[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]






 
                  MEETING THE MOMENT: IMPROVING ACCESS
                  TO BEHAVIORAL AND MENTAL HEALTH CARE

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

                                HEARING

                               before the

                            SUBCOMMITTEE ON
                          HEALTH, EMPLOYMENT,
                          LABOR, AND PENSIONS

                                 of the

                    COMMITTEE ON EDUCATION AND LABOR
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

             HEARING HELD IN WASHINGTON, DC, APRIL 15, 2021

                               __________

                            Serial No. 117-6

                               __________

      Printed for the use of the Committee on Education and Labor
      

                                     
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 

                                     

          Available via: edlabor.house.gov or www.govinfo.gov

                               __________
                               
   
               U.S. GOVERNMENT PUBLISHING OFFICE 
 44-330 PDF             WASHINGTON : 2022 
                             
                               
                               
                               
                               

                    COMMITTEE ON EDUCATION AND LABOR

             ROBERT C. ``BOBBY'' SCOTT, Virginia, Chairman

RAUL M. GRIJALVA, Arizona            VIRGINIA FOXX, North Carolina,
JOE COURTNEY, Connecticut              Ranking Member
GREGORIO KILILI CAMACHO SABLAN,      JOE WILSON, South Carolina
  Northern Mariana Islands           GLENN THOMPSON, Pennsylvania
FREDERICA S. WILSON, Florida         TIM WALBERG, Michigan
SUZANNE BONAMICI, Oregon             GLENN GROTHMAN, Wisconsin
MARK TAKANO, California              ELISE M. STEFANIK, New York
ALMA S. ADAMS, North Carolina        RICK W. ALLEN, Georgia
MARK De SAULNIER, California         JIM BANKS, Indiana
DONALD NORCROSS, New Jersey          JAMES COMER, Kentucky
PRAMILA JAYAPAL, Washington          RUSS FULCHER, Idaho
JOSEPH D. MORELLE, New York          FRED KELLER, Pennsylvania
SUSAN WILD, Pennsylvania             GREGORY F. MURPHY, North Carolina
LUCY Mc BATH, Georgia                MARIANNETTE MILLER-MEEKS, Iowa
JAHANA HAYES, Connecticut            BURGESS OWENS, Utah
ANDY LEVIN, Michigan                 BOB GOOD, Virginia
ILHAN OMAR, Minnesota                LISA C. Mc CLAIN, Michigan
HALEY M. STEVENS, Michigan           DIANA HARSHBARGER, Tennessee
TERESA LEGER FERNANDEZ, New Mexico   MARY E. MILLER, Illinois
MONDAIRE JONES, New York             VICTORIA SPARTZ, Indiana
KATHY E. MANNING, North Carolina     SCOTT FITZGERALD, Wisconsin
FRANK J. MRVAN, Indiana              MADISON CAWTHORN, North Carolina
JAMAAL BOWMAN, New York, Vice-Chair  MICHELLE STEEL, California
MARK POCAN, Wisconsin                Vacancy
JOAQUIN CASTRO, Texas                Vacancy
MIKIE SHERRILL, New Jersey
JOHN A. YARMUTH, Kentucky
ADRIANO ESPAILLAT, New York
KWEISI MFUME, Maryland

                   Veronique Pluviose, Staff Director
                  Cyrus Artz, Minority Staff Director
                                 ------                                

        SUBCOMMITTEE ON HEALTH, EMPLOYMENT, LABOR, AND PENSIONS

                 MARK De SAULNIER, California, Chairman

JOE COURTNEY, Connecticut            RICK W. ALLEN, Georgia
DONALD NORCROSS, New Jersey            Ranking Member
JOSEPH D. MORELLE, New York          JOE WILSON, South Carolina
SUSAN WILD, Pennsylvania             TIM WALBERG, Michigan
LUCY Mc BATH, Georgia                JIM BANKS, Indiana
ANDY LEVIN, Michigan                 DIANA HARSHBARGER, Tennessee
HALEY M. STEVENS, Michigan           MARY E. MILLER, Illinois
FRANK J. MRVAN, Indiana              SCOTT FITZGERALD, Wisconsin
ROBERT C. ``BOBBY'' SCOTT, Virginia  VIRGINIA FOXX, North Carolina
  (ex officio)                         (ex officio)
  
                            C O N T E N T S
                            

                              ----------                              
                                                                   Page

Hearing held on April 15, 2021...................................     1

Statement of Members:
    DeSaulnier, Hon. Mark, Chairman, Subcommittee on Health, 
      Employment, Labor, and Pensions............................     1
        Prepared statement of....................................     5
    Allen, Hon. Rick, Ranking Member, Subcommittee on Health, 
      Employment, Labor, and Pensions............................     6
        Prepared statement of....................................     7

Statement of Witnesses:
    Bendat, Meiram, JD, Ph.D., Founder, Psych-Appeal.............    51
        Prepared statement of....................................    53
    Gelfand, James, Senior Vice President, Health Policy, The 
      ERISA 
      Industry Committee.........................................    32
        Prepared statement of....................................    35
    Moutier, Dr. Christine Yu, Chief Medical Officer, American 
      Foundation for Suicide Prevention..........................    24
        Prepared statement of....................................    27
    Smedley, Dr. Brian D., Chief of Psychology in the Public 
      Interest of the American Psychological Association.........     9
        Prepared statement of....................................    11

Additional Submissions:
    Chairman DeSaulnier:
        Prepared statement from the Western Governors' 
          Association............................................    87
    Mr. Allen:
        Prepared statement from the HR Policy Association and the 

          American Health Policy Institute.......................    93
        Prepared statement from the American Benefits Council....    97
    Courtney, Hon. Joe, a Representative in Congress from the 
      State of Connecticut:
        Prepared statement from the American Psychiatric 
          Association............................................   106
    Walberg, Hon. Tim, a Representative in Congress from the 
      State of Michigan:
        Prepared statement from the Partnership for Employer-
          Sponsored Coverage.....................................   113
    Questions submitted for the record by:
        Chairman DeSaulnier......................................   124
        Scott, Hon. Robert C. ``Bobby'', a Representative in 
          Congress from the State of Virginia....................   116
        Mr. Allen................................................   122
    Responses to questions submitted for the record by:
        Ms. Bendat...............................................   117
        Mr. Gelfand..............................................   123
        Dr. Moutier..............................................   125


                  MEETING THE MOMENT: IMPROVING ACCESS

                  TO BEHAVIORAL AND MENTAL HEALTH CARE

                              ----------                              


                        Thursday, April 15, 2021

                  House of Representatives,
                Subcommittee on Health, Employment,
                               Labor, and Pensions,
                          Committee on Education and Labor,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:15 a.m., via 
Zoom, Hon. Mark DeSaulnier (Chairman of the subcommittee) 
presiding.
    Present: Representatives DeSaulnier, Courtney, Norcross, 
Morelle, Wild, McBath, Stevens, Levin, Scott (Ex Officio), 
Allen, Walberg, Harshberger, Miller, Fitzgerald, and Foxx (Ex 
Officio.)
    Staff present: Phoebe Ball, Disability Counsel; Ilana 
Brunner, General Counsel; Ijeoma Egekeze, Professional Staff; 
Daniel Foster, Health and Labor Counsel; Christian Haines, 
General Counsel; Sheila Havenner, Director of Information 
Technology; Carrie Hughes, Director of Health and Human 
Services; Ariel Jona, Policy Associate; Andre Lindsay, Policy 
Associate; Max Moore, Staff Assistant; Mariah Mowbray, Clerk/
Special Assistant to the Staff Director; Kayla Pennebecker, 
Staff Assistant; Veronique Pluviose, Staff Director; Banyon 
Vassar, Deputy Director of Information Technology; Joshua 
Weisz, Communications Director; Cyrus Artz, Minority Staff 
Director; Courtney Butcher, Minority Director of Member 
Services and Coalitions; Rob Green, Minority Director of 
Workforce Policy; Georgie Littlefair, Minority Legislative 
Assistant; John Martin, Minority Workforce Policy Counsel; 
Hannah Matesic, Minority Director of Operations; Audra 
McGeorge, Minority Communications Director; Carlton Norwood, 
Minority Press Secretary; Ben Ridder, Minority Professional 
Staff Member; and Taylor Hittle, Minority Professional Staff 
Member.
    Chairman DeSaulnier. The Subcommittee on Health, 
Employment, Labor and Pensions will come to order. Welcome 
everyone. I note that a quorum is present. The Subcommittee is 
meeting today to hear testimony on Meeting the Moment: 
Improving Access to Behavioral and Mental Health Care.
    This is an entirely remote hearing. All microphones will be 
kept muted as a general rule to avoid unnecessary background 
noise. Members and witnesses will be responsible for unmuting 
themselves when they are recognized to speak, or when they wish 
to seek recognition. I also ask that Members please identify 
themselves before they speak.
    Members should keep their cameras on while in the 
proceeding. Members shall be considered present in the 
proceeding when they are visible on camera, and they will be 
considered not present when they are not visible on camera. The 
only exception to this is if they are experiencing technical 
difficulty and inform Committee staff of such difficulty.
    If any Member experiences technical difficulties during the 
hearing, you should stay connected on this platform, make sure 
you are muted, and use your phone to immediately call the 
committee's IT Director, whose number was provided in advance.
    Should the Chair experience technical difficulty, or need 
to step away to vote on the floor, Mr. Levin, as a Member of 
this subcommittee, or another majority Member if I am not 
available, or if he is not available, is hereby authorized to 
assume the gavel in the Chair's absence.
    Again, this is an entirely remote hearing and as such, the 
committee's hearing room is officially closed. Members who 
choose to sit with their individual devices in the hearing room 
must wear headphones to avoid feedback, echoes and distortion 
resulting from more than one person on the software platform 
sitting in the same room.
    Members are also expected to adhere to social distancing 
and safe health care guidelines, including the use of masks, 
hand sanitizer, and wiping down their areas both before and 
after their presence in the hearing room.
    In order to ensure that the committee's five-minute rule is 
adhered to, staff will be keeping track of time using the 
committee's field timer. The field timer will appear in its own 
thumbnail picture and will be named 001_timer. There will be no 
one-minute remaining warning. The field timer will sound its 
audio alarm when time is up. Members and witnesses are asked to 
wrap up promptly when their time has expired.
    While a roll call is not necessary to establish a quorum in 
official proceedings conducted remotely, or with remote 
participation, the Committee has made it a practice whenever 
there is an official proceeding with remote participation for 
the Clerk to call the roll, and to help make clear who is 
present at the start of the proceeding.
    Members should say their name before announcing they are 
present. This helps the Clerk, and also helps those watching 
the platform and the livestream who may experience a few 
second's delay.
    At this time I'd like to ask the Clerk to call the role.
    The Clerk. Chairman DeSaulnier?
    Chairman DeSaulnier. Here.
    The Clerk. Mr. Courtney?
    Mr. Courtney. Courtney present.
    The Clerk. Mr. Norcross?
    Mr. Norcross. Here.
    The Clerk. Mr. Morelle?
    Mr. Morelle. Morelle present.
    The Clerk. Ms. Wild?
    Ms. Wild. Present.
    The Clerk. Mrs. McBath?
    Mrs. McBath. McBath present.
    The Clerk. Ms. Stevens?
    Ms. Stevens. Stevens is present.
    The Clerk. Mr. Levin?
    [No response]
    The Clerk. Mr. Mrvan?
    [No response]
    The Clerk. Mr. Scott?
    Mr. Scott. Chairman Scott is present.
    The Clerk. Ranking Member Allen?
    Mr. Allen. I was on mute, OK. All right. I'm present. I 
think I'm unmuted.
    The Clerk. Mr. Wilson?
    [No response]
    The Clerk. Mr. Walberg?
    Mr. Walberg. Walberg present.
    The Clerk. Mr. Banks?
    [No response.]
    The Clerk. Mrs. Harshbarger?
    Mrs. Harshbarger. Harshbarger is present.
    The Clerk. Mrs. Miller?
    [No response.]
    The Clerk. Mr. Fitzgerald, excuse me? Mr. Fitzgerald I 
think I see you.
    Voice. Yes we're still working on the audio.
    The Clerk. Understood. Mrs. Foxx?
    [No response.]
    The Clerk. Chairman DeSaulnier that concludes the roll 
call.
    Chairman DeSaulnier. Thank you. Pursuant to Committee Rule 
8(c), opening statements are limited to the Chair and the 
Ranking Member. This allows us to hear from our witnesses 
sooner, and provides all Members with adequate time to ask 
questions.
    I recognize myself now for the purpose of making an opening 
statement.
    I want to thank you all. I want to thank Chairman Scott and 
Ranking Member Allen. I'm very excited and enthusiastic about 
this subcommittee and the work we're going to pursue, and 
particularly the subject matter that we will discuss today. And 
I want to thank all the panelists and the staff for the 
terrific job they've done putting this meeting together.
    I want to thank Ranking Member Allen for the time we had 
the last few days to catch up, and to talk about how we can 
collaborate. And again I want to thank Chairman Scott. So with 
that, one thing about this issue is in our conversations with 
other Members and with our staff, this is an issue that is of 
importance personally and professionally to many of us.
    And it's my hope that we work aggressively on the 
subcommittee and with the Chairman and the Ranking Member of 
the full committee to make sure that we're doing everything we 
can to be knowledgeable and to help get valuable behavioral 
health and mental health services to Americans.
    Today in this meeting we are here to discuss the importance 
of improving access to behavioral health and mental health 
services. This morning's hearing comes amid a pandemic-driven 
surge in the demand for mental health services. Across this 
country essential workers are grappling with the trauma of 
working through the pandemic.
    Millions of workers are struggling with the loss of their 
livelihoods, and countless people have been unable to 
appropriately grieve the deaths of their loved ones. Overall, 
the number of individuals reporting symptoms of depression or 
anxiety has increased from 11 percent before the pandemic to 41 
percent now. I'm going to repeat that: 11 percent before the 
pandemic, 41 percent now.
    As with nearly all consequences of this pandemic, the 
mental health and behavioral health challenges, some 
communities have it harder than others. This is particularly 
true for people of color who entered the pandemic with 
disproportionately limited access to affordable health care and 
stable employment.
    Regrettably, individuals seeking affordable mental health 
services are facing significant barriers for far too long that 
have kept quality mental health care out of reach for far too 
many people, and unfortunately make their individual situations 
more challenging and much more difficult to overcome.
    And, with the addition of the pandemic, have made them more 
isolated. In fact, even before the pandemic, less than half of 
individuals with mental illness, and only 11 percent of 
individuals with a substance abuse disorder received services 
and treatment. And those services and treatment the quality was 
varied to say the least.
    This is due in part to the high cost of care and nationwide 
shortage of mental health providers. However, the most glaring 
barrier to these critical services is a health insurance system 
that still does not provide true and equal coverage for both 
mental health services and medical health services, known as 
mental health parity.
    This barrier is particularly frustrating given the 
significant steps Congress has taken to get insurers to cover 
both behavioral and medical health services. In 2008, for 
example, Congress passed the Mental Health Parity and Addiction 
Equity Act, which prohibited employer-sponsored health plans 
from placing restrictions on benefits for mental health and 
substance abuse disorder than are greater than those applied to 
medical and surgical benefits.
    And in 2010 of course, Congress passed the landmark 
Affordable Care Act to extend this protection to the individual 
insurance market. Despite these efforts, our Federal agencies 
still do not have the resources they need to protect and 
oversee millions of people's health benefits.
    The Employee Benefits Security Administration investigates 
workplace benefits issues on behalf of more than 150 million 
Americans, yet its enforcement and consumer assistance budget 
has been frozen at less than $150 million dollars for several 
years now, meaning that the agency has only about one dollar to 
protect the health benefits of each person.
    Even when they do find wrongdoing, the agency lacks the 
authority to penalize insurers who restrict coverage for mental 
health services. In other words, our communities, particularly 
underserved communities, have been left to deal with the 
lasting and potentially fatal mental health consequences on 
this pandemic on their own.
    This in spite of exponential research and knowledge about 
behavioral health and substance abuse, and evidence-based 
research that would help Americans if we provide these 
services. I'm going to have to pause for a second because I 
told by staff that we've got some livestream issues.
    Mr. Vassar. Mr. Chairman, I believe we're good to go sir. 
Thank you everyone for your patience.
    Mr. DeSaulnier. Thank you. Sorry for that interruption. Oh, 
I left off about the difficulty in getting these services. This 
is unacceptable. One of our basic responsibilities as elected 
officials is to care for the well-being of our constituents, 
and that means providing--means ensuring people have sufficient 
access to affordable behavioral and mental health care.
    The first step is enforcing the laws we have already 
passed. We should all be able to agree that this is a step 
worth taking to ensure that all Americans have access to the 
care that they need, and we all benefit from. And we must take 
additional steps to build upon these laws to ensure that they 
more fully protect consumers and are as efficient in delivering 
services as is possible.
    I also know that many employers, unions, health plans and 
providers are rising to the challenge to meet the unique needs 
of workers and families during this time, and we look forward 
to the benefit of what they are doing after the pandemic.
    I also look forward to hearing from our expert witnesses 
about solutions to securing access to equitable mental and 
behavioral health care for all of our constituents, all 
Americans.
    I now would like to recognize the distinguished Ranking 
Member for the purpose of making an opening statement. 
Congressman Allen.
    [The statement of Chairman DeSaulnier follows:]

             Statement of Hon. Mark DeSaulnier, Chairman, 
        Subcommittee on Health, Employment, Labor, and Pensions

    Today, we are meeting to discuss the importance of improving access 
to behavioral and mental health care.
    This morning's hearing comes amid a pandemic-driven surge in the 
demand for mental health services. Across the country, essential 
workers are grappling with the trauma of working through the pandemic; 
millions of workers are struggling with the loss of their livelihoods; 
and countless people have been unable to appropriately grieve the 
deaths of their loved ones. Overall, the number of individuals 
reporting symptoms of depression or anxiety has increased from 11 
percent before the pandemic to 41 percent this year.
    As with nearly all consequences of the coronavirus pandemic, the 
mental and behavioral health challenges have hit some communities 
harder than others. This is particularly true for people of color who 
entered the pandemic with disproportionately limited access to 
affordable health care and stable employment.
    Regrettably, individuals seeking affordable mental health services 
are facing significant barriers that--for far too long--have kept 
quality mental health care out of reach for far too many people.
    In fact, even before the pandemic, less than half of individuals 
with mental illness--and only 11 percent of individuals with a 
substance use disorder--received services and treatment.
    This is due, in part, to the high cost of care and the nationwide 
shortage of mental health providers.
    However, the most glaring barrier to these critical services is a 
health insurance system that still does not provide true, equal 
coverage for both mental health services and medical health services--
known as mental health parity.
    This barrier is particularly frustrating given the significant 
steps Congress has taken to get insurers to cover both behavioral and 
medical health services.
    In 2008, for example, Congress passed the Mental Health Parity and 
Addiction Equity Act, which prohibited large employer-sponsored health 
plans from placing restrictions on benefits for mental health and 
substance use disorder that are greater than those applied to medical 
and surgical benefits. And, in 2010, Congress passed the landmark 
Affordable Care Act to extend this protection to the individual 
insurance market.
    Despite these efforts, our Federal agencies still do not have the 
resources they need to protect and oversee millions of people's health 
benefits.
    The Employee Benefits Security Administration investigates 
workplace benefits issues on behalf of more than 150 million people. 
Yet, its enforcement and consumer assistance budget has been frozen at 
less than $150 million for several years, meaning that the agency has 
about one dollar to protect the health benefits of each person.
    Even when they do find wrongdoing, the agency lacks the authority 
to penalize insurers who restrict coverage for mental health services.
    In other words, our communities--particularly underserved 
communities--have been left to deal with the lasting and potentially 
fatal mental health consequences of this pandemic on their own.
    This is unacceptable. One of our most basic responsibilities as 
elected officials is to care for the well-being of our constituents--
and that means ensuring people have sufficient access to affordable 
behavioral and mental health care.
    The first step is enforcing the laws we have already passed. We 
should all be able to agree that this is a step worth taking to ensure 
that all Americans have access to the care they need and we all benefit 
from. And we must take additional steps to build upon these laws to 
ensure that they more fully protect consumers and are as efficient at 
delivering services as possible. I also know that many employers, 
unions, health plans, and providers are rising to the challenge to meet 
the unique needs of workers and families during this time and we look 
forward to the benefit of what they are doing after the pandemic.
    I look forward to hearing from our expert witnesses about solutions 
to securing access to equitable mental and behavioral health care for 
all of our constituents and all Americans.
    I now recognize the distinguished Ranking Member for the purpose of 
making an opening Statement.
                                 ______
                                 
    Mr. Allen. Thank you Chairman. We're having a little 
anxiety and behavioral problems with technology today. It makes 
us all a little anxious doesn't it. But I want to thank 
everybody for joining us here today for this important 
discussion about the quality and accessibility of mental health 
and behavioral health services for American workers.
    The well-being of America's workers have always been a 
priority for committee republicans, that's why Congress is 
engaged in ongoing efforts to address worker's mental and 
behavioral health needs, including efforts to improve access to 
high-quality and innovative treatment and services.
    Sadly, due to the COVID-19 pandemic and related lockdowns, 
this past year has been very trying for families across the 
country. Almost overnight schools and workplaces closed 
upending American's lives, and creating barriers to key mental 
health services.
    While upsetting, but perhaps not surprising, these events 
triggered an increase in symptoms of anxiety and depression in 
the United States. In 2020 four in 10 adults reported symptoms 
of anxiety or depression up from one in 10 in 2019. More 
Americans are struggling with substance abuse disorder leading 
to rising overhead death rates.
    In response to growing mental health needs Congress in a 
bipartisan manner, increased funding to the Substance Abuse and 
Mental Health Services Administration through the Care's Act in 
2021 appropriations, which include additional money for 
emergency grants for behavioral health services to states and 
other grantees.
    The COVID-19 pandemic also accelerated the use of 
telehealth services, and in response to the increased need, 
Congress provided additional temporary flexibility for 
employers to provide telehealth benefits to more workers.
    Congress should strongly consider permanent expansions of 
telehealth coverage that may improve access to quality care, 
including behavioral health care. As a committee of 
jurisdiction over employer sponsored healthcare, republicans 
understand that employers want what is best for their 
employees, which means having the flexibility to provide 
quality healthcare and addressing workers' mental and 
behavioral health needs.
    Ensuring workers have access to high-quality treatment 
services is key to maintaining a healthy and successful 
workplace. And I add that that is what employers want. Thank 
you very much and that concludes--I yield my time.
    [The statement of Ranking Member Allen follows:]

           Statement of Hon. Rick W. Allen, Ranking Member, 
        Subcommittee on Health, Employment, Labor, and Pensions

    Thank you all for joining us here today for an important discussion 
about the quality and accessibility of mental and behavioral health 
services for American workers.
    The well-being of America's workers has always been a priority for 
Committee Republicans. That's why Congress is engaged in on-going 
efforts to address workers' mental and behavioral health needs, 
including efforts to improve access to high-quality and innovative 
treatments and services.
    Sadly, due to the COVID-19 pandemic and related lockdowns, this 
past year has been a very trying one for families across the country. 
Almost overnight, schools and workplaces closed, upending Americans? 
lives and creating barriers to key mental health services.
    While upsetting, but perhaps not surprising, these events triggered 
an increase in symptoms of anxiety and depression in the United States. 
In 2020, four in 10 adults reported symptoms of anxiety or depression, 
up from one in 10 in 2019. More Americans are struggling with substance 
use disorder leading to rising overdose death rates.
    In response to growing mental health needs, Congress, in a 
bipartisan manner, increased funding to the Substance Abuse and Mental 
Health Services Administration through the CARES Act and 2021 
appropriations, which included additional money for emergency grants 
for behavioral health services to States and other grantees.
    The COVID-19 pandemic also accelerated the use of telehealth 
services, and in response to the increased need, Congress provided 
additional temporary flexibilities for employers to provide telehealth 
benefits to more workers. Congress should strongly consider if 
permanent expansions of telehealth coverage may improve access to 
quality care, including behavioral health care.
    As the Committee of jurisdiction over employer-sponsored health 
care, Republicans understand that employers want what is best for their 
employees, which means having the flexibility to provide quality health 
care and addressing workers? mental and behavioral health needs. 
Ensuring workers have access to high-quality treatment services is key 
to maintaining a healthy and successful work force.
    According to a 2020 Congressional Budget Office estimate, 151 
million Americans receive health insurance through employer-provided 
plans which is the largest single source of coverage. Yet, Democrats 
are seeking to eliminate employer-sponsored health care through their 
socialist Medicare-for-All scheme, which would force millions of 
Americans into a one-size-fits-all, government-run system and cost more 
than $30 trillion dollars over the next decade.
    A 2018 survey by American's Health Insurance Plans reveals that 71 
percent of Americans are satisfied with their current employer-provided 
health coverage. By all metrics, satisfaction with employer health 
coverage outpaces public support for the Democrat's Medicare-for-All 
scheme.
    Employers around the country continue to make concerted efforts to 
meet the mental and behavioral health needs of workers through 
implementation of coordinated care programs, employee wellness 
programs, use of telehealth services, and additional employee 
assistance programs, though Democrats will ignore this fact and 
unjustifiably assume that employers are short-changing their employees.
    House Republicans want to empower America's job creators to expand 
access to quality care and mental health services for workers and their 
families. While the system can be improved, we also recognize employers 
are attuned to the needs of their employees, as I know firsthand. For 
37 years, I ran a construction business where we provided staff 
benefits. I knew my employees? needs and what benefits and services 
were best suited to meet them. That is why I believe employers play a 
critical role in enhancing the system moving forward, which will 
benefit workers by ensuring that effective mental and behavioral health 
services are offered.
                                 ______
                                 
    Chairman DeSaulnier. Thank you, Mr. Allen. Without 
objection all other Members who wish to insert written 
statements into the record may do so by submitting them to the 
Committee Clerk electronically in Microsoft Word format by 5 
p.m. on April 28, 2021.
    And now I'd like to welcome and again thank our witnesses. 
We are just delighted that you would take the time to share 
your experience and your expertise with the committee. It's a 
really important endeavor that we are about to embark on.
    Dr. Brian Smedley is Chief of Psychology in the Public 
Interest at the American Psychological Association. He is a 
psychologist by training, and an expert in the field of healthy 
equity. Thank you Doctor for being here.
    Dr. Christine Yu Moutier, and if I mispronounce your name 
please forgive me. It's happened to me many times in my life, 
and correct us all--correct me I should say, when you start 
your comments. Dr. Moutier is Chief Medical Officer at the 
American Foundation for Suicide Prevention. She is a 
psychiatrist by training and a leader in the field of suicide 
prevention.
    James Gelfand is Senior Vice president for Health Policy at 
the ERISA Industry Committee. He works on the development of 
policies that support employer-sponsored health plans.
    Dr. Meiram Bendat is the founder of Psych-Appeal. He is a 
licensed psychotherapist as well as an attorney who has 
litigated numerous cases on behalf of consumers and behavioral 
health providers. Welcome to all of you.
    Instructions--we appreciate the witnesses for participating 
again today and look forward to your testimony. Let me remind 
the witnesses that we have read your statements, and they will 
appear in full in the hearing record.
    Pursuant to Committee Rule 8(d) and the committee practice, 
each of you is asked to limit your oral presentation to a five-
minute summary of your written statement. Before you begin your 
testimony, excuse me, please remember to unmute your 
microphone.
    During your testimony, staff will be keeping track of time 
and a timer will sound when time is up. Please be attentive to 
the time, wrap up when your time is over, and re-mute your 
microphone.
    If any of you experience technical difficulties during your 
testimony or later in the hearing, you should stay connected on 
the platform, make sure you are muted, and use your phone to 
immediately call the committee's IT Director whose number was 
provided to you in advance.
    We will let all of the witnesses make their presentations 
before we move to Member questions. When answering a question 
please remember to unmute your microphone.
    The witnesses are aware of their responsibility to provide 
accurate information to the committee and therefore we will 
proceed with their testimony.
    I will first recognize Dr. Smedley. Dr. Smedley please go 
ahead.

          STATEMENT OF DR. BRIAN D. SMEDLEY, CHIEF OF 
           PSYCHOLOGY IN THE PUBLIC INTEREST OF THE 
               AMERICAN PSYCHOLOGICAL ASSOCIATION

    Dr. Smedley. Thank you Chairman DeSaulnier. Chairman 
DeSaulnier, Ranking Member Allen, and Members of the 
subcommittee, thank you for the opportunity to testify today. 
I'm Dr. Brian Smedley and I'm the American Psychological 
Association's Chief of Psychology in the Public Interest.
    APA's public interest directorate, which I lead, fulfills 
APA's commitment to apply the science and practice of 
psychology to the fundamental problems of human welfare and the 
promotion of equitable and just treatment of all segments of 
society through education, training and public policy.
    The COVID-19 pandemic has contributed to what we have 
called a mental health tsunami in this country. APA's Stress in 
America survey series shows that over the past year COVID-19 
consistently exacted a higher emotional toll than other common 
stressors.
    We also know that patient's coping mechanisms for the 
public health and economic impacts of the pandemic are serious, 
and highly individualized, including undesired weight changes, 
increased use of alcohol and other drugs, or even suicidal 
behaviors and ideation.
    Our Member clinicians continue to see an increase inpatient 
demand for treatment of anxiety disorders, depressive 
disorders, and stress or trauma disorders than before COVID-19. 
Research suggests that we may be grappling with the mental 
health impact of this pandemic long after the pandemic itself 
ends.
    However, we also know that not all Americans are equally 
affected. The mental health impact of COVID-19 is especially 
prominent in black, indigenous and other people of color 
communities, which are more likely to report anxiety about 
contracting the virus, in addition to other stresses related to 
the virus like economic instability, social and economic 
inequality, racism, discrimination and stigma are at the root 
of mental and behavioral health inequities experienced by BIPOC 
communities.
    I'd like to mention two other highly impacted groups. 
First, children and younger adults are experiencing higher 
rates of stress, anxiety and fear than older generations. 
School closures and social activity suspensions are a factor, 
but we're particularly concerned about the potential for 
increased rates of abuse, neglect, or other household trauma 
occurring in the home.
    Second, frontline health care providers, including 
psychologists, are also exhibiting more frequent symptoms of 
post-traumatic stress disorder, depression, anxiety, sleep 
disorders and burnout due to the workplace stress occasioned by 
the pandemic.
    APA urges action in two key areas in response. First, the 
2008 Mental Health Parity Law has in some ways fallen short of 
its promise. Congress can do more to ensure adequate oversight 
and enforcement of insurers' compliance with the law, and close 
gaps permitting states to exempt their own employees, including 
essential frontline workers such as police officers and 
firefighters from the law's provisions.
    The second area is telehealth, which has been a rare silver 
lining of the pandemic. Congress and CMS have greatly expanded 
access to telehealth services, including audio only telehealth 
under Medicare. We urge the subcommittee to support measures 
that would ensure that ERISA plans equally cover and reimburse 
for these services.
    We also believe Medicare's telemental health coverage 
flexibilities should extend beyond the pandemic. Specifically, 
we urge Members of the subcommittee to support the bipartisan 
Parity Enforcement Act of 2021, H.R. 1364, introduced by 
Congressman Norcross to strengthen the Department of Labor's 
ability to enforce the parity law by giving it the authority to 
levy civil fines.
    We also urge that we close the loophole in the Federal 
Parity Law that allows states to opt out of parity requirements 
for State employees. We also urge that we support increased 
funding to enable better oversight and stronger enforcement of 
insurers' compliance with the Federal Parity Law.
    And we urge you to support measures such as the bipartisan 
Tele-Mental Health Improvement Act, H.R. 2264, that would 
increase private coverage of telebehavioral services, including 
audio-only services, and establish permanent Medicare coverage 
of essential mental and behavioral health services by audio-
only telehealth.
    I applaud the committee for examining the long-term 
behavioral health effects of the pandemic and urge you to 
support an approach to this crisis that provides equitable 
access to care and preventive interventions to avert worse 
patient outcomes further downstream.
    APA would welcome an opportunity to collaborate with the 
subcommittee on efforts to address inequitable access to care, 
and the ongoing mental health impact of his pandemic. Thank you 
for the opportunity to testify today, and I look forward to 
answering any questions you have.
    [The prepared statement of Dr. Brian Smedley follows:]

                Prepared Statement of Dr. Brian Smedley
                
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    Chairman DeSaulnier. Thank you, Doctor. That was terrific. 
We will now go Dr. Yu Moutier. Doctor? There you go.

       STATEMENT OF DR. CHRISTINE YU MOUTIER, MD, CHIEF 
  MEDICAL OFFICER, AMERICAN FOUNDATION FOR SUICIDE PREVENTION

    Dr. Moutier. Sorry about that. Great. I am Dr. Christine 
Moutier, Chief Medical Officer for the American Foundation for 
Suicide Prevention, the Nation's largest non-profit dedicated 
to saving lives and bringing hope to those affected by suicide. 
My message today about the growing gap between mental health 
needs and accessible care is critically serious, hopeful and 
actionable.
    Thank you Chair DeSaulnier, Ranking Member Allen and 
Members of the subcommittee for your time today. The pandemic 
has clearly been a time of increased attention to mental health 
and very real heightened distress in our Nation.
    However, even pre-pandemic we have seen changes in the 
landscape around mental health. We've seen a 35 percent 
increase in the national suicide rate from 1999 through 2018. 
One in four Americans has a diagnosable mental health condition 
in their lifetime, and yet less than half of those are 
receiving care.
    The degree of suffering experienced by millions of 
Americans and families is enormous with barriers still impeding 
mental health, being approached on par with physical health. We 
say there is no health without mental health because research 
shows the brain and the body are connected.
    People with mental illness have higher risks of suffering 
disability and die 15 to 20 years younger than their 
counterparts, mostly due to medical causes, and for people with 
mental illness of course the risk of dying by suicide is also 
much higher, as much as 30 times higher than the general 
population.
    Health system delivery in the U.S. was oddly designed 
without mental health in mind. The public, including people 
with lived experience of mental health conditions and suicide 
loss, and suicidal experiences, have been making change at the 
grassroots level.
    But until the health system improves and makes mental 
health a real priority, the gap between the demand for quality, 
timely, culturally competent treatment, and the ability to 
access those mental health services will only grow larger 
because attitudes are opening up among the public.
    Research shows that when primary care and health systems 
embrace mental health, and substance use disorders as integral 
targets of health care delivery, many health outcomes improve. 
And there are enormous economic benefits for societies that 
prioritize mental health--a proven return on investment for 
each dollar spent on mental health promotion and prevention.
    So, in many ways, we cannot afford inaction. To put it 
succinctly, with all of our advances in science, systems design 
and technology, we can, and we must reconcile the growing 
mismatch in our Nation's mental health needs with the ability 
to access services and support.
    During the COVID-19 pandemic, data show that upwards of 40 
to 50 percent of the population report elevations in 
experiences of depression, anxiety, trauma, loss and increased 
substance use. Suicidal thoughts are also much more prevalent 
during this time, especially among young people, with one in 
four young adults reporting suicidal ideation.
    As the pandemic has progressed, the proportion of 
respondents to these surveys with detrimental effects on their 
mental health continue to rise, and there are reasons to be 
especially concerned about particular populations.
    Minoritized communities, essential and frontline health 
workers, caregivers, youth, rural residents, and LGBTQ people. 
Despite the evident need for broad and equitable access to 
mental health care, many are having trouble accessing care. 
These challenges have worsened during the pandemic despite 
greater access via telehealth services.
    The subcommittee is asked to consider efforts that would 
support enhanced mental health parity enforcement, to ensure 
that coverage for mental health care is no less restrictive 
than medical or surgical care. Recent analyses found evidence 
of lack of parity and behavioral health services, compared with 
med/surg in terms of higher out of network use, and lower 
reimbursement for behavioral services.
    And these disparities are trending in the wrong direction. 
There must be much more accountability and oversight of parity 
to ensure that mental health conditions are not being 
discriminated against.
    In closing, I urge the subcommittee to consider legislation 
and policies to: one, ensure effective enforcement of mental 
health parity and broaden access to mental health care 
generally; two, support a robust, diverse mental health 
workforce; and three, integrate mental health and suicide 
prevention in health systems, workplaces and schools as 
critical touchpoints that can establish a culture that is 
responsive to mental health needs.
    The steps we take in the aftermath of the pandemic will set 
the trajectory for the Nation's mental health for years to 
come. Parity must be enforced, and disparities must be 
addressed to ensure equitable access and care for those in 
need.
    I thank the subcommittee for appreciating the gravity of 
the situation and look forward to hearing your comments and 
answering your questions. Thank you.
    [The prepared statement of Dr. Christine Yu Moutier 
follows:]

                   Prepared Statement of Dr. Moutier
                   
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    Chairman DeSaulnier. Thank you Doctor that was terrific. We 
will now go to Mr. Gelfand. Please go ahead, Mr. Gelfand.

          STATEMENT OF MR. JAMES GELFAND, SENIOR VICE 
         PRESIDENT, HEALTH POLICY, THE ERISA INDUSTRY 
                           COMMITTEE

    Mr. Gelfand. Thank you Chair DeSaulnier, Ranking Member 
Allen and Members of the subcommittee for this opportunity to 
testify today. I'm James Gelfand, Senior Vice President for 
Health Policy at the ERISA Industry Committee or ERIC, a trade 
association representing large employer plan sponsors.
    ERIC Member companies are the Nation's top employers in 
every sector of the economic, every region in industry, and in 
every congressional district. These employers offer 
comprehensive health benefits. Our Member companies pay around 
85 percent of healthcare costs on behalf of beneficiaries, and 
that would be a gold or a platinum plan if bought on an 
exchange.
    And every one of them includes a substantial mental and 
behavioral health program to protect employees and their 
families. Employers know all too well the challenges that 
patients face. Too often patients lack access to the providers 
they need, not enough low-cost in-network doctors available, 
unacceptable wait times, gaps in information about quality and 
efficacy.
    The system is leaving many patients behind. And this is on 
top of an opiod epidemic, and COVID exacerbated the problem for 
many--the isolation, the disruption of routine, reduced access 
to medical care, and other interventions, all combined to make 
things harder for patients.
    Employers are committed to being part of the solution, and 
we have acted. Employers offer health insurance to help our 
employees, so when we see unmet needs we address them.
    Employers worked hard to stop the opioids crisis from 
limiting prescription drug fills to more carefully scrutinizing 
the facilities and providers in their networks, to offering new 
programs to help employees get counseling and care.
    Employers have innovated many new programs and strategies 
to increase access to mental health from enhancing paid time 
off to beefing up employee assistance programs, mindfulness 
campaigns, sleep management programs, crisis hotlines and much 
more.
    Many employers hire vendors specifically to enhance and 
manage mental and behavioral health benefits. When COVID hit, 
telehealth really shined, securing care for employees isolated 
at home. Telehealth vendors compete not just on cost and 
quality, but on metrics like how quickly they can get a patient 
access to an appropriate provider.
    Employers moved quickly to expand telehealth, offering care 
for free, even to patients in high deductible plans, and 
offering telehealth benefits to part-time workers and others 
who are not eligible for full benefits. And employers who have 
worksite health centers often went virtual, offering more 
mental and behavioral health options to employees, but there's 
much more we can do.
    ERIC Members have convened a mental health task force, and 
will soon be issuing a report, including dozens of policy 
proposals Congress could implement to improve access and 
affordability without compromising quality. Here are three 
options to consider today.
    First, promote cross State medical practice, especially in 
ERISA plans. You can instantly improve mental health access for 
tens of millions of people by allowing some of the excess 
volume on the coast to serve patients in other parts of the 
country. Start by passing the TREAT Act to at least solve this 
during COVID.
    But long-term we need a comprehensive solution to connect 
willing and able providers to patients in need.
    Second, make the private sector gains in telehealth 
permanent. Allow employers to offer telehealth benefits to all 
of our employees. This isn't a replacement for comprehensive 
health insurance, but it can be a lifeline for mental and 
behavioral health. Many employers, especially retailers, and 
others with large part-time, hourly or seasonal workforce have 
done amazing work expanding telehealth during COVID. But unless 
Congress acts soon, these gains will disappear due to 
antiquated rules.
    Third, fix the rules in the high deductible plans. In the 
CARES Act last year Congress temporarily allowed dollar 
coverage of telehealth. We should make it permanent, and add 
coverage of worksite health clinics too. If Congress doesn't 
act starting on January 1, tens of millions of patients will 
have to pay their entire deductible before employers can 
subsidize these benefits.
    And one quick caution--these problems won't be solved via 
penalties and mandates. It might make more money for trial 
lawyers, but patients will be hurt with higher premiums, lower 
value networks and the loss of quality, accessibility and 
safety within their plan.
    Congress has repeatedly told the Department of Labor to do 
a better job explaining and investigating mental health parity 
requirements, including more new rules that were passed in 
December. Let's see how those rules work before piling on.
    In conclusion, employers are acutely aware of the 
challenges patients face in accepting quality, affordable, 
mental and behavioral health treatment.
    We are leading from the front, innovating, and finding ways 
to help our beneficiaries, but policy changes are needed, 
especially to ensure that millions can continue to have access 
to telehealth.
    We hope to work with Congress to advance meaningful 
legislation to help our employees and their families. Thank you 
for this opportunity to testify.
    [The prepared statement of James Gelfand follows:]

                   Prepared Statement of Mr. Gelfand
                   
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    Chairman DeSaulnier. Thank you, Mr. Gelfand. I look forward 
to working with you for just that purpose. And our last 
panelist is Dr. Bendat. Please go ahead, Doctor.

          STATEMENT OF DR. MEIRAM BENDAT, JD, Ph.D., 
                     FOUNDER, PSYCH-APPEAL

    Dr. Bendat. Good morning Chairman DeSaulnier, Ranking 
Member Allen, and Members of the subcommittee. Thank you for 
the opportunity to testify at today's hearing. I'm Meiram 
Bendat, founder of California-based Psych-Appeal, a law firm 
exclusively dedicated to mental health insurance advocacy.
    I am by education, training, and practice, an attorney and 
psychotherapist. Since 2011 I have spearheaded cutting-edge 
litigation against managed care barriers to mental health and 
substance use treatment. Most of my cases have been brought 
under ERISA.
    ERISA establishes uniform, albeit limited, protections for 
approximately 136 million people covered by employer sponsored 
health plans, two-thirds of which participate in self-funded 
plans, entirely exempt from State insurance laws and 
regulation.
    This renders the Department of Labor's role critical. Since 
2014, ERISA has required fully insured small group plans to 
provide essential mental health benefits. Due to historic 
discrimination, the Federal Parity Act amended ERISA to 
prohibit health plans and fiduciaries from imposing disparate 
lifetime or annual limits, financial requirements, and 
treatment limitations on mental health and substance use 
disorder benefits.
    Unsurprisingly, treatment limitations expressed 
quantitively are easier to identify and challenge than 
undisclosed, as applied non-quantitative treatment terms, which 
include medical necessity and network access standards.
    Consequently, ERISA was recently amended to require health 
plans to robustly analyze and disclose their non-quantitative 
treatment limitation comparability analyses. While ERISA 
provides for essential mental health benefits, it does not 
define medical necessity, a core term of coverage.
    And while the Federal Parity Act requires non-quantitative 
treatment limitations, such as medical necessity, to be applied 
comparably to mental health and medical benefits, it does not 
require medical necessity determinations to comport with 
generally accepted standards of clinical practice or GASC.
    Thus, absent ERISA expressly conditioning medical necessity 
and adherence to GASC, health plans are free to create and 
operationalize self-serving, overly restrictive medical 
necessity definitions that undermine access to essential mental 
health benefits.
    Even when ERISA plans include medical necessity 
definitions, adhering to GASC, coverage decisions and mental 
health cases are all too often based on deficient, non-
transparent utilization review criteria, developed or licensed 
by risk-bearing health insurance issuers who also act as well-
compensated claims administrators for self-funded group plans.
    This dynamic was fleshed out in a landmark class action Wit 
v. United Behavioral Health, in which a Federal court found 
that over a 7-year period the Nation's largest managed 
behavioral health company developed and applied pervasively 
flawed utilization review criteria to wrongly deny nearly 
70,000 claims for outpatient, intensive outpatient, and 
residential treatment by ERISA participants.
    While mental health and substance use disorders are largely 
chronic and pervasive, UBH's utilization review criteria 
operationalized an acute care utilization management model that 
myopically focused on short-term crisis stabilization, rather 
than treatment of underlying conditions.
    The lack of a uniform definition of medical necessity is 
not the only impediment to coverage of mental health treatment 
under ERISA plans. Since ERISA does not establish network 
adequacy standards, self-funded ERISA plans generally do not 
provide participants with any notice of timeliness or 
geographic access standards in plan documents.
    Absent notice of such standards or remedies for the 
unavailability of in-network services, ERISA plan participants 
must often wait protracted periods, or travel extensive 
distances to receive mental health treatment to obtain 
inconsistent authorizations for out-of-network care.
    Given the prevalence of narrow and phantom networks, it is 
unsurprising that mental health treatment at disproportionately 
rendered out-of-network or forsaken altogether.
    In light of the low and disparate reimbursement rates set 
by health insurance issuers and claims administrators, it is 
equally unsurprising that mental health providers balk at 
joining their networks.
    ERISA's remedial scheme should be updated to account for 
the modern reality that health plan issuers who serve as claims 
administrators are the actual fiduciaries who adjudicate mental 
health benefits based on self-selected uniform criteria, and 
who sell network access to group health plans.
    While these fiduciaries enjoy annual profits in the 
billions, ERISA's deferential standard of judicial review and 
exclusion of extracontractual damages against them, continue to 
reward and incentivize their brazen self-dealing.
    To truly guarantee meaningful access to mental health care, 
I urge Congress to pass the Parity Enforcement Act of 2021, and 
consider legislation that conditions medical necessity and 
adherence to GASC, eliminate the differential standard of 
judicial review in benefit cases, permits damages against 
health insurance issuers and claims administrators that 
discriminate, and protects access to open courts by exempting 
ERISA claims from binding arbitration. Thank you.
    [The prepared statement of Dr. Meiram Bendat follows:]

                    Prepared Statement of Dr. Bendat
                    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Chairman DeSaulnier. Thank you, Doctor.
    Under Committee Rule 9(a), we will now question witnesses 
under the five-minute rule. I will be recognizing subcommittee 
Members in seniority order. Again, to ensure that Members' 
five-minute rule is adhered to, staff will be keeping track of 
time and the timer will sound when your time has expired.
    Please be attentive to the time, wrap up when your time is 
over, and remute your microphone.
    As chair, I now recognize myself for five minutes.
    Dr. Bendat, I apologize for the mispronunciation, Dr. 
Moutier and my high school French. Forgive me for silencing 
your name. So, I wanted to ask you a question about California, 
my home state's parity law that was recently passed, SB 855. 
The law included a new definition of the term medical 
necessity.
    It requires insurance companies to cover behavioral health 
based on generally accepted standards of care. Could you 
explore--you did explore this concept of medical necessity in 
your testimony when you discussed the United Behavioral Health 
case.
    I was wondering if you might be willing to briefly give us 
an assessment of the California law, and what lessons can we 
learn from it?
    Dr. Bendat. Sure. So, I would hold that the California 
legislation that's now law as of January 1 should serve as 
model legislation around the country, and I would urge Congress 
to consider adopting the definition of medical necessity in SB 
855.
    Essentially, the law defines medical necessity to mean, 
among a few other things, that services that are offered for 
mental health and substance use disorders must be consistent 
with generally accepted standards of care.
    And it requires health insurers who operate in the State of 
California to make decisions about medical necessity utilizing, 
or based on utilization review criteria that are in fact 
consistent with generally accepted standards of care.
    These standards are generally set by non-profit clinical 
specialty associations with familiarity over subject matter and 
peer reviewed research. In California, the law requires 
exclusive application of the non-profit professional society 
guidelines for determining the level of care--meaning 
outpatient, intensive outpatient, residential treatment--that 
patients seek.
    And it limits the ability of insurers to apply self-serving 
criteria that they developed or licensed, that may not at all 
be consistent with generally accepted standards of care that 
may have boilerplate references and footnotes to underlying 
standards but that deviate markedly from them.
    Chairman DeSaulnier. Thanks. Clearly a challenge as the 
science evolves to make this as understandable as possible, and 
benefits the consumer, also benefits the employers and the 
consumers as well in a balanced way.
    One of the big challenges is of course the concept of 
mental health parity and putting it in the reality of the 
consumer level is dealing with the issue of non-quantitative 
treatment limits, or NQTL. These are restrictions that plans 
place on benefits through medical management, have a number 
associated with them, and so it can be tricky to compare 
between behavioral health and medical and surgical cases.
    Dr. Bendat how has the newly enacted law, the Strengthening 
Behavioral Health Parity Act, helped improve oversight of NQTLs 
and can you think of any ways that we should further strengthen 
it?
    Dr. Bendat. So, the law is wonderful in that it really 
shines a light on the most complicated part of parity, which is 
enforcement and compliance with the non-quantitative treatment 
limitation rules. As I mentioned in my testimony, non-
quantitative treatment limitations can be written, but often 
they are just applied.
    In other words, you don't get advance notice of what they 
are. They are not spelled out for you in the plan documents. So 
a plan sponsor, an employer may write a really nice package, or 
benefits into a plan, but then these plans, especially in the 
ERISA context, the self-funded plans are effectively 
administered day-to-day by claims administrators, not the 
employers, not the plan sponsors.
    These claims administrators employ all sorts of internal 
policies and procedures to effectuate their administration of 
plans across entire swaths of group plans and market sectors. 
And the law that has been enacted essentially requires a robust 
analysis of these, as applied, as well as written, non-
quantitative treatment limitations.
    The issue historically has been that although ERISA 
requires disclosure of the non-quantitative treatment 
limitations, employers are generally stumped when asked for 
these, and must obtain them from health insurance issuers.
    Chairman DeSaulnier. Can I ask you to wrap up, Doctor?
    Dr. Bendat. Sure. These aren't often disclosed, so to the 
extent that the law really takes into account disclosure from 
health insurance issuers, and puts it into the hands of 
consumers, all the better.
    Chairman DeSaulnier. Thank you. I appreciate that. I now 
want to recognize the Ranking Member for the purpose of 
questioning the witnesses. Mr. Allen.
    Mr. Allen. Thank you Mr. Chairman. Mr. Gelfand the COVID-19 
pandemic has completely disrupted many American's way of life. 
Business closures have caused Americans to relocate, to find a 
job, and students returning home to live with parents and 
attending classes online.
    In relocating many have unfortunately lost access to mental 
health care during a time they need it most. Patients may face 
provider shortages in their new areas, government lockdowns may 
prevent them from finding a new provider, and they may be 
unable to visit their old provider remotely due to barriers 
created by State licensure laws.
    How do you propose we overcome these barriers to preserve 
and expand access to care?
    Mr. Gelfand. Thank you Representative Allen. While 
employers support long term solutions to increase the supply of 
mental and behavioral health providers throughout the country, 
many employees need help right now. They don't have the luxury 
of waiting for 50 states to sign interState compacts, or for 
providers to be coaxed into moving from the coast.
    So to help them right now employers propose focusing on 
telehealth. There are willing and able providers out there. 
Telehealth is interState commerce, and we should eliminate 
State barriers by allowing providers who are practicing via 
telehealth within one uniform framework to see patients in 
other states.
    There are a half a dozen different ways Congress could do 
this, but one might be to say that a provider participating in 
an ERISA plan, or a service contracted by an ERISA plan, can be 
subject to one uniform framework.
    Mr. Allen. Well Congress recently added additional mental 
health parity requirements as part of the Consolidated 
Appropriations Act of 2021. Mr. Gelfand can you update this 
committee on the implementation status of these new provisions. 
In your view is it premature for Congress to consider 
additional mandates, or to suggest monetary penalties for 
parity violations?
    Mr. Gelfand. Yes. So in the December Omnibus Bill for 
probably the third time, Congress told Department of Labor to 
be clear about parity rules, and non-quantitative treatment 
limitations, ordered more audits, and clarified that employers, 
not vendors, need to have documents ready to explain all of the 
limits in their plans.
    So this triggered a process by which the employers are now 
working with vendors to produce a huge amount of documents 
explaining any limitations on mental behavioral health and 
benefits, analyzing how they compare to the medical side, 
explaining a lot of very in-depth info.
    DOL is going to start selecting plans and asking to review 
this info. So we think it would make sense to see what DOL 
finds, and how employers do on compliance before piling on new 
requirements for punishment. It's our opinion that employers 
are doing a good job of compliance, and that violations are 
concentrated outside of the large group self-insured market.
    It's imperative that we see the results of these new 
requirements before we invent new ones or create penalties.
    Mr. Allen. Well as I said in my opening statement, it's 
obvious we're in the middle of a mental health crisis. This 
COVID-19 pandemic and lockdown have taken a toll on employers, 
workers, and their families. How are your Member companies 
helping their employees cope with the stress created by the 
pandemic and associated lockdowns?
    Can you elaborate on programs or best practices that 
Congress should support?
    Mr. Gelfand. Sure. Employers have been part of the solution 
stepping up to improve access for our employees and their 
families. We've contracted with companies that specialize in 
this area, created many new programs for employees. Employers 
also realized that the pandemic created mental health needs 
that were beyond just insurance coverage.
    For instance, people needed time off, and we actually 
needed management to lead by example and show that it was OK to 
take their time off. We set up virtual challenges to sort of 
gamify and get people engaged on these issues.
    Employers offered online classes and more. But the best 
thing Congress could probably do would be to give employers 
more space to experiment and innovate. So right now the rules 
related to mental health parity, the ACA, Americans With 
Disabilities Act, GINA, COBRA and other laws, they make it 
super complicated to try anything new.
    So what if Congress was to say you know so long as an 
employer has a plan that meets the requirements under these 
rules, they could experiment with a new, more limited benefit 
that could be offered on a supplemental basis, not subject to 
all of those complicated new rules.
    That would get new ideas and new money on the table to 
potentially help employees.
    Mr. Allen. Well thank you so much. I'm about out of time, 
but I do understand the importance of price transparency, and 
if you could address this maybe with another Member. We should 
use every dollar wisely. The employees enrolled in high 
deductible health plans with health savings accounts are 
rightly cost conscious and seek to make healthcare choices that 
work best for their families and their budget.
    The CARES Act allows employees participating in such plans 
to benefit from first dollar coverage for telehealth, but only 
through 2021. And what I'd like you to address is how do you 
explain further how does first dollar coverage of telehealth 
services help these patients?
    And we'll be able to do that with the next question and I 
yield back.
    Chairman DeSaulnier. Thank you, Mr. Allen. We're now going 
to go to Chairman Scott for five minutes, Chairman Scott.
    Mr. Scott. Thank you, Mr. Chairman. And I'd like to point 
out that in introducing Dr. Smedley you left out a substantial 
portion of his distinguished resume, and that is the fact that 
a long time ago he served as an American Psychological 
Association Fellow in a congressional office--mine.
    Mine. He did a great job and it's great to see him now.
    Chairman DeSaulnier. Dr. Smedley. I need an intervention on 
my behalf with the Chairman.
    Mr. Scott. So, Dr. Smedley we've heard a lot about 
stretching out the providers we have. What initiatives do we 
have to increase the number of providers? I understand in terms 
of psychiatrists, if the VA staffed up appropriately with 
psychiatrists, there wouldn't be any left for anybody else.
    And obviously, that is a great problem. What are we doing 
to increase the number of providers?
    Dr. Smedley. Well thank you, Congressman. It's good to see 
you again. You are absolutely right that in terms of the mental 
health and behavioral health workforce, we are sorely behind. 
We need to dramatically increase the number of well-trained, 
culturally competent providers that are available, and we need 
to increase the diversity of these providers to better reflect 
the demographics of the U.S. population.
    At the APA we're very proud of programs such as the 
Minority Fellowship Program, which has done a tremendous job in 
increasing access to behavioral health and mental health 
careers for diverse populations.
    These are talented individuals who are often going into 
underserved communities and providing those services. But we 
certainly need to increase and expand these kinds of programs. 
As has been indicated, we are woefully under prepared to 
address the mental health challenges that are before the 
country now, so we urge expansion of these kinds of important 
programs.
    Mr. Scott. Are there scholarship programs, or something 
that can get people on track through college and professional 
schools to get them on track to be providers?
    Dr. Smedley. Certainly, there are some resources. Yes, the 
Minority Fellowship Program helps to provide some of those 
resources, but it's also true that the National Health Service 
Corps and other programs have been vitally important in 
providing access to training, often with service payback 
agreements whereby those trainees go into underserved 
communities for a number of years, provide high-quality 
services in exchange for government assistance with their 
tuition costs.
    So, again, these programs need to be expanded. They are 
vitally important, and we certainly call for more 
psychologists, behavioral health and mental health 
professionals to be able to access these important programs 
such as the National Health Service Corps.
    Mr. Scott. Thank you. Dr. Bendat it's true that the 
Department of Labor has enforcement over ERISA programs in 
terms of mental health parity. Isn't there a private 
enforcement right by consumers?
    Dr. Bendat. So, there is in fact a private enforcement 
right for consumers. The problem however is that it is a very 
limited right. Consumers are not able to generally recover 
anything more than their benefits, and while $5,000, $10,000 
may seem--and actually be--a lot of money to most Americans, if 
that's the size of your claim you're generally not able to 
pursue it because there are very plaintiff's attorneys around 
the country who are able to bring claims of that sort.
    So, the end result is that you have lots and lots of people 
who are out precisely amounts in this kind of range, and are 
unable to vindicate their claim. So essential that the DOL 
steps in. Also essential that Congress consider bringing in 
again the opportunity for extracontractual damages to be 
obtained from fiduciaries, namely claims administrators, TPA's 
that improperly deny claims and disincentivize people from 
getting the care they need.
    Mr. Scott. And what arbitration clauses do to the right to 
bring a claim even if you could bring it?
    Dr. Bendat. Well, for one they make things secret. So DOL 
doesn't find out about potential allegations and findings. 
Arbitrations don't always follow the law in a way that courts 
do, and arbitrations can also potentially limit the types of 
relief sought, so a real danger.
    Mr. Scott. Thank you, Mr. Chairman.
    Chairman DeSaulnier. Thank you, Mr. Scott. I apologize for 
that omission. Next we go to Mr. Walberg. Mr. Walberg?
    Mr. Walberg. Thank you Mr. Chairman. And before I begin my 
questioning I would like to ask permission for unanimous 
consent to put into the record a letter from the partnership 
for employer sponsored coverage if that would be allowed?
    Chairman DeSaulnier. Without objection.
    Mr. Walberg. Thank you Mr. Chairman. And thanks for the 
hearing today. And thanks to the witnesses for being here. We 
all know, and as we've heard already on this hearing that the 
COVID-19 pandemic has exacerbated barriers to care as people 
have become fearful or discouraged from traveling to seek the 
care they need.
    If there's one bright spot that we've discussed even this 
morning from the pandemic it's been the expansion of telehealth 
services which really has become a lifeline for ensuring access 
to healthcare during the pandemic.
    However, State licensing restrictions can hinder a 
patient's ability to receive care from health professionals 
that are not licensed in the patient's State. Occupational 
licensing reform has been an issue of particular interest of 
mine, and I recently cosponsored the TREAT Act, which would 
provide temporary State licensing reciprocity for licensed 
practitioners during COVID-19 public health emergency.
    And so, Mr. Gelfand, in your written testimony you note 
that encouraging interState provider license reciprocity would 
improve access to mental health services. Can you please 
describe the regulatory barriers providers face when they seek 
to treat patients from across State lines?
    Mr. Gelfand. Absolutely. Thank you Mr. Walberg. So there is 
a financial cost for providers to get licensed or certified in 
different states. That cannot be overlooked. We've estimated 
the cost for a doctor just to practice in the 28 states that 
participate in the InterState Medical Licensure Compact, at 
nearly $12,000.00 payable every 2 years or so.
    However, that is only one of many complicating factors. 
Every State has its own set of rules which could include 
different continuing education requirements, different 
renewables, different financial systems et cetera.
    Some states might require applications to be completed in 
person. Others might have fingerprinting requirements. The list 
just goes on. The problem is particularly extreme for patients 
with rare or complicated diagnoses who need to see a very 
specialize provider like those who practice at academic medical 
centers, but there are many other examples like a patient who 
travels a long distance for highly specialized care, but isn't 
well enough for whom they could travel, or traveling would be a 
major inconvenience.
    We recently heard a story about a spouse who was left with 
no other option than to drive his wife, the patient, across the 
State line into Maryland to receive post-surgery telehealth 
from her car, parked in Maryland, rather than from her home in 
Delaware because of the differing rules.
    So this isn't serving patients, and it's certainly causing 
a lot of barriers for doctors.
    Mr. Walberg. Amazing, amazing, but glad we're finding these 
things out now. How are employers that operate in multiple 
states navigating these barriers? And especially as they relate 
to telehealth?
    Mr. Gelfand. Right. So an employer sponsored ERISA plan 
will offer pretty much identical benefits to all of our 
beneficiaries all over the country no matter where they live, 
where they work, or where they receive medical care, except not 
for telehealth.
    Telehealth is governed at the State level, which means that 
an employee in one State may be able to do all kinds of 
telehealth visits, whereas in another State they may be 
required to do video only. So unless they have broadband 
internet access, they're banned from telehealth.
    In some states the patient can simply pick up their smart 
phone and find a doctor, while in other states you can only do 
telehealth with a provider who is already your doctor. In some 
states they don't allow prescriptions over telehealth. In some 
states they still have super antiquated originating site rules 
as if it was 1992, and to use to the internet we had to go to a 
cybercafe.
    So that's why ERIC is calling for a national set of rules 
for telehealth, so that our plan's beneficiaries can get one 
set of rules and we can end this mismatched set that is 
creating a fundamental unfairness for our employees and their 
families.
    Mr. Walberg. Mr. Gelfand following that track a bit as you 
are well aware, this committee has jurisdiction over the 
Employer Retirement Income Security Act, ERISA, which was 
enacted way back in 1974, long before the internet or concept 
of telehealth.
    Does Congress need to take a look at ERISA or other laws if 
we want to encourage expansion of telehealth services and 
promote states to adopt licensing reciprocity?
    Mr. Gelfand. It is our belief that ERISA is one avenue 
through which a national framework could be made such that an 
ERISA plan could contract with providers, and those providers 
could see their patients in that ERISA plan no matter where 
they worked.
    There are still going to be details that will have to be 
worked out to ensure that a patient has somewhere that they can 
go if there's a problem. If they have an authority that is 
regulatory in nature, but Congress can absolutely work those 
problems out. It's not a question of whether. It's a question 
of how.
    Mr. Walberg. Thank you my time has expired. I appreciate 
your input. I yield back.
    Chairman DeSaulnier. Thank you, Mr. Walberg. Nicely done. 
We are now going to the distinguished gentleman from New York, 
Mr. Morelle.
    Mr. Morelle. Thank you very much, Mr. Chairman, for hosting 
this hearing on obviously one of the most important questions 
coming out of the pandemic, and I appreciate everything my 
colleagues said, and appreciate the witnesses.
    I did want to follow up a little bit with Mr. Walberg's 
questions regarding telehealth. I spent a fair number of years 
in the State legislature, and was a big advocate for telehealth 
and telemedicine, and I've been I think pleasantly surprised by 
some of the information that's come out about how people have 
received treatment and services through telehealth, and it may 
be just auditory with just telephonically.
    And I know Dr. Smedley had mentioned in his opening 
comments. Just aside from the public policy issue, we're 
talking to constituents and taxpayers about telehealth. They 
may have some hesitancy. They may wonder how this could be 
successful.
    Do you have any thoughts on first of all the degree to 
which people are compliant with going to actual appointments 
and not missing appointments--which I gather happens in the 
physical arena--as well as mental health arena with some degree 
of frequency--how that's worked in the pandemic.
    And also just the efficacy of treatment either through 
telehealth on sessions like this, or that are purely 
telephonic. Could you just comment on that anything that you 
gleaned, or any information that would help us talk to people 
about the efficacy of this treatment?
    Dr. Smedley. Congressman is that for me?
    Mr. Morelle. Yes sir.
    Dr. Smedley. OK yes thank you. Yes, we certainly know that 
telehealth services has been indicated, can be an equity 
enhancer in terms of ensuring that people have appropriate 
access to culturally appropriate mental health services, 
reducing geographic, cultural and linguistic barriers by 
increasing the pool of available providers to patients is 
critically important.
    Certainly, it has great potential to reduce the number of 
no-shows, and we're certainly looking to compile research on 
efficacy, but to date all the indications are that telehealth 
can provide high-quality services that importantly improve 
patient outcomes just as the case for the traditional in-person 
service.
    Mr. Morelle. Well I appreciate that, and I look forward to 
working with some of my colleagues to expand opportunities for 
the telehealth services. A different topic, Dr. Smedley. I 
wonder, we talked about the disproportionate impact of the 
pandemic in communities of color, older Americans, and people 
with disabilities, particularly those who receive long-term 
care in congregate settings have also been particularly hard 
hit by the pandemic.
    This does not get as much attention from my perspective, 
but can you talk about the impact that it's had on older 
Americans and people with disabilities, and what you think, if 
anything, the recommendations for us on how we can address this 
lack of service?
    Dr. Smedley. Sure. Congressman you are correct that there 
are many populations that have been disproportionately impacted 
by the COVID pandemic with the combination of physical 
distancing, social isolation, economic anxiety, fears of 
transmitting the virus, and for many in communities of color we 
are facing a resurgence of overt expressions of racism, 
xenophobia and intolerance, which adds to stress, fear and 
anxiety in many communities of color.
    What can we do? Certainly, No. 1 for me would be to enforce 
the Mental Health Parity Act, particularly for the Medicaid-
eligible patient population, ensuring that we have adequate 
networks, ensuring adequate reimbursement will be a huge step 
that can be taken to ensure that these patients have access to 
needed high-quality services, and then as we've discussed 
expanding and ensuring the continuation of audio-only 
telehealth will be a significant opportunity for patients to 
receive services that they might not otherwise receive.
    So these are important steps that Congress can take now 
addressing the needs of these vulnerable populations.
    Mr. Morelle. And what's your sense in terms of the 
underserved population, you talked about communities of color. 
We now just talked about older Americans, people with 
disabilities. What are the long-term consequences of this?
    What should we expect in terms of additional healthcare 
costs, et cetera of going forward as a result of the lack of 
services during the pandemic?
    Dr. Smedley. Sure. As the other witnesses have described, 
we certainly know that there's a strong relationship between 
mental health symptoms and distress, and other physical health 
symptoms. We absolutely need to address both and ensure that we 
have a holistic approach to treating the needs of patients, and 
particularly for those populations that you indicated which 
have been historically underserved and marginalized in our 
health care systems.
    Mr. Morelle. Thank you. Thank you, Mr. Chair. I yield back.
    Chairman DeSaulnier. Thank you, Mr. Morelle. We're now 
going to Mrs. Harshbarger.
    Mrs. Harshbarger. Thank you Chairman and Ranking Member 
Allen. I appreciate the witnesses being here today. I do have 
experience with this. I've been a pharmacist for 34 years and I 
absolutely have seen the increase in mental health, you know, 
drug therapies, the increase in opiod abuse, especially during 
COVID-19.
    I just came back from the border. I hear my counties 
talking about how methamphetamine use is up by 40 percent. It's 
unbelievable. And I think brain health is the last frontier, 
and I talked to psychologists that say it's absolutely an organ 
that we treat that we cannot see.
    One of the few professionals that do that. You know Mr. 
Gelfand I live in an area that's very rural, and we have a 
deficiency and a limited amount of behavioral health and mental 
healthcare providers. And you know I've talked to counties that 
absolutely have to wait a year to get one applicant to treat 
patients in their communities, and I'd like to know what 
Congress can do as a whole to increase the number of behavioral 
health providers.
    I understand telehealth has exploded during COVID, and it's 
here to stay. And we need to have reciprocity rules. As a 
pharmacist I know that every State has different rules, and if 
I want to reciprocate to another State that's a large fee. You 
know there's different rules, State laws, all that.
    We know that we need to make that cohesive across State 
lines, but how do we recruit these individuals, especially into 
rural areas where they are the hardest hit with the opiod 
crisis, and you know we need those mental health providers 
there.
    What can you tell me, and what can Congress do to help with 
that issue.
    Mr. Gelfand. Thank you Representative. In the long-term 
employers very much support efforts like targeting education 
funds and loan forgiveness to mental and behavioral health 
providers, but that's a long-term solution. And it's not going 
to help your constituents today.
    So if you want to do something today, the No. 1 thing that 
Congress should do is just pass the TREAT Act. You pass the 
TREAT Act, you instantly open up an immense supply of providers 
to these patients, both via telehealth and in-person, but it's 
only temporary right?
    So if we want to sustain the gain we have to explore 
permanent solutions to allow cross State practice. And you know 
we have to be honest about this that it's not at all clear that 
increasing you know pay for providers you know, $30.00-$40.00 
an hour is going to get them to close up shop and move, right, 
and change where they're practicing.
    So we need to think about you know this committee has 
jurisdiction over ERISA, and could potentially give our plans 
and their vendors the ability to contract with providers 
elsewhere and beam them him via telehealth. ERISA is not the 
only way to do it, but it's a way that this committee could do 
it and could do it quickly.
    Mrs. Harshbarger. OK. Well I appreciate that verse. Like I 
said we've seen that uptick in opiod abuse. You know people 
they're anxious, and it's those younger people that we see the 
most, and we've seen an uptick in that. And it's because they 
haven't been on the job. They haven't been able to get out and 
socialize. That's a huge problem.
    And I think we would benefit if we did get things opened 
up. You know as more people get vaccinated, hopefully that will 
happen, but addressing this real shortage of healthcare 
providers is key, especially in my district. And I'm here to 
help in any way I can, and I appreciate all the witnesses 
today.
    I know this is a problem. This is something that like I 
said it's the last frontier and we need to address these 
situations, and I appreciate you being here, and I yield back.
    Chairman DeSaulnier. Thank you. We are now going to 
recognize Mr. Norcross from the great State of New Jersey.
    Mr. Norcross. Thank you, Chairman. And it's good to see you 
there. I really appreciate your insight and quite a legacy 
coming from George Miller and what he's done for this great 
committee. Dr. Smedley, thank you for your opening comments, 
particularly in dealing with the parity issue.
    By giving this additional support tell me how the 
Department of Labor can use this to change the way that some of 
the bad actors are playing now. If you can give us some context 
of why this is relative and important.
    Dr. Smedley. Sure. Thank you, Congressman. So, as we 
discussed earlier what's lacking with the current mental health 
parity law is teeth--enforcement. And so for the Department of 
Labor clearly capacity has been part of the problem.
    There are an enormous Member of insurance plans to regulate 
a few investigators, and an analogy would be that if we had 
only one State trooper patrolling I-95 between Washington, DC 
and Richmond that would not suffice to adequately police that 
highway.
    So, we need better enforcement, more teeth, we need to 
ensure adequacy of networks. We need to ensure adequacy of 
reimbursement, and so your legislation would give the 
Department of Labor that capacity to ensure that insurers are 
complying with the law.
    Mr. Norcross. I would certainly appreciate that. I thought 
you were going to comment about my driving techniques, but the 
idea we believe, even without police, that they'll do the right 
thing is simply not happening across the board and we 
appreciate.
    Dr. Bendat tell me the ways that the insurance companies, 
as you see them, try to circumvent the Parity Act. What are 
common areas that you've been involved in, or that you've seen 
that you can share with us.
    Dr. Bendat. Sure. So, as I mentioned earlier the easiest 
way to circumvent parity is to adopt non-quantitative treatment 
limitations that are not disclosed, or that are discrepant. In 
other words, incomparably applied to mental health and 
substance use benefits.
    The most prominent NQTL of them all is medical necessity. 
Medical necessity is generally again something that has to be 
set by law or a plan, and it can be interpreted in different 
ways if it isn't properly structured, so I would say medical 
necessity and utilization review criteria that interpret 
medical necessity, those are tremendous ways in which insurers 
can deny coverage without triggering any oversight or alerting 
the public that there is something really foul going on.
    Mr. Norcross. Well, when you look at the capacity for the 
Department of Labor in its present configuration to go after 
this and there was a letter circulated today by my colleague 
Joe Courtney about increasing the funding to the Department of 
Labor. Right now, it seems that the balance is extremely far 
off.
    Our capacity to look at this and those to come into 
compliance willingly. Are there some more subtle ways? The two 
that you mentioned obviously, are out there and easier to see. 
What are some more of the subtle ways that some of this is 
going on?
    Dr. Bendat. Well, apart from medical necessity and network 
adequacy, which are huge in their right, and probably the 
biggest impediments to access to care that health insurance 
issuers control, you all--and reimbursement figures into the 
equation. In other words, how are reimbursement rates set? That 
is not a transparent thing.
    How are in-network reimbursement rates set? That's 
particularly not transparent. So, when we get more answers to 
those questions, we'll have a lot more insight as to kind of 
the methodologies that are being applied and the 
incomparability. I would also say that you know apart from 
these you've got potential deductibles and plan specific things 
that can drive people not to receive benefits.
    Mr. Norcross. I very much appreciate it. And it's the 
context of which we live in and the pandemic. You never want to 
suggest that there's a silver lining, but the idea that mental 
health is so important, and so many people who have not really 
been challenged by it are now seeing it across the board, and 
we have to get that to them, that's why this legislation is so 
important.
    Mr. Chairman, I yield back and thank you for the time.
    Chairman DeSaulnier. Thank you, Mr. Norcross. And having 
ridden with you, I want to confirm your observations about your 
driving skills. We will now go to Congresswoman Miller.
    Mrs. Miller. Sorry.
    Chairman DeSaulnier. No worries.
    Mrs. Miller. Yes. Mr. Gelfand thank you again for your 
thought provoking testimony. It's wonderful to hear about the 
great work that companies across the country are doing to 
support the health and well-being of our employees. And I have 
witnessed what we are discussing as I travel the district, and 
people are struggling to fill their--get workers.
    But anyway back to the opiod epidemic. I would like to know 
you shared testimony that some actions that employers have 
taken to combat this terrible epidemic, you've already 
explained some, but could you expand on any other unique 
approaches that your Member organizations have taken?
    Mr. Gelfand. Thank you Representative. You know 
unfortunately COVID did cause a lot of disruption, including 
for many employers opiod mitigation efforts. The economic 
squeeze separated a lot of employees from these programs, made 
it impossible to do a lot of things that we were doing in 
person, and activities that we have rolled out, plus mental 
health toll taken on workers because of COVID and because of 
isolation and lockdown have led some back to dependency.
    So this is very real for us. The good news though is that 
many of these programs that we implemented before COVID, we 
were able to sustain because they were cultural changes within 
our health benefits. For instance, we're not going back to 
unlimited fills for opioids.
    I mean should we dispense the amount that they need for 
immediately relief? And this should be monitored and re-
evaluated, and when possible a patient should be steered to 
other options. These are just lessons learned, and we're never 
going to let those go.
    And many of the programs that we developed like educational 
sessions, group counseling, this can and has gone virtual, and 
maybe that will change back when we can meet in person again. 
But for now it seems sustainable to use these online platforms.
    Mrs. Miller. I do have another comment. Do I have time?
    Chairman DeSaulnier. Yes, you do.
    Mrs. Miller. OK. I don't know if this would be the 
appropriate place, but actually my son-in-law is an orthopedic 
surgeon, and of course he prescribes these. But he brought up 
how Americans want to be pain free and they demand pain relief. 
But then when physicians don't give them what they want, then 
they turn a bad report in on the physician.
    And so they're kind of caught in between on that.
    Chairman DeSaulnier. Any of you care to comment?
    Dr. Smedley. Mr. Chairman, I would if you don't mind. This 
speaks to the importance of non-pharmacologic behavioral 
treatments. There are many behavioral treatments that are 
highly effective in reducing pain and increasing patient 
comfort, and of course they're much healthier coping responses.
    So, doing what we can to ensure the promotion of non-
pharmacologic behavioral treatments can be an important and 
effective alternative.
    Mrs. Miller. Well getting the doctors to use those and then 
get that out to the patients.
    Chairman DeSaulnier. Absolutely. Anyone else?
    Mrs. Miller. Thank you
    Chairman DeSaulnier. Thank you Representative, is that it? 
I appreciate it. We will now go to Representative Wild.
    Ms. Wild. Thank you, Mr. Chair. My question is for Dr. 
Moutier, but I'm happy to have any of the panelists respond. As 
many of you know I am proud to be a leading advocate in 
Congress for, excuse me, suicide prevention.
    I am extremely concerned about the rise of suicide among 
young people and children and the deterioration of their mental 
health. And although many have claimed and argued that school 
closures have adversely affected children's mental health, and 
I'm sure that is true, we know that this problem existed long 
before COVID-19.
    The number of children ages 6 to 12 who visited children's 
hospitals for suicidal thoughts or self-harm has more than 
doubled since 2016, according to data released earlier this 
month from children's hospitals across the country. They 
documented 5,485 emergency room or inpatient visits for 
suicidal thoughts and self-harm among 6 to 12 year old's at 
these hospitals in 2019, which is notably pre-pandemic, which 
is up from 2,555 in 2016.
    And visits for teenagers with suicidal thoughts or self-
harm at these hospitals also rose from 2016 to 2019 by a 
staggering 44 percent. According to the most recent data we 
have from the CDC, suicide is now the second leading cause of 
death among young people ages 15 to 24.
    How can making sure that our kids get the mental health 
care they need, including mental health care covered by their 
health insurance the same way they cover physical health 
issues, prevent these suicides, and address these suicidal 
thoughts?
    And how do we ensure, and I know this has been touched on 
already, but it's such an important issue. How do we ensure 
that robust mental health care receives parity in insurance 
coverage? And with that Dr. Moutier I'm going to turn it over 
to you, and if anybody else would like to weigh in on this very 
important topic I'd be happy to hear them. Thank you.
    Dr. Moutier. Thank you, Congresswoman Wild. Yes, the 
suicide crisis in our Nation has been on the rise and that 
actually is true for all age groups, but certainly for youth. 
The rise in not only suicidal ideation attempts but rates, has 
been tremendous pre-COVID.
    What we know so far during COVID is that during 2020 the 
number of suicides compared to 2019 actually went down by 5.6 
percent around the Nation. We don't know the demographic 
breakdown of that yet by age, or by race ethnicity. And we know 
that the pandemic is affecting all people, but affecting 
different groups differently.
    So, I am very concerned about what we will ultimately see 
in terms of not only the demographic breakdown for suicide 
rates during 2020, but also now what is coming here now in 2021 
because the effects of trauma can be delayed.
    So, the big picture is that we have had a broken system 
when it comes to accessing mental health care. There has been 
stigma, internal and external, cultural barriers, but now that 
that is going down, I believe that that is one of the reasons 
we see help-seeking so much more on the rise, but the access to 
care has not been there to meet it.
    And so, parity is essential when it comes to suicide 
prevention. It is one of the most concrete and powerful things 
we could do to potentially prevent suicide and drive suicide 
rates back down, and particularly now that mental health needs 
are being expressed by everyone, as has been pointed out.
    That's a good thing. People can talk about their internal 
experiences now. But it's not a good thing if we don't have 
care that is ready to meet that. And that is certainly 
incumbent upon the legislative tool that we have to enforce 
parity.
    But it also means that parents in schools, in workplaces, 
that we have to build cultural competency and capacity around 
being able to dialog about these things and get people the help 
that they need.
    Ms. Wild. Thank you. And I'm going to just take the last 30 
seconds and ask you Dr. Moutier. Can you comment on the new 988 
line for suicide prevention that will be available I believe 
within the next year? Would that help adolescents and children?
    Dr. Moutier. Yes, it absolutely will. That will come into 
effect. It's planned for July 2022. It's an extension of the 
suicide prevention lifeline. What will happen is that volume 
will go up tremendously more. Right now we have capacity 
limitations due to funding as well as having culturally 
appropriate providers available, but yes, that is an enormous 
opportunity for us as a nation to build a new system that is 
ready to meet the demand.
    So, the 988 legislation is a critically important piece, 
but we have to pay attention to how we resource it and staff.
    Ms. Wild. How we fulfill that need. Thank you so much, Dr. 
Moutier. I look forward to continuing the work with you on this 
very important topic.
    Dr. Moutier. Thank you.
    Ms. Wild. I yield back Mr. Chair.
    Chairman DeSaulnier. Thank you. And thank you for your 
advocacy on this issue in particular. We next go and recognize 
Representative Fitzgerald.
    Mr. Fitzgerald. Sorry about that.
    Chairman DeSaulnier. There you go.
    Mr. Fitzgerald. Sorry about that. Yes Mr. Gelfand and maybe 
some of the other witnesses would like to comment as well. But 
a challenge over the last year continually trying to stay in 
contact with some of the healthcare systems within my 
congressional seat, and even before that in my State Senate 
seat that I had represented for a number of years, but the one 
hospital is Children's Hospital in Milwaukee.
    And there was this kind of constant drum beat about trying 
to find qualified providers for kids who were experiencing 
behavioral health care issues, and obviously issues related--
not just for the pandemic, but family situations, school 
situations.
    And I'm just curious if some of the things that ERIC or its 
Members have done or are currently doing on the provider 
shortage front, because it seems to be something that you hear 
about quite a bit.
    Mr. Gelfand. Thank you Representative, and Children's 
Wisconsin is well-known to be an outstanding hospital. So if 
even they are having trouble attracting these professionals, 
there should be little doubt that this is a market-wide 
problem. This is a problem that exists all over the United 
States.
    Employers know that sometimes throwing more money at the 
problem just isn't enough, and in this case you may be able to 
double the amount that you're paying per hour, and you still 
may not get those child psychologists to leave New York and LA. 
So we think that you have three options here.
    Option one is focus on increasing the number of these 
providers that exist. And we should do this, but it takes a lot 
of time. So that alone won't suffice. No. 2 is we can do more 
with the providers that we do have with more resources, tools, 
education, collaborative care and colocation efforts, we can 
enhance access to care by equipping more professionals to 
practice in this space.
    So for instance, you know funding, perinatal psychiatry 
access programs. But third, and perhaps most immediate, to help 
patients right now is we've got to be able to bring those 
providers from out of State to Wisconsin and into your 
district, and to do that we just need more access to 
telehealth, and we need to be able to facilitate across State 
practice period.
    Mr. Fitzgerald. Thank you Mr. Chair I yield back.
    Chairman DeSaulnier. Thank you, Mr. Fitzgerald. We will now 
go to Mrs. McBath. Lucy, the floor is yours.
    Mrs. McBath. Thank you, Chairman DeSaulnier. Thank you so 
much for convening this group of experts today to discuss the 
issues of access to mental health services. Almost a year ago 
we began social distancing in order to stop the spread of this 
deadly pandemic, but social distancing has really taken a toll 
on our mental health and feelings of isolation and 
disconnection that has affected just absolutely everyone.
    And it's been inspiring to see so many people across 
America kind of come together to actually help and support and 
service one another. And the mental health and recovery 
community has really been a shining example, I believe, of how 
people can really come together to overcome this terrible 
disease.
    However, you know these communities have not always been 
able to access the care that they need, and we've talked about 
that today. And COVID-19 has just truly laid bare many of the 
inequities of our health care system. And you know I have seen 
a host of disparities develop and worsen with the onset of this 
pandemic, even within my own constituency.
    So, as the increased isolation of the pandemic has taken 
its toll on people with mental health issues, I've observed how 
barriers to coverage and access to care have just contributed 
to increased rates of severe mental illness and even suicide.
    Dr. Bendat, in your testimony you talked about the issue of 
the adequacy of provider networks, and the importance of making 
sure that you have enough doctors in your plan, and in your 
plan network to make sure that parity is meaningful.
    Can you tell us what are some of the issues that lead to 
relatively narrow behavioral health networks?
    Dr. Bendat. Well so you've got narrow networks that are 
narrow by design. In other words, there are insurance plans out 
there that intentionally sell access to networks that are meant 
to be narrow. Nonetheless, these types of plans are supposed to 
cover all of the benefits that they promised to offer.
    So, the problem of course is that when it comes to mental 
health care, oftentimes they don't. We also have networks that 
on the surface appear to be robust. They're not limited. Plans 
sell them as PPO's, essentially large group products that they 
offer the promise of wide coverage.
    But when patients try to access in-network care for mental 
health and substance use disorders they can't. Largely the 
issues they confront have to do with not being able to get 
timely care, so if there's an urgent situation patients are not 
able to access the type of provider within a reasonable period 
of time, or they can't find someone that is available and 
accepting patients within a particular distance.
    The problem is that insurers typically, or thus far at 
least, have failed to update their provider directories. And 
so, patients are just told go take a look at our directory. 
Find yourself a provider. That is not a very helpful stance to 
take when someone is in crisis or in distress. And so, and 
especially when patients have to call multiple providers and be 
told no, we're full or no, we no longer are with this insurer. 
That's just terrible.
    So, I would say that putting the onus in the hands of the 
patient who's already struggling with distress, having that 
patient look for providers instead of telling them here is 
where they're available, here is where they are, here's their 
availability window. That really creates a major barrier to 
care.
    Mrs. McBath. So, then let me ask you how do some states 
like California for example address the issue of network 
adequacy for insurance, and if you can give us a very brief 
explanation as to why laws do not apply in self-insured ERISA 
plans.
    Dr. Bendat. Sure. So, there's ERISA preemption for self-
funded plans which means that they are just not subject to 
State laws period. That is something that only Congress can 
address. So, your committee has absolute jurisdiction over this 
issue. The way that California deals with fully insured plans 
is by telling them hey, you've got to arrange for example 
coverage within 15 miles or 30 minutes to a patient's home.
    You've got to do it within a certain period of time. If you 
don't, you must let the patient go out of network and subject 
the patient to no more than in-network cost-sharing. So in 
other words, if there's a balance, you're on the hook for it--
you the insurer, not the patient.
    That's going to create an incentive for insurers to broaden 
their networks and to raise reimbursement rates to attract 
providers.
    Mrs. McBath. Thank you, Mr. Bendat. And Mr. Chairman I 
yield back the balance of my time.
    Chairman DeSaulnier. Thank you, Representative. Now we're 
going to go to the Ranking Member Representative Foxx.
    Ms. Foxx. Thank you Mr. Chairman. I want to make a quick 
comment before I ask my questions. It's so frustrating when we 
focus these hearings on bashing employers, bashing providers, 
or bashing healthcare networks.
    Mr. Gelfand has given us some great alternatives that don't 
require money, and I think it would have been wonderful if we 
could have heard more about how the private sector is handling 
these things and looking for ways. Employers want to help their 
employees, not harm them.
    Mr. Gelfand thank you for being with us today. On June 23, 
2020, the Department of Labor issued temporary guidance 
allowing employers to offer stand alone telehealth coverage to 
certain employees ineligible for any other group health plan. 
Had this guidance increased access to mental health services 
for employees, should Congress consider expanding this 
flexibility to all employees and making it permanent?
    Mr. Gelfand. Thank you Dr. Foxx. The guidance temporarily 
allowing stand alone telehealth has been a huge success. 
Millions of part-time workers and others have deemed coverage 
that they didn't have before, largely at the employer's 
expense, and employers celebrate this.
    But as you know though, when the emergency ends, so too 
does the guidance, and so those benefits will disappear. And 
keep in mind that the temporary nature of the guidance caused 
some employers to hold back. So we think that if we were to 
permanently allow stand alone telehealth benefits, a lot more 
employers would roll it out since they could do it for the 
long-term.
    And we ought to help even more patients, and we do that by 
broadening the eligibility to include unenrolled workers--for 
instance young adults that are on their parent's plan.
    Ms. Foxx. Thank you. Mr. Gelfand the Mental Health Parity 
and Addition Equity Act requires employers to offer mental 
health and behavioral health benefits, do not place more 
stringent limitations such as visit limits or preauthorization 
requirements on those benefits than they do on medical or 
surgical benefits.
    Your testimony explains the Department of Labor's parity 
regulations are especially subjective and difficult to 
interpret. What steps can Congress, or the administration take 
to ensure that plans are able to comply with mental health 
parity requirements?
    Mr. Gelfand. So Congress has more than once directed DOL to 
better explain the most complicated part of parity which is the 
non-quantitative limitations, but for some reason DOL has given 
many examples of what is not allowed, but continually failed to 
give clear guidelines on what is allowed.
    There is now an extremely complicated self-compliance tool 
that just seemed to further confuse folks. Considering that 
these NQTL's did not exist in the legislation that Congress 
passed, and were invented by President Obama's Department of 
Labor, the least that the department could do is to give a more 
complete and comprehensive explanation, not just on how to 
violate the rules, but on how to affirmatively comply with 
them.
    Perhaps the most important thing that Congress can do is to 
continually support DOL's compliance-driven, rather than 
penalty-driven approach. Right now when there's a problem DOL 
helps the employer to get it right and re-adjudicate claims to 
make patients whole.
    This doesn't make much money for trial lawyers, but it 
ensures that our workers actually get the care that they need.
    Ms. Foxx. Thank you. Mr. Gelfand 151 million Americans are 
covered under employer-sponsored coverage, which is more 
individuals than are covered by Medicare, Medicare or the 
exchanges.
    Knowing that employer-sponsored plans are the largest 
single source of coverage, can you discuss how health benefits, 
including those related to mental and behavioral health are 
mutually beneficial for workers and employers?
    What actions have employers taken to manage the increasing 
costs of coverage?
    Mr. Gelfand. Thank you Dr. Foxx. Employers are committed to 
offering quality affordable mental and behavioral health 
benefits. Remember that parity is not a mandate. Employers are 
choosing to offer this benefit, and thus choosing to become 
subject to these very complicated rules, but they do it because 
it's the right thing to do, and it's integral to keeping our 
employees healthy and productive, and providing peace of mind.
    Now as with any employee benefit, there are always 
tradeoffs. Some limitations are needed to keep coverage 
affordable because if costs go up health employees start opting 
out which makes costs go up even more.
    Now employers work hard to develop strategies focused on 
improving health and safety, which can also help to control 
costs, but in the end if we're not able to employ sophisticated 
medical management and offer reasonable reimbursement to 
providers, or make decisions to exclude certain low-value 
facilities or treatments, this will just make it impossible to 
offer affordable coverage to our workers.
    Ms. Foxx. Yep. Has the COVID-19 pandemic changed the way 
employers deliver mental health care, and what innovations 
would you highlight that they have put into place?
    Mr. Gelfand. So it's safe to say that the past 13 months 
have seen more innovation and experimentation in employer 
coverage than ever before. And here are the three big 
takeaways. First, telehealth is crucial.
    We can overcome a lot of provider shortages, we can 
overcome access and wait time problems, and already some are 
advocating that we need to tear it down by having the 
government mandate reimbursement rates in telehealth.
    Second, a lot of people are getting their mental and 
behavioral health needs met in the primary care setting. We've 
got to support this, from enhancing worksite health clinics, to 
providing education and resources. This should be an easy one.
    And third, a lot of our employees are getting support 
that's not traditionally thought of as medical care right? 
Whether that's attending AA meetings, or care giving by family 
Members, or they're engaged in meditation, mindfulness type 
programs.
    Employers are going to pivot even more to support these 
activities, but there are some areas in which law and policy 
really needs to catch up to help us do that.
    Ms. Foxx. Mr. Chairman I thank you very much. I want to 
make one more quick comment. My husband was having a problem 
with terrible indigestion about 3 months ago, and he was able 
to do a telehealth meeting.
    He had an appointment with the doctor. The doctor got sick, 
and was afraid to see him in person. And so, he had my husband 
do it through telehealth, and he was able to diagnose--maybe 
not completely, but help him a lot. So I really am an advocate 
for the telehealth opportunities that are out there.
    So thank you Mr. Chairman for your dispensation here.
    Chairman DeSaulnier. I'm always happy to dispensent you, 
Ranking Member, and as a friend, I just want a brief comment 
that I was just saying to my staff how happy I was at the tone 
of this conversation and very hopeful that we can work together 
so.
    Ms. Foxx. Thank you.
    Chairman DeSaulnier. With all due respect I didn't hear the 
bashing, although I have heard it in the past. And I do 
appreciate Mr. Gelfand's comments and look forward to 
continuing conversation about how we get these needed services, 
which I hear a consensus about from everyone, as efficiently as 
possible, and on that I agree with you.
    Ms. Foxx. Thank you.
    Chairman DeSaulnier. The best of employers do it. We just 
want to make sure that they do. With that we go to the 
distinguished gentleman from Michigan, Mr. Levin.
    Mr. Levin. Thank you so much, Chairman DeSaulnier for this 
really important hearing. And thanks to all the witnesses. Dr. 
Smedley, let me start with you.
    In your testimony you discussed the structure of mental 
health parity enforcement, and you point out there are a lot of 
problems--Federal oversight of ERISA plans is weakened by 
several factors, the requirements for insurance laws vary 
state-by-State, and for State and local government employees 
plans can simply opt out of the system altogether.
    What long-term consequences could patients experiencing 
COVID-19 related trauma face if they have limited mental health 
coverage due to weak enforcement?
    Dr. Smedley. Well thank you, Congressman. As I indicated in 
my testimony, we are witnessing a mental health tsunami. It is 
upon us. And so, it is critically important that we do all we 
can to ensure access to appropriate behavioral and mental 
health services.
    As some of the other witnesses have indicated, the absence 
of culturally appropriate high-quality services can make these 
conditions worse, leading to far more debilitating illness and 
worse case, you know, suicidal ideology, et cetera.
    And also, has been indicated these mental health issues are 
not limited to psychological stress and anxiety. They also 
manifest as physical health problems as well. So, we need to do 
all we can right now to get out ahead of these challenges 
starting with things like putting teeth into the parity law.
    Mr. Levin. Well so, let's focus in particular on you know 
sort of the meat of this question of better enforcement. And 
given our committee's jurisdiction, which is ERISA, what are 
your top recommendations to improve enforcement for ERISA 
plans? Lay that out for us.
    Dr. Smedley. Sure. There are a number of steps we can take, 
and I actually would like to respond to your question more 
fully with a written statement, but certainly.
    Mr. Levin. I would appreciate that.
    Dr. Smedley. Yes. The legislation offered by Representative 
Norcross is an important start toward ensuring that we have 
adequate capacity for enforcement, and that plans are aware of 
the consequences of not ensuring appropriate access to mental 
and behavioral health services.
    Mr. Levin. OK. Let me ask you about a different thing which 
is peer support for people with mental health issues. I'd like 
to ask you to speak about the importance to that, and you know 
whether there are challenges to ensuring that people are able 
to access the peer supports that may be critical to their 
ability to build resilience during these difficult times.
    Dr. Smedley. That's a great question, Congressman. Thank 
you for that. Certainly, there are a number of risk factors 
that people are facing in terms of building and enhancing 
social support. So certainly, the need to be physically distant 
during this time is one of those, but we have encouraged people 
while we are physically distancing, to be socially--to not 
socially isolate.
    Because it's important that we build those connections. 
Doing things like training people in psychological first-aid, 
and skills for psychological recovery, offer ways of helping to 
train lay individuals, non-professionals to provide health 
coping skills and mechanisms to others.
    And certainly, there have been other very impressive 
developments. Like mutual aid societies that again provide 
social support without the risks associated with physically 
coming together. So, it is critically important that we address 
peer support. These informal sources of support, and often 
based in communities, drawing on sources of community-based 
resiliency are critically important, and we should do all we 
can to help enhance and support those efforts.
    Mr. Levin. Thank you very much. Mr. Chairman let me end 
with a couple comments. One is the reflection on this whole 
thing, the immense complexity of achieving parity for mental 
health services.
    I just want to emphasize that those of us who support 
Medicare for all, are not just talking about giving the current 
Medicare program, with all its limitations to everybody, but 
having a full system of health care, including dental, vision, 
and mental health, you know to all Americans.
    And second, I want to emphasize how strongly I feel that we 
have a new opportunity to permanently expand telehealth 
services. I've been on the hearing the whole time, and I think 
I'm going to try to partner with my colleague from Michigan, 
Mr. Walberg on this, because his questioning was really great 
on it, and it would be wonderful for Mr. Walberg and I to be 
able to collaborate.
    With that I yield back, Mr. Chairman, with more thanks for 
your leadership on this.
    Chairman DeSaulnier. Thank you. And I do note the 
disproportionate number of Members from the State of Michigan 
on this subcommittee. I'm glad to have you all here. Speaking 
of which, we have a great State. We will now go to the 
distinguished gentleman from Connecticut, Mr. Courtney.
    Mr. Courtney. Thank you, Mr. Chairman. I have not 
unfortunately, been able to attend the full hearing as much as 
Andy did, but you know I actually just wanted to follow up on 
his last question with the other witnesses where again, I 
thought, you know, Dr. Smedley got right into really the crux 
of the issue, which is what does non-compliance mean to the 
patient.
    And Dr. Moutier and Dr. Bendat if you wanted to sort of 
comment on you know what we're really talking about here is the 
impact on people.
    Dr. Moutier. Absolutely. Thank you, Representative 
Courtney. What it means is that in the moment when an 
individual or a family is realizing that their loved one may be 
struggling with a mental health condition, may be suicidal. And 
so, the need becomes dire, that they go to figure out how to 
access a mental health professional.
    And there are more external barriers in the way of that 
than probably any other type of health situation. So, you know 
I think it does boil down to the way it's playing out in day to 
day real people's lives and families, is presenting enormous, 
and honestly unnecessary barriers that should not be there.
    It is an absolute form of discrimination right now, the way 
that mental health conditions are not being addressed in 
actuality, even though there's a lot now of kind of open-
mindedness. I don't want to say lip service, but until we fix 
this issue, we can say that mental health is valid, critically 
important, that suicide is a complex, but a health issue at the 
end of the day.
    But we will only get so far because in every instance of 
every suicide prevention effort that is shown to be effective, 
it drives people who have those needs to a health professional. 
And so, this really is the crux of the matter, and I appreciate 
you bringing it up in terms of the impact on real people and 
real families.
    Mr. Courtney. All right thank you. And Dr. Bendat?
    Dr. Bendat. Yes, so ultimately non-compliance with parity 
and with the essential health mandates is that patients either 
are undertreated, or not treated at all, and ultimately end up 
far worse than they began, if not dead. And it's very simple.
    Mr. Courtney. Well thank you for your clarity and bluntness 
because I do think that that's really important for people to 
realize that you know this is not sort of a you know, kind of a 
bureaucratic, you know, political argument. This is really 
about saving lives, so thank you.
    You know assuming you know we were able to put in again a 
better sort of regulatory structure, someone has to regulate 
it, OK, at the Department of Labor. And the agency, you know, 
Mr. Norcross's bill you know would appropriately designate is 
the Employee Benefit Security Administration, EBSA, and you 
know it's a big job.
    You know if we're going to put in a new sort of effective 
regulatory structure that requires you know boots on the ground 
and resources. Again, the American Psychological--sorry, 
American Psychiatric Association has worked with my office 
about trying to get EBSA's budget actually increased in this 
year's Fiscal Year budget, which again is not sort of our 
portfolio.
    But you know, Mr. Chairman, I would like to ask that the 
Psychiatric Association's statement be added to the record 
regarding again this important piece of the puzzle if we're 
able to again enact smart legislation.
    Chairman DeSaulnier. Without objection, Mr. Courtney.
    Mr. Courtney. Thank you. And again, I don't know if any of 
the witnesses would want to talk about that because again, you 
know obviously having you know a cop, you can pick up the phone 
and call when there's a non-compliance issue, is kind of a 
critical piece.
    And you know obviously the Psychiatric Association I think 
flagged this for Congress, and I don't know if any of you 
wanted to sort of join in with any comments.
    Dr. Bendat. Well I would add that there's absolutely no 
doubt that strengthening EBSA's ability to enforce parity in 
ERISA, particularly with respect to mental health benefits is 
critical. Again, it's a large department, but by no means 
substantial enough in order to be able to take on 136 million 
people.
    You can imagine at least one-fifth at least, have mental 
health and substance use disorders. That's a national 
statistic. So, think about what that means for EBSA's 
regulation and the importance of being able to effectively 
address issues that States cannot touch because of preemption, 
again critical.
    Mr. Courtney. Thank you. You get the final word Dr. Bendat, 
and again I appreciate the witnesses--really, you know, great 
testimony on such a critical issue. I yield back Mr. Chairman.
    Chairman DeSaulnier. Thank you, Mr. Courtney. I'll now go 
to Ms. Stevens.
    Ms. Stevens. Well thank you so much, Mr. Chairman for this 
critically important hearing, particularly as it's something 
that I hear from constituents and stakeholders in my district, 
on the regular, from the Livonia Chamber of Commerce, President 
Dan West who asked me about what we are going to do to meet the 
moment to improve access to behavioral and mental health care.
    And, to our panelists who have done just a great job today, 
and I want to recognize you, Dr. Moutier, for your testimony 
and your expert asking, answering of questions. Although the 
last 2 years have seen an overall reduction in suicide rates, 
the number of young people who have reported suicidal ideation 
has increased dramatically since the pandemic.
    And I know you have been touching on this throughout 
today's session, but over the past year communities in my 
district have just experienced countless tragedies of young 
people dying by suicide. Sometimes, oftentimes with no warning. 
No warning indicators, and no recognition that they might be 
depressed, or might be in need of help.
    Going out with their friends or family the night before 
such a tragic incident takes place. So, Dr. Moutier can you 
just speak a little bit to the importance of either early 
recognition, or community conversation that we could take, the 
accessing of care, and maybe the ways in which we can broach 
this topic as community leaders more effectively.
    And if there's anything that we need to know about trends, 
or maybe not fully developed brains that are also contributing 
to these tragic incidences.
    Dr. Moutier. Thank you so much. This is such a huge part of 
the pandemic experience as well. Because young people, as you 
mentioned, our brains don't finish all the way developing until 
we're in our mid-20s. So it means the primitive part of our 
brain, fear, anxiety, stress, fight-or-flight, is fully 
developed, but the thinking part, the planning part, the part 
that allows us to see the long-term future, and see through the 
crisis moment is not fully in place for most people until their 
mid-20s.
    And so, impulsivity can be a much greater factor for young 
people when they're in suicidal distress, and that is something 
that we are gravely worried about. Again, stigma going down is 
fantastic, but that has to be just the start.
    And so we have to build capacity for parents, communities, 
faith leaders, school personnel, workplaces, to have dialog 
about these experiences because the truth is while it always 
feels out of the blue, and like you're blindsided by a suicide 
attempt or a death, the truth is that person was experiencing 
something that we as a society have not provided ways for them 
to express and have their needs met.
    And that's what we're building. And we are doing that. But 
much more is needed in that regard.
    Ms. Stevens. Right. And just as we say that we have been 
working really closely with stakeholders on removing the stigma 
of depression and trauma, and needing help, or asking for help 
in providing those spaces, we also want to send a message that 
we don't want you to kill yourself, and that it is, you know, 
that we want you to get the help.
    And so, looking at you know the role that mental health 
services play or just the understanding of, for an 
underdeveloped brain, what actually happens when you do kill 
yourself, and the results of it.
    Dr. Smedley, COVID-19 has had devastating consequences for 
millions of people, but there are you know also just some 
lessons that have been learned from this pandemic that will 
allow us to improve health care moving forward, including the 
advancement of telemedicine and making mental health services 
available in communities that might traditionally lack access.
    Could you just walk us through some of the things that 
we've learned during the pandemic about the different ways that 
mental health services can be provided? I know we've been 
covering that at length today.
    And also, do you have any other recommendations for 
Congress so that we can ensure high-quality mental health 
services are available, including communities that might be 
lacking sufficient access to the internet for example?
    Dr. Smedley. Thank you, Congresswoman. I will try to speak 
very quickly because I know time's running short.
    Ms. Stevens. Yes.
    Dr. Smedley. And I would love to offer a full written 
response as well, but you are absolutely right that we need to 
ensure that culturally appropriate community-based services are 
available. I would point out that suicide rates are 
particularly escalating among African-American and Native 
American youth. We need to have services in communities for 
those young people, and so we will be very happy to provide a 
fuller written response to your question given the time.
    Ms. Stevens. Thank you. And I yield back, Mr. Chair.
    Chairman DeSaulnier. Thank you for yielding back. Very 
artfully getting that last question in was good work. Excuse 
me. So, that is our last testimony unless I've missed someone. 
I'm going to before we go to the Ranking Member for closing 
comments and conclude, I just want to thank everybody again.
    Thank the Members, terrific, terrific hearing, and an 
important one that we intend to pursue on this committee and 
would love to work with all of you, all of you, in a bipartisan 
way. I'm sure we're going to have some differences in terms of 
the deployment, but what I hear is so encouraging and just 
following up the last conversation.
    It's striking to me, having been involved in this field for 
a long time, personally and professionally that the lack of 
stigma, and it's really beyond my expectation when I started in 
this 30-35 years ago. That we don't have more stigma, so a 
wonderful thing I thought it would--I'm encouraged by that.
    Having said that, it's very frustrating to see the richness 
of the research, and the ability to get that research deployed 
to individual Americans, and we're losing people that we don't 
need to lose if we get the infrastructure up, and get the 
performance standards right so Congress can provide the 
necessary oversight.
    So, I want to remind my colleagues that pursuant to 
committee practice materials for submission for the hearing 
record must be submitted to the Committee Clerk within 14 days 
following the last day of the hearing, so by close of business 
on April 28, 2021, preferably in Microsoft Word format.
    The materials submitted must address the subject matter of 
the hearing, obviously. Only a Member of the subcommittee or an 
invited witness may submit materials for inclusion in the 
hearing record. Documents are limited to 50 pages each. 
Documents longer than 50 pages will be incorporated into the 
record via an internet link that you must provide to the 
Committee Clerk within the required timeframe.
    Please recognize that in the future that link may no longer 
work, so just we'll work with you as best we can, but we wanted 
to give you some warning.
    Pursuant to House rules and regulations, items for the 
record should be submitted to the Clerk electronically by 
emailing submissions to [email protected].
    Member officers are encouraged to submit materials to the 
inbox before the hearing or during the hearing at the time the 
Member makes the request. We will furnish that email to anyone 
who has trouble getting it.
    Again, I want to thank the witnesses. Really terrific 
hearing, thanks for your vocation, your commitment to these 
issues. It's certainly an exciting time to be in your field 
with your expertise, and we intend to take advantage of your 
expertise. And I would include all of those, the witnesses.
    Mr. Gelfand, I really appreciate your perspective. And 
Members of the subcommittee may have additional questions and 
we ask witnesses to please respond to those questions in 
writing. The hearing record will be held open for 14 days in 
order to receive those responses.
    I remind my colleagues that pursuant to committee practice, 
witness questions for the hearing record must be submitted to 
the Majority Committee Staff, or the Committee Clerk within 7 
days. The questions submitted must address, again, the subject 
matter of the hearing.
    I now recognize Mr. Allen for any closing comments that you 
have. Go ahead, Rick, if you could unmute.
    Mr. Allen. OK we'll try again. Thank you Mr. Chairman. And 
I want to thank all the witnesses for their testimony today. 
This has opened my eyes a great deal to the complexity of this 
issue. I would like to ask unanimous consent to enter in the 
record statements from the American Benefits Council and the 
H.R. Policy Association.
    Chairman DeSaulnier. Without objection.
    Mr. Allen. Thank you Mr. Chairman. And to just highlight a 
couple things that I think are important, particular with 
listening to the discussion today that we need to consider is 
according to a 2020 Congressional Budget Office estimate, 151 
million Americans received health insurance through employer-
provided plans, which is the largest single source of coverage.
    Yet the democrats are seeking to eliminate employer-
sponsored healthcare through their socialist Medicare for all 
plan which would force millions of Americans into a one-size-
fits-all government-run system, and cost more than 30 trillion 
dollars over the next decade.
    A 2018 survey by America's Health Insurance Plan reveals 
that 71 percent of Americans are satisfied with their current 
employer-provided health coverage. By all metrics, satisfaction 
with employer health coverage outpaces public support for the 
democrats Medicare for all scheme.
    Employers around the country continue to make concerted 
efforts to meet the mental and behavioral health needs of 
workers through implementation of coordinated care programs, 
employee wellness programs, use of telehealth services, and 
additional employee assistance programs.
    The democrats will ignore this fact and unjustifiably 
assume that employers are short-changing their employees. I 
encourage Members to talk with companies about this, and find 
out exactly what they are doing, so we can get to the root of 
the issue.
    House republicans want to empower America's job creators to 
expand access to quality care and mental health services, for 
workers and their families. While the system can be improved, 
we also recognize employers are attuned to the needs of their 
employees, as I know first-hand.
    For 37 years I ran a construction business where we 
provided staff benefits. I knew my employee's needs, and what 
benefits and services were best suited to meet their needs. 
That is why I believe employers play a critical role in 
enhancing the system moving forward, which will benefit workers 
by ensuring that effective mental and behavioral health 
services are offered.
    I believe that employers truly know that their employees 
are the most important factor in the success of their business, 
and they want to take care of them. Again I thank the witnesses 
for participating today, and I yield back.
    Chairman DeSaulnier. Thank you, Mr. Allen. I look forward 
to continuing the conversation, discussion with you. We have 
mutual experiences as former employers. You, in the 
construction industry, and I admire that, and myself in the 
restaurant business, as I have explained many times in this 
committee.
    One of my big concerns about employer-based wages and 
benefits is not that the employers are bad, or inherently bad, 
but some of them are. So, I think the discussion is, and I 
always--some of my colleagues on the left, sometimes they're 
surprised that I actually admire some of the work by Francis 
Fukuyama at the Hoover Institute, in particularly his work 
about trust, about the most efficient way to deliver services.
    Having said that, and government isn't always that 
provider, what we want to do, and what I've heard clearly from 
everyone's testimony, and I hope we can focus on, is the 
importance of these services. Being able to have metrics so we 
could measure them both at the clinician level through the 
employer relationship, and the health provider relationship.
    But most importantly, for Congress and the Department of 
Labor, for us to be able to clearly evaluate the quality and 
the access for Americans to get these services. Because my own 
belief is over the next 30-50 years as all this research 
evolves, we're going to learn a lot, and we're going to save a 
lot of people's lives, and allow them to be able to live great 
lives, even if they've been challenged either genetically, or 
through their environment.
    So, I'm really excited about this. I really hope, and I 
appreciate the testimony and the tone, that for me, I want to 
focus on the deliverables of these important resources as we go 
through. And I know you do too, Rick, and I'm looking forward 
to focusing on that.
    We'll have our disagreements, and I respect that, but you 
and I share a perspective. In my case we both ran low profit 
margin businesses. The restaurant business is historic, so it 
was just getting the services that my employees needed, that I 
wanted them to get.
    And then the challenge of competing against other employers 
who weren't doing the things that you and I did and tried to. 
And in California we had a big initiative that was bipartisan, 
yet at the underground economy, to incentivize employers who 
needed those incentives.
    So, I agree with you. The hammer is not always the best 
tool to reach for in the toolbox. So, I'd love to work with you 
to figure out ways to get those, to reward those good 
employers. And Mr. Gelfand, I'd be happy to have those further 
discussions, but also to be mindful.
    Human nature being what is it, that not everyone, whether 
they be employers or employees, or providers, always have those 
best interests. So, how we do that, I think is really 
important. And it would really be wonderful I think for this 
country to know that this little subcommittee really focused on 
those things and accepted the fact that we're going to have 
some disagreements.
    But the delivery of these services are so important, and 
we're losing. We've lost 87,000 Americans to overdoses in this 
country. When you look at diseases of despair, Deaths of 
Despair, a wonderful, but sad book, a recent book on this 
subject matter.
    And there really is an emergency. We're losing too many 
people every day. For me this is personal. As I've mentioned, 
on April 20, it will be the 32d anniversary of when I found out 
that my father took his life. He had had chronic problems with 
substance abuse, and depression.
    He was actually the first behavioral health substance abuse 
counselor. He went back to college, got a master's degree at 
Rutgers, so he could give substance abuse counseling to the New 
England Patriot's players and staff.
    He was terminated after a couple of years because they got 
a new coach who said in Sports Illustrated--editorialized 
against this. The next coach said, ``These are professional 
athletes. They don't have substance abuse problems.''
    So, we can look back on that comment and that culture, and 
say that clearly isn't true either for them, or for the general 
public. So, as I reflect on my dad's experience and having lost 
him, and the years I've spent dealing with that, but also 
discovering the things that we could do, and the wonderful work 
you all do, but particularly Ms. Moutier and a bill that we've 
worked with your group on that we helped provide for services 
that will help with suicide.
    But there's so much to be gained, and I think back on my 
dad, and think, you know if we knew then what we know now, and 
got him the services he wouldn't have done what he did, and he 
would have lived a full contributing life where he could help 
other people who dealt with depression and substance abuse.
    So, I'm not depressed by that. I am encouraged by how far 
we've come. But I do feel the urgency, and we're going to work 
on this in this committee.
    And last, just an observation. The jurisdiction of this 
committee and the relationship of employer-employee benefits of 
course came up historically during out of the Depression. And 
to some degree it is the jurisdiction of this committee, we'll 
focus on that.
    But be mindful that although this is a key component, 
there's so many other areas, and I think of a field hearing 
that then Chairman Foxx had in the Bay Area about 5 or 6 years 
ago when we dealt with the gig economy, and how we get benefits 
to people who don't have traditional employer-employee 
relationships.
    So, I'll conclude there and just say again how encouraged I 
am, and, Mr. Allen, I hope you share this, the tone, the tenor 
of this conversation and all of our witnesses. And I want to 
thank the staff again, and look forward to really delivering 
for the United States on a bipartisan level to get these 
services to people out there in the community, so there will be 
less suffering tomorrow, next month, and years to come by 
people because we delivered these services to the American 
people.
    Thank you so much. We are now adjourned.
    [Additional submission by Chairman DeSaulnier follow:]
    
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    [Additional submission by Mr. Allen follow:]
    
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    [Additional submission by Mr. Courtney follow:]
    
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    [Additional submission by Mr Walberg follow:]
    
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    [Questions submitted for the record and the responses by 
Ms. Bendat follow:]

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    [Questions submitted for the record and the responses by 
Mr. Gelfand follow:]

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    [Questions submitted for the record and the responses by 
Dr. Moutier follow:]

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    [Whereupon, at 12:30 p.m., the subcommittee was adjourned.]