[Senate Hearing 117-503]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 117-503

                   THE COVID-19 PANDEMIC AND BEYOND:
                      IMPROVING MENTAL HEALTH AND
                 ADDICTION SERVICES IN OUR COMMUNITIES

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

                                HEARING

                              BEFORE THE

                      SUBCOMMITTEE ON HEALTH CARE

                                 OF THE

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 12, 2021

                               __________

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                                     
                                     

            Printed for the use of the Committee on Finance

                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
49-785-PDF                WASHINGTON : 2022                     
          
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\                        COMMITTEE ON FINANCE

                      RON WYDEN, Oregon, Chairman

DEBBIE STABENOW, Michigan            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey          JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware           JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland         RICHARD BURR, North Carolina
SHERROD BROWN, Ohio                  ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado          PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania   TIM SCOTT, South Carolina
MARK R. WARNER, Virginia             BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island     JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire         STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada       TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts      BEN SASSE, Nebraska
                                     JOHN BARRASSO, Wyoming

                    Joshua Sheinkman, Staff Director

                Gregg Richard, Republican Staff Director

                                 ______

                      Subcommittee on Health Care

                    DEBBIE STABENOW, Michigan, Chair

ROBERT MENENDEZ, New Jersey          STEVE DAINES, Montana
THOMAS R. CARPER, Delaware           CHUCK GRASSLEY, Iowa
BENJAMIN L. CARDIN, Maryland         JOHN THUNE, South Dakota
ROBERT P. CASEY, Jr., Pennsylvania   RICHARD BURR, North Carolina
MARK R. WARNER, Virginia             PATRICK J. TOOMEY, Pennsylvania
SHELDON WHITEHOUSE, Rhode Island     TIM SCOTT, South Carolina
CATHERINE CORTEZ MASTO, Nevada       BILL CASSIDY, Louisiana
MAGGIE HASSAN, New Hampshire         JAMES LANKFORD, Oklahoma
ELIZABETH WARREN, Massachusetts      TODD YOUNG, Indiana
                                     JOHN BARRASSO, Wyoming

                                  (ii)
                                  
                                  
                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Stabenow, Hon. Debbie, a U.S. Senator from Michigan, chair, 
  Subcommittee on Health Care, Committee on Finance..............     1
Daines, Hon. Steve, a U.S. Senator from Montana..................     3

                               WITNESSES

Armstrong, Victor, MSW, Director, Division of Mental Health, 
  Developmental Disabilities, and Substance Abuse Services, North 
  Carolina Department of Health and Human Services, Raleigh, NC..     6
Woodard, Stephanie, Psy.D., Senior Advisor, Division of Public 
  and Behavioral Health, Nevada Department of Health and Human 
  Services, Carson City, NV......................................     8
Kosovich, Lenette, R.N., MHA, chief executive officer, Rimrock 
  Foundation, Billings, MT.......................................    10
Newman, Malkia, team supervisor, CNS Healthcare Anti-Stigma 
  Program, Waterford, MI.........................................    12

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Armstrong, Victor, MSW:
    Testimony....................................................     6
    Prepared statement...........................................    25
Daines, Hon. Steve:
    Opening statement............................................     3
    Prepared statement...........................................    26
Kosovich, Lenette, R.N., MHA:
    Testimony....................................................    10
    Prepared statement...........................................    27
    Responses to questions from subcommittee members.............    28
Newman, Malkia:
    Testimony....................................................    12
    Prepared statement...........................................    29
    Responses to questions from subcommittee members.............    30
Stabenow, Hon. Debbie:
    Opening statement............................................     1
    Prepared statement...........................................    31
Woodard, Stephanie, Psy.D.:
    Testimony....................................................     8
    Prepared statement...........................................    32
    Responses to questions from subcommittee members.............    34

                             Communications

American College of Physicians...................................    39
American Pharmacists Association.................................    46
American Psychological Association...............................    48
Center for Fiscal Equity.........................................    51
Eating Disorders Coalition for Research, Policy, and Action......    52
Healthcare Leadership Council....................................    55
Mental Health Liaison Group......................................    56
National Association of Health Underwriters......................    60

 
                   THE COVID-19 PANDEMIC AND BEYOND:
                      IMPROVING MENTAL HEALTH AND
                 ADDICTION SERVICES IN OUR COMMUNITIES

                              ----------                              


                        WEDNESDAY, MAY 12, 2021

                               U.S. Senate,
                       Subcommittee on Health Care,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 3 p.m., 
via Webex, in Room SD-215, Dirksen Senate Office Building, Hon. 
Debbie Stabenow (chair of the committee) presiding.
    Present: Senators Cardin, Whitehouse, Hassan, Cortez Masto, 
Thune, Burr, Toomey, Cassidy, and Daines.
    Also present: Democratic staff: Alex Graf, Legislative 
Advisor for Senator Stabenow. Republican staff: Rachel Green, 
Health Care Policy Advisor for Senator Daines; and Stuart 
Portman, Senior Health Policy Advisor.

OPENING STATEMENT OF HON. DEBBIE STABENOW, A U.S. SENATOR FROM 
  MICHIGAN, CHAIR, SUBCOMMITTEE ON HEALTH CARE, COMMITTEE ON 
                            FINANCE

    Senator Stabenow. Well, good afternoon. It is my pleasure 
to call this hearing of the Finance Subcommittee on Health Care 
to order. And I am so pleased to be here during Mental Health 
Month talking about the urgent need to improve behavioral 
health-care services in our communities. And I am really 
pleased to be here as well with Ranking Member Daines. I am so 
glad you are my partner on this subcommittee, and I think there 
are a lot of great things that we can do on this subject, and 
others as well.
    Everyone affected by mental illness or substance abuse 
disorders should be able to get the help they need so they can 
live a healthy and fulfilling life, period. And the good news 
is, we can make this a reality.
    Before the pandemic, nearly one in five Americans had some 
form of mental illness, although fewer than half received 
treatment. This lack of support was even worse in the 
communities of color.
    The pandemic has made things worse and exposed the 
weaknesses in the way we pay for behavioral health care in this 
country. In January, 41 percent of American adults reported 
that they were struggling with anxiety or depression. That is 
up from 11 percent before the pandemic. And more than one in 
four young people have reported having suicidal thoughts.
    Meanwhile, overdose deaths have surged during the pandemic. 
The CDC reported that more than 87,000 Americans died of drug 
overdoses during the 12-month period that ended last September. 
That was the most deaths in any year since the opioid epidemic 
began in the 1990s.
    And long after the pandemic ebbs, these behavioral health 
needs are going to continue, and that is why we are here today 
talking about these issues. We need to finally treat health 
care above the neck the same way we treat health care below the 
neck. And the good news is, we are making progress.
    I have worked with my friend Senator Roy Blunt and so many 
people on the committee to create the Certified Community 
Behavioral Health Clinics program, now fully operational in 10 
States, with over 300 startup grants bringing services to 
people in 41 States now.
    We have a structure that allows clinics to truly meet the 
needs of their communities. This has been a tremendous success 
in a short amount of time, and it is the model for the future, 
I believe. These clinics are required to provide comprehensive 
services, including 24/7, 365 mobile crisis team services, 
immediate screening and risk assessment, and easy access to 
care. They see everyone who walks in the door. They have 
tailored care for active duty military and our veterans, care 
coordination with primary care providers, and coordination with 
law enforcement.
    The results are stunning. According to HHS numbers included 
in the budget request last year, people who received services 
through what we call CCBHCs had 63 percent fewer emergency 
department visits for behavioral health. A lot of times folks 
are just sitting in the emergency room, maybe an officer with 
them, with no behavioral health services available.
    We have seen 60 percent less time spent in jails by people 
who really needed health services, and law enforcement now has 
other opportunities and places where they can work with people 
to get people the care they need rather than sitting in jail. 
And we saw a 40.7-percent decrease in homelessness--so 
important.
    And today the National Council for Mental Wellbeing, which 
was previously the National Council for Behavioral Health, 
released a new CCBHC impact report with similarly stunning 
results. They found that more than half of these clinics offer 
same-day services, and nearly all of them offer treatment 
within a week.
    Compare that to the average wait time of 48 days 
nationally. And they are serving thousands of new people. 
Ninety-five percent of CCBHCs have engaged in promising new 
practices in collaboration with law enforcement and our 
criminal justice agencies.
    This month, Senator Blunt and I, hopefully joined by all of 
you, will be introducing legislation giving every State in the 
country the option of participating in this fully successful 
program.
    It will ensure that behavioral health care clinics are 
reimbursed for services in the same way we fund Federally 
Qualified Health Centers. We can get this done, and we can 
bring community care to millions of Americans who need it.
    So I am going to thank our wonderful witnesses who are with 
us today virtually. We have colleagues who are here with us in 
the Finance Committee room, and others who are with us 
virtually as well. And so many of my colleagues have focused on 
this issue and care so much about it--I am so grateful--whether 
it is what I am talking about with CCBHCs, or the importance of 
telehealth, crisis supports, coordination with law enforcement 
and schools, and so many other ways to address mental health 
and substance abuse. It is all very important, and I really 
look forward to working with each of you.
    Now I would like to turn to Senator Daines.
    [The prepared statement of Senator Stabenow appears in the 
appendix.]

            OPENING STATEMENT OF HON. STEVE DAINES, 
                  A U.S. SENATOR FROM MONTANA

    Senator Daines. Madam Chair, thank you. I am really glad to 
be here with you today for the first subcommittee hearing of 
the year. It is also great to have a fellow Montanan joining us 
today. We will get into a more formal introduction in a bit, 
but a warm welcome to Lenette. I am glad you could be here with 
us today.
    May is Mental Health Awareness Month, an issue at the top 
of my mind and many others following a year of isolation for 
Montanans and Americans across the country. In fact last year, 
due to COVID restrictions, Montanans and Americans were forced 
to stay home. We saw family-owned and small businesses shutter; 
workers struggling; family members isolated from loved ones; 
and schools closing, directly impacting our Nation's youngest 
and brightest.
    Through no fault of their own, hardworking Montanans and 
Americans across the country lost their jobs, leaving them 
wondering how they are going to keep a roof over their 
families' heads, and food on the table. Instead of socializing 
and learning with their friends in classrooms, students were 
stuck behind computer screens. Symptoms of anxiety and 
depression are on the rise.
    In fact, one survey states that more than half of the 
adults reported that worry or stress related to the pandemic 
was having a negative effect on their mental health. As we all 
know, mental health issues were a problem before the pandemic. 
In fact, it is estimated that nearly one in five American 
adults had some form of mental illness, but fewer than half of 
those adults received treatment in 2019.
    Since the pandemic, lockdowns, economic hardships, and 
social isolation have only helped to intensify what we already 
knew, and that is, we need mental health services in our 
communities, and we need to make this a priority.
    The pandemic has also helped expose and magnify the flaws 
in our mental health system. Sadly, in 2020 suicide was the 
10th leading cause of death, and drug overdose deaths hit a 
record high. In Montana we are, unfortunately, not immune to 
these devastating statistics. We are fourth in the Nation for 
suicides. We are first in the Nation per capita for children 
being placed in foster care, most often due to a parent's drug 
or alcohol use. And we are witnessing a disturbing increase in 
meth-related violent crime.
    It is clear that more needs to be done to support 
individuals and families struggling with addiction or mental 
illness. We are fortunate in Montana to be home to treatment 
facilities like Rimrock, which I have had the opportunity and 
the privilege of visiting several times over the years. In 
fact, I even had the opportunity to bring Vice President Pence 
and his wife Karen to show them firsthand the great work the 
organization does for Montanans struggling with addiction and 
mental health issues.
    In fact, one visit I will never forget. I had the chance to 
meet with a few moms who were receiving substance abuse 
treatment. I had just become a grandfather. I was overwhelmed 
with emotion to see the little ones there with these moms 
struggling with these addiction issues. But there I saw hope, 
and I saw struggle, and I saw commitment, and so much love that 
the Montana moms had for their children. Because at Rimrock, 
thanks to a bill that I had led in the Senate and was signed 
into law by President Trump, moms who are working to get back 
on their feet are able to stay with their children. Let me tell 
you, that means the world to these moms. It gives them a 
reason, a very important reason, to get better.
    Treatment centers like Rimrock make a world of difference 
in our communities, and they are more important now than ever 
before as we come out of this pandemic. And after a year of 
lockdowns and closures, we are finally starting to see light at 
the end of the tunnel. And thanks to the leadership of our new 
Governor Greg Gianforte, life in Montana is on its way to 
getting back to normal.
    We have vaccinated over 350,000 Montanans and have led the 
Nation in vaccine administration. We are now open for business 
in Montanan, and we are open for school. We are incentivizing 
getting back to work versus staying at home, something I 
believe is also important for mental health, because I believe 
there is dignity in work.
    But the reality is that there will likely be long-lasting 
impacts of the pandemic, particularly on mental health. We must 
aim to meet the challenges of today, and prepare for the 
increased needs that this pandemic has created. So I am very 
committed to working with my colleague Senator Stabenow towards 
that goal.
    And again, I appreciate our witnesses being here today 
offering their advice and their expertise on such a very 
important topic.
    Thank you, Madam Chair.
    Senator Stabenow. Thank you so much.
    [The prepared statement of Senator Daines appears in the 
appendix.]
    Senator Stabenow. We will now introduce our witnesses, and 
I would like to start by inviting Senator Burr to introduce a 
great witness from North Carolina.
    Senator Burr. Madam Chair, thank you very much for having 
this hearing, but more importantly for the opportunity to 
introduce Victor Armstrong from Charlotte, NC, a constituent of 
mine.
    I am proud to say Mr. Armstrong has both decades of 
experience with behavioral health, and strong North Carolina 
roots. Mr. Armstrong currently serves as the North Carolina 
Department of Health and Human Services Director of Mental 
Health, Developmental Disabilities, and Substance Abuse.
    He began serving in this capacity in March 2020, taking the 
directorship at a critical time for behavioral health care. 
COVID-19 was beginning to upend society as we knew it, causing 
economic and social turmoil that has had extraordinary impacts 
on mental health and addiction.
    Prior to assuming his current role, Mr. Armstrong was the 
vice president of behavioral health with Atrium Health Care, 
where he was responsible for operations at Atrium's largest 
behavioral health hospital. He currently serves on the board of 
directors of the American Foundation for Suicide Prevention, 
North Carolina. And he previously served as board chair of the 
North Carolina chapter of the National Alliance of Mental 
Health.
    Mr. Armstrong, thank you for your service, for your 
willingness to be here today, and for the challenging times we 
continue to go through, both in North Carolina and across the 
country. I look forward to your testimony, and I thank the 
chair.
    Senator Stabenow. Thank you very much.
    I would now like to turn to Senator Cortez Masto, who I 
know has placed these issues at the very, very top of her 
issues that she is working on and leading on in Nevada. And so 
I will turn to you, Senator.
    Senator Cortez Masto. Madam Chair and Vice Chairman Daines, 
thank you for holding this important hearing. I am honored to 
introduce Dr. Stephanie Woodard, the Senior Advisor on 
Behavioral Health for Nevada's Department of Health and Human 
Services.
    In that capacity, she manages the planning, policy, and 
funding for our State's substance use disorder and mental 
health programming. In addition to her deep knowledge of our 
behavioral health system, Dr. Woodard also brings clinical 
expertise as a front-line practitioner. She is a licensed 
psychologist whose body of work has focused on behavioral 
health integration, co-occurring disorders, and mindfulness-
based treatments.
    I am especially pleased to have Dr. Woodard here to speak 
to her great leadership in standing at Nevada's nine Certified 
Community Behavioral Health Clinics, or CCBHCs, that Senator 
Stabenow has been so instrumental in building here at the 
Federal level.
    My State has been particularly hard hit by this pandemic. 
The twin public health and economic crises have taken a toll on 
the mental health of Nevada families. And, Dr. Woodard, I am 
glad to have you here today to share your experience and 
insight on how we can better serve families across the country 
as we emerge from the pandemic.
    I look forward to your testimony.
    Senator Stabenow. Thank you so much. And I am going to turn 
it back over now to Ranking Member Daines to introduce a great 
person from Montana.
    Senator Daines. Well, thank you, Chair Stabenow. She is a 
great person from Montana. I am very pleased to introduce and 
welcome Lenette Kosovich to the committee. Lenette serves as 
the CEO of Rimrock Foundation in Billings, MT, which is the 
largest behavioral health organization in the State, providing 
substance abuse treatment and mental health services.
    She has been in this role for over a decade and is well-
versed on the complexities of providing mental health and 
addiction services. I was with her when she hosted Vice 
President Pence in fact, when she had a chance to show him what 
they were doing to help these moms there. She is a trusted 
advocate in Montana and works every day to improve the lives of 
Montanans in need of substance use and mental health 
assistance.
    I am glad my colleagues and others here today will get to 
hear her experiences firsthand. So, thanks for joining us 
today, Lenette. It is great to have you here.
    Senator Stabenow. Well, thanks so much. And last, but 
absolutely not least, I would like to introduce Malkia Newman, 
who is a team supervisor for the CNS Healthcare Anti-Stigma 
Program in Michigan. I have known Malkia for many years, and 
she is a leading advocate, not just in Michigan but nationwide, 
for individuals with mental health and substance abuse issues.
    She is a peer educator, developing and leading programs in 
our State, and sharing her expertise around the country. She is 
also an ordained minister at New Birth International Church in 
Pontiac, MI, and she is a board member of the Oakland Community 
Health Network and has served several terms as board chair and 
vice chair. You know, I could go on and on, but let me just say 
in summary, she is a voice for so many people struggling with 
mental illness and substance use disorders. And she is working 
hard every day to make people's lives better.
    So I am so grateful that you are with us, Ms. Newman. Thank 
you so much for participating today.
    So let me start first--and we will ask each of our 
witnesses to speak for 5 minutes, and we certainly welcome any 
other supplemental information you want to share in writing 
with the committee as well.
    But, Mr. Armstrong, we will start with you. Welcome.

   STATEMENT OF VICTOR ARMSTRONG, MSW, DIRECTOR, DIVISION OF 
MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE 
    SERVICES, NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN 
                     SERVICES, RALEIGH, NC

    Mr. Armstrong. Good afternoon. Thank you, Chair Stabenow, 
Ranking Member Daines, and honorable members of the committee, 
for the opportunity to testify about North Carolina's approach 
to equity in community behavioral health services.
    My name is Victor Armstrong. I am the Director of North 
Carolina's Division of Mental Health, Developmental 
Disabilities, and Substance Abuse Services. I am a social 
worker, a husband, and a father to three black boys. I am a 
mental health advocate, and I am the son of a preacher, born 
and raised in rural North Carolina--Plymouth, to be specific--
but I now reside in Charlotte, NC.
    I share all of this because I am the sum of all of these 
things. This will no doubt create a perception for who I am 
based not only on what I have just shared, but also based on 
your lived experiences and mine.
    Much as you today will interact as tradition and formality 
dictate, in many ways our mental health and substance use 
system has worked the same way until COVID-19 and social 
injustice rocked our Nation.
    Unfortunately, it is a system that has not been practiced 
nor been funded through a lens of equity. The lens of equity is 
about the intersectionality of race, culture, and ethnicity in 
addition to living with mental health and substance abuse 
challenges.
    It is about being black and living with a serious mental 
illness. It is about being Latino and living with intellectual 
disabilities and with traumatic brain injuries. It is about 
being an American Indian and living with a substance abuse 
disorder. It is about being an Asian or trans person, 
struggling with an anxiety disorder exacerbated by the 
discrimination that often accompanies mental illness, the 
bigotry that is perpetrated toward trans Americans, and the 
increasing rates of violence against Asian Americans.
    We cannot ignore how a person of color enters the 
behavioral health system. People of color often do not have 
access to outpatient services within their communities. This 
makes it more likely that they are introduced to the behavioral 
system when they are in a state of crisis, and more likely to 
enter the system via the back of a police car or an acute care 
emergency department, neither of which is conducive to good 
clinical outcomes, and neither of which is likely to foster 
positive relationships with the mental health system.
    Systemic racism and bias, both explicit and implicit, are 
multilayered and seep into every crevice of society. This 
includes our mental health and substance use care, but we can 
change that if you are willing to help to reform our system.
    We know that inequity exists. It is our moral 
responsibility to address that inequity by leaning into equity. 
Every decision that we make as clinicians, policy-makers, or 
simply as agents of change, either leans into creating a more 
equitable system or perpetuates our existing problem of 
inequity.
    We can address the issue of access by supporting the 
creation of more mental health resources in communities of 
color and under-served ZIP codes. We can create more community-
based resources that provide access to upstream treatment.
    One way that communities are doing this is through the 
Certified Community Behavioral Health Clinic, or CCBHC, model. 
CCBHCs are required to provide comprehensive, timely, and 
culturally competent services to anyone in their communities. 
One CCBHC here in North Carolina--Monarch--has embedded a peer 
support specialist with the EMS team that responds to opioid 
overdoses. The peer stays with that person through the trip to 
the hospital and helps to connect them to community treatment 
upon release, making sure that that person does not get lost on 
the road to recovery in the community.
    We support the CCBHC model and appreciate any funding to 
increase CCBHCs. We can support efforts to build a workforce 
that mirrors the population it serves. In North Carolina we 
have roughly 4,000 trained certified peer specialists 
representing black, white, Latino, Asian, and American Indians, 
with only about 1,600 individuals gainfully employed.
    We need to utilize the peer workforce and pay them a living 
wage. We need to partner with Historically Black Colleges and 
Universities to build a multicultural workforce. We need to 
partner with clinicians of color and provide them access to 
government grants and contracts. We need to partner with the 
faith-based organizations, and we need to fund studies that 
consider the nuances of race, culture, and ethnicity and the 
impact on mental wellness.
    Further, we need to better understand the impact of 
systemic racism and complex trauma experienced by people of 
color. In North Carolina, it has taken intentionality to 
mitigate the effects of the COVID-19 pandemic, particularly the 
disproportionate impact of the virus on black and brown 
communities.
    As the North Carolina Department of Health and Human 
Services sought to intervene, we recognized that without 
incorporating trusted voices who represent the individuals we 
seek to assist, we would lack credibility, and full engagement 
would be difficult if not impossible.
    Historically marginalized communities, those marginalized 
by race, ethnicity, or diagnosis, are simply looking for a 
collaborative partner who will value their expertise and life 
experience. We have the resources to build a more equitable 
system. If we do not build equity into our mental health and 
substance abuse programs and practices, we will ultimately fail 
the most powerless and vulnerable.
    I will leave you with one final thought. Mental health and 
substance use transcends barriers, divides, and differences. 
People from all walks of life are dying every day from suicide 
or overdose. Mental health and substance abuse do not see race, 
culture, or ethnicity. The same cannot be said of our treatment 
systems. It is time that we fix our system to serve the diverse 
communities in our Nation. Thank you for your time.
    [The prepared statement of Mr. Armstrong appears in the 
appendix.]
    Senator Stabenow. Thank you so much for that very, very 
important testimony.
    We will now turn to Stephanie Woodard. We appreciate very 
much, Dr. Woodard, your being with us.

    STATEMENT OF STEPHANIE WOODARD, Psy.D., SENIOR ADVISOR, 
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH, NEVADA DEPARTMENT OF 
           HEALTH AND HUMAN SERVICES, CARSON CITY, NV

    Dr. Woodard. Thank you, Senator Stabenow, Ranking Member 
Daines, and members of the committee.
    My name is Stephanie Woodard, and I am a licensed 
psychologist and serve as the Department of Health and Human 
Services' Senior Advisor on Behavioral Health. I also serve on 
the board at the National Association of State Mental Health 
Program Directors.
    I am humbled and honored to have the opportunity to testify 
before you today to discuss how the COVID-19 pandemic has 
highlighted the critical role of crisis services and Certified 
Community Behavioral Health Clinics, as well as underscored the 
importance of Federal spending strategies to support the States 
as they look to build sustainable standards of care.
    National guidelines by the NASMHPD, the Substance Abuse 
Mental Health Services Administration, and the National Council 
have been and continue to be invaluable resources as Nevada 
develops our crisis continuum of care. A coordinated crisis 
continuum of care ensures that when individuals are in crisis, 
they have someone to talk to, someone to respond, somewhere to 
go, and that the system is rooted in effective practices.
    Crisis services should be available to anyone, anywhere, 
any time, regardless of insurance status. It is this cascade of 
care that provides appropriate community-based response to a 
behavioral health crisis, and is essential in saving lives.
    With the implementation of 988 coming in July of 2022, the 
time to act is now. During COVID, Nevada has seen an influx of 
calls and texts through our Lifeline, but also the acuity and 
urgency of those calls have increased. And while we have huge 
Federal grant funds to enhance staffing to meet the increased 
demand, we are still faced with the limitations of the current 
system. 988 presents challenges to States to ensure call 
centers are sufficiently staffed to respond timely to people 
who are reaching out in crisis.
    With 80 to 90 percent of callers having their immediate 
needs addressed by the call, the call center will need to have 
technology to deploy mobile crisis teams, ensure individuals 
have access to needed stabilization services, and 
interoperability with 911.
    We remain hopeful that sustainability will be possible with 
pending 988 State legislation and through Medicaid. 
Overutilization of the 911 emergency response system with EMS 
and law enforcement has resulted in inappropriate and costly 
use of public safety and health-care resources.
    Mobile crisis teams offer an alternative response to 
individuals and families in crisis, allowing for stabilization 
in the community. By providing alternative destinations for 
individuals in crisis, Crisis Stabilization Centers divert 
patients away from costly emergency room visits and unnecessary 
inpatient hospitalizations. Together, these services result in 
cost savings across criminal justice, law enforcement, and 
health care.
    We thank Chairman Wyden and Senator Cortez Masto for the 
inclusion of Medicaid crisis care funding in the American 
Rescue Plan. Within Nevada, a new Medicaid rate for Crisis 
Stabilization Centers is expected to result in a cost savings 
to Nevada over the long term. The recent infusion of Federal 
funds is necessary for the development of this essential 
infrastructure. However, it is insufficient for long-term 
sustainability.
    To bring the entire crisis continuum to scale, Nevada, 
along with other States, will need guidance from the Centers 
for Medicare and Medicaid services to ensure these services are 
sustainable into the future. For States to be successful in 
rising to the challenge 988 presents, coordination between 
SAMHSA and CMS is recommended by the Medicaid and CHIP Payment 
Access Commission, or MACPAC. It will be essential.
    Nevada was fortunate to be selected to participate in the 
CCBHC demonstration grant in 2018. And over the course of the 
demonstration, CCBHCs had increased access to critical safety 
net behavioral health services, while lowering cost of care and 
improving outcomes.
    The success of the CCBHCs can be measured by the 
relationships the clinics have within their communities, 
collaboration with law enforcement for community-based crisis 
intervention services, expansion of services into schools, 
comprehensive case management and peer recovery support to 
better address social determinants of health, and increased 
engagement in care. Additionally, the cost-based reimbursement 
has enhanced their ability to recruit and retain qualified 
behavioral health professionals.
    Nevada's CCBHCs were able to pivot quickly during the 
pandemic to expand telehealth services, resulting in high rates 
in the continuity of care. We would also like to express our 
gratitude to Senator Stabenow, Senator Blunt, the National 
Council, and Nevada's Governor Sisolak, who have supported the 
CCBHC model and expanded the demonstration to 2022.
    Since 2018, we have made significant investment in the 
CCBHCs through our mental health block grant, and continue to 
support the CCBHC expansion grant.
    Thank you for your time, and I am happy to answer any 
questions that you may have.
    [The prepared statement of Dr. Woodard appears in the 
appendix.]
    Senator Stabenow. Thank you so much. We are really 
appreciative that you are with us.
    Lenette Kosovich--we would appreciate Ms. Kosovich sharing 
her testimony.

   STATEMENT OF LENETTE KOSOVICH, R.N., MHA, CHIEF EXECUTIVE 
           OFFICER, RIMROCK FOUNDATION, BILLINGS, MT

    Ms. Kosovich. Senator Stabenow, Senator Daines, and members 
of the committee, thank you for inviting me to talk about one 
of the most complex and far-reaching issues facing Montana and 
our Nation.
    My name is Lenette Kosovich. I am the CEO of Rimrock 
Foundation, the largest behavioral health-care facility in 
Montana, and we are one that provides the full continuum of 
services, including peer support and detoxification, inpatient 
residential, outpatient, and mental health treatment. And we 
have extended treatment for 12 months or longer, as Senator 
Daines said, for women with their children as they recover. We 
also have a reentry program for those recently released from 
incarceration.
    We serve seven treatment courts, including a Family Drug 
Court, a Veteran Court, and recently an Indian Child Welfare 
Act Family Recovery Court. And all in all, we see nearly 2,000 
clients a year.
    There is no doubt that COVID has exacerbated an already 
complex problem. Before COVID, substance use disorder and 
mental illness were already the top health needs in our county 
and our State.
    We have had a methamphetamine-fueled increase in violent 
crime, and we have also had a burgeoning child welfare system 
where four out of every five cases involved parental drug use. 
And over the last 5 or 6 years, our clients are considerably 
more compromised than even a decade ago. Along with serious 
illicit substance use disorder, patients most likely have 
mental health disorders, and they are accompanied by one or two 
comorbidities like hypertension or diabetes. And it has become 
the norm for us to have a 25-year-old patient in our care who 
has already received a heart valve replacement due to 
endocarditis resulting from IV drug use.
    So, enter COVID. Alcohol consumption, drug use, and mental 
illnesses have increased. Our referrals have gone up 40 percent 
in 11 months. The calls to our State suicide hotline have 
doubled. And unfortunately, violent crime in our county has 
increased nearly 70 percent. And one thing we know for certain 
is that drugs have played a part in all of this.
    COVID complicated and delayed service delivery. The 
quarantine and social distancing that we needed to do really 
reduced the space we had to provide services by about a third. 
And many of our industry partners suspended their services, or 
even closed. And so our wait list has increased.
    With physical space at a premium, COVID accelerated the 
adoption of telehealth tenfold. And with that came incredible 
pressure. iPads were needed for all, except it was hard to get 
iPads in some cases. Group therapy via telehealth, except 
Johnny's Internet wasn't that reliable in some parts of 
Montana. Family week via Zoom is great, except Suzy's mom 
didn't have a computer.
    So training and new admission policies, new safety 
protocols; every part of our industry was stretched to the max. 
But the worst challenge of COVID for me was workforce. Before 
COVID, the workforce shortage was severe. Wait times for 
positive COVID results made the problem much worse. And when I 
don't sleep at night, it is often because I am worried about 
the number of my employees pulling a double shift on the brink 
of a mental breakdown themselves.
    History teaches us--we have talked about this--that the 
mental health impact of a catastrophic event such as a pandemic 
will far outlast the physical impact. So I, as well as you, are 
probably buckled in for a bumpy road. Fortunately, we do 
believe there is hope on the horizon with the expansion of the 
Certified Community Behavioral Health Clinics.
    Rimrock in Billings, and two other organizations in 
Montana, were recently granted CCBHC expansion pilots. In the 
active CCBHC sites, this innovative model of care has 
dramatically increased access to mental health and substance 
use disorder treatment. And it has been proven to address the 
pain points, just as I have shared, and I am looking forward to 
some of the same outcomes that were highlighted already by 
Senator Stabenow that were recently released in an impact study 
by the National Council for Mental Wellbeing.
    We must increase the number of clients that are served. 
There is no doubt about that. And we see that a CCBHC model 
does increase the number that are available to serve.
    Wait times are another issue that is always at the top of 
our mind, and we know that 84 percent of clients in this model 
are seen within a week. Investing in the workforce--this is an 
enhanced reinforcement model that allows States to have the 
funds for us to hire more people to the clinic. And then, 
making the crisis service supports available to all.
    Delivery of services in the community, not just in 
facilities, and the innovation and the collaboration with 
criminal justice, community services, helping to divert people 
from crisis--from emergency rooms and jails--and getting them 
into the appropriate level of care is a must.
    Senator Stabenow, Senator Daines, and the committee, there 
is not one constituent whose life has not been impacted by 
substance use disorder or mental illness. And there is not one 
of our economies that also has not had negative impact. And we 
can do better. And the CCBHC model does do better, and I am 
very encouraged and continue to urge you to support these 
models throughout the States.
    Thank you for inviting me to speak on this issue, and I am 
open to answering any questions also.
    [The prepared statement of Ms. Kosovich appears in the 
appendix.]
    Senator Stabenow. Well, thank you so much.
    And again, last but not least, Malkia Newman. Ms. Newman, 
we welcome you. It is wonderful to have a chance to see you 
again, even if it is only virtually.

  STATEMENT OF MALKIA NEWMAN, TEAM SUPERVISOR, CNS HEALTHCARE 
               ANTI-STIGMA PROGRAM, WATERFORD, MI

    Ms. Newman. [Sings a song.]
    Good afternoon, members of the U.S. Senate, staff, and 
guests. I am very honored to be asked to give testimony to this 
distinguished body today. I want to especially thank Health 
Care Chairwoman Debbie Stabenow and Ranking Member Steve Daines 
for convening this vitally important discussion today.
    My name is Malkia Newman, and I am living proof that the 
services and support that are available through our community 
mental health system work. I am not naive to the fact that many 
areas need to be improved, but I know that my life would not be 
the amazing life that I am living now had I not received 
treatment for bipolar disorder almost 20 years ago.
    I am a survivor of childhood sexual trauma, as well as a 
survivor of intergenerational trauma, a sad legacy of slavery 
and discrimination. I wrestled with suicidal thoughts, had 
difficulties maintaining relationships or employment. My 
daughter Tracie--I call her my miracle--she was my reason for 
living when all hope was gone.
    Mental health conditions are prevalent in my family. The 
treatment and hospitalizations that my brother Ronnie endured, 
who had schizophrenia, terrified me, which made it harder for 
me to ask for help until there was no other option available.
    Fast forward 20 years. I have 15 years of continuous 
employment with CNS Healthcare's Anti-Stigma Program. I have 
been a homeowner for 9 years. And on June 5th, my husband 
Dubrae and I will celebrate our 15-year wedding anniversary. I 
have reconciled with my family, and I serve proudly as an 
ordained minister at my Church, New Birth International. My 
list of community service awards and recognitions is long.
    I am living proof, I am an advocate, and I am proud to 
speak on behalf of those who have not yet found their voice. It 
is vitally important that we not just continue to offer 
behavioral health treatment, but that we prepare for the 
increased need that the pandemic has created.
    We need more qualified providers--doctors, nurses, 
therapists, and other support personnel, especially Peer 
Support Specialists--people with lived experience and expertise 
in the mental health field who can encourage and educate people 
receiving services in a richer way than the other professionals 
can.
    We need to compensate our professionals at every level to 
make sure that we have qualified, culturally and linguistically 
competent people meeting the needs of people no matter what 
their background.
    The Certified Community Behavioral Health Clinics, the 
CCBHCs, have made it easier for people to access services 
regardless of if they have insurance or not, which in the past 
has created a huge barrier for people needing help.
    Integration of physical and mental health has been a topic 
of discussion for many years. Integration is needed to help 
people with mental health disorders live longer, healthier 
lives, but the focus has shifted from people getting whole 
health treatment from head to toe, to an argument about who 
will fund and administer the dollars associated with the 
treatment.
    I believe that the people served, and their loved ones, 
should have a role in shaping what health care should be, as 
people with intimate knowledge of what works and what does not. 
Advisory groups can and should be involved at every level of 
program development, implementation, and evaluation. The 
finished product would be more efficient and cost-effective as 
well.
    It is my prayer and hope that we will not rush to get back 
to ``normal'' at the expense of programs and systems that work.
    Thank you for this time of testimony, and I am available to 
answer any questions that you may have. Thank you.
    [The prepared statement of Ms. Newman appears in the 
appendix.]
    Senator Stabenow. Well, thank you so much, Malkia. It is 
wonderful to see you again, and I so appreciate your courage 
and your work in Michigan.
    We will now turn to questions. And let me start by first 
saying that there are so many things that we need to do in this 
area, but fundamentally for me, and the work that Senator Blunt 
and I have done, is to basically say we should fund mental 
health and substance use disorders as health care--health care. 
And yet we fund Federally Qualified Health Centers in a 
permanent way, fully reimbursing for the cost of services, and 
in the area of mental health, of course, and substance use, as 
you know, we do not. We basically have done it traditionally 
through grants. And when the grant runs out, the service is 
gone.
    So that is the whole point of CCBHCs: to move to what we 
know works in the community. So right now we have wonderful 
support for fully expanding across the country the opportunity 
to fully fund health care that is above the neck. In fact, we 
have 22 members of the Finance Committee now who have at least 
the start-up grants in their State. There are 10 States that 
are fully funded as health care, and we want to expand that.
    But I would like to ask each of you a question relating to 
CCBHCs as we move forward with the next legislation we will be 
offering soon.
    Ms. Kosovich, you were awarded a CCBHC expansion grant 
earlier this year, and I understand you are going live next 
month. I wondered if you might just speak a little bit more 
about the kind of services that you are going to be able to 
provide in the community as a result of the new funding, and 
what it would mean to take the next steps to be fully funded 
like health centers are.
    Ms. Kosovich. Certainly. Thank you for the question. We 
have already implemented one of the components, and that is the 
PACT team, which is the Program for Assertive Community 
Treatment.
    This is about taking care of people where they are in the 
community. Again, they are not necessarily coming to a 
facility. They are being served at their house, at a coffee 
shop, sometimes we take them for a ride in their car, or in our 
car. And we have found already some amazing results from that.
    Our local health-care organizations are talking about how 
that has reduced ER visits already. We are a huge proponent of 
peer supports, and we have been using those also with our PACT, 
and with our other treatment services.
    And one of the things probably most important to our county 
right now is crisis services. We have had a plethora of crime 
over the last 6 weeks, devastating crime, like I said earlier 
in my testimony, methamphetamine-fueled. And for us to be able 
to get to a crisis before it comes to the level that there 
might be loss of life, is so important for us.
    So those are some of the things that we are most excited 
about bringing forward.
    Senator Stabenow. Thank you so much. I appreciate it.
    And, Dr. Woodard, I know that you were the lead for the 
State of Nevada in putting together the CCBHC planning grants, 
and one of the 10 States that are receiving the full funding 
now, reimbursement and prospective payment for staffing and so 
on.
    So I wonder if you could talk a little bit about what this 
program has meant for communities in the State and what 
services you are providing that you were not able to provide 
before you had the stability of this funding?
    Dr. Woodard. Thank you for the question, Senator Stabenow. 
CCBHCs actually have accelerated a lot of momentum related to 
implementing evidence-based practices, as well as ensuring that 
communities have a full continuum of care that is available to 
them.
    So one of the basic premises around CCBHCs is being able to 
provide services in the community, moving outside of the four 
walls, and ensuring that individuals, whether it be children, 
adolescents, or adults and families, have access to the care 
that they need in the most timely way.
    Crisis services have expanded the opportunity for 
individuals who need immediate services to be able to receive 
those services, whether it is within the clinic or out in the 
community. Partnerships with law enforcement have also 
encouraged more individuals to be interfaced with crisis 
services versus going to the emergency room or to jails.
    The access to services, especially during COVID, has been 
incredibly important. We have been able to see continued care 
that has been throughout COVID. We actually did not see a big 
decrease in access to care through our CCBHCs. So the 
comprehensive array of services that is available, was, and 
continues to be available during COVID, was really critical in 
ensuring that individuals had timely access to services.
    Through some of the evidence-based practices--I heard PACT 
be mentioned before--making sure that assertive community 
treatment is available in our communities has also been very 
important. It is really critical to ensure that people have the 
opportunity to remain in their communities, and are supported 
with wrap-around services in order to continue to remain 
stable.
    We also have focused a lot on transitions of care. So as 
individuals are moving from inpatient psychiatry back into the 
community, or as they are moving at the continuum of care, the 
CCBHCs are able to support that individual wherever they move 
throughout the system so that they have a home, a behavioral 
health home, which will allow them to continue to repeat those 
services over the long term.
    It is really the continuity of care and the continuum of 
care that CCBHCs have provided that have had, I think, some of 
the greatest results in the communities where CCBHCs are. We 
also know that our CCBHCs were not previously community mental 
health clinics. The vast majority, actually eight of the nine, 
had started out as substance abuse and disorder treatment 
providers. These providers had a lot of work to do in order for 
them to be able to meet the demands and the rigors of the CCBHC 
model, and in partnering with the States they are able to 
achieve what I think are some pretty phenomenal achievements in 
being able to build the expansion of services necessary to meet 
the CCBHC certification criteria.
    We have one FQHC, and that dually certified FQHC is also 
working through what it means to have the dual certification 
for the FQHC and the CCBHC. But we have leaned in very hard 
into the CCBHC model, investing mental health block grant 
dollars to expand the CCBHC even outside of the expansion 
grants, because we have seen that the value these Certified 
Community Behavioral Health Clinics bring to our communities is 
worth the investment.
    Senator Stabenow. Well, thank you so much.
    I am going to turn now to Senator Hassan, and thanks, 
Senator Daines. For the audience, we are in the middle of 
votes, so we are running back and forth to vote and coming 
back. Senator Daines voted and is now back, but I know Senator 
Hassan is going to go vote in a moment. So I am going to turn 
it over to Senator Hassan, who is certainly a passionate 
advocate and certainly understands all of these issues, and we 
are so glad to have your voice in the U.S. Senate.
    Senator Hassan. Thank you so much, Senator Stabenow. And 
thank you to the ranking member for his courtesy in letting me 
go first.
    I have a question for Dr. Woodard. Even before the COVID-19 
pandemic, our health-care system was grappling with an 
unprecedented workforce shortage. Today, as more and more 
Americans are struggling to access mental health and substance 
use disorder treatment services, it is critical that Congress 
ensures robust support for the behavioral health workforce.
    That is why I reintroduced bipartisan legislation with 
Senator Collins that creates 1,000 new medical residency 
positions focused on addiction medicine at teaching hospitals 
in New Hampshire, Maine, and all across the country.
    Dr. Woodard, can you please speak to the existing mental 
and behavioral health-care workforce shortage that we are 
facing? And what steps should Congress take to provide support 
for these providers in the coming years?
    Dr. Woodard. Thank you for the question. Nevada actually 
has a very significant workforce shortage in the majority of 
our State, about 14 counties that experienced severe workforce 
shortages.
    One hundred percent of Nevadans actually live in a 
workforce shortage area. So workforce shortages are something 
that we have prioritized as a State for quite some time. And 
what we have seen is, when we have been able to track the 
pipeline for behavioral health providers, it includes reaching 
down to the K-12 programs and beginning to build opportunities 
for specialization and introduction into careers in the 
behavioral health-care system, as well as in the broader 
health-care system.
    Being able to track individuals and how students really 
engage in education around health care and behavioral health 
care is one of the greatest strategies that we can use--so, 
ensuring that we have some opportunity to build capacity within 
our K-12 system and to begin to introduce careers and then, 
once individuals are engaged in education, making sure that the 
cost of education is not so great that it keeps people who are 
very capable and motivated in being part of the workforce from 
actually engaging in education.
    So we want to encourage individuals to go into careers, 
especially in the behavioral health field, without fear of 
being saddled with overwhelming student debt when they get out. 
Certainly loan repayment programs--and from a Federal level, 
loan repayment programs are very helpful in encouraging 
individuals to move into these critical health-care fields, 
knowing that the risk for financial burden in the future can be 
limited.
    Also the opportunity is there to build residencies and 
internships within States so that people who are moving through 
the professional training path can remain in the communities 
that they wish to live and serve in so that they do not have to 
travel to other communities in other States to receive the 
enriched experience, education, and training necessary to move 
into the professional field.
    And it is also looking to stratify the behavioral health 
workforce. You know, one of the greatest workforce multipliers 
that we have seen in Nevada is the introduction of the Peer 
Recovery Support Services. Community health-care workers and 
Peer Recovery Supports really help to build upon a foundation 
of a strong behavioral health care delivery system and really 
do serve as a workforce multiplier.
    So an opportunity to continue to build those professions as 
well, can certainly help to offset some of the workforce 
shortages that we see in the behavioral health-care field.
    Senator Hassan. Thank you very much.
    I have one more question to Director Armstrong. The 
dramatic expansion of telehealth during the pandemic has 
increased access to mental health services for many Americans. 
But rural residents, low-income individuals, and communities of 
color have faced unique hurdles accessing the technology needed 
to get mental health telehealth services.
    Moving forward, Congress has to work to address the 
remaining inequities that limit access to mental health 
telehealth services for underserved communities.
    Director, how can Congress work to expand access to mental 
health services through telehealth for rural areas, low-income 
individuals, and communities of color?
    Mr. Armstrong. Thank you for that question. I think there 
are a number of things that we can do.
    First of all, we do need to expand broadband access in our 
rural communities. We here in North Carolina have a number of 
people in our most rural communities who do not have adequate 
broadband access. So that is one of the things that we have to 
address.
    But one of the other things that I think we have to look at 
is, while access to telehealth has been a huge advantage during 
the COVID-19 pandemic because it has allowed us to continue to 
provide services to people who otherwise would not have been 
able to have access, the other thing that I think we have the 
ability to do and that we could use support and funding for is 
that we have done, over the years, a decent job of integrating 
behavioral health into primary care, and primary care into 
behavioral health. With the expansion of telehealth, it also 
gives us an ability to expand into communities where people 
live, work, and play. In addressing the social determinants of 
health, that is our primary goal.
    And by that, I give an example of looking at, particularly 
in some of these rural communities where people may not have 
access at home, why can we not incorporate telehealth and 
behavioral health into the faith-based community, into the 
YMCAs, into the community centers?
    So one of the things I think Congress can look at is, how 
do we provide more resources to expand and partner differently 
than we have in the past? This also helps us to address some of 
the issues around access to care for communities of color. In 
many of the communities that have socioeconomic challenges, 
access to those services is not available in their communities. 
And if we want to address those access issues, we can do that 
by expanding telehealth, by relaxing some of the restrictions 
around utilizing telehealth, and by allowing funding that 
allows organizations and State systems to partner more easily 
with communities.
    Part of our challenge oftentimes is that the funding that 
we receive--while we greatly appreciate the Federal funding--is 
often restricted in how we can use it. Oftentimes we can only 
use the funding for individuals who are severely mentally ill, 
or children who have severe emotional disturbances. And what 
would allow us to utilize those services more easily would be 
if we were able to use it for more prevention, and be able to 
use that telehealth service to reach people before they reach 
that point of crisis.
    Senator Hassan. Thank you. Thank you very much. And thank 
you, Madam Chair and Ranking Member, for your indulgence. And 
now I am going to vote.
    Senator Stabenow. Yes, please do. And thank you.
    Now, Ranking Member Daines.
    Senator Daines. Right. Thank you, Chair Stabenow.
    In Montana, meth--and it's Mexican meth--is taking a 
devastating toll on our communities. It has contributed to an 
increase in violent crimes across our State. In fact, a few 
weeks ago when I was on our southern border, I heard directly 
from Border Patrol agents of the need to secure the southern 
border to stop the flow of illegal drugs into our country, and 
in this case into Montana, as well as directly into our State.
    In fact, I spoke with the Cascade County sheriff recently 
who told me they have Mexican cartel members who have been 
incarcerated in the county jail there in Great Falls.
    Ms. Kosovich, could you speak a bit about how Rimrock is 
working to support those in need of behavioral health services? 
And importantly, what might Congress or the Biden 
administration do to help combat meth use and crime?
    Ms. Kosovich. It is--thank you for the question, Senator 
Daines. It is one of the most concerning things that we see 
here. And like I said earlier, the amount of crime that we're 
seeing resultant of meth use is seriously out of control.
    I had the honor to work with Kurt Alme, who was our former 
U.S. Attorney General for Montana for the last 3 years, and we 
talked very deeply about where this meth is coming from. And he 
said unequivocally we know there are five different Mexican 
cartels that are using I-90 all the way up to Montana. They 
have foregone the use of the middle man. They are selling 
directly.
    So there are a couple of things that I think would really 
help. One, it is a supply and demand issue. Let's take away the 
demand through treatment. Let's make sure that we get to those 
folks who have been suffering with meth addiction and get them 
on the road to recovery.
    One of the challenges we know with meth is, it really does 
change some brain chemistry. And it takes a while for a person 
to have the clarity to even engage deeply in treatment when 
they have been on meth.
    One of the things that I would like to see is funding for 
longer-term treatment for meth itself, meth addiction itself, 
so we have that opportunity of time to get the brain to start 
healing and reduce some of the cravings and those things that 
make them want to continue to go out and seek and feed their 
addiction.
    So I think that that is one thing. If we have the funding 
for longer-term meth use, let's also just cut off the supply 
and get people treated so we do not have these cartels on this 
highway-to-high coming up I-90.
    Senator Daines. Thanks, Ms. Kosovich. In Montana and across 
the country, we do not have a job shortage; we have a labor 
shortage. Businesses across Montana, as I drive around the 
State, I see their struggles to find workers. In fact, when you 
drive across our State, you see a lot of ``Now Hiring'' or 
``Help Wanted'' signs. Some Montana businesses in fact are 
being forced to close because they cannot find enough workers.
    Ms. Kosovich, in your experience, is there a correlation 
between employment, working, and mental health?
    Ms. Kosovich. There absolutely is. I mean, we look at it as 
one of the social determinants of health. Your overall well-
being--there is data that shows it will be better if you are 
employed.
    A couple of weeks ago we actually partnered--the Billings 
Chamber of Commerce partnered with the U.S. Chamber of Commerce 
and gave a seminar to employers across Montana talking about 
drug use in the work environment. How do you recognize it? What 
do you do about it? Because, like you said, we need everybody 
who wants to work and is available to work to work so we can 
start addressing this shortage.
    I felt it was very helpful. There were some great 
questions. I think that there are some strategies that are 
going to be coming out of both the Montana Chamber of Commerce 
and the U.S. Chamber of Commerce to directly address this 
issue, to make sure that we have everybody out there who wants 
to work working.
    It absolutely is a direct correlate of the social 
determinant of care.
    Senator Daines. So experts said, as you did in your 
testimony, that we have not even reached the peak need for 
behavioral health services as a result of the COVID-19 
pandemic. In fact, local leaders in Montana say we will not see 
the peak negative health effect until probably 18 to 24 months 
after this public health emergency.
    As discussed earlier, we are already facing workforce 
shortages across Montana, including in the mental health and 
behavioral health space.
    Ms. Kosovich, how do we ensure that we are better equipped 
to serve those in need when we have not even seen the full 
effects of the pandemic on mental health? I will also ask Ms. 
Newman to respond to that question.
    Ms. Kosovich. It is a horrifying question to answer. We are 
competing, with mental health worker wages, with every industry 
there is. We have been historically paid poorly, or low, and it 
is mainly because of the reimbursement levels. I believe the 
CCBHC model really will give us a leg up to be able to be 
competitive to attract that talent and the skill set that we 
need to sustain a hardy behavioral health service.
    I think there is hope on the horizon because of the CCBHC 
and the enhanced reimbursement.
    Senator Daines. Thank you.
    Ms. Newman, do you have a thought on that question? Then 
I've got to yield back my time; I'm over.
    Ms. Newman. Yes, I do have a thought on that question. My 
work on the Anti-Stigma team is to address the negative 
connotation that is associated with mental health in general. 
And sometimes when we speak to audiences, they do not always 
understand what it is like living with a mental health 
condition, and that you do not have to be fearful.
    We speak to nursing students. We speak to psychiatric 
students. We go into colleges. And we have a chance for them to 
meet us on this side of graduation. And many times when they 
have had a chance to interact with us and see that we are not 
cutters and slashers, and that we will not con them, people are 
more inclined to want to go into mental health as a profession 
because the stigma has been taken away, that negative 
connotation has been taken away. I think that is one of the 
areas that we definitely need to do more work in: the way we 
speak about mental health, the way we speak about people who 
receive mental health treatment. We are not junkies. We are not 
frequent fliers. We are not bipolar. We are people who have 
conditions that are treated successfully and live very 
successful lives, and we need to highlight that more so that 
people know that this is an honorable profession and it is one 
that you may want to pursue.
    Senator Daines. Thank you, Ms. Newman.
    Ms. Newman. Thank you for the question.
    Senator Stabenow. Thank you very much, Senator Daines.
    I believe Senator Cortez Masto is back with us.
    Senator Cortez Masto. I am; thank you to the chairwoman. I 
apologize. I have two committee hearings going at the same 
time.
    But let me start with Dr. Woodard. One of the most 
concerning patterns that we have seen emerge from the pandemic 
is the relative spike in behavioral health cases that present 
in our emergency rooms. That worries me, and I think it worries 
many of us, because it could suggest that we are seeing more 
severe cases. But I am also concerned that the ER may not be 
the best place for many of these cases.
    So, Dr. Woodard, can you talk about the importance of 
providing the right care in the right setting?
    Dr. Woodard. Thank you for the question. We have seen that, 
on any given day, pre-COVID, we had 90 individuals waiting in 
our emergency rooms for inpatient hospitalization.
    In an effort to try to resolve this, we have looked to see 
what in our community is missing. Is there an opportunity for 
us to do a better job of aiding individuals where they are at, 
with the issues that they are bringing forward? And what we 
have realized is that we have some pretty critically 
significant gaps in our communities to be able to address some 
of those most immediate needs.
    As I had mentioned in some of my testimony before, we 
really believe that building out the 988 system is critical to 
helping individuals on the other end of the phone--who can 
answer that call 24 hours a day, 7 days a week--to be able to 
address whatever their needs are.
    And what we see from some of the data is, approximately 80 
to 90 percent of individuals who call the crisis line are able 
to have their issues resolved, at least resolved to a point 
where they can get maybe a same-day or a next-day appointment. 
Without that critical service, an individual may, in a time of 
desperation, go to the emergency room to present for treatment.
    We also recognize that mobile crisis teams are an essential 
component to getting services to an individual in the community 
where they are at when they need the service. Our Children's 
Mobile Crisis Team works with families 24 hours a day, 7 days a 
week, to be able to go into the home, meet with the family, 
help to deescalate the crisis. And more often than not, that is 
a diversion from the emergency room. Parents and families who 
are struggling with no other options most likely will seek care 
in an emergency room.
    What we also see is that crisis stabilization--so that 
alternative destination, that alternative front door--is very 
important so, instead of having people go to the emergency 
rooms, which are providing critical emergency medical services, 
we have a place for people to be able to go that is welcoming 
that can serve them in a way that they need to be served by 
providing screening and assessment in behavioral health 
services. A large peer workforce incorporated into those Crisis 
Stabilization Centers helps individuals really strategize and 
problem-solve. And when we have seen this model work, we see 
that actually relatively few individuals who were touched by 
these systems end up needing that higher level of care for 
inpatient psychiatry.
    So overall, we believe that it is all solutions. It is 988, 
it is Mobile Crisis, and it is Crisis Stabilization Services in 
our community that will make the greatest difference in helping 
to keep individuals from needing care in the emergency room.
    Senator Cortez Masto. Oh, I could not agree more. And that 
is why I so appreciate Chairwoman Stabenow for having this 
hearing today, and all the good work that she has done on this 
issue in addressing mental health in our communities--and 
Senator Blunt as well.
    I am working with Senator Cornyn on a bill that seeks to 
better integrate behavioral health crisis services, including 
those provided by the CCBHCs, and health planning, and to 
really put crisis services on par with physical health care.
    So, thank you for your comments, and for the panel members. 
Thank you so much.
    Ms. Newman, thank you for sharing your story. I believe 
strongly that community leaders like you who have experienced 
some of life's toughest challenges will be key to helping us 
meet the country's mental and behavioral health needs moving 
forward.
    Can you talk a little bit about the benefits of peer 
support when they are provided as part of a patient's care 
plan?
    Ms. Newman. One of the greatest benefits of peer support is 
when you are in crisis and you are talking to a peer, you do 
not have to explain. Some things you cannot even put into 
words. We connect on a level that is really deep.
    I will give you an example. A young lady called me a couple 
of weeks ago and started to share with me why she was suicidal. 
And she had three children. Two of her sons had been murdered. 
One of them died in her arms, screaming, ``Mama, help me!''
    She was going through a divorce, and she saw both of her 
parents take their last breath. I started crying with her on 
the phone, but I also told her any one of those things would be 
enough to put somebody on the brink, but you must be a very 
special person; you are surviving all of that.
    I was able to help her see her situation in a different 
light. Even though all those things were horrible things that 
happened, and sad, she still came away from the conversation 
with hope, because she did not want to die, and I recognized 
that. She did not want to die. She just wanted the pain to stop 
and for somebody to be able to say, ``I hear. You are hurt. I 
hear that you need help.'' And she was in treatment within 4 
days of that phone call. I reached out to our CCBHC and got her 
an intake within days.
    So when you talk to a peer, it is like a warm fuzzy 
blanket. You do not have to explain. You do not have to be 
ashamed. You do not have to feel like you are less than because 
you are struggling. Peers do amazing work, amazing work. I love 
my job. If I did not get paid to do what I do, I would still do 
it.
    Thank you for the question.
    Senator Cortez Masto. Oh, thank you. I agree with you. I 
have learned the benefits of peer support and peer counseling. 
It just really makes the difference that I have seen. So thank 
you. Thank you to all the panelists.
    Senator Stabenow. Thank you so much, Senator Cortez Masto. 
I just want to say ``amen'' to Malkia. Thank you so much. We 
are so proud of you in Michigan and for all that you do to help 
people reach out to get the help they need, and the recovery 
they need. So we are so grateful that you are part of what is 
happening in Michigan to help people.
    At this point, I am going to have to leave to go vote on 
the floor. There are actually a couple of votes. And so, we are 
at a point where I am going to turn the gavel--we have a 
bipartisan hearing going on. I am turning the gavel over and 
trusting Senator Daines to wrap up the meeting.
    He has one other question he wants to ask. I have 50 I 
could ask, and certainly I will continue to work with all of 
you because there is so much to do, and we are so grateful, and 
we are excited about moving forward to the next step to be able 
to make CCBHCs available to every State, the full funding, 
treating health care above the neck, funding it the same as 
health care below the neck. And so we are excited about moving 
forward with all of you to get that done.
    But at this point, I will turn to Senator Daines. And he 
will wrap up the hearing, and we will follow up with questions 
for everyone. But we appreciate you. Mental Health Month is 
this month, and let's all reach out to tell our own stories and 
then move forward together to make things better.
    Thank you.
    Senator Daines?
    Senator Daines [presiding]. Senator Stabenow, thanks for 
your help and your leadership. And I think the American people 
would like to see more of this. We are literally sharing a 
gavel. So thank you. I will be down to join the vote here in 
just a minute. So thank you.
    I do have one more question, Ms. Kosovich, that relates to 
stigma associated with seeking mental health treatment. If your 
neighbor can recognize your truck or a vehicle outside a 
treatment facility, you might not be comfortable seeking help.
    With Montana in the top five States with the highest 
suicide rate, sadly, this seriously concerns me. That is why I 
think it is important that we look for ways to increase access 
to mental health treatment and really think outside the box 
when it comes to increasing access, including using mental 
health telehealth services.
    Ms. Kosovich, do you think it is important for individuals 
to have access to mental health services outside of the 
traditional brick and mortar doctor's office?
    Ms. Kosovich. I absolutely do believe so, and thanks for 
that question. You know, we have been doing telehealth before 
COVID. COVID forced us to do it better and look at different 
access points for everything. And I would go as far as saying 
there are other applications for telehealth too, when we are 
talking about the crisis continuum and how we are going to 
serve that.
    We have some very promising pilots going on with tablets, 
with our law enforcement, that they are out in the road and 
they can actually connect somebody in mental health crisis with 
the appropriate level of care, either a peer or a counselor, 
whatever it may be.
    So the applications are just so profound. And it should not 
be contained just to a mere facility. We do have some people 
who have done a lot better on telehealth during COVID, 
especially people who have anxiety disorders. We also have a 
contingency, if they really want to have that face-to-face, but 
I think finally we have the opportunity to have both.
    And one comment on stigma. I remember when I was a little 
girl and my mom would have a coffee klatch, and I could hear 
them whispering about the neighbor who had ``cancer.'' They 
whispered the word ``cancer.'' And I thought it was something 
so bad, and we know how far we have come over the years in 
treatment of cancer.
    And if we just would stop whispering about ``mental 
health'' and ``addiction'' and people who--I am so proud of 
this panel talking about their own stories. Maybe stopping that 
whisper will be the impetus for us to stop the stigma. And that 
would be my encouragement for everybody who has a story and can 
tell it; we might get there some day.
    Senator Daines. Well, thank you, Ms. Kosovich. And thanks 
to the panel today. I share your gratitude, Ms. Kosovich. This 
has been a great panel, and I appreciate the expertise, the 
passion, and the compassion that we saw today from our 
witnesses.
    This concludes the subcommittee hearing. We have up to 7 
days if changes need to be made to the record. But without any 
further Senators here seeking to question, this subcommittee is 
now adjourned.
    [Whereupon, at 4:15 p.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


  Prepared Statement of Victor Armstrong, MSW, Director, Division of 
    Mental Health, Developmental Disabilities, and Substance Abuse 
    Services, North Carolina Department of Health and Human Services
    Good afternoon. Thank you, Chair Stabenow, Ranking Member Daines, 
and the honorable members of the committee, for the opportunity to 
testify on North Carolina's approach to ensuring equity in community 
behavioral health services.

    My name is Victor Armstrong. I am the Director of the North 
Carolina Division of Mental Health, Developmental Disabilities, and 
Substance Abuse Services. I am a social worker, a husband, and a father 
to three black boys. I am a mental health advocate, and I am the son of 
a preacher, born and raised in rural North Carolina--Plymouth to be 
specific--though I now reside in Charlotte, NC. I share all of this 
because I am the sum of all these things. This will no doubt create a 
perception of who I am, based not only on what I have just shared, but 
also based on both your lived experience and mine. Much as you today 
will interact as tradition and formality dictate, in many ways our 
mental health and substance use system has worked the same way. 
Unfortunately, it is a system that has not been practiced nor been 
funded through a lens of equity.

    The lens of equity is about the intersectionality of race, culture, 
and ethnicity, in addition to living with mental health and substance 
use challenges. It is about being black and living with a serious 
mental illness. It is about being Latino and living with intellectual 
disabilities or traumatic brain injury. It is about being American 
Indian and living with a substance use disorder. It is about being an 
Asian or trans person struggling with an anxiety disorder exacerbated 
by the discrimination that often accompanies mental illness, the 
bigotry that is perpetrated toward trans Americans, and the increasing 
rates of violence against Asian Americans.

    We cannot ignore how a person of color enters the behavioral health 
system. People of color often do not have access to outpatient services 
within their communities. This makes it more likely that they are 
introduced to the behavioral health system when they are in a state of 
``crisis'' and more likely to enter the system via the back of a police 
car or an acute care emergency department, neither of which is 
conducive to good clinical outcomes, and neither of which is likely to 
foster a positive relationship with the mental health system.

    Systemic racism and bias, both explicit and implicit, are 
multilayered and seep into every crevice of society. This includes our 
mental health and substance use care, but we can change that if you are 
willing to help to reform our system. When we know that inequities 
exist, it is our moral responsibility to address those inequities by 
leaning into equity. Every decision that we make as clinicians, policy-
makers, or simply as agents of change, either leans into creating a 
more equitable system or perpetuates our existing problem of inequity.

    We can address the issue of access by supporting the creation of 
more mental health resources in communities of color and underserved 
ZIP codes. We can create more community-based resources that provide 
access to upstream treatment.

    One way that communities are doing this is through the Certified 
Community Behavioral Health Clinic, or CCBHC, model. CCBHCs are 
required to provide comprehensive, timely, and culturally competent 
services to everyone in their communities. One CCBHC here in North 
Carolina--Monarch--has embedded a Peer Support Specialist with the EMS 
team that responds to opioid overdoses. The peer stays with that person 
through the trip to the hospital and helps to connect them to community 
treatment upon release, making sure that the person does not get lost 
on the road to recovery in the community. We support the CCBHC model 
and appreciate any funding to increase CCBHCs.

    We can support efforts to build a workforce that mirrors the 
populations served. In North Carolina, we have roughly 4,000 trained 
Certified Peer Specialists, representing blacks, whites, Latinos, 
Asians, and American Indians, with only about 1,600 individuals 
gainfully employed. We need to utilize the peer workforce and pay them 
a living wage. We need to partner with Historically Black Colleges and 
Universities (HBCUs) to build a multicultural workforce. We need to 
partner with clinicians of color and provide them access to government 
grants and contracts. We need to partner with faith-based 
organizations, and we need to fund studies that consider the nuances of 
race, culture, and ethnicity and the impact on mental wellness. 
Further, we need to better understand the impact of systemic racism and 
complex trauma experienced by people of color.

    In North Carolina, it has taken intentionality to mitigate the 
effects of the COVID-19 pandemic, particularly the disproportionate 
impact of the virus on black and brown communities. As the North 
Carolina Department of Health and Human Services sought to intervene, 
we recognized that without incorporating trusted voices who represent 
the individuals that we seek to assist, we will lack credibility, and 
full engagement will be difficult, if not impossible. Historically 
marginalized communities--whether marginalized due to race, ethnicity, 
or diagnosis--are simply looking for a collaborative partner who will 
value their expertise and life experience. We have the resources to 
build a more equitable system. If we do not build equity into our 
mental health and substance use programs and practices, we will 
ultimately fail the most powerless and vulnerable.

    I will leave you with one final thought: mental health and 
substance use transcends barriers, divides, and differences. People 
from all walks of life are dying every day from suicide or overdose. 
Mental health and substance use do not see race, culture, or ethnicity. 
The same cannot be said of our treatment system. It is time that we fix 
our system to serve the diverse communities in our Nation. Thank you 
for your time.

                                 ______
                                 
               Prepared Statement of Hon. Steve Daines, 
                      a U.S. Senator From Montana
    Thank you, Madam Chairwoman. I'm glad to be with you hosting our 
first subcommittee hearing of the year. It's also great to have a 
fellow Montanan join us today. We'll get into a more formal 
introduction in a bit, but welcome, Lenette. I'm glad you could be 
here.

    May is Mental Health Awareness Month--an issue at the top of my 
mind and many others following a year of isolation for Montanans and 
Americans across the country. Last year due to COVID restrictions, 
Montanans and Americans were forced to stay home--we saw family-owned 
and small businesses shutter; workers struggle; family members isolated 
from their loved ones; and schools close, directly impacting our 
Nation's youngest and brightest.

    Through no fault of their own, hardworking Montanans and Americans 
across the country lost their jobs--leaving them wondering how they 
were going to keep a roof over their families' heads and food on the 
table. Instead of socializing and learning with their friends in 
classrooms, students were stuck behind computer screens. Symptoms of 
anxiety and depression are on the rise.

    In fact, in one survey, more than half of adults reported that 
worry or stress related to the pandemic was having a negative effect on 
their mental health. As we all know, mental health issues were a 
problem before the pandemic. In fact, it's estimated that nearly one in 
five American adults had some form of mental illness, but fewer than 
half of those adults received treatment in 2019.

    Since the pandemic, lockdowns, economic hardships, and social 
isolation have only helped intensify what we already knew: we need 
mental health services in our communities, and we need to make them a 
priority. The pandemic has also helped expose and magnify the flaws in 
our mental health system.

    In 2020, suicide was the tenth leading cause of death, and drug 
overdose deaths hit a record high. In Montana, we are unfortunately not 
immune to these devastating statistics. We are fourth in the Nation for 
suicides and first in the Nation per capita for children placed in 
foster care--most often due to a parent's drug or alcohol use. And we 
are witnessing a disturbing increase in meth-related violent crime.

    It is clear that more needs to be done to support individuals and 
families struggling with addiction or mental illness. We are fortunate 
in Montana to be home to treatment facilities like Rimrock, which I've 
had the privilege of visiting several times over the years. I even had 
the opportunity to bring Vice President Pence to show him firsthand the 
great work the organization does for Montanans struggling with 
addiction and mental health issues.

    One visit I will never forget, I had the chance to meet with a few 
moms who were receiving substance use treatment. I had just become a 
grandfather. I was overwhelmed with emotion. There I saw devotion, 
struggle, commitment, and so much love that the Montana moms had for 
their children.

    Because at Rimrock, thanks to a bill I led in the Senate, which was 
signed into law by President Trump, moms who are working to get back on 
their feet are able to stay with their children. Let me tell you, this 
means the world to these moms. Treatment centers like Rimrock make a 
world of difference in our communities, and they are more important now 
than ever as we come out of this pandemic.

    After a year of lockdowns and closures, we are finally seeing a 
light at the end of the tunnel. Thanks to the leadership of our new 
Governor, Greg Gianforte, life in Montana is on its way to being back 
to normal. We've vaccinated over 350,000 Montanans and have led the 
Nation in vaccine administration.

    Montana is now open for business. We are open for school. We are 
incentivizing getting back to work versus staying home--something I 
believe is also important for mental health, because I believe there is 
dignity in working. But the reality is that there will likely be long-
lasting impacts of the pandemic, particularly on mental health. We must 
aim to meet the challenges of today and prepare for the increased need 
that this pandemic has created.

    I am committed to working with my colleague Senator Stabenow toward 
that goal.

    Again, I appreciate our witnesses being here today and offering 
their advice and expertise on such an important topic.

    Thank you, Madam Chairwoman.

                                 ______
                                 
          Prepared Statement of Lenette Kosovich, R.N., MHA, 
              Chief Executive Officer, Rimrock Foundation
    Senator Stabenow, Senator Daines, and members of the committee, 
thank you for inviting me to talk about one of the most complex and 
far-reaching issues facing Montana and our Nation. My name is Lenette 
Kosovich. I'm the CEO of Rimrock Foundation, the largest behavioral 
health care facility in Montana. We provide a full continuum of 
services, including peer support, medical detoxification, inpatient, 
residential, and outpatient treatment. We have extended treatment--12 
months or longer, for mothers with their children, and those recently 
released from incarceration. We serve seven treatment courts, including 
Family Drug Court, Veteran Court, and Indian Child Welfare Act Family 
Recovery Court. All in all, we see nearly 2,000 clients a year.

    There is no doubt that COVID has exacerbated an already complex 
problem. Before COVID:

        Substance use disorders and mental illness were already the 
top health needs in our county.
        We had a methamphetamine-fueled increase in violent crime, and 
a burgeoning child welfare system where four out of every five cases 
involved drugs or alcohol.
        Over the last 5 or 6 years, our clients are considerably more 
compromised than a decade ago. Along with serious illicit substance use 
disorders, patients most likely have mental health issues accompanied 
by 1 or 2 comorbidities, like hypertension or diabetes.
          It has become the norm to have 25-year-old 
patients in our care who have already received a heart valve 
replacement due to endocarditis resulting from IV drug use.

    Enter COVID.

    (1) Alcohol consumption, drug use, and mental illness are up.
        Our referrals are up forty percent.
        Calls to our State suicide hotline have doubled.
        Violent crime in our county has increased nearly 70 percent in 
the past 12 months. One thing is certain: drugs played a role.

    (2) While increasing the need, COVID complicated and delayed 
service delivery.
        Quarantine and social distance needs reduced the space we have 
to provide treatment by about one third. Many of our industry partners 
suspended services, so waitlists increased.
        With physical space at a premium, COVID accelerated adoption 
of telehealth tenfold. With that acceleration came incredible pressure. 
iPad needed for all--except you couldn't get iPad. Group therapy via 
telehealth, except Johnny's Internet doesn't work. Family week via 
Zoom--great, except Suzy's mom doesn't have a computer. Training, new 
admit policies, new safety protocols. . . . Every part of our industry 
was stretched to the max.
        But the worst challenge of COVID for me was workforce. Before 
COVID, the workforce shortage was severe. Wait times for COVID results 
and positives made the problem much worse. When I don't sleep at night, 
it is often because I am worried about the number of my employees 
pulling double shifts, on the brink of mental breakdown themselves.

    History teaches us that the mental health impact of a catastrophic 
event, such as the pandemic, will far outlast the physical impact. So I 
am buckled in for a bumpy road.

    Fortunately, there is hope on the horizon with the expansion of the 
Certified Community Behavioral Health Clinic model or CCBHC. Rimrock in 
Billings, and two other organizations in Montana, were recently granted 
a CCBHC expansion pilot.

    In active CCBHC sites, this innovative model of care has 
dramatically increased access to mental health and substance use 
disorder treatment and been proven to address the pain points I just 
shared. I look forward to achieving outcomes like those highlighted in 
the recent impact study by The National Council for Mental Wellbeing. 
We must:

        Increase the number of clients served--according to The 
National Council, CCBHCs increased clients served by 17 percent.
        Decrease wait times for care--remarkably 84 percent of clients 
in a CCBHC are seen within 1 week.
        Invest in the workforce--there is an enhanced reimbursement 
with CCBHC which allows clinics to increase hiring.
        Make crisis services and supports available to all--CCBHCs 
deliver crisis support services in the community, not just in 
facilities. Innovative collaboration with criminal justice and 
community services help to divert people in crisis from emergency rooms 
and jails and get them to the appropriate level of care.
        Address health disparities--CCBHCs increase screening for 
unmet social needs that affect health, like housing or transportation. 
We improve care coordination and partnerships to address those needs.

    Thanks to Federal and State investment, today 340 CCBHCs are 
operating in 40 States, Washington, DC, and Guam.

    Senator Stabenow, Senator Daines, and the committee, there is not 
one of your constituents whose life has not been impacted by substance 
use disorder or mental illness. There is not one of your economies that 
has not suffered. We can do better, and the CCBHC model does do better. 
I unequivocally urge your continued support of the CCBHC model of care.

                                 ______
                                 
   Questions Submitted for the Record to Lenette Kosovich, R.N., MHA
               Question Submitted by Hon. Debbie Stabenow
    Question. What strategies have you used, or seen succeed around the 
country, to provide high-quality comprehensive services in rural 
communities? What is the role of mobile units?

    Answer. Immediate access is necessary. Bringing the care to people 
with a mobile unit eliminates traditional access barriers. It helps 
increase compliance and carries with it a strong message that there are 
people who can help.

                                 ______
                                 
             Questions Submitted by Hon. Sheldon Whitehouse
    Question. In your testimony, you describe how workforce shortages 
challenge your ability to care for your patients. My legislation with 
Senator Portman, CARA 3.0, would provide funding for training and 
employment for substance abuse professionals, including peer recovery 
specialists, and for dedicated retention efforts through SAMHSA and 
HRSA.

    How would additional funding for workforce training and employment 
address the challenges you've identified?

    Are there other workforce challenges beyond funding that we should 
address?

    Answer. This is a complicated question to answer. Montana, as well 
as other States, is facing other challenges that are outside training 
and employment. We have a shortage of affordable housing and many 
people are willing to be employed but can't afford a place to live. 
Also, they may simply lack reliable transportation to get to their work 
or not have childcare.

    Question. Your CCBHC offers same-day services, as does Newport 
Mental Health in Rhode Island.

    How does your ability to offer same-day services help you better 
serve patients experiencing mental and behavioral health crises?

    Answer. Access is everything. And immediate access is crucial in a 
behavioral health crisis. A true behavioral crisis may gradually 
subside with the passing of time (or conversely, end tragically). But 
the root cause of the crisis may not diminish and the likelihood of a 
reoccurrence of the crisis or one of a more elevated nature is great. 
The urgency of access in a timely manner is key to getting people on 
their way to wellness.

                                 ______
                                 
         Prepared Statement of Malkia Newman, Team Supervisor, 
                   CNS Healthcare Anti-Stigma Program
    ``I was born by the river, in a little tent. Then I go to my 
brother, I say, brother, help me please. It's been too hard living, but 
I'm afraid to die. It's been a long, a long time coming, but I know, a 
change is gonna come, oh yes it will.''

    Good afternoon, members of the U.S. Senate, staff, and guests. I am 
very honored to be asked to give testimony to this distinguished body 
today. I want to especially thank Health Chairwoman Debbie Stabenow and 
Ranking Member Steve Daines for convening this vitally important 
discussion.

    My name is Malkia Newman, and I am living proof that the services 
and supports that are available through our community mental health 
system work. I am not naive to the fact that there are many areas that 
need to be improved. But I know that that my life would not be the 
amazing life that I'm living now had I not received treatment for 
bipolar disorder almost 20 years ago.

    I am a survivor of childhood sexual trauma, as well as a survivor 
of intergenerational trauma, a sad legacy of slavery and 
discrimination. I wrestled with suicidal thoughts, had difficulties 
maintaining relationships or employment. My daughter Tracie, who I call 
my miracle, was my reason for living when all hope was gone.

    Mental health conditions are very prevalent in my family. The 
treatments and hospitalizations that my brother Ronnie endured, who had 
schizophrenia, terrified me, which made it harder for me to ask for 
help until there was no other option available.

    Fast forward 20 years. I have 15 years of continuous employment 
with CNS Healthcare's Anti-Stigma Program, I've been a homeowner for 9 
years, and on June 5th my husband Dubrae and I will celebrate our 15th 
wedding anniversary. I have reconciled with my family, and I serve as 
an ordained minister at my church, New Birth International of Pontiac, 
MI. My list of community service awards and recognitions is long. I 
have provided a copy of my resume to the subcommittee.

    I am living proof, I am an advocate, and I am proud to speak on 
behalf of those who have not yet found their voice. It is vitally 
important that we not just continue to offer behavioral treatment, but 
that we prepare for the increased need that the pandemic has created. 
We need more qualified providers, doctors, nurses, therapists, and 
other support personnel, especially Peer Support Specialists, persons 
with lived experience and expertise in the mental health field who can 
encourage and educate people receiving services in a richer way than 
other professionals can. We need to compensate our professionals at 
every level, to make sure that we have qualified, culturally, and 
linguistically competent people meeting the needs of people, no matter 
what their background.

    The Certified Community Behavioral Health Clinics, CCBHCs, have 
made it easier for people to access services regardless of if they have 
insurance or not, which in the past created a huge barrier to people 
needing help.

    Integration of physical and mental health has been a topic of 
discussion for many years. Integration is needed to help people with 
mental health disorders live longer, healthier lives, but the focus has 
shifted from people getting whole health treatment from head to toe to 
an argument about who will administer the dollars associated with the 
treatment. I believe that people served, and their loved ones, should 
have a role in shaping what health care should be, as people with 
intimate knowledge of what works and what doesn't. Advisory groups can 
and should be involved at every level of program development, 
implementation, and evaluation. The finished product would be more 
efficient and cost-effective as well.

    It is my prayer and hope that we will not rush to get back to 
``normal'' at the expense of programs and systems that work.

                                 ______
                                 
          Questions Submitted for the Record to Malkia Newman
              Questions Submitted by Hon. Debbie Stabenow
    Question. CNS Healthcare, where you serve as team supervisor of the 
Anti-Stigma Program, has received a CCBHC expansion grant. What has 
that meant for your work?

    Answer. It has made it much easier to refer the people that I meet 
in the community that are looking for help to CNS no matter where they 
live or their ability to pay. They don't always have the insurance 
necessary or sometimes they don't have any insurance at all. The safety 
net that CCBHC provides takes the guesswork out of the equation. It has 
made so many more families happier and healthier in every way.

    Question. I think the work you and your team do as Peer Support 
Specialists is incredibly important and effective. We talk a lot about 
strategies to address stigma and break down the barriers to seeking 
treatment, but I think what sometimes is underappreciated is the fact 
that people like you are out in communities doing that right now.

    What strategies do you use to help people get the treatment they 
need? What types of services and connections do you provide to help 
people recover?

    Answer. I have a great working relationship with our intake staff, 
they are good at following up on all the people I refer to the agency. 
They did such a great job with me when I came in as a person in 
desperate need of help, that I have peace of mind when I send someone 
else in to get the lifesaving treatment that I was able to get way back 
in 2004!

    When people see us in the community, whether it's in a virtual 
format or in person, they can see what a difference treatment has made 
in our lives. We're open and honest about our experiences, that it 
doesn't matter how far they have gone, there are places where people 
can go and get the treatment and support necessary to help turn their 
lives around.

    We also make our presentations as entertaining as possible so that 
people can hear our message. We want people to see that we're not weird 
or unnatural, we have the same challenges, we've found a healthy way to 
move past the stigma that has held us captive in the past. Truth really 
does free you from misconceptions and stereotypes that limit the kind 
of life you can have, no matter your age, race, culture, religion. We 
love to bust stigmas with truth.

    My role is more that of providing education, and hope. There aren't 
many situations that we can't identify with, and in doing so let people 
know, you still have an opportunity to live a life worth living by 
taking advantage of the services and supports that our CCBHC provides. 
The ability to access services without going through the uncertainty of 
who's going to pick up the tab so to speak, and letting the system do 
what it was designed to do. Help those with insurance and the ability 
to pay and having to extra funds available to help those who aren't as 
fortunate. I am living proof that there is a life worth living after 
receiving a mental health diagnosis!

                                 ______
                                 
             Questions Submitted by Hon. Sheldon Whitehouse
    Question. In your testimony, you describe how workforce shortages 
challenge your ability to care for your patients. My legislation with 
Senator Portman, CARA 3.0, would provide funding for training and 
employment for substance abuse professionals, including peer recovery 
specialists, and for dedicated retention efforts through SAMHSA and 
HRSA.

    How would additional funding for workforce training and employment 
address the challenges you've identified?

    Answer. Ability to fully implement team-based care approach 
(holistic approach to care with teams comprised of Case Managers, 
Therapists, Peer Recovery Coaches, Peer Support Specialists, and Nurse 
Practitioners).

    Ability to offer competitive salaries for limited licensed and 
fully licensed staff.

    Ability to offer a good salary/wage for peers reflective of the 
importance and value of hiring persons with lived experiences and the 
significant positive contributions they make for those served and the 
team overall. Would also allow for ability to hire more peers to 
enhance offerings.

    Ability for more staff to be trained, receive support/monitoring/
supervision towards substance use disorder credentialing (i.e., 
development plans) and more supervision time overall to increase the 
number of staff obtaining substance use disorder credentialing.

    Question. Are there other workforce challenges beyond funding that 
we should address?

    Answer. We need credentialing across health plans to be consistent. 
Current limitations limit mental health professionals from providing 
services they are trained to provide (i.e., significant limitations for 
Licensed Professional Counselor and Limited License Psychologist).

    Need for CCBHCs to have consistent policies/practices regardless of 
what county individuals are seeking care from. Additionally, 
established clinical care pathways with recommended guidelines are 
needed similar to FQHCs to ensure continuity of care and remove 
barriers.

    Question. Your CCBHC offers same-day services, as does Newport 
Mental Health in Rhode Island.

    How does your ability to offer same-day services help you better 
serve patients experiencing mental and behavioral health crises?

    Answer. It increases our ability to engage individuals immediately 
with no delays and to provide an expedited response when persons are 
seeking help. Same-day services also reduce occurrences of emergency 
department visits for mental health/behavioral health circumstances and 
provides services through less restrictive, 
community-based means.

                                 ______
                                 
              Prepared Statement of Hon. Debbie Stabenow, 
                      a U.S. Senator From Michigan
    I call this hearing of the Finance Subcommittee on Health Care to 
order.

    I'm so pleased to be here, during Mental Health Month, talking 
about the urgent need to improve behavioral health-care services in our 
communities.

    Ranking Member Daines, it is great to have you as my new partner on 
this subcommittee, and I know we can do a lot of great work on this 
issue, and many others.

    Mental Health Month is when we raise awareness, take on stigma, 
celebrate triumphs, and make sure no one feels alone. Everyone affected 
by mental illness or substance use disorders should be able to get the 
help they need so they can live a healthy and fulfilling life--period. 
We can make this a reality!

    This issue is personal to so many of us. It affected my own father.

    Before the pandemic, nearly one in five Americans had some form of 
mental illness, yet fewer than half received treatment. This lack of 
support is even worse in our communities of color.

    Our overworked and underfunded health-care system was already 
leaving millions of Americans without the treatment they need. The 
pandemic has made things worse and exposed the weaknesses in the way we 
pay for behavioral health care in this country.

    In January, 41 percent of American adults reported that they were 
struggling with anxiety and depression. That's up from 11 percent 
before the pandemic. And more than one in four young people have 
reported having suicidal thoughts. Meanwhile, overdose deaths have 
surged during the pandemic.

    The CDC reported that more than 87,000 Americans died of drug 
overdoses during the 12-month period that ended in September--the most 
deaths in any year since the opioid epidemic began in the 1990s. And 
long after the pandemic ebbs, these behavioral health issues will 
linger. We need to finally treat health care above the neck the way we 
treat health care below the neck. The need has never been more urgent.

    The good news is that we are making progress. I've worked with my 
friend Senator Roy Blunt and many of you to create and expand the 
Certified Community Behavioral Health Clinics program.

    Now fully operational in 10 States with startup grants bringing the 
program to 41 States, we have a structure that allows clinics to truly 
meet the needs of their communities. This has been a tremendous 
success, and is the model for the future.

    These clinics are required to provide comprehensive services 
including 24/7/365 Mobile Crisis Team services; immediate screening and 
risk assessment; easy access to care--they see everyone who walks in 
the door; tailored care for active-duty military and veterans; care 
coordination with primary care providers; and coordination with law 
enforcement.

    The results are stunning. According to HHS numbers included in the 
budget request last year, people who received services at CCBHCs had 
63.2 percent fewer emergency department visits for behavioral health 
issues, spent 60.3 percent less time in jails, and saw a 40.7-percent 
decrease in homelessness

    And today, the National Council for Mental Wellbeing (previously 
the National Council for Behavioral Health) released a new CCBHC impact 
report with similarly stunning results:

      More than half of CCBHCs offer same-day services, and nearly all 
of them offer treatment within a week. Compare that to the average wait 
time of 48 days nationwide--and they are serving thousands of new 
clients.
      CCBHC funding created an average of 41 new jobs per clinic.
      Ninety-five percent of CCBHCs have engaged in promising new 
practices in collaboration with law enforcement or criminal justice 
agencies.

    This month, Senator Blunt and I--hopefully joined by all of you on 
this subcommittee--will be introducing legislation giving every State 
in the country the option of participating in the full program. It will 
ensure that behavioral health care clinics are paid in the same way we 
pay Federally Qualified Health Centers (FQHCs).

    We can get this done and bring quality community-based care to 
millions of Americans who need it.

    Thank you to our fantastic witnesses for being here today. I look 
forward to hearing from you and know we will have a great bipartisan 
discussion.

    So many of my colleagues are focused on this issue, and whether it 
is CCBHCs, telehealth, crisis supports, coordination with law 
enforcement, schools, and many other issues, I look forward to working 
with you.

                                 ______
                                 
   Prepared Statement of Stephanie Woodard, Psy.D., Senior Advisor, 
 Division of Public and Behavioral Health, Nevada Department of Health 
                           and Human Services
    Senator Stabenow, Ranking Member Daines, and members of the 
committee, my name is Stephanie Woodard. I am a licensed psychologist 
and serve as the Nevada Department of Health and Human Services' Senior 
Advisor on Behavioral Health. I also serve on the board for the 
National Association of State Mental Health Program Directors and the 
Nevada Board of Psychological Examiners.

    I am humbled and honored to have the opportunity to testify before 
you today to discuss how the COVID-19 pandemic has highlighted the 
critical role of crisis services and Certified Community Behavioral 
Health Clinics and our opportunities to build strong, resilient 
communities throughout the recovery.

    Inadequate access to critical behavioral health infrastructure has 
long contributed to Nevada's struggles to address the behavioral health 
needs of the population. Nevada's vast geography combined with 
workforce shortages, insufficient access to critical health and 
behavioral health resources, and high rates of uninsured and 
underinsured have been amplified during the pandemic and contributed to 
the disproportionate impacts of COVID-19 across communities in our 
state.

    When compared to previous years, in 2020 Nevadans experienced 
higher rates of depression and anxiety. Emergency room admissions for 
overdose, suicide attempt, and suicide ideation all increased over the 
course of last year resulting in the highest number of admissions in 
the past decade. While overall deaths by suicide decreased, the suicide 
rate rose 25 percent in youth and young adults age 8 to 24. 
Additionally, opioid-related overdose deaths increased 44 percent with 
synthetic opioid overdose deaths accounting for more than 50 percent of 
the overdose fatalities in Nevada. These data underscore the urgent 
need to address substance use, mental illness, and suicide, they help 
us to understand the magnitude of suffering occurring in our neighbors, 
co-workers, children, friends, and family members, and they provide an 
imperative to act.

    Informed by the body of knowledge on disaster behavioral health, 
Nevada's COVID-19 Disaster Behavioral Health Response and Recovery 
Plan, established in May of 2020, used a population health model 
focused on promotion, prevention, early intervention, continuity of 
behavioral health care, and access to recovery supports. Our Certified 
Community Behavioral Health Clinics, suicide prevention crisis hotline, 
mobile crisis teams, and crisis stabilization centers provided the 
necessary foundation for Nevada's plan.
            nevada's comprehensive crisis continuum of care
    National guidelines developed by the NASMHPD, SAMHSA, and the 
National Council were valuable tools as we developed a coordinated 
crisis continuum of care. Essentially, a coordinated system of crisis 
care ensures that when individuals are in crisis, they have someone to 
talk to, someone to respond, somewhere to go and the services and 
supports are based on best practices. These guidelines have been the 
road map for the crisis system in Nevada statewide, and regionally, 
over the past 3 years.

    Nevada completed assets and gaps mapping in July 2020 and found 
significant gaps in the capabilities across continuum of care, however, 
knowing the gaps in the system has led to strategic use of Federal 
funding through CMS and SAMHSA to respond to community needs for crisis 
services.
                 crisis call hubs/care traffic control
    Crisis Support Services of Nevada is part of the National Suicide 
Prevention Hotline, meaning no call goes unanswered. Through grant 
funds we have been able to increase staffing on the crisis line to 
increase in-state answer volume, decrease wait times for callers, and 
begin to ready the system for 988 in July of 2022. Nevada has pending 
legislation to establish a fee and a fund to support the implementation 
of 988 by July 2022.
                         mobile crisis services
    Ultimately, overutilization of emergency services within EMS and 
law enforcement has resulted in costly use of critical public safety 
resources with lengthy wait-times and a mismatch of intervention to 
support the individual. COVID-19 grant funding has been used to divert 
children and families away from emergency rooms through the expansion 
of children's mobile crisis teams. We plan to further this work with 
the new supplemental funding through the American Rescue Plan 
Supplemental Block Grant funding and the enhanced FMAP through Medicaid 
to sustain more mobile crisis teams across the State.
                      crisis stabilization centers
    Prior to COVID-19, on any given day an average of 90 people would 
be waiting in an emergency room for an inpatient psychiatric bed, the 
vast majority of whom were underinsured or uninsured. We expanded 
funding for uncompensated care to 24/7 crisis stabilization centers 
through Federal grant funding in order to provide an alternative 
destination for individuals in crisis and diverted from emergency 
rooms.

    Statewide expansion of mobile crisis teams and crisis stabilization 
centers is planned with new supplemental funding through the American 
Rescue Plan Supplemental Block Grant and enhanced FMAP for 
sustainability for mobile crisis. A new Medicaid rate for crisis 
stabilization centers is expected to result in cost saving to Nevada 
over the long term. The recent infusion of Federal funding is necessary 
in the development of essential infrastructure; however, it is 
insufficient for long-term sustainability. To bring the entire crisis 
continuum to scale, Nevada, along with other States, will need guidance 
from CMS to ensure these services are sustainable into the future. For 
States to be successful in rising to the challenges 988 presents, 
collaboration between SAMHSA and CMS, as recommended by the Medicaid 
and CHIP Payment Access Commission (MACPAC), will be essential.

    Nevada established Certified Community Behavioral Health Clinics 
through the SAMHSA CCBHC planning grant in 2016 and the demonstration 
grant in 2018. Nevada's investment in CCBHCs through the demonstration 
grant, mental health block grant funding, and the CCBHC expansion grant 
has resulted in nine CCBHCs under the Medicaid State plan.

    Over the course of the demonstration, CCBHCs have increased access 
to critical safety net behavioral health services including 24/7 crisis 
services, while lowering costs of care and improving outcomes. CCBHCs' 
success can also be measured by the relationships the clinics have with 
the communities they serve. Collaboration with law enforcement for 
community-based crisis intervention has reduced unnecessary 
incarceration and emergency room visits. Expansion of services into 
schools has increased access to care for students with behavioral 
health needs. Comprehensive case management and peer recovery supports 
better address social determinants of health and increase engagement in 
care. Cost-based reimbursement has enhanced their ability to recruit 
and retain qualified behavioral health professionals in competitive job 
markets despite workforce shortages across all regions of our State.

    In addition, while many behavioral health providers experienced 
significant challenges in maintaining operations over the past year, 
Nevada's CCBHCs were able to pivot quickly to expand telehealth 
services and offer hybrid services to individuals for in-person care. 
We anticipate continued CCBHC continued success and look forward to 
onboarding an additional four CCBHCs under the most recent SAMHSA 
expansion grant.

    Nevada expresses our gratitude to Senator Stabenow, Senator Blunt, 
the National Council, and countless others who have supported the CCBHC 
model and expanded the demonstration until 2022.
                      opportunities and solutions
    Collaboration between SAMHSA and CMS, as recommended by the 
Medicaid and CHIP Payment Access Commission (MACPAC), will be essential 
for States to fully leverage Medicaid to sustain the crisis continuum 
of care.

    Looking ahead, we would encourage SAMHSA to work closely with State 
mental health program directors as they administer the expansion 
grants. CCBHC certification requires State time and resources and is 
essential in ensuring all clinics qualifying as CCBHCs meet the 
rigorous certification criteria.

                                 ______
                                 
    Questions Submitted for the Record to Stephanie Woodard, Psy.D.
               Question Submitted by Hon. Debbie Stabenow
    Question. We've seen a huge expansion of telehealth services during 
the pandemic, particularly in behavioral health care. We hope that 
COVID cases continue to go down, and in-person care becomes safer, but 
I think we all agree telehealth is an important option.

    As providers in your State scaled up their telehealth services, 
what have you seen work well? What needs to happen to improve these 
services going forward?

    Answer. Nevada experienced a profound and rapid transition to 
telehealth services following the declaration of the COVID-19 public 
health emergency in March of 2020. Several factors facilitated this 
rapid transition, including allowing our subgrant recipients to amend 
subawards to allow for the purchase of telehealth equipment, Centers 
for Medicare and Medicaid allowing for telephonic-only services, and 
clear communication with providers on policy changes to allow for 
telehealth services and information on how to properly bill for 
services. We have heard from providers that the vast majority, if not 
all, behavioral health services were offered both in-person and through 
telehealth during 2020 and early 2021. As restrictions are lifted and 
more providers are moving to greater availability of in-person 
services, most providers anticipate a significant percentage of 
services to still be provided via telehealth. Following the first 6 
months of the pandemic, we conducted a study of Medicaid recipients 
initiating and receiving behavioral health services in-person and 
through telehealth the 12 months prior to March 2020 compared to March-
August of 2020. This study found that the year prior to COVID, only 29 
percent of new behavioral health patients initiated care via 
telehealth, whereas from March through August 2020, 41 percent of new 
behavioral health patient initiated care by telehealth. The study also 
found that for patients who were engaged in behavioral health care 
prior to the pandemic, the majority of those patient continued with 
care despite the public health crisis as much of their care continued 
either in-person or via telehealth. In Nevada ongoing discussions 
around the merits of telehealth expansion have promoted debate over 
issues such as payment parity for telehealth or telephonic services 
versus in-person care. Many patient advocates have expressed concern 
that, gone unchecked, telehealth services that do not have enough 
evidence to substantiate their efficacy or effectiveness is 
commensurate with in-person care may be offered to vulnerable 
populations or that patients may not have freedom of choice to receive 
care by the modality of their choosing. Dialogue with national thought 
leaders on these and other issues has underscored the need for 
continued evaluation of telehealth practices and policies to ensure 
equity in access, patient rights, medical necessity, and ethical 
decision making are a taken into careful consideration at Federal and 
State levels.

                                 ______
                                 
             Questions Submitted by Hon. Sheldon Whitehouse
    Question. Reforming how individuals experiencing mental and 
behavioral health crises are treated requires working with a broad 
coalition of stakeholders at the State and local levels, such as health 
departments, behavioral health providers, and law enforcement.

    Are there any jurisdictions in your State successfully coordinating 
various State and local stakeholders? What best practices have they 
developed?

    Answer. Yes, Nevada has several regional and local coalitions of 
stakeholders who convene around behavioral health issues, including 
crisis services. Nevada established Regional Behavioral Health Policy 
Boards (RBHPB) during the 2017 legislative session and further expanded 
upon that work in 2019 (NRS433.429). The Regional Behavioral Health 
Policy Boards are supported by the Department of Health and Human 
Services (DHHS) to convene stakeholders monthly in each region to 
address issues around behavioral health, including crisis. The RBHPB 
have diverse memberships, including legislative representation and 
members who represent law enforcement, community-based organizations, 
the criminal justice system, providers of residential substance use 
disorder treatment, social services, public health, psychology or 
psychiatry, payers of health care, and individuals with lived 
experience. The duties of the RBHPB include but are not limited to 
advising the Department on the behavioral health needs of children and 
adults in the region, planning to address the needs and improve access 
to services, addressing gaps within the region, priorities for 
allocating funding for behavioral health services, promoting 
improvements in care, and collecting and reporting behavioral health 
data. The RBHPBs and coordinators of the boards have been instrumental 
in assessing the assets and gaps within each region's crisis continuum. 
Beginning in 2018, the RBHPBs have been engaged in ongoing mapping, 
planning, and prioritizing of crisis services with their region. In 
2020, in collaboration with Regional Behavioral Health Coordinators, 
stakeholders within each region supported the completion of assets and 
gaps mapping, and prioritized activities to develop the crisis 
continuum. A summary of this work can be found here: https://
socialent.com/2020/06/nevada-crisis-response-system-virtual-summit/.

    Additionally, Nevada also convenes Regional Children's Mental 
Health Consortia (RCMHC), which were established by statute in 2001 
(NRS433b.333). The RCMHC are supported by DHHS to engage regional 
stakeholders in developing long-term strategic plans for children's 
mental health services and supports. The RCMHC have diverse membership, 
including representation from State children's mental health services, 
child welfare, State Medicaid, school districts, juvenile justice, 
providers of behavioral health care and foster care, parents of 
children with severe emotional disturbance, and providers of substance 
use prevention services. The long-term strategic plans for mental 
health service and support for children includes active engagement of 
families whose children have severe emotional disturbance, ensures the 
mental health system is flexible and offers timely access to affordable 
care, emphasizes screening and early identification, offers services in 
the least restrictive environment, and must be responsive to the 
cultural and gender-based differences and special needs of children. 
Nevada's RCMHC are strong advocates for crisis services to be designed 
for children, youth, and families to access with the goal of offering 
assessment and stabilization supports in-home with wrap-around 
services, respite, and parenting support. Current planning for 988, 
mobile crisis, and crisis stabilization services includes the design 
and implementation for a children's system of care with the RCMHC as 
critical partners in this work.

    Question. How can the Federal Government promote better 
coordination of funding, training, and resources among stakeholders 
responding to behavioral and mental health crises?

    Answer. Nevada strives to support better coordination of funding, 
training, and resources among stakeholders. However, this work requires 
an intentional approach to ensuring timely, clear communication, 
transparent processes to determine allocation of funding, and 
dissemination of best practices through training and technical 
assistance, and resources. We have recognized the need to not only 
continue to engage traditional stakeholders in the development of the 
crisis continuum, but we have also recognized the need to reach 
stakeholders across different sectors and individuals within 
disproportionality impacted communities. We have begun to use an 
approach called Community Based Participatory Research to engage 
community members in meaningful dialogue to gather information needed 
to design the crisis system with the community in mind. We would 
encourage the Federal Government to consider the necessary time for 
convening stakeholders in meaningful inquiry around the needs and 
assets in their communities when developing plans when infusing dollars 
into States to address behavioral health crisis. Nevada is grateful for 
the additional funding through the block grants for crisis services, 
however, the timeline for the plans for the funding is very aggressive 
and does not necessarily allow for the time needed for the meaningful 
engagement of the community in designing the plan for the allocation of 
funding. We would encourage the consideration of sufficient time for 
States to plan for the use of this funding to ensure the projects that 
are funded are developed to have the greatest impact and have the 
opportunities for sustainability once the funding ends.

    Question. One of the primary challenges I hear from Rhode Island 
providers is that the current funding streams for crisis intervention 
and mental and behavioral health services are not consistent. This can 
lead to funding cliffs that force States to scramble to come up with 
money or programs to end.

    How have cities and States created sustainable funding for these 
programs?

    Answer. Sustainability of programming is a primary consideration in 
planning for the use of the funding offered to States for crisis 
services. All States want the ability to give careful consideration of 
the use of the funding to limit the risks of funding cliffs to occur. 
When programs are built in communities without sustainability plans, 
there is incredible risk that harm can come to those communities when 
the grants funding ends and programming must be dismantled and 
discontinued. Nevada is fortunate for the passage of Senate Bill 390 
(SB390; https://www.leg.
state.nv.us/App/NELIS/REL/81st2021/Bill/8095/Text) during the 2021 
legislative session which was enabled by the National Suicide 
Prevention Designation Act of 2020 being signed into Federal law in 
October 2020. Several States have initiated similar legislation under 
the Federal frame which allows States to establish a fee on 
telecommunications and a fund for that fee to support the necessary 
expansion of the crisis system for 988 implementation. States have had 
varying levels of success in passing such laws. In SB390, we were able 
to establish a cap for the fee at .35 per line/month. The law also 
established funding Nevada will receive as a result of opioid 
settlement litigations as a possible additional funding sources for the 
988 and crisis system. While these investments will assist the State in 
long-term financing options for the crisis system we are working to 
establish with the new allocation of block grant funding, Nevada also 
realizes we must constantly evaluate the system as it is implemented to 
identify any possible funding cliff that could arise without sufficient 
funds to continue the services. The Medicaid payment enhancements 
through the American Rescue Plan and existing Medicaid authority are 
sources of possible sustainability that Nevada plans to evaluate. We 
are encouraged by the promise of increased collaboration across Federal 
Health and Human Services agencies to support States in exploring the 
options to use Medicaid to support sustainability of crisis services. 
Nevada anticipates the need for technical assistance to understand and 
plan for the use of Medicaid options in our sustainability planning.

    Question. What can the Federal Government do to help other 
jurisdictions do the same?

    Answer. Technical assistance from HHS agencies to States to plan 
for sustainability through Medicaid would assist States in exploring 
the possible long-term options for maintaining crisis services. In 
addition, States would benefit from the expressed allowance of the use 
of block grant dollars to be used more flexibly within their State to 
invest in additional technical assistance and support to develop 
changes to the Medicaid State plans, applications for Medicaid waivers, 
building out the data and technology infrastructure needed to implement 
programs through Medicaid State agencies. This type of flexibility 
would support States in successfully leveraging Medicaid as a viable 
source of sustainability for crisis services. Without such flexibility 
in funding, it may be challenging for some States to move from concept 
to implementation within Medicaid.

                                 ______
                                 
             Questions Submitted by Hon. Patrick J. Toomey
    Question. The COVID-19 pandemic has had a dramatic effect on our 
Nation's public health. Recent data from the Centers for Disease 
Control and Prevention (CDC) demonstrates that overdose deaths reached 
an all-time high between October 2019 and September 2020.\1\ Moreover, 
improper opioid prescribing and substance misuse has had substantial 
effect on Medicaid enrollees living in Appalachian counties. The OIG 
recently found that Medicaid enrollees across the Appalachian region 
are even more at risk of opioid misuse and overdoes than prior to the 
pandemic.\2\
---------------------------------------------------------------------------
    \1\ ``12 Month-Ending Provisional Number of Drug Overdose Deaths,'' 
Centers for Disease Control and Prevention, https://www.cdc.gov/nchs/
nvss/vsrr/drug-overdose-data.htm#selection_
specific_states_jurisdictions.
    \2\ U.S. Department of Health and Human Services Office of 
Inspector General, ``Opioids in Medicaid: Concerns About Opioid Use 
Among Beneficiaries in Six Appalachian States,'' December 2020, https:/
/oig.hhs.gov/oei/reports/OEI-05-19-00410.pdf.

    While the pandemic exacerbated the Nation's opioid crisis, issues 
with how State Medicaid programs identify overdose victims and connect 
them to treatment pre-date the pandemic. One study found that less than 
one in three Medicaid-enrolled adolescents who experienced an opioid-
related overdose received any treatment whatsoever.\3\ The trends are 
similar for adult Medicaid beneficiaries--approximately 60 percent of 
those who suffered a nonfatal overdose between 2007 and 2013 among a 
sample of enrollees received another legal opioid prescription within 
six months of the event.\4\
---------------------------------------------------------------------------
    \3\ Rachel Alinsky, Bonnie Zima, Jonathan Rodean, et al., ``Receipt 
of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled 
Adolescents and Young Adults,'' JAMA Pediatrics, January 6, 2020, 
https://jamanetwork.com/journals/jamapediatrics/article-abstract/
2758103.
    \4\ Winfred Frazier, Gerald Cochran, Wei-Hsuan Lo-Ciganic, et al., 
``Medication-Assisted Treatment and Opioid Use Before and After 
Overdose in Pennsylvania Medicaid,'' JAMA, August 22, 2019, https://
jamanetwork.com/journals/jama/fullarticle/2649173.

    For these reasons, Senator Manchin and I recently introduced the 
Improving Medicaid Programs' Response to Overdose Victims and Enhancing 
(IMPROVE) Addiction Care Act (S. 1575) to address this information gap. 
Among its provisions, the IMPROVE Addiction Care Act would require 
State Medicaid programs to make efforts to connect Medicaid enrollees 
to treatment after a nonfatal overdose and ensure that prescribers are 
alerted of a patient's previous, nonfatal opioid overdose, as well as 
---------------------------------------------------------------------------
fatal overdose.

    Can you describe the barriers or fragmentation that occurs in the 
Medicaid program that may be allowing prescribers to subsequently 
prescribe an opioid to an overdose victim?

    Answer. Nevada established statutory requirements for prescribing 
controlled substances in 2017 through the Controlled Substance Abuse 
Prevention Act through Assembly Bill 474. Among the many provisions 
within the State statute is the requirement for providers register with 
the Prescription Drug Monitoring Program (PDMP) if they have a license 
to prescribe controlled substances, check the PDMP, assess for patient 
risk for misuse, addiction and overdose, and obtain informed consent 
from the patient. Since this legislation's implementation we have seen 
a 40-percent decrease in the rate of opioid prescriptions per 100 
people, with the most significant decrease occurring in initial 
prescriptions. In that same time period, Nevada had a 68-percent 
reduction in the co-prescribing of opioids and benzodiazepines. 
Overdose deaths related to prescription drugs have also decreased since 
2017, while overdose rates from synthetic opioids have increased to now 
account for over 50 percent of opioid overdoses. Fragmentation occurs 
when data on overdoses is not available to prescribers prior to 
initiating or continuing a prescription for an opioid medication. 
Nevada has long contemplated a adding a flag in the PDMP to alert 
prescribers of an overdose for their consideration and evaluation of 
risk for prescribing and subsequent overdose however, we have not yet 
instituted such a warning system. Within the Medicaid program, it would 
be possible to match data between a patient who has survived a non-
fatal overdose to provide such information to a prescribed for 
consideration, but such a data matching process does not currently 
exist.

    Question. What factors or indicators are you aware of that have 
been associated with increased risk for overdose deaths?

    Answer. The number of opioid-related overdose deaths in Nevada 
decreased from 437 in 2010 to 374 in 2019, in large part due to the 
deaths associated with prescription opioids decreasing. The rate per 
100,000 Nevada residents for opioid-related overdose deaths decreased 
by 4 percent from 16.2 to 15.4 from 2010 to 2020. Roughly 85 percent of 
all benzodiazepine-related overdose deaths in Nevada also involve 
opioids while roughly 30 percent of all opioid-related overdose deaths 
also involve benzodiazepines. The co-prescribing of benzodiazepines is 
widely recognized as a risk factor for overdose death. Other risk 
factors include risk of misuse and addiction, dosage, patient risk 
factors including age and co-morbid medical conditions, and previous 
overdoses. The Nevada Controlled Substance Abuse Prevention Act of 2017 
addresses many of these risk factors through prescribing protocols 
while maintaining the prescriber-patient relationship and supporting 
prescribers' clinical 
decision-making.

    Question. Do States have the capability to implement a mechanism to 
identify a Medicaid enrollee who has suffered a nonfatal overdose? Can 
you discuss the challenges that a predominately fee-for-service State 
versus managed care State may encounter?

    Answer. Nevada is able to collect and report data on non-fatal 
overdoses through both billing and claims records or through mandated 
reporting from hospitals to the Department of Health and Human 
Services. Through rigorous evaluation, Nevada has determined that 
billing and claims data can be used to identify beneficiaries who have 
survived a non-fatal overdose; however, claim lags create some issues 
around timely notification to prescribers. Data matching from the 
mandated reporting may be more timely, however data matching to the 
Medicaid databases for medical and pharmacy to trace back to the 
prescribing provider(s) of record may cause a delay.

    Either approach is feasible in Nevada, though consideration would 
need to be given to accuracy and timeliness of the information to 
determine which process would be most efficient. While we cannot speak 
to other States experiences with fee-for-service or managed care, 
Nevada does operate Medicaid programs in both systems.

    We anticipate Managed Medicaid may experience less challenges in 
data matching and timely notification to prescribers because of the 
closed system they operate within. Fee-for-service Medicaid may pose 
more challenging because of the multiple data sets that would need to 
be used for matching and likely cause a delay in prescriber 
notification.

                                 ______
                                 

                             Communications

                              ----------                              


                     American College of Physicians

                 25 Massachusetts Avenue, NW, Suite 700

                       Washington, DC 20001-7401

                              202-261-4500

                              800-338-2746

                       https://www.acponline.org/

The American College of Physicians (ACP) is pleased to submit this 
statement and offer our views on how to improve mental health and 
addiction services during and after the COVID-19 pandemic. We greatly 
appreciate that Senators Stabenow and Daines have convened this 
hearing, ``The COVID-19 Pandemic and Beyond: Improving Mental Health 
and Addiction Services in Our Communities.'' Thank you for your 
commitment to ensuring that clinicians have the opportunity to share 
their views about the response to the public health emergency (PHE) 
caused by COVID-19 including how we can use the lessons learned during 
the PHE caused by COVID-19 to improve mental health and increase access 
to addiction services. Through the experiences of its physicians on the 
frontlines of furnishing primary care during the COVID-19 pandemic, ACP 
would like to share its input and recommendations surrounding COVID-19 
and mental health and addiction services, including integrating primary 
care and behavioral health, expanding the available tools to treat 
mental health, substance use disorders (SUDs), and increasing the 
physician workforce.

The American College of Physicians is the largest medical specialty 
organization and the second-largest physician membership society in the 
United States. ACP members include 163,000 internal medicine physicians 
(internists), related subspecialists, and medical students. Internal 
medicine physicians are specialists who apply scientific knowledge and 
clinical expertise to the diagnosis, treatment, and compassionate care 
of adults across the spectrum from health to complex illness. Internal 
medicine specialists treat many of the patients at greatest risk from 
COVID-19, including the elderly and patients with pre-existing 
conditions like diabetes, heart disease and asthma.

 The Pandemic Increased Demand for Mental Health and Addiction Services

Recently, the U.S. Government Accountability Office (GAO) released a 
report, Behavioral Health: Patient Access, Provider Claims Payment, and 
the Effects of the COVID-19 Pandemic. The purpose of the report was to 
determine if the need for and access to mental health and addiction 
services varied as the availability to care diminished during the PHE 
caused by COVID-19. The report showed several concerning trends. The 
Centers for Disease Control and Prevention (CDC) found that 38 percent 
of individuals surveyed reported symptoms of anxiety or depression from 
April 2020 to February 2021. This was a 27 percent increase from 2019 
for the same time period. CDC data found that emergency department 
visits for overdoses was 26 percent higher and suicide attempts were 36 
percent higher for the time period of mid-March through mid-October 
2020 when compared to that period during 2019. The Substance Abuse and 
Mental Health Services Administration (SAMHSA) found that in September 
2020 opioid deaths in certain sections of the United States increased 
anywhere from 25 to 50 percent when compared to the same time during 
2019. SAMHSA data also showed that contacts by individuals to the 
Disaster Distress Helpline increased during the PHE in 2020 over 
comparable timeframes in 2019. For example, between March and August 
2020, calls hit a high in April 2020 at almost 10,000 calls, which is 
an 890 percent increase over April 2019. In August 2020, a survey 
conducted by the National Council for Behavioral Health (NCBH), found 
that over half of their member organizations had an increase in demand 
for their services in the three-month period before the survey. A 
February 2021 follow-up survey by NCBH discovered that the demand for 
services had increased by 67 percent.\1\ Clearly, the U.S. population 
has experienced a sharp increase in mental health issues and SUDs 
during the COVID-19 pandemic.
---------------------------------------------------------------------------
    \1\ U.S. Government Accountability Office. (2021) Behavioral 
Health: Patient Access, Provider Claims Payment, and the Effect of the 
COVID-19 Pandemic. GAO-21-437R. https://www.gao.gov/assets/gao-21-
437r.pdf.
---------------------------------------------------------------------------

 Mental Health and Addiction Services Workforce Shortage Made Worse by 
                    the COVID-19 Pandemic

Meanwhile, persistent mental health and addiction services workforce 
shortages from before the pandemic only worsened during the PHE caused 
by COVID-19. Before the pandemic, the Health Resources and Services 
Administration (HRSA) found that by 2025, shortages of seven different 
types of mental health clinicians were anticipated, with shortages of 
10,000 and above in some clinician fields of practice. In September 
2020, HRSA designated over 5,700 mental health provider shortage areas 
with 119 million people living in one of these areas. HRSA estimated 
that available mental health clinicians in these areas were only 
adequate enough to meet 27 percent of the need for services.\2\ SAMHSA 
reported that due to a combination of reasons, including laying off 
staff and the closure of clinicians offices that could not sustain 
themselves financially, led to a decrease in access. In February 2021, 
NCBH reported that member organizations had decreased staff and 
services because of the pandemic caused by COVID-19, including 27 
percent laying off staff and 23 percent furloughing staff, resulting in 
68 percent of member organizations canceling, rescheduling, or turning 
away patients.\3\ Not unexpectedly, the demand for mental health and 
addiction services rapidly increased during the PHE caused by COVID-19 
while at the same time access to these services diminished.
---------------------------------------------------------------------------
    \2\ U.S. Government Accountability Office. (2021) Behavioral 
Health: Patient Access, Provider Claims Payment, and the Effect of the 
COVID-19 Pandemic. GAO-21-437R, https://www.gao.gov/assets/gao-21-
437r.pdf.
    \3\ U.S. Government Accountability Office. (2021) Behavioral 
Health: Patient Access, Provider Claims Payment, and the Effect of the 
COVID-19 Pandemic. GAO-21-437R. https://www.gao.gov/assets/gao-21-
437r.pdf.
---------------------------------------------------------------------------

 Integrate Primary Care and Behavioral Health

ACP strongly supports the integration of behavioral health care into 
primary care and encourages its members to address behavioral health 
issues within the limits of their competencies and resources. 
Accordingly, ACP supports using the primary care setting as the 
springboard for addressing both physical and behavioral health care. 
The basis for using the primary care setting to integrate behavioral 
health is consistent with the concept of ``whole-person'' care, which 
is a foundational element of primary care delivery. It recognizes that 
physical and behavioral health conditions are intermingled: many 
physical health conditions have behavioral health consequences, and 
many behavioral health conditions are linked to increased risk for 
physical illnesses. In addition, the primary care practice is currently 
the entry point and the most common source of care for most persons 
with behavioral health issues--it is already the de facto center for 
this care. The degree of medical practice integration can vary, from 
basic coordination between a primary care physician and behavioral 
health clinicians, to collocation with a behavioral health clinician 
practicing in close proximity to the primary care physician, to a truly 
integrated care approach in which all aspects of care delivered in the 
primary care setting recognize both the physical and behavioral 
perspective. For example, the patient-centered medical home (PCMH) has 
been proposed as an appropriate model to address the integration of 
primary and behavioral care, highlighting its emphasis on primary care, 
care coordination, and delivery of care by a team of professionals. The 
Affordable Care Act incentivized the development of Medicaid health 
homes, which promote addressing behavioral health issues in the primary 
care setting. Evidence also shows opportunities in the primary care 
setting not only to address current behavioral health conditions but 
also to serve as a platform to promote prevention in at-risk patients 
or populations and address behavioral health conditions before symptoms 
can occur in patients.\4\
---------------------------------------------------------------------------
    \4\ Crowley R, Kirschner N; Health and Public Policy Committee of 
the American College of Physicians. The Integration of Care for Mental 
Health, Substance Abuse, and Other Behavioral Health Conditions into 
Primary Care: An American College of Physicians Position Paper. 
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.

ACP recommends that public and private health insurance payers, 
policymakers, and primary care and behavioral health-care professionals 
work to remove payment barriers that impede behavioral health and 
primary care integration. Stakeholders should also ensure the 
availability of adequate financial resources to support the practice 
infrastructure required to effectively provide such care. The barriers 
to seamless integration of behavioral and primary care are both 
administrative and financial. Behavioral and physical health-care 
clinicians have a long history of operating in different care silos. 
The artificial separation of behavioral and physical health care is 
reflected in many ways. For example, primary care physicians generally 
lack extensive clinical training in behavioral health, and traditional 
medical and mental health training models and practice environments are 
substantially different, which may lead to cultural clashes if they are 
not thoughtfully integrated.\5\
---------------------------------------------------------------------------
    \5\ Crowley R, Kirschner N; Health and Public Policy Committee of 
the American College of Physicians. The Integration of Care for Mental 
Health, Substance Abuse, and Other Behavioral Health Conditions into 
Primary Care: An American College of Physicians Position Paper. 
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.

Even though there are challenges, the evidence shows that integrating 
behavioral health and primary care leads to improved mental health 
outcomes, improved physical health, improved quality of life, and lower 
costs. The available research evidence, while limited, does support the 
efficacy of this approach.\6\ The Behavioral Health Integration (BHI) 
Collaborative, in which ACP participates, has found that benefits of 
integration can include promoting long-term value, improved patient 
satisfaction, and reducing the stigma of mental health issues and 
SUD.\7\ Primary care physicians also support integrated care and report 
that the integrated care model encourages better communication and 
coordination among behavioral health and primary care physicians and 
reduces mental health stigma.\8\
---------------------------------------------------------------------------
    \6\ Crowley R, Kirschner N; Health and Public Policy Committee of 
the American College of Physicians. The Integration of Care for Mental 
Health, Substance Abuse, and Other Behavioral Health Conditions into 
Primary Care: An American College of Physicians Position Paper. 
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
    \7\ Behavioral Health Integration Collaborative. Behavioral Health 
Integration Compendium. American Medical Association, 2020. https://
www.ama-assn.org/system/files/2020-12/bhi-compendium.pdf.
    \8\ Crowley R, Kirschner N; Health and Public Policy Committee of 
the American College of Physicians. The Integration of Care for Mental 
Health, Substance Abuse, and Other Behavioral Health Conditions into 
Primary Care: An American College of Physicians Position Paper. 
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.

Accordingly, Congress can and should take action to encourage primary 
care and behavioral health integration. Congress could establish grant 
programs with adequate funding to incentivize primary care uptake of 
the various integrated care models. These grants could help defray 
costs of establishing and delivering integrated primary and behavioral 
health services. These costs can include but are not limited to, hiring 
additional staff such as behavioral health managers, contracts with 
other needed health-care clinicians such as psychiatrist consultants 
and behavioral health managers, and purchasing or upgrading software 
and other resources to provide new services such as more coordinated 
care. Congress could also encourage additional payment models that 
potentially facilitate integrated care including bundling payments, 
partial and full capitation, and even fee-for-service. For example, 
additional fee-for-service payment codes could be aligned to 
incentivize integration by establishing payment for behavioral health--
primary care consultations, multidiscipline care plan development, and 
related activities.\9\
---------------------------------------------------------------------------
    \9\ Crowley R, Kirschner N; Health and Public Policy Committee of 
the American College of Physicians. The Integration of Care for Mental 
Health, Substance Abuse, and Other Behavioral Health Conditions into 
Primary Care: An American College of Physicians Position Paper. 
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.

ACP also strongly supports increased research to define the most 
effective and efficient approaches to integrate behavioral health care 
in the primary care setting and Congress should prioritize research in 
this area. Although a review of the current literature supports the 
efficacy of the integration of behavioral health care in the primary 
care setting, it is limited and filled with many gaps. Substantial 
research is needed to focus on the efficacy of various models of 
integration, as well as the diagnostic and treatment interventions most 
appropriate for use in these models. The following additional factors 
should be considered within research efforts: specific conditions 
addressed, populations involved (such as child vs. adult), funding 
structures, personnel employed, and resources available to the 
participating practices.\10\ Federal research agencies, such as the 
Agency for Healthcare Research and Quality (AHRQ) are well suited to 
study the best ways of integrating behavioral health care in the 
primary care setting and Congress should provide the resources to 
enable this type of care.
---------------------------------------------------------------------------
    \10\ Crowley R, Kirschner N; Health and Public Policy Committee of 
the American College of Physicians. The Integration of Care for Mental 
Health, Substance Abuse, and Other Behavioral Health Conditions into 
Primary Care: An American College of Physicians Position Paper. 
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.

 Improve Mental Health Parity with Increased Federal Oversight and 
                    Enforcement

One of the barriers to true integrated primary and behavioral health 
care are the likely instances of noncompliance by insurance plans with 
mental and SUD coverage parity required by federal law. While the Paul 
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity 
Act of 2008 (MHPAEA) requires parity for mental health and SUD 
coverage, state and federal oversight and compliance efforts have been 
uneven. Unfortunately, according to the GAO, the true nature of the 
problem of noncompliance with MHPAEA is not well known.\11\ While 
noncompliance violations have been reported, these complaints were 
relatively small in number and not considered a true snapshot of the 
magnitude of noncompliance. While the GAO found that insurance-plan 
compliance with federal parity law was key to coverage parity, federal 
agencies are only aware of a small number of patient complaints and 
discovered violations of coverage parity law. In addition, the GAO 
found that when federal agencies did engage in compliance reviews for 
coverage parity that there was a high rate of insurance plan 
violations. This frequency, the GAO determined, could indicate that 
insurance-plan noncompliance with mental health and SUD coverage parity 
law could be a common occurrence.\12\ In response, the GAO recommended 
that the federal government should determine whether current targeted 
oversight of compliance efforts are sufficient and effective and then 
develop better ways in which to enforce MHPAEA as well as attain 
greater oversight authority if needed.\13\ ACP strongly recommends that 
federal and state governments, insurance regulators, payers, and other 
stakeholders address behavioral health insurance coverage gaps that 
remain barriers to integrated care. This includes strengthening and 
enforcing relevant nondiscrimination laws, including oversight and 
compliance efforts by federal and state agencies.\14\
---------------------------------------------------------------------------
    \11\ U.S. Government Accountability Office. (2019) Mental Health 
and Substance Use, State and Federal Oversight of Compliance with 
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf
    \12\ U.S. Government Accountability Office. (2019) Mental Health 
and Substance Use, State and Federal Oversight of Compliance with 
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf.
    \13\ U.S. Government Accountability Office. (2019) Mental Health 
and Substance Use, State and Federal Oversight of Compliance with 
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf.
    \14\ Crowley R, Kirschner N; Health and Public Policy Committee of 
the American College of Physicians. The Integration of Care for Mental 
Health, Substance Abuse, and Other Behavioral Health Conditions into 
Primary Care: An American College of Physicians Position Paper. 
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
---------------------------------------------------------------------------

 Make Naloxone More Available to Prevent Overdoses

ACP supports funding to distribute naloxone to individuals with opioid 
use disorder to prevent overdose deaths and train law enforcement and 
emergency medical personnel in its use. A 2019 CDC report found that 
not all individuals in need of naloxone are receiving it due to 
prescribing and dispensing variations across the country. The CDC 
recommended actions to improve naloxone access such as reducing patient 
insurance copays, enhancing clinician training and education, and 
focusing allocation, especially to rural areas.\15\ Legal protections 
(that is, Good Samaritan laws) should continue to be established or 
refined to encourage use of naloxone and the reporting of opioid 
overdoses in instances where an individual's life is in danger. A GAO 
review found that overall state Good Samaritan laws helped in reducing 
deaths by overdose and that states that enacted such laws have lower 
rates of opioid overdose deaths when compared to before the law's 
enactment or to states without these laws at all.\16\ Physician 
standing orders to permit pharmacies to provide naloxone to eligible 
individuals without a prescription should be explored. Insurance and 
cost related barriers that limit access to naloxone should also be 
addressed. As the need for naloxone has grown, so has its price. In 
response, government representatives and private sector entities have 
partnered to make bulk purchases of naloxone at substantial discounts 
for state and local jurisdictions fighting the opioid epidemic. These 
and other efforts must be accelerated to ensure that naloxone continues 
to reach those in need.\17\
---------------------------------------------------------------------------
    \15\ Life-Saving Naloxone from Pharmacies, More dispensing needed 
despite progress. CDC Vital Signs. Centers for Disease Control and 
Prevention, August 2019. https://www.cdc.gov/vitalsigns/naloxone/
index.html.
    \16\ U.S. Government Accountability Office. (2020) Drug Misuse, 
Most States Have Good Samaritan Laws and Research Indicates They May 
Have Positive Effects. https://www.gao.gov/assets/gao-21-248.pdf.
    \17\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public 
Policy Committee of the American College of Physicians. Health and 
Public Policy to Facilitate Effective Prevention and Treatment of 
Substance Use Disorders Involving Illicit and Prescription Drugs: An 
American College of Physicians Position Paper. Washington, DC: American 
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
---------------------------------------------------------------------------

 Expand Medication-Assisted Treatment (MAT) for Physicians

In order to expand access to medication-assisted treatment (MAT) of 
opioid use disorders, improved training in the treatment of substance 
use disorders is necessary, including for buprenorphine-based 
treatment. Pre- and post-buprenorphine training support and education 
tools and resources should be made available and widely disseminated to 
assist physicians in their treatment efforts. Physician support 
initiatives, such as mentor programs, shadowing experienced providers, 
and telemedicine, can help improve education and support efforts around 
substance use treatment.\18\ In addition, continued efforts are needed 
to remove barriers or administrative burdens for physicians to fully 
take advantage of using MAT to treat their patients, such as 
eliminating burdensome prior authorization requirements. These 
roadblocks can delay or deny needed treatment that utilize already 
approved medications in the course of MAT to treat SUDs. Several states 
have already taken action to eliminate or reduce prior authorization 
requirements for MAT and Congress should explore legislative options on 
the federal level.\19\
---------------------------------------------------------------------------
    \18\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public 
Policy Committee of the American College of Physicians. Health and 
Public Policy to Facilitate Effective Prevention and Treatment of 
Substance Use Disorders Involving Illicit and Prescription Drugs: An 
American College of Physicians Position Paper. Washington, DC: American 
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
    \19\ American Medical Association. Opioid Task Force 2019 Progress 
Report. https://www.end-opioid-epidemic.org/wp-content/uploads/2019/06/
AMA-Opioid-Task-Force-2019-Progress-Report-web-1.pdf.
---------------------------------------------------------------------------

 Establish a National Prescription Drug Monitoring Program (PDMP)

ACP reiterates its support for the establishment of a national 
Prescription Drug Monitoring Program (PDMP). Until such a program is 
implemented, ACP supports efforts to standardize state PDMPs through 
the federal National All Schedules Prescription Electronic Reporting 
program. The College strongly urges prescribers and dispensers to check 
PDMPs in their own and neighboring states (as permitted) before writing 
and filling prescriptions for medications containing controlled 
substances. All PDMPs should maintain strong protections to ensure 
confidentiality and privacy. In addition to a national PDMP, ACP 
strongly encourages Congress to be helpful in this area by requiring 
efforts to facilitate the use of PDMPs, such as by linking information 
with electronic medical records and permitting other members of the 
health-care team to consult PDMPs.\20\
---------------------------------------------------------------------------
    \20\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public 
Policy Committee of the American College of Physicians. Health and 
Public Policy to Facilitate Effective Prevention and Treatment of 
Substance Use Disorders Involving Illicit and Prescription Drugs: An 
American College of Physicians Position Paper. Washington, DC: American 
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
---------------------------------------------------------------------------

 Conduct Research to Implement Effective Public Health Interventions

ACP believes more federal research is needed. The effectiveness of 
public health interventions to combat substance use disorders and 
associated health problems should be studied further. Public health-
based substance use disorder interventions, such as syringe exchange 
programs (SEPs) and safe injection sites that connect the user with 
effective treatment programs should be explored and tested. Risky 
injection drug use habits, such as needle sharing, contribute to the 
spread of HIV, hepatitis C virus, and other blood-borne pathogens. 
Several SEPs have shown the potential to reduce the spread of these 
diseases. Indeed, the federal government has already established and 
funded Syringe Services Programs (SSPs) through the CDC.\21\ These 
community-based prevention programs have a track record of furnishing 
much-needed services, such as disposal of sterile syringes, 
vaccination, testing, infectious disease care, and most critically, SUD 
treatment.\22\ These programs may also connect individuals with other 
health and social services, as well as referrals to SUD treatment, as 
mentioned above, prevention supplies, and health screenings. As the 
opioid epidemic continues to increase the number of people who inject 
drugs, federal and state funding should be directed to communities to 
prevent the spread of blood-borne diseases, such as HIV infection and 
hepatitis C, as well as connect people to social and health-care 
services that can provide necessary assistance. Because safe injection 
facilities have not been extensively tested in the United States, state 
and local health officials need the resources to conduct pilot tests 
prior to any possible full implementation.\23\
---------------------------------------------------------------------------
    \21\ Centers for Disease Control and Prevention. Syringe Services 
Programs (SSPs) Funding. Accessed at https://www.cdc.gov/ssp/ssp-
funding.html.
    \22\ Centers for Disease Control and Prevention. Syringe Services 
Programs (SSPs) Safety and Effectiveness Summary. Accessed at https://
www.cdc.gov/ssp/syringe-services-programs-summary.html.
    \23\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public 
Policy Committee of the American College of Physicians. Health and 
Public Policy to Facilitate Effective Prevention and Treatment of 
Substance Use Disorders Involving Illicit and Prescription Drugs: An 
American College of Physicians Position Paper. Washington, DC: American 
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
---------------------------------------------------------------------------

 Ensure Adequate Physician Workforce to Integrate Behavioral Health and 
                    Primary Care

ACP encourages efforts by federal and state governments, relevant 
training programs, and continuing education providers to ensure an 
adequate workforce to provide for integrated behavioral health care in 
the primary care setting. Cross-
discipline training is needed to prepare behavioral health and primary 
care physicians to effectively integrate their respective specialties. 
Primary care physicians need to be trained to screen, manage, and treat 
common behavioral health conditions, and behavioral health providers 
need to be trained to understand care for common medical needs. Both 
sectors need to overcome the operational and cultural barriers that 
prevent seamless integration. A report from the SAMHSA-HRSA Center for 
Integrated Health Solutions cited inadequate skills for integrated 
practices and reluctance to change practice patterns.\24\
---------------------------------------------------------------------------
    \24\ Crowley R, Kirschner N; Health and Public Policy Committee of 
the American College of Physicians. The Integration of Care for Mental 
Health, Substance Abuse, and Other Behavioral Health Conditions into 
Primary Care: An American College of Physicians Position Paper. 
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.

The workforce of professionals qualified to treat behavioral health and 
substance use disorders should be expanded. ACP supports policies to 
increase the professional workforce engaged in treatment of behavior 
health and substance use disorders. Loan forgiveness programs, 
mentoring initiatives, and increased payment may encourage more 
individuals to train and practice as behavioral health 
professionals.\25\
---------------------------------------------------------------------------
    \25\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public 
Policy Committee of the American College of Physicians. Health and 
Public Policy to Facilitate Effective Prevention and Treatment of 
Substance Use Disorders Involving Illicit and Prescription Drugs: An 
American College of Physicians Position Paper. Washington, DC: American 
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.

Primary care physicians, including internal medicine specialists, 
continue to serve on the frontlines of patient care during this 
pandemic with increasing demands placed on them. Funding should be 
continued and increased for programs and initiatives that work to 
increase the number of physicians and other health-care professionals 
providing care for all communities, including for racial and ethnic 
communities historically underserved and disenfranchised.\26\ According 
to the Association of American Medical Colleges (AAMC), before the 
Coronavirus crisis, estimates were that there would be a shortage of 
21,400 to 55,200 primary care physicians by 2033. In addition, the 
federal government determined that an additional 14,900 primary care 
physicians and 6,894 psychiatrists were needed in 2018 to provide 
services that would have eliminated a HPSA designation for areas with 
primary care and mental health shortages.\27\ Now, with the closure of 
many physician practices and near-
retirement physicians not returning to the workforce due to COVID-19, 
it is even more imperative to assist those clinicians serving on the 
frontlines and increasing the number of future physicians in the 
pipeline.
---------------------------------------------------------------------------
    \26\ Serchen J, Doherty R, Hewett-Abbott G, Atiq O, Hilden D; 
Health and Public Policy Committee of the American College of 
Physicians. Understanding and Addressing Disparities and Discrimination 
Affecting the Health and Health Care of Persons and Populations at 
Highest Risk: A Position Paper of the American College of Physicians. 
Philadelphia: American College of Physicians; 2021. https://
www.acponline.org/acp_policy/policies/understanding_discrimi
nation_affecting_health_and_health_care_persons_populations_highest_risk
_2021.pdf.
    \27\ Prepared for the AAMC by IHS Markit Ltd. The Complexities of 
Physician Supply and Demand: Projections From 2018 to 2033. Association 
of American Medical Colleges, June 2020. https://www.aamc.org/media/
45976/download.

For example, many residents and medical students are playing a critical 
role in responding to the COVID-19 crisis all while they carry an 
average debt of over $200,000. In addition, international medical 
graduates (IMGs) are currently serving on the frontlines of the U.S. 
health-care system, both under J-1 training and H-1B work visas and in 
other forms. These physicians serve an integral role in the delivery of 
health care in the United States. IMGs help to meet a critical 
workforce need by providing health care for underserved populations in 
the United States. They are often more willing than their U.S. medical 
graduate counterparts to practice in remote, rural areas and in poor 
underserved urban areas. More must be done to support their vital role 
---------------------------------------------------------------------------
in health-care delivery in the United States.

ACP supports several pieces of legislation from the 116th Congress that 
should be reintroduced as well as legislation recently introduced that 
should be passed in the current 117th Congress to assist medical 
graduates and the overall physician workforce as well as address the 
mental and behavioral health needs of physicians themselves.

      The Resident Education Deferred Interest Act (H.R. 1554, 116th 
Congress) would make it possible for residents to defer interest on 
their loans.
      The Conrad State 30 and Physician Access Reauthorization Act (S. 
948, 116th Congress) and the Healthcare Workforce Resilience Act (S. 
3599, 116th Congress), would help with medical student loan forgiveness 
and support IMGs and their families by temporarily easing immigration-
related restrictions so IMGs and other critical health-care workers can 
enter the U.S. to train in internal medicine residency programs, assist 
in the fight against COVID-19, and provide a pathway to permanent 
residency status.
      The Student Loan Forgiveness for Frontline Health Workers Act 
(H.R. 2418, 117th Congress) would assist frontline clinicians as they 
provide care during the pandemic.
      The Dr. Lorna Breen Health Care Provider Protection Act (H.R. 
1667/S. 610, 117th Congress) is an important proposal because it aims 
to prevent and reduce incidences of suicide, mental health conditions, 
substance use disorders, and long-term stress, sometimes referred to as 
``burnout'' among physicians themselves. Through grants, education, and 
awareness campaigns, the legislation will help reduce stigma and 
identify resources for health-care clinicians seeking assistance. The 
legislation also supports research on health-care professional mental 
and behavioral health, including the effect of the COVID-19 pandemic. 
View ACP's letter of support to the House and Senate for H.R. 1667 and 
S. 610.

In addition, ACP was encouraged that bipartisan congressional leaders 
worked together last year to provide 1,000 new Medicare-supported 
Graduate Medical Education (GME) positions in the Consolidated 
Appropriations Act, 2021 (H.R. 133)--the first increase of its kind in 
nearly 25 years--and that some of those new slots will be prioritized 
for hospitals that serve Health Professional Shortage Areas (HPSAs).

      ACP now calls on Congress to pass the Resident Physician 
Reduction Shortage Act of 2021 (H.R. 2256/S. 834, 117th Congress) which 
would provide 14,000 new GME positions over seven years, or 2,000 per 
year to build on the 1,000 new GME slots mentioned above.
      Congress should also pass the Opioid Workforce Act of 2021 (S. 
1483, 117th Congress). This bill would provide Medicare funding for 
1,000 more GME positions over five years in hospitals that already have 
established, or are in the process of establishing, accredited 
residency programs in addiction medicine, addiction psychiatry, or pain 
medicine.

ACP also supports other physician and clinician workforce programs and 
we strongly supported providing $800 million for the National Health 
Service Corps (NHSC) and $330 million to expand the number of Teaching 
Health Centers (THC) Graduate Medical Education (GME) sites nationwide 
and increase the per resident allocation that were enacted in the 
American Rescue Plan (ARP) Act, H.R. 1319. Indeed, a recent study 
appearing in the Annals of Internal Medicine showed that in counties 
with fewer primary care physicians (PCP) per population, increases in 
PCP density would be expected to substantially improve life 
expectancy.\28\ Accordingly, Congress should enact policies that will 
not only increase the overall number of PCPs, but also ensure that 
these additional PCPs are located in the communities where they are 
most needed in order to furnish primary care, behavioral health, and 
SUD services. Enhanced investments in programs such as the NHSC and 
THCGME that increase the physician workforce should be sustained after 
the pandemic caused by COVID-19 has come to an end.
---------------------------------------------------------------------------
    \28\ Sanjay Basu, M.D., Ph.D.; Russell S. Phillips, M.D.; Seth A. 
Berkowitz, M.D., MPH. Estimated Effect on Life Expectancy of 
Alleviating Primary Care Shortages in the United States. Ann Intern 
Med. 2021. https://www.acpjournals.org/doi/pdf/10.7326/M20-7381.
---------------------------------------------------------------------------

Conclusion

We commend you and your colleagues for working in a bipartisan fashion 
to examine any lessons learned about treating mental health and 
addiction services during the COVID-19 pandemic to improve health 
outcomes and to develop legislative proposals to combat not only the 
ongoing Coronavirus crisis--but to address any issues caused by the 
current pandemic as well as future pandemics. We wish to assist in the 
Finance Committee's efforts in this area by offering our input and 
suggestions about ways that Congress and federal health departments and 
agencies can intervene through evidence-based policies both now and 
beyond the PHE. Thank you for consideration of our recommendations that 
are offered in the spirit of providing the necessary support to 
physicians and their patients going forward. Please contact Brian 
Buckley, Senior Associate, Legislative Affairs, by phone at (202) 261-
4543 or via email at [email protected] with any further questions 
or if you need additional information.

                                 ______
                                 
                    American Pharmacists Association
Chairwoman Stabenow, Ranking Member Daines, and Members of the 
Committee, the American Pharmacists Association (APhA) is pleased to 
submit the following Statement for the Record for the U.S. Senate 
Finance Subcommittee on Health Care Hearing, ``The COVID-19 Pandemic 
and Beyond: Improving Mental Health and Addiction Services in Our 
Communities.''

APhA is the largest association of pharmacists in the United States 
advancing the entire pharmacy profession. APhA represents pharmacists 
in all practice settings, including community pharmacies, hospitals, 
long-term care facilities, specialty pharmacies, community health 
centers, physician offices, ambulatory clinics, managed care 
organizations, hospice settings, and government facilities. Our members 
strive to improve medication use, advance patient care, and enhance 
public health.

APhA thanks the Committee for holding this important hearing on 
improving mental health and substance use disorder (SUD) and opioid use 
disorder (OUD) services. Unfortunately, the COVID-19 pandemic has 
exacerbated the drug overdose crisis. According to the Centers for 
Disease Control and Prevention (CDC), during the period October 2019 
through September 2020, there were more than 87,000 overdose deaths--a 
record high.\1\ Clearly, additional steps need to be taken to address 
this crisis.
---------------------------------------------------------------------------
    \1\ CDC National Center for Health Statistics. 12 Month-ending 
Provisional Number of Drug Overdose Deaths, based on data available for 
analysis on 4/4/2021, available at: https://www.cdc.gov/nchs/nvss/vsrr/
drug-overdose-data.htm.

Pharmacists are important providers on the patient's health care team 
and play a critical role in caring for patients with acute and chronic 
pain and/or OUD including prescribing medications, as authorized; 
medication management; administering; dispensing; and educating 
patients about opioid and non-opioid pain medications, as well as 
talking to patients about nonpharmacologic therapies. Pharmacists also 
provide services focused on screening for mental health conditions and 
work with other members of the patient's team to manage medications 
---------------------------------------------------------------------------
used in the treatment of mental health conditions.

Pharmacists have more medication-related education and training than 
any other health care professional. As medication experts, pharmacists 
are uniquely qualified to provide opioid stewardship and medication 
management services including comprehensive medication management, dose 
optimization, appropriate tapering of opioids and other pain 
medications, and education on safe storage and disposal methods. In 
addition, pharmacists aid opioid overdose reversal efforts by 
furnishing naloxone and training patients and community members on its 
use.

In order to increase access to pharmacist-provided patient care 
services for patients with mental health conditions, SUD, and OUD, APhA 
urges Congress to pass the following legislation:

 S. 1362/H.R. 2759, the Pharmacy and Medically Underserved Areas 
                    Enhancement Act

Despite the fact that many states and Medicaid programs are turning to 
pharmacists to increase access to health care, Medicare Part B does not 
cover many of the impactful and valuable patient care services 
pharmacists can provide. While over 90% of Americans live within 5 
miles of a community pharmacy,\2\ and pharmacists are also present in 
clinics and physician office practices, many of our nation's seniors 
are medically underserved. As proven during the COVID-19 pandemic, 
pharmacists are an underutilized and accessible health care resource 
who can positively affect beneficiaries' care and the entire Medicare 
program.
---------------------------------------------------------------------------
    \2\ NCPDP Pharmacy File, ArcGIS Census Tract File. NACDS Economics 
Department.

Accordingly, APhA strongly urges the Committee to include S. 1362, the 
Pharmacy and Medically Underserved Areas Enhancement Act, recently 
introduced by Committee members Charles Grassley (R-IA), Robert Casey 
(D-PA), and Sherrod Brown (D-OH), in the Committee's legislative 
package to allow pharmacists to deliver vital patient care services in 
medically underserved areas to help break down the barriers to 
achieving health care equity in this country, improve patient care, 
health outcomes, the impact of medications,\3\ and consequently, lower 
health care costs and extend the viability of the Medicare program.
---------------------------------------------------------------------------
    \3\ See, Avalere Health. Exploring Pharmacists' Role in a Changing 
Healthcare Environment. May 2014, available at: http://avalere.com/
expertise/life-sciences/insights/exploring-pharmacists-role-in-a-
changing-healthcare-environment. Also, see, Avalere Health. Developing 
Trends in Delivery and Reimbursement of Pharmacist Services. October 
2015, available at: http://avalere.com/expertise/managed-care/insights/
new-analysis-identifies-factors-that-can-facilitate-broader-
reimbursement-o.

By recognizing pharmacists as providers under Medicare Part B, S. 1362 
would enable Medicare patients in medically underserved communities to 
better access health care--including mental health, SUD, and OUD care--
through state-licensed pharmacists practicing according to their own 
state's scope of practice. In medically underserved communities, 
pharmacists are often the closest health care professional and the most 
accessible outside normal business hours. The ongoing COVID-19 pandemic 
has further illustrated how difficult it is for patients living in 
medically underserved communities to access care and achieve optimal 
medication therapy outcomes. S. 1362 recognizes that pharmacists can 
play an integral role in addressing these longstanding disparities to 
help meet health equity goals \4\ and ensure that our most vulnerable 
patients have access to the care they need. Helping patients receive 
the care they need, when they need it, is a common sense and bipartisan 
solution that will improve outcomes and reduce overall costs.
---------------------------------------------------------------------------
    \4\ The White House. Executive Order on Advancing Racial Equity and 
Support for Underserved Communities Through the Federal Government. 
January 20, 2021, available at: https://www.whitehouse.gov/briefing-
room/presidential-actions/2021/01/20/executive-order-advancing-racial-
equity-and-support-for-underserved-communities-through-the-federal-
government/.
---------------------------------------------------------------------------

 S. 445/H.R. 1384, the Mainstreaming Addiction Treatment (MAT) Act

Only 1 in 5 Americans with opioid use disorder receive 
buprenorphine.\5\ The Department of Health and Human Services' (HHS) 
recent issuance of Practice Guidelines for the Administration of 
Buprenorphine for Treating Opioid Use Disorder \6\ is a step in the 
right direction to increase patient access to buprenorphine, which has 
been proven to cut the risk of overdose death in half.\7\ However, the 
Practice Guidelines exclude pharmacists--the most accessible healthcare 
providers--because pharmacists are statutorily ineligible to apply to 
the Substance Abuse and Mental Health Services Administration (SAMHSA) 
for a DATA 2000/X waiver \8\ necessary to prescribe buprenorphine as 
medication-assisted treatment (MAT) for OUD.
---------------------------------------------------------------------------
    \5\ Rebecca Haffajee, Ph.D., J.D., M.P.H. et al., Policy Pathways 
to Address Provider Workforce Barriers to Buprenorphine Treatment, 54 
Am. J. Prev. Med. S230-42 (2019).
    \6\ HHS. Practice Guidelines for the Administration of 
Buprenorphine for Treating Opioid Use Disorder. 86 FR 22439. April 28, 
2021, available at: https://www.federalregister.gov/documents/2021/04/
28/2021-08961/practice-guidelines-for-the-administration-of-
buprenorphine-for-treating-opioid-use-disorder.
    \7\ National Academy of Sciences, Engineering, and Medicine. 
Consensus Study Report: Medications for Opioid Use Disorder Save Lives, 
Nat'l Acad. Press (2019), available at: https://www.nap.edu/catalog/
25310/medications-for-opioid-use-disorder-save-lives.
    \8\ 21 U.S.C. Sec. 823(g)(2).

Under certain states' scope of practice laws, pharmacists are eligible 
to prescribe Schedule III controlled substances but are unable to 
prescribe certain Schedule III medications, such as buprenorphine, 
because they are not eligible for a DATA waiver. When pharmacists 
partner with physicians and other healthcare providers to provide MAT, 
they streamline and improve care. Pharmacists' MAT-related services may 
include treatment plan development, patient communication, care 
coordination, and adherence monitoring and improvement activities, 
among others. Allowing pharmacists to prescribe buprenorphine according 
to their states' scope of practice laws will increase patients' access 
---------------------------------------------------------------------------
to MAT and help address treatment gaps.

Accordingly, APhA strongly urges the Committee to include S. 445, the 
Mainstreaming Addiction Treatment (MAT) Act, introduced by Committee 
member Maggie Hassan (D-NH) and Senator Lisa Murkowski (R-AK), in the 
Committee's legislative package to further expand the number of 
practitioners--including pharmacists--who are ready, willing, and able 
to prescribe buprenorphine to patients in their jurisdictions.

Conclusion

APhA would like to thank the Committee for holding this important 
hearing and for continuing to work with us by including S. 1362 and S. 
445 in your legislative package to increase access to pharmacist-
provided patient care services for patients with mental health 
conditions, substance use disorder, and opioid use disorder. Please 
contact Alicia Kerry J. Mica, Senior Lobbyist, at [email protected] or 
by phone at (202) 429-7507 as a resource as you consider this 
legislation. Thank you again for the opportunity to provide comments on 
this important issue.

                                 ______
                                 
                   American Psychological Association

                          750 First Street, NE

                       Washington, DC 20002-4242

                              202-336-5800

                            202-336-6123 TDD

                          https://www.apa.org/

       Statement of Katherine B. McGuire, Chief Advocacy Officer

The American Psychological Association (APA) thanks the Subcommittee 
for the opportunity to offer evidence-based solutions to address the 
mental and behavioral health impact of the COVID-19 pandemic, which the 
nation will continue to confront long after the pandemic ends. APA is 
the nation's largest scientific and professional nonprofit organization 
representing the discipline and profession of psychology. APA has more 
than 122,000 members and affiliates who are clinicians, researchers, 
educators, consultants, and students.

As the U.S. Government Accountability Office (GAO) recently found, 
``longstanding unmet needs for behavioral health services'' continue to 
persist and were in fact ``worsened by new challenges associated with 
the COVID-19 pandemic'' (GAO, March 31, 2021). Over the past year, the 
pandemic created ``a cascade of societal challenges, including illness 
and death, prolonged social isolation, job loss, and reliance on remote 
work and online education'' while also ``cast[ing] a bright light on 
the destructive effects of health, educational, employment, legal, and 
criminal justice disparities and inequities.'' (American Psychological 
Association, August 2020). The results of APA's ``Stress in America'' 
survey series during this time tell a compelling story about the mental 
health impact of the pandemic on everyday Americans, particularly on 
communities of color and other underserved communities (American 
Psychological Association, 2021). This impact manifests in a highly 
individualized manner, which includes but is not limited to higher 
rates of emotions associated with prolonged stress, such as anxiety, 
stress and anger; unexpected fluctuations in weight; disruptions in 
sleep; and increased consumption of alcohol and dangerous substances.

Innovative solutions are urgently required if we are ever to meet the 
challenge of addressing the long-term mental health impact of this 
pandemic while remedying preexisting barriers to accessing these 
services. However, there is no ``one size fits all'' approach to 
addressing this crisis. This Subcommittee and its members have at their 
disposal an array of solutions, which we respectfully outline in this 
document.

      Support Permanent Expansions in Medicare Coverage of Certain 
Audio-Only Telehealth Services. Congress' and CMS' decision to expand 
Medicare coverage of mental and behavioral services via telehealth--
including those furnished via audio-only communication--prompted a 
long-overdue expansion of mental health services to many communities 
that traditionally lacked access to such services. Audio-only services 
in particular are a critical (and often the only) link to mental and 
behavioral health services for many individuals and communities that 
are less likely to have reliable access to technological training or 
broadband technology, such as older adults, individuals with 
disabilities, people in rural and frontier areas, lower-income 
families, and communities of color.

       We remain concerned, however, that this access expansion will 
abruptly end once the current public health emergency ends, and we hope 
members of the Subcommittee will help avoid this ``access cliff'' and 
permanently authorize Medicare to cover audio-only telehealth for 
mental, behavioral, and substance use disorder services. Additionally, 
while APA supports Congress's decision to eliminate certain site-of-
service requirements on Medicare tele-mental health coverage in the 
year-end budget and COVID package, we are concerned that the new six-
month in-person service requirement will inequitably limit access to 
services. Finally, we hope this Subcommittee will support a bipartisan 
bill co-sponsored by Chairwoman Stabenow, the Tele-Mental Health 
Improvement Act (S. 660), which will--both during and shortly after the 
pandemic--place coverage and reimbursement for mental health and 
substance use disorder services on the same footing as services 
provided in-person.

      Support Innovative Approaches to Combating the Resurgent Opioid 
and Substance Use Disorder Crisis. Despite Congress' commendable 
efforts to combat the opioid epidemic, the COVID-19 pandemic worsened 
rates of opioid and substance use. According to CDC data, over 88,000 
individuals died due to a drug overdose between August 2019 and August 
2020, an astounding 26.8% increase over the previous year (Ahmad, et. 
al. 2021). CDC data also shows that while opioids, and especially 
fentanyl, continue to account for the bulk of overdose deaths, the use 
of psychostimulants such as methamphetamine increased by 46% over the 
previous year (Volkow, 2021). The drug overdose crisis demands a strong 
public health response which meets individuals with substance use 
disorders where they are. The CAHOOTS Act (S. 764) introduced by 
Chairman Wyden embodies this approach, and we urge both its enactment 
and the adoption of mobile crisis intervention services by Medicaid 
programs nationwide.

       We urge the Subcommittee to advance similarly innovative 
approaches to this crisis, such as those outlined in: (1) the 
bipartisan Medicaid Reentry Act (S. 285), co-sponsored by Sen. 
Whitehouse, which allows inmates within 30 days of release to enroll in 
Medicaid to reduce the risk of relapse upon release; (2) Sen. Hassan's 
Mainstreaming Addiction Treatment Act (S. 445), which eliminates the 
unnecessary and counterproductive requirement that prescribing 
providers obtain a waiver from the Drug Enforcement Agency (DEA) before 
prescribing buprenorphine for the treatment of substance use disorders; 
(3) H.R. 2051, legislation introduced by Rep. Scott Peters to designate 
methamphetamine as an emerging drug threat; and (4) H.R. 2366, the 
``Support, Treatment, and Overdose Prevention of Fentanyl Act of 
2021'', introduced by Rep. Ann Kuster. We would like to especially 
highlight H.R. 2366's provisions that: (a) remove barriers to the 
establishment of contingency management programs, an evidence-based 
form of behavioral treatment developed by psychologists for treatment 
of methamphetamine, cocaine, and other substance use disorders (De 
Crescenzo, et. al., 2018); (b) fund grants to states, localities, and 
community-based programs for harm reduction programs; (c) remove the 
one-year waiting period for admission to maintenance treatment for 
opioid use disorders; and (d) request a study on the effectiveness of 
overdose prevention centers on reducing overdose deaths and improving 
access to effective treatment and recovery.

      Support Increased Funding for Programs to Strengthen School-
Based Mental Health Programs. The pandemic continues to have an 
outsized impact on children and youth, with nearly a third of parents 
reporting that their child experienced some degree of harm to their 
emotional or mental health during the pandemic (Gallup, 2020). This 
population is of particular concern not only due to their higher 
overall vulnerability to stress, but also because of the increased risk 
they will experience adverse childhood experiences (ACEs) such as 
various forms of abuse, neglect, and household dysfunction.

       One of the major disruptions in the lives of children and youth 
involve disruption in their daily school schedules, which often led to 
higher levels of social isolation. As schools are a key provider of 
mental and behavioral health services to children, the pandemic often 
cut off access to mental health services for many children (Nuamah, et. 
al., 2020). We hope members of the Subcommittee will consider a 
significant increase in funding for services under the Individuals with 
Disabilities in Education Act, Project AWARE, Title IV-A Student 
Support and Academic Enrichment Grants, and the Safe Schools National 
Activities Program, along with support for school-based health centers 
that provide an array of mental health services to Medicaid-eligible 
students and their families.

      Expand Research in Social and Behavioral Science to Invest in 
Health Equity. The COVID-19 pandemic both highlighted and exacerbated 
longstanding disparities in access to mental health services, 
particularly amongst individuals from communities of color. 
Psychological science continues to inform innovative solutions to 
combat challenges related to health equity including, for example, 
guidance on facilitating transparent and thoughtful conversations 
between community leaders and individuals to enable informed decisions 
about vaccine behaviors. As a critical first step in remedying these 
disparities, APA hopes members of the Subcommittee will support H.R. 
1475, the Pursuing Equity in Mental Health Act, which is among the 
bills listed on the House suspension calendar this week. Among other 
provisions, this bill would authorize funding to support health equity 
research, build outreach programs to reduce the stigma of seeking 
mental health treatment, and develop a training program for providers.

       To develop more innovative approaches to health equity, we hope 
members of this Subcommittee will also support National Institutes of 
Health (NIH) and National Science Foundation (NSF) research in social 
and behavioral science, as well as increased funding for the health 
equity offices across HHS to enhance equity-focused emergency 
preparedness planning and response to future public health emergencies. 
Specifically, we hope that members of this Subcommittee will support a 
significant increase in funding for the NIH Office of Behavioral and 
Social Sciences Research, which has a critical role in coordinating 
trans-NIH initiatives examining the social and economic impact of the 
COVID-19 crisis including its effect on mental health. Understanding 
the disruption in work and schooling, the economic uncertainty, grief, 
stress, unhealthy coping mechanisms, and the mechanisms that convey 
risk and resilience will help policymakers improve their long-term 
response to the current pandemic.

      Increase Funding for the Psychology Workforce Programs. Among 
the most effective ways to expand access to services for those 
experiencing mental health challenges from the pandemic is to develop 
the psychology workforce to reach underserved and marginalized 
communities. Programs such as the Graduate Psychology Education (GPE) 
program and the Behavioral Health Workforce Education and Training 
(BHWET) Grant Program serve a critical role in expanding access to 
mental health services in traditionally underserved areas, while the 
Minority Fellowship Program (MFP) serves a dual function to both expand 
access to patients while increasing the racial and ethnic diversity of 
the workforce itself. We hope members of this Subcommittee will support 
increased funding for all these programs to help meet an expected 
increase in need for mental health services due to the public health 
and economic impact of the pandemic.

APA stands ready to assist the Subcommittee in finding impactful 
bipartisan solutions to address the mental health and substance use 
disorder impact of this pandemic. Please contact Andrew Strickland, 
J.D. at [email protected] if our association can serve as a resource.

REFERENCES

Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. 
National Center for Health Statistics. 2021. Accessed at https://
cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

American Psychological Association (August 2020). Psychology's 
Understanding of the Challenges Related to the COVID-19 Global Pandemic 
in the United States. https://www.apa.org/about/policy/covid-
statement.pdf.

American Psychological Association (2021). Stress in America Press 
Room. https://www.apa.org/news/press/releases/stress?tab=2.

De Crescenzo et al., PLoS Medicine 2018; 15(12): e1002715.

Gallup (June 16, 2020). U.S. Parents Say COVID-19 Harming Child's 
Mental Health. https://news.gallup.com/poll/312605/parents-say-covid-
harming-child-mental-health.aspx.

Gold, J.A., Rossen, L.M., Ahmad F.B., et al. Race, Ethnicity, and Age 
Trends in Persons Who Died from COVID-19--United States, May-August 
2020. MMWR Morb Mortal Wkly Rep 2020; 69:1517-1521. DOI: https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC7583501/.

Nuamah, S., Good, R., Bierbaum, A., and Simon, E. (2020). School 
closures always hurt. They hurt even more now. Education Week. 
Retrieved from https://www.edweek.org/ew/articles/2020/06/09/
schoolclosures-always-hurt-they-hurt-even.html.

U.S. Government Accountability Office, March 31, 2021. Behavioral 
Health: Patient Access, Provider Claims Payment, and the Effect of the 
COVID-19 Pandemic. https://www.gao.gov/assets/gao-21-437r.pdf.

Volkow, N. National Institute on Drug Abuse, 2021. ``U.S. Overdose 
Deaths Involving Psychostimulants (Mostly Amphetamine), by Race'' 
[Powerpoint presentation]. Accessed at https://www.apa.org/members/
content/methamphetamine-addiction.

                                 ______
                                 
                        Center for Fiscal Equity

                      14448 Parkvale Road, Suite 6

                          Rockville, MD 20853

                      [email protected]

                    Statement of Michael G. Bindner

Chairman Stabenow and Ranking Member Daines, thank you for the 
opportunity to submit these comments for the record to the 
Subcommittee.

Mental health care and addiction services have actually stood up rather 
well during the pandemic. Zoom, and similar platforms, have stepped in 
nicely to continue face to face care where needed. Phone appointments 
and video calls have also worked in family practice settings where 
medication management is the only task.

Managing my prescriptions and assisting my housemate in managing his 
contacts with his are much easier than a trip to our respective mental 
health providers.

Detox and rehabilitative services for alcohol and drug abuse are still 
active, although sometimes bringing in outside speakers is not possible 
if there are glitches in electronic media or in the event a facility is 
moving to a new location. This is the exception, not the rule.

In Montgomery County, housing of Drug Court clients has been moved from 
our Pre-Release Center to contracted half-way houses. The system has 
kept up with COVID.

Regular Twelve Step meetings are occurring remotely as well. Some new 
members have never been to an in-person meeting, although clubhouses 
and church basement meetings are now opening up and outdoor meetings 
(both masked and unmasked) have been occurring throughout the pandemic.

Coronavirus and SARS2 infections occurred in the recovery community 
even when meetings were not held in person. People have mostly gotten 
sick in other places. Last year, older members got sick. This year, it 
is our younger members who suffer from the second wave. Older members 
have not been ill, having already recovered.

For many, including me, the virus spreads by being sneezed on in 
private during the first phase of the illness, which occurs before the 
asymptotic phase and the more serious symptoms.

The first phase is largely attributed to seasonal allergies or bad 
colds. People die in the more serious phase because they expect it to 
go away as the first did. The CDC has either not detected this pattern 
or has not informed the nation of it, for whatever reason. This is more 
of a factor in causing death than masking ever was.

While I might have been infected at a public event last February, it is 
as or more likely that infection occurred as I was typing Comments for 
the Record at the local library or by having coffee or a meal or seeing 
a movie during that period. I infected others during the first period. 
During the later part of the asymptotic period, no one I breathed on 
took ill.

There is one area of major concern that must be addressed, although I 
am not sure how we can go about it. During this crisis, before there 
was vaccine hesitancy, there was Zoom hesitancy. Some of our older 
members simply could not figure out or declined to use video calls to 
attend meetings.

I experienced this reticence myself, not wanting to download software 
to my phone that was unknown to me. In the beginning, I was also too 
ill to do much more than eat, be tired from eating, rest and then go 
back to bed. It was only the usual miracles experienced by those who 
are spiritually awake that had me download the software and attend a 
midnight meeting.

My housemate is not technically savvy. Without my help, and the use of 
my Chromebook, he would still be visiting his psychiatrist in person, 
where he would be taken into a room for a teleconference with his 
doctor.

He is a victim of the digital divide. It inhibits him (as well as the 
lack of a computer of his own) to seek English as a Second Language 
courses, which are free at Montgomery College (our local community 
college). His disability, which is matched by his lack of education and 
equipment hamper both his treatment and his ability to improve his 
skills.

This is where improvement is necessary. As I have stated in previous 
comments for the record, paying a stipend to undertake both computer 
and basic literacy training is an essential incentive to seek it. Such 
stipends should not count against his disability payments. If they did, 
they would be a disincentive toward learning. It is a conservative meme 
that poverty leads to self-improvement. Research has shown that the 
opposite is the case. It certainly is for him.

And yes, better broadband in some areas of the country would be 
helpful, although this would not solve the problem of digital 
illiteracy, especially among vulnerable populations. Most people have 
access to the Internet through their cable companies, although those 
that do not should be given free access paid for by higher cable fees.

Thank you for the opportunity to address the committee. We are, of 
course, available for direct testimony or to answer questions by 
members and staff.

                                 ______
                                 
      Eating Disorders Coalition for Research, Policy, and Action

                           PO Box 96503-98807

                          Washington, DC 20090

                          Phone: 202-543-9570

                  http://eatingdisorderscoalition.org/

Chairwoman Stabenow, Ranking Member Daines and members of the U.S. 
Senate Committee on Finance, Subcommittee on Health Care, thank you for 
holding this important hearing entitled, ``The COVID-19 Pandemic and 
Beyond: Improving Mental Health and Addiction Services in Our 
Communities'' to ensure the nation has the services and supports in 
place to care for individuals across the nation with mental illness and 
addiction, including those with eating disorders.

The Eating Disorders Coalition for Research, Policy and Action (EDC) is 
a nonprofit organization comprised of patient and caregiver advocates, 
treatment providers, advocacy organizations, and academics, aimed to 
advance the recognition of eating disorders as a public health priority 
throughout the U.S. By promoting federal support for improved access to 
care, the EDC seeks to increase the resources available for education, 
prevention, and improved training, as well as for scientific research 
on the etiology, prevention, and treatment of eating disorders.

As the number of new COVID-19 cases continues to decline, eating 
disorders diagnoses continue to climb. Research indicates a 30 percent 
increase in eating disorder diagnoses since March 2020 compared with 
data in previous years.\1\ EDC members, the National Eating Disorders 
Association has seen a 53 percent increase in their call volume to 
their helpline since March 2020 and the Alliance for Eating Disorders 
Awareness has already served 7,000 individuals representing all 50 
states and 32 countries and provided approximately 50,000 referrals for 
treatment since January 2021. This is just a sampling of the magnitude 
of services our coalition members are doing to support individuals and 
families in need. Despite this incredible work, we know there is still 
work to be done to improve the care for individuals with eating 
disorders.
---------------------------------------------------------------------------
    \1\ Tanner, Lindsay. (May 23, 2021). Pandemic has fueled eating 
disorders surge in teens, adults. Associated Press. Retrieved from: 
https://apnews.com/article/coronavirus-pandemic-virus-lifestyle-eating-
disorders-health-27c9d5680980b1452f7e512db4d9f825.

Eating disorders are serious mental illnesses that affect 28.8 million 
Americans over the course of their lifetime.\2\ They have the second 
highest mortality rate of any psychiatric illness, with one death 
occurring every 52 minutes as a direct result of an eating disorder.\3\ 
Without access to comprehensive treatment, eating disorders create 
great economic distress, costing the U.S. economy $64.7 billion 
annually with the federal government shouldering $17.7 billion of that 
cost.\4\ Ensuring comprehensive coverage for eating disorders treatment 
has the potential to mitigate disease progression or relapse into 
higher levels of treatment. Without access and/or coverage to 
treatment, higher levels of eating disorders treatment cost the U.S. 
$29.3 million in emergency room visits and $209.7 million in inpatient 
hospitalizations annually.\5\
---------------------------------------------------------------------------
    \2\ Deloitte Access Economics. The Social and Economic Cost of 
Eating Disorders in the United States of America: A Report for the 
Strategic Training Initiative for the Prevention of Eating Disorders 
and the Academy for Eating Disorders. June 2020. Available at: https://
www.
hsph.harvard.edu/striped/reporteconomic-costs-of-eating-disorders/.
    \3\ Ibid.
    \4\ Ibid.
    \5\ Ibid.

Eating disorder prevalence rates among the senior and disabled 
populations are similar to the general population at approximately 3 
percent to 6 percent.\6\, \7\ However, older Americans with 
eating disorders are particularly serious as chronic disorders or 
diseases may already compromise their health.\8\ Inadequate nutrition 
as a result of their eating disorder can result in memory deficits; 
cognitive decline; decubitus ulcers; impaired healing of sores, wounds, 
or infections; and dizziness, disorientation, and falls, which can 
initiate a cascade of pathophysiological events leading to a 30 percent 
to 40 percent mortality rate.\9\ Tragically, 78 percent of deaths from 
anorexia nervosa occur in the elderly.\10\
---------------------------------------------------------------------------
    \6\ Peat, Christine; Peyerl, Naomi; and Muehlenkamp, Jennifer. 
(2010). Body Image and Eating Disorders in Older Adults: A Review. The 
Journal of General Psychology, 135:4, 343-358.
    \7\ Mangweth-Matzek B, Hoek HW. Epidemiology and treatment of 
eating disorders in men and women of middle and older age. Curr Opin 
Psychiatry. 2017;30(6):446-451. doi: 10.1097/YCO.0000000000000356.
    \8\ Peat, Christine; Peyerl, Naomi; and Muehlenkamp, Jennifer. 
(2010). Body Image and Eating Disorders in Older Adults: A Review. The 
Journal of General Psychology, 135:4, 343-358.
    \9\ Dudrick, Stanley. (2013). Older Clients and Eating Disorders. 
Today's Dietitian, 15:11, 44.
    \10\ Dudrick, S. (2014). Older clients and eating disorders. 
Today's Dietitian, 15(11), 44.

Prevention and early intervention are the best tools to prevent disease 
progression for those with mental illness or substance use disorders. 
Given the complexity of eating disorders, a multidisciplinary treatment 
team that includes a medical provider, psychiatrist, psychologist, and 
registered dietitian is considered to be the four key provider 
components for comprehensive eating disorders treatment. The 
exponential rise in eating disorders as a consequence of the pandemic 
---------------------------------------------------------------------------
further underscores the importance of early intervention.

Unfortunately, Medicare does not provide outpatient coverage for 
medical nutrition therapy (MNT) for individuals with eating disorders. 
This coverage only applies to beneficiaries that are diagnosed with 
diabetes or end stage renal disease. This lack of coverage leaves 
individuals susceptible to disease progression and in need of a higher, 
costlier level of treatment. According to the American Dietetic 
Association, nutritional therapy conducted by a registered professional 
is an ``essential component'' for the treatment of patients with 
anorexia nervosa, bulimia nervosa, and other eating disorders.\11\ 
Research shows mental health interventions for eating disorders may not 
be successful if the underlying nutritional issues haven't been 
addressed first, since nutritional deficiency causes cognitive issues 
(e.g., depression) that can impede recovery.\12\ Nutrition counseling 
guides patients in identifying problematic behaviors and setting 
realistic and achievable nutrition related goals to support clients in 
making behavior changes. Nutrition education includes conversations 
about discrepancies between knowledge, beliefs and behaviors, 
ultimately empowering the patient to normalize eating and make 
healthier decisions.\13\
---------------------------------------------------------------------------
    \11\ Ozier, AD and Henry, BW. ``Position of the American Dietetic 
Association: nutrition intervention in the treatment of eating 
disorders.'' NCBI/NLM/NIH. https://www.ncbi.nlm.nih.gov/pubmed/
21802573.
    \12\ Rosen, David. (2010). Clinical Report--Identification and 
Management of Eating Disorders in Children and Adolescents. American 
Academy of Pediatrics, 126:6.
    \13\ Ruiz-Prieto, Inmaculada, Bolanos-Rios, Patricia and Jauregui-
Lobera, Ignacio. (2013). Diet Choice in weight-restored patients with 
eating disorders; progressive autonomy by nutritional education. 
Nurtricion Hospitlaria, 28:5, 1725-1731.

Fortunately, Congress has legislation to address this gap in coverage 
with a bipartisan bill entitled, the Nutrition Counseling Aiding 
Recovery for Eating Disorders Act or the Nutrition CARE Act (H.R. 1551/
S. 584) led by Senators Maggie Hassan (D-NH) and Lisa Murkowski (R-AK) 
and Representatives Judy Chu (D-CA-27), Jackie Walorski (R-IN-02) and 
Lisa Blunt Rochester (D-DE-AL). The legislation would provide Medicare 
Part B coverage for medical nutrition therapy for beneficiaries 
diagnosed with an eating disorder at the same coverage levels 
---------------------------------------------------------------------------
beneficiaries with diabetes and end stage renal disease receive.

This legislation is a small, critical step in ensuring the federal 
government is meeting the mental health needs of Americans across the 
lifespan. We urge the U.S. Senate Committee on Finance, Health 
Subcommittee to move this bill forward for consideration to the full 
committee as we work together to support the 2 to 2.5 million Medicare 
beneficiaries with eating disorders that could benefit from the 
Nutrition CARE Act.

Thank you for your consideration.

Sincerely,

Eating Disorders Coalition for Research, Policy and Action Members in 
Formation:


 
 
 
Academy for Eating Disorders                Reston, VA
Academy of Nutrition and Dietetics          Chicago, IL
Alliance for Eating Disorders Awareness     West Palm Beach, FL
Alsana: Eating Disorders Treatment and      Ballwin, MO
 Recovery Centers
Bannister Consultancy                       Durham, NC
BE REAL USA                                 Chicago, IL
Cambridge Eating Disorder Center            Cambridge, MA
Center for Change                           Orem, UT
Center for Discovery                        Los Alamitos, CA
Eating Disorder Coalition of Iowa           Clive, IA
Eating Disorder Hope                        Redmond, OR
Eating Recovery Center                      Denver, CO
Farrington Specialty Centers                Fort Wayne, IN
Gail R. Schoenbach FREED Foundation         Warren, NJ
International Association of Eating         Pekin, IL
 Disorders Professionals
International Federation of Eating          Dallas, TX
 Disorders Dietitians
Laureate Eating Disorders Program           Tulsa, OK
Monte Nido and Affiliates                   Miami, FL
Montecatini                                 Carlsbad, CA
Moonshadow's Spirit                         Webster, NY
Multi-Service Eating Disorders Association  Newton, MA
National Eating Disorders Association       New York, NY
Park Nicollet Melrose Center                St. Louis Park, MN
Project HEAL                                Brooklyn, NY
REDC Consortium                             St. Paul, MN
Rogers Behavioral Health                    Oconomowoc, WI
Rosewood Centers for Eating Disorders       Wickenburg, AZ
Stay Strong Virginia                        Chesterfield, VA
Strategic Training Initiative for the       Boston, MA
 Prevention of Eating Disorders
SunCloud Health                             Northbrook, IL
The Donahue Foundation                      Richmond, VA
The Emily Program                           St. Paul, MN
The National Association of Anorexia        Chicago, IL
 Nervosa and Associated Eating Disorders
The Renfrew Center                          Pittsburgh, PA
Veritas Collaborative                       Durham, NC
Walden Behavioral Care                      Waltham, MA
WithAll                                     St. Louis Park, MN
Wrobel and Smith, PLLP                      St. Paul, MN
 


                                 ______
                                 
                     Healthcare Leadership Council

                     750 9th Street, NW, Suite 500

                          Washington, DC 20001

May 11, 2021

The Honorable Debbie Stabenow       The Honorable Steve Daines
Chair                               Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Subcommittee on Health Care         Subcommittee on Health Care
Washington, DC 20510                Washington, DC 20510

Dear Chair Stabenow and Ranking Member Daines:

On behalf of the Healthcare Leadership Council (HLC), we thank you for 
holding a hearing on, ``The COVID-19 Pandemic and Beyond: Improving 
Mental Health and Addiction Services in Our Communities.''

HLC is a coalition of chief executives from all disciplines within 
American healthcare. It is the exclusive forum for the nation's 
healthcare leaders to jointly develop policies, plans, and programs to 
achieve their vision of a 21st century health-care system that makes 
affordable high-quality care accessible to all Americans. Members of 
HLC--hospitals, academic health centers, health plans, pharmaceutical 
companies, medical device manufacturers, laboratories, biotech firms, 
health product distributors, post-acute care providers, homecare 
providers, and information technology companies--advocate for measures 
to increase the quality and efficiency of healthcare through a patient-
centered approach.

The COVID-19 health pandemic has further exacerbated the substance use 
disorder (SUD) crisis in the United States. From May 2019--June 2020, 
the number of deaths related to drug overdoses rose 20% and a record 
number of Americans died from overdoses.\1\ Preliminary data expects 
2020 to be the worst year on record for drug overdoses.\2\ In order to 
respond to this crisis, Congress and federal agencies took swift action 
to ensure patients struggling with SUDs received proper care. We 
applaud the Drug Enforcement Agency's (DEA) decision to temporarily 
waive in-
person requirements to prescribe controlled substances. This has 
allowed patients to continue to receive important medications, 
particularly buprenorphine. HLC also thanks the Centers for Medicare 
and Medicaid Services (CMS) for finalizing regulations mandated under 
the SUPPORT Act that require providers to use electronic prescribing 
for controlled substances (EPCS). Requiring EPCS puts a more advanced 
monitoring system in place to ensure that controlled substances are 
only prescribed when necessary and allows for relevant authorities to 
monitor potential trends. We encourage Congress to work with federal 
agencies to further implement flexibilities that would allow patients 
to receive needed medications through the duration of the public health 
emergency (PHE) while maintaining robust safety and monitoring 
programs.
---------------------------------------------------------------------------
    \1\ Usha Lee McFarling, As the pandemic ushered in isolation and 
financial hardships, overdose deaths reached new heights, STAT News 
(February 16, 2021), https://www.statnews.com/2021/02/16/as-pandemic-
ushered-in-isolation-financial-hardship-overdose-deaths-reached-new-
heights/. 
    \2\ Chris Sweeney, A crisis on top of a crisis: COVID-19 and the 
opioid epidemic, Harvard T.H. Chan School of Public Health (February 
16, 2021), https://www.hsph.harvard.edu/news/features/a-crisis-on-top-
of-a-crisis-covid-19-and-the-opioid-epidemic/.

While HLC supports the regulatory flexibilities implemented during the 
PHE, Congress should further examine ways to combat the SUD crisis. We 
support efforts to permanently remove the ``X-Waiver'' provision under 
the Drug Treatment Act of 2000 that requires providers to receive a 
special waiver from the DEA to prescribe buprenorphine. We also 
encourage Congress to allow patients to receive prescriptions for 
controlled substances via telemedicine permanently once the waivers 
---------------------------------------------------------------------------
under the PHE expire.

As stakeholders continue to respond to the growing SUD challenges, we 
encourage Congress to work with federal agencies and additional 
partners to continue to develop educational resources on appropriate 
use of controlled substances as well as resources for patients 
struggling with SUDs. These tools will allow stakeholders to take 
sustainable steps in responding to the substance use disorder crisis by 
identifying best practices in prevention and treatment and ensure that 
patients have essential SUD healthcare options.

The COVID-19 health pandemic has also created barriers to accessing 
mental health services. A January study found that over 40% of adults 
have reported struggling with anxiety or depression since the beginning 
of the pandemic.\3\ If left untreated, many of these mental health 
challenges can further exacerbate SUD. We applaud Congress for 
providing over $4 billion in the Consolidated Appropriations Act for 
mental health services. HLC hopes that Congress will continue to 
examine ways to improve access to mental health services, particularly 
through telehealth.
---------------------------------------------------------------------------
    \3\ Nirmita Panchal et al., The Implications of COVID-19 for Mental 
Health and Substance Abuse, Kaiser Family Foundation (February 10, 
2021), https://www.kff.org/coronavirus-covid-19/issue-brief/the-
implications-of-covid-19-for-mental-health-and-substance-use/.

HLC, through its National Dialogue for Healthcare Innovation, continues 
to be focused on ways to address the substance use disorder crisis and 
make continued investments in mental health. Please feel free to 
contact Tina Grande at 202-449-3433 or [email protected] with any 
---------------------------------------------------------------------------
questions.

Sincerely,

Mary R. Grealy
President

                                 ______
                                 
                      Mental Health Liaison Group

                        1400 K Street, Suite 400

                          Washington, DC 20005

                         https://www.mhlg.org/

                              May 21, 2021

The Honorable Ron Wyden             The Honorable Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Washington, DC 20510                Washington, DC 20510

The Honorable Debbie Stabenow       The Honorable Steve Daines
Chair                               Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Subcommittee on Health Care         Subcommittee on Health Care
Washington, DC 20510                Washington, DC 20510

Re: Comments for the Record for the May 12, 2021 Hearing on ``The 
COVID-19 Pandemic and Beyond: Improving Mental Health and Addiction 
Services in Our Communities''

Dear Chairmen Wyden and Stabenow and Ranking Members Crapo and Daines:

On behalf of national organizations representing consumers, family 
members, mental health and addiction professionals, advocates, payers 
and other stakeholders, we thank you for your ongoing leadership to 
address the rising demand for mental health and substance use disorder 
treatment and to advance telehealth both during the COVID-19 Public 
Health Emergency (PHE) and beyond.

As you are well aware, the flexibilities granted by the '1135 emergency 
telehealth waivers have provided critical stability for healthcare 
professionals, patients and families across the nation during this 
challenging time. In particular, telehealth access for mental health 
and substance use disorder treatment services have served as a lifeline 
for many Americans struggling with isolation, grief, future 
uncertainty, and other new stressors this past year. On August 14, 
2020, the Centers for Disease Control and Prevention (CDC) reported 
that rates of substance abuse, anxiety, severe depression, and suicidal 
ideation increased across many demographics.\1\ Of grave concern, the 
report indicated that over 1 in 4 young adults had recently 
contemplated suicide. Additional research revealed that over 40 states 
saw a rise in opioid-related overdose deaths since the start of the 
pandemic.\2\ Overall, mental health conditions were the top telehealth 
diagnoses in the nation in November 2020--signifying an almost 20% 
increase year over year, with no indication that this trend is 
reversing.
---------------------------------------------------------------------------
    \1\ https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6932-
H.pdf?deliveryName=USCDC_
921-DM35222.
    \2\ https://www.ama-assn.org/system/files/2020-11/issue-brief-
increases-in-opioid-related-overdose.pdf.

To that end, we applaud the Committee for holding this important 
hearing to examine policy considerations for mental health and 
substance use treatment and telehealth as the nation moves out of the 
COVID-19 Public Health Emergency. With a surge in demand for behavioral 
health services that are only expected to increase, our nation needs to 
apply every tool at our disposal to ensure that Americans have access 
to the mental health and substance use services they need. As such, our 
respective organizations offer the following recommendations to the 
---------------------------------------------------------------------------
Committee as Congress reviews next steps on telehealth.

 I. Extend all telehealth flexibilities for mental health and substance 
                    use disorders at least one year beyond the end of 
                    the PHE to maintain access to care and better 
                    inform policymakers how to make permanent 
                    telehealth policies that increase equitable access 
                    to quality, evidence-based care

Telehealth helps to reduce the stigma around seeking mental health or 
substance use disorder treatment for those who want to seek care 
confidentially, and it makes access to services more available to those 
without childcare or transportation. Furthermore, audio-only 
telehealth, which has been a digital equalizer for those who lack 
access to broadband Internet or video-enabled devices and for those who 
cannot utilize dual audio-video devices, is a critical flexibility. The 
ability to communicate between patients and behavioral health providers 
according to individuals' own needs is crucial to eliminating 
artificial barriers to care.

Extending these flexibilities for at least one year beyond the 
conclusion of the PHE will allow for additional time to evaluate 
questions associated with cost, utilization, efficacy, and compliance. 
Taking this step is fully consistent with recent recommendations to the 
Congress from the Medicare Payment Advisory Committee, which asked for 
an extension of current telehealth flexibilities--including audio-
only--for up to 2 more years to gather more evidence about the impact 
of telehealth on access, quality, and cost, and for policymakers to use 
this evidence to inform any permanent changes.\3\ This additional time 
could provide more baseline data to address concerns, such as those 
relative to Congressional Budget Office (CBO) scoring, by allowing real 
world data rather than non-dynamic projections to guide policy decision 
making. Historical advancements have been made in telehealth over the 
last year and consumer support for continuing these advancements 
remains strong, particularly for mental health and substance use 
disorder treatments. We therefore implore this Committee to take 
action--via seeking an extension of telehealth flexibilities at least 
one year beyond the PHE--to ensure that these immense gains in virtual 
care are not lost or discontinued abruptly.
---------------------------------------------------------------------------
    \3\ Medicare Payment Advisory Commission, Report to Congress (March 
15, 2021).
---------------------------------------------------------------------------

 II. Allow telephonic (audio only) services for mental health and 
                    substance use disorder services after the PHE 
                    concludes

In 2019, the Federal Communications Commission (FCC) reported that 
between 21.3 and 42 million Americans lacked access to broadband. Many 
older adults and people with disabilities lack access to video-enabled 
devices or struggle to use the more complex video-enabled devices even 
if they have access to them. Likewise, many in racial/ethnic and low-
income communities lack access to broadband or video-enabled devices.

Additionally, there is strong evidence to support the efficacy of 
telephonic behavioral health services. A review of 13 studies found 
reduced symptoms of anxiety and depression when therapy was conducted 
via telephone.\4\ Patients have also benefited from receiving various 
interventions over the telephone, such as combined tele-pharmacotherapy 
and tele-cognitive-behavioral therapy (tele-CBT),\5\ tele-CBT 
alone,\6\, \7\, \8\ receiving short-term tele-CBT 
in primary care settings,\9\ and tele-bibliotherapy for older adults 
with anxiety.\10\ Veterans with comorbid psychological distress and 
combat-related mild traumatic brain injury have also benefited 
significantly from receiving telephone-problem solving therapy (Tele-
PST).\11\ After receiving tele-PST, veterans reported improved quality 
of sleep and reduction of symptoms of depression and PTSD.
---------------------------------------------------------------------------
    \4\ Coughtrey, A.E., and Pistrang, N. (2018). The effectiveness of 
telephone-delivered psychological therapies for depression and anxiety: 
A systematic review. Journal of Telemedicine and Telecare, 24(2), 65-
74. https://doi.org/10.1177/1357633X16686547.
    \5\ Ludman, E.J., Simon, G.E., Tutty, S., and Von Korff, M. (2007). 
A randomized trial of telephone psychotherapy and pharmacotherapy for 
depression: Continuation and durability of effects. Journal of 
Consulting and Clinical Psychology, 75(2), 257-266. https://doi.org/
10.1037/0022-006X.75.2.257.
    \6\ Mohr, D.C., Hart, S.L., Julian, L., Catledge, C., Honos-Webb, 
L., Vella, L., Tasch, E.T. (2005). Telephone-administered psychotherapy 
for depression. Archives of General Psychiatry, 62, 1007-1014. https://
jamanetwork.com/journals/jamapsychiatry/article-abstract/1108409.
    \7\ Stiles-Shields, C., Kwasny, M.J., Cai, X., and Mohr, D.C. 
(2014). Therapeutic alliance in face-to-face and telephone-administered 
cognitive behavioral therapy. Journal of Consulting and Clinical 
Psychology, 82(2), 349-354. https://psycnet.apa.org/fulltext/2014-
02032-001.html.
    \8\ Stiles-Shields, C., Corden, M.E., Kwasny, S., Schueller, M., 
and Mohr, D.C. (2015). Predictors of outcome for telephone and face-to-
face administered cognitive behavioral therapy for depression. 
Psychological Medicine, 45(15), 3205-3215. https://doi.org/10.1017/
S0033291715001208.
    \9\ Watzke, B., Haller, E., Steinmann, M., Heddaeus, D., Harter, 
M., Konig, H.-H., Wegscheider, K., and Rosemann, T. (2017). 
Effectiveness and cost-effectiveness of telephone-based cognitive-
behavioural therapy in primary care: study protocol of TIDe--telephone 
intervention for depression. BMC Psychiatry, 17(263). https://doi.org/
10.1186/s12888-017-1429-5.
    \10\ Brenes, G.A., McCall, W.V., Williamson, J.D., and Stanley, 
M.A. (2010). Feasibility and acceptability of bibliotherapy and 
telephone sessions for the treatment of late-life anxiety disorders. 
Clinical Gerontologist, 33(1), 62-68. https://doi.org/10.1080/
07317110903344968.
    \11\ Bell, K.R., Fann, J.R., Brockway, J.A., Cole, W.R., Bush, 
N.E., Dikmen, S., Hart, T., Lang, A.J., Grant, G., Gahm, G., Reger, 
M.A., De Lore, J.S., Machamer, J., Ernstrom, K., Raman, R., Jain, S., 
Stein, M.B., and Temkin, N. (2017). Telephone problem solving for 
service members with mild traumatic brain injury: a randomized, 
clinical trial. Journal of Neurotrauma, 34, 313-321. https://doi.org/
10.1089/neu.2016.4444.

Given the significant increase in demand for behavioral health services 
and the significant role of audio-only as a digital equalizer, we 
recommend continuing this flexibility for the provision of mental 
health and substance use disorder services for at least 1 year beyond 
the PHE. During this time, regulators may evaluate data to better 
understand which modalities may be considered for audio-only on a 
permanent basis.

 III. Remove the in-person requirement for telemental health services

While we applaud inclusion of the telemental health services in the 
end-of-year COVID relief package, we urge Congress to remove the in-
person requirement it established. Imposing service restrictions on 
telehealth access through arbitrary in-person requirements undermines 
the flexibility and access afforded by telehealth and other virtual 
care modalities. Additionally, as many providers around the nation have 
created virtual front doors for their services, they have also started 
serving larger geographic areas. As such, this new requirement, which 
would go into place after the PHE concludes, would place an unnecessary 
burden on consumers and providers alike.

IV. Continue payment parity for telehealth services

As more providers transitioned to telehealth, payers are starting to 
evaluate cutting rates, often making the case that delivering care for 
telehealth is less expensive. This is simply not the case for 
behavioral health providers that provide both in-
person and telehealth services. First, it assumes that behavioral 
health rates were already actuarially sound. However, because the 
Mental Health Parity and Addiction Equity Act has not been enforced 
since its inception over ten years ago, in many cases rates are already 
below the actuarial costs of delivering care and coverage of behavioral 
health services is limited.\12\,  \13\ Second, proposing 
rate cuts for telehealth assumes that telehealth delivery for providers 
operating a hybrid (in-
person and digital) service environment is less costly than the 
delivery of in-person care. However, this is also inaccurate as many 
providers continue to maintain much of their brick and mortar overhead 
while also seeking to invest in telehealth platforms, hire more tech 
support staff, and make overall and continuing IT investments. These 
additional costs do not have a reimbursement mechanism and overlay 
current operating costs. As such, we recommend that telehealth--for 
mental health and substance use disorder services--continue to be 
reimbursed on par with in-
person services.
---------------------------------------------------------------------------
    \12\ https://www.naatp.org/sites/naatp.org/files/MillimanReport11-
20-19.pdf.
    \13\ https://www.statnews.com/2019/03/18/landmark-ruling-mental-
health-addiction-treatment/.

In conclusion, even with today's telehealth emergency waivers, 
providers around the nation are struggling to meet the growing need for 
services at a time when many payers are already beginning to decrease 
rates for telehealth encounters. These combined effects--limited 
workforce, rate cuts, and an already underfunded system coupled with 
predictions that demand for behavioral health services will only 
increase--signals the clear need for urgent and immediate action. 
Through passing legislation that extends the telebehavioral health 
flexibilities, including audio-only services, beyond the PHE, removes 
the in-person requirement for telemental health services, and secures 
telebehavioral health parity--we can provide additional tools to 
---------------------------------------------------------------------------
increase access, break down stigma, and advance health equity.

We thank the Committee for its ongoing attention to addressing the 
mental health and substance use disorder crisis in our country, as well 
as for its consideration of the critical role that telehealth access 
can play for our nation both during and, importantly, beyond the PHE. 
Should you have any questions, or we can be of further assistance, 
please reach out to Laurel Stine ([email protected]), Lauren Conaboy 
([email protected]), and Elizabeth Cullen 
(elizabeth.cullen@jewish
federations.org).

Sincerely,

American Art Therapy Association

American Association for Geriatric Psychiatry

American Association for Marriage and Family Therapy

American Association for Psychoanalysis in Clinical Social Work

American Association of Child and Adolescent Psychiatry

American Association of Nurse Anesthetists

American Association of Suicidology

American Association on Health and Disability

American Foundation for Suicide Prevention

American Group Psychotherapy Association

American Psychiatric Association

American Psychological Association

Anxiety and Depression Association of America

Association for Ambulatory Behavioral Healthcare

Association for Behavioral and Cognitive Therapies

Centerstone

Center for Law and Social Policy

Children and Adults with Attention-Deficit/Hyperactivity Disorder

Clinical Social Work Association

College of Psychiatric and Neurologic Pharmacists (CPNP)

Confederation of Independent Psychoanalytic Societies

Depression and Bipolar Support Alliance

Eating Disorders Coalition for Research, Policy & Action

Education Development Center

Global Alliance for Behavioral Health and Social Justice

The Jed Foundation

The Jewish Federations of North America

International OCD Foundation

International Society for Psychiatric-Mental Health Nurses

Mental Health America

NAADAC, The Association for Addiction Professionals

National Alliance on Mental Illness

National Association for Children's Behavioral Health

National Association of County Behavioral Health & Developmental 
Disability Directors

National Association of Pediatric Nurse Practitioners

National Association for Rural Mental Health

National Association of Social Workers

National Association of State Mental Health Program Directors

National Board for Certified Counselors

National Council for Behavioral Health

National Federation of Families for Children's Mental Health

National League for Nursing

National Register of Health Service Psychologists

Network of Jewish Human Service Agencies

Postpartum Support International

Psychotherapy Action Network (PsiAN)

REDC Consortium

RI International, Inc.

Schizophrenia and Psychosis Action Alliance

SMART Recovery

The American Counseling Association

The Kennedy Forum

The Michael J. Fox Foundation for Parkinson's Research

The National Alliance to Advance Adolescent Health

The Trevor Project

Well Being Trust

Wounded Warrior Project

                                 ______
                                 
              National Association of Health Underwriters

                  1212 New York Avenue, NW, Suite 1100

                          Washington, DC 20005

                              202-552-5060

                            http://nahu.org/

I am writing on behalf of the National Association of Health 
Underwriters (NAHU), a professional association representing over 
100,000 licensed health insurance agents, brokers, general agents, 
consultants and employee benefits specialists. The members of NAHU work 
daily to help millions of individuals and employers of all sizes 
purchase, administer and utilize health plans of all types. These plans 
include coverage for mental and behavioral health benefits as is 
required by law. We are pleased to have the opportunity to submit 
recommendations to the subcommittee in regards to improving access to 
behavioral and mental healthcare. These recommendations were put 
together with the help of NAHU's Mental Health Task Force, a 
legislative working group made up of NAHU members who are health 
insurance and employee benefit professionals with an advanced 
understanding of mental and behavioral health services and how they are 
provided and used in health plans.

Access to mental health services is a crucial component of healthcare. 
National discussion has addressed mental health care for years, but 
often focuses more on physical health. The COVID-19 pandemic has 
reminded us of the importance of adequate mental health care and 
exposed a mental health crisis: About 4 in 10 adults in the U.S. have 
reported symptoms of anxiety or depressive disorder, a share that has 
been largely consistent, up from one in ten adults who reported these 
symptoms from January to June 2019.\1\ For these reasons it is more 
vital than ever that consumers are able to access and afford behavioral 
health services.
---------------------------------------------------------------------------
    \1\ March 15, 2021. Adults Reporting Symptoms of Anxiety or 
Depressive Disorder During COVID-19 Pandemic. Kaiser Family Foundation. 
https://www.kff.org/other/state-indicator/adults-reporting-symptoms-of-
anxiety-or-depressive-disorder-during-covid-19-pandemic/?current
Timeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22
%7D.
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Continuity of Care

The Mental Health Parity and Addiction Equity Act of 2008 created 
standards for the financial requirements and treatment limitations that 
a group health plan or group health plan issuer may impose on mental 
health and substance use disorder (MHSUD) benefits. MHPAEA established 
that financial requirements (such as copayments, coinsurance) and 
treatment limitations (such as limits on the number of outpatient 
visits, or prior authorization requirements) cannot be more restrictive 
than those that apply to medical and surgical benefits. With regard to 
financial requirements or quantitative treatment limitations (such as 
the number of inpatient days covered), a plan cannot impose a 
requirement or limitation on MHSUD benefits that is more restrictive 
than what is imposed on two-thirds of the medical and surgical benefits 
in the same classification. While this legislation made great strides 
in improving access and affordability, more must be done to improve 
continuity of care and network adequacy in the behavioral health space.

One major example of an improper break in continuity of care occurs 
during the appeals process when a claim for mental or behavioral health 
service is denied. The family, or responsible party, of a patient must 
sign a financial agreement that makes them liable for the full cost of 
care during the grievance process if the individual is to remain in 
treatment while appeals are completed, imposing undue financial and 
emotional duress.

Currently the time allowed for appeal of a denial of payment for Mental 
Health Services is 30 days, the same length of time for medical and 
surgical appeals. For mental health patients, this gap in treatment can 
lead to the loss or reversal of clinical gains. For some patients this 
can include life-threatening consequences, readmissions and the 
potential waste of initial investment in treatment. Ultimately, this 
gap caused by a long appeal process has an immensely harmful impact on 
the patient and their family or caregiver, emotionally and financially. 
For these reasons, NAHU recommends requiring all appeals of denials and 
grievances for MHSUD to automatically be escalated to urgent status. 
Urgent status usually allows a review time of significantly less than 
30 days and will ensure that these appeals are expedited leveraging an 
existing method.

Network Adequacy

Another way in which Congress can improve Americans' access to mental 
and behavioral health services is by addressing network adequacy. 
Network adequacy has been an issue in the mental and behavioral health 
service sphere for quite some time. While attempts have been made to 
make improvements in this area, there is still a significant amount of 
ground to cover. There are 119.3 million Americans that live in areas 
designated as ``Mental Health Professional Shortage Areas.''\2\ Often 
it is difficult for patient to locate a provider that accepts insurance 
at all, much less participates in their insurer's network. If a 
provider does participate, that participation may not be consistent 
resulting in provider directory inadequacy. A survey of privately 
insured patients found that 53 percent of those that used provider 
directories found inaccuracies in their insurer's provider directory, 
often leading them to receive care from out-of-network providers.\3\
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    \2\ September 30, 2020. Mental Health Care Health Professional 
Shortage Areas (HPSAs). Kaiser Family Foundation. https://www.kff.org/
other/state-indicator/mental-health-care-health-
professional-shortage-areas-hpsas/
?currentTimeframe=0&sortModel=%7B%22colId%22:%22Loca
tion%22,%22sort%22:%22asc%22%7D.
    \3\ Busch, S. and Kyanko, K. June 2020. Incorrect Provider 
Directories Associated with Out-Of-Network Mental Health Care and 
Outpatient Surprise Bills. Health Affairs. Retrieved February 1, 2020 
at https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.01501.

NAHU recommends that Congress consider incentives to encourage 
providers to participate in network plans including plans that use 
mental health carve-outs, as well as increase incentives for plans with 
mental health carve-outs to contract with willing MHSUD providers, 
possibly by increasing the percentage of the Medicare rate at which 
they are reimbursed. We also recommend increasing incentives for 
carriers with mental health carve-out plans to expedite the contracting 
process, and prioritize updating provider lists. The contract 
negotiation process between carriers and providers is a source of 
inefficiency, as the process can take a significant amount of time and 
can add yet another barrier to receiving care.

Collaborative Care Model

One glaring cause of inefficiency impeding Americans' access to mental 
and behavioral health is the lack of communication between behavioral 
health and primary care providers. Since mental and behavioral health 
is often not integrated with primary care, this leaves patients with 
undiagnosed or poorly managed mental and behavioral health conditions, 
despite the fact that mental and behavioral health conditions often 
initially appear in a primary care setting.

Currently, primary care clinicians provide mental health and substance 
use care to the majority of people with mental and behavioral disorders 
and prescribe the majority of psychotropic medications. NAHU believes 
that a collaborative care model that incorporates behavioral health and 
primary care could significantly decrease the weight of other illness, 
lessen the demand for mental and behavioral health services, and 
thereby lower medical costs and reduce disparities in identification 
and the effectiveness of treatment for behavioral health issues.

Telehealth

Because of the pandemic, rules related to all aspects of telehealth, 
including tele-behavioral health (TBH), have been loosened. This has 
resulted in immense increase in the use of tele-behavioral health 
services, enabling cross-state care which has been critical to 
underserved areas and rural communities. TBH has the potential to 
overcome patient stigma and improve access and efficiency of care for 
mental and behavioral health services. In general, when patients keep 
their first appointment, they are more likely to keep subsequent 
appointments; and when patients are satisfied with treatment, they are 
more likely to continue with their course of therapy which could lead 
in a decrease in cost for treatment of an individual over the course of 
their care.

Unfortunately, many older adults and people with disabilities, lack 
access to video-enabled devices or struggle to use the more complex 
video-enabled devices even if they have them. Likewise, many in ethnic 
and low-income communities lack access to broadband or video-enabled 
devices, which only expands the health inequities in the U.S. Due to 
this, NAHU recommends eliminating cross-state border restrictions on 
tele-behavioral health, permanently, as well as adopting technology-
neutral requirements, permitting use of different types of technology 
platforms that are designed for telehealth.

Mental Health Parity

Fully insured and self-funded ERISA plan sponsors are required to 
comply with the quantitative treatment limits imposed by the Mental 
Health Parity Act. However, fully insured and ERISA plan sponsors have 
no control over the non-quantitative treatment limits associated with 
Mental Health parity laws since they rely on their intermediaries such 
as third party administrators to monitor and comply with network 
adequacy requirements for access to mental and behavioral health care. 
There have been several lawsuits related to the non-quantitative 
treatment limits of mental health parity laws. NAHU recommends that the 
federal government create a safe harbor status for fully insured and 
self-insured ERISA plan sponsors which rely on independent 
certification of compliance with Mental Health parity requirements as 
included in the MHPAEA and most recently the Consolidated 
Appropriations Act of 2021.

We appreciate the opportunity to provide these comments and would be 
pleased to respond to any additional questions or concerns of the 
committee. If you have any questions about our comments or if NAHU can 
be of assistance as you move forward, please do not hesitate to contact 
me at either (202) 595-0639 or [email protected].

Sincerely,

Janet Stokes Trautwein
CEO, National Association of Health Underwriters

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