it at the border, being able to stop 
incoming into our country would give me the ability to shift my 
resources to do the other crime prevention efforts that we need 
to be focused on.
    Mr. Hice. Well, I hope we are succeeding, going to succeed 
in doing that.
    Director, coming back to you, probably for my final 
question, you say we have got to enforce this with China. What 
type of things do we need to keep our eye on as it relates to 
China, whether they are serious on this?
    Director Carroll. There are two things that I think we can 
see right off the bat in the public space. One is having them 
talk about it publicly, having the government officials there 
do what you all are doing and having hearings on this, talking 
about this. The other thing that we will see in the public 
space is actually prosecution and enforcement of drug 
traffickers, of those who are producing fentanyl. If we see 
those two things in the public space, we will be able to get a 
sense that China is taking this seriously.
    Mr. Hice. Thank you.
    Ms. Hill. The gentleman's time has expired.
    Mr. Khanna, I recognize you for five minutes.
    Mr. Khanna. Thank you, Madam Chair.
    Thank you to the witnesses.
    Thank you, Director Carroll, for your service. As you know, 
buprenorphine has been crucial to the treatment of disease for 
opioid addiction. Currently, about six percent of doctors have 
the authorization to do that. I appreciate that you have called 
for increasing that goal to 10 percent in five years.
    I guess my question is, when you look at France's 
experience when they had a major epidemic in the 1980's and 
early 1990's, they eliminated completely the similar waiver 
requirement, and my understanding is opioid overdoses dropped 
by nearly 80 percent after they did that. Why have a goal of 
only 10 percent? Why can we not be more aggressive in that?
    Director Carroll. Buprenorphine is a very effective 
medication for those suffering, but it is not without its own 
dangers. So, we do need to make certain that the people who are 
prescribing it are properly trained. The original cap for 
doctors was to make sure that they are able to focus in on the 
patients instead of just writing prescriptions, are not out of 
control.
    The original cap was 100. The Secretary of HHS engaged in 
rulemaking and moved that up to 275. So, we are seeing how that 
is going. But I think you are right, and that is one of the 
goals, to make sure that buprenorphine is more available to 
individuals who are suffering from the disease of addiction.
    Mr. Khanna. Would you be open to studying what France did 
and looking at how they managed to get rid of the waiver and 
seeing if there is something we can learn there?
    Director Carroll. We are working with HHS, and it is 
actually one of the things that they are doing now, is to make 
sure that everyone understands the impact and to see if--just 
like what we were doing with Huntington, the lessons learned.
    Mr. Khanna. Are you supportive if this Congress allocated 
$100 billion over 10 years to help you and others fight this 
opioid epidemic?
    Director Carroll. I am certainly supportive of any 
effective, efficient means of taxpayer dollars to save lives. 
In terms of the right amount, it is hard to say what the right 
amount is, at least in the next two minutes and 45 seconds. But 
certainly in the CARE Act the heart is there in terms of what 
we need to do to prevent this, treat this, and stop the flow 
from coming in.
    Mr. Khanna. And that is, of course, our Chairman's bill, 
Chairman Cummings. Do you think that could be an area of 
potential bipartisan cooperation, that we get something like 
that passed?
    Director Carroll. I probably should not say this publicly, 
but I actually enjoy a good relationship with Chairman 
Cummings. Please do not report that back. I hope the mic is 
off.
    On this issue, it really is bipartisan, and I have good 
conversations with Chairman Cummings, his counsel, on the 
minority and majority side, to try to figure out how we are 
going to do this and save lives.
    At the end of the day, that is all I think any of us care 
about, if we are going to save lives, how we are going to do 
it, how we are going to spend taxpayer dollars wisely. These 
are tough questions, though.
    Mr. Khanna. Dr. Rattay, I wanted to ask you about the 
Vermont model, the hub and spoke system where we have seen 
terrific success, where people are not just treated for their 
mental health issue and drug addiction but also given 
counseling, given a way to reintegrate with society.
    What is your view of that hub and spoke model and whether 
it could be replicated in other parts of the country?
    Dr. Rattay. We really have learned a lot from the hub and 
spoke model. One of the ways in which it showed in Vermont to 
be helpful is by having primary care providers providing 
treatment, learning how to help manage individuals. You could 
increase treatment capacity significantly. In Delaware we have 
created a similar model that we call the START system. But 
really, again, what is so important is that you engage people 
in treatment, that it is effective evidence-based treatment, 
which includes both the physical, the mental health, and the 
wrap-around services that people need, and that it is really 
treated as a disease, which is why primary care providers and 
buprenorphine play an important role in considering it just a 
disease like any other.
    Mr. Khanna. I am glad you are making progress in Delaware. 
My understanding is in Vermont--and I am not sure of the 
statistics in Delaware--opioid injections have actually fallen 
almost 90 percent. How much do you think that we can look to 
the expansion of Medicaid that helped the Vermont program, and 
how important do you think expanding Medicaid is to being able 
to deal with the opioid addiction?
    Dr. Rattay. It is so important that individuals have access 
to treatment, effective evidence-based treatment. In our state, 
expanding Medicaid has been very helpful to increase access to 
treatment for individuals in that expansion group, but it has 
also enabled us to free up funding to be able to increase our 
overall treatment capacity, as well as increase some of those 
wrap-around and other services that are important, including 
peer recovery coaches or working on addressing housing or other 
issues.
    Mr. Khanna. Thank you.
    Ms. Hill. The gentleman's time has expired.
    I now recognize Mr. Cloud for five minutes.
    Mr. Cloud. Thank you.
    Let me again first echo the sentiment of so many others on 
this committee to the families who came here and shared their 
personal stories. It was truly touching. And to the members 
here, and Dr. Carroll specifically, how you keep bringing back 
the focus on saving lives, I think that is keeping this 
committee in the right spirit, that that is really what we are 
trying to do here, is to save lives.
    Of course, Sheriff Ivey, I appreciated your analogy about 
the bulletproof vest and that this is a multi-layered approach. 
We talk about prevention, we talk about treatment, and both are 
needed. I was happy to hear that, from a financial standpoint, 
we are investing in both of those substantially and need to 
continue to do so.
    I happen to be from south Texas, and my community is right 
in the middle of what is called the fatal funnel, where two 
highways converge from the southern border, and then drugs and, 
unfortunately, human trafficking is dispersed throughout the 
Nation and beyond through that. As my friend from Texas was 
talking about meth coming across the border, the majority 
across the southern border, we have the issue with fentanyl 
coming between the borders.
    It is really a mess down there. I have been down to the 
border, talked to Customs and Border Patrol, and I asked them, 
I said what is the next win for you, and they said we would 
like situational awareness. We want the tools and resources 
just to have situational awareness. We are not at the point yet 
where we are trying to mitigate the problem. We are just trying 
to understand what is going on. I think that is a travesty.
    A couple of weeks ago I was back in the district and had 
the opportunity to sit in on what is a weekly law enforcement 
briefing where the law enforcement, Highway Patrol, sheriffs, 
police officers from throughout the district that I live in 
meet weekly to talk about how what is going on at the border is 
affecting what they are dealing with throughout the region, and 
it is certainly with the hospitals that are having to deal with 
this, the schools that are having to deal with this, it is 
certainly having an impact, and there is the lives and friends 
and family that we all have that have people who have dealt 
with addiction and the consequences of it.
    My question is what tools do we need? What are we doing to 
disrupt the drug trade, and what tools do we need to mitigate 
this crisis? Because treatment is awesome, and we want 
treatment. What is even better is if people do not need it.
    Dr. Carroll, I guess you can start.
    Director Carroll. I realize you could talk to any of us and 
we probably all--actually, we probably do not have dissimilar 
ideas.
    One thing is we need to start at the very beginning, as I 
talked about earlier, with the prevention programs that are out 
there that are targeting kids to make sure that they 
understand. Our drug-free communities, we have 731 plus 55, and 
I appreciate the 55 because of Congress. We have 786 Drug-Free 
Communities across the country. What we are seeing there is a 
rapid decline in past-30-day drug use of kids, and we talked 
about kids earlier today, and so that is critical.
    The treatment admissions are up. We need more. There is no 
question that we need more people accessing treatment, and we 
have to make sure that they can find it. That is why the HHS 
Treatment Locator is so important.
    But then we also need the third pillar, which is the law 
enforcement and interdiction side of this. We have all of our 
partner agencies working together at the national, state, 
local, and tribal levels to make sure we do this. So, it is 
with our partners at DEA. I am proud to have my HIDTA, my High-
Intensity Drug Trafficking Area, pin on today. We love our 
HIDTAs because they are a combination of law enforcement 
working together, as you heard Sheriff Ivey say, and they 
actually work at these drug-free communities to make sure the 
prevention folks and efforts there work.
    One last thing when we talk about what we can do, I would 
ask that the members of the committee go back to their 
jurisdictions. One of the things that the HIDTAs have developed 
is an OD map system. There are many places in Delaware that use 
it, and we are trying to get more states. Chairman Cummings was 
instrumental in getting an awareness to Maryland so every 
county in Maryland now provides real-time data not only to law 
enforcement about where overdoses are occurring so that they 
know they have a problem, but more importantly it provides it 
to the public health officials in the community to get ready, 
there is a spike, there is something happening in this area of 
town. It is all anonymized so there is no privacy information 
concerns, but it allows public health officials to be aware, 
schools to be aware, and even in some counties parents who have 
a child who is suffering from an addiction. Sometimes they will 
get the alert so they will know, oh-oh, I am not going to let 
my kid out of the house tonight.
    Ms. Hill. The gentleman's time has expired.
    Mr. Cloud. Thank you.
    Ms. Hill. I recognize Mr. Welch for five minutes.
    Mr. Welch. Thank you. Thank you very much.
    Dr. Rattay, I want to just ask you a little bit about the 
wrap-around services. I am from Vermont, and we heard some 
questions from my Silicon Valley friend about Vermont, but I 
want to ask you about Delaware and wrap-around services. How 
essential are they, and how can we provide them?
    Dr. Rattay. They are very essential.
    Mr. Welch. Define it, define what that means.
    Dr. Rattay. So, when we think about wrap-around services--
well, they are defined differently by different folks. I mean, 
when we talk about comprehensive services, we want to make sure 
that individuals do not just have their opioid use disorder 
treated but also any other mental health conditions, as well as 
physical health conditions.
    But then also, for a person to be able to be successful in 
recovery, they need to have a safe place to live, and they are 
going to do much better in recovery if they are either on a 
pathway toward a career or they have a job, or both. Whether it 
is legal issues that are making it difficult for them to stay 
in recovery because they are very anxious, we have to make sure 
that we understand what is it that a person needs to be able to 
stay in recovery.
    We also include peer coaches, peer recovery coaches as a 
part of that as well, because they are very important for 
people to navigate.
    Mr. Welch. Can you talk a little bit about that? Because it 
is so hard, if a person gets addicted, it is such a challenge 
for that individual to try to stay the course, especially when, 
by the time they get to that point, a lot of the supports in 
their life have vanished, including people in their lives. Can 
you just comment on the challenge that is there for service 
providers?
    Dr. Rattay. Yes. I mean, first of all, it is a difficult 
system to navigate. There are so many different parts to the 
system, so just navigating the system itself, most people, 
families and individuals, really need help navigating the 
system. But because there is so much stigma as well, they need 
somebody they can trust who is not judging them to help support 
them in their journey for treatment and recovery. This is why 
we found peer recovery coaches to be so helpful for 
individuals, getting them connected to treatment and 
navigating.
    Mr. Welch. Thanks.
    Let me ask Director Carroll about the peer support. Somehow 
that makes an awful lot of sense to me. In our roundtables in 
Vermont, the peer coaches just had an immense amount of 
credibility with folks who are struggling with an addiction.
    Director Carroll. They really do. They are really able to 
reach out to people that are struggling and say I have been 
there, I will hold your hand, I will help get you through this.
    Again, talking about the Democratic mayor in West Virginia 
who I am friends with because of this--sadly, it is because of 
this. But to go back to the communities, one thing that they 
have developed is the QRT, quick response team, and other 
communities have it as well. But people who have just had an 
overdose and thankfully their life has been saved because of 
naloxone, something that most people should carry--I had all my 
staff trained on it. The next day, after someone has survived 
an overdose, four people go see them because they know at that 
point they are most receptive. It is a member of law 
enforcement who is not wearing a uniform at the time but to 
say, look, I will take any drugs you have, I am not going to 
arrest you. It is a member of the public health team. It is a 
member of the faith-based community to say I will provide 
support if you have family or children. But it is also someone 
in recovery, a peer. So, when you go back home and think about 
this type of QRT, quick response team, it works.
    Mr. Welch. Thank you very much.
    Sheriff, what do you think about peer support, and what 
frustrations do you and your officers face when you are called 
to a scene involving a person that you were called to a week or 
two weeks before?
    Sheriff Ivey. It is incredibly frustrating and, quite 
frankly, heartbreaking, especially when you see the potential 
end result, like we heard from many of our parents and family 
members today. From the peer support aspect, I cannot speak 
enough about that because, as Director Carroll said, having 
somebody who has been through it that can help guide you 
through it, we use that same aspect or concept, if you will, in 
helping officers who have been involved in shootings or other 
critical incidents. So, the peer support group is going to be 
of great value.
    But to speak directly to frustrations, we spend an 
incredible amount of time doing just that, responding over and 
over again to those who are addicted to this.
    Mr. Welch. I yield back. Thank you.
    Ms. Hill. Thank you.
    I would like to recognize Mr. Grothman for five minutes.
    Mr. Grothman. Yes, thanks for being back here again.
    I do not remember if I asked this question last time. A 
relatively high percentage of American troops used heroin in 
Vietnam, and within a few years of returning a very small 
percentage of those people were using heroin. What happened 
there?
    Director Carroll. I am sorry, I am happy to do some more 
research into the Vietnam era and get back to your staff. One 
thing I am sure about is there was not fentanyl coming over 
from China and coming up from Mexico.
    Mr. Grothman. That is true. I am just saying--who knows 
what to believe on the Internet, but from what I read, about 15 
percent of American troops in Vietnam were using heroin, maybe 
even described as heroin addicts, and they returned, and in a 
relatively short period of time that number almost entirely 
disappeared. I wondered whether any of you four experts were 
familiar with that or have looked into it.
    Director Carroll. I am not familiar. I am happy to look 
into it and get back to you.
    Mr. Grothman. Good.
    Yes, Sheriff Ivey?
    Sheriff Ivey. Yes, sir. The only thing I can speak to is, 
in talking with my team, we are seeing an increasing number of 
our veterans that are falling into this epidemic, and that is 
both accidental and intentional overdoses that are taking 
place, and that is one of the things that we are looking at.
    Mr. Grothman. Okay, that is okay.
    The next question that just popped into my head. As far as 
when you are keeping track of these statistics, percent of 
people who die of a heroin overdose, do you know what 
percentage are married compared to the general population?
    Director Carroll. We do not track that. I can ask the CDC 
if they have such information and get back to you.
    Mr. Grothman. You should track that.
    Director Carroll. Sadly, I think what is happening is that 
it is more and more kids, younger people who are passing away, 
but I am happy to go back and see if----
    Mr. Grothman. Yes, see if the number of people who are age 
35 die, what percent are married compared to the population as 
a whole.
    Okay. Of all the programs you are familiar with, and I 
think everybody here who has any sort of political career has 
voted for all sorts of money to fight this, what is the most 
successful program? I mean, what program has, say, the highest 
rate of no relapse within five years? What is the best program 
you found?
    Director Carroll. We really have to be able to look at this 
as everything. We cannot--respectfully, I cannot take just one 
program. We have to do programs that work on prevention, and 
then on the treatment side we know that MAT is incredibly 
effective. We also know faith-based. It really is such an 
individualized one, it is hard for me to say----
    Mr. Grothman. Well, I will put it this way. Before you guys 
came up here, we heard some heart-rending stories of parents 
and a daughter whose mother or children died, and some of them 
just seem to go through this revolving door of treatment, 
treatment, treatment. And I just wondered, is there any program 
out there that you can say, at least say 70 percent of the 
people who go through this program do not relapse within five 
years? Is there such a program that exists?
    Director Carroll. I will say that probably the most 
effective thing that we can do that has almost zero dollars 
attached to it is getting rid of stigma, is telling people that 
it is okay to----
    Mr. Grothman. Is there any program like that? Does anybody 
know? For all the time we spend on this, can anybody say if you 
go to such and such a program in Columbus, Ohio, 70 percent of 
the people do not relapse within five years? Is there any such 
program that even exists?
    Director Carroll. This issue is so complex that there is 
not one single solution for individuals. We have to take this 
as a step-by-step process.
    Mr. Grothman. Well, I know we do, but we have been studying 
this thing forever. I mean, I have done this job for three or 
four years. I wish I could keep track of all the hearings I 
have spent before this. Do we know of any program that we can 
say that, say, I am going to send my son here, whatever, and 
say with 70 percent certainty that person will not relapse 
within five years? Is there any such program?
    Dr. Rattay. There is no magic program like that at this 
point. But we----
    Mr. Grothman. How about 40 percent?
    Dr. Rattay. But we have learned a lot over----
    Mr. Grothman. I only have five minutes. Is there a program 
that you can even say 40 percent of the people have not 
relapsed within five years?
    Dr. Rattay. Again, I agree with the comprehensive approach. 
If I were to point to one thing, medication-assisted 
treatment----
    Mr. Grothman. So, there is no program, or you just do not 
know.
    Dr. Rattay [continuing]. Is critical.
    Mr. Grothman. Final question. As far as other countries--
and maybe I will give this to Sheriff Ivey. Some people do not 
like to deal with deterrence, you know, let's do treatment but 
we cannot deal with deterrence. I went to Taiwan about 14 years 
ago, and they have almost no drug problem. Can you tell us what 
type of--does deterrence work in some of these southeastern 
Asian countries?
    Sheriff Ivey. I am assuming by ``deterrence'' you mean the 
type of penalties and the incarceration----
    Mr. Grothman. Yes.
    Sheriff Ivey. I am a strong believer--in fact, I absolutely 
advocate the harsher the penalty to these that are dealing--
preying on those addicted, the harsher penalties we can give, 
hitting them with racketeering, conspiracy to racketeer, 
putting them away for life, is certainly a deterrent. I 
absolutely believe it.
    Mr. Grothman. Yes, these----
    Ms. Hill. The gentleman's time has expired.
    I recognize Ms. Pressley for five minutes.
    Ms. Pressley. Thank you, Madam Vice Chair.
    Structural racism and systemic biases have shaped our 
responses to addiction, which has resulted in the criminalizing 
and the devastating of whole communities for decades. I do 
believe we perpetuate those practices when we ignore and leave 
out of the conversation and the profile of who has been 
impacted by this public health crisis and epidemic expectant 
mothers, when we leave out the black and Latinx communities, 
and when we leave out those that are incarcerated.
    Again, one of the groups most at risk of opioid-related 
deaths--and pregnant women and new moms have been especially 
vulnerable. The CDC found that the number of pregnant women 
with an opioid addiction more than quadrupled in the last 15 
years. And for these new moms experiencing addiction, a year 
after childbirth is the deadliest.
    Mr. Carroll, what is ONDCP doing to partner with HHS to 
improve comprehensive health services, particularly for 
postpartum women, who are often most susceptible to relapse and 
opioid-related overdoses?
    Director Carroll. One of the things that is important to do 
is to make sure we are reaching every community that is out 
there. You mentioned the incarcerated. Let me start with the 
order that you went. You were talking about the population that 
is incarcerated, and it----
    Ms. Pressley. We can go there, but I would like to stay on 
the moms right now.
    Director Carroll. I am trying to answer your question.
    Ms. Pressley. Okay.
    Director Carroll. And I will get there, I promise.
    What we are trying to do for the incarcerated population, 
sadly, in many communities, those are the facilities that 
provide the most treatment for individuals. So, that leads to 
change, but the change is at the fundamental level in making 
sure that we are not criminalizing addiction and so fewer and 
fewer people are going to jail. We are doing that--we did an 
additional $4 million in drug court diversion so they are not 
going to jail and they can get treatment on the outside.
    In terms of----
    Ms. Pressley. I am sorry. So, yes or no, does that mean 
that ONDCP is working with the Bureau of Prisons to expand 
access to medication-assisted treatment for incarcerated 
people? Since we know that two-thirds of incarcerated people 
suffer from substance abuse disorders, and only one-quarter of 
those people receive any drug treatment.
    Director Carroll. One of the things that is important when 
we talk about----
    Ms. Pressley. Yes or no, do you have a partnership? I am 
sorry, I have a limited time. I am trying to be respectful.
    Director Carroll. And I am trying to be respectful, too.
    Ms. Pressley. Okay.
    Director Carroll. What we are trying to do is expand the 
number of prescribers, because once we have a bigger work 
force, we can get more people into an incarcerated population 
to provide them the treatment that they need.
    Ms. Pressley. So, those reentering society, they are 40 
times more likely to die from an opioid overdose.
    Director Carroll. And there are some local jails that are 
doing this. We are trying to incorporate it at the Federal 
level as well.
    Ms. Pressley. Okay, very good. Thank you.
    Director Carroll. But one thing it is important----
    Ms. Pressley. I am short on time. I want to get to my 
question about moms.
    Director Carroll. In terms of moms, that is one of the 
saddest things that you see is when you see a child who has NAS 
and they truly have that pain. So, the idea is making sure that 
we are having specialized care for them with HHS, to make sure, 
such as Lilly's Place in West Virginia that we talked about, 
and other places, to make sure we are going right at--we have 
to treat these----
    Ms. Pressley. Excuse me. I am sorry. But at the same time, 
you are intent on overturning the ACA, rolling back protections 
for preexisting conditions, and undermining the expansion of 
Medicaid, which can be a critical source for addiction 
treatment. So, yes or no, will this Administration's attack on 
the ACA and efforts to stop Medicaid expansion help tackle the 
opioid epidemic?
    Director Carroll. The failed policies of health insurance 
do not actually mean health care, and I think it is important 
that we understand that at the outset. We have to make sure, 
and it is my responsibility to advise the President on making 
sure that as the reforms go forward, getting treatment to 
individuals is the most important thing that I can do in terms 
of helping whether it is moms who have an addiction, parents, 
children, or anyone. That is my responsibility, to make sure 
that we have a health care system that works.
    Ms. Pressley. Excuse me. I just want to be clear, because 
mothers are dying. Do you believe the Administration's efforts 
to undermine the ACA will help in the opioid crisis?
    Director Carroll. I believe that the health care policy 
going forward will save more lives, absolutely. We are going to 
make it a sound policy.
    Ms. Pressley. Okay. We disagree on that.
    In my home state of Massachusetts, the opioid crisis is 
robbing lives at a rate that is two times higher than the 
national average, and the death rates in black and brown 
communities are spiking at record rates. Yet these communities 
most at risk are less likely to have access to critical 
services and medication-assisted treatment.
    Mr. Carroll, what is ONDCP doing to ensure that black and 
Latino communities are not left behind?
    Director Carroll. One of the things we have to do, as I 
talked about a minute ago, was to make sure that there is not 
stigma in terms of the population, the prescribing population, 
to make sure that we are getting treatment and facilities that 
provide quality, effective care. Sometimes we have seen in 
communities, especially in urban areas, our methadone clinics 
that are not providing quality care. What we have to do is make 
sure that there are qualified individuals out there providing 
MAT----
    Ms. Pressley. And also culturally competent. I just wanted 
to add that.
    And then just for the balance of my time, we do not have 
much time for you to answer but I just want to say on the 
record, your Administration has indicated that they plan to 
eradicate and end the HIV and AIDS epidemic in the next decade. 
So, I do hope that this is a part of that broader strategy 
since we do know a number of the new infections. There is an 
overlay in all of these issues.
    Director Carroll. God bless you. I hope you are right.
    Ms. Pressley. Okay. I yield my time.
    Ms. Hill. Thank you so much.
    I now recognize the Ranking Member for five minutes.
    Mr. Jordan. Director Carroll, what year was the ACA passed?
    Director Carroll. Boy, you are probably a better guess. 
Four years ago? Five years ago?
    Mr. Jordan. It passed in 2010.
    Director Carroll. Okay. Time flies. Sorry.
    Mr. Jordan. Is it still the law?
    Director Carroll. It is.
    Mr. Jordan. Yes. And what has happened to the opioid crisis 
during that time?
    Director Carroll. We have seen the number of deaths just 
skyrocket.
    Mr. Jordan. Yes. So, the idea that somehow the Trump 
Administration and us trying to do what we promised the voters 
we were going to do, which is replace, repeal and replace the 
ACA, that has not happened. So, the idea that that somehow has 
contributed to this terrible crisis across the country is just 
crazy; right?
    Director Carroll. We need an efficient and effective system 
to get help to people.
    Mr. Jordan. I agree.
    Sheriff, how big is your county?
    Sheriff Ivey. A population of 600,000.
    Mr. Jordan. Big county.
    Sheriff Ivey. Yes, sir.
    Mr. Jordan. How long have you been in law enforcement?
    Sheriff Ivey. I have been in law enforcement almost 40 
years, sir.
    Mr. Jordan. Forty years? Most of it in your county?
    Sheriff Ivey. No, sir. Actually, I served--the biggest part 
of my career is supervisor with the Florida Department of Law 
Enforcement across the state.
    Mr. Jordan. Across the state. A pretty big state, too.
    Sheriff Ivey. Yes, sir.
    Mr. Jordan. Yes. So, in 40 years of experience in a county 
of 600,000 that you are now the sheriff of, and then I think in 
my opening remarks I talked about you had a fentanyl bust of 
like--I forget how many pounds. What was the number?
    Sheriff Ivey. The investigation yielded three pounds of 
fentanyl.
    Mr. Jordan. Which is enough, as I think I said, or someone 
said, enough to kill----
    Sheriff Ivey. In lethal dose form, it would have killed 
everybody in my county.
    Mr. Jordan. Yes. That is serious. Do you know where that 
came from?
    Sheriff Ivey. We know that the direct point to us was from 
Georgia. That is where the subject picked it up. But according 
to our partners with DEA, we see the fentanyl coming in from 
China and through Mexico.
    Mr. Jordan. Yes, like Director Carroll has talked about and 
most of us know.
    And I think earlier you talked about what we need to do on 
the border. Would you describe the situation on our southern 
border as a crisis?
    Sheriff Ivey. There is absolutely no question. We need to 
secure our southern border. In doing so, we will eliminate and 
eradicate a lot of problems that law enforcement faces each and 
every day.
    Mr. Jordan. And potentially, when you go after the supply, 
you can potentially help stop some of the tragic stories we 
heard earlier this morning from the families who have lost a 
loved one.
    Sheriff Ivey. Yes, sir, absolutely. In fact, one of our 
families this morning talked about law enforcement did not go 
after the dealer. I am a strong, strong advocate of we need to 
go after these dealers with every ounce of passion we have to 
lock them up. They are preying on the addictions of others.
    Mr. Jordan. Question that is related, not maybe directly to 
this, but what is your position on liberalizing marijuana laws?
    Sheriff Ivey. I am absolutely 1,000 percent against it.
    Mr. Jordan. In your experience, 40-some years in law 
enforcement, sheriff of a county of over 600,000 people, do you 
think liberalized marijuana laws can lead to, then, this 
addiction problem in the opioid area?
    Sheriff Ivey. Yes, sir. Actually, the greatest education I 
ever got in why we should not legalize marijuana came from our 
chain gang who we use often to talk to parents who are trying 
to help their kids stay out of trouble. They absolutely said 
that marijuana, the dealers of marijuana turned them on to the 
other dealers who then sold them coke and heroin and the other 
things. So, ironically, out of the mouths of what you would 
probably call criminal experts because they are sitting in our 
jail, they say it is a bad move as well.
    Mr. Jordan. Yes. Mr. Sheriff, we appreciate your service, 
and all of you, for your testimony today.
    Director Carroll, what are your thoughts on liberalizing 
marijuana?
    Director Carroll. What we have seen is that the marijuana 
we have today is nothing like what it was when I was a kid, 
when I was in high school. Back then, the THC, the ingredient 
in marijuana that makes you high, was in the teens in terms of 
the percentage. Now what we are seeing is twice that, three 
times that in the plant. But then in the edibles, 80 percent, 
90 percent THC. We just do not understand yet. We are doing 
more research. DEA is working hard. HHS is working hard to make 
sure that we understand the impact of legalization of marijuana 
on the body. We know already the impact it has on----
    Mr. Jordan. One of the things that passed out of the 
Judiciary Committee last Congress was this idea that--and I 
think this is where you were going, Director--we need the 
research and the studies done before we allow this to happen, 
we liberalize these laws, as some states have already done. It 
seems to me at least figure out what the research shows, and I 
see Dr. Rattay shaking her head as well. Would you agree with 
that?
    Dr. Rattay. Yes, I would.
    Mr. Jordan. All right. I appreciate that. Thank you all.
    And with that, Chairman, I yield back.
    Ms. Hill. Thank you.
    I recognize Congresswoman Speier for five minutes.
    Ms. Speier. Thank you, Madam Chair.
    And thank you all for the good work that you are doing.
    Director Carroll, when you last were with us, I submitted a 
question for the record, asking you to provide the status of 
each of the 56 recommendations from the Christie Commission, 
including whether ONDCP or other Federal agencies had adopted 
the recommendations, the reason why the recommendation was or 
was not adopted, and all actions taken or planned to be taken 
by ONDCP or a Federal agency in furtherance of the 
recommendation. So, it is important once we create these 
commissions, they come up with these far-reaching 
recommendations, that we actually act upon them.
    So, your response to me was a one-pager, as well as a one-
year report update on the Commission. Neither of these 
documents provides specific information I requested on each of 
the 56 Commission recommendations.
    So, I am going to ask you one more time. Can we as a 
committee receive from you a complete response to each of the 
56 recommendations whether or not you have taken action, and if 
not, why not, so that we can have a full understanding of 
whether or not you have implemented those recommendations?
    Director Carroll. We have given you a full answer in terms 
of how the Commission--we grouped it into headings of nine, 
because that is the way, when you look at the report, how they 
fell. In terms of if there is a specific question, I am happy 
to work with your staff to explain as to specific questions.
    Ms. Speier. All right. Maybe--you know what? All we are 
doing is asking for information that you should be able to 
provide us.
    Director Carroll. I am able to--ma'am, I just said I will 
provide it.
    Ms. Speier. Okay. Then that is what we will do.
    Director Carroll. I am happy to come up and talk to you 
about it.
    Ms. Speier. Then that is what we will do. We will have you 
come up, and you can make a presentation to me and anyone else 
on this committee who would like to go over recommendation 
after recommendation, and we will go over all 56, if that is 
easier for you to do.
    Director Carroll. Ma'am, I am trying to save lives on a 
daily basis.
    Ms. Speier. I understand that. So, are we.
    Director Carroll. And so what I am trying to do is make 
sure that I am focusing on the priority targets. I gave you a 
response to the Commission and, as I said, I am happy to go--if 
you have a specific one you want to go through, I am happy to 
send my staff up to work with your staff or to work with you.
    Ms. Speier. That is not what you just said. You said that 
you would come up.
    Director Carroll. I said I would--I am happy to come up 
with my staff and sit down and answer any questions about a 
specific one you want.
    Ms. Speier. All right. Then I will get specific questions, 
and they will be submitted to you, and then you will come up 
with your staff, and we will invite other members of the 
committee to join me to get the----
    Director Carroll. I want to be sure I send the right staff 
to answer your questions, ma'am.
    Ms. Speier. I think you are being very belligerent, and I 
do not think that is conducive to us working together.
    Director Carroll. I think I am trying to answer this in the 
most bipartisan fashion I can. And in terms of being 
belligerent, I am trying to get you answers that you want.
    Ms. Speier. All we did was ask you to respond to the fact 
that Mr. Christie was in charge of this Commission, he came up 
with 56 recommendations. We wanted to know where you were in 
implementing the 56 recommendations, and instead you sent us a 
one-page with another document that does not really answer 
whether or not these 56 recommendations have been implemented. 
It was a pretty simple request, and it should have been 
something that you could have responded to in a very simple 
manner, but you chose not to.
    Director Carroll. I think I did respond in a very simple 
manner that pretty much anyone can read and see exactly how we 
went about trying to answer these questions.
    Ms. Speier. Well, that was not sufficient, so you can come 
back, then. Thank you.
    Director Carroll. I will send the right staff to come back 
and meet with you, ma'am. Do not worry.
    Ms. Speier. Again, I object to the tone that you are 
using----
    Director Carroll. I object to the tone you are using.
    Ms. Speier. Well, you do not have the right to object to my 
tone, because we have two different roles here.
    Director Carroll. Yes, ma'am. I am saving lives.
    Ms. Speier. I have oversight role----
    Director Carroll. And my job is to save lives, and that is 
what I am trying to do every day.
    Ms. Speier. Well, if you are trying to do that every day, I 
would think you would want to work with the committees that 
have the authority to provide you with the resources to do your 
job so you can save more lives.
    Director Carroll. I have a great relationship, I think, 
with most members of the committee and their staff. We are 
trying so hard. We have been working with GAO. They have been a 
great partner in the last 60 days to be able to work with them 
and show them exactly the direction we are going.
    Ms. Speier. Well, if I remember correctly, GAO was not 
happy with how the Office was operating and made 
recommendations. I am glad to know that Ms. McNeil feels that 
you are indeed responding to them.
    Is that true, Ms. McNeil?
    Ms. McNeil. Yes. We have had four meetings with ONDCP staff 
since the last hearing, and then we had an additional briefing 
where I brought some experts over and walked them through some 
best practices related to collaboration and strategic planning.
    But I do want to highlight there are two things we have 
been asking for that we really need from ONDCP for us to 
continue to make progress. One, the budget guidance that they 
used before there was a Strategy. We need to understand what 
that guidance entails. And two, the National Security Council's 
Strategic Framework for Reducing the Availability of Illicit 
Drugs. The staff told us that is what they used in lieu of a 
Strategy in prior years. We would like access to that. We asked 
for it in December and still have not received it.
    Ms. Speier. Okay. So, you asked for it in December and have 
not yet received it----
    Director Carroll. Ma'am, if you listen to what she just 
said----
    Ms. Hill. The gentlewoman's time has expired.
    Director Carroll.--by the National Security Council. We do 
not own the document. I am not the National Security Council. 
We have given them the information----
    Ms. Hill. Director Carroll, I need you to stop. Thank you.
    Next I would recognize Mr. Comer for five minutes.
    Mr. Comer. Thank you, Madam Chair, and Director Carroll, 
and Sheriff Ivey. I just want to thank you for doing everything 
you can to try to save lives, and I believe that you all are 
trying to save lives.
    We have had committee hearings here and countless meetings 
and discussions about the opioid issue and crisis for months 
and years, and one of the things that has been mentioned today 
by the Sheriff and others is that we have a drug problem in 
America, and many of the drugs are coming illegally across the 
border. We have a President and at least a majority of one 
party that is serious about securing the border to try to stop 
the illegal flow of drugs into the United States, and I think 
that what we are seeing from a few members of this committee in 
differing parties is that one party wants more money, more 
money, more money, and at the end of the day, until we cutoff 
the flow of illegal drugs crossing the border, we can spend all 
the money in the world, we are still going to have a major drug 
problem in the United States.
    So, I think it is important to reiterate the fact that if 
we are serious about stopping the flow of illegal drugs into 
the United States, we are going to have to get serious in this 
Congress about securing the border. So, I just wanted to 
mention that.
    And in my remaining time, I kind of wanted to shift gears 
because I think that the biggest part of the opioid problem we 
have had in America is the business model to treat pain has 
been wrong. Doctors, at least in my Kentucky district, have, 
for whatever reason, over-prescribed opioids for the treatment 
of pain, and I think that we have come a long way in education, 
in educating our medical providers on the perils of opioids.
    But my question, Director Carroll, is as we move forward 
and we talk about the opioid issue, again, I will say over and 
over, I think the number-one thing that we can do is secure the 
border. But as we move forward, there are a lot of people in 
America that have legitimate pain, and there are people that 
deserve and have the right to treat their pain.
    One of the things that I have been doing a lot of research 
on is alternative forms of pain treatment. In Kentucky, before 
I came to Congress, I was Commissioner of Agriculture, and we 
became the first state to legalize industrial hemp. The hemp 
industry in Kentucky and in many states now is really booming. 
It is an emerging industry. And one of the biggest products 
that is coming from industrial hemp is CBD oil, cannabinoid 
oil, non-THC, so we are not talking about marijuana, we are 
talking about hemp, non-THC CBD oil for treatment of minor pain 
like inflammation and other forms of minor pain. This seems to 
be really making a difference.
    We also, in my research, my staff, we have listened to 
physical therapists, chiropractors, other alternative forms of 
pain treatment.
    Director Carroll, what are your thoughts on how we move 
forward in trying to treat pain in America other than the old 
business model that has failed so miserably in prescribing 
severe pain medication?
    Director Carroll. One of the things that I think is 
important to do, and actually the Commission talked about this, 
was removing the pain questions when there are surveys for 
health care professionals. Working with HHS and working with 
Members of Congress, one of the things that we have done is 
removed the pain questions from the reimbursement side. So, 
effective October 1, 2019, the questions on pain as they 
determine reimbursement rates will no longer be asked.
    So, the people understand that sometimes if you have--I 
think we were talking earlier, one of the young men who lost 
his life was because of an appendix, to be able to say to them 
it is going to hurt, you just had surgery. So, by removing the 
pain survey, that is one of the things that I appreciate 
[about] the committee and Chairman Cummings, and I have talked 
about too: making sure that we treat appropriate pain, but that 
we also do not spend too much of an emphasis on it.
    In terms of the CBD, that is something again that I think 
HHS is going to regulate to make sure that we understand the 
health impact of it. I do not know if Dr. Rattay feels 
differently, but I think right now we are on the cutting edge 
of research to show the----
    Ms. Hill. The gentleman's time has expired.
    Director Carroll. I am sorry.
    Ms. Hill. I recognize Ms. Maloney for five minutes.
    Mrs. Maloney. I thank the Chairwoman for yielding and all 
of the panelists for your service.
    One of the recommendations in the report really builds on 
the question of Mr. Comer, and I applaud his questioning. It is 
the same that I have heard from doctors in the city that I 
represent, but they say they want to reduce opioid prescription 
fills by 33 percent within three years. I think one of the 
problems I have heard from doctors is the incentive is to give 
pain medication, and I am pleased that that question has been 
removed. It should be removed from everything.
    Director Carroll. Thank you for your help on that.
    Mrs. Maloney. They told me that they felt like they had to 
give pain pills because they were being drilled on it, and I 
think that removing it--my question is if you change the 
incentive and instead of asking people to rate whether the 
doctor took away all their pain, you could ask the question to 
the doctor: ``Did you try every other alternative form of pain 
relief before you moved to an opioid?'' Because what doctors 
are telling me is that there is Tylenol, all types of different 
pain relief that can help people. And I think if you changed 
that incentive, I think it would be better.
    Personally, I think we should take opioids totally off the 
market unless you are in hospice, because it is harmful to 
people. From the stories that we read, most people are addicted 
by their doctors giving them these pills.
    I want to tell a story of a constituent who became addicted 
in five days on opioids. She was in one of the finest hospitals 
in my district, and they asked her all the time to fill out 
forms on whether or not she was in pain. Of course she was in 
pain. She had a minor operation. They cut on you, you are in 
pain. She did not want all these pain pills. They kept giving 
them to her. When she left they gave her three different 
painkillers, big bottles of opioids to take home with her and 
fill out her form that she did not have any pain, because the 
doctors did not want to be rated badly.
    So, I think removing that rating completely--it should not 
be anywhere--it should be removed, and I think the incentive 
should be changed to what are you doing to prevent having to go 
on opioids.
    And my question is why do we continue to allow this to be 
legally dispensed when we know it is killing people? We know it 
is killing. The numbers are astronomical of people becoming 
addicted. This woman became addicted in five days.
    Now, people are different. Some people will never become 
addicted for whatever reason, the chemistry in the body. She 
became addicted and had a difficult, difficult time getting off 
of it. But she did not want all these pain pills. They just 
kept giving them to her because the incentive was do you have 
any pain, you cannot have any pain, do not rate me for giving 
you pain.
    But I would just like to ask the panel, what about changing 
the incentive and saying instead of do you have any pain, ask 
the doctor have you tried every other way to relieve the pain 
and give the incentive to the doctor to talk to the person that 
you may be uncomfortable for one day but you are much better 
off not taking these killer opioids.
    If anybody wants to comment, I would like to hear your 
response.
    Director Carroll. I will just take 10 seconds at the end.
    Dr. Rattay. This is a tough-to-crack. Changing prescribing 
practices is much more stubborn than we realized. The Centers 
for Disease Control and Prevention has done a nice job 
reviewing the evidence. I think we all know now opioids really 
are not very effective for pain management, and the risks are 
much, much higher. But access to alternative and more effective 
approaches to pain management has been limited.
    So, one of the things we have done in our state is not only 
educating the public and providers but changing insurance----
    Mrs. Maloney. May I ask a question, with all respect? Why 
is it difficult? Why is it difficult for your states to have 
alternatives that could save a life if you kept them off of 
opioids? Why is it difficult? There is Tylenol. I mean, I am 
not a doctor, I do not know these terms, but there are lots of 
little drugs that can help you. Why is it difficult to get an 
alternative?
    Dr. Rattay. There is a lot of resistance overall. The 
public still has--there is a lot of demand for opioids for pain 
management. Physicians, many do not particularly want to be 
told to decrease their prescribing. But you mentioned, and I 
think it is very much the case, insurance is much better at 
reimbursing for pharmaceuticals, including opioids, and we are 
really pushing change to get chiropractic care, physical 
therapy. We have removed the caps for those in our state. We 
are now working on massage and acupuncture, requiring 
reimbursement for those, as examples.
    But right now, a lot of people do not have access through 
their insurance to alternative approaches.
    Ms. Hill. The gentlewoman's time has expired.
    Mrs. Maloney. Thank you.
    Ms. Hill. With that, I recognize Ms. Ocasio-Cortez for five 
minutes.
    Ms. Ocasio-Cortez. Thank you so much. I would like to thank 
the Chair and the committee for convening today's hearing, as 
well as all of our witnesses for joining us today.
    While I am pleased to hear that the Administration is 
supporting efforts to combat the opioid crisis, and that the 
President's budget requests some discretionary funds for this 
purpose, it seems that upon closer inspection he is actually 
gutting the very programs that are critical to combating the 
opioid epidemic.
    The Medicaid program is the Nation's single largest payer 
for behavioral health services, and it covers nearly four in 10 
non-elderly adults struggling with opioid addiction, and adults 
with Medicaid are more likely than even the privately insured 
and the uninsured to receive substance use disorder treatment.
    So, at the same time we should be dedicating greater 
resources to this critical program, the President's budget is 
proposing $1.5 trillion in cuts to the Medicaid program over 
the next 10 years, the very program that is the largest payer 
and the larger assistant in behavioral health services.
    So, I have a question, Dr. Rattay. In your written 
testimony you speak about the importance of Delaware's Medicaid 
expansion. What would it mean for your state, and how would 
this impact your ability to respond to the opioid epidemic, if 
the ACA were repealed?
    Dr. Rattay. We have great concerns that if the ACA were 
repealed and we went backward regarding expansion, that many 
people would lose access to life-saving treatment services. So, 
on the flip side, Medicaid expansion not only has been able to 
enable us to increase access to services for individuals, but 
it has also enabled us to use resources, other resources 
differently; so, for example, whether it is wrap-around 
services or peer recovery coaches.
    Ms. Ocasio-Cortez. Have you seen any sort of relationship, 
whether it is correlative or otherwise, between states that 
have not expanded Medicaid and the depth of the opioid crisis 
there, and the ability of people to seek treatment?
    Dr. Rattay. I know that there has been a look at that, but 
I have not studied that closely.
    Ms. Ocasio-Cortez. Thank you.
    In addition to the opioid crisis, I think one of the issues 
that we have had here is that we do not see these crises hit 
until they are crises, especially on the legislative side as 
well. But we have to be able to identify emerging threats, and 
what I have been seeing here is one of the lessons that we 
learned from the opioid crisis and the rapid rise of fentanyl 
and synthetic opioids is that we need to be prepared to react 
quickly when new crises and new drugs emerge as threats.
    Dr. Carroll, can you update us on the process of 
identifying emerging threats when it comes to drugs and public 
health? And when can we expect the Emerging Threats Committee 
to be up and running?
    Director Carroll. Thank you. If I may just spend 30 seconds 
responding to Congresswoman Maloney, Congresswoman Maloney 
referenced about reimbursement rates and tying it to pain. It 
is an interesting idea. Maybe we should take a reverse approach 
and for people----
    Ms. Ocasio-Cortez. I would like to reclaim my time, Dr. 
Carroll. I am so sorry. Her time has expired.
    Director Carroll. I promise----
    Ms. Hill. I will give you an extra 30 seconds.
    Ms. Ocasio-Cortez. Great. Thank you.
    Director Carroll. Maybe that is a great idea to say when 
you cut down your prescriptions for--well, protecting chronic 
pain people, the reimbursement rates will go higher the fewer 
opioid prescriptions you write.
    One of the things we are also doing is working with 
medical----
    Ms. Hill. I want to be sensitive to time. Can you please 
answer the gentlewoman from New York?
    Director Carroll. Thank you. I apologize, Congresswoman, 
and I appreciate the committee, when you reauthorized us to 
make that a centerpiece. So, we have sent invitations out to 14 
members across the country from every disciple, every 
discipline, and we will be hosting our first meeting with our 
new Emerging Threats Coordinator on time.
    Ms. Ocasio-Cortez. All right. Great. Thank you very much.
    Director Carroll. I apologize for 30 seconds.
    Ms. Ocasio-Cortez. No worries, no worries.
    In fact, at our hearing in March, the Houston HIDTA 
Director McDaniels testified that, quote, ``Our major threats 
in Houston are methamphetamine, cocaine, and synthetic drugs.'' 
Our country, unfortunately, has a history of racial inequity 
when it comes to how we pursue either enforcement or treatment, 
depending on the type of drug.
    I was wondering if you agree that one of our goals should 
be to increase treatment for all drug addiction, including 
addiction to methamphetamines, cocaine, and other drugs in 
addition to opioids.
    Director Carroll. Absolutely. I think we need to--people 
say ``opioid crisis'' because that is what is killing so many 
people, but at its core, you are right, this is an addiction 
crisis, and we have to treat people as we find them.
    Ms. Ocasio-Cortez. Thank you very much.
    I will yield the rest of my time to the Chair.
    Ms. Hill. Thank you.
    With that, I will recognize myself for five minutes.
    This question is to--well, first, I want to say thank you 
so much to everyone for testifying, especially to those who 
joined us earlier today.
    But, Director Carroll, I am particularly glad to hear that 
you are testifying about the importance of evidence-based 
treatment. We actually see extensively in the GAO testimony 
that highlights that medication-assisted treatment is 
demonstrated that it reduces opioid use and increases treatment 
retention compared to abstinence-based treatment.
    One of the challenges identified in increasing access to 
MAT is really about access to coverage, right? And the 
availability and limits of insurance coverage for MAT. You 
state that patients with no insurance coverage for MAT could 
face prohibitive out-of-pocket costs that could limit their 
access, and if coverage for MAT varied for those individuals 
with insurance and coverage varied. Insurance plans, including 
state Medicaid plans, did not always cover the medications, and 
they sometimes imposed limits on the length of treatment.
    That said--I have a lot of papers here, by the way. Sorry. 
That said, we have the study that I earlier introduced from the 
American Journal of Public Health that stated that the ACA 
provides greater access to substance use disorder treatment 
through major coverage expansions, regulatory changes, 
requiring the coverage of substance use disorder treatment, and 
existing insurance plans and requirements for treatment to be 
offered on par with medical and surgery, as well as 
opportunities to integrate substance use and to mainstream 
health care. A Kaiser study, as mentioned previously, shows 
that 4 in 10 adults with opioid addiction are covered by 
Medicaid, and 21 million Americans have gained coverage through 
the ACA, including 12 million through Medicaid.
    So, Ms. McNeil, do you believe that if the ACA is 
overturned, this issue of coverage would be better or worse?
    Ms. McNeil. I will invite my colleague, Mary Denigan-
Macauley, to answer that.
    Ms. Denigan-Macauley. I apologize. Can you repeat the 
question, please?
    Ms. Hill. The question was, given all of the information I 
just shared and your belief that access to coverage and 
provisions around coverage that makes it more difficult for 
people to get MAT, is this something that you believe would be 
made worse or better if the ACA was overturned?
    Ms. Denigan-Macauley. Well, GAO would certainly encourage 
any increased access to treatment, and Medicaid is one program 
that does improve access to treatment. So, our concern would be 
ensuring that that remains.
    Ms. Hill. Do you have any estimates of how much was 
provided by Medicaid or how much was spent by Medicaid on such 
treatment?
    Ms. Denigan-Macauley. We do not, but we do know that in 
those states that had Medicaid expansion, that there were more 
people who had the access, but we do not have a number.
    Ms. Hill. Thank you.
    And, Director Carroll, one of your goals listed in your 
Performance Reporting Supplement is increasing the percentage 
of specialty treatment facilities providing MAT for opioid use 
by 100 percent within five years. I recently visited one such 
facility in my district. It seems to be a great program, but 
they spoke extensively about the challenges around coverage, 
and the majority of their patients are covered by Medicaid, and 
others are covered by health insurance that in many cases they 
did not have prior to the ACA.
    So, my question is, if the issue of coverage is 
exponentially exacerbated by a successful overturn of the ACA, 
how do you think you would be able to accomplish this 
objective?
    Director Carroll. Thank you. I am bipartisan on this issue. 
We have to save lives regardless, and providing treatment to 
everyone is critical to do this.
    Ms. Hill. And to be clear, I am not making this about 
partisanship. I am concerned about what the courts are going to 
do, so I honestly want to know what is going to happen if the 
ACA is overturned.
    Director Carroll. In terms of first to talk about the 
Medicaid and the reimbursement, as well as health insurance, we 
have to make sure that it is sustainable going forward. So, to 
be able to give states the authority to help more at that level 
than at the Federal level to determine how they are going to 
provide treatment for people I think is critical.
    One of the things we are also seeing is making sure for 
those people that do have insurance under the ACA--what we are 
seeing are co-pays that are so high that it is really not 
effective. There was a report this week that was talking about 
co-pays for individuals under some of the ACA plans. I think it 
is $6,000 or $8,000 per year, and $12,000 for families. At that 
point, you really have to wonder whether it is working or not.
    Ms. Hill. Right. Well, in large part that is because of the 
increasing pressure we have seen from other attempts to 
undermine the ACA that the costs have gone up and co-pays have 
gone up exponentially.
    But for me, I am wondering, and I do not know if this is 
possible to request, but I would love to see some contingency 
plans or other efforts from GAO and from your office on how 
such an overturn of the ACA would affect treatment.
    Director Carroll. I will see what we can get you as soon as 
possible.
    Ms. Hill. Thank you.
    With that, I would like to thank our witnesses so much for 
testifying today, and to you both who are still here, I was 
incredibly moved by your testimony, and I am so sorry for your 
loss, and thank you, really, for bringing this to life in the 
halls of Congress.
    Without objection, all members will have five legislative 
days within which to submit additional written questions for 
the witnesses to the Chair, which will be forwarded to the 
witnesses for their response. I ask our witnesses to please 
respond as promptly as you are able to.
    And this hearing is adjourned.
    [Whereupon, at 1:32 p.m., the committee was adjourned.]

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