[Senate Hearing 117-628]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-628

                     MENTAL HEALTH CARE IN AMERICA:
                       ADDRESSING ROOT CAUSES AND
                      IDENTIFYING POLICY SOLUTIONS

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

                                HEARING

                               BEFORE THE

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION
                               __________

                             JUNE 15, 2021
                               __________

                                     
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                                     


            Printed for the use of the Committee on Finance
                        
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
51-591-PDF                  WASHINGTON : 2023  




                          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

                                  (II)

                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee 
  on Finance.....................................................     1
Crapo, Hon. Mike, a U.S. Senator from Idaho......................     3
Bennet, Hon. Michael F., a U.S. Senator from Colorado............     4
Warren, Hon. Elizabeth, a U.S. Senator from Massachusetts........     6

                               WITNESSES

Miller, Benjamin F., Psy.D., chief strategy officer, Well Being 
  Trust, Oakland, CA.............................................     7
Jett, Chantay, MA, MFT, executive director, Wallowa Valley Center 
  for Wellness, Enterprise, OR...................................     8
Durham, Michelle P., M.D., MPH, FAPA, DFAACAP, assistant 
  professor of psychiatry, Boston University School of Medicine; 
  and vice chair of education, and psychiatry residency training 
  director, Department of Psychiatry, Boston Medical Center, 
  Boston, MA.....................................................    11
Betlach, Thomas, MPA, partner, Speire Healthcare Strategies, 
  Phoenix, AZ....................................................    13

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Bennet, Hon. Michael F.:
    Opening statement............................................     4
Betlach, Thomas, MPA:
    Testimony....................................................    13
    Prepared statement...........................................    47
    Responses to questions from committee members................    50
Cassidy, Bill:
    Submitted letters............................................    54
Crapo, Hon. Mike:
    Opening statement............................................     3
    Prepared statement...........................................    58
Durham, Michelle P., M.D., MPH, FAPA, DFAACAP:
    Testimony....................................................    11
    Prepared statement...........................................    58
    Responses to questions from committee members................    60
Jett, Chantay, MA, MFT:
    Testimony....................................................     8
    Prepared statement...........................................    65
    Responses to questions from committee members................    67
Miller, Benjamin F., Psy.D.:
    Testimony....................................................     7
    Prepared statement...........................................    69
    Responses to questions from committee members................    80
Warren, Hon. Elizabeth:
    Opening statement............................................     6
Wyden, Hon. Ron:
    Opening statement............................................     1
    Prepared statement...........................................    90

                             Communications

American Academy of Family Physicians............................    93
American Hospital Association....................................    97
American Psychological Association...............................    99
Association for Behavioral Health and Wellness...................   103
Center for Fiscal Equity.........................................   107
Eating Disorders Coalition for Research, Policy, and Action......   111
Healthcare Leadership Council....................................   113
HR Policy Association, American Health Policy Institute, and 
  National Alliance of Healthcare Purchaser Coalitions...........   115
The Partnership to Amend 42 CFR Part 2...........................   116
Office of the United States Surgeon General......................   120

 
                     MENTAL HEALTH CARE IN AMERICA:
                       ADDRESSING ROOT CAUSES AND
                     IDENTIFYING POLICY SOLUTIONS

                              ----------                              


                         TUESDAY, JUNE 15, 2021

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:10 
a.m., via Webex, in Room SD-215, Dirksen Senate Office 
Building, Hon. Ron Wyden (chairman of the committee) presiding.
    Present: Senators Stabenow, Cantwell, Carper, Cardin, 
Bennet, Casey, Warner, Whitehouse, Hassan, Warren, Crapo, 
Grassley, Thune, Portman, Cassidy, Daines, Young, and Sasse.
    Also present: Democratic staff: Eva DuGoff, Senior Health 
Advisor; Marisa Dowling, Health Policy Fellow; and Kristen 
Lunde, Health Policy Advisor. Republican staff: Kellie 
McConnell, Health Policy Director; Gregg Richard, Staff 
Director; and Stuart Portman, Senior Health Policy Advisor.

   OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM 
             OREGON, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The Senate Finance Committee will come to 
order. The Finance Committee meets this morning to discuss 
mental health care in America, and this issue certainly ought 
to bring Democrats and Republicans together, starting with a 
single, clear lodestar. That lodestar is: every American must 
have mental health care when they need it.
    The shameful reality is, the United States does not come 
close to meeting that bar today. Multiple Federal laws say that 
mental health care is supposed to be on a level playing field 
with physical health care. In practice, however, the system 
still reflects the dangerous, outdated stigma against 
recognizing and treating mental illness. And that is why 
millions of Americans are now falling between the cracks.
    For someone with a mental illness, it can often be nearly 
impossible to find a provider who can meet your needs, or one 
who accepts insurance, particularly in rural communities or 
communities of color. Insurance claims often get denied or cut 
off too quickly, particularly for those experiencing 
homelessness. The outcome of a mental health crisis is often 
incarceration instead of treatment.
    Prior to the pandemic, one in five Americans was living 
with mental illness. All the evidence suggests that the 
pandemic is adding to that crisis. The proportion of Americans 
reporting symptoms of anxiety or depression has nearly 
quadrupled.
    On Friday, the Centers for Disease Control and Prevention 
released a new report finding that, over the last year, suicide 
attempts among teenaged girls were up more than 50 percent. 
Meanwhile, studies that the Government Accountability Office 
conducted at our request found that many provider offices 
closed or cut staff during the pandemic, and then too many 
patients were turned away.
    So, there is a lot for this committee to work on on a 
bipartisan basis. There are a few key challenges.
    First, the country clearly needs a larger mental health 
workforce. There simply are not enough providers, whether 
psychiatrists or therapists or staff in inpatient facilities. 
For example, due to a major staffing shortage, the psychiatric 
hospital in my home State of Salem, OR, is currently being 
staffed by members of the Oregon National Guard. That is in the 
State Capitol where there are people and resources to focus on 
the issue. Many other communities have it far worse. More than 
one in three Americans lives in an area with a serious shortage 
of mental health-care professionals.
    Second, insurance companies must not be allowed to cut 
corners when it comes to mental health coverage. I hear about 
this issue constantly at town hall meetings. People describe 
having their claims denied. In other cases, insurance only 
covers a portion of the treatment that people need. 
Furthermore, it does not make any sense to leave somebody 
experiencing a true mental health crisis waiting for a green 
light from an insurance company before they can get treated.
    Third, clearly the committee has a big challenge to address 
racial inequities in mental health care. Black and Latino 
Americans are roughly half as likely as white Americans to 
receive treatment for mental illness. Suicide rates are much 
higher among black kids. There are not enough black, Latino, 
and Native American mental health providers. So this is a 
question of equity, and we have a long way to go.
    Finally, the committee ought to build on recent telehealth. 
For example, early in the pandemic this committee led the fight 
to get Medicare to cover mental health services via telehealth. 
In December, the Congress made that permanent. I believe that 
is going to be a game changer, particularly for seniors who 
live in rural areas, and it is going to work in traditional 
Medicare as well.
    My colleagues all know that so many of our reforms have 
helped, particularly with Medicare Advantage and other programs 
where there is coordinated care, but we have to make sure 
traditional Medicare is afforded these benefits as well.
    Finally, Senator Stabenow has been a champion of mental 
health-care treatment, and I have watched for years as she has 
led the effort to bring Certified Community Behavioral Health 
Clinics, a program that she battled for and created, to 
American communities. These clinics are up and running now in 
40 States, including Oregon. It is an approach that works and 
meets major needs.
    I believe the Congress ought to look at ways to build on 
the success that my colleague has led, and we should also note 
again the bipartisan route, because I cannot tell Senators how 
often I have seen Senator Stabenow and Senator Blunt huddled in 
intense discussions about how they are going to expand this.
    Finally, the Congress also passed a big down payment for 
pioneering a new approach on mental health services and law 
enforcement. It is called the CAHOOTS program. It originally 
comes from Eugene--Eugene, OR--where I went to law school. But 
it is expanding now all over the country.
    Essentially what happens with this approach is, you have a 
911 call with somebody experiencing a mental health crisis. And 
at that point, the mental health-care professionals and the law 
enforcement in these communities have essentially teamed up and 
figured out a way to actually meet the needs of the patient and 
the community.
    So, in many instances, these are joint efforts of the 
mental health professionals and law enforcement--a team, a 
coalition approach. In Oregon, I have talked to the police 
officials in Eugene, the mental health professionals in Eugene, 
and very often the response--and they both have kind of worked 
up a system to do the right thing--is to use mental health 
professionals rather than law enforcement. And law enforcement, 
to their credit, is saying that they want to do that, and often 
the mental health professionals are the right response.
    The American Rescue Plan included a billion-dollar payment 
to help States build on their own programs, and I think we 
ought to look at what else ought to be done.
    The last point I will make--and Dr. Cassidy is here, and he 
has great expertise in this area. Colleagues, this is an 
enormous challenge, and I think it is natural for Democratic 
and Republican members of this committee to step up and shape a 
major response that we can take to the full Senate. I look 
forward to working with all my colleagues.
    Senator Crapo?
    [The prepared statement of Chairman Wyden appears in the 
appendix.]

             OPENING STATEMENT OF HON. MIKE CRAPO, 
                   A U.S. SENATOR FROM IDAHO

    Senator Crapo. Thank you very much, Mr. Chairman. I 
appreciate you holding this hearing, and I agree with your 
comments that this is an issue that deeply needs good 
solutions, and on which we can build strong bipartisan 
solutions that work. And I look forward to working with you, 
Senator Stabenow, and all the others that you have mentioned, 
on these issues.
    Ensuring access to high-quality mental health services has 
been and must continue to be a priority. Far too often, 
individuals with mental health, addiction, or substance abuse 
disorders find themselves isolated from their communities and 
separated from their providers. While Congress has taken 
decisive steps to address addiction, bolster behavioral health 
care, and curb substance abuse disorders, challenges remain. 
This committee has the ability to turn the tide. We can begin 
by empowering States to craft innovative, targeted solutions. 
Medicaid functions most effectively when States have the 
flexibilities they need to address patients' unique care needs 
and adapt to unforeseen circumstances.
    As the Nation's largest payer of mental health and 
substance abuse disorder services, Medicaid must support rather 
than subvert State efforts to serve communities in need. 
Unfortunately, the COVID-19 pandemic has highlighted and 
exacerbated the mental and behavioral health challenges we 
continue to confront.
    Loss of loved ones, increased isolation, and delayed 
treatment prompted a spike in anxiety, depression, and other 
debilitating conditions. While many are returning to their pre-
pandemic lives, we should not be content to allow our mental 
health-care delivery system to revert to its pre-pandemic ways.
    Whether for rural communities, urban areas, or tribes, 
telehealth has undoubtedly increased access to care. Through 
emergency flexibilities and permanent legislation authored by 
this committee late last year, we have taken crucial first 
steps toward modernizing telehealth coverage. I look forward to 
working with you, Mr. Chairman, and the other members of this 
committee to build on those efforts in the months ahead.
    Further, by partnering with State and local leaders, we can 
spur care coordination, strengthen the mental health workforce, 
and drive value through delivery system reforms. While there is 
no silver bullet here, I am confident we can tackle all of 
these challenges while upholding core principles of fiscal 
responsibility and program integrity.
    Before concluding, it bears emphasizing that we must 
continue to make progress in improving understanding of mental 
health so that people in need are not afraid or ashamed to seek 
treatment. We cannot discount the impact of stigma on 
preventing those in need of treatment from receiving care.
    I look forward to hearing our witnesses' testimony today, 
and I appreciate each of you coming here to share your 
expertise and ideas about how we can achieve these objectives.
    Thank you very much.
    [The prepared statement of Senator Crapo appears in the 
appendix.]
    The Chairman. Thank you, Senator Crapo.
    We have four terrific witnesses. The one who will testify 
first--and I think we will do the introductions, because 
colleagues are juggling a lot this morning--is Dr. Miller. And 
Senator Bennet will give the introduction for Dr. Miller. And 
we will introduce all our witnesses, and then we will hear 
their testimony.

         OPENING STATEMENT OF HON. MICHAEL F. BENNET, 
                  A U.S. SENATOR FROM COLORADO

    Senator Bennet. Thank you, Mr. Chairman. I would like to 
thank you and Senator Crapo for holding this important hearing. 
From the perspective of Colorado, it could not come soon 
enough. In my calls with parents and teachers over the past 
year, the number one issue has been mental health.
    Over the years, the person my office has turned to for 
advice on these issues is Dr. Benjamin Miller, one of our 
witnesses today. Dr. Miller is one of the country's foremost 
experts on mental health. Today he serves as the chief strategy 
officer for Well Being Trust, a national foundation dedicated 
to advancing a more holistic approach to the health of every 
American.
    In his early training, which included a doctorate from 
Spalding University and post-doctoral roles at the University 
of Colorado and the University of Massachusetts, Dr. Miller saw 
firsthand how America's inattention to mental health inflicts a 
terrible cost on our society, from our schools to our foster 
care, health-care, and criminal justice systems.
    Dr. Miller has not just studied these issues in the 
academy, he has worked on them firsthand in our communities. He 
has helped emotionally disturbed children make it through 
school, cancer patients cope with difficult diagnoses, and 
prisoners plan their reintegration into society. He has also 
trained physicians to better handle their patients' mental 
health. These issues are not abstractions for him, they are 
real people whose lives have directly benefited from greater 
attention to their mental health.
    I know Dr. Miller from his time at the University of 
Colorado, where he led the University's Health Policy Center 
for 6 years and was an invaluable resource to my team. During 
his time at the Center, Dr. Miller led a breakthrough project 
demonstrating the cost savings of integrating mental health 
with primary care. That project saved over $1 million for 
Medicare and Medicaid beneficiaries in Colorado by 
significantly reducing hospitalizations and other medical needs 
down the road.
    As health-care costs in this country continue to rise, I 
think the committee has a lot to learn from Dr. Miller's 
experience and expertise. I could spend the next 5 minutes 
listing the numerous awards and appointments he has earned over 
the years, but let me instead conclude by thanking Dr. Miller 
for joining us today, especially since he is supposed to be on 
vacation right now with his wife and two daughters. We are 
grateful for Dr. Miller's time, and for his service to Colorado 
and the country.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Bennet.
    The next witness will be from Oregon, Chantay Jett, who is 
the executive director of Wallowa Valley Center for Wellness in 
Enterprise, OR. It is a small community--I have been there 
often--in rural eastern Oregon. And as is the case for so many 
people I have the honor to represent, she is the bionic woman. 
She is basically everywhere, colleagues.
    She has worked in the Wallowa River House, a residential 
treatment facility for folks in Oregon afflicted with severe 
mental illness. She has been an outpatient mental health 
clinician. She is a pillar of the community. I remember 
recently--we have sessions in schools called ``Listening to the 
Future.'' Chantay was there. And she holds a master's degree in 
psychology with a child, couple, and family emphasis; a 
bachelor's degree in business administration; and she also 
worked with children in the inpatient psychiatric unit at 
Children's Hospital.
    Chantay, thank you for making the long journey from rural 
Oregon. We are so glad you are here. I know the committee is 
going to appreciate hearing from you.
    Next we will have Dr. Durham, a great advocate for patients 
and those facing health challenges. Senator Elizabeth Warren 
is, I believe, online and she can introduce Dr. Durham.
    Senator Warren, are you out there in cyberspace?

          OPENING STATEMENT OF HON. ELIZABETH WARREN, 
               A U.S. SENATOR FROM MASSACHUSETTS

    Senator Warren. I am. Thank you very much, Chairman Wyden, 
Ranking Member Crapo. Thank you for having this hearing today.
    I have the privilege of introducing Dr. Michelle Durham of 
Massachusetts. She has agreed to speak to the committee today 
about the importance of expanding access to mental health 
services all across our country.
    Dr. Durham currently works as a pediatric and adult 
psychiatrist at Boston Medical Center. Now, BMC is the largest 
safety-net hospital in New England, and it is also an academic 
medical center that is located in the heart of Boston. And it 
is an amazing place. Most of BMC's patients are low-income or 
from underserved populations. About half are covered by 
Medicaid. Throughout the COVID-19 pandemic, providers at Boston 
Medical Center, including Dr. Durham, have gone above and 
beyond to get patients the health-care services that they need. 
Our communities owe a great debt to the folks at BMC.
    At BMC, Dr. Durham serves as the vice chair of education in 
the Department of Psychiatry. She also has a joint appointment 
as assistant professor of psychiatry at Boston University 
School of Medicine, and she runs the training program for BMC's 
general psychiatry residency program.
    As you say, Chair Wyden, this is another woman who is 
everywhere. Throughout her career, Dr. Durham has been a 
tireless advocate of health, equity, and mental health. And she 
is the associate director of BMC's Global and Local Center for 
Mental Health Disparities. She also co-leads the TEAM UP for 
Children initiative at BMC, which works to expand pediatric 
mental health care at Federally Qualified Community Health 
Centers.
    Dr. Durham was an expert on mental health long before the 
coronavirus, and she also worked on the front lines of the 
pandemic. Her testimony today will offer significant insight 
into how Congress should be considering reforming and improving 
our mental health system to both build back from the pandemic, 
and to fix problems that existed long before that pandemic hit.
    So, Dr. Durham, I am deeply grateful for the work you do 
for patients, for students, and for the people of the 
Commonwealth of Massachusetts. I look forward to having a great 
discussion today.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much, Senator Warren. Thanks 
for your help in assisting us in making sure Dr. Durham could 
be with us today.
    Our last witness will be Tom Betlach, a partner at Speire 
Healthcare Strategies. Prior to joining Speire, Mr. Betlach 
served the State of Arizona for 27 years under five different 
Governors in three different cabinet positions. For 10 years he 
served as Director of the Arizona Health Care Cost Containment 
System. That is, as I understand it, Arizona's Medicaid 
program. He has a bachelor's and a master's in public 
administration from the University of Arizona, and a bachelor 
of arts in political science from the University of Wisconsin. 
So we are very glad you are here as well.
    Let's begin, and we will start with Dr. Miller.

    STATEMENT OF BENJAMIN F. MILLER, Psy.D., CHIEF STRATEGY 
             OFFICER, WELL BEING TRUST, OAKLAND, CA

    Dr. Miller. Well, thank you for that wonderful 
introduction, Senator Bennet.
    Chairman Wyden, Ranking Member Crapo, and members of the 
committee, my name is Dr. Benjamin F. Miller, and I am the 
chief strategy officer for Well Being Trust, a national 
foundation started in 2016 through a gift by the Providence 
Health System that is focused on advancing the mental, social, 
and spiritual health of the Nation.
    I am a clinical psychologist by training and have spent 
most of my adult life pursuing strategies that can advance 
mental health to a place of priority within our society. This 
goal has guided much of my work during my time as the founding 
director of the University of Colorado's Farley Health Policy 
Center, and is continuing today in my capacity as an adjunct 
professor at Stanford School of Medicine and at Well Being 
Trust.
    It is an honor to be able to speak to you today about an 
issue that every American is experiencing, an issue that we 
need to aggressively pursue, and which COVID-19 has all but 
exacerbated, especially among communities of color and other 
marginalized people: their mental health.
    Several government reports highlight how broken our mental 
health system is. The 2020 DoD Inspector General report found 
over 52 percent of service members and their families who 
needed mental health care did not receive it. SAMHSA found that 
over 56 percent of adults with mental illness did not receive 
any treatment in the past year, nor did 35 percent of those 
with serious mental illness. And a recent GAO report 
highlighted a multitude of issues at multiple levels for mental 
health, including ongoing challenges with health insurance, 
enforcing laws like mental health parity, and finding the right 
clinician who can help. In one survey, almost 30 percent of 
people reported not seeking care because they did not know 
where to go.
    The need to solve these and other existing problems is real 
and immediate. Clear pathways do not exist for people seeking 
mental health care. There are not obvious doors to enter, and 
we have no system that routinely is able to identify and treat 
people in a timely manner. This is perhaps our greatest 
challenge as we emerge from the devastating COVID-19 pandemic.
    With broad majorities of both parties now understanding the 
importance of addressing mental health, I believe it is time to 
enact immediate fixes for people in need, as well as to begin 
to lay the foundation for a reimagined mental health system, a 
mental health system that is grounded in community and is an 
integral part of a broader health-care infrastructure.
    There are three key priorities I believe this committee 
should consider as it pursues both short- and long-term reforms 
for mental health. First and foremost, we need to bring mental 
health care to where people are. This includes schools and even 
our work places. But to most immediately meet this moment, the 
best place to start is primary care, the largest platform of 
health-care delivery. In one poll, 70 percent of adults agreed 
that it would be more convenient if their mental health and 
substance use services were integrated into their primary care 
doctor's office.
    To do this, we must create more global and flexible funding 
mechanisms for primary care practices that are working to 
integrate mental health. Our payment mechanisms often reinforce 
a siloed delivery model, and this must change. By first using 
existing payment structures like those found in Medicaid 
managed care organizations, Medicare Accountable Care 
Organizations, and Medicare Advantage Plans to expand mental 
health integration work, primary care practices would have the 
flexible financial resources to onboard mental health 
clinicians as a part of their integrated team.
    Second, we must reconsider the design and capabilities of 
our workforce. Demand for care has far outpaced the supply of 
mental health clinicians, and it is inconceivable to rely upon 
clinician recruitment strategies alone to meet our ever-growing 
need.
    There are two things we can do simultaneously to address 
this workforce issue. First, we can map out mental health 
utilization gaps to better determine where services are needed, 
and for whom. Without this, we run the risk of widening 
disparities, or putting money into places or programs that 
people are not using for their mental health. Second, we can 
invest in our community workforce, those like peer support 
specialists, community health workers, or more broadly, lay 
people in our communities. We can train them in mental health 
skills to help become the first line of mental health support, 
complementing our clinical enterprise and enhancing the overall 
capacity for communities to address mental health needs.
    Finally, we must modernize and connect our Federal programs 
and systems to collaboratively solve our common mental health 
problems. I realize it is hard to ask committees to work across 
jurisdictional boundaries, but so many aspects of our mental 
health need to be understood together, and implemented 
together, at both the State and community level. Because there 
are multiple agencies, funding streams, and programs that 
support mental health, performing a landscape analysis can 
create a strategy for synergistic efficiencies by breaking down 
silos across Federal agencies and departments, and allowing for 
a more cohesive plan for mental health.
    In closing, I thank this committee again for holding this 
hearing on mental health. This is our moment to be bold in what 
we can do to boost our Nation's mental health and ultimately 
save lives.
    Thank you, Mr. Chairman.
    [The prepared statement of Dr. Miller appears in the 
appendix.]
    The Chairman. Thank you very much, Dr. Miller.
    Okay, I think next we will go to--Dr. Miller has gotten us 
off to a strong start, and now we will hear from Ms. Jett.
    [Pause.]

STATEMENT OF CHANTAY JETT, MA, MFT, EXECUTIVE DIRECTOR, WALLOWA 
           VALLEY CENTER FOR WELLNESS, ENTERPRISE, OR

    Ms. Jett. Good morning, Chairman Wyden, Ranking Member 
Crapo, and members of the Senate Finance Committee. Thank you 
for the opportunity to appear before the committee to discuss 
policy solutions to address both the mental health and 
substance use crises impacting the United States, and in 
particular the rural and frontier areas of our Nation. My name 
is Chantay Jett, and I am executive director of Wallowa Valley 
Center for Wellness (WVCW), which provides community-based 
mental health and substance use treatment services in the most 
remote region of the great State of Oregon.
    We represent a truly frontier area of our Nation where the 
cows outnumber the people and our closest major airport is in 
Boise, ID, nearly 4 hours away. We are literally at the end of 
the road, where everyone knows everyone, which unfortunately 
contributes to the stigma and lack of access for people seeking 
treatment services.
    I am here to tell you that the Certified Community 
Behavioral Health Clinic model has truly made a difference in 
our frontier communities. I hope every State in the near future 
has an opportunity to use the resources this model has made 
available to us to meet the specific needs of our community.
    The State of Oregon participates in the 10-State 
demonstration of the Excellence in Mental Health and Addiction 
Treatment Act that this committee helped to establish in 2014 
through the bipartisan leadership of Senators Stabenow and 
Blunt. The Center for Wellness is one of 12 CCBHCs that operate 
within our State. We provide high-quality integrated community-
based mental health and substance use services to individuals, 
while also screening for possible co-morbid conditions like 
heart disease, diabetes, HIV, and AIDs.
    Among the most important services that CCBHCs provide, both 
in Oregon and Nationwide, are immediate access to medication-
assisted treatment services for substance use and 24-hour 
psychiatric services. Please permit me to provide some very 
brief context of CCBHCs within rural and frontier counties in 
the State of Oregon.
    According to the Oregon Health Authority, our State reports 
higher rates of mental health conditions, including severe and 
persistent mental illness and suicidal ideation. The COVID-19 
pandemic has only exacerbated an ongoing mental health and 
substance use crisis in rural Oregon.
    OHA also detailed the lack of access to mental health and 
substance use care, especially in frontier communities. To give 
you a sense, there is no stop light within this 76-mile radius 
of Wallowa County. OHA reports an average wait time of as much 
as 6 months Statewide due to a lack of providers. However, we 
are the lucky ones, because the CCBHC model helped create an 
internal reorganization of service delivery which resulted in 
same-day access to care.
    Prior to becoming a CCBHC, the Center for Wellness was 
heavily reliant upon grants. Grant funding is crucially 
important, but it carries limitations. Grants typically end 
every 2 to 3 years. They all have different reporting 
requirements and different program specifications, which 
ultimately result in more time spent filling out paperwork 
rather than treating our patients.
    By contrast, the CCBHC prospective payment system allows us 
to do three major things. First, the Center for Wellness 
contracts with more skilled clinicians, including psychiatrists 
and medical professionals, to prescribe medication-assisted 
treatment for patients with opioid use disorder. This directly 
results in decreased wait times and reduced emergency 
department visits.
    Secondly, the CCBHC program is designed to expand access to 
underserved populations. In our communities, the CCBHC really 
opened the door for mental health care to veterans. According 
to our local VSO in our county, there are at least 1,000 
community members who have donned the uniform out of 7,000 
residents. Becoming a CCBHC has allowed us to increase our 
services to 23 veterans in our community. This may not seem 
significant to you, but it is a 300-percent increase in 
services.
    Thirdly, consistent CCBHC resources are a fundamental 
driver of integrated care. In Oregon, the CCBHC demonstration 
financing has made it possible to integrate with a local 
Federally Qualified Health Center, allowing primary care and 
behavioral health services all under the same roof.
    We also share a single electronic health record to permit 
immediate care coordination. Patients often tell me that it is 
such a relief to not have to retell their stories with every 
provider they meet. We are lucky that we have a great neighbor 
in the State of Idaho when we have no acute psychiatric beds 
available. This component of care coordination in partnership 
with primary care in hospitals, even across State lines, is 
imperative because patients with severe mental illness and 
substance abuse challenges have shockingly high rates of 
medical conditions. The CCBHC model allows us to have these 
partnerships and get patients the services they deserve in a 
timely manner.
    In closing, I strongly believe that this model represents 
the future of community-based mental health and substance abuse 
treatment in the United States. This is why I am asking you to 
make this model available to every State Nationwide. As a 
Nation, we can do better than first treating mental health and 
substance abuse in hospitals, homeless shelters, and our county 
jails. Investing in CCBHCs is streamlining services in 
efficient ways that drive costs down over the entire continuum 
of care.
    Despite being from a tiny frontier community at the end of 
the road in northeast Oregon, I hope you can see that CCBHCs 
make an enormous impact. Again, thank you for the opportunity 
to testify, and I am happy to answer any questions.
    [The prepared statement of Ms. Jett appears in the 
appendix.]
    The Chairman. Thank you very much, Ms. Jett. You make 
Oregonians proud this morning. I would also note you mentioning 
the Idaho-Oregon alliance. Senator Crapo's ears perked up when 
he heard that. And on all these incredible efforts, we have 
talked about a lot of them. And I just want you to know that it 
is a tremendous honor to really be your wing man in some of 
these causes, because we have a lot of work to do, and you have 
laid out a very powerful case about some of the most important 
elements. So thank you. And thank you for making the long trip.
    Okay; next will be Dr. Durham.

  STATEMENT OF MICHELLE P. DURHAM, M.D., MPH, FAPA, DFAACAP, 
ASSISTANT PROFESSOR OF PSYCHIATRY, BOSTON UNIVERSITY SCHOOL OF 
MEDICINE; AND VICE CHAIR OF EDUCATION, AND PSYCHIATRY RESIDENCY 
  TRAINING DIRECTOR, DEPARTMENT OF PSYCHIATRY, BOSTON MEDICAL 
                       CENTER, BOSTON, MA

    Dr. Durham. Thank you, Chairman Wyden, Ranking Member 
Crapo, and distinguished members of the Senate Committee on 
Finance, for holding this hearing and providing me with the 
opportunity to speak today about the state of the mental 
health-care system in America--where it is working, where it 
falls short, and how the Federal Government can play a role in 
helping to fill the gaps. Thank you, Senator Warren, for the 
kind introduction.
    Boston Medical Center is an academic medical center and the 
largest safety-net hospital in New England. The patients we 
serve are predominantly low-income, with approximately half of 
our patients covered by Medicaid or the Children's Health 
Insurance Program--the highest percentage of any acute care 
hospital in Massachusetts, and one of the highest in the 
country.
    Mental illnesses are all too common among the patients BMC 
treats in our emergency department and across our continuum of 
mental health-care services, which include outpatient 
integrated mental health care within our pediatric and adult 
primary care clinics, and at local community health center 
partners. A mental health urgent care clinic, a crisis 
stabilization unit, and our Boston Emergency Services Team 
(BEST) provide community-based evaluations and a jail-diversion 
program. At present, BMC does not own or operate a locked 
inpatient psychiatric unit.
    The patients we see at BMC who present with mental illness 
frequently have co-occurring substance use disorders, 
homelessness, malnutrition, and other health-related social 
needs linked to poverty. The current COVID-19 pandemic, 
structural racism, and economic crisis have further exacerbated 
the mental illness and trauma experienced by our patients.
    In my 10 years at BMC, I have never seen our mental health-
care services stretched so far beyond their capacity as they 
are now. Just the other day we had 25 patients in our 
psychiatric emergency department, more than triple its 
capacity, presenting with much higher level of acuity, some 
waiting for evaluations, and others boarding, awaiting 
placement in an inpatient psychiatric unit.
    It is widely understood and well documented that America 
has a dearth of licensed mental health professionals in 
general, and that particular areas of the country, largely 
rural and outside of the Northeast, are disproportionately 
impacted. Even where I practice in Boston, which has one of the 
highest numbers of child and adolescent psychiatrists per 
capita in the country, the capacity is insufficient to meet the 
mental health needs of the community.
    Increased Medicare graduate medical education funding for 
psychiatry residency slots can help increase the physician 
workforce. Increased funding for loan forgiveness programs for 
those who work in underserved areas can help alleviate the over 
$250,000 of debt that the average medical student has 
accumulated by the time their residency education is completed. 
The need to pay off medical school loan burdens is also likely 
to cause physicians to pursue practice in more affluent areas, 
adversely impacting access to care for low-income populations.
    Beyond the shortage of providers, the mental health 
workforce is not diverse--for instance, only 2 percent of 
psychiatrists identify as black--and not representative or 
reflective of the U.S. population. In order to address this, we 
must understand that the issue at its root is a pipeline issue 
that requires holistic solutions.
    Just as we say in medicine that a person's ZIP code is more 
influential than their genetic code in determining life 
trajectory and long-term health, where a person lives, the 
color of their skin, and the language they speak is highly 
determinative of quality of education and resources available, 
the level of exposure to the mental health field, and the 
stigma associated with mental illness.
    In terms of access to mental health services, COVID-19 led 
to an accelerated adoption of telemedicine. At peak, over 90 
percent of our outpatient psychiatric visits were conducted via 
telehealth, which enabled BMC to maintain and exceed our pre-
pandemic volume of service. That said, while telehealth is an 
important tool for ensuring patient access to mental health 
care, it does not work for everyone, due to digital inequities 
that exist related to Internet access and digital literacy, 
especially among low-income communities.
    The social determinants of mental health and structural 
vulnerabilities inherently involved with treating low-income 
patients require more dedicated time with patients to provide 
appropriate care. Insufficient Medicaid reimbursement acts as a 
deterrent for providers to see Medicaid patients, producing a 
cascade effect in which the more oppressed, marginalized 
populations have limited to no access to mental health 
professionals.
    At BMC, we have developed some innovative models to improve 
access to mental health services, which are ripe for 
replication and scaling. Transforming and Expanding Access to 
Mental Health Care in Urban Pediatrics, otherwise known as TEAM 
UP for Children, a pediatric integrated model in Federally 
Qualified Health Centers in Massachusetts, builds the capacity 
of health centers to deliver high-quality, evidence-informed 
care to children and families. The model includes behavioral 
health clinicians and community health workers working with 
pediatric primary care providers to provide timely mental 
health treatment.
    The Wellness and Recovery After Psychosis program is 
tailored for people experiencing psychotic symptoms using a 
team-based approach and providing individual, group, and family 
therapy; medication management; case management; and peer 
support.
    In addition, Massachusetts is home to some other models in 
which BMC participates. The Massachusetts Child Psychiatry 
Access Program, known as MCPAP, improves access to treatment 
for children with behavioral health needs and their families by 
making child psychiatry services accessible to primary care 
providers across Massachusetts via remote consultation and 
education. This model has been expanded to other States such as 
Connecticut, where I completed my fellowship. The Metro Boston 
Recovery Learning Community offers peer-to-peer services for 
people in recovery from mental health and/or substance use 
issues through peer support, advocacy, and career coaching.
    We are at a pivotal time in our country. Over a year into 
the COVID-19 pandemic, every person's mental well-being has 
been impacted in some way. The need for a more robust mental 
health-care system has never been more clear or pronounced.
    Treatment for mental health issues should be accessible, no 
matter who you are, where you live, or your ability to pay. 
Appropriate investment along the care continuum and for the 
mental health workforce can improve access to care and 
retention and recruitment of mental health professionals. The 
time is now to invest in a 21st-century mental health-care 
system in America.
    Thank you for your time, and I look forward to the 
discussion.
    [The prepared statement of Dr. Durham appears in the 
appendix.]
    The Chairman. Very good, Dr. Durham. I know that we will 
have questions for you in just a couple of minutes.
    Mr. Betlach, welcome.

          STATEMENT OF THOMAS BETLACH, MPA, PARTNER, 
           SPEIRE HEALTHCARE STRATEGIES, PHOENIX, AZ

    Mr. Betlach. Thank you, Chairman Wyden, Ranking Member 
Crapo, and members of the Senate Finance Committee. Thank you 
for the opportunity to testify today on policy solutions for 
addressing mental health.
    I had the privilege of serving as the Arizona Medicaid 
Director for almost a decade and, for a portion of that time, 
as the Mental Health Commissioner. Medicaid serves over 70 
million members, offering comprehensive mental health benefits 
to some of the country's most complex populations. As you 
formulate health policy options, State Medicaid programs should 
be a critical component of the discussion. Understanding the 
system and the forces prevailing on it should be at the core of 
the discussion.
    The last year brought to light the extreme fragmentation of 
our health-care delivery system at all levels. Our policy and 
program structures are in silos. Funding streams to support 
these populations follow those siloed program and policy 
structures. Providers gravitate towards these funding streams, 
creating more complexity at the point of care, and the very 
beneficiary the system is designed to serve is forced to 
navigate the maze we have created.
    Today's environment has challenges, but States and Medicaid 
programs now have access to considerable Federal investments to 
address these challenges. Examples include the 5-percent set-
aside for mental health block grants used for crisis, 85-
percent enhanced match in Medicaid for the CAHOOTS program, 10-
percent increase in Federal funding for home and community-
based services for the rehab option services, and the expansion 
of Certified Community Behavioral Health Clinics.
    In February 2021, the National Association of Medicaid 
Directors published ``Medicaid Forward: Behavioral Health,'' 
outlining a series of strategies Medicaid programs are pursuing 
to advance mental health services for members. The strategies 
vary based on the unique population served by Medicaid. This 
report highlighted initiatives such as expanding access and 
improving timeliness to care, integrating physical health and 
behavioral health, and expanding access for the full continuum 
of care, including crisis services.
    Further, a March 2021 Bipartisan Policy Council report 
concluded that integrating primary and behavioral health care 
is necessary and would ensure that individuals with behavioral 
health conditions and co-morbid physical health problems 
receive high-quality access to care. Arizona provides a strong 
example of this. In 2011, we pursued a multiyear strategy to 
better integrate services for individuals with serious mental 
illness. This strategy was focused on driving integration at 
three levels: policy integration, payer integration, provider 
integration. In 2018, Mercer consulting conducted an analysis 
of the integration efforts. Their final report for individuals 
with serious mental illness found that all measures of 
ambulatory care, preventative care, and chronic disease 
management demonstrated improvement. Just as important, all 
indicators of patient experience improved, with 5 of 11 
measures exhibiting double-digit increases.
    Another opportunity highlighted by NAMD is to strengthen 
crisis systems. This issue is front and center with the 
implementation of 988. SAMHSA provided extensive thought 
leadership with the development of the Crisis Now model to 
serve anyone, anywhere, at any time.
    The Crisis Now model is based on three critical components: 
call center capability, 24-by-7 community mobile response 
teams, and 23-hour crisis receiving and stabilization units.
    In Arizona, the system has been developed over the past 20 
years and serves all Arizonans. The financing for the system 
comes from creative multiple funding streams, while leveraging 
Medicaid for support. While we have seen improvement, there is 
clearly much more to do.
    To that end, Congress and the executive branch need to 
develop and implement strategies holistically by ensuring 
Medicaid and behavioral health collaborate and partner in a 
meaningful manner. On several occasions, Congress has leveraged 
the mental health expertise of SAMHSA to advance policy 
initiatives. However, there do not appear to be sufficient 
expectations established by Congress that these important 
planning and investment dollars are to be linked to the 
Medicaid program. Unfortunately, the dollars often get siloed, 
and the opportunity is suboptimal. At the end of the day, 
Medicaid beneficiaries may or may not benefit from these 
forward-looking investments.
    Congress should provide more flexibility with block grant 
funds for States to address social determinants of health, as 
States look at ways to support these investments. Congress 
should look at legislation to establish parity between Medicare 
and Medicaid. Where Medicaid has led the way in developing 
paraprofessional staff such as peer support services and 
systems to support broader populations like Crisis, Medicare 
should follow.
    Congress should continue to provide financial incentives 
for States to modernize mental health infrastructure, like the 
investments made in CAHOOTS and CCBHCs. Congress should 
continue to evaluate the impact of the IMD 16-bed limit. While 
there have been efforts made to allow for some payments in 
select instances, some States have not been able to avail 
themselves of these opportunities.
    Congress should rectify the fact that behavioral health 
providers were excluded from the electronic health record 
incentive program provided through the HITECH Act. And finally, 
as was mentioned by Dr. Durham, Congress should revisit the GME 
funding that is made available through Medicare and the 1996 
caps.
    We are at a critical moment in time to advance the delivery 
of mental health services, not only with Medicaid, but for our 
entire country. Thank you for your time and interest in these 
topics.
    [The prepared statement of Mr. Betlach appears in the 
appendix.]
    The Chairman. Thank you very much, Mr. Betlach.
    We will start with you, Ms. Jett. I think what you and your 
colleagues are saying is, you cannot expand mental health care 
without expanding a trained workforce. And this is especially 
true in rural areas. And your eloquent words, I believe, spoke 
for a lot of providers from rural areas. And it seems to me you 
have a big challenge filling key slots like licensed clinical 
social workers who serve Medicare and Medicaid patients, nurses 
who do so many things well, starting with health screening and 
recovering patients, who play a key role in terms of peer 
support. In listening to you over the years, you have convinced 
me the professionals are essentially the glue holding the 
mental health system together.
    Now I would like to get your thoughts with respect to the 
workforce, and particularly on the question of having enough 
people, and then preventing burnout. Because my understanding 
is that the pandemic just made things a lot more treacherous 
for so many professionals who just wanted to step up and help 
people.
    Deaths from opioids are 30 percent higher than last year. 
The number of emergency department visits for suicide and drug 
overdoses are up more than 25 percent. Three to four times as 
many people are identifying as facing depression today than 
before the pandemic.
    Why don't you tell the committee--because I have heard you 
speak to this in the past. It was always a challenge before the 
pandemic. Tell us what you think is really happening now with 
how the pandemic has made it much harder for you and your 
colleagues to do the terrific advocacy you do.
    Ms. Jett. Sure. I am happy to speak to that. Crisis burnout 
is at an all-time high. Every single one of our crisis 
clinicians will--well, clinicians in general that we hire have 
to take a crisis rotation. The crisis numbers since the 
pandemic started have tripled. And the acuity level of those 
crises has gone from a very simple ``I have a lot of anxiety''; 
``my cat is stuck in a tree for the past 2 days, and I am not 
sure what to do''; ``I am having a panic attack''; to the most 
recent crisis call that we had, which was, ``I have a loaded 
shotgun, and I intend to use it as soon as we get off this 
call.''
    I have never, in my 15 years of being part of a mental 
health system, ever experienced the acuity level of crises, the 
burnout with clinicians, and crisis acuity levels with the 
patients that we see now.
    The Chairman. Well, thank you for giving us a case example. 
I have heard you speak to this challenge of facing cases that 
are so much more serious--I guess the technical lingo is the 
greater level of acuity--but what a wake-up call, to go from 
having lots of calls where people are facing anxiety with cats 
in the trees and the like, to people with loaded shotguns 
saying that they are prepared to use them. So, thank you very 
much for that, and for coming.
    Dr. Durham, I want to talk to you about our challenges with 
parity. As you know, we got a Government Accountability Office 
report documenting all the barriers people face in trying to 
get behavioral health. The Federal laws have been on the books. 
I remember the day my Dad and I talked about the parity law. We 
said, ``This could help Jeff Wyden, a schizophrenic.'' We 
rejoiced. And yet, what I hear is that there are still all 
kinds of barriers to patients getting the care they need.
    And I would like to have you describe what you think is 
really going on out there with the parity law. And I gather 
your patients are facing a lot of barriers, and you still do 
not think the spirit of the law that would treat mental health 
like physical health is being honored.
    I would like to hear your words.
    Dr. Durham. Thank you for the question, Senator Wyden. I 
completely agree that we have not made any headway with parity 
for mental health and physical health. We have a long way to 
go.
    A really concrete example is that I work in the psychiatric 
emergency room at Boston Medical Center. As I mentioned in my 
oral testimony, we have people who--we have like tripled, 
quadrupled the capacity during the pandemic. One of the things 
that slows the process for us as a team of psychiatrists, 
licensed clinical social workers, psychologists, is that we 
evaluate the patient, we decide that they need inpatient 
psychiatric level of care, and then we start talking to the 
insurer.
    And that takes a lot of time, where we could be seeing 
other patients that are acutely in need of services by us, and 
we have to go back and forth faxing paperwork. Then you have to 
do a bed search and see what psych unit will accept your 
patient. And if it is Medicaid or Medicare, generally they want 
to know for Medicare, ``Well, have they met their capacity of 
days they can be in a psych unit?'' And then if they have, 
total lifetime days, then we are stuck with a patient boarding 
with us until we can figure out what else we can do.
    And for Medicaid, it is a lot of back and forth for our 
folks. And around 50 percent of our patients are on Medicaid. 
So that is a huge amount of time when we are in the emergency 
room spent going back and forth for, essentially, a prior 
authorization.
    And I like to use the example that when a patient comes 
into the emergency room in acute stroke, or having a heart 
attack, the physician in that moment makes a decision that they 
need inpatient hospitalization, and they go to the medical 
floor without having to go back and forth with an insurer 
deciding if that is actually the appropriate level of care.
    The Chairman. Thank you. And you know, obviously it was not 
the spirit of this bipartisan law from Senator Wellstone and 
Senator Domenici, to have patients and providers having to go 
into what is almost armed battle to try to navigate just a fair 
shake for patients and their providers. So I really appreciate 
your being here.
    I am over my time.
    Senator Crapo?
    Senator Crapo. Thank you, Mr. Chairman.
    This question is for you, Mr. Betlach. There is bipartisan 
interest in expanding opportunities for integration of physical 
and mental health services across all payers. While some 
approaches prioritize payment, others use co-location services, 
or the use of case managers under a medical home model, to 
achieve this goal.
    What are some of the examples of integration that could be 
a road map for Medicare or Medicaid in the near future? And how 
could waivers be used in State Medicaid programs to enhance 
access to care?
    Mr. Betlach. Senator, thank you for the question. I think 
there are a lot of different approaches States can take, and 
certainly it depends upon the ecosystem of each unique State.
    I think the first thing it starts with is, States need a 
strategy. What is your integration strategy? So as States think 
about this, they should be able to develop a plan in terms of a 
multiyear strategy that they are going to be implementing 
around integration.
    And as I mentioned in my testimony, there are really three 
levels to integration. There is how you think about it at the 
policy level. And for us in Arizona, it was thinking about some 
simple things like, what are the regulations that we have in 
place for providers to help build integration? Do we require 
some silly things like--we had two separate entryways and 
challenges around billing; and so making sure that, as a State, 
we were clearing out some of those regulatory burdens that 
existed for integration.
    States may or may not want to integrate and braid funding 
sources like we did in Arizona at the payer level, but States 
should certainly have a strategy around maximizing care 
coordination between payers. So if you are going to have a 
carve-out of behavioral health services, how are you going to 
ensure that there is care coordination for individuals who 
require both physical health and behavioral health services?
    And then finally, States need a strategy in terms of how 
they are supporting providers in terms of integration. It may 
be opening up things like the collaborative care model codes in 
terms of being able to pay for services that are done at the 
primary care site, like Dr. Miller talked about. There may be 
other incentives.
    We leveraged, in Arizona, an 1115 waiver to create provider 
payments for milestones that were achieved in terms of 
advancing integration strategies like connecting to our health 
information exchange and other areas like that.
    So States need a plan, and the plan needs to address each 
of those three critical areas: policy, pay integration, and 
provider support of integration.
    Senator Crapo. Thank you.
    Ms. Jett, you have very well described the issues that you 
face in a rural community in providing the needed services we 
are discussing today. Unfortunately, the stigma around 
receiving mental health treatment can be even higher in rural 
areas.
    Can you speak to these challenges? And what approaches has 
your clinic taken to combat them?
    Ms. Jett. I can. Thank you for the question.
    We have been integrated with primary care since 2012 
through a series of SAMHSA and HRSA grants. We are partnered, 
as I said in my testimony, with a local Federally Qualified 
Health Center. And together we have built a 20,000-square-foot 
building to provide primary care, dental services, VA services, 
and behavioral health, all under one roof.
    We are moving in, hopefully in August, and we are hoping 
that this destigmatizes your car from being in the parking lot, 
because people will not understand why you are there or what 
services you are receiving. So this is one way that we thought, 
in a frontier community, we could reduce the stigma of people 
receiving services.
    Senator Crapo. Well, thank you very much.
    And, Dr. Durham, one of the positive outcomes of the 
pandemic has been, as we have discussed here, the significant 
expansion of telehealth, which is an important tool to expand 
access.
    Have you found any limitations to tele-mental health for 
treating your patients, and particularly the younger ones?
    Dr. Durham. Thank you for the question. Absolutely, I think 
telehealth has been critical to meeting our patients' needs 
during this time. But there is a subset of the population where 
I think we need more research and understanding of how it is 
going to work fundamentally.
    I am a child psychiatrist who practices in a child clinic, 
and we went to telehealth pretty quickly as well. And I think 
it was difficult with some of our families too, because when we 
practice, we want a place where someone can speak to us 
directly. We want the parents to be separate from the room so 
that we can engage with the kid, whether that is a 5-year-old, 
or a 12-year-old, or a 16-year old.
    And it was very hard for some of the families who are in 
low-income communities, who are in multigenerational homes, to 
have that private place to have a session. And so that was some 
of the difficulty we saw.
    I think for little ones, especially kids who have early 
intervention services as well, so that 0 to 5 age range, we are 
also thinking about how we come back now to the office space 
again. And some of those kids we probably will need to see in 
person at some point and then maybe go back to telehealth once 
we have established a relationship. For the little ones, it is 
a little bit more challenging.
    And I think for the adult population, some of our folks who 
have substance use disorders in particular, and are homeless, 
really did not have the technology necessary to always engage 
with that support. So throughout the pandemic as well, what we 
did was, every day of the week we always had somebody who was 
there in person in our clinics to make sure that people could 
get the care they needed and did not have to rely on tele-
technology to get the services they wanted.
    So I think there is work to do. And I would also say that 
the audio-only was critical during this time as well. And so, 
any way we can expand that and make sure post-COVID, if you 
will, that we still get reimbursement for that, especially in 
some of our integrated care models--it was critical to have the 
audio-only be reimbursed at the same rate.
    Senator Crapo. Thank you. I am out of time.
    The Chairman. Thank you, Senator Crapo.
    Senator Stabenow?
    Senator Stabenow. Well, thank you very much, Mr. Chairman 
and Senator Crapo. I really want to thank you for this hearing. 
It has been a while since we have had a hearing focus on mental 
health and substance abuse services, and I really appreciate 
your leadership. And to all of you, you have all raised issues 
that are so incredibly important.
    I want to speak specifically to what I think is 
foundational in the community. And, Ms. Jett, you were talking 
about the Certified Community Behavioral Health Clinics that go 
to the core of integrating funding and really treating mental 
health and substance abuse as part of the health-care system. I 
always say we should treat health care above the neck the same 
as health care below the neck, and not just through a focus on 
grants that stop and start. It needs to be integrated in 
Medicaid, and it needs to be prospective payment so we can have 
the full opportunity for professionals being funded.
    So today I am really pleased to say that Senator Blunt and 
I--along with our chairman, Senators Daines, Cortez Masto, 
Smith, and Tester--welcome all the members of the committee to 
be co-sponsors in the next step. We have 10 States that have 
been doing a demonstration of how this can work with high-
quality standards, and today we introduced legislation that 
would allow States across the country to be able to do this, 
which is incredibly important.
    We have, through our startup grants, through the COVID 
process, we have been able to bring in dollars, as has been 
indicated, to over 300 communities across the country, 40 
States plus DC, to do startup grants. But what we need is 
comprehensive community care. And this all really started, I 
have to say, because Senator Blunt and I worked together on 
Federally Qualified Health Centers, which are widely supported 
on a bipartisan basis. And the idea, as you said, is quality 
standards. If the community clinic can meet the high quality 
standards, they get full reimbursement in the health-care 
system. And so that is what this is. The idea is to integrate 
those payments.
    So, Ms. Jett, no surprise, I have a question for you to 
expand on CCBHCs. You really were one of the very first in the 
country and have done just a marvelous job in showing what can 
be done. But I wonder if you could expand more on the issue of 
permanent funding.
    You know, I have always said to colleagues that it is like 
having someone having a heart attack, and they go to the 
hospital and they are going to immediately get treated. Right 
now, in too many places around the country, if somebody walks 
into a mental health center, it is the equivalent of saying, 
``I am sorry, the grant ran out, can you come back in a few 
months?'' when somebody is in crisis, which obviously is 
ridiculous.
    So, could you talk a little bit more about the importance 
of integrating funding and permanent funding in the mental 
health and substance abuse system?
    Ms. Jett. Of course. I would like to give a couple of 
examples first about how the system is currently funded, which 
presents a variety of challenges for us.
    For example, on the Medicare side, only licensed clinical 
social workers or medical doctors can treat Medicare patients 
for mental health services. What this means in a frontier 
county is, if we only have one or two licensed clinical social 
workers on staff, then the remainder of those services being 
delivered to Medicare patients are being written off.
    In our CCBHC, we write off upwards of $500,000 a year for 
Medicare-delivered services. Our growing population is over 65 
and under 17. We have the under-17 covered, but the over-65 
population is underserved. And really the reason is, we do not 
have the licenses available to treat those people.
    So the funding for CCBHCs allows that wrap-around payment 
to bridge the gap of services not being currently financed. It 
is vital, and it is important that we fund the business of 
mental health. People just want to fund the services, but there 
is an actual infrastructure that is required to provide this 
high level of integrated care.
    Senator Stabenow. Thank you so much. And in the limited 
time I have left, let me ask you to speak a little bit more to 
integrating care. Again, the financing model really is about 
integrating primary care for individuals. It is a whole person, 
and we segregate them when we are talking about various ways to 
provide health care. But could you talk about the delivery of 
behavioral health services and what you do in the context of 
providing primary care for people?
    Ms. Jett. Sure. Well, the CCBHC model in Oregon allows for 
20 hours or more of primary care to be delivered, as we say, on 
our turf in the behavioral health system. This building, co-
located with our local FQHC, works both sides of that equation, 
right? Because we understand that there are many people who 
want to access behavioral health services--specifically those 
with persistent and severe mental illness--on the behavioral 
health side.
    Conversely, there are people on the primary care side who 
only want to access behavioral health services from their 
primary care doc. And so, having both an FQHC and a CCBHC in 
one location allows for multiple access to services in the 
integration.
    Senator Stabenow. Thank you very much. Thank you, Mr. 
Chairman.
    The Chairman. I thank my colleague.
    Senator Crapo and I will be working very closely with you 
and Senator Daines as we go forward on these issues in a 
bipartisan way.
    Let's see. What we are going to do, because I think a 
couple of our hearings have been a challenge with so many 
Senators having hectic schedules, I am just going to call the 
names in order of appearance.
    So, Senator Grassley would be next. I am not sure he is 
available, but I thought we ought to check. Senator Grassley?
    [No response.]
    The Chairman. Okay. Senator Cantwell is of course here and 
has been a longstanding leader in terms of health-care 
advocacy, so let's recognize Senator Cantwell.
    Senator Cantwell. Thank you, Mr. Chairman. And thank you 
and the ranking member for holding this important hearing, and 
my colleague Senator Stabenow for her leadership on this.
    Many of you have mentioned--well, a big theme this morning 
is the integration of mental and physical health. I appreciate 
everybody honing in on what we could do about that. To me, this 
is--you know, when I look at 20 to 25 percent of the homeless 
population having mental health problems, I think there are 
costs. These are just continued costs to the system that we 
have not taken care of. And if we had an integrated system, and 
I think even better case management, because--who is managing 
the situation? If the person has mental health problems, who is 
managing the situation? And if no one can talk to any of the 
people, how could you possibly integrate the physical and 
mental health?
    I am sure I am not telling you anything. The drugs that 
people are taking for mental health cause a lot of physical 
problems. So this has to be fixed.
    So what do you think we can do to get our colleagues to 
understand that we are losing money that we could save now if 
we would just fix this integration? So either Dr. Miller, since 
you were very big on this, or Dr. Durham--either one.
    Dr. Miller. Well, Senator, thank you for the question. I 
will just begin by saying that I think you put your finger 
right in the center of the biggest problem that we have, which 
is how we have bifurcated, trifurcated, and split apart health. 
When you talk about services for the unhoused, or you begin to 
look at our children versus adults, we have fragmentation in 
almost every level. So to integrate requires us to have really 
thoughtful strategies that look at the issue at multiple levels 
simultaneously. And I will give you one example of that.
    If we simply look at how we clinically integrate care, 
without paying attention to how we financially support that 
integration, it usually falls apart. If we do not look at the 
administrative or operational functions that also provide 
oversight, it means that a lot of well-intended folks out there 
trying to bring these integration services together usually 
fall apart because there is not a structure for them to 
ultimately be grabbed by and supported.
    So, when we look at health, it is an opportunity to really 
think about that integration at multiple levels. So thank you 
for the question.
    Senator Cantwell. Dr. Durham?
    Dr. Durham. Sure. Thank you for that question. I am very 
aligned with what you said about case management and those 
services needed for families that present with a lot of issues 
besides just the mental health issue.
    In our model for TEAM UP for Children, which is in FQHCs in 
the greater Boston area, we have a community health worker as 
part of the model for just that: to do some of that care 
coordination not only between the schools, but thinking about 
housing insecurity, food insecurity, and what other services 
are needed.
    I think what happens many times, though, is that the case 
management service, the community health worker, or even a peer 
coach, are not usually reimbursed by the system. And so it does 
end up being a lot of grant funding. And I appreciated what Ms. 
Jett said as well, that the grant funding ends and then all 
those services that helped support families and patients also 
go away.
    And so, ways that we can embed that more into the system 
from a reimbursement perspective would be fantastic.
    Senator Cantwell. Well, I just go back to an example of 
the--as the chairman knows, I am a big supporter of affordable 
housing too, but hospitals are now helping to finance 
affordable housing so you can have a roof over somebody's head 
so that they do not keep coming to the emergency room. And 
while you are talking about helping families, I am talking 
about the cost to the system when people have no support or no 
help.
    I do not think we have a clue about how much we are running 
up the bills that we could do a better job with if we just had 
integration and case management for these people. Then we could 
make better decisions and lower the costs.
    And so, I hope we come to understand this, because a lot of 
our--I think what we are seeing in homelessness is people who 
just literally fall through the cracks. They do not have 
anybody advocating for them. They have bounced in between these 
things. They do not have the issue taken care of, and the next 
thing you know, they are out on the street.
    This is then costing all of us in all sorts of other ways. 
So to me, let's understand that this is a task certainly about 
helping people, but it is also a task about fixing the system 
that is costing us way more than it needs to cost us at this 
point.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cantwell. And as usual, 
you go right to the heart of the case, which is, who manages a 
lot of these cases? Who is, in effect, in charge? And as I saw 
with my late brother, as he suffered from schizophrenia, he got 
good care in a number of instances, but too often we could not 
figure out who was in charge. And I said to myself continually 
through this odyssey, if this is what an elected official who 
has tried to specialize in health care faces--and I spent years 
and years in those communities playing basketball--what is it 
like for the typical person? So, thank you. Thank you for 
hitting the question of who is going to manage these cases, and 
Senator Cantwell said it so well, as always.
    Senator Thune, I believe you are out there on the web.
    Senator Thune. Yes, I am.
    The Chairman. Are you available?
    Senator Thune. Yes, sir. Thank you, Mr. Chairman. And 
thanks to our panelists for being with us today.
    I think most everyone can agree that telehealth has proven 
to be an important tool on our tool belt for increasing access 
to mental health services. And once we get past this pandemic, 
I have concerns about a policy enacted last year that will 
require an in-
person visit for Medicare to pay for tele-mental health.
    One of the things I hear everywhere in South Dakota is, it 
does not matter what the provider setting is, whether it is 
Indian Health Service or the VA or our public hospitals in 
South Dakota, our schools, we cannot find, recruit, and retain 
providers. And so, as we are talking about the need to increase 
access, it seems to me that this arbitrary and inconsistent 
barrier does not make sense. In fact, in rural America it 
stands to make access even more inequitable.
    Ms. Jett, can you share some perspectives on how telehealth 
has helped rural patients overcome the stigma of seeking mental 
health services and the potential challenge an in-person 
requirement can have moving forward?
    Ms. Jett. Of course. Thank you for the question. Of course, 
there are both pros and cons to receiving telehealth services. 
I am happy to say that our clinic provided services nearly 
seamlessly through the pandemic because of the use of 
telehealth.
    However, as Dr. Durham has pointed out, those in 
underprivileged or underserved communities often struggle with 
technology, as well as appropriate hot spots or Wi-Fi 
capability.
    And so, what we have done as a community is, we took some 
of the FEMA crisis money that we received, and we bought 10 
iPads and 10 hot spots to deliver to children and families and 
community members who were without Wi-Fi or technology services 
that were available to them.
    We would often have them drive into the clinic and park in 
the parking lot. We would walk out an iPad, and they would hook 
up to our system right there in the parking lot and have their 
psychiatrist appointment or therapist appointment right there 
in the parking lot.
    So, telehealth services have certainly expanded the access, 
but also have prevented some people from accessing services 
too, specifically the population with severe and persistent 
mental illness. This has been a great barrier to them, 
unfortunately.
    It is very difficult to explain to someone with severe and 
persistent mental illness that their therapist is on the TV. 
That is a little odd. So it has been a bit of a challenge with 
that particular population. But overall, I think it has 
improved access.
    Senator Thune. Well, thank you. And I guess I would direct 
this to anybody on the panel. The in-person requirement passed 
last year is not consistent with multiple telehealth policies 
previously enacted by this committee, like the eTREAT Act for 
substance use disorder, and the FAST Act for stroke.
    Would you support legislation to remove the face-to-face 
requirement for mental health, like Senator Cassidy has 
introduced along with Senators Cardin, Smith, and I? And keep 
in mind that there is nothing to stop an individual provider 
from requiring their patient to have an in-person visit. And to 
Ms. Jett's earlier comment, I serve on another committee, the 
Commerce, Science, and Transportation Committee, which is 
working on the Wi-Fi issue and trying to make those services 
available to more people across the country.
    But with respect to this issue, this piece of legislation 
that Senator Cassidy is leading, and some of us are co-
sponsoring, does anybody want to talk about that particular 
legislation, whether or not you think that is something that 
you all could support and that makes sense as we look at better 
solutions to deal with mental health challenges facing this 
country?
    Dr. Durham. Yes, I can take that. I think that having a 6-
month in-person provision will really be an unnecessary barrier 
to folks getting care. And I think it should be at the 
discretion of the clinician or physician seeing the patient 
whether or not they need to see them again for an in-person 
visit. And I think we would go down this road again of, it is a 
parity issue of why, for certain illnesses or disorders you do 
not need it, and for mental health you would need it.
    So I would be very aligned with not having this provision 
and just using the discretion of the clinician on whether or 
not they need an in-person evaluation.
    Senator Thune. Great. Anybody else?
    Ms. Jett. Well, I think the bottom line is, we just have to 
be a flexible system that is amenable to serving all people of 
all populations at any time they request access for services.
    So, requiring these barriers seems sort of silly to me. And 
I hope that we can think twice about something like that.
    Mr. Betlach. Especially if the beneficiaries have now seen 
the value in receiving services through this mode of treatment.
    Senator Thune. Okay. Great. My time has expired.
    Thank you, Mr. Chairman. Thank you, panel.
    The Chairman. Thank you, Senator Thune. And I think you are 
making very important points with respect to these various 
issues requiring a previous appointment in order to get to 
telehealth. We have to work through those issues, and we are 
going to do it in a bipartisan way
    Senator Grassley would be next.
    Senator Grassley. Thank you, Mr. Chairman.
    In 2019, I passed the bipartisan ACE Kids Act, with the 
help of Senator Bennet, that will align Medicaid rules and 
payments to incentivize coordination and improve health 
outcomes. This Congress, I am working with Senator Bennet to 
build onto the ACE Kids Act with the Accelerating Kids Access 
to Care Act. A key aspect of this effort is to enable the 
pediatric health home to coordinate care with children, 
including the prevention and treatment of mental illness and 
substance abuse.
    So, for Mr. Betlach and Dr. Durham, you both discussed in 
your written testimony the importance of care coordination to 
addressing fragmentations in the health-care system. The ACE 
Kids Act requires States to ensure mental health-care 
coordination is included when establishing a pediatric health 
home. What lessons can be learned from both your experience as 
a provider and a State Medicaid Director with upcoming 
implementation of the ACE Kids Act in 2022?
    Dr. Durham. Thank you for the question, Senator Grassley. I 
think the more we can coordinate care for kids and families, 
the better, at any opportunity. Kids are in many different 
systems: school systems, their community, their family network, 
and all of their providers, especially as kids have more 
complex medical conditions. And so, I would be in great 
support--any time we can provide the services to coordinate 
care, the better it is. And I think what we have seen in some 
of our models that have focused on pediatric and mental health 
integration in FQHCs is that, the more members of the team that 
are involved with every system that the kid is in, the better 
it is for the kid. Their mental health gets better. Their 
physical health gets better. And then of course, where they 
thrive is at school and at home, ultimately. So, thank you for 
that question.
    Mr. Betlach. Senator Grassley, what we have seen in Arizona 
is that States need to have a strategy around the different 
silos that exist in terms of where complex kids may be, whether 
it is working with the foster care system, whether it is 
working with kids who may be receiving services through a 
waiver for individuals with developmental disabilities. Really, 
the State needs to be looking at the delivery of behavioral 
health services holistically and how it is going to serve those 
populations and reduce the fragmentation.
    And so, it is leveraging the investments that SAMHSA has 
made, for example, with first-episode psychosis to make sure 
that Medicaid is plugging into the infrastructure that is being 
created, and looking at that. So, if it is using managed care 
or fee-for-service, the State needs a plan in terms of how it 
is going to take kids with these complex needs and get them the 
services that they need.
    Senator Grassley. In the last Congress, we made mental 
health services via telehealth a permanent benefit of Medicaid. 
So, for Dr. Durham and Dr. Miller: as health-care providers, 
how best can Congress support this expansion of mental 
telehealth while ensuring improved health outcomes for 
individuals served by the expansion of access?
    Dr. Durham. Access has been greatly improved with 
telehealth. We have seen that throughout the pandemic, and with 
our patients. You know, as we discussed previously, I do think 
there are certain populations where it is more difficult.
    And so, audio-only has been very helpful throughout the 
pandemic. We have seen that a lot in some of our integrated 
care settings, whether that is pediatric integrated care, or 
internal medicine integrated care for primary care--at least at 
Boston Medical Center.
    And so, I hope that the provision would still continue to 
allow audio-only visits at the same reimbursement rates, 
because it has significantly impacted and helped many of the 
homeless population, folks who do not always have access to the 
technology.
    Dr. Miller. I agree with Dr. Durham. And, Senator Grassley, 
thank you for the question.
    The uptick in telehealth utilization for mental health has 
been a very helpful sign. The people like it when care is able 
to come to them. And if we are really going to put the patients 
and families first, we do have to consider policies like the 
in-person requirement we just discussed and consider whether or 
not these things are good or bad for people. Does it restrict 
their access? Does it restrict where they are going to be able 
to ultimately use these services?
    So, making permanent the audio-only, having payment parity, 
and allowing this for all forms of outpatient care, is a 
tremendous benefit for so many people across our country.
    Senator Grassley. I will yield.
    The Chairman. Thank you, Senator Grassley.
    Next would be Senator Carper. Is he available on the web?
    Senator Carper. Senator Carper is right here.
    The Chairman. Okay, and we can hear you. Go ahead.
    Senator Carper. Thank you, sir. I welcome each of our 
witnesses today.
    My staff and I have heard from pediatricians from across 
the country, including in the Nemours Children's Hospital, the 
fabled children's hospital that we are very proud of. And we 
hear from any number of sources that our country is 
experiencing a mental health crisis among our children. And I 
do not think it is just in Delaware, I think it is throughout 
our country.
    But during the pandemic, children have experienced major 
disruptions as a result of public health safety measures, 
including school closures, social isolation, financial 
hardships, and gaps in health-care access. It has become clear 
that COVID-19 has significantly exacerbated the health stress 
on our children and youth, highlighting our Nation's acute 
shortage of mental health services and the need to reinforce 
and expand the pediatric mental health delivery systems and 
infrastructure.
    A question for Dr. Durham, if I could. Dr. Durham, what 
more can those of us in the Congress do to address root causes 
and support effective approaches to prevention and early 
identification of mental and behavioral health issues? Dr. 
Durham?
    Dr. Durham. Thank you very much for that question. As you 
mentioned, many of our kids have experienced a lot of loss. And 
when we think of loss, it is not only death within their 
family, but also thinking of not being able to see their 
friends or do the social activities and other things that 
fulfill and support their livelihood.
    I do think one thing that we need to think through from a 
prevention/promotion standpoint is that many of our schools, 
even in the Boston area, do not have school therapists that 
they have access to. So, we do not want people to always get 
treatment once there is a severe level of illness and they need 
to be in a hospital or an emergency room, but how can we start 
thinking in a prevention and promotion framework of just 
touches, if you will? So, meaning that something is going on. A 
teacher notes it, or a principal, or someone in the school or 
the family, and they have the services right there within the 
school system before we get to the point where you are calling 
the emergency services or a crisis line.
    There are not enough supports within the school system to 
do any of that sort of prevention and promotion framework. 
Teachers are doing a lot. They are doing their job. But we do 
not have therapists embedded in many of our schools, even when 
we think about a resource-rich place like Massachusetts. And 
so, I think it is critical that we think about it in that 
framework.
    I do think pediatric integrated care is another way to 
think more about prevention and promotion; so, seeing children 
and families at their well-child visit, which we do in 
Massachusetts, and start thinking and asking those questions 
about what stresses are happening in their lives and getting 
care for immediate needs--whether it is a mild behavioral 
health need, depression or anxiety that is not to the point 
where maybe they are thinking about harming themselves or 
harming anyone else.
    So, using that framework of prevention and promotion, I 
think, is critical. And sometimes that is not necessarily 
reimbursable from a mental health standpoint as it is for 
physical health. Kids are supposed to go get their visits quite 
early in life for a check-in. And the more we can think about 
even like a mental health check-in with their primary care 
provider or therapist in the school, I think the better we 
would all be in the long run.
    Senator Carper. Thanks.
    A question for the record, if I could, for all of our 
witnesses. Several months ago I was in the Bay Area in 
California visiting a number of promising technology companies. 
One was called Ginger, G-i-n-g-e-r, in the Bay Area. And they 
focus on coverage for--or they focus on mental health 
screenings, and behavioral health coaching. And I have a 
question regarding the coverage for those screenings and 
coaching. And I would just ask you if any of you find virtual 
behavioral health coaching to be an efficient means of 
preventing serious mental illness? And if so, should Congress 
consider mandating coverage for virtual mental health 
screenings and behavioral health coaching in plans offered on 
the health insurance marketplace? That is a question for the 
record for each of you.
    Thank you, very much. Thank you, Mr. Chairman and Ranking 
Member.
    The Chairman. Thank you, Senator Carper.
    So, colleagues, we are going to keep this going. Our guests 
will, I am sure, find this somewhat entertaining, because we 
have all these votes, and Senators are coming in and going, but 
we are going to keep it going.
    The next four questioners from the committee will be 
Senator Cardin, Senator Cassidy, Senator Bennet, and Senator 
Daines.
    So, Senator Cardin, if he is available on the web, would be 
next. And as I say, we are just going to keep this going.
    Senator Cardin, are you out there in cyberspace?
    [No response.]
    The Chairman. Okay. Senator Cassidy has been sitting here 
all morning.
    Senator Cassidy. Thank you, Mr. Chairman.
    Dr. Durham, I think I may have given you a lecture in 
medical school.
    Dr. Durham. I think you may have. [Laughter.]
    Senator Cassidy. You may recall, it was on diarrhea and 
hepatitis. I was famous on those lectures. There will be a quiz 
as to hepatitis A and how it is transmitted, but we will do 
that off the record. Thank you, very much.
    It is incredibly gratifying to me to see you and how your 
career has gone.
    Dr. Durham. Thank you very much.
    Senator Cassidy. Let me echo Senator Thune's endorsement of 
the bill that we have introduced as regards telehealth, tele-
mental health. And, Mr. Chair, I would like to submit two 
letters which support this legislation that we are putting 
forward with Senator Thune, as you mentioned, but also Senators 
Smith and Cardin--and I have lost the list. And so this letter 
is from the American Telemedicine Association, and this is a 
group of folks with the Health Innovation Alliance of the 
American Telemedicine Association.
    The Chairman. Without objection, so ordered, Senator 
Cassidy. And Senator Crapo and I will be working very closely 
with you and the coalition on this very important idea.
    [The letters appear in the appendix on p. 54.]
    Senator Cassidy. Thank you.
    Mr. Betlach, good to see you.
    Mr. Betlach. Senator Cassidy, good to see you, sir.
    Senator Cassidy. Your hair is a little longer---- 
[Laughter.]
    Listen, several questions for you. You and I both know, in 
fact we all know, dual-eligibles are just a terrible mess, very 
expensive to care for, with terrible outcomes. We are spending 
incredible amounts of money to get terrible outcomes. It is the 
worst of all.
    Now SAMHSA has a lot of grants out there in order to 
address the issues of the mentally ill, as well as those who 
have substance abuse, and yet there seems to be poor 
coordination with Medicaid. You have experience. Can you give 
some ideas as to how we could better coordinate those programs?
    Mr. Betlach. Sure, Senator Cassidy. That is an incredibly 
important question. In Arizona, roughly 40 percent of the 
population of individuals with serious mental illness are dual-
eligible members, which actually leads to incredible 
fragmentation, as you described.
    When I first became the Medicaid Director, if you were an 
individual with a serious mental illness, you had a plan for 
physical health for Medicaid, a plan for behavioral health for 
Medicaid, Medicare fee-for-service, Medicare Part D--four 
different organizations that were potentially involved in 
paying for your services, none of them coordinated.
    As you said, it has led to just terrible results. On 
average, an individual with serious mental illness dies 25 
years younger than peers, and oftentimes it is from untreated 
chronic diseases.
    And so in Arizona, it all comes back to the system design 
issue. Who is accountable in this? And it is very challenging 
with dual-eligible members. But we created and built off some 
of the Federal regulations that exist that said the managed 
care organization that was responsible for providing services 
for individuals with serious mental illness not only had to 
deliver Medicaid services but Arizona Medicaid programs, the 
third largest housing authority, so there were rental subsidies 
that were flowing through the Medicaid program--employment 
support services. Very importantly, the plan had to be a dual 
special needs plan, which meant that it offered the Medicare 
services, which meant it was then accountable for delivering 
Medicare services to that population.
    Senator Cassidy. Let me stop you.
    Mr. Betlach. Yes.
    Senator Cassidy. Great ideas: aligning incentives, a point 
of authority, everything that checks the boxes. What were your 
outcomes? Were you able to improve outcome for the duals?
    Mr. Betlach. Yes. In the independent third-party study that 
was done by Mercer, we saw an increase in terms of all the 
HEDIS scores for ambulatory and chronic management, and an 
increase in all of the CAHPS scores.
    Senator Cassidy. Now let me ask, because sometimes those 
are process-oriented as opposed to outcomes-oriented----
    Mr. Betlach. Right.
    Senator Cassidy. And so, to what degree did you see 
emergency room visits decrease? Return to workforce? Longer 
life span, et cetera?
    Mr. Betlach. We do not have the indicator yet on longer 
lifespan. We are only a few years into this, right? So that is 
going to be a lagging measure as we look at the different 
indicators. But we did see a decrease in emergency department 
utilization and an increased use of primary care. Again, not 
necessarily outcome measures, right, but it is a start.
    Senator Cassidy. Well, let me ask, then--because I am 
almost out of time--specifically, integrating SAMHSA grants in 
there, were you able to do that as well?
    Mr. Betlach. We did. We flowed all of the SAMHSA block 
grant dollars to that organization. They were responsible for 
those as well. So again, a single accountable organization that 
had all those dollars braided in it.
    Senator Cassidy. Gotcha. I thank you all for your good 
work. I really appreciate it.
    And again, Dr. Durham, it is great to see your success.
    Dr. Durham. Thank you.
    Senator Cassidy. And I yield back.
    The Chairman. Thank you, Senator Cassidy. We are going to 
be working very closely with you as we go forward on this 
committee effort.
    Senator Bennet is next.
    Senator Bennet. Thank you, Mr. Chairman. And again, thank 
you very much for holding this hearing. I hope that it is only 
the start of a larger effort to address the mental health 
issues in our country. I, like my colleagues, am deeply 
concerned about the issue of parity and how insurance companies 
and providers often erect barriers to adequate mental health 
coverage.
    Senator Kaine and I were working on developing our 
Medicare-X Choice Act to create a public option, and mental 
health access was at the top of our mind. We viewed this as an 
opportunity to improve access to people, especially in rural 
areas. And a key provision in this proposal provides primary 
care to patients with a public option without cost sharing--and 
this should absolutely include mental health care.
    Dr. Miller--and anybody else on the panel who would like to 
answer--can you speak to how a public option could be designed 
to integrate mental health and primary care? How should this 
elevate the standards on parity that currently do not exist in 
the private health insurance market?
    Dr. Miller. Thank you for the question, Senator Bennet, and 
thanks for your ongoing leadership in this space.
    First, from a coverage perspective, any public option 
should incorporate some of the key lessons that we are learning 
from landmark Federal cases like Wit vs. United Behavioral 
Health. This includes things like requiring coverage to be 
consistent with generally accepted standards of care that 
ensure the inclusion of civil enforcement provisions.
    Second, a public option can actually create a standard for 
integrating care. A public option can determine the scope of 
services, and it can actually raise the bar on expectations for 
integrated practices. This is needed, and overnight it could 
create a new mechanism to support integrated primary care.
    And then finally, a public option could expand the scope of 
services and the range of providers to make sure that it pays 
for critical services that augment the onsite delivery, like 
peer support specialists. Hence really, if you bake it into a 
public option, you are beginning to change the game from how 
people have experienced mental health and primary care on the 
ground.
    Senator Bennet. Anybody else?
    [No response.]
    Senator Bennet. I am deeply concerned with the increased 
rates of mental illness that young people are experiencing, 
leading to death by suicide, substance use, or other mental and 
behavioral health challenges.
    In Colorado, it has been 5 years since suicide became the 
leading cause of death for kids aged 10 and older. And at the 
same time, we have seen a reduction in beds for youth suffering 
from mental illness. We have seen that decreased by 1,000 in 
the past decade.
    A few weeks ago, our children's hospital declared, quote, 
``a pediatric mental health state of emergency,'' as emergency 
mental health visits were up 90 percent in April of 2021 
compared to April 2019.
    What gaps exist in the tools needed to address the mental 
health challenges facing our children and young adults across 
the continuum of mental health care, particularly for the 
Medicaid population? I know a lot of our colleagues are working 
on improving home and community-based services. How can we 
ensure that kids and families are receiving mental health 
services at home or in their communities? I don't know, Dr. 
Durham, whether you might want to get us started?
    Dr. Durham. Sure, I can get us started. I think it is a 
fantastic and great question, so I appreciate it. I think it 
also has a lot to do with the care continuum. I think what we 
have seen is, everything has been exacerbated. What we knew 
pre-pandemic was that we do not have enough services for kids. 
I think a State like Massachusetts has done a good job. Senator 
Cassidy is from Louisiana, which is my home State, which is 
very different. And my family and friends are still there, and 
I can compare Massachusetts and Louisiana.
    And so we do have a continuum for care. We have in-home 
services for kids on State Medicaid in Massachusetts with 
different language capacities. And I think that model should be 
replicated in other States similar to the State of Louisiana, 
where I come from, where there are very limited resources for 
kids on the State Medicaid.
    And that care continuum has day programs in Massachusetts. 
We have crisis units for kids so we do not have to go all the 
way to the highest level of care, which is a locked psychiatric 
unit for kids. And you know, as previously stated, I do think 
we need to do something to expand school-based therapists at 
schools.
    We do not have enough. That is where kids are most of the 
day. That is what gets noticed quickly by teachers and other 
people who see them day in and day out. And so these are ways 
that we can work from a prevention and promotion framework. 
Kids as young as 12, 13, and 14 will tell you when they are in 
their early 20s, ``I knew when I was 12 that something was 
going on.'' And either maybe a parent or a caregiver did not 
recognize, but also there was no one to go to.
    So, the more that we can invest in that, all the way from 
prevention and promotion along the care continuum, I think the 
better for all of our kids.
    Senator Bennet. Thank you, Mr. Chairman.
    I am out of time, but I appreciate that answer very much.
    Senator Crapo [presiding]. Thank you, Senator Bennet. The 
chairman has gone over to vote. I don't know if it has been 
explained that we have two votes going right now, so we are 
kind of rotating back and forth. Plus, we have a lot of members 
who may or may not be available because of that. But I am just 
going to go down the list.
    I am told that Senator Daines is on his way here, but let 
me just ask. Is Senator Daines on the Internet?
    [No response.]
    Senator Crapo. All right. I am just going to call out some 
names, and if nobody answers, I am going to--did I just hear 
somebody? If nobody answers, I will ask a few of my own 
additional questions.
    Senator Casey?
    [No response.]
    Senator Crapo. Senator Young?
    [No response.]
    Senator Crapo. Senator Warner?
    [No response.]
    Senator Crapo. Senator Whitehouse?
    [No response.]
    Senator Crapo. Senator Hassan?
    Here is Senator Daines. You are up.
    [Pause.]
    Senator Daines. Mr. Chairman, thank you. And truly, I am 
very glad that we are holding this hearing today on such an 
important topic.
    Last month, Senator Stabenow and I hosted our first Finance 
Health Care Subcommittee hearing of the year, since May was 
mental health month. We focused on the importance of improving 
access to mental health services and how the COVID crisis has 
impacted patients as well as providers.
    We were fortunate to have Lenette Kosovich as our Montana 
witness. She is the CEO of the largest behavioral health 
organization in Montana, and she was able to highlight the 
challenges our rural communities face when it comes to 
accessing mental health care. She also discussed the benefits 
of the Certified Community Behavioral Health Clinic model, 
known as the CCBHC model, which brings the reimbursement for 
behavioral health services on par with that for physical 
health-care services.
    In fact, following that hearing, Senator Stabenow and I 
decided to team up in this legislation to allow States, 
including Montana, to adopt the CCBHC model. In fact, we are 
introducing it today. Our bipartisan bill will integrate the 
physical and the mental health care and provide patients with 
access to treatment more quickly.
    Ms. Jett, how can the CCBHC model help rural communities 
like those in Montana that face access challenges and have a 
shortage of mental health professionals?
    Ms. Jett. Thank you for your question. We really believe in 
the CCBHC model. In fact, we have been one of the first to 
adopt it and have been using the model for about 4 years now.
    We find that integrating the services, or creating what we 
like to call the neck in between the head and the body, really 
helps improve outcomes for patients that we serve. It also 
improves access to underserved populations, specifically 
veterans in our community who have really benefited from us 
becoming a CCBHC, primarily because Oregon wrote a waiver with 
the CCBHC model that would allow veterans to access care from 
non-veteran clinics.
    So where we live in northeast Oregon is about a 2-hour 
drive for any veteran receiving any sort of services, medical 
or mental health services. And so by becoming a CCBHC, and 
along with that Oregon waiver, we are able to treat local 
veterans for behavioral health issues. It has been really 
powerful.
    Senator Daines. As the son of a veteran, thank you.
    I recently introduced legislation with Senator Cortez Masto 
to make permanent a CARES Act policy that I championed allowing 
first-dollar coverage of virtual care under these high-
deductible health plans. Our bipartisan bill would allow 
Montanans and Americans across our country to continue 
accessing essential care like mental health and primary care 
services, without the burden of first meeting a deductible. 
With more than 50 percent of American workers now receiving 
their health-care coverage through the high-deductible health-
care plans, I believe this policy should be made permanent.
    A question for Dr. Miller. Do you agree that limiting 
barriers to telehealth services, after the public health 
emergency, would benefit patients seeking mental health 
services?
    Dr. Miller. Senator Daines, thank you for the question. As 
we have discussed today, there is such power in being flexible 
with how we are able to deliver services to where people are. 
And so what we need to do is continue to explore how these 
services have added value to people's lives, and how they have 
improved outcomes.
    Many of the changes that we have seen through the emergency 
order have made a difference in countless lives. And I think to 
take that away would not only be to the detriment of those 
families that have become dependent on it, it would also hurt 
our Nation's overall health.
    And so, we have to be very thoughtful and very considerate 
when it comes to these issues of telehealth. I would recommend 
that this group, this committee and this Congress, really 
consider ways to either make some of these changes permanent, 
or to consider an extension that goes on for the next year to 2 
years to allow for us to continue to maximize on what many 
folks have benefited from.
    Senator Daines. Thank you.
    I want to shift gears and talk about a problem we are 
facing in Montana, and that is meth. In Montana, meth is taking 
a devastating toll on our families and our communities. I had a 
briefing with our Guard in Montana on Friday, their Counter-
Drug Task Force, and we were talking about significant 
increases year over year in 2020 versus 2019 on drug seizures 
in our State--meth and heroin.
    In fact, in 2020 drug overdose deaths hit a record high. We 
are now looking at a disturbing increase in meth-related 
violent crime. While medications can be effective in treating 
some substance use disorders, there are currently no FDA-
approved medications to help meth addiction.
    According to the National Institute of Drug Abuse, 
contingency management, which involves giving patients 
incentives to not use drugs, is an effective treatment for some 
individuals suffering with addiction. Mr. Betlach, in your 
experience, are there any Federal barriers that prevent States 
from implementing effective contingency management?
    Mr. Betlach. Senator, thank you for the question. I would 
say, I am not aware of any, but we can do some further research 
and get back to you.
    Senator Daines. Okay. Thank you.
    Thanks, Mr. Chairman.
    Senator Crapo. Thank you very much.
    And I do understand that Senator Young is on the web. 
Senator Young, are you there?
    Senator Young. I am, Mr. Chairman. Thank you so much for 
holding this hearing. I think this is a really important topic.
    The coronavirus outbreak has created an unprecedented 
mental health challenge for our country. I know it has 
certainly created challenges back home for many of my Hoosier 
constituents. While we do not yet know the full impact of the 
coronavirus pandemic on mental health, we do know it has forced 
Americans to isolate from their loved ones and other support 
systems, causing a troubling spike in mental health and 
substance abuse problems.
    A Kaiser Family Foundation poll found that 45 percent of 
adults say that the outbreak has affected their mental health, 
almost half of adults. Among adults in Indiana who reported 
experiencing symptoms of anxiety or depressive disorder, almost 
20 percent, one out of five, reported needing counseling or 
therapy but not receiving it, in the past 4 weeks.
    I have a few questions related to this directed towards Dr. 
Durham. Dr. Durham, access has long been a barrier to adequate 
behavioral health care. The public health emergency is only 
exacerbating the existing challenges and increasing the need 
for providers and treatment.
    How are providers responding to this increased need?
    Dr. Durham. Thank you for the question. I think that you 
are absolutely correct that we have seen a lot of people, and a 
lot of uptake in services because of what we have all, I think, 
noted today, which is that there has been an increase in 
flexibility when we have added audio and video telehealth 
capability to all of our clinics throughout the country.
    And like most have said previously, I do not think we 
should change that moving forward. We need to meet people where 
they are and whenever they can access the technology without 
having to necessarily come and drive in to appointments, or if 
you are in a rural community where you may not have access in 
your community to a mental health provider.
    So, what has happened is that our clinics are full. We are 
seeing people back to back with telemedicine and our audio 
appointments. And what it leads to is that, you know, we have a 
workforce issue. And we need to figure out ways that we can 
expand on who is able to provide care, as Ms. Jett mentioned 
earlier. There are certain insurers that do not allow for 
certain services to be provided. And so we need to look at that 
more deeply, the issue of who can provide services and be 
reimbursed for the services.
    I am a firm believer that whatever you trained for and went 
to school for, you should be able to practice and get 
reimbursed appropriately for it. So I think that telehealth has 
expanded so much for our communities, and I think there is more 
research to be done as well about which patient populations it 
works for and how we need to pivot in some other ways to make 
sure it is accessible for them too, due to other digital 
inequities, and maybe a lack of digital literacy as well. But 
it has definitely aided that process of engaging and reducing 
stigma, I think, in mental health. Not having to physically 
come in to see a mental health provider, I think, has helped 
substantially.
    Senator Young. Well, I agree that these additional 
flexibilities, based on my consultation with providers back 
home, have just been essential. So I think it is really 
important that we continue to maintain these flexibilities.
    If time remains, I will briefly touch on social 
determinants of health. Because we know that these are the 
economic and social conditions in which people live and learn 
and work and play. And they also impact one's ability to access 
transportation and stable housing. And by extension, these 
factors can positively impact the health and well-being of the 
most vulnerable Americans.
    So, Dr. Durham, once again, just briefly, how might we 
better leverage existing programs and address the barriers to 
coordination between mental health and some of these social 
service programs that I alluded to? Is there anything that 
comes to mind that you see as a real opportunity for us in 
Congress?
    Dr. Durham. So, I can talk based on my experience, just as 
a clinician and as someone who works in outpatient child 
psychiatry. We have folks at Boston Medical Center with exactly 
what you mentioned. They are struggling with food insecurity, 
housing insecurity, transportation issues--all of the social 
determinants. But what is lacking, most times from a Medicaid 
perspective, is we are not necessarily reimbursed for that time 
that we take to coordinate the care. It is very difficult to 
get case management as a psychiatrist, or as a social worker in 
our clinic, or we have LMHCs in our clinic--the time dedicated 
to coordinate all of those services that family may need from a 
case management standpoint are not necessarily reimbursed.
    And so that happens but is carved out at other times during 
the day when maybe we have a gap, if you will, in our 
schedules. And I wholeheartedly agree that a person's mental 
health is affected by all of those social determinants. And the 
more that we can think about how we provide care and get 
reimbursed so that we can talk about all the social 
determinants, get them the services they need and also, as a 
provider, focus on their mental health, I think the better, you 
are right, our families would be. And then the communities 
would be as well, ultimately.
    So many times that mechanism is funded by grants, and 
grants go away. And then we are stuck with, how do we help our 
families with all of the needs that they need in order to focus 
on the mental health issue at hand?
    Senator Young. Thank you so much. Yes, sustainable 
reimbursement for transportation to a primary care provider, 
and in under-served populations, so that we do not end up 
paying, as taxpayers, for something that becomes far more 
costly in the longer term, and certainly costly to that 
person's health, reimbursement to replace an air conditioning 
unit--or a heater--so that somebody does not become incredibly 
ill. It is the whole ounce of prevention notion. And we have 
just got to get better at that.
    So thank you so much.
    Senator Crapo. We will have to move on to the next Senator, 
which is Senator Casey, who I understand is on the web.
    Senator Casey. Thank you, Senator Crapo. Thanks very much.
    I just have one question, and I know this may be plowing 
ground that has been plowed during the hearing, but I want to 
reiterate some of it.
    I will direct my question to Dr. Durham and Dr. Miller. We 
know that, even before the COVID-19 pandemic, children were 
facing both behavioral and mental health crises all across the 
country. This need obviously is much greater because of the 
pandemic. And now kids are waiting weeks to months to get 
mental health care, both in the evaluation and the treatment. 
So it is highly unlikely to get markedly better even as the 
pandemic is receding.
    We have heard a lot today about telemedicine and the 
benefit it provides. But used alone, it does not help us with 
the question of increasing the number of trained professionals 
who can help both children and teens access the mental and 
behavioral health care that they need.
    Primary care docs and nurses are often the first point of 
contact for kids, and for teens and their families, whether 
they are struggling with anxiety or depression or substance use 
disorder issues. Yet too often, many of these primary care 
providers believe they are not prepared to respond 
appropriately.
    So there is not a lot in the way of incentives to provide 
to child health providers to either engage in or expand their 
provision of mental or behavioral health care. So we know that 
that lack of incentives can contribute to both racial and 
ethnic health-care disparities, both in terms of care and 
outcomes.
    So to both Doctors, Dr. Miller and Dr. Durham, how do we 
better support or incentivize health-care providers, advanced 
practitioners, and other therapists to increase or enhance 
their ability to respond to these mental health needs?
    Dr. Miller. Thank you for the question, Senator Casey. And 
I will just begin by briefly saying that I think you have your 
finger right at the center of this issue, which is that people, 
families, children, have to work too hard to get access to 
care. So how do we incentivize the places where the kids show 
up to make sure that they are providing adequate onsite mental 
health care?
    And I think it begins with the flexibility of funding. One 
of the most profound barriers as to why people do not adopt 
integrated mental health care is because of the up-front 
startup costs. If they had flexible funding, what they could do 
is be a little more creative with how they were able to onboard 
a clinician to make sure that they were there in that pediatric 
setting to help that family and that child.
    The second thing is that we have to provide some level of 
technical assistance. Integrating care, as powerful and potent 
as it is, can be difficult. And so an added incentive beyond 
just the flexible funding is helping practices make that 
change, make that transformation. Without that, sometimes we 
see people start and stop because of the difficulty of it.
    Senator Casey. Thanks.
    Dr. Durham?
    Dr. Durham. Yes, thank you for the question. I will echo 
everything Dr. Miller said, and I will just add to it in that 
our TEAM UP for Children model, which is at FQHCs in Boston, 
the greater Boston area, did exactly that. You have to have 
some funding in order for those health centers to start doing 
some of that work. And so that is what some of the grant 
initiatives did.
    But then on top of that, I would say that what we have also 
added to that care team--and make sure that it is a true team--
is that the pediatrician or the pediatric primary care provider 
does not feel alone, that there is a behavioral health 
clinician and community health worker as a part of that model 
to get at kids that have the most needs--these are kids on our 
State Medicaid--to make sure, as the previous Senator 
mentioned, that we are tucking away housing, and food 
insecurity, and all of those other things so that we are not 
continuing to cost the system, but helping with that as well.
    But I do think that that team effort, so that the pediatric 
primary care doc does not go at it alone, we have also 
integrated training within that, so they learn more about 
mental health conditions at the primary care level, which has 
been instrumental. And then also clinical work flows, because 
it is different, when we decide to start shifting from just 
physical health to both mental and physical health, that they 
have to shift their practice in some way. So the technical 
assistance aspect, I think, is also very key.
    Senator Casey. Thanks very much.
    Thanks, Senator Crapo.
    Senator Crapo. Thank you.
    And I understand Senator Warner is now with us. Senator 
Warner?
    Senator Warner. Thank you, Senator Crapo. And I thank the 
panel and the chairman for holding this hearing.
    I know we have been talking about a variety of mental 
health issues. I want to talk about one that is quite close to 
home with me in terms of my own family, and that is some of the 
challenges around eating disorders.
    We have seen from the Journal of Eating Disorders that 
about 62 percent of the individuals with eating disorders have 
seen an increase in stress due to COVID-19. We have seen a 
dramatic increase in binge eating as well.
    I have seen around Virginia--again both on a personal basis 
and on a more global basis--how this disease can really 
challenge not only the afflicted, but whole families. As a 
matter of fact, eating disorders have the highest incidence of 
mortality of any mental health issue.
    Dr. Durham, given your experiences as a physician 
specializing in pediatric and adult psychiatry, what do you 
think, both COVID-related and non-COVID-related, we can do to 
get ahead of this issue around eating disorders, from anorexia 
to bulimia to a host of other kinds of manifestations of this 
challenge?
    Dr. Durham. Thank you for the question. This is not 
necessarily my area of expertise, but what I will say is that I 
understand, and can understand how eating disorders, among many 
other disorders that we treat during the pandemic, are on the 
rise. I think what happens when you are in a position of high 
stress, social isolation, lots of loss, is that you do not have 
all those reserves, those emotional reserves, that you had 
prior to the pandemic, and lack all the social connectedness 
that we all want and strive for.
    And so, I think that is why we have seen rates rising in 
depression, anxiety, and folks maybe going back to some 
restrictive or binge-eating behavior. And we have also seen 
that for folks with substance use disorders, who had a period 
of sobriety for maybe years and now unfortunately have relapsed 
during this time because it has been stressful for everyone, 
and you sort of fall back to maybe things that felt more 
comfortable, or that were habit-forming at some point.
    And so now, we have talked a lot too today about thinking 
about this critical time. But I do not think we have seen--you 
know, we need that year or two to see the devastating 
consequences of this pandemic, because I think it is going to 
take time for people to get back to their normal level of 
functioning, if you will, and to their own baseline.
    And so whatever we can do to extend services for telehealth 
and other services, and increase that flexibility, I think will 
be key moving forward.
    Senator Warner. I agree with you. I do think it is going to 
take us that time. What is the new baseline going to be? I 
mean, Dr. Miller, in your testimony you noted the need to 
integrate mental health within the primary care field and to 
modernize the workforce. The National Center of Excellence for 
Eating Disorders trained primary care practitioners on 
screening, brief intervention, and referral to treatment called 
SBIRT.
    Do you view these cyber-trainings for primary care 
practitioners as helpful in addressing some of these workforce 
issues around mental health; not just eating disorders but more 
broadly?
    Dr. Miller. Yes. Thank you for the question, Senator 
Warner. And I think any time we do not ask, we do not know. So 
we have to be able to screen to detect if there are issues that 
are under the surface that our patients and families are not 
necessarily raising on their own.
    So I think it is a positive thing to screen. However, I 
have to point out that screening alone without treatment is 
insufficient. We need to be providing incentives, as we have 
discussed today, to onboard experts, clinicians who can help 
when those individuals do come forward with a positive 
screening, if it is an eating disorder, if it is anxiety, and 
if it is depression. This is a very positive thing for us. It 
not only normalizes how people begin to talk about issues like 
eating disorders, but it also creates a team-based environment 
so that we can provide the most comprehensive care necessary 
for that patient.
    Senator Warner. Well, this is an area--I wish, Mr. 
Chairman, I was not as much of an expert as I have become over 
the last 12 or 14 years, but I appreciate the comments.
    I want to go to Dr. Durham again. You know, when we are 
talking about practitioners, we had an enormous tragedy with 
Dr. Lorna Breen in Charlottesville, VA, who was a solo 
practitioner. In many ways the stress and overwhelming nature 
of COVID-19 unfortunately led her to, with the level of 
depression--she took her own life. Along with Senator Kaine and 
others in Congress, we introduced the Lorna Breen Health Care 
Provider Protection Act that would address professionals in 
terms of trying to make sure that we train folks on how to deal 
with these high-stress circumstances.
    Dr. Durham, I know we are down to the last couple of 
seconds. Do you want to comment on how we make sure that we 
take care of patients, but also our providers?
    Dr. Durham. Yes, in the last couple of seconds, I 
appreciate that. And I appreciate that that is happening, 
because we do need to take care of all of our providers. It has 
been an equally stressful time for all of us, no matter if you 
are a physician or a social worker, an LMHC, nurses; we have 
been working really hard. And I think that at a place like BMC, 
a lot of things have happened where they were even just doing 
wellness check-ins for all of our staff, from people that 
deliver food to patient rooms, to physicians, to the nurses. 
And I think that that is important.
    And any time we can integrate more initiatives for the 
workforce, I think the better. We are going through this 
equally, as all of our patients are.
    Senator Warner. Thank you, Mr. Chairman. Thank you, Dr. 
Durham.
    The Chairman. Thank you, Senator Warner.
    Our next three are Senator Whitehouse, Senator Hassan, and 
Senator Warren.
    Senator Whitehouse, are you out there?
    Senator Whitehouse. Thanks, Mr. Chairman. I am out here. I 
appreciate this hearing very much.
    First, one of the things that I have gotten for feedback 
from my mental health community in Rhode Island is that the 
increase in telehealth during COVID had kind of a hidden 
benefit, very hard to quantify, but I heard it repeatedly, and 
that was the sense from practitioners that the qualitative 
input that they were getting through telehealth was actually 
better, more meaningful, than beforehand when people had to 
find their way across town, wait in the waiting room, fill out 
the stupid clipboard, go into an unfamiliar room, and then have 
a chat with the practitioner. To be able to do it from a place 
of safety at home seemed to bring out better interaction, 
better substantive qualitative interaction.
    And I am wondering if any of you have had that experience, 
or if you have seen any--I know it is hard to quantify, but has 
anybody tried to quantify it in any way?
    Mr. Betlach. Thank you for the question, Senator. The only 
thing I would add to that is that, in talking with providers, 
not only have they heard that from an impact, but also a lower 
notional rate. So, definitely----
    Senator Whitehouse. Yes, definitely a lower notional rate.
    Mr. Betlach. So, in addition to being able to have a better 
impact, you also have people showing up more for appointments. 
They have not had conflicts. They have not had transportation 
issues. So a number of those factors have been taken out of the 
equation, and as a result, more people have accessed services.
    Senator Whitehouse. So let me leave it at that. And if 
anybody else wants to expand on that for the record, please let 
me know. But I am going to take it as the agreement of the 
panel that there were those two improvements, both in showing 
up and in being engaged and getting better engagement as a 
result of telehealth.
    The other topic I wanted to go into was the interface 
between law enforcement and mental health, which plays out 
first directly on the street with law enforcement and then, 
depending on how the individual engaged with law enforcement, 
maybe at the local police station or jail; and if not, then 
usually a ride over to the emergency room, where they get 
dropped on the unhappy ER docs to cope with.
    So, Senator Cornyn and I are working on a bill to improve 
the engagement of law enforcement in this space so that there 
is an accredited curriculum and training programs for people so 
that they know they are getting the real deal in terms of 
training to improve crisis intervention teams and their 
engagement with law enforcement, to figure out how to improve 
the referrals to community-based mental and behavioral health 
service folks, and to improve de-escalation tactics. All of 
this, I think, is pretty important.
    And I just wanted to get your sense--anybody who would care 
to respond--on the extent to which law enforcement today is the 
entry point for people who are in need of and have not received 
adequate mental health and behavioral health services and the 
extent to which it is a successful entry point.
    Mr. Betlach. Senator, thank you for the comments. In terms 
of the interaction between the mental health delivery system 
and law enforcement, I guess I would invite you to come out to 
Arizona and see what is going on with regards to the crisis 
system in our State in which, not only do we have robust mobile 
response teams but also crisis stabilization facilities to be 
able to work with law enforcement. There are thousands of drop-
offs that occur annually within a 5-minute time span 
oftentimes.
    There is also a lot of training in terms of the CIT model 
that you mentioned. So clearly there is a role, from my 
perspective, that Medicaid should be playing in helping to 
support the interaction and support of law enforcement, mental 
health providers, through a stabilization crisis 
infrastructure. And really, there has been a lot of discussion 
and a lot of new resources for States to be able to establish 
more robust systems.
    There is also going to be an expectation from individuals 
as they dial 988 in the future in terms of what types of 
infrastructure will be available for individuals.
    Senator Whitehouse. Thanks. And I think my time is running 
out. So, if anybody else has best practices or really good 
local examples that you would like to share with us, if you 
could please get that information into the committee, both 
Senator Cornyn and I would be very grateful.
    Thanks, all, for your terrific work and for helping get us 
through the COVID situation.
    The Chairman. Thank you, Senator Whitehouse.
    Senator Hassan, and then Senator Warren.
    Senator Hassan. Well, thank you, Chair Wyden and Ranking 
Member Crapo, for this hearing. And to all of our witnesses, 
thank you so much for taking the time to be with us today.
    Dr. Miller, I want to start with a couple of questions to 
you, and then I will move on to the other panelists. The demand 
for mental health and substance use disorder treatment and 
services skyrocketed during the COVID-19 pandemic, as millions 
of Americans grappled with grief, isolation, and economic 
uncertainty. We have helped meet that demand by providing new 
means to access mental and behavioral services such as 
telehealth, and there has been a lot of discussion about that 
this morning. Unfortunately, even as we move to make it easier 
to access some services, the stigma still associated with 
substance misuse prevents too many people from getting the 
behavioral health services they need.
    Dr. Miller, how does the stigmatization of substance use 
disorder impact access to treatment and services, and what 
steps can Congress take to better integrate substance use 
disorder treatment into primary care settings?
    Dr. Miller. Well, thank you for your question, Senator, and 
thank you for your ongoing passion and views in this space.
    You know, to your point on stigma, we know that only about 
10 percent of individuals with substance use disorders receive 
care. And that tells me a lot about stigma. It says both 
socially that we do not talk about it as much as we should but, 
more importantly however, structurally we have these fragmented 
ways of individuals being able to get access to care.
    One of the views that I think you are very familiar with, 
and that we have discussed today, is that we need to make it 
easier for individuals who are identified with a substance use 
disorder to be able to get access to care. That means bringing 
that care to where people are.
    We have to train up our providers to identify it, and we 
have to train up our clinicians to treat it, and we have to 
recognize that undergirding all of the substance use disorders 
is also mental health. The reasons that we provide gold 
standard treatment for things like substance use disorders is 
because we need to provide counseling at the same time. This is 
how we begin to destigmatize substance use disorders and, 
hopefully, encourage more people to seek care.
    Senator Hassan. Thank you. I am also continuing to work on 
trying to change the X-waiver requirement as we move forward, 
because I think that stigmatizes the provision of treatment for 
some health-care providers too.
    Dr. Miller, I want to turn to another devastating public 
health crisis that we have to work on, which is the issue of 
suicides. A report published yesterday--and Senator Wyden 
mentioned it earlier--by the CDC found that, earlier this year, 
emergency department visits for suicide attempts by adolescent 
girls increased 51 percent on average when compared to 2019.
    And I have heard directly from New Hampshire students about 
the mental health concerns that they have. That is why I have 
introduced the bipartisan STANDUP Act with my colleague, 
Senator Ernst, that is going to encourage the implementation of 
evidence-based policies and training in schools and communities 
across the country that will help to prevent suicide.
    Dr. Miller, can you speak to the importance of providing 
kids and teenagers with the tools that they need to recognize 
if they, or someone they know, is at increased risk of suicide?
    Dr. Miller. Thank you again for the question, Senator. As 
the father of two children, I can tell you this is the one that 
I really want to make sure that we get right. We teach our 
youth, our kids, all about aspects of physical health. We even 
teach them things like how to drive a car, and even how to save 
someone's life with CPR. And so, yes, we have to be able to 
equip our youth and our schools, frankly, where our youth are 
basically a lot, with the ways to identify issues related to 
suicide.
    In fact, there was one survey that came out from Mental 
Health America that showed how youth are talking more to each 
other around the issues of mental health, which includes 
suicide, rather than their parents.
    So, because our youth are the front lines, we need to equip 
them with those skills necessary to know how to be there for 
one another. This could be the way to augment the workforce 
that we have discussed today. If we simply depend on our 
clinical workforce to address the demand, especially with our 
youth, we will fail.
    We have to be more creative, more thoughtful, and most 
importantly, we have to have the youth at the table and with us 
as we design the solution to work with them on ways that they 
can better help each other.
    Senator Hassan. Thank you.
    Mr. Betlach, I want to move on with a question for you. We 
increased Federal funding for home and community-based Medicaid 
services under the American Rescue Plan. This funding helps 
ensure that older adults and individuals with disabilities, 
including those with mental health conditions such as bipolar 
disorder and schizophrenia, can access mental health services 
outside of institutional settings.
    Can you, from your experiences as Director at the Arizona 
Medicaid program, speak to the important role that home and 
community-based mental health professionals play in delivering 
care for individuals who experience severe mental health 
disabilities? And what can we do in Congress to expand access 
to home and community-based care for those struggling with 
mental health conditions?
    Mr. Betlach. Senator, the investment that you have made is 
really a once-in-a-generation investment in terms of where 
States are at in the ability to leverage that 10-percent home 
and 
community-based bump. And it is really broader, I think, than a 
lot of people appreciate. It is also on behavioral health 
services that States deliver through the rehab option as well. 
And those are incredibly important.
    So States are right now developing their plans. I am 
working with a number of States, and they are generating their 
options that they want to invest in. So it is an exciting time 
for States. But States are feeling like there is a very 
significant time crunch here in terms of being able to 
establish this investment and do it in the right way.
    So I think those plans will be evolving. But there is 
clearly a unique opportunity, and these services are so 
important to be able to deliver services in the communities 
that serve these populations.
    So it is an exciting time for States to have these 
resources to be looking at workforce issues, to be looking at 
being able to deliver more services in the community.
    Senator Hassan. Thank you.
    And thank you, Mr. Chair.
    The Chairman. I thank my colleague.
    Senator Warren?
    Senator Warren. Thank you, Mr. Chairman.
    COVID-19 is the worst public health crisis that our Nation 
has tackled in over a century, but it does not exist in a 
vacuum. The pandemic has exacerbated every preexisting public 
health problem facing our Nation. And that is especially true 
for substance use disorder, which often co-occurs with other 
mental health conditions.
    Dr. Durham, I am sure that you are familiar with the data. 
Did substance use disorder and drug overdoses increase or 
decrease during the pandemic?
    Dr. Durham. Thank you, Senator Warren. They definitely 
increased during the pandemic. I think DPH in Massachusetts 
reported, for black Americans in particular, a 69-percent 
increase over the pandemic----
    Senator Warren. Sixty-nine percent increase?
    Dr. Durham. Yes, in Massachusetts, specifically. That could 
have been from various, you know--this is usually fentanyl-
laced substances. Many times, cocaine use disorder is pretty 
prevalent in some of the black patients that we see, 
specifically at BMC. And so we can think of lots of things that 
happened during this period. What happened to everyone happened 
also to the folks we see with substance use disorders: job 
loss, economic insecurity, housing insecurity, the loss of 
social supports. You know, substance use disorders are a 
remitting and relapsing disease. People sort of think of one 
moment in time you are sober, and then that's it. But it is 
not. And so, it is a chronic medical condition, and we should 
treat it as such.
    Senator Warren. So let me just push on this a little bit 
and let that sink in a little bit, that we saw a 69-percent 
increase in opioid deaths in Massachusetts.
    You know, we were already, Nationwide, losing tens of 
thousands of Americans to drug overdoses. And the problem has 
only gotten worse. And I think this is where you were headed. 
It has gotten worse--differently in different communities.
    So you were serving on the front lines of this pandemic at 
Boston Medical Center, which serves many low-income patients 
and communities of color. As the coronavirus spread through 
Massachusetts and substance use disorder worsened, what 
patterns did you see in terms of the types of patients you saw 
at BMC, the types of communities that were affected? Can you 
just say a little more about that? I think that is where you 
were headed.
    Dr. Durham. Yes, sure. Well, we predominantly serve about 
70 percent black and Latinx at BMC, people who identify as 
black and Latinx, and about 30 percent do not speak English as 
their first language.
    Just like many, I think many people were scared to come 
into the hospital at the beginning of the pandemic. And so I 
think what happened, though, is that we got high acuity as we 
hit December and January, where people were coming in with 
severe--whether that be mental illness, but also severe relapse 
on whatever substance that they may have been previously using 
and maybe had stopped. I think poverty and job loss, like I 
mentioned earlier--you know, health, access to health care in 
general, there was a change in that. We have talked a lot about 
telehealth, but it does not work for everybody.
    And so this is the particular population where I do not 
think it worked well. You needed to be on a Zoom link with your 
recovery coach. Did you have access to a computer and to get 
the Zoom link, and then have a smartphone? So I will pause 
there.
    Senator Warren. That is very helpful. So you have told us 
about the scope of the problem. You have told us about how it 
hits different communities differently. Let's talk a little bit 
about the solution.
    In recent years, Congress has taken some steps, like 
passing the SUPPORT Act, to expand access to addiction 
treatment services. But it is clear that more resources are 
needed.
    So let me ask you. Boston Medical Center is a national 
leader in addiction and substance use disorder treatment, 
research, and training. Would a significant Federal investment 
in substance use disorder prevention help lower overall deaths, 
reduce these disparities, and help support providers like BMC?
    Dr. Durham. Absolutely. I think that we need parity in 
mental health and substance use treatment. I think we also silo 
substance use disorders from mental health disorders from 
physical health. The more we can combine all of that, because 
it is one person that presents, the better we will all be.
    I do think that we need to start early with community 
outreach and more investment in the community. I think when we 
speak about black and Latinx communities in particular, we need 
more research that allows us to partner with community-based 
services to do some of that research, because we are not 
targeting that population well, and we need to invest dollars 
to do that.
    Senator Warren. Well, I really appreciate it. You know, we 
have an opportunity here not just to build back to where we 
were before the pandemic, but to drastically improve our public 
health infrastructure.
    I was very happy to see President Biden's commitment back 
as a candidate to invest $125 billion over 10 years in 
substance use disorder and the opioid crisis. And that is why, 
in the coming weeks, I will be reintroducing my Comprehensive 
Addiction Resources Emergency Act, or the CARE Act. This 
legislation would provide State and local governments the 
resources to combat substance use; to invest in biomedical 
research, public health surveillance, and professional 
training; and to expand access to naloxone.
    I am looking forward to working with my colleagues to get 
this done. I appreciate all the work that all of you are doing. 
I hope you can get better support from Washington to continue 
to do it.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren. And I believe what 
you and Dr. Durham have just done in terms of laying out the 
69-percent increase in substance abuse in your State really 
conveys the urgency of what this committee has to do. So I 
thank you very much, and I thank you, Dr. Durham, because that 
is what this is all about.
    Senator Warren and I talk about this all the time. The 
committee has a lot of stuff we have to deal with. We have all 
kinds of issues. But when you hear about a 69-percent increase 
in substance abuse, you say, ``This is something that cannot 
wait.'' So I really thank you, Senator Warren.
    And I am just going to wrap up with a couple of comments. I 
want to thank our witnesses. You all have been terrific. And I 
think you have seen from the Senators the very strong feelings 
about how important it is that we work on this, and we do it 
coming together in a very polarized political environment.
    I do not know if any of you are aware of the Wyden story. 
My father wrote a book called ``Conquering Schizophrenia.'' It 
was about my late brother. And for years and years on end, my 
brother had schizophrenia and would be out on the streets in 
California, and the Wyden family went to bed at night worried 
that he was going to hurt himself or somebody else. And I think 
that is pretty typical of what families are facing when they 
are dealing with mental illness. And you all have described how 
many people fall between the cracks--the incredible stigma of 
this.
    Chantay, thank you so much for describing what you are 
trying to do in rural Oregon, the part of the State I love so 
much, to try to reduce the stigma. And you all have laid out a 
lot of solutions here. You have laid out a lot of solutions, 
and I have been talking with Senator Crapo. We think that this 
is an issue where the committee can come together and do 
better.
    We have currently reviewed the committee records. This is 
the second-ever hearing of the Senate Finance Committee on the 
issue of mental health care in our over 100-year history. 
Senator Stabenow and Senator Daines are doing good work in the 
subcommittee, and I think now both Democrats and Republicans 
understand that we have to bring a greater sense of urgency and 
commitment and resources into this issue so that mental health 
is really in line with physical health, which of course was the 
dream of Senators Wellstone and Domenici,
    And I think I touched on it. I remember opening up the 
paper the next day, and I said to myself, ``Hallelujah; there 
is hope for Jeff Wyden and all the families who have 
suffered.'' And as you said very eloquently, Dr. Durham, in a 
lot of instances, the commitment to parity is honored more in 
the breach than in the observance.
    So I thank you all very much for your excellent testimony. 
It is a great kickoff to the committee's work in this area. I 
think you have heard from my Republican colleagues--they were 
raising important issues. I looked at the comments made by my 
Republican colleagues and my Democratic colleagues, and there 
was not an off-base idea in the house today. You can literally 
go up and down both sides of the dais and see Senators with 
great sincerity offering concrete ideas.
    So we are going to wrap up for today. But for all of you 
and your colleagues who are out there on the web, we are 
wrapping up for today, but make no mistake about it: we are 
going to be consulting with you. This is a ``to be continued'' 
discussion.
    Members know that questions have to be produced, what we 
call QFRs, within a week. And I want to thank our witnesses 
again.
    And with that, the Senate Finance Committee is adjourned.
    [Whereupon, at 12:30 p.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


              Prepared Statement of Thomas Betlach, MPA, 
                 Partner, Speire Healthcare Strategies
    Chairman Wyden, Ranking Member Crapo, and members of the Senate 
Finance Committee, thank you for the opportunity to testify today on 
policy solutions for addressing mental health. I had the privilege of 
serving as the Arizona Medicaid Director for almost a decade and for a 
portion of the time, as the Mental Health Commissioner.

    Medicaid serves over 70 million members, offering comprehensive 
mental health benefits to some of our country's most complex 
populations. In 2020, the Medicaid and CHIP Payment and Access 
Commission (MACPAC) published mental health statistics that showed, for 
non-institutionalized adults, 27.6 percent of the Medicaid population 
had an indicator of mental illness compared to 18.7 percent of the 
commercially insured population. And for individuals with Serious 
Mental Illness, the numbers were 8.2 percent for Medicaid, and 4.3 
percent for commercial populations.\1\
---------------------------------------------------------------------------
    \1\ Behavioral Health in Medicaid Presentation, MACPAC, September 
2020.

    As you formulate health policy options, State Medicaid programs 
should be a critical component of the discussion. Understanding the 
system and the forces prevailing on it should be at the core of 
---------------------------------------------------------------------------
discussion.

    The last year brought to light the extreme fragmentation of our 
healthcare delivery system at all levels. Our policy and program 
structures are in silos. Funding streams to support these populations 
follow those siloed program and policy structures. Providers gravitate 
towards these funding streams creating more complexity at the point of 
care. The very beneficiary the system is designed to serve is forced 
navigate the maze we created.

    Fragmentation is often discussed, so I would like to explain how 
that fragmentation manifests in our system. When I became Medicaid 
director, individuals with serious mental illness had up to four 
different payers to navigate. Forty percent of that population were 
Medicaid and Medicare dual-eligible members. An individual had a 
Medicaid plan for physical health, a Medicaid plan for behavioral 
health, traditional Medicare and a Part D plan or a Medicare Advantage 
plan. Unfortunately, this level of fragmentation is common. The result 
is misaligned incentives and the bureaucracies of Medicare and Medicaid 
spending considerable time and resources creating payment rules and 
refereeing rather than focusing on improving care for our populations.

    Now, in addition to fragmentation, Medicaid leaders are contending 
with the impact that the pandemic has had on an individual's mental 
health. It has been well documented that the pandemic has had a more 
negative impact on individuals with less means, both in terms of health 
and financial stress.

    This last year has brought important issues such as social justice 
and health equity to the surface and at the same time there was rapid 
innovation. For example, the use of telehealth and the deployment of 
the 988 crisis hotline. Both will require much work ahead to ensure 
long-term success.

    Today's environment has challenges. But States and Medicaid 
programs now have access to considerable investment resources to 
address these challenges and advance the delivery of mental health 
services.

      1.  Congress has authorized a 5-percent set-aside funding from 
the Mental Health Block Grant to be used for Crisis Systems.

      2.  Congress has authorized an 85-percent enhanced match in 
Medicaid for community mobile response teams.

      3.  Additional resources are now available for States that use 
the rehabilitation option to cover behavioral health services, which 
was included in the 10-
percent increased Federal funding for home and community-based 
services.

      4.  Finally, additional resources are available for expanding 
Certified Community Behavioral Health Clinics.

    In February 2021, The National Association of Medicaid Directors 
(NAMD) published ``Medicaid Forward: Behavioral Health,'' outlining a 
series of strategies Medicaid programs are pursuing to advance mental 
health services for members. The strategies varied based on the unique 
populations served by Medicaid. This report highlighted initiatives 
such as, expanding access and improving timeliness to care, integrating 
physical health and behavioral health, and expanding access for the 
full continuum of care including crisis services.

    Populations identified included children with complex needs, 
individuals experiencing homelessness, older adults, individuals with 
intellectual and developmental disabilities, and individuals involved 
in criminal justice.

    The NAMD report provided proof that when implemented, the 
highlighted strategies make a difference.

    Further, a March 2021 Bipartisan Policy Council report concluded 
that ``integrating primary and behavioral health care is necessary and 
would ensure that individuals with behavioral health conditions and 
comorbid physical health problems receive high-quality access to care. 
Comorbid behavioral and physical health diagnoses are common. 
Addressing them together through integration can provide a patient-
centered approach that can be cost-effective for payers and providers, 
reduce health disparities, and improve patient outcomes.''\2\
---------------------------------------------------------------------------
    \2\ Tackling America's Mental Health and Addiction Crisis Through 
Primary Care Integration. Bipartisan Policy Council, March 2021, page 
8.

    Arizona provides a strong example of this, in 2011, we pursued a 
strategy to better integrate services for individuals with serious 
mental illness. This strategy was focused on driving integration at 
---------------------------------------------------------------------------
three levels.

      1.  Policy integration--Arizona merged behavioral health policy 
expertise into the Medicaid program and reviewed all policies that 
limited integrated services.

      2.  Payer integration--Arizona braided multiple funding streams 
including Medicaid, SAMHSA block grants, and local dollars to support 
housing and other non-Medicaid compensable services.

      3.  Provider integration--Arizona created new incentives and 
supported providers in developing more coordination and integration at 
a provider level. This included opening up new codes to support the 
collaborative care model. This model has been shown to improve clinical 
outcomes and reduce costs by further integrating care at the primary 
care provider.

    In 2018, Mercer consulting conducted an analysis of the integration 
efforts. Their final report for individuals with serious mental illness 
found that all measures of ambulatory care, preventive care, and 
chronic disease management demonstrated improvement. For example, 
Medication management for people with asthma (75-percent compliance) 
increased 35 percent. Just as important, all indicators of patient 
experience improved, with five of the 11 measures exhibiting double-
digit increases. For example, shared decision-making improved 61 
percent.\3\
---------------------------------------------------------------------------
    \3\ Independent Evaluation of Arizona's Medicaid Integration 
Efforts, Mercer, 2018.

    Another opportunity highlighted by NAMD is to strengthen crisis 
systems. This issue is front and center with the implementation of 988. 
SAMHSA provided extensive thought leadership with the development of 
the Crisis Now model and the publication of the National Guidelines for 
Behavioral Health Crisis Care Best Practice Toolkit. This document 
provides the details on how to establish a system to serve anyone, 
---------------------------------------------------------------------------
anywhere at any time.

    The Crisis Now model is based on three critical components.

      1.  Call center capability.

      2.  Twenty-four by seven Community Mobile Response Teams.

      3.  Twenty-three hour crisis receiving and stabilization units.

    In Arizona, this system was developed over 20 years and serves all 
Arizonans. The call centers answer thousands of calls every month, 
meeting the State's expectations of three rings or less. Mobile 
response teams located throughout the State serve individuals in the 
community. Stabilization facilities provide services for individuals 
experiencing severe crisis episodes and offer continuous support for 
law enforcement to drop off individuals and to return to the field 
within 5 minutes. The financing for this system comes from creatively 
braiding multiple funding streams while leveraging Medicaid for 
support.

    While we have seen improvement, there is clearly much more to do. 
We stand today at a unique moment with the power to address complex 
issues and continue the momentum of innovation by making strategic 
policy changes. To that end:

      1.  Congress and the executive branch need to develop and 
implement strategies holistically by ensuring Medicaid and behavioral 
health collaborate and partner in a meaningful manner. On several 
occasions Congress has leveraged the mental health expertise that lives 
at the Substance Abuse and Mental Health Services Administration 
(SAMHSA) to advance policy initiatives. This includes set-aside funding 
for first episode psychosis and crisis system planning. However, there 
does not appear to be sufficient expectations established by Congress 
that these important planning and investment dollars are to be linked 
to the Medicaid program. Unfortunately, the dollars often get siloed 
and the opportunity is suboptimal. SAMHSA traditionally works directly 
with its network of mental health commissioners, and Medicaid programs 
sometimes lack the expertise or bandwidth to leverage these 
opportunities. At the end of the day, Medicaid beneficiaries may or may 
not benefit from these forward-looking investments.

      2.  Congress should provide more flexibility with block grant 
funds for States to address social determinants of health as States 
look at ways to support these investments. As coverage has expanded, 
there may be opportunities for States to leverage block grants to 
support select social determinants for specific populations and improve 
outcomes.

      3.  Congress needs to legislate to establish payment parity 
between Medicare and Medicaid. Where Medicaid has led the way in 
developing paraprofessional staff such as peer support services and 
systems to support broader populations like Crisis, Medicare should 
follow. To achieve parity, Congress must act to have Medicare cover 
these and similar services.

      4.  Congress should continue to provide financial incentives for 
States to modernize the mental health infrastructure. Programs like 
Money Follows the Person worked well for home and community-based 
services. I am excited to see Congress using similar approaches for 
behavioral health services like community mobile response teams and 
CCBHCs. Congress should consider lending financial support towards 
models that improve care and access. This approach should also be 
expanded to dual eligible members as well.

      5.  Congress should continue to evaluate the impact of the IMD 
16-bed limits. While there have been efforts made to allow for some 
payments in select instances, some States have not been able to avail 
themselves of these opportunities. A good place to start the policy 
discussion is looking at select settings like crisis stabilization.

      6.  Congress should rectify the fact that behavioral health 
providers were excluded from the electronic health records incentive 
program provided through the HITECH Act. Data aggregation and analytics 
are an important component of improved care coordination. This is an 
investment that should be made to advance integration.

      7.  Finally, Congress should evaluate how graduate medical 
education financing policies negatively impact the ability to attract 
specialists, such as child psychiatrists, to meet the needs of the 
Medicaid population. Many States, like Arizona, are punished as a 
result of the Medicare formulas that are locked in at 1996 allocations.

    We are at a critical moment in time to advance the delivery of 
mental health services, not only within Medicaid but for our entire 
country. Thank you for your time and interest in these topics.

                                 ______
                                 
       Questions Submitted for the Record to Thomas Betlach, MPA
           Questions Submitted by Hon. Catherine Cortez Masto
    Question. Arizona has been a leader in behavioral health crisis 
services as the State's crisis now model has been incredibly successful 
in supporting individuals experiencing crisis, and creating a safety 
net for folks who have slipped through the cracks of our mental health 
system for far too long. Senator Cornyn and I have introduced 
legislation that seeks to empower communities across the country to 
build crisis services. The crux of our bill is insurance coverage--
these are services that should be covered, no matter where people get 
their insurance.

    What kind of difference would insurance coverage make as States 
look to build crisis services similar to the Arizona model?

    Answer. Having all insurers provide coverage for crisis services 
would greatly benefit States. True parity would enable additional 
resources to be made available to support important crisis 
infrastructure. If all plans (e.g., commercial insurers and Medicare) 
covered a broad continuum of behavioral health services, it would 
reduce stigma, educate consumers on the importance, and improve access 
to behavioral health resources.

    Question. What else can Congress do to facilitate the delivery of 
crisis services across the country?

    Answer. Congress can continue to provide financial incentives like 
the block grant set-aside funding for crisis services and the 
additional funding for mobile response teams. Additionally, Congress 
can work closely with the administration to ensure appropriate 
coordination is occurring at the Federal level to maximize 
collaboration between agencies, including SAMHSA and Medicaid.

    Question. In your testimony you also highlighted a recent report 
from the Bipartisan Policy Center on behavioral health integration.

    What does that look like in practice and how easy or difficult 
would it be to implement this kind of integration into risk-based 
payment models such as Accountable Care Organizations, Medicaid Managed 
Care Organizations, and Medicare Advantage?

    Answer. It is challenging to implement integration well with 
managed care. States should be thoughtful purchasers and make sure that 
appropriate contracts and policies are in place to support payer and 
provider integration. However, as more States have adopted integrated 
purchasing models, lessons learned and best practices are available to 
other States to enable them to successfully design and implement 
structures. State experience tells us that while it is challenging, if 
done correctly there are positive impacts associated with payer 
integration.

    Question. What difference would that make in boosting access to 
services?

    Answer. The Arizona experience shows that for individuals with 
serious mental illness there has been an increase in access when 
measured based on HEDIS scores. When done appropriately, integration 
results in additional providers being able to deliver behavioral health 
services.

                                 ______
                                 
                Questions Submitted by Hon. John Barasso
    Question. The health-care professionals, along with all front-line 
workers, deserve our gratitude and appreciation. Their dedication to 
our communities during this pandemic is something we must recognize and 
never forget.

    A top concern of Wyoming mental health facilities is making sure 
there are enough staff to care for their patients. It is especially 
challenging to attract and keep health-care providers in rural 
communities. Can you discuss solutions related to workforce development 
you believe will improve the ability of mental health facilities to 
attract and maintain staff in rural areas?

    Answer. Medicaid has done some excellent work expanding the 
behavioral health workforce through the use of peer supports. By 
leveraging individuals with lived experience, Medicaid has been able to 
expand access and better engage patients. Medicaid (and other payers) 
need to continue to expand the use of peer and family supports for 
behavioral health. In addition, the significant growth of telehealth, 
in response to COVID, expanded access and should continue to improve 
workforce capacity particularly in rural areas.

    Question. Can you specifically discuss changes to GME policy you 
believe would improve the pipeline of mental health physicians?

    Answer. There are a range of policy changes that Congress should 
consider with regards to GME. Three GME policy changes that would have 
a strong positive impact and improve capacity are:

      Change the Medicare formula to recognize the growth that has 
occurred especially in States like Arizona that are at an extreme 
disadvantage based on the Medicare formula being frozen for the past 25 
years.
      Provide incentives for GME programs that specialize in 
behavioral health training.
      Increase expectations and create incentives so that more 
training can be done in outpatient clinics and in rural settings.

    Question. As a doctor, I strongly support increasing access to 
mental health services, especially in rural communities. Senator 
Stabenow and I have previously introduced legislation for many years 
that would allow mental health counselors and marriage and family 
therapists to receive reimbursement from Medicare.

    Can you discuss how the Department of Health and Human Services can 
improve access for mental health services, especially for those on 
Medicare?

    Answer. Access will be improved when Medicare improves the overall 
benefits for behavioral health by expanding who can deliver services 
and where those services may be delivered.

    Question. In particular, can you comment on the merits of allowing 
licensed professional counselors and marriage and family therapists to 
receive reimbursements from Medicare?

    Answer. Some State Medicaid programs have determined that covering 
these codes are valuable in increasing access for members. Given the 
limited benefits within Medicare today for behavioral health services, 
especially in comparison to the robust Medicaid benefits, this is an 
important area for Congress to evaluate.

                                 ______
                                 
                 Questions Submitted by Hon. Tim Scott
    Question. The toll that union-sponsored excuses for ``virtual 
learning'' has taken on actual kids is extraordinarily sad, especially 
for our Nation's most vulnerable children. In October 2020, a survey 
conducted by the Jed Foundation showed that 31 percent of parents said 
their child's mental or emotional health was worse than before the 
pandemic. Private insurance data also shows that while all health care 
claims for adolescents ages 13-18 were down in 2020 compared to 2019, 
mental health-related claims for this age group increased sharply. 
Additionally, the Centers for Disease Control and Prevention (CDC) 
reports 25 percent of parents whose children attended school virtually 
were more likely to report an overall worsened mental or emotional 
health compared to only 16 percent of parents of children attending 
school in-person.

    What strategies and collaboration efforts would you recommend to 
encourage the infrastructural changes and technical assistance 
necessary to promote school safety and proactive approaches to mental 
health challenges?

    Answer. We need to continue our efforts to train and support 
parents, teachers, staff, and students about the importance of 
behavioral health. Programs like mental health first aid have shown 
benefits towards reducing stigma and providing individuals with 
important tools on how to have challenging conversations.

    Question. What programs within the Department of Health and Human 
Services' (HHS) purview are best poised to support children and schools 
as they return to complete in-person learning?

    Answer. See above.

    Question. How can we integrate more telehealth opportunities to 
expand access to mental health services in schools?

    Answer. Medicaid and other purchasers should work with insurers and 
schools to leverage telehealth and other mobile technologies to engage 
students. These opportunities extend beyond just K-12 into higher 
education. Some States are evaluating policies that will expand the 
capacity to use schools as sites for delivering telehealth services.

    Question. Telehealth has expanded rapidly as a result of the COVID-
19 pandemic. Numerous studies have demonstrated the effectiveness of 
telehealth for behavioral health services. As telehealth becomes more 
common among health-care providers, what can Congress do to ensure that 
patients do not suffer from unnecessary bureaucratic delays?

    Answer. States with support from the Federal Government greatly 
expanded access to telehealth services for programs like Medicaid. 
Post-COVID, States will need to monitor access to ensure that 
inappropriate barriers are not being placed on the delivery of 
services. Access to care and the quality of the services being 
delivered are ultimately what Congress may want to consider evaluating 
as the telehealth evolution moves forward.

    Question. There is a well-researched connection between 
unemployment and mental health. As recently as April 2021, despite 
billions of dollars of COVID-19 stimulus, aggregate employment remained 
7.9 million jobs below its pre-recession level.

    What impact will this failure to get people back to work have on 
mental health?

    Answer. Recent surveys and studies indicated that individual stress 
levels are higher today than pre-COVID. There are many factors in place 
that have resulted in increased stress, including employment status. 
There will need to be continued efforts to provide education to 
individuals and families on the importance of mental health along with 
information on how individuals may access care in a timely matter.

    Question. Last November, an article published in the Journal of the 
American Medical Association noted that multiple studies indicated that 
older adults may be less negatively affected by certain mental health 
outcomes than other age groups. Are these study outcomes consistent 
with your own professional experiences working with older adults?

    Answer. This in not my area of expertise, and I do not feel 
comfortable commenting on this.

    Question. Current network adequacy standards often allow networks 
of specialists who aren't taking new patients or who have long waiting 
lists. That means that many people needing treatment must go out of 
network to get care, and only those who can afford the high cost get 
it. One of the biggest challenges to access to behavioral health care 
services is that many behavioral health specialists don't participate 
in health plan networks.

    Why is that, and how can we change that?

    Answer. Market dynamics often drive provider utilization. It is 
clear that the country needs more specialists and a broader workforce 
to meet the increased demand. Congress should evaluate the impact of 
Graduate Medical Education funding and how that has resulted in 
constraints in behavioral health specialists. Medicaid has overcome 
some of the constraints by establishing a para-professional workforce 
of Peer supports.

    Question. Outside of the public health emergency, telehealth 
services are restricted to certain geographic and clinical settings. 
Beneficiaries must live in a rural area and have an initial face-to-
face visit with the distant-site provider. Once a relationship has been 
established, periodic in-person visits are also required. With few 
exceptions, patients must be located in a clinical setting and may not 
receive care from their homes. In addition, the distant- site provider 
cannot be located in a rural health clinic or FQHC.

    Telehealth has been used broadly during the pandemic to expand 
health-care access to individuals throughout the country. During the 
pandemic, Medicare significantly expanded the coverage of telehealth 
services. A recent Bipartisan Policy Center poll suggests that people 
receiving mental health and substance use services want a combination 
of in-person, video, and telephone services even after the pandemic has 
passed.

    What telehealth expansions should remain after the pandemic?

    Answer. I believe that consumers will expect all telehealth 
expansions to remain in place after the pandemic and purchasers and 
payers will need to ensure appropriate oversight is in place to drive 
the level of quality required from this platform.

                                 ______
                                 
                Questions Submitted by Hon. John Cornyn
    Question. Could you please explain why utilizing the primary care 
physician as the coordinator for a patient's mental health will result 
in better access to care and, ultimately, better patient outcomes?

    Answer. Primary care physicians in many instances can serve as an 
initial access point for individuals with behavioral health needs. Like 
other acute or chronic issues, more serious cases may require a 
referral to specialists. However, a primary care provider may in fact 
be well-positioned to deal with the behavioral health needs of the 
patient in that moment. For many patients, the relationship with the 
primary care provider is already established and there will be more 
interactions. There also may be an ability to deal with stigma and 
educational issues around behavioral health diagnosis. Like many other 
cases that are more complex, primary care providers may not ultimately 
be the only provider involved with a patient but we need to do more to 
leverage and incentivize our primary care providers to meet the 
behavioral health needs of patients.

    Question. Do you foresee any differences in integrating care with 
pediatricians and perhaps geriatricians as well?

    Answer. Yes. Integration will look different for subsets of 
populations. Pediatricians need support for certain diagnosis and 
subpopulations. For example, children with more severe cases of autism 
may need to be referred to other providers for specialty services. More 
complex cases like children involved with the foster care system may 
require additional behavioral health supports. Populations served by 
geriatricians may require more robust specialty home and community-
based services. Coordination between providers, patients and families 
are critical and pediatricians and geriatricians should be able to lean 
on insurers and managed care organizations to support and enhance 
service coordination.

    Question. As COVID-19 closed down our society, health-care 
providers still cared for patients. And with the pandemic came 
increased isolation, loneliness, anxiety, and depression.

    Sadly, nearly 40 percent of American adults reported struggling 
with mental health or substance use. Anxiety and depression rose by 31 
percent and serious suicidal ideation increased by 11 percent.

    Points of access for those in crisis is a high priority for me. 
Last Congress I, alongside my colleague Senator Bennet, introduced the 
Suicide and Crisis Outreach Prevention Enhancement Act. This bill would 
reauthorize the National Suicide Prevention Lifeline for 5 years and 
collect more data on outcomes, providing a feedback loop of perfecting 
best practices. We think this legislation could save lives and help 
breakdown the stigma of seeking mental health care.

    Can you describe the impact that you see this pandemic having on 
the need for access to mental and behavioral health services?

    Answer. The pandemic has resulted in an increased need for 
behavioral health services. It has also increased expectations that 
these services be delivered through a full continuum of platforms 
including in-person, telehealth, and the ability to have individuals 
receive services in-home.

    Question. What gaps do you continue to see in access to mental and 
behavioral health care?

    Answer. Consistent with my testimony, we need to continue to 
support integration so that more patients can access behavioral health 
services in more settings. We need to continue to create incentives for 
a full continuum of services. The Lifeline program is a great start, 
but there is significant work to be done to enable success.

    With the advent of 988, we need to make sure States are creating 
the infrastructure to respond to the expected increased demand. We also 
need a full continuum of crisis services. While Lifeline call center 
capacity is critical so are community services like mobile response 
teams and stabilization centers who handle more complex cases that 
cannot be resolved by call center teams. We need to create alternatives 
to emergency department boarding and short-term incarceration for those 
in crisis. We need to have Medicare and commercial carriers provide 
more financial support for behavioral health services and follow the 
lead Medicaid has established with broader services and provider 
access. We need to incentivize GME programs to create more specialists 
to support the behavioral health needs of patients.

    Question. You mention in your testimony the National Association of 
Medicaid Director's recommendation of Crisis Systems. These are teams 
that are mobile, in the community and respond to individuals who may be 
experiencing a mental health crisis.

    I am honored to work with my colleague from Nevada, Senator Cortez 
Masto, on the Behavioral Health Crisis Services Expansion Act. This 
bill would help communities establish a continuum of care for those 
undergoing a mental health crisis and support first responders and care 
providers by making such services reimbursable under Medicare and 
Medicaid.

    This model would transform the way communities care for individuals 
in crisis and, in turn, it would help those who are most in need. I 
know you outlined the Crisis Now model in your testimony, but could you 
reemphasize the potential impact of such a crisis care system?

    Answer. In Arizona, the Crisis Now model has been a critical part 
of the behavioral health continuum. It has provided robust call center 
teams that support individuals experiencing behavioral health crisis. 
Consistently, Arizona has one of the highest answer rates of any State 
for calls made to the Lifeline that originate from Arizona area codes. 
These call centers are able to support those in crisis by activating 
robust mobile response teams that serve all Arizonans (not just 
Medicaid members) in both urban and rural parts of the State. For the 
most complex cases, individuals may be served by short-term 
stabilization units. These stabilization units have also supported tens 
of thousands of law enforcement drop-offs that often occur in under 5 
minutes. A robust crisis system can serve anyone anywhere at any time. 
Unfortunately, Arizona is somewhat unique in having this level of 
infrastructure. The overall impact is that people experiencing a 
behavioral health crisis are served in their time of need by 
individuals trained to deal with those in need. Crisis Now offers an 
appropriate array of vital services as an alternative to how people 
were treated previously through Emergency Department bed holds and 
incarceration.

    Question. Do you see these teams as part of a larger strategy for 
addressing mental health?

    Answer. Yes. The Crisis Now model serves individuals experiencing a 
crisis. We need to continue to expand access to prevent individuals 
from moving into crisis. We need to expand educational efforts around 
the importance of behavioral health and reduce stigma. We need to look 
at creative ways to deliver engaging behavioral health services through 
various platforms. We need to continue to improve culturally 
appropriate services and expand behavioral health access to address 
health equity issues. Crisis is an important step for improving 
behavioral health services but it is not the only policy focus that 
needs to be addressed to meet the needs of our country.

                                 ______
                                 
     Submitted by Hon. Bill Cassidy, a U.S. Senator From Louisiana

                   American Telemedicine Association

                      901 N. Glebe Road, Suite 850

                          Arlington, VA 22203

                             T 703-373-9600

June 15, 2021

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

Dear Chairman Wyden and Ranking Member Crapo:

On behalf of the American Telemedicine Association (ATA), I commend you 
for holding an important and timely hearing entitled, ``Mental Health 
Care in America: Addressing Root Causes and Identifying Policy 
Solutions.'' This hearing presents an excellent opportunity for members 
of your committee to thoughtfully consider the future of mental health 
care and how Congress can act to expand access to quality care for 
patients across the country. One such way you can accomplish this goal 
is to support the Telemental Health Care Access Act of 2021, bipartisan 
legislation championed by Senators Cassidy (R-LA), Smith (D-MN), Cardin 
(D-MD), and Thune (R-SD). The ATA enthusiastically endorses this 
important legislation and asks that you give it every possible 
consideration as you work together to identify policy solutions to 
improve mental health services.

As the only organization exclusively dedicated to expanding access to 
care through telehealth, the ATA appreciates and commends your 
committee's continued work to thoughtfully consider sound health care 
policies, including those impacting Medicare beneficiaries' access to 
telehealth services. Telehealth allows patients to receive safe, 
affordable, and quality care where and when they need it and has been a 
lifeline for millions of Americans during the COVID-19 pandemic. Before 
COVID-19, 65% of patients felt hesitant about telehealth, but now 87% 
want to continue using telehealth services post-pandemic.\1\ Behavioral 
health services lend themselves particularly well to remote care, both 
because physical presence is not always clinically necessary for care 
and because of the great need for more access to mental health 
services.
---------------------------------------------------------------------------
    \1\ How Americans Feel About Telehealth: One Year Later, SYKES' 
2021 Telehealth Survey Report, April 9, 2021.

We appreciate Congress's acting swiftly at the beginning of the COVID-
19 Public Health Emergency (PHE) to ensure patients could safely access 
health care services from their homes. As you know, should Congress 
fail to act before the end of the current PHE, millions of Medicare 
beneficiaries will lose the choice to use these telehealth services. We 
look forward to continuing to work with you and your dedicated staff on 
policies that ensure these beneficiaries are not pushed off the 
telehealth cliff. Further, we commend you for already recognizing this 
looming cliff by including in the Consolidated Appropriations Act, 
2021, Pub. L. 116-260, a provision to ensure Medicare beneficiaries can 
access telemental services moving forward. However, one well-
intentioned part of this policy provision, the in-person requirement, 
could have unintended negative consequences on Medicare beneficiaries.

 In-Person Requirements for Telehealth Are Clinically Inappropriate

There is no clinical evidence for an arbitrary in-person requirement 
before a patient can access telehealth services. In fact, evidence has 
demonstrated that telemental services like telepsychology are just as 
effective as in-person visits.\2\ Further, there is clear consensus 
that a provider can establish a relationship with a patient via a 
telehealth visit. The association of state regulators who oversee 
standards of medical care, the Federation of State Medical Boards, 
states that ``. . . the relationship is clearly established when the 
physician agrees to undertake diagnosis and treatment of the patient, 
and the patient agrees to be treated, whether or not there has been an 
encounter in person between the physician (or other appropriately 
supervised health care practitioner) and patient.''
---------------------------------------------------------------------------
    \2\ How well is telepsychology working?, American Psychological 
Association, July 1, 2020.
---------------------------------------------------------------------------

 In-Person Requirements Exacerbate Provider Shortages

The United States has a deficit of 6,000 mental health providers, and 
this shortage is expected to grow to a quarter of a million by 2030.\3\ 
As we saw in 2020 and 2021, telehealth increases the capacity of the 
providers we do have to see more patients by removing geographic and 
other physical barriers. We must work together to increase the number 
of mental health providers to ensure all Americans get the care they 
need. However, explicitly denying a patient's access to mental health 
services based on his or her inability to find a scarce mental health 
provider is simply unreasonable.
---------------------------------------------------------------------------
    \3\ Triple-Tree: A New Era of Virtual Health Q2, 2021.
---------------------------------------------------------------------------

 In-Person Requirements Increase Barriers and Worsen Health Inequities

The ATA strongly opposes statutory in-person requirements as they 
create arbitrary and clinically unsupported barriers to accessing 
affordable, quality health care. Requirements such as these could 
negatively impact those in underserved communities who may not be able 
to have an in-person exam due to provider shortages, work, lack of 
childcare, and/or other resources. Recent CDC data demonstrate that 23% 
of American adults do not have an existing relationship with a health 
care provider, and that statistic is alarmingly high in minority 
populations.\4\ We cannot ignore the importance of providing all 
Americans, regardless of whether they have an established relationship 
with a medical provider, the opportunity to access life-saving health 
care.
---------------------------------------------------------------------------
    \4\ Adults Who Report Not Having a Personal Doctor/Health Care 
Provider by Race/Ethnicity, KFF, Accessed June 8, 2021.
---------------------------------------------------------------------------

Federal In-Person Requirements Unnecessarily Preempt State Laws

The in-person requirement for telehealth services is at odds with the 
direction telehealth policy has moved over the last decade. It disrupts 
Medicare's historical approach, which is to remain deferential to state 
laws on professional practice requirements and clinical standards of 
care. Today, no state practice of medicine law in the U.S. requires a 
prior in-person visit. The ATA urges Congress to ensure telemental 
health services continue post-pandemic but to recognize federal laws 
restricting these services are inappropriate. Instead, Congress should 
defer to states and individual payers to determine telehealth 
prerequisites. For the Medicare program, instead of codifying service-
specific restrictions in statute, Congress should work with HHS to 
ensure the Secretary has the authority at the regulatory level to 
implement any appropriate health care requirements. By explicitly 
limiting care in statute, legislators will unnecessarily stifle 
innovation and tie the hands of regulators, providers, and patients.

For each of the reasons listed above, the ATA is proud to strongly 
support the Telemental Health Care Access Act and applauds the 
leadership of Senators Cassidy, Smith, Thune, and Cardin in introducing 
this essential legislation. We ask that you, too, consider the 
importance of this legislation and how we can work together to identify 
commonsense policies to not only expand access to care but also ensure 
beneficiaries and federal taxpayers are protected. Thank you for your 
consideration, and please feel free to contact the ATA policy director 
Kyle Zebley should you have any questions about our support for 
thislegislation or ATA's broader federal policies.

Kind regards,

Ann Mond Johnson
CEO
American Telemedicine Association

CC: The Honorable Bill Cassidy
    The Honorable Tina Smith
    The Honorable John Thune
    The Honorable Ben Cardin

                                 ______
                                 
                   Health Innovation Alliance et al.

June 22, 2021

Senator Bill Cassidy                Senator Tina Smith
520 Hart Senate Office Building     720 Hart Senate Office Building
Washington, DC 20510                Washington, DC 20510

Senator Ben Cardin                  Senator John Thune
509 Hart Senate Office Building     511 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

Dear Senators Cassidy, Smith, Cardin, and Thune:

We write to thank you for your support of patients and providers in the 
mental health community by introducing the Telemental Health Care 
Access Act. We endorse your bill and applaud your efforts to ensure 
consistent coverage of mental health services furnished through 
telehealth.

Congress and the Administration have done much to utilize telehealth in 
response to COVID-19, and the results have been impressive. Prior to 
the pandemic just one percent of primary care visits were delivered via 
telehealth. Immediately after COVID-19 came ashore, primary care visits 
were delivered via telehealth more than 40 percent of the time. 
Telehealth improved access to care without generating cost increases 
for many, and at the exact time it was needed to help safeguard 
patients and prevent additional infections. It is a solid investment.

We were glad to see language pass through the Consolidated 
Appropriations Act of 2021 to remove Medicare restrictions on the 
mental health services delivered through virtual means, but we believe 
the inclusion of the in-person requirement every six months was 
unnecessary and a step in the wrong direction. Your legislation seeks 
to rectify that issue and we appreciate your leadership. Over the past 
10 years, all 50 states and the District of Columbia have removed in-
person requirements as a prerequisite to treatment through telehealth. 
In-person requirements on telehealth services create unnecessary 
barriers to care and can be especially harmful for those seeking mental 
and behavioral health services. The Health Resources and Services 
Administration reports a shortage of over 6,500 providers in the mental 
and behavioral health specialty. The scarcity of providers, 
particularly in rural and underserved areas makes lifting the in-person 
requirement even more critical. Those seeking care should not, and in 
many instances cannot, travel for hours to see an in-person provider.

By removing the automatic application of an in-person requirement for 
telemental health services in Medicare, Congress can improve health and 
lower costs while increasing access and utilization. This is where 
health care must head to become 
consumer-focused and responsive in the 21st century. We strongly urge 
Congress to pass the Telemental Health Care Access Act and continue 
increasing patient access to convenient at-home telehealth services. 
Thank you for considering our comments and for your leadership on this 
important issue.

Sincerely,

Health Innovation Alliance
American Telemedicine Association
STCHealth
CoverMyMeds
HIMSS
PCHAlliance
National Council for Mental Wellbeing
athenahealth
Alliance for Connected Care
eHealth Initiative
Doctor On Demand
Hims & Hers
Association for Behavioral Health and Wellness
GO2 Foundation for Lung Cancer
Partnership to Advance Virtual Care
Teladoc Health
Centerstone
American Psychiatric Association
3M Health Information Systems
American Foundation for Suicide Prevention
American Psychological Association
The Michael J. Fox Foundation for Parkinson's Research
American Medical Association
College of Healthcare Information Management Executives
Connected Health Initiative
American College of Physicians
Federation of American Hospitals
American Heart Association
Greenway Health
Marshfield Clinic Health System
Association of American Medical Colleges
American Medical Group Association
Vanderbilt University Medical Center

                                 ______
                                 
                Prepared Statement of Hon. Mike Crapo, 
                       a U.S. Senator From Idaho
    Thank you, Mr. Chairman. Ensuring access to high-quality mental 
health services has been--and must continue to be--a priority.

    Far too often, individuals with mental health, addiction, or 
substance use disorders find themselves isolated from their communities 
and separated from their providers. While Congress has taken decisive 
steps to address addiction, bolster behavioral health care, and curb 
substance use disorders, challenges remain. This committee has the 
ability to turn the tide.

    We can begin by empowering States to craft innovative, targeted 
solutions. Medicaid functions most effectively when States have the 
flexibilities they need to address patients' unique care needs and 
adapt to unforeseen crises. As the Nation's largest payer of mental 
health and substance use disorder services, Medicaid must support, 
rather than subvert, State efforts to serve communities in need.

    Unfortunately, the COVID-19 pandemic has highlighted--and 
exacerbated--the mental and behavioral health challenges we continue to 
confront. Loss of loved ones, increased isolation, and delayed 
treatment prompted a spike in anxiety, depression, and other 
debilitating conditions.

    While many are returning to their pre-pandemic lives, we should not 
be content to allow our mental health-care delivery system to revert to 
its pre-pandemic ways. Whether for rural communities, urban areas, or 
tribes, telehealth has undoubtedly increased access to care. Through 
emergency flexibilities and permanent legislation authored by this 
committee late last year, we have taken crucial first steps toward 
modernizing telehealth coverage.

    I look forward to working with you, Mr. Chairman, and with other 
members of this committee to build on those efforts in the months 
ahead. Further, by partnering with State and local leaders, we can spur 
care coordination, strengthen the mental health workforce, and drive 
value through delivery system reforms.

    While there is no silver bullet here, I am confident we can tackle 
all of these challenges while upholding core principles of fiscal 
responsibility and program integrity.

    Before concluding, it bares emphasizing that we must continue to 
make progress in improving understanding of mental health so that 
people in need are not afraid or ashamed to seek treatment. We cannot 
discount the impact of stigma on preventing those in need of treatment 
from receiving care. I look forward to hearing our witness testimony 
today to learn more about the solutions they have identified.

                                 ______
                                 
  Prepared Statement of Michelle P. Durham, M.D., MPH, FAPA, DFAACAP, 
    Assistant Professor of Psychiatry, Boston University School of 
    Medicine; and Vice Chair of Education, and Psychiatry Residency 
   Training Director, Department of Psychiatry, Boston Medical Center
    Thank you, Chairman Wyden, Ranking Member Crapo, and distinguished 
members of the Senate Committee on Finance, for holding this hearing 
and providing me with the opportunity to speak today about the state of 
the mental health-care system in America--where it's working, where it 
falls short, and how the Federal Government can play a role in helping 
to fill the gaps.

    My name is Dr. Michelle Durham. I am a pediatric and adult 
psychiatrist at Boston Medical Center, and vice chair of education in 
the Department of Psychiatry, where I also trained for my residency, 
and now have the distinct honor of serving as the psychiatry residency 
training director. I hold a joint appointment at the Boston University 
School of Medicine as an assistant professor of psychiatry. Boston 
Medical Center (BMC) is an academic medical center and the largest 
safety-net hospital in New England. The patients we serve are 
predominantly low-income, with approximately half of our patients 
covered by Medicaid or the Children's Health Insurance Program (CHIP)--
the highest percentage of any acute care hospital in Massachusetts.

    The BMC emergency department, which includes 8 adult psychiatric 
emergency beds, is among the top ten busiest in the country. Mental 
illnesses are all too common among the patients BMC treats in our 
emergency department and across our continuum of mental health care 
services, which include outpatient integrated mental health care within 
our pediatric and adult primary care clinics and at local community 
health center partners, a mental health urgent care clinic, a crisis 
stabilization unit, and our Boston Emergency Services Team (BEST) 
provides community-based evaluations and a jail diversion program. At 
present, BMC does not own or operate a locked inpatient psychiatric 
unit.

    To give you a sense of who BMC serves, 70 percent of our patients 
identify as black or Latinx, approximately one in three (32 percent) 
speak a language other than English as their primary language, and over 
half live at or below the Federal poverty level. The patients we see at 
BMC who present with mental illness frequently have co-occurring 
substance use disorders, homelessness, malnutrition, and other health-
related social needs linked to poverty. The current COVID-19 pandemic, 
structural racism, and economic crisis has further exacerbated the 
mental illness and trauma experienced by our patients. In my 10 years 
at BMC, I have never seen our mental health-care services stretched so 
far beyond their capacity as they are now. Just the other day, we had 
25 patients in our psychiatric emergency department--more than triple 
its capacity--presenting with a much higher level of acuity, some 
waiting for evaluation and others boarding awaiting placement in an 
inpatient psychiatric unit.

    A severe lack of capacity in our country's mental health-care 
system existed long before the COVID-19 pandemic. The reasons for this 
are multifactorial; however, for the sake of my remarks today I will 
broadly categorize them into issues related to the mental health-care 
workforce and patient access to care.

    It is widely understood and well-documented that America has a 
dearth of licensed mental health professionals, in general, and that 
particular areas of the country--largely rural and outside of the 
Northeast--are disproportionately impacted.\1\ Even where I practice in 
Boston, which has one of the highest number of child and adolescent 
psychiatrists per capita in the country, the capacity is insufficient 
to meet the mental health needs of the community.\2\ Increased Medicare 
graduate medical education (GME) funding for psychiatry residency slots 
can help increase the physician workforce. Increased funding for loan 
forgiveness programs for those who work in underserved areas can help 
alleviate the $250,000 of debt that the average medical student has 
accumulated by the time their residency education is completed. The 
need to pay off medical school loan burden is also likely to cause 
physicians to pursue practice in more affluent areas, adversely 
impacting access to care for lower-income populations.\3\
---------------------------------------------------------------------------
    \1\ U.S. Health Resources and Services Administration. Health 
Professional Shortage Areas Data Dashboard. Last Updated: June 10, 
2021. https://data.hrsa.gov/topics/health-workforce/shortage-areas.
    \2\ American Academy of Child and Adolescent Psychiatry. Practicing 
Child and Adolescent Psychiatrists Workforce Maps by State. Last 
Updated: March 2018. https://aacap.org/AACAP/Advocacy/
Federal_and_State_Initiatives/Workforce_Maps/Home.aspx.
    \3\ Zimmerschied C. How med student loan burdens can deepen health 
disparities. American Medical Association. April 27, 2017. https://ama-
assn.org/education/medical-school-diversity/how-med-student-loan-
burdens-can-deepen-health-disparities.

    Beyond the shortage of providers, the mental health workforce is 
not diverse--for instance, only 2 percent of psychiatrists identify as 
black--and not representative or reflective of the U.S. 
population.\4\, \5\ In order to address this, we must 
understand that the issue at its root is a pipeline issue that requires 
holistic solutions. Just as we say in medicine, that a person's ZIP 
code is more influential than their genetic code in determining life 
trajectory and long-term health, where a person lives, the color of 
their skin, and language they speak is highly determinative of the 
quality of education and resources available, the level of exposure to 
the mental health field, and stigma associated with mental illness.
---------------------------------------------------------------------------
    \4\ Lin L, Stamm K, Christidis P. How diverse is the psychology 
workforce? American Psychological Association. 2018; 49(2). https://
apa.org/monitor/2018/02/datapoint.
    \5\ American Hospital Association (2016). The State of the 
Behavioral Health Workforce: A Literature Review. https://aha.org/
system/files/hpoe/Reports-HPOE/2016/aha_Behavioral_
FINAL.pdf.

    In terms of access to mental health services, COVID-19 led to an 
accelerated adoption of telemedicine. At peak, over 90 percent of our 
outpatient psychiatric visits were conducted via telehealth, which 
enabled BMC to maintain and exceed our pre-pandemic volume of service. 
That said, while telehealth is an important tool for ensuring patient 
access to mental health care, it does not work for everyone due to 
digital inequities that exist related to Internet access and digital 
---------------------------------------------------------------------------
literacy, especially among low-income communities.

    Additional barriers to care exist as a result of disparate 
insurance coverage, lack of mental health parity, and insufficient 
insurance uptake by licensed mental health providers (especially for 
Medicaid). The social determinants of mental health and structural 
vulnerabilities inherently involved with treating low-income patients 
require more dedicated time with patients to provide appropriate care. 
Insufficient Medicaid reimbursement acts as a deterrent for providers 
to see Medicaid patients, producing a cascade effect in which the more 
oppressed, marginalized populations have limited to no access to mental 
health professionals.

    I welcome the Senate Finance Committee's involvement in exploring 
ways for Federal policy to improve mental health care across various 
settings, as well as incentivize and seed the development and scaling 
up of innovative models of mental health care delivery in order to 
improve access. A few such examples include:

        Transforming and Expanding Access to Mental Health Care in 
Urban Pediatrics (TEAM UP) for Children, a pediatric integrated model 
in Federally Qualified Health Centers in Massachusetts, builds capacity 
of health centers to deliver high-quality, evidence-informed care to 
children and families. The model includes behavioral health clinicians 
and community health workers working with pediatric primary care 
providers to provide timely mental health treatment.

        The Massachusetts Child Psychiatry Access Program (MCPAP) 
improves access to treatment for children with behavioral health needs 
and their families by making child psychiatry services accessible to 
primary care providers across Massachusetts via remote consultation and 
education. This model has been expanded to other States such as 
Connecticut where I completed my fellowship.

        The Wellness and Recovery After Psychosis (WRAP) Program is 
tailored for people experiencing psychotic symptoms using a team-based 
approach and providing individual, group and family therapy, medication 
management, case management, and peer support.

        The Metro Boston Recovery Learning Community (MBRLC) offers 
peer-to-peer services for people in recovery from mental health and/or 
substance use issues through peer support, advocacy, and career 
coaching.

    We are at a pivotal time in our country. Over a year into the 
COVID-19 pandemic, every person's mental well-being has been impacted 
in some way. The need for a more robust mental health care system has 
never been more clear or pronounced. Treatment for mental health issues 
should be accessible--no matter who you are, where you live or your 
ability to pay. Appropriate investment along the care continuum and for 
the mental health workforce can improve access to care and retention 
and recruitment of mental health professionals.

    Mental health is health and should not be thought of or managed 
separate or apart from physical health in the ways it historically has 
been. The time is now to invest in a 21st-century mental health-care 
system in America.

    Thank you for your time. I look forward to the discussion.

                                 ______
                                 
       Questions Submitted for the Record to Michelle P. Durham, 
                        M.D., MPH, FAPA, DFAACAP
              Questions Submitted by Hon. Elizabeth Warren
    Question. During your testimony and conversations with my staff, 
you mentioned that telehealth flexibilities were not enough to fully 
capture people with substance use disorder that encountered BMC 
providers (for example, it was harder to connect individuals that 
entered the emergency room with SUD services that were online, as 
opposed to available in person and in the moment). Congress should take 
steps to expand telehealth flexibilities beyond the pandemic, but it 
should also identify and seek to mitigate gaps that emerge when 
telehealth is the default.

    What additional barriers, if any, did virtual telehealth services 
pose to patients in need of SUD services, and what specific steps 
should Congress take to address those barriers in advance of future 
pandemics?

    Answer. Telehealth video was difficult for patients who didn't have 
reliable access to the needed technology (phones with video, computers, 
Internet, etc.) and a confidential place to have an appointment. 
Patients who need certain medications still were required to come into 
the clinic (e.g., methadone and injections for naltrexone or extended-
release buprenorphine). Reimbursement for audio-only appointments 
allowed clinicians to connect with folks who did not have access to 
technology with video capabilities and should be continued beyond the 
pandemic. Expanding mobile services for methadone and injectable 
medications would also help to reduce barriers to treatment. The 
infrastructure proposals before Congress that seek to expand broadband 
access would also be beneficial to enable more of the population to 
reliably access telehealth services. In addition, the Federal 
Government could work with local communities to establish centralized 
locations in the community where people can attend telehealth 
appointments.

    Question. During your testimony, you raised the alarming statistic 
that black men in Massachusetts saw a 69-percent increase in overdoses 
and overdose deaths during the pandemic.

    As Congress seeks to develop future legislation that responds to 
overdoses and overdose deaths through a health equity lens, what types 
of questions should members ask to ensure they are identifying 
challenges facing communities of color in SUD policy development?

    Answer. I really appreciate this question. I think it's important 
for members of Congress to ask, ``Who is not at the table?'' It is 
important to include people with lived experience with addiction, 
including persons of color, in the conversation as they are so often 
left out, and ask them directly, ``What are the challenges you 
personally faced in getting the care you needed to get better?'' In 
addition, using a health equity lens, Congress could ask, ``How does 
SUD treatment offered to white patients differ from what is offered to 
persons of color, in terms of where services are offered, how they are 
advertised, and what specific treatment are offered to individuals? 
Data suggest that racial disparities exist in each of these arenas.

    It is also important to acknowledge that stigma related to 
addiction and mental health is very real and differs by community and 
culture. Stigma is a challenge for ensuring access to care and stigma 
is a challenge for policymaking. Members of Congress can help reduce 
stigma by validating the experiences of persons of color with substance 
use disorders by inviting them to have a seat at the table in the 
development of SUD policy. Congress could seek to learn more about why 
stigma exists against seeking help, including the particular stigma 
associated with receiving medications for addiction, and what added 
stigma exists for persons of color who use drugs.

    The Federal response to addiction should not focus on a specific 
class of substances like opioids at the exclusion of others as use 
patterns oftentimes cuts across racial/ethnic lines. In addition, use 
of more than one substance (or polysubstance use) is common and 
government policies and funding would do better to reflect that 
reality. As members of Congress are likely well aware, fentanyl is 
increasingly being mixed into other substances like cocaine, which 
users may ingest unknowingly, and may influence overdose and overdose 
death rates. The Congress could inquire, ``How does the availability of 
drugs and presence of fentanyl in the drug supply create further 
disparities in overdoses and overdose deaths for persons of color?''

    There are numerous historical policies related to drug use that 
have resulted in the systematic exclusion of people of color from 
addiction treatment services. Reviewing past policies through a health 
equity lens can help to correct past inequities in order to create a 
more equitable and accessible SUD treatment system for persons of 
color. In particular, decriminalizing drug possession can help 
individuals get the treatment they need and avoid incarceration where 
comprehensive addiction services, including medications for addiction 
treatment, are rarely available. Additionally, a health equity lens 
should be applied to examining racial disparities in access to 
different medications for opioid use disorder, like methadone, which is 
more commonly prescribed to persons of color, and buprenorphine, which 
is more commonly prescribed to white patients, as well as the disparate 
regulations pertinent to these treatments. Research is necessary to 
better characterize the needs of people of color and to design 
addiction treatment programs that may be more responsive to their goals 
and expectations--the Federal Government can play a role in catalyzing 
and seeding this research. Additionally, Congress can create 
sustainable funding and additional incentives for integrated mental 
health and primary care services, which especially for low-income 
populations, like those served at BMC, should incorporate the capacity 
to address social determinants of health.

    Question. In your experience as a provider, how do you see these 
communities left out of SUD conversations, and what preemptive steps 
should policymakers take to center these communities in policy 
discussions?

    Answer. The one-size-fits-all approach of the American health care 
system does not work for all communities--i.e., expecting patients to 
show up to clinic to get care, instead of bringing care to places and 
people that communities trust. For example, care provided in houses of 
worship, community centers or home visits. In general, there's not a 
lot of focus on prevention and promotion in our addiction and mental 
health-care system. Greater investment in community-based organizations 
and support services, such as case management focused on psychosocial 
needs, would help reach more people that the current system fails to 
catch. It also could help to create a seat at the table in SUD policy 
discussions for community health workers (CHWs) and recovery coaches.

                                 ______
                                 
           Questions Submitted by Hon. Catherine Cortez Masto
    Question. In your testimony you touched on the continuum of crisis 
services that are provided by Boston Medical Center.

    If you were to be able to expand the capacity of programs like the 
behavioral health urgent care clinic or the crisis stabilization unit, 
would you expect to see changes in ER volume or even hospital 
readmissions?

    Answer. Expanding the continuum of crisis services at Boston 
Medical Center (BMC) would probably not realistically impact the volume 
of patients we see presenting with behavioral health issues in the 
emergency room (ER) or inpatient setting. A regional approach to expand 
the full continuum of care services, not just crisis services, 
including an emphasis on prevention and moving upstream to address 
health-related social needs, behavioral health integration in primary 
care settings, and other means of enabling individuals to access 
outpatient mental health services when they need it, would be more 
likely to reduce reliance on ER and inpatient mental health services. 
Timely response is key and can potentially avoid requiring ER or 
inpatient-level care.

    Question. You spoke about the workforce challenges that we're 
seeing across the country, and the lack of diversity among providers 
that seems to exacerbate access issues among LGBT populations, 
communities of color and underserved communities.

    Do you think expanding the types of clinicians who can practice 
behavioral health services would help to build the pipelines of 
providers who can meet the needs of diverse communities?

    Answer. Increased use of behavioral integration in primary care and 
allowing mental health professionals to work to the full extent of 
their license within scope of practice could help address workforce 
shortages and improve access to behavioral health care. Including CHWs 
and peer support in care models, and reimbursing them for their time is 
crucial to better serving the needs of diverse communities.

    Question. How else can Congress develop a provider workforce that 
is able to serve diverse communities most effectively?

    Answer. As I mentioned in my testimony, I see the provider 
workforce shortage as a pipeline issue. Additional education and 
training opportunities writ large and for communities of color in 
particular would go a long way. Increased resources should be targeted 
to historically disinvested communities. Barriers to education and 
training can be addressed with additional funding for scholarships for 
people of color and individuals from low-income communities to complete 
their primary education and higher education, as well as loan repayment 
programs to reduce the financial burden/barriers to getting people into 
the field. Addressing stigma in the community--what it means to work in 
the mental health profession, and what it means to get mental health 
care--is imperative as well. In terms of legislation before Congress, 
the Pursuing Equity in Mental Health Act (S. 1795)--which you've 
cosponsored and has passed the House as H.R. 1475--if passed by the 
Senate would help provide additional resources to recruit and sustain a 
diverse mental health workforce. BMC is very much in support of S. 
1795/H.R. 1475.

                                 ______
                                 
                Questions Submitted by Hon. John Barasso
    Question. The health-care professionals, along with all front-line 
workers, deserve our gratitude and appreciation. Their dedication to 
our communities during this pandemic is something we must recognize and 
never forget.

    A top concern of Wyoming mental health facilities is making sure 
there are enough staff to care for their patients. It is especially 
challenging to attract and keep health-care providers in rural 
communities.

    Can you discuss solutions related to workforce development you 
believe will improve the ability of mental health facilities to attract 
and maintain staff in rural areas?

    Answer. The mental health burden in some communities, rural, urban, 
and suburban, is tremendous, and requires significantly more resources 
to adequately support the mental health workforce and address the need. 
Overtaxing the limited mental health resources that exist in high need 
areas contributes to high churn among mental health professionals. A 
model like the Massachusetts Child Psychiatry Access Program (MCPAP), 
which I referenced in my testimony, is one way to stretch existing 
resources and increase access to psychiatric consults for primary care 
providers in rural areas.

    Question. Can you specifically discuss changes to GME policy you 
believe would improve the pipeline of mental health physicians?

    Answer. Increased funding for GME slots in general, as proposed in 
the Resident Physician Shortage Reduction Act (S. 834/H.R. 2256), and 
targeted to a particular specialty, such as addiction medicine and 
addiction psychiatry, as proposed in the Opioid/SUD Workforce Act (S. 
1438/H.R. 3441), would help significantly improve the pipeline of 
mental health physicians.

    Question. As a doctor, I strongly support increasing access to 
mental health services, especially in rural communities. Senator 
Stabenow and I have previously introduced legislation for many years 
that would allow mental health counselors and marriage and family 
therapists to receive reimbursement from Medicare.

    Can you discuss how the Department of Health and Human Services can 
improve access for mental health services, especially for those on 
Medicare?

    Answer. One way HHS could help improve access to mental health 
services is by removing the Medicare cap on the number of inpatient 
psychiatric days a beneficiary can have in their lifetime--this is a 
lack of parity with physical health care. People under age 65 who are 
chronically or severely mentally ill and on Medicare, who need 
inpatient mental health care, end up stuck in the hospital emergency 
department because of this restriction.

    Question. In particular, can you comment on the merits of allowing 
licensed professional counselors and marriage and family therapists to 
receive reimbursements from Medicare?

    Answer. People should get reimbursed for what is in their scope of 
practice, so I don't see any reason why licensed professional 
counselors (LPCs) or marriage and family therapists (MFTs) should not 
receive reimbursement from Medicare for the services they are trained 
to provide.

                                 ______
                                 
                 Questions Submitted by Hon. Tim Scott
    Question. The toll that union-sponsored excuses for ``virtual 
learning'' has taken on actual kids is extraordinarily sad, especially 
for our Nation's most vulnerable children. In October 2020, a survey 
conducted by the Jed Foundation showed that 31 percent of parents said 
their child's mental or emotional health was worse than before the 
pandemic. Private insurance data also shows that while all health care 
claims for adolescents ages 13-18 were down in 2020 compared to 2019, 
mental health-related claims for this age group increased sharply. 
Additionally, the Centers for Disease Control and Prevention (CDC) 
reports 25 percent of parents whose children attended school virtually 
were more likely to report an overall worsened mental or emotional 
health compared to only 16 percent of parents of children attending 
school in-person.

    What programs within the Department of Health and Human Services' 
(HHS) purview are best poised to support children and schools as they 
return to complete in-person learning?

    Answer. I'm not sure of the particular programs within HHS that may 
best support children and schools as they return to in-person learning, 
but either way more therapists are needed in schools. Kids spend most 
of their waking hours in school so it is best to make mental health 
services and supports available to them there. In addition, mental 
health support for school teachers, staff, administrators, and parents 
of school-aged children will be vitally important as kids look to 
adults for modeling especially during times of transition and 
uncertainty. The Federal Government can and should play a role in 
helping to facilitate connections to care within the community in 
instances when it is beyond the capacity of school (e.g., funding and 
supporting crisis management services in the community). All of this 
should be integrated into a prevention and promotion framework, which 
includes psychoeducation and group intervention, in order to help kids 
and adults connect the dots of what they have experienced and identify 
how trauma may manifest and when to ask for help.

    Question. How can we integrate more telehealth opportunities to 
expand access to mental health services in schools?

    Answer. I think it would be very impactful if students could access 
telehealth in schools. Schools or community health center partners 
should be outfitted with the technology to enable access for kids who 
may not have the necessary technology or private space at home, 
assuming the location of the child is no longer relevant for 
reimbursement. Parents will have to be involved to a certain extent 
with the care of minors, particularly with respect to prescribing 
medication, so it will be important for schools and communities to set 
up systems and processes to engage parents without creating additional 
barriers.

    Question. Telehealth has expanded rapidly as a result of the COVID-
19 pandemic. Numerous studies have demonstrated the effectiveness of 
telehealth for behavioral health services.

    As telehealth becomes more common among health care providers, what 
can Congress do to ensure that patients do not suffer from unnecessary 
bureaucratic delays?

    Answer. Congress can help to ensure parity for mental health 
services with physical health services. In my experience, prior 
authorization for behavioral health services is not level with physical 
health and should be addressed to reduce unnecessary barriers to care.

    Question. There is a well-researched connection between 
unemployment and mental health. As recently as April 2021, despite 
billions of dollars of COVID-19 stimulus, aggregate employment remained 
7.9 million jobs below its pre-recession level.

    What impact will this failure to get people back to work have on 
mental health?

    Answer. Engaging people with meaningful work, financial security, 
and structure is helpful for maintaining and supporting mental health. 
In places where insurance is more closely tied to work, rising or 
stagnant unemployment could reduce access to health care for people 
facing unemployment.

    Question. Last November, an article published in the Journal of the 
American Medical Association noted that multiple studies indicated that 
older adults may be less negatively affected by certain mental health 
outcomes than other age groups.

    Are these study outcomes consistent with your own professional 
experiences working with older adults?

    Answer. N/A.

    Question. Current network adequacy standards often allow networks 
of specialists who aren't taking new patients or who have long waiting 
lists. That means that many people needing treatment must go out of 
network to get care, and only those who can afford the high cost get 
it. One of the biggest challenges to access to behavioral health care 
services is that many behavioral health specialists don't participate 
in health plan networks.

    Why is that, and how can we change that?

    Answer. Low reimbursement and administrative burden, including 
dealing with prior authorization, act as deterrents to providers 
accepting health insurance. Improving reimbursement and expanding team-
based care models that support integration of behavioral health into 
primary care settings could help.

    Question. Outside of the public health emergency, telehealth 
services are restricted to certain geographic and clinical settings. 
Beneficiaries must live in a rural area and have an initial face-to-
face visit with the distant-site provider. Once a relationship has been 
established, periodic in-person visits are also required. With few 
exceptions, patients must be located in a clinical setting and may not 
receive care from their homes. In addition, the distant-site provider 
cannot be located in a rural health clinic or FQHC.

    Telehealth has been used broadly during the pandemic to expand 
health care access to individuals throughout the country. During the 
pandemic, Medicare significantly expanded the coverage of telehealth 
services. A recent Bipartisan Policy Center poll suggests that people 
receiving mental health and substance use services want a combination 
of in-person, video, and telephone services even after the pandemic has 
passed.

    What telehealth expansions should remain after the pandemic?

    Answer. Particularly for the patients that I see at Boston Medical 
Center, a majority of whom are low-income, maintaining coverage and 
reimbursement for audio-only telehealth is essential. Insurers should 
also not require an in-person visit for mental health visits in order 
to permit continued telehealth use (e.g., requiring one in-person visit 
within 6 months of the first telehealth appointment). The decision of 
whether to see a patient in person or virtually should instead be up to 
the discretion of the clinician.

                                 ______
                                 
                Questions Submitted by Hon. John Cornyn
    Question. Your testimony outlines the collaborative care model and 
integrated care. I can appreciate the benefit of this collaboration 
between practitioners, and I too am concerned about the education and 
support our primary care physicians receive for addressing mental 
health.

    The Massachusetts Child Psychiatry Access Program, as you claim, 
``improves access to treatment for children with behavioral health 
needs and their families . . . via remote consultation and education.'' 
Telehealth is a tool that delivered positive results during the 
pandemic and is largely here to stay. And I look forward to working 
with my colleagues on ensuring patients have access to care through 
telehealth, including mental health care.

    What type of education regarding mental health is offered to 
primary care physicians in collaborative care models?

    What about outside of those care models?

    Do you have any recommendations for Congress to consider regarding 
disseminating mental health best practices or education items to 
primary care physicians?

    Answer. Congress could play a role in funding a national technical 
assistance program for collaborative care models, including access to 
start-up capital to get behavioral health clinicians, managers, and 
systems in place. Training and education works best when built into 
clinicians' workflow/time. Additional research funding is needed in 
order to learn more about the best forms of integrated care for 
different patient populations.

                                 ______
                                 
             Prepared Statement of Chantay Jett, MA, MFT, 
         Executive Director, Wallowa Valley Center for Wellness
                        introduction/background
    Good morning, Chairman Wyden, Ranking Member Crapo, and members of 
the Senate Finance Committee. Thank for you for the opportunity to 
appear before the committee to discuss policy solutions to address both 
the mental health and substance use crises impacting the United States 
and in particular the rural and frontier areas of our percent. My name 
is Chantay Jett, and I am executive director of Wallowa Valley Center 
for Wellness (WVCW), which provides community-based mental health and 
substance use treatment services in the most remote region of the great 
State of Oregon.

    We represent a truly frontier area of our Nation where the cows 
outnumber the people and our closest major airport is in Boise, ID--
nearly 4 hours away. We are literally at the end of the road where 
everybody knows everybody, which unfortunately contributes to both 
stigma and lack of access for people seeking treatment services. I am 
here to tell you that the Certified Community Behavioral Health Clinic 
(or CCBHC) model has truly made a difference in our frontier community. 
I hope every State in the near future has the opportunity to use the 
resources this model has made available to us to meet the specific 
needs of our wonderful community.

    The State of Oregon participates in a 10-State demonstration of the 
Excellence in Mental Health and Addiction Treatment Act that this 
committee helped to establish in 2014 through the bipartisan leadership 
of Senators Stabenow and Blunt. The Center for Wellness is one of 12 
CCBHCs that operate in our State. We provide high-quality, integrated, 
community-based mental health and substance use services to 
individuals, while also screening for possible co-morbid conditions 
like heart disease, diabetes, and HIV/AIDS. Among the most important 
services that CCBHCs provide--both in Oregon and nationwide--are 
immediate access to Medication Assisted Treatment (MAT) for substance 
use and 24-hour emergency psychiatric care.
         prevalence of behavioral health conditions in oregon/
                  mental health professional shortages
    Please permit me to provide some very brief context of CCBHCs 
within rural and frontier counties in the State of Oregon. According to 
the Oregon Health Authority (OHA), our State reports higher rates of 
mental health conditions, including severe and persistent mental 
illness and suicidal ideation. The COVID-19 pandemic has only 
exacerbated an ongoing mental health and substance use crisis in rural 
Oregon.

    OHA also details a lack of access to mental health and substance 
use care, especially in frontier communities which face greater 
distances for referral to outpatient and inpatient services. To give 
you a sense, there is no stoplight within a 76-mile radius of Wallowa 
County. The OHA reports average wait times of as much as 6 months 
Statewide due to a lack of providers. However, we are the lucky ones, 
because the CCBHC model helped created an internal reorganization of 
service delivery which resulted in same day access to care.
        wallowa valley center for wellness: the ccbhc experience
    Prior to becoming a CCBHC, The Center for Wellness was heavily 
reliant upon grants. Grant funding is crucially important, but it 
carries limitations. Grants typically end every 2 to 3 years; they all 
have different reporting requirements and different program 
specifications, which unfortunately results in more time spent filling 
out paperwork, rather than treating our patients.

    By contrast, the CCBHC prospective payment system permits us to do 
three big things. First, The Center for Wellness is able to contract 
with more skilled clinicians--including psychiatrists and medical 
professionals to prescribe Medication Assisted Treatment for patients 
with opioid use disorder. This directly results in decreased wait times 
and reduced emergency department utilization.

    Secondly, the CCBHC program is designed to expand access to 
underserved populations. In our case, becoming a CCBHC really opened 
the door for mental health care to veterans as it requires the staffing 
of services specifically for veterans. According to the Veterans 
Service Organizations (VSO) in our county, there are at least 1,000 
community members who have donned the uniform out of 7,000 residents. 
One of our CCBHC funded clinicians has been invited to the weekly PTSD 
groups at the Veterans of Foreign Wars (VFW) for veterans and their 
families. Becoming a CCBHC has allowed us to increase our services to 
23 veterans in our community. This may not seem significant to you, but 
it's an increase of 300 percent--a big deal for us here in rural 
Oregon.

    Thirdly, consistent CCBHC resources are a fundamental driver of 
integrated care. In Oregon, the CCBHC demonstration financing has made 
it possible to integrate with a local Federally Qualified Health Center 
(FQHC) allowing primary care, specialty medical services, and 
behavioral health services to be accessible under the same roof. We 
also share a single Electronic Health Record with our partner FQHC and 
local critical access hospital to permit immediate care coordination. 
Patients tell me that it is such a relief to not have to retell their 
story with every multidisciplinary provider they see. I will add that 
if there is no open acute psychiatric bed in our hospital or an acute 
bed is too distant in time traveled, we are lucky to have a great 
neighbor and partner across the State line in Idaho to access acute 
care psychiatric hospitalization. This component of care coordination 
and partnership with primary care and hospitals even across State lines 
is imperative because patients with severe mental illness and substance 
use challenges have shockingly high rates of chronic conditions, 
encompassing everything from cirrhosis to emphysema to heart disease. 
The CCBHC model allows us to have these partnerships and get patients 
the services they deserve in a timely manner.

    In closing, I strongly believe that this model represents the 
future of community-based mental health care and substance use 
treatment in the United States. This is why I am asking you to make 
this model available to every State nationwide. As a percent, we can do 
better than first treating mental health and substance use in hospital 
emergency departments, homeless shelters, and the county jails. 
Investing in CCBHC's is streamlining services in efficient ways that 
drive costs down over the entire continuum of care. Despite being from 
a tiny frontier community at the end of the road in northeastern 
Oregon, I hope you see that CCBHCs make an enormous impact.

    Again, thank you for the opportunity to testify, I am happy to 
answer any questions you may have.

                                 ______
                                 
      Questions Submitted for the Record to Chantay Jett, MA, MFT
                  Question Submitted by Hon. Ron Wyden
    Question. I understand you employ a range of physician and non-
physician providers.

    Can you tell the committee more about the clinical staff you employ 
who can and cannot receive Medicare reimbursement? In rural and 
frontier counties it is very difficult to find licensed providers in 
this workforce shortage landscape.

    Answer. Many of the service providers, such as peer support, case 
management, skills training, Supported Employment, Early Assessment 
Support Alliance (EASA), Assertive Community Treatment Team (ACT), med 
management, and Substance Use Providers (SUD) are not compensated at 
all by Medicare. The Licensed Clinical Social Workers we employ along 
with psychiatrists are compensated less than the value of the service 
they provide.

    Question. In a typical year, about how much does Medicare's 
provider policy cost your clinic?

    Answer. Wallowa Valley Center for Wellness writes off more than 
$500,000 per year in uncovered Medicare services.

                                 ______
                                 
                Questions Submitted by Hon. John Barasso
    Question. The health-care professionals, along with all front-line 
workers, deserve our gratitude and appreciation. Their dedication to 
our communities during this pandemic is something we must recognize and 
never forget.

    A top concern of Wyoming mental health facilities is making sure 
there are enough staff to care for their patients. It is especially 
challenging to attract and keep health-care providers in rural 
communities.

    Can you discuss solutions related to workforce development you 
believe will improve the ability of mental health facilities to attract 
and maintain staff in rural areas?

    Answer. Attracting and retaining a highly qualified workforce 
requires easier loan repayment programs and equalizing the requirements 
for school BH, primary care BH and community BH. We currently see the 
other sectors being able to pay more for less requirements and we 
cannot compete with this. The solution is to create an environment of 
equal parity in base salary for behavioral health workers as well as 
parity with the paperwork administrative burden placed only on the 
community mental health programs, as well as primary care providers 
sharing the risk for acute care hospital placements. I believe these 
three practices would remove a significant barrier to workforce 
development and the inability to offer competitive employment for a 
spouse/partner of a master's level clinician.

    Question. Can you specifically discuss changes to GME policy you 
believe would improve the pipeline of mental health physicians?

    Answer. As a community mental health program, we do not deal 
specifically with the guidelines and policies related to GME programs 
on the primary health-care side. I do not feel like I could offer an 
educated answer to your question.

    Question. As a doctor, I strongly support increasing access to 
mental health services, especially in rural communities. Senator 
Stabenow and I have previously introduced legislation for many years 
that would allow mental health counselors and marriage and family 
therapists to receive reimbursement from Medicare.

    Can you discuss how the Department of Health and Human Services can 
improve access for mental health services, especially for those on 
Medicare?

    Answer. Medicare reimbursement for Licensed Professional Counselors 
(LPCs) and Licensed Marriage and Family Therapists (LMFTs) would vastly 
improve access to care. Currently, a consumer has to either wait for an 
available (and scarce) LCSW or pay full fee for services, both of which 
are unacceptable. The ability to conduct telephonic and video sessions 
has addressed some barriers to care and these services must continue to 
be reimbursed/billable regardless of the status of COVID.

    Question. LMFTs and LPCs are as qualified or more to serve our 
community members, and the alliance between Medicare and LCSWs is 
purely an outcome of effective lobbying not good practice. In 
particular, can you comment on the merits of allowing licensed 
professional counselors and marriage and family therapists to receive 
reimbursements from Medicare?

    Answer. Please see above.

                                 ______
                                 
                 Questions Submitted by Hon. Tim Scott
    Question. The toll that union-sponsored excuses for ``virtual 
learning'' has taken on actual kids is extraordinarily sad, especially 
for our Nation's most vulnerable children. In October 2020, a survey 
conducted by the Jed Foundation showed that 31 percent of parents said 
their child's mental or emotional health was worse than before the 
pandemic. Private insurance data also shows that while all health care 
claims for adolescents ages 13-18 were down in 2020 compared to 2019, 
mental health-related claims for this age group increased sharply. 
Additionally, the Centers for Disease Control and Prevention (CDC) 
reports 25 percent of parents whose children attended school virtually 
were more likely to report an overall worsened mental or emotional 
health compared to only 16 percent of parents of children attending 
school in-person.

    What programs within the Department of Health and Human Services' 
(HHS) purview are best poised to support children and schools as they 
return to complete in-person learning?

    Answer. Regardless of the location of the instruction, a global 
event like COVID impacts the mental health of students. DOE and HHS 
need to partner on grasping the impact of collective trauma. Educators 
and school-based counselors need to recognize and support the lasting 
effects that COVID has had on our Nation and world and help students 
gain an understanding and normalize the emotional response to a life 
changing event.

    Question. How can we integrate more telehealth opportunities to 
expand access to mental health services in schools?

    Answer. A barrier to tele-health BH services is ensuring IT systems 
have the necessary permissions to ``talk'' to teach other. Our 
experience is that the school's Internet blocks our access.

    Question. Telehealth has expanded rapidly as a result of the COVID-
19 pandemic. Numerous studies have demonstrated the effectiveness of 
telehealth for behavioral health services.

    As telehealth becomes more common among health care providers, what 
can Congress do to ensure that patients do not suffer from unnecessary 
bureaucratic delays?

    Answer. Unnecessary bureaucratic delays are often due to the 
payment structure and how Medicare and private insurance will not pay 
for less expensive evidence-based services such as IPS-supported 
employment, case management, skills training, etc.

    Question. There is a well-researched connection between 
unemployment and mental health. As recently as April 2021, despite 
billions of dollars of COVID-19 stimulus, aggregate employment remained 
7.9 million jobs below its pre-recession level.

    What impact will this failure to get people back to work have on 
mental health?

    Answer. Like students, the entire Nation has experienced collective 
trauma, and employers need to recognize that status quo employment 
practices and some of the barriers to things like affordable housing 
and child care have a ripple effect across the employment rate.

    Question. Last November, an article published in the Journal of the 
American Medical Association noted that multiple studies indicated that 
older adults may be less negatively affected by certain mental health 
outcomes than other age groups.

    Are these study outcomes consistent with your own professional 
experiences working with older adults?

    Answer. Actually, older adults identify ``not needing'' MH support 
but that does not correlate with overall health outcomes and behaviors 
(such as obesity, smoking, gambling, alcohol abuse, and suicide). Our 
older community members cite stigma and rugged individualism as factors 
in avoiding MH services. This is also relevant to accessing/pursuing 
preventative medical care. ``I'm not sick, so why should I see a 
doctor?''

    Question. Current network adequacy standards often allow networks 
of specialists who aren't taking new patients or who have long waiting 
lists. That means that many people needing treatment must go out of 
network to get care, and only those who can afford the high cost get 
it. One of the biggest challenges to access to behavioral health care 
services is that many behavioral health specialists don't participate 
in health plan networks.

    Why is that, and how can we change that?

    Answer. In my opinion, this problem is specific to the failure of 
health plan networks. The most common feedback I hear is that ``the 
network is full and not accepting any new providers.'' This is 
something providers in private practice face; this is not generally an 
issue in a community mental health program which employs a wide range 
of behavioral health specialists within their own programs.

    Question. Outside of the public health emergency, telehealth 
services are restricted to certain geographic and clinical settings. 
Beneficiaries must live in a rural area and have an initial face-to-
face visit with the distant-site provider. Once a relationship has been 
established, periodic in-person visits are also required. With few 
exceptions, patients must be located in a clinical setting and may not 
receive care from their homes. In addition, the distant-site provider 
cannot be located in a rural health clinic or FQHC.

    Telehealth has been used broadly during the pandemic to expand 
health care access to individuals throughout the country. During the 
pandemic, Medicare significantly expanded the coverage of telehealth 
services. A recent Bipartisan Policy Center poll suggests that people 
receiving mental health and substance use services want a combination 
of in-person, video, and telephone services even after the pandemic has 
passed.

    What telehealth expansions should remain after the pandemic?

    Answer. All of them! We are finding greater engagement to care by 
being offering an array of access points for folks. Even in the 
pandemic our yearly hours of service only fluctuated by about 60 hours 
from the previous year. However, the number of visits nearly doubled 
due to shorter encounters made possible through a variety of video, 
telephonic and in-person visits.

                                 ______
                                 
           Prepared Statement of Benjamin F. Miller, Psy.D., 
                Chief Strategy Officer, Well Being Trust
    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
my name is Dr. Benjamin F. Miller, and I am the chief strategy officer 
for Well Being Trust, a national foundation started in 2016 through a 
gift by the Providence Health System that is focused on advancing the 
mental, social, and spiritual health of the Nation.

    I am a clinical psychologist by training and have spent most of my 
adult life pursuing strategies that can advance mental health to a 
place of priority within our society. This goal has guided much of my 
work during my time as the founding director of the University of 
Colorado's Farley Health Policy Center and continuing today in my 
capacity as an adjunct professor at Stanford School of Medicine and at 
Well Being Trust.

    It is an honor to be able to speak to you today about an issue that 
every American is experiencing--an issue that we need to aggressively 
pursue, and which COVID-19 has all but exacerbated especially among 
communities of color and other marginalized people: our mental health. 
Several government reports highlight how broken our mental health 
system is. The 2020 DoD Inspector General report that found over 50 
percent of service members and their families who needed mental health 
care did not receive it.\1\ SAMHSA found that over 56 percent of adults 
with mental illness did not receive any treatment in the past year, nor 
did 35 percent of those with serious mental illness.\2\ And a recent 
GAO report highlighted a multitude of issues at multiple levels for 
mental health, including ongoing challenges with health insurance, 
enforcing laws like mental health parity, and finding the right 
clinician who can help.\3\ In one survey, almost 30 percent of people 
reported not seeking care because they did not know where to go.\4\
---------------------------------------------------------------------------
    \1\ https://www.dodig.mil/reports.html/Article/2309785/evaluation-
of-access-to-mental-health-care-in-the-department-of-defense-dodig-2/.
    \2\ https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/
NSDUHDetailedTabs2018
R2/NSDUHDetTabsSect10pe2018.htm.
    \3\ https://www.gao.gov/products/gao-21-437r.
    \4\ https://www.thenationalcouncil.org/press-releases/new-study-
reveals-lack-of-access-as-root-cause-for-mental-health-crisis-in-
america/.

    The need to solve for these and other existing problems is real and 
immediate. Clear pathways do not exist for people seeking mental health 
care--there are not obvious doors to enter, and we have no system that 
routinely is able to identify and treat people in a timely manner. This 
is perhaps our greatest challenge as we emerge from the devastating 
---------------------------------------------------------------------------
COVID-19 pandemic.

    With broad majorities in both parties now understanding the 
importance of addressing mental health, I believe it is the time to 
enact immediate fixes for people in need, as well as begin to lay the 
foundation for a reimagined mental health system--a mental health 
system that is grounded in community and an integral part of our 
broader health-care infrastructure.

    There are three key priorities I believe this committee should 
consider as it pursues both short- and long-term reforms for mental 
health.

    First and foremost, we need to bring mental health care to where 
people are. This includes schools, and even our workplaces, but to most 
immediately meet this moment, the best place to start is in primary 
care, the largest platform of health-care delivery. In one poll, 70 
percent of adults agreed that it would be more convenient if their 
mental health and substance use services were integrated into their 
primary care doctor's office.\5\
---------------------------------------------------------------------------
    \5\ https://bipartisanpolicy.org/download/?file=/wp-content/
uploads/2021/03/BPC-MC-FINAL-Slide-deck-on-Mental-Health-Analysis-
Poll.pdf.

    To do this, we must create more global and flexible funding 
mechanisms for primary care practices who are working to integrate 
mental health. Our payment mechanisms often reinforce a siloed delivery 
---------------------------------------------------------------------------
model, and this must change.

    By first using existing payment structures like those found in 
Medicaid Managed Care Organizations, Medicare Accountable Care 
Organizations, and Medicare Advantage plans to expand mental health 
integration work, primary care practices would have the flexible 
financial resources to onboard mental health clinicians as a part of 
their integrated care team.

    Second, we must reconsider the design and capabilities of our 
workforce. Demand for care has far outpaced the supply of mental health 
clinicians, and it is inconceivable to rely upon clinician recruitment 
strategies alone to meet our ever-growing need. There are two things we 
can do simultaneously to address this workforce issue.

    First, we can map out mental health utilization and gaps to better 
determine where services are needed and for whom.\6\ Without this we 
run the risk of widening disparities or putting money into places or 
programs people are not using for their mental health.
---------------------------------------------------------------------------
    \6\ https://www.thelancet.com/journals/lanpsy/article/PIIS2215-
0366(21)00073-0/fulltext.

    Second, we invest in our community workforce--those like peer 
support specialists, community health workers, or more broadly, lay 
people in our communities. We train them in mental health skills to 
help become the first line of mental health support, complementing our 
clinical enterprise and enhancing the overall capacity for communities 
to address mental health needs.\7\
---------------------------------------------------------------------------
    \7\ https://onlinelibrary.wiley.com/doi/abs/10.1111/jrh.12229.

    Finally, we must modernize and connect our Federal programs and 
systems to collaboratively solve for common mental health problems. I 
realize it is hard to ask committees to work across jurisdictional 
boundaries, but so many aspects of our mental health need to be 
understood together and implemented together--at the State and 
community level. Because there are multiple agencies, funding streams, 
and programs that support mental health, performing a landscape 
analysis can create a strategy for synergistic efficiencies by breaking 
down silos across Federal agencies and departments and allow for a more 
---------------------------------------------------------------------------
cohesive plan for mental health.

    In closing, I thank the committee again for holding a hearing on 
mental health. This is our moment to be bold in what we can do to boost 
our Nation's well-being, and ultimately save lives.
                                context
    In 2019, 156,242 Americans were lost to alcohol, drugs, or 
suicide--one person every 3\1/2\ minutes. 39,043 of those deaths were 
tied to alcohol misuse--a 4-percent increase over 2018--and drug-
induced deaths in 2019 increased by 5 percent to account for 74,511 of 
the totals.\8\
---------------------------------------------------------------------------
    \8\ https://wellbeingtrust.org/news/pain-in-the-nation-annual-
deaths-due-to-alcohol-drugs-or-suicide-exceeded-156000/.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    A few things to note. First, this data represents societal 
behaviors before COVID-19. While we do not have all the data from 2020 
yet, preliminary CDC data suggests a 27-percent increase over 2019 in 
drug overdose deaths offering a glimpse into how much worse it could 
be.\9\ In addition, between 2003 and 2018, the age-adjusted suicide 
rate reported by the CDC increased by more than 30 percent--and early 
data indicates that this number will continue to grow in the face of 
COVID-19.\10\
---------------------------------------------------------------------------
    \9\ https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-
covid-19.html.
    \10\ https://stacks.cdc.gov/view/cdc/100479.

    Second, the data highlight our ongoing problems with health 
disparities. In these data, we saw a 2-percent increase in drug 
overdose deaths in whites but a 15-
percent increase in blacks and Latinos, an 11-percent increase in 
American Indians, and a 10-percent increase in people of Asian descent. 
These are statistically significant differences that highlight how even 
dominant legislative responses to major issues like our opioid crisis 
can work well with some populations but not all. These ongoing 
disparities require a level of attention in system design that is 
currently missing. Simply decreasing the supply of opioids overall 
without addressing the demand and its underlying causes leaves us in a 
place where unintended consequences are likely to occur, such as 
increases in deaths from synthetic opioids or some subpopulations 
failing to sufficiently benefit from even the most well-intentioned 
---------------------------------------------------------------------------
reforms.

    Finally, it's important to see these data points for what they 
are--a macro trend line going in the wrong direction. While the 
calculations are ongoing, the projections informed by the CDC data and 
others suggest that our problems are only getting worse and are 
overwhelming communities. We must stop trying to see substance us 
disorder and mental, physical and behavioral health as separate 
issues--they are all interconnected. Assessing and addressing all is 
essential to achieve the outcomes and well-being we want for 
individuals and society as a whole. But in order for us to do this, and 
do this well, we need a system that can take care of all aspects of our 
health and not just the pieces. In fact, COVID-19 has given our Nation 
an opportunity to see mental health for what it is--a foundation to our 
overall health and well-being.

    As seen below, Kaiser Family Foundation has tracked the mental 
health impact of COVID-19 throughout the pandemic. This is truly an 
issue that impacts us all.

    In early 2020, the number of adults who said worry and stress 
related to the coronavirus was having a negative impact on their mental 
health increased from about one-third (32 percent) in March 2020 to 
roughly half (53 percent) in July 2020.\11\ While the impact appears to 
have normalized, data from March 2021 finds thatalmost half of adults 
report negative mental health impacts due to COVID-19.
---------------------------------------------------------------------------
    \11\ https://www.kff.org/coronavirus-covid-19/poll-finding/mental-
health-impact-of-the-covid-19-pandemic/.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    In another survey conducted in the fall of 2020, almost 80 
percent of surveyed registered voters described how COVID-19 had 
impacted their mental health. In the same survey, 9 out of 10 people 
believed that elected officials should be doing more for mental 
health.\12\ And when compared to the rest of the world, the U.S. has a 
much higher mental health burden from COVID-19 than other high-income 
countries.\13\
---------------------------------------------------------------------------
    \12\ https://wellbeingtrust.org/news/viacomcbs-well-being-trust-
2020-mental-health-survey/.
    \13\ https://www.commonwealthfund.org/publications/issue-briefs/
2020/may/mental-health-conditions-substance-use-comparing-us-other-
countries.

    Perhaps most concerning is the impact that COVID-19 has had on our 
kids and younger adults. Thirty-one percent of 18-29-year-olds report 
stress has had a major impact on their mental health. Schools are 
overwhelmed by the mental health needs of students but must make 
---------------------------------------------------------------------------
difficult decisions on where to invest their limited resources.

    Some of these issues are the expected result of a national health 
emergency; however, our Nation's fragmented approach to mental health 
and addiction impedes treatment and has exacerbated these problems. In 
addition, some facets of society, like our Nation's jails and prisons, 
are full of people with mental health and addiction needs. Many of 
these people had significant unmet need for mental health and addiction 
services before they were incarcerated. And too often, these needs 
unaddressed by the time they move back into community settings--further 
stressing the ability of local systems to adequately respond.\14\ These 
national problems and others are a constant threat against the well-
being of our communities until comprehensive reforms are embraced.
---------------------------------------------------------------------------
    \14\ https://www.mhanational.org/issues/access-mental-health-care-
and-incarceration.

    It should be no surprise that when people don't have any place to 
go, they show up in the emergency department--but these are often some 
of the worst places for people to go who are in a mental health crisis 
as they are often ill-equipped to manage acute psychiatric crises 
potentially exacerbating an already existing problem. Data from the CDC 
found that compared with 2019, the proportion of mental health-related 
visits to emergency departments for children aged 5-11 and 12-17 years 
old in 2020 increased approximately 24 percent and 31 percent, 
respectively.\15\
---------------------------------------------------------------------------
    \15\ https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm.

    To make this crisis even more challenging, two commercial payers 
\16\,\17\ have stated that they will retroactively review 
why a person went to the ED, and if they determine it wasn't warranted, 
they can restrict or deny these Americans coverage. Imagine showing up 
thinking you are having a heart attack only to be told it's a panic 
attack, and then have to pay out of pocket after the cause of the 
emergency was diagnosed. This could further discourage American 
families from seeking out help, and while one payer has temporarily 
walked back this policy,\18\ it remains something that could reemerge.
---------------------------------------------------------------------------
    \16\ https://www.uhcprovider.com/en/resource-library/news/2021-
network-bulletin-featured-articles/0621-ed-facility-commercial-
claims.html.
    \17\ http://file.anthem.com.s3-website-us-east-1.amazonaws.com/
04591CAEENABC.pdf.
    \18\ https://www.nytimes.com/2021/06/10/health/united-health-
insurance-emergency-care.html.

    In summary, unaddressed mental health and addiction needs will 
negatively impact the collective spirit and well-being of individuals, 
families, and communities. The 116th Congress passed landmark 
legislation establishing streamlined crisis hotlines (988 crisis 
hotlines), which could very well overwhelm an already fragile system 
without support. I am hopeful that this committee might take the 
opportunity afforded by this legislative effort to begin laying the 
foundation for a truly modern system of care that works to integrate 
---------------------------------------------------------------------------
mental health through delivery, financing, and policy.

    Below I outline the three areas that I believe hold the most 
promise for mental health.
1. Reimagine Care Delivery
    Mental health is local. We need to consider all the places that 
people show up with need and be prepared with a mental health response. 
From community settings like schools, and workplaces to health delivery 
settings like primary care, one of the best ways we can begin to 
enhance access and more proactively address mental health needs is to 
integrate mental health.

    What does this look like? At a high level it means that the 
location--whether it's a primary care office or a school--has the 
resources to have an onsite mental health professional who can help 
identify, treat, and coordinate. This approach helps us begin to better 
distribute mental health services throughout the community in an effort 
to better be responsive to needs. Below I outline a few specific policy 
ideas that can support this reimagined approach to mental health.
            Primary Care
    Care for those seeking mental health services is fragmented in many 
of today's local systems, leaving even the most connected of people 
waiting for help. The issues that contribute to the problems in our 
current care delivery systems include: (1) unnecessary care limitations 
restricting where and how a person can get access to care; (2) 
referrals being the dominant intervention for mental health in most 
health-care settings; and (3) care approaches remain fragmented with 
team-based interventions remaining an aspirational goal in most 
settings. Integrating mental health into primary care addresses all 
three of these issues head on.

    The Bipartisan Policy Center's report on mental health and primary 
care integration offers several key recommendations for this committee 
to consider.\19\ And rather than list all of those recommendations 
here, I would encourage the committee and staff to look into the report 
at the three major areas the report covers: transforming payment and 
delivery to advance value-based integrated care, expanding and training 
the integrated workforce, and promoting technology and telehealth to 
support integrated care.
---------------------------------------------------------------------------
    \19\ https://bipartisanpolicy.org/download/?file=/wp-content/
uploads/2021/03/BPC_
Behavioral-Health-Integration-report_R02.pdf.

---------------------------------------------------------------------------
    Additional integration recommendations include:

        Creating a definition for mental health and primary care 
integration. The definition should allow for local adaptation and 
flexibility in how practices implement an integrated model of care. 
There are operational definitions that have been created, which may 
prove useful in this process.\20\ The evidence for integration is that 
patients like it, clinicians like it, it saves money from total costs, 
the costs are currently borne by practices and are 
unsustainable.\21\, \22\ The National Academies' report on 
Implementing High Quality Primary Care published last month with 
support from four Federal health agencies, points to mental health 
integration in primary are as the team-based intervention most 
supported by evidence.
---------------------------------------------------------------------------
    \20\ https://integrationacademy.ahrq.gov/products/lexicon.
    \21\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5698230/.
    \22\ https://jamanetwork.com/journals/jama/fullarticle/2545685.

        Fixing the financing of integrated mental health in primary 
care because practices typically bear the cost, one size will not fit 
all, and flexible financing options will allow for practices to create 
a model of care that works best for their community. I have offered an 
---------------------------------------------------------------------------
example below from Colorado.

       Western Colorado's Rocky Mountain Health Plans (RMHP) has 
pursued a comprehensive approach to mental health integration and found 
the model necessary to meet the needs of their members, wherever they 
choose to access care. Specifically, they have implemented enhanced, 
non-volume-based payment models to promote and sustain integrated 
mental health clinicians in advanced primary care sites. Their payment 
models sustain services that are often not recognized in conventional 
private payer or State programs, such as health and behavioral 
encounters or care coordination services. These embedded mental health 
clinicians provide immediate support for the emotional well-being of 
patients and families and improve the overall capacity of scarce 
primary care providers to serve the population.

       Additionally, when extended or specialty therapy is necessary, 
primary care-based providers receive reimbursement for care alongside 
other provider options in the inclusive network. They admit all willing 
and qualified providers promptly to their mental health provider 
network, credentialing over 90 percent of all complete applications 
within 45 days, often a major rate limiting factor in expanding our 
workforce.

       Patrick Gordon, RMHP's CEO, attributes the positive performance 
of their health plans to comprehensive primary care and integrated 
mental health. They routinely exceed quality benchmarks set by the 
State of Colorado in their year-to-year agreements and have achieved 
Commendable accreditation distinction from the National Committee for 
Quality Assurance, as well as statutory and contractual financial 
performance requirements that require an annual return of 2 percent 
savings to taxpayers.

       The key? They have embraced a new model of care that pays for 
mental health differently in primary care settings. This model begins 
to take us away from traditional fee-for-service codes and embraces the 
power of what can happen when we push for flexibility in our financing 
that supports the concept of a team working in concert to improve 
health. A recent report from the National Academies reinforces this by 
recommending paying for primary care teams to care for people, not 
doctors to deliver services.\23\ A forceful charge to move away from 
volume-driven payment mechanisms that may reinforce a siloed approach 
to mental health.
---------------------------------------------------------------------------
    \23\ https://www.nationalacademies.org/our-work/implementing-high-
quality-primary-care.

       Future Accountable Care Organization efforts and primary care 
value-based payment models should include specific incentives to 
---------------------------------------------------------------------------
promote mental health integration.

       In addition, as States move away from carved-out financial 
models for mental health, new arrangements emerge that better support 
integrating care. Each decision of how mental health is financed can 
have an impact on how care is delivered on the ground.\24\ We should 
continue to promote payment models that reinforce the concept of a team 
and facilitate easier access for mental health services in primary 
care.
---------------------------------------------------------------------------
    \24\ https://www.ohsu.edu/sites/default/files/2021-05/
McConnell%20et%20al.%20Financial%
20Integration%20of%20Behavioral%20Health%20in%20Medicaid.pdf.

        Assuring that our mental health workforce is trained and 
prepared to work in integrated settings.
         Most mental health clinicians are trained to work in specialty 
mental health settings. While some training programs have recognized 
the importance of training their mental health clinicians to work in 
places like primary care, without proper training, many mental health 
clinicians may not adapt to a primary care culture, making it difficult 
to sustain integrated efforts.

         To this end, the Federal Government could consider:

            Expanding financial support for continuing education 
programs that prepare providers to work in integrated settings;

            Increasing financial support for programs that recruit 
diverse students into primary care and mental health professions and 
improve access to and affordability of health-care education;

            Creating learning collaboratives for integrated 
programs and increasing preference for integration as a quality 
improvement activity under programs like MIPS; and

            Funding the incubation of new models of integrated 
training for primary care and mental health professionals in medical 
schools/other training institutions.

        Providing technical assistance to primary care practices 
looking to integrate mental health.

         Integrating care requires a change in workflow and overall 
practice culture. It becomes about the team and not just the individual 
clinician. Practices could benefit greatly from having some form of 
technical assistance to help them with this transformation. Recent 
evidence from the Agency for Healthcare Research and Quality 
demonstrates that this facilitation is key to enabling transformation 
and for speeding it up.\25\, \26\ There are two immediate 
options to help here:
---------------------------------------------------------------------------
    \25\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118489/.
    \26\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827672/.

            Provide appropriate funding for the Primary Care 
---------------------------------------------------------------------------
Extension Program; and

            Establish grant funding for technical assistance for 
implementation and the ongoing delivery of integrated care.
            Schools
    Federal policies, initiatives, regulations, and guidance are 
important tools for the promotion and widespread adaption of 
comprehensive school mental health systems. In addition to Federal 
agencies with responsibility over the well-being of children and youth 
such as the Department of Education (DOE) and the Department of Health 
and Human Services (HHS), congressional champions are increasingly 
leaning into their role in this space.

    We have a patchwork of grants at SAMHSA, and elsewhere that either 
promote school climate or integrate mental health services, and ESSA 
allows flexibility, but we need an ambitious goal of making sure that 
our initiatives reach every school and that they're equipped to engage 
all of the school staff in promoting the mental well-being of the 
students and addressing the needs of those with mental health 
conditions.

    Before the pandemic, clinicians were seeing alarming trends in 
adolescent mental health, with increased reporting of depression, 
anxiety, and suicidal ideation. Unfortunately, those trends were 
accelerated by the pandemic. Emergency room visits for mental health 
for adolescents 12-17 rose by 30 percent last year. To put it simply, 
America's children are in trouble.

    The good news is that we know what can be done to help alleviate 
this mental health crisis in our youth. We want to see strong community 
and family supports, and importantly we know that one of the best 
chances we have to get children the mental health care they need is 
actually in the one place they all have to go every day, and that's in 
our school systems. The adoption of comprehensive mental health systems 
in our school systems will help make sure that every child has the 
opportunity to thrive, while also making sure we offer immediate help 
to those who might be falling through the cracks.

    Congress has a significant role to play in promoting school mental 
health. Federal policies, initiatives, regulations, and guidance are 
important and necessary tools for the widespread adaption of 
comprehensive school mental health systems.

    Congress can provide three major lanes of support to comprehensive 
school mental health programs: providing funding via appropriations, 
grants, and initiatives; setting up sustainable funding mechanisms and 
incentives such as increasing the Federal Medicaid matching rate for 
school-based health services and working with schools to support their 
ability to bill Medicaid; and scaling up technical assistance centers 
and programs to provide ongoing support for implementation at the 
district and school levels.

    However, and important to note, promoting school-wide mental health 
is not a one-and-done program--it's a process of engaging staff, 
students, and parents to identify needs and continuously improve. And 
to accomplish this, schools need support.

    Making concrete investments in school mental health won't just 
address the current crisis we find ourselves in, it will pay dividends 
for generations, giving all children the chance to thrive, and building 
a next generation resilient and prepared workforce.
2.  Reconsider the Design and Capabilities of our Workforce
    To make it easier for people to access and pay for mental health 
care, we need a different way of thinking about workforce--one that 
helps us respond to mental health needs in a timely manner and do so in 
a high quality and effective way. Solving these problems goes beyond 
simply adding more clinicians.

    The existing mental health workforce access challenges within our 
communities are well understood. They result in the following 
statistics:

        Thirty-three percent of those seeking care wait more than a 
week to access a mental health clinician;
        Fifty percent drive more than one-hour round trip to mental 
health treatment locations;
        Fifty percent of counties in the U.S. have no psychiatrist;
        And only 16 percent of active psychologists are from minority 
populations despite comprising 40 percent of the U.S. population;\27\ 
and
---------------------------------------------------------------------------
    \27\ American Psychological Association. Demographics of the U.S. 
psychology workforce: Findings from the American Community Survey. 
Washington, DC, 2015.
---------------------------------------------------------------------------
        Only 10 percent of practicing psychiatrists are from 
underrepresented minorities.\28\
---------------------------------------------------------------------------
    \28\ Wyse R., Hwang W.-T., Ahmed A.A., Richards E., Deville C. 
Diversity by Race, Ethnicity, and Sex Within the U.S. Psychiatry 
Physician Workforce. Acad Psychiatry. 2020;44(5):523-530.

    There are two immediate steps we can take to best begin to address 
---------------------------------------------------------------------------
our workforce shortage problem.

    First, we can map out mental health utilization and gaps to better 
determine where services are needed and for whom.\29\ We should look at 
where people are showing up for care and who is available to help. 
Without this important foundational step, we run the risk of widening 
disparities or putting money into places or programs people are not 
using.
---------------------------------------------------------------------------
    \29\ https://www.thelancet.com/journals/lanpsy/article/PIIS2215-
0366(21)00073-0/fulltext.

    Second, we need to invest in our community workforce--those like 
peer support specialists, community health workers, or more broadly, 
lay people in our communities with no formal role or title. We train 
them in mental health skills to help become the first line of mental 
health support, complementing our clinical enterprise and enhancing the 
overall capacity for communities to address mental health needs.\30\ 
Frameworks have been proposed that offer guidance on how best to 
enhance our mental health workforce, and much of it begins with 
strengthening our unlicensed and community-based workforce.\31\ 
Solutions for the mental health workforce can be broken down further 
into three distinct buckets of improving our current workforce, 
enhancing the pipeline for the future workforce, and creating a new 
community workforce.
---------------------------------------------------------------------------
    \30\ https://onlinelibrary.wiley.com/doi/abs/10.1111/jrh.12229.
    \31\ https://thinkbiggerdogood.org/enhancing-the-capacity-of-the-
mental-health-and-addiction-workforce-a-framework/.
---------------------------------------------------------------------------
            Current Workforce
    We should take the clinicians we have out there in the field and 
retrain or prepare them to work in new settings. For mental health 
clinicians, this might be primary care or schools. We should also look 
to our unlicensed workforce--peer support specialists and community 
health workers and seek ways to support, finance, and scale their work.

    The education, training, and development of new generations of 
health professionals will be needed to address existing and expected 
unmet needs in areas such as crisis care and maternal and childhood 
mental health. The following steps should be taken in the short-term to 
address immediate areas of unmet medical need and prepare for expected 
increases in service requests once the 988 community crisis hotlines 
come online in the near future.

        Increase funding for Medicare residency slots. Without this, 
it's nearly impossible to increase the number of clinicians like 
psychiatrists. Of note, parity implementation and enforcement may also 
help here considering that some clinicians eligible to bill for 
services may be under-reimbursed making it less desirable to fill a 
residency slot.
        Make permanent 1135 waiver allowing Medicaid providers in 
another State to provide Medicaid services (though State licensing laws 
still apply).
        Promote telehealth and other digital service options to expand 
the service reach of our existing medical professionals.
        Incentivize providers to take additional Continuing Medical 
Education (CME) classes on current mental health best practices.\1\
        Focus existing federally funded quality improvement 
organizations on mental health integration across diverse primary care 
practices and for serving diverse populations, and finance additional 
learning collaboratives as necessary.
            Future Workforce
    We should provide prospective health-care professionals with the 
appropriate training by making mental health a core curricular 
component of medical school education. In addition, we should train our 
future clinicians to understand what it's like to work within a team-
based, multidisciplinary setting and provide incentives to higher 
education institutions to offer training in integrated mental health 
care, through graduate medical education (GME), graduate nursing 
education (GNE), and other programs.

    While increasing our future workforce is necessary, it alone cannot 
solve our workforce problem. The time and resources needed will always 
present limitations to the numbers of new mental health and medical 
professionals our Nation can train at any one time. Therefore, steps 
should be taken to expand workforce capabilities in new ways to address 
current and expected service needs.

    Policymakers should consider the following reforms to help local 
systems begin to update their local workforce capabilities:

        Develop non-medical multi-discipline community workforces to 
help address service requests that do not require a medical license to 
satisfy. Offering up payment mechanisms like Medicare to support 
critical services like peer support specialists would go a long way in 
strengthening this approach.
        Promote the use of innovative technologies like automated 
testing and screening platforms to reduce the requirements on medical 
professionals.
        Develop innovating payment methods and coverage designs like 
global payments to promote additional testing services from non-medical 
and technology platforms to better identify and improve access to the 
right care at the right time.
            Community Workforce
    We should empower everyone to perform tasks that traditionally 
clinicians would. There's robust literature out there on it, and it 
seems to solve several problems at once.\32\
---------------------------------------------------------------------------
    \32\ https://pubmed.ncbi.nlm.nih.gov/29914185/.

    We must also recognize that there are never going to be enough 
clinicians to meet service demands. Even as we reform Medicare and 
Medicaid to help primary care better integrate mental health, we will 
still run into the issue of finding time to undergo trainings and 
recruit mental health professionals to join their practice in the short 
term. And in truth, many mental health needs people have are not going 
to be solved solely at a clinical level, e.g., housing, employment, 
etc. Of course we will need people to be able to diagnose and 
prescribe, but we also need many more people to be able to teach 
important skills for navigating recovery or building a sense of 
community that supports people in times of crisis. Ideally, these 
skills would be spread out across many people and can mutually 
---------------------------------------------------------------------------
reinforce one another.

    In the long term, we are likely to never have enough clinicians to 
meet the community's demand without additional effort to increase the 
pipeline. Like what we've seen successfully work in other countries, we 
need to tap into our unlicensed yet credentialed workforce--such as 
peer support specialists and community health workers--and also adopt 
models that empower everyone to take on mental health at a local level. 
Innovative technologies such as digital therapeutics and telehealth can 
open up new access opportunities to train communities as well as reach 
individuals in need.

    Congress and this committee could consider grants or financing 
mechanism to States to help them sort out the regulatory and multipayer 
financing issues that often stymie creative and innovative ideas for 
mental health.
3. Modernize Federal Programming and Operations Strategies
    We must modernize and connect our Federal programs and operational 
systems to collaboratively solve for common goals within communities, 
and to better bring mental health into the national mainstream. Like 
when corporations merge, we should do a landscape analysis and create a 
national strategy for synergistic efficiencies among the 55 or more 
payment systems and thousands of programs that support mental health 
care in our communities today. Such a step can also help identify 
redundancies and inefficiencies by allowing for modern programming 
strategies to break down these silos across all Federal departments and 
agencies to allow for a more cohesive system for the future. For 
example, modern Federal funding and programming strategies might allow 
families and individuals to access a host of different Federal health 
care, workforce and educational services from multiple different 
Federal agencies, departments and programs through community and health 
system access routes.

    There are a host of additional steps we can take such as doing a 
better job of enforcing and expanding existing mental health parity 
laws that equate mental health and physical or improving care 
coordination for physical, mental, and behavioral care. In addition, 
public and private means of coverage.

    Communities and local health systems are on the front lines of 
managing services critical to the mental health and well-being of all 
Americans. Traditionally, the Federal Government's role has been to 
provide funding and other resources to these communities to help them 
manage their service needs. There are dozens of programs, funding 
streams, and other Federal resources available to communities and local 
health systems to support the provision of mental health services. 
However, allowing local communities greater flexibility to plan, 
program, and allocate these resources would allow programs the 
opportunity to manage their service needs while investing in local 
system innovations.

    Policymakers should consider reforms to key Federal financing 
authorities as a means of promoting greater local control over how 
resources are programmed. At the same time, policymakers can improve 
how the Federal Government plans for and allocates funds to communities 
to help maximize on these critical investments and better justify new 
expenditures that might be required in the future.

    Policymakers should consider:

        Establishing a national strategy for how the Federal 
Government can establish ``smart'' or collaborative financing 
strategies to improve the efficiency of Federal spending, leverage new 
uses of existing funds, and create better budgetary certainty for local 
communities. The 21st Century Cures Act, which became law, contained 
provisions intended to establish such a strategy. Policymakers might 
consider steps already taken by the agency in response to the act to 
establish such a national strategy more quickly.

         In 2016, there was a Community Solutions Task Force that had a 
focus on solving major challenges facing communities.\33\ Congress 
could use this as a model for mental health and ensure that in each 
policy it works on it specifically enables cross-agency and community-
level collaboration.
---------------------------------------------------------------------------
    \33\ https://obamawhitehouse.archives.gov/the-press-office/2016/11/
16/fact-sheet-establishing-council-community-solutions-align-federal.

        Repositioning the Family First Prevention Services Act (FFPSA) 
and Community Mental Health Services Block Grant (CMHSBG) to act as 
lead funding authorities for the various acts with overall 
responsibility for managing and verifying performance aspects related 
to Federal funds and other resource allocations meant to support the 
---------------------------------------------------------------------------
provision of mental health services within local communities.

        Requiring the Federal Government to regularly update the 
Committees of Jurisdiction in the House and Senate on the goals of the 
reformed financing process including progress against those goals.

         While the resources provided for by the Federal Government are 
substantial, overly prescriptive Federal requirements and lack of 
collaboration amongst the various Federal authorities in charge of 
overseeing these resource allocations impede the ability of communities 
to use these resources effectively.

         As example, the Community Mental Health Services Block Grant 
(CMHSBG) requires communities seeking funding to ``ensure that 
community mental health centers provide such services as screening, 
outpatient treatment, emergency mental health services, and day 
treatment programs.'' While community mental health centers play an 
important role, such requirements on local system performance 
unnecessarily tie the hands of officials struggling to manage growing 
service needs--especially in areas where solutions would otherwise 
exist except for Federal regulation.

        Reviewing the Federal requirements under existing community 
mental health Federal funding streams and considering easing 
requirements that unnecessarily impede care.

        Including program sustainability measures with new sources of 
funding or other resources meant to support the operation and 
modernization activities of local systems.

         Modern Federal laws like 988 promote modern programming 
strategies such as program sustainability best practices combined with 
local autonomy measures to ensure that local officials have sufficient 
freedom to establish successful and predictable local systems for 
individuals in need. The ability of local systems to improve their own 
systems operations through use of information sharing that leads to 
evidence development and best-practice adoption can help pave the way 
for continuous system improvement. Such a ``system of learning'' can 
provide Federal policymakers and local officials greater ability to 
collaborate and plan for program modernization today and in the future.

        Developing information-sharing and best practice development 
processes to provide local communities and Federal policymakers 
insights into the need for and design of future reforms.

    While the above areas are the three priorities I have chosen to 
focus on for today--reimagine care delivery, reconsider the design and 
capabilities of our workforce, and modernize Federal programming and 
operations strategies--outlined below are several other notable issues 
this committee should consider.
Other Issues and Recommendations to Consider
            Mental health parity and health insurance coverage
        The Finance Committee could take aggressive steps to ensure 
parity enforcement in Medicaid managed care and expansion populations, 
which is critical to both mental health equity and racial equity. There 
could now be an opportunity to engage consumers in setting key 
indicators of access and track progress with intensive oversight from 
CMS/CCIIO.

        The Finance Committee could ensure parity be applied to 
Medicare and Medicare Advantage. This will require eliminating 
discrimination against MH/SUD that is baked into title XVIII of the 
Social Security Act, and ensuring the full continuum of services are 
covered, including all intermediately levels of care.\34\
---------------------------------------------------------------------------
    \34\ https://www.realclearpolicy.com/articles/2020/12/30/
medicare_must_cover_mental_health
_654797.html.

        The Finance Committee could require Medicaid and Medicare 
Advantage plans to follow Generally Accepted Standards of Care and use 
level of care criteria from non-profit clinical specialty associations 
as outlined in the Federal case Wit v. United Behavioral Health.
            988 and crisis response
        The Finance Committee could make the CAHOOTS enhanced match 
permanent and extend it to a comprehensive range of crisis services to 
create a continuum beyond response.

        The Finance Committee could make sure Medicare and commercial 
insurance plans cover crisis services and look to Medicaid crisis 
benefits as a model.

                                 ______
                                 
    Questions Submitted for the Record to Benjamin F. Miller, Psy.D.
           Question Submitted by Hon. Catherine Cortez Masto
    Question. In your testimony you noted that it is ``inconceivable to 
rely upon clinician recruitment strategies alone to meet our ever-
growing need.'' Stakeholders across the behavioral health spectrum--
including policymakers--are looking at overwhelming workforce 
challenges.

    You mentioned peer support services as one solution. Can you 
elaborate on how peers help to address unmet need?

    Answer. Bringing a workforce that has experience, both firsthand 
and through additional training, into clinical and community settings 
can be a powerful tool in enhancing the capacity of our systems and our 
frontline licensed workforce. And the evidence is clear that peer 
support services (PSS) work.1 In fact, in 2007 CMS lifted up PSS as an 
evidence-based practice, and--while Medicare still does not pay for 
these services--many State Medicaid programs have adopted the model.

    There are three characteristics that stand out about PSS.

    First, as the name implies, they are peers to those they are 
serving meaning they have some form of personal or lived experience. In 
the mental health and addiction field, having a person that knows the 
challenges of what you are going through can be a powerful tool for 
healing unto itself.

    Second, these peers are equipped with skills that not only allow 
them to be more than supportive, but also to intervene with evidence-
based skills that can be further beneficial to the person they are 
trying to help. This allows peers to provide higher-touch care than the 
current workforce would allow, while also ensuring that other 
clinicians work at the top of their licensure.

    Third, PSS can offset the load placed on clinicians and become an 
extension of clinical services and clinical settings. When we look at 
wait times for clinicians, it forces us to begin to look to more 
creative ways to help people in a more expeditious timeframe. PSS do 
just that--there is an endless supply of individuals with lived 
experience who can be trained as peers.

    For PSS to scale, however, it could benefit from several policy 
changes. Medicare and most commercial health insurers do not cover PSS, 
as well as other mental health crisis services, Assertive Community 
Treatment, Coordinated Specialty Care (for early psychosis), and other 
team-based interventions. Allowing PSS services to be eligible for 
Medicare payment would go a long way in helping expand this service 
line.

    In the immediate term, the committee could ensure that mental 
health and substance use peers could be offered as a supplemental 
benefit by Medicare Advantage plans, and that they can offer PSS 
services in the context of integrated mental health care already 
billable under Medicare, as the recently introduced PEERS Act of 2020 
in the House would support. Peers also have a clear role in promoting 
value in Medicare Accountable Care Organizations (ACOs), and the 
committee could direct CMS to provide technical assistance to ACOs to 
better integrate PSS.

    And while outside of the scope of PSS specifically, it is important 
to note that Medicare only covers certain licensed mental health 
clinicians (e.g., LCSW, psychologists) to bill for services, which 
leaves a major challenge in building and diversifying the clinical 
workforce. Medicare has not updated its mental health provider 
licensure standards since 1989 and is still unaccountable to the Mental 
Health Parity and Addiction Equity Act. This presents major gaps in 
coverage for Medicare beneficiaries and can further interrupt 
continuity of care--leaving families to pay out of pocket or forego 
essential care entirely. It seems time to modernize Medicare policies 
for mental health in general and address PSS as we do so.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. The health-care professionals, along with all front-line 
workers, deserve our gratitude and appreciation.

    Their dedication to our communities during this pandemic is 
something we must recognize and never forget.

    A top concern of Wyoming mental health facilities is making sure 
there are enough staff to care for their patients. It is especially 
challenging to attract and keep health-care providers in rural 
communities.

    Can you discuss solutions related to workforce development you 
believe will improve the ability of mental health facilities to attract 
and maintain staff in rural areas?

    Answer. Mental health workforce recruitment and retention is a 
major need, especially in rural communities. And while I will address 
this issue, I think it's critical that we think beyond simply finding 
more clinicians and opening up the pipeline. As I have written about in 
my testimony, only choosing to focus on these pipeline issues, 
including attracting the right kinds of clinicians to the settings they 
are most needed, does not provide immediate relief nor does it enhance 
a mental health clinic or systems capacity to see more people. If our 
focus can become on better creating new pathways to allow for 
individuals to be identified and treated, it's inevitable that new 
solutions emerge beyond just a clinical workforce.

    I believe that Congress and this committee should pursue options 
like Community Initiated Care (CIC), a concept based on a rich 
evidence-based often called ``task-sharing'' or ``task-shifting.'' This 
is a model of intervention that is not dependent on licensed clinicians 
and has shown to be highly effective by allowing non-specialized, 
trained workers, and even ``lay'' members of the community to learn 
mental health skills.\1\
---------------------------------------------------------------------------
    \1\ https://www.commonwealthfund.org/publications/2021/feb/making-
it-easy-get-mental-health-care-examples-abroad.

    Community initiated care is a broadly inclusive concept that 
democratizes knowledge and empowers individuals to learn how to respond 
to mental health and addiction issues. Effective components include 
training and supporting community members to ensure that they acquire 
the knowledge, skills, and competencies necessary to deliver high 
quality evidence-informed programs for prevention and early 
---------------------------------------------------------------------------
intervention of mental health concerns.

    Bringing more mental health skills into the community can help 
solve several issues at once--it can make the workforce more readily 
available because we are creating capacity for communities to intervene 
on issue of mental health and addiction.

    To this end, Congress and this committee could consider grants or 
financing mechanism to States to help them sort out the regulatory and 
multi-payer financing issues that often stymie creative and innovative 
ideas for mental health like the community initiated care model 
described above. Offering up payment mechanisms like Medicare to 
support critical services like peer support specialists or a community 
workforce could go a long way in strengthening this approach and making 
it more viable. SAMHSA could push out pilot programs with community 
health workers, community-based organizations, and other community-
based non-professionals to deliver psychological interventions based on 
the learnings from global mental health. Currently, SAMHSA funds 
gatekeeper type programs through non-specialists as well as peer-
specialists programs, but there has been less support for these 
community based models. A final option is to consider pilot programs 
with additional funds through block grants if States commit to 
exploring the community initiated care approach.

    Question. Can you specifically discuss changes to GME policy you 
believe would improve the pipeline of mental health physicians?

    Answer. The first step to growing our pipeline of mental health 
clinicians is to increase funding for Medicare residency slots. Without 
this, it will be nearly impossible to increase the number of clinicians 
like psychiatrists.

    Parity implementation and enforcement may also help here, 
considering that some clinicians eligible to bill for services may be 
under-reimbursed. A lack of reimbursement makes mental health a less 
desirable residency slot.

    So too would modifying primary care residency training programs. 
Primary care remains one of the largest platforms for mental health 
delivery in this country. However, not all residency programs train the 
future workforce much in mental health--family medicine training 
programs do train their residents in mental health and in most cases, 
expose them to onsite mental health clinicians who they can work and 
train beside. Internal medicine and pediatrics residents get much if 
any such training.

    To change this, we should create mental health training 
requirements in all primary care residency programs modeled off of 
family medicines current requirements. In addition, residency programs 
should also require and support mental health integrated in primary 
care so that all trainees are acculturated to working in such models 
and can advocate for them later. If medical education had additional 
resources and incentives to bolster mental health and substance use 
training for more categories of clinicians, this would further extend 
the workforce.

    In addition, I shared some ideas in my testimony that I feel could 
be additive to changes in GME policy. For example:

        Make permanent 1135 waiver allowing Medicaid providers in 
another State to provide Medicaid services (though, State licensing 
laws still apply).

        Promote telehealth and other digital service options to expand 
the service reach of our existing medical professionals.

        Incentivize providers to take additional Continuing Medical 
Education (CME) classes on current mental health best practices.

        Focus existing federally funded quality improvement 
organizations on mental health integration across diverse primary care 
practices and for serving diverse populations, and finance additional 
learning collaboratives as necessary.

    Question. As a doctor, I strongly support increasing access to 
mental health services, especially in rural communities. Senator 
Stabenow and I have previously introduced legislation for many years 
that would allow mental health counselors and marriage and family 
therapists to receive reimbursement from Medicare.

    Can you discuss how the Department of Health and Human Services can 
improve access for mental health services, especially for those on 
Medicare?

    Answer. One of the best ways to improve access to mental health 
services is to first consider who is eligible to bill what, where, and 
for whom.

    CMS can ensure that Medicare payments for mental health integration 
are properly valued and that primary care clinicians have the necessary 
support and technical assistance they need to implement integrated 
care. Implementing integrated care models requires time, effort, and 
practice expenses that may not be fully captured in the current 
valuation. Further, interested clinicians might not have access to 
resources they need to set up integrated care in their practice. CMS 
should work with clinicians to identify barriers for the adoption of 
integrated care in Medicare, including misvaluing of codes, to ensure 
that beneficiaries get access to effective care.

    Recently, CMS launched the Community Health Access and Rural 
Transformation (CHART) model, which could be a promising approach to 
building the infrastructure for defragmentation and care transformation 
in rural America. One strategy that HHS could consider is building on 
the Community Transformation Track of the CHART model but with a 
specific focus on ensuring comprehensive access to mental health and 
substance use treatment, unlocking the full range of innovations from 
virtual care, peer support services, and integrated care models.

    The committee could also work with CMMI to ensure that alternative 
payment models (APMs) currently in progress adequately incentivize 
implementation of integrated care for Medicare beneficiaries. Model 
evaluations indicate that past APMs have had little effect on mental 
health outcomes. However, as mental health has been subject to chronic 
underinvestment--especially in rural communities--it counts against the 
benchmark for shared savings when providers implement effective early 
intervention (such as integrated care models), unless it very rapidly 
reduces hospitalizations. To address this issue and incentivize 
investment in early intervention, CMMI could:

            Adjust risk adjustment in ACOs, CPC+, and others to 
accommodate expected costs from integrated care in mental health, and 
pair with appropriate quality measure recommendations to ensure 
accountability; or

            Temporarily waive costs from integrated care models 
from shared savings calculations.

    Question. In particular, can you comment on the merits of allowing 
licensed professional counselors and marriage and family therapists to 
receive reimbursements from Medicare?

    Answer. Allowing other mental health clinicians outside of 
psychologists and licensed clinical social workers the chance to bill 
Medicare could be a slight help in our never-ending numbers game for 
the clinical workforce--how to get more. There are several benefits to 
allowing LPC and LMFT to bill Medicare, but the top one is infusing 
thousands of new clinicians into the workforce.

                                 ______
                                 
                 Questions Submitted by Hon. Tim Scott
    Question. The toll that union-sponsored excuses for ``virtual 
learning'' has taken on actual kids is extraordinarily sad, especially 
for our Nation's most vulnerable children. In October 2020, a survey 
conducted by the Jed Foundation showed that 31 percent of parents said 
their child's mental or emotional health was worse than before the 
pandemic. Private insurance data also shows that while all health-care 
claims for adolescents ages 13-18 were down in 2020 compared to 2019, 
mental health-related claims for this age group increased sharply. 
Additionally, the Centers for Disease Control and Prevention (CDC) 
reports 25 percent of parents whose children attended school virtually 
were more likely to report an overall worsened mental or emotional 
health compared to only 16 percent of parents of children attending 
school in-person.

    What programs within the Department of Health and Human Services' 
(HHS) purview are best poised to support children and schools as they 
return to complete in-person learning?

    Answer. Each agency within HHS offers incredible programs to help 
support our Nation's children. This includes Project AWARE at SAMHSA, 
Healthy Schools at CDC, school-based billing under Medicaid, support 
for school-based health centers at HRSA, and support for families' 
social and economic needs via the Administration on Children, Youth, 
and Families (ACYF).

    The biggest problem with these programs is scale--these programs 
benefit the grantees, but don't help most of the children who need 
them.

    To meet this moment, interagency collaboration is needed to 
coordinate and leverage all available resources to support States and 
local school systems to provide effective mental health supports for 
their students. CMS also needs to work with States to help them 
streamline appropriate billing for mental health services in schools 
under Medicaid. Several advocacy organizations have also offered up the 
idea of creating a White House Office on Children and Youth, and/or a 
Federal Children's Cabinet to help specifically on many of these issues 
above.

    Question. How can we integrate more telehealth opportunities to 
expand access to mental health services in schools?

    Answer. Congress has already done incredible work promoting access 
to virtual mental health consults for children in primary care by 
funding HRSA's Pediatric Mental Health Care Access Program. Congress 
can integrate more telehealth opportunities in schools by expanding 
this program further initiating a similar program to support 
integration with schools as well. As part of this work, CMS can provide 
technical assistance to States for ensuring that their current approach 
to Medicaid billing supports telehealth for children's mental health in 
schools. With these investments in infrastructure and attention to 
sustainability, millions more children can gain access to virtual 
mental health services where they are--in schools.

    We should also allow States to continue utilizing telehealth 
flexibilities put in place during the pandemic which facilitate schools 
both delivering mental health services and billing Medicaid for those 
services. For example, during the pandemic audio only was an allowable 
modality of telehealth services, both in terms of being able to deliver 
services and bill for services delivered using audio only. Other 
flexibilities include allowing school districts to access out of State 
providers for telehealth which helps address some of the workforce 
shortage issues and in general, just allowing school health provider 
types to bill Medicaid for services delivered.

    Congress should also support States in expanding their school 
Medicaid programs. States that had expanded their school Medicaid 
programs to allow for billing for non-IEP (individualized education 
program) services were able to do significantly more Medicaid claiming 
for telemental health services.

    And finally, there should be guidance issued to schools on how best 
to utilize telehealth to expand access to mental health services in 
schools. More guidance is needed to help States and school districts 
navigate Federal policies around telehealth, including reimbursement 
procedures.

    Currently, there is no designated guidance on telehealth for 
schools, and it would be a perfect opportunity for cross-agency 
collaboration to develop a piece that supports school districts in 
expanding access to mental health services in schools via 
telehealth.\2\
---------------------------------------------------------------------------
    \2\ https://healthyschoolscampaign.org/dev/wp-content/uploads/2021/
03/Providing-Health-Services-During-School-Closures-March-2021.pdf.

    Question. Telehealth has expanded rapidly as a result of the COVID-
19 pandemic. Numerous studies have demonstrated the effectiveness of 
---------------------------------------------------------------------------
telehealth for behavioral health services.

    As telehealth becomes more common among health-care providers, what 
can Congress do to ensure that patients do not suffer from unnecessary 
bureaucratic delays?

    Answer. It's going to take time for Congress to ensure that every 
American has access to broadband--this is needed so that everyone has 
access to telehealth and that existing disparities aren't made worse. 
However, in the interim, to make sure the greatest number of American 
can most immediately access telehealth services, Congress should make 
permanent some of the policies they temporarily put in place during the 
pandemic. Congress should make audio-only telehealth services 
permanent, enact payment parity, and allow for telehealth to be 
available for all forms of outpatient care.

    Question. There is a well-researched connection between 
unemployment and mental health. As recently as April 2021, despite 
billions of dollars of COVID-19 stimulus, aggregate employment remained 
7.9 million jobs below its pre-recession level.

    What impact will this failure to get people back to work have on 
mental health?

    Answer. There is a well-researched connection between unemployment 
and mental health, but it just makes sense: financial insecurity can 
increase stress, and stress can exacerbate underlying mental health and 
addiction issues.\3\
---------------------------------------------------------------------------
    \3\ https://wellbeingtrust.org/wp-content/uploads/2020/05/
WBT_Deaths-of-Despair-COVID-19-FINAL.pdf.

    Unfortunately, despite billions of dollars of COVID-19 stimulus 
funds, as recently as April 2021 aggregate employment remained 7.9 
million jobs below its pre-
recession level. And the longer it takes use to close that gap, the 
great risk we run of seeing an increase in the number of lives lost to 
---------------------------------------------------------------------------
suicide and drug overdoses.

    Question. Last November, an article published in the Journal of the 
American Medical Association noted that multiple studies indicated that 
older adults may be less negatively affected by certain mental health 
outcomes than other age groups.

    Are these study outcomes consistent with your own professional 
experiences working with older adults?

    Answer. That study found that older adults appeared to experience 
less mental health impacts during the early days of the COVID-19 
pandemic that other age groups. The article also notes the following:

        The data from various studies contrast the numerous personal 
        stories about how difficult the pandemic has been for the older 
        population. This divergence likely represents the heterogeneity 
        that is a hallmark of aging. Also, resilience captured at the 
        population level may not translate to individuals in specific 
        circumstances. Thus far, there is not a clear understanding of 
        which risk factors and protective factors are the strongest 
        determinants of mental health outcomes, although these may vary 
        from person to person.

        Many older adults do not have the resources required to deal 
        with the stress of COVID-19. This may include material (e.g., 
        lack of access to smart technology), social (e.g., few family 
        members or friends), or cognitive or biological (e.g., 
        inability to engage in physical exercise or participate in 
        activities or routines) resources. Clinicians and caregivers 
        must estimate resource availability and consider how the 
        absence of resources can be mitigated for a given individual 
        and family. Of particular importance is the role of technology, 
        which has emerged as an important factor for maintaining social 
        connection as well as accessing mental health services.\4\
---------------------------------------------------------------------------
    \4\ https://jamanetwork.com/journals/jama/fullarticle/2773479.

    In general, older adults are heavily impacted by mental health 
problems, although in different ways than their younger counterparts. 
For example, among men, suicide rates are the highest for those over 75 
years of age.\5\ Other recent studies find relatively consistent 
prevalence of depression across adulthood.\6\ Although risk factors 
evolve with age, mental health remains a serious issue and older adults 
often do not have access to appropriate care that meets their 
particular needs. This is in part why any conversations on Medicare 
reform must begin to address the deficiencies in the program for mental 
health and substance use disorders.\7\
---------------------------------------------------------------------------
    \5\ https://pubmed.ncbi.nlm.nih.gov/32487287/.
    \6\ https://www.cdc.gov/nchs/products/databriefs/db303.htm.
    \7\ https://www.realclearpolicy.com/articles/2020/12/30/
medicare_must_cover_mental_health_
654797.html.

    Question. Current network adequacy standards often allow networks 
of specialists who aren't taking new patients or who have long waiting 
lists. That means that many people needing treatment must go out of 
network to get care, and only those who can afford the high cost get 
it. One of the biggest challenges to access to behavioral health-care 
services is that many behavioral health specialists don't participate 
---------------------------------------------------------------------------
in health plan networks.

    Why is that, and how can we change that?

    Answer. The consequences of inadequate networks can be devastating 
for American families. Inadequate networks are a major driver of 
enormous disparities in out-of-network utilization for mental health 
and substance use disorder (MH/SUD) treatment compared to physical 
health care. Patients are far too often forced to find out-of-network 
MH/SUD services because in-network services are not available, and are 
therefore exposed to much higher out-of-pocket costs, balance billing, 
and more aggressive insurer utilization controls. Data from Milliman 
shows out-of-network MH/SUD utilization for both inpatient and 
outpatient facilities is more than five times higher than out-of-
network physical health utilization.\8\
---------------------------------------------------------------------------
    \8\ Steve Melek, et al., Addiction and mental health vs. physical 
health: Widening disparities in network use and provider reimbursement, 
Milliman, November 19, 2019, https://assets.
milliman.com/ektron/
Addiction_and_mental_health_vs_physical_health_Widening_disparities_
in_network_use_and_provider_reimbursement.pdf.

    Strong network adequacy standards are essential to ensuring access 
to MH/SUD care. Unfortunately, for many types of health plans, network 
adequacy standards are weak, if existent all, and often qualitative in 
nature. Weak standards effectively contribute to inadequate networks 
that result in Americans not receiving the MH/SUD services they need, 
at enormous cost to individuals, families, and our society. For 
example, while Federal law requires Medicaid managed care and 
Affordable Care Act qualified health plans (QHP) to maintain adequate 
networks, Federal law simply defers to a hodgepodge of State regulatory 
standards, which often fail to establish concrete access standards that 
are plainly transparent to consumers, providers, and health plans 
alike. According to a recent report by the Legal Action Center, only 
seven States have created standards for State-regulated plans relating 
to the three most meaningful network adequacy measures: appointment 
wait times, provider/enrollee ratio, and distance standards.\9\
---------------------------------------------------------------------------
    \9\ Ellen Weber, Spotlight on Network Adequacy Standards for 
Substance Use Disorder and Mental Health Services, Legal Action Center, 
May 2020, https://www.lac.org/resource/spotlight-on-network-adequacy-
standards-for-substance-use-disorder-and-mental-health-services.

    Importantly, self-funded health plans subject to the Employee 
Retirement Income Security Act of 1974 (ERISA), which are exclusively 
regulated by the U.S. Department of Labor, are not subject to any 
legally imposed network adequacy standards at all. Given that the 
majority of Americans in ERISA plans are covered by self-funded plans, 
this significant gap in law leaves tens of millions of Americans 
---------------------------------------------------------------------------
without a right to adequate networks.

    Strong, quantitative network adequacy requirements should be 
expanded to all types of health plans. These requirements should 
include provider/enrollee ratios that only measure providers who are 
active plan providers (measured by billings within the last 6 months to 
prevent ``ghost'' networks), as well as appointment wait times (i.e., 
timely access standards) and distance standards. Timely access and 
geographic standards directly measure patient access to care and should 
be required together. After all, care that is theoretically available 
now but at a great distance or theoretically available nearby but not 
when needed is tantamount to no care at all. All health plans that 
cannot ensure suitable, timely and geographically accessible in-network 
care should be required to cover the cost of out-of-network treatment, 
without any additional cost-sharing for patients.

    Standards should be set, measured and enforced separately for MH 
and SUD providers, with requirements that plans meet timely access, 
distance, and patient/
enrollee ratios for the full range of provider types and settings that 
are necessary to treat MH/SUD. While telehealth should be allowed to 
help plans meet network adequacy requirements in areas with few 
providers (e.g., rural areas), the availability of telehealth providers 
should not be allowed to replace patients' ability to access in-person 
care.

    Placing the obligation of maintaining adequate networks on health 
plans--particularly by requiring health plans to pay for out-of-network 
care without additional cost-sharing by patients--is the only way to 
ensure that patients are not continuously victimized by insurers' 
phantom networks and inaccurate provider directories. Only when 
insurers must bear the financial risk of out-of-network coverage will 
they have sufficient incentive to maintain accurate provider 
directories and recruit sufficient providers into their networks.

    Question. Outside of the public health emergency, telehealth 
services are restricted to certain geographic and clinical settings. 
Beneficiaries must live in a rural area and have an initial face-to-
face visit with the distant-site provider. Once a relationship has been 
established, periodic in-person visits are also required. With few 
exceptions, patients must be located in a clinical setting and may not 
receive care from their homes. In addition, the distant- site provider 
cannot be located in a rural health clinic or FQHC.

    Telehealth has been used broadly during the pandemic to expand 
health-care access to individuals throughout the country. During the 
pandemic, Medicare significantly expanded the coverage of telehealth 
services. A recent Bipartisan Policy Center poll suggests that people 
receiving mental health and substance use services want a combination 
of in-person, video, and telephone services even after the pandemic has 
passed.

    What telehealth expansions should remain after the pandemic?

    Answer. Telehealth has been used broadly during the pandemic to 
expand health-care access to individuals throughout the country, as 
Medicare significantly expanded the coverage of telehealth services.

    Outside of the public health emergency, telehealth services are 
restricted to certain geographic and clinical settings. Beneficiaries 
must live in a rural area and have an initial face-to-face visit with 
the distant-site provider. Once a relationship has been established, 
periodic in-person visits are also required. With few exceptions, 
patients must be located in a clinical setting and may not receive care 
from their homes. In addition, the distant-site provider cannot be 
located in a rural health clinic or FQHC. These are all barriers that 
will emerge again if the emergency order provisions for telehealth 
expire--with consequences. For example, placing an in-person 
requirement back on the patient works against patients as it restricts 
access to telehealth for those individuals with transportation issues, 
those in provider shortage areas, or other access barriers. It also 
prevents the use of telehealth for new patients experiencing a crisis.

    The uptick in telehealth utilization for mental health signals that 
people enjoy when care comes to them--and Americans should continue to 
have that choice post-pandemic. That's why Well Being Trust supported a 
Bipartisan Policy Center report earlier this year that highlighted the 
importance of removing site of service, geographic, and established 
patient restrictions for telehealth services.\10\ In addition, it 
called for the elimination of the two-way video requirement, which will 
begin to help address the digital divide and access disparities for 
those without broadband or video technology.
---------------------------------------------------------------------------
    \10\ https://bipartisanpolicy.org/report/behavioral-health-2021/.

    Congress should make permanent audio-only telehealth services, 
enact payment parity, and allow for telehealth to be available for all 
forms of outpatient care. Congress therefore must also, as many have 
pointed out, make sure broadband is accessible and affordable as to not 
further disparities, and encourage that we ask clinicians using 
telehealth services to measure outcomes to show that they work for 
---------------------------------------------------------------------------
mental health.

                                 ______
                                 
                Questions Submitted by Hon. John Cornyn
    Question. Your testimony provides a piece to the puzzle of mental 
health policy that our Nation is currently lacking: strategy. I would 
like to follow up on this point with a few questions.

    Your testimony included thoughts on how the Senate Finance 
Committee and U.S. Senate should pursue reforms for immediate problems 
strategically so that these efforts can also allow communities to begin 
modernizing local systems of mental and behavioral health.

    Could you elaborate on those thoughts?

    How should Congress pursue legislation to support these twin goals?

    Answer. Good mental health is foundational to the health and well-
being of every American. Our society, however, treats mental health all 
too often as a system of medical services for people experiencing a 
mental health crisis. It spends very little time investing thinking 
about how we can prevent some of these episodes from occurring in the 
first place or how to help young people develop strong foundations and 
self-care tools so that individuals might avoid a mental health crisis 
in the first place.

    Immediate steps need to be taken by Congress to address unmet 
medical needs such as increasing the availability of the workforce to 
manage the expected increase in call volume from 988. S.B. 1902 holds 
great promise in helping address this issue by clearly laying out 
standards for what should be in a crisis continuum, assuring 
comprehensive coverage of these services, and finding sustainable 
funding mechanisms.

    However, any legislative vehicle required to pass these reforms 
could also be used to lay the groundwork for a modern, more wholistic 
approach to solving our Nation's mental health needs. We need to get 
ahead of our problems if we are to solve many of them, and reforms at 
the local level are needed to get us there. We can achieve this by 
creating opportunities for Americans at all stages of life to 
participate in mental health and well-being.

    First and foremost, we need to enhance the capabilities of local 
workforces and programs to increase service availability for local 
communities. Some of that can be addressed through medical professional 
workforce development but we cannot solve our need for services through 
them alone. The development of non-medical community workforces and use 
of digital therapeutics are two steps that Congress can undertake to 
broaden the response beyond the need to increase the numbers of local 
medical workforces. The benefits of the overall availability of 
services within local communities should have the added benefit of 
taking some of the burden off of health professionals thereby allowing 
them greater capacity to address the most severe cases.

    Second, I believe the Federal Government needs to reimagine its 
approach to funding mental health and addiction services in local 
communities. There are numerous autonomous Federal funding streams and 
other resources that have been developed over the years but no 
comprehensive strategy for how they all work together to best support 
Federal interests. This lack of coordination and differing funding 
authorities needlessly places undue administrative burden and cost on 
communities which can lead to inefficient spending and diminished 
results. outdated approaches to addressing mental health and addiction 
issues are contributing to ineffective community approaches that don't 
do enough. Communities in this country need to go through the same type 
of process to reimagine local operations--a process to help them reform 
and hold them accountable for improved operations and programming could 
help improve the effectiveness of the Federal effort even further.

    Third, establishing foundations for good mental health should begin 
early. Our formative years, from birth through the age of 18, are 
critical to an individual's overall mental health and well-being. 
Creating early opportunities for education and the development of self-
help tools to help a person manage mental health throughout their lives 
can go a long way to preventing some medical issues before they arise, 
and help every American build the tools they will need to succeed. 
There is an immediate need to reinforce this approach right now in our 
schools, assuring that the staff, the students, and all those connected 
have access to mental health services and supports.

    Lastly, there are concrete steps that Congress can take to improve 
local health system approaches to mental health care. Some of these 
ideas are already being advanced by members of the Senate. Others I am 
happy to provide.

    Legislatively speaking, I believe that the Senate Finance Committee 
has unique statutory authority to lead the charge on larger reform. 
While a comprehensive solution will need to involve the Public Health 
Service Act as well, the Family First Prevention Services Act presents 
a unique model that if adapted could help initiate the type of system 
and generational reforms that are needed today. In the interest of 
helping support your efforts, I am in the process of developing a draft 
legislative outline for your consideration and should be delivering 
that to you in the next couple of weeks.

    Taken together, these steps can begin to create opportunities for 
Americans at all stages of life to pursue and embrace mental health and 
well-being.

    Question. Your testimony touched on a key concept--updating Federal 
approaches to funding care for local communities.

    How can we more efficiently spend Federal funds already allocated 
today to local communities?

    Also, in what ways can modern technologies improve community and 
Federal Government return-on-investments?

    Answer. The Federal Government spends very inefficiently on mental 
health and addiction care. There are dozens of Federal programs and 
authorities created over the years by Congress with no overarching 
Federal strategy for how they are to work together. This fact 
contributes to duplicative and other wasteful spending practices.

    In addition, some of the Federal rules governing these 
authorities--such as spending requirements that prevent long-term 
planning of awarded funds--encourages wasteful and inefficient spending 
by communities fearful of missing out on Federal dollars. The lack of 
an overarching strategy for how the Federal Government funds 
communities, combined with the time and cost of running separate 
regulatory channels, needlessly adds administrative burden on both 
communities and Federal officials as well.

    As for communities, being more efficient with Federal funds need 
not only rely upon spending efficiencies alone. For instance, there are 
numerous programmatic improvements already vetted and proven to save 
money (under the Family First Prevention Services Act and other 
sources) that many local communities have failed to adopt. In addition, 
self-sustainability provisions and other mechanisms to ensure efficient 
programming and spending can be added to reform efforts to ensure they 
maintain fiscal integrity.

    Digital technologies offer other options for improving access while 
improving spending efficiencies. Digital therapeutics (like cognitive 
behavioral therapy) offer communities alternative sources of medical 
service without the commiserate cost of training and employing medical 
professionals. Best practice and evidence development aided by modern 
digital technologies such as AI can help systems identify where future 
improvements can be made.

    Digital therapeutics along with non-medical workforces also have 
the added benefit of freeing up medical professionals so that they can 
focus on the highest-acuity patients. Where local systems are able to 
recognize and use such alternative service providers, access to care 
can increase beyond what a traditional workforce can provide--at a 
lower cost.

    Question. You write in your testimony that, ``we need to bring 
mental health care to where people are.'' This includes schools, 
workplaces, and primary care. As primary care is the largest delivery 
of health care this inclusion makes sense, but as you note, there are 
some barriers.

    Can you expand on this thinking?

    Answer. Bringing mental health care to where people are is a way of 
speaking to the need to engage individuals in all phases of their lives 
in ways most conducive to securing engagement. Fragmentation of mental 
health and addiction care has made it an ongoing challenge for people 
to get easy and timely access to services. By bringing care to where 
people are, we begin to offer more timely opportunities for engagement 
and lessen the likelihood that a person does not get much-needed care. 
Delaying care does not lead to improvement--we must be more responsive 
to our communities needs by assuring care is integrated into the 
settings they present. We need to pursue novel models that integrate 
care and support those models with the appropriate payment mechanisms.

    Erasing the stigma and improving societies embrace of mental health 
can best be achieved by engaging people at all stages of life. The 
stigma of mental health and addiction in our society may be one of the 
biggest barriers our Nation faces. As a society, we are taught by 
example to avoid talking about or seeking help for mental illness and 
give little thought to building familiarity with the pursuit of well-
being. Parents typically do not realize the extent to which their own 
behavior is held up as a model for children. Society does not typically 
teach children the basics of mental health or the importance of 
building self-care tools early on as a means of preparing for the years 
to come. As we grow older, there are many different things that can 
reinforce these avoidance lessons. The net result is a community 
approach that encourages people to ignore mental and behavioral issues 
until they manifest as health-care issues. By then, our lack of 
familiarity with these areas makes treatment very difficult on people 
who may have a long course of treatment and recovery ahead of them.

    If we are to achieve more positive outcomes in areas of mental 
health and addiction, we need to break this stigma for current and 
future generations. For those alive today, that means finding ways to 
engage people who might otherwise avoid these issues altogether. Each 
generation alive today can benefit from opportunities to engage in 
mental and behavioral well-being. If we are to succeed in breaking the 
stigma for them, we need to create opportunities that relate to where 
they are in their lives. For children, basic education on the ABCs of 
mental health can help establish familiarity and strong foundations 
upon which to deal with issues of mental and behavioral health later in 
life. For families of young children or those expecting, educational 
and medical services for mental health can be better integrated in the 
physical care model in a physician offices or other site of service. 
For adults and seniors, access to wellness, treatment, and referral 
services through community workforces or community access points like 
employers can help begin to break down barriers and make it easier for 
people interested in taking the next step to more easily find answers.

    All policies should be scrutinized for how they limit a person 
getting access to mental health care--in some cases further fragmenting 
care--and how they may inadvertently reinforce stigma.

                                 ______
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    The Finance Committee meets this morning to discuss mental health 
care in America. This issue ought to bring Democrats and Republicans 
together, starting with a single, clear lodestar: every American must 
have mental health care when they need it.

    The shameful reality is, the United States does not come close to 
meeting that bar today. Multiple Federal laws say that mental health 
care is supposed to be on a level playing field with physical health 
care. In practice, however, the system still reflects the dangerous, 
old stigma against recognizing and treating mental illness, and that's 
why millions of people are falling through the cracks.

    For someone with a mental illness, it can be nearly impossible to 
find a provider who can meet your needs, or one who accepts insurance--
particularly in rural areas or in communities of color. Insurance 
claims too often get denied or cut off too quickly. Particularly for 
those experiencing homelessness, the outcome of a mental health crisis 
is too often incarceration instead of treatment.

    Prior to the pandemic, one in five Americans was living with a 
mental illness. All the evidence suggests the pandemic is adding to the 
crisis. The proportion of Americans reporting symptoms of anxiety or 
depression has nearly quadrupled. On Friday, the Centers for Disease 
Control and Prevention released a new report finding that over the last 
year, suicide attempts among teenage girls were up by more than 50 
percent. Meanwhile, a study the Government Accountability Office 
conducted at my request found that many provider offices closed or cut 
staff during the pandemic, resulting in too many patients turned away.

    There's a lot for this committee to work on. There are a few key 
challenges. First, the country needs a larger mental health workforce. 
There simply are not enough providers, whether it's psychiatrists or 
therapists or staff in inpatient facilities. For example, due to a 
major staffing shortage, the psychiatric hospital in Salem is currently 
being staffed in part by members of the Oregon National Guard. That's 
in a State capital, where there are people and resources focused on 
this issue. Other areas have it worse. More than one in three Americans 
lives in an area with a severe shortage of mental health professionals.

    Second, insurance companies must not cut corners when it comes to 
mental health coverage. This issue comes up all the time during town 
hall meetings I hold in Oregon--people describing having their claims 
denied. In other cases, insurance only covers a portion of the 
treatment people need. Furthermore, it doesn't make any sense to leave 
somebody experiencing a true mental health crisis waiting for a green 
light from an insurance company before they can get treatment.

    Third, this committee must address the racial inequities in mental 
health care. Black and Latino Americans are roughly half as likely as 
white Americans to receive treatment for a mental illness. Suicide 
rates are much higher among black children. There aren't enough black, 
Latino, and Native American mental health providers. This is a basic 
matter of health-care equity, and there's a long way to go.

    Finally, the Finance Committee ought to build on areas of recent 
progress. For example, early in the pandemic this committee led the 
fight to get Medicare to cover mental health services via telehealth. 
In December, the Congress made that permanent. This is going to be a 
game changer, particularly for seniors who live in rural areas. It 
would work outside of traditional Medicare too.

    Senator Stabenow has long been a champion of mental health care. 
Today the committee will hear about the success of Certified Community 
Behavioral Health Clinics, a program she fought for and created. These 
clinics are up and running in 40 States, including Oregon. It's an 
approach that works, and it's meeting big needs. I believe the Congress 
ought to look at ways to build on its success.

    In March, the Congress also passed a big down payment for a 
pioneering new approach on mental health services and law enforcement 
called the CAHOOTS program. It originally comes from Eugene, OR, and it 
has expanded in bigger cities and rural areas around the State. Under 
this approach, when there's a 911 call dealing with someone 
experiencing a mental health crisis, CAHOOTS sends trained health 
professionals as first responders instead of just police. Health-care 
providers like it; law enforcement likes it. The American Rescue Plan 
included a billion-dollar down payment to help States build their own 
programs like CAHOOTS. Now the Congress needs to consider what comes 
next to build these programs successfully and make sure people are 
getting the help they need, even after the immediate crises end.

    It's clear there's a lot of work to be done. Members on both sides 
have important ideas addressing these issues and more. I want to 
continue working with members in the weeks ahead, because I believe 
there's a big need and a big opportunity for legislation on mental 
health.

                             Communications

                              ----------                              


                 American Academy of Family Physicians

                 1133 Connecticut Ave,. NW, Suite 1100

                       Washington, DC 20036-4305

                             (800) 794-7481

                             (202) 232-9033

June 25, 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

Dear Chairman Wyden and Ranking Member Crapo:

On behalf of the American Academy of Family Physicians (AAFP) and the 
133,500 family physicians and medical students we represent, I applaud 
the committee for its consideration of the mental health challenges in 
the U.S. I write in response to the hearing: ``Mental Health Care in 
America: Addressing Root Causes and Identifying Policy Solutions'' to 
share the family physician perspective and the AAFP's policy 
recommendations for ensuring all patients who need mental health care 
are able to access it.

Mental illness is highly prevalent in the United States and is 
associated with an increased risk of morbidity and mortality. There are 
significant gaps in the provision of mental health care services in the 
U.S., especially related to vulnerable populations. While psychiatric 
and other mental health professionals can play an important role in the 
provision of high-quality mental health care services, primary care 
physicians are the main providers for the majority of patients. Most 
people with poor mental health will be diagnosed and treated in the 
primary care setting. Mental illness also complicates other medical 
conditions, making them more challenging and more expensive to manage. 
Together, this makes mental health an important issue for primary care 
physicians.

Screening for mental illness is not new to family medicine but has more 
recently been linked to quality metrics and payment. Screening for 
mental illness can be an important strategy for decreasing morbidity, 
as well as preventing adverse maternal and child health outcomes 
associated with perinatal depressive symptoms, postpartum depression, 
or maternal suicide.\1\, \2\, \3\ While 
important, screening in a busy practice can seem overwhelming, but 
practices can leverage technology, empower staff, and utilize wellness 
visits to complete this screening.\4\
---------------------------------------------------------------------------
    \1\ LeFevre ML, U.S. Preventive Services Task Force. Screening for 
Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care: 
U.S. Preventive Services Task Force Recommendation Statement. Ann 
Intern Med. 2014;160(10):719.
    \2\ Kendig S, Keats JP, Hoffman MC, et al. Consensus bundle on 
maternal mental health: Perinatal depression and anxiety. Obstet 
Gynecol. 2017;129(3):422-430.
    \3\ Yonkers KA, Wisner KL, Stewart DE, et al. The management of 
depression during pregnancy: A report from the American Psychiatric 
Association and the American College of Obstetricians and 
Gynecologists. Obstet Gynecol. 2009;114(3):703-713.
    \4\ Savoy M, O'Gurek DT. Screening your adult patients for 
depression. Fam Pract Manag. 2016;23(2):16-20.

Integrating mental health into primary care settings, as well as the 
blending of primary and preventive medicine into traditional mental 
health settings, represents a more holistic approach to treatment than 
the traditional consultative and referral models. Integrating primary 
care and mental health services increases access for patients by making 
mental health services available in their regular primary care clinics. 
When integrated into primary care, mental health clinicians can impact 
the care of more patients than in the specialty mental health referral 
sector.\5\ In the primary care setting, mental health clinicians take 
on a more consultative and team-based role and focus on helping primary 
care physicians treat mental health disorders. In this context, mental 
health clinicians typically reach more patients, and have shorter and 
more problem-focused encounters than in the context of traditional 
specialty mental health.
---------------------------------------------------------------------------
    \5\ Collins C, Hewson DL, Munger R, Wade T. Evolving models of 
behavioral health integration in primary care. Milbank Memorial Fund. 
2010. Accessed January 22, 2018.

The Collaborative Care Model, supported by various organizations 
including the AAFP and the American Psychiatric Association, is a model 
for the successful integration of primary care and behavioral and 
mental health.\6\ At its core, the idea of collaborative care is 
anchored in team-based care, often in the context of a medical home, 
and steered by primary care physicians. It involves behavioral health 
specialists and consulting mental health professionals delivering 
evidence-based care that is patient-centered.
---------------------------------------------------------------------------
    \6\ American Psychiatric Association Academy of Psychosomatic 
Medicine. Dissemination of integrated care within adult primary care 
settings. Accessed January 22, 2018.

The collaborative care model at its core is: (1) team driven, (2) 
population focused, (3) measurement guided, and (4) evidence based. 
These four elements, when combined, can allow for a fifth guiding 
principal to emerge--accountability and quality improvement. 
Collaborative care is team-driven, led by a primary care clinician with 
support from a ``care manager'' and consultation from a psychiatrist 
who provides treatment recommendations for patients who are not 
achieving clinical goals. Other mental health professionals can 
contribute to the Collaborative Care Model. Collaborative care is 
population focused, using a registry to monitor treatment engagement 
and response to care. Collaborative care is measurement guided with a 
consistent dedication to patient-reported outcomes and it utilizes 
evidence-based approaches to achieve those outcomes. Care remains 
patient centered with proactive outreach to engage, activate, promote 
self-management and treatment adherence, and coordinate services.\7\
---------------------------------------------------------------------------
    \7\ Ibid.

The AAFP urges Congress to support the adoption of the Collaborative 
Care Model by funding grant programs for primary care practices and 
encouraging Center for Medicare and Medicaid Innovation models for 
---------------------------------------------------------------------------
behavioral health integration.

Telemedicine for mental health is a growing interest in primary care 
and telehealth initiatives for mental health care are expanding 
rapidly. While the research is limited on this topic, there are a 
growing number of studies assessing the benefits, comparative 
effectiveness with face-to-face visits, and cost comparisons. From 
January to March 2020, at the beginning of the COVID-19 pandemic, 
telehealth visits increased by 135% compared to that time period in 
2019, and 93% of those visits were for non-COVID concerns.\8\ In 
addition, mental health concerns increased rapidly during the pandemic. 
Four in ten adults reported symptoms of anxiety, an increase from one 
in ten the year prior, and more than half of all young adults ages 18-
24 reported symptoms of anxiety and depression and were more likely 
than other age groups to report substance use and suicidal thoughts.\9\ 
Other trends should a disproportionate effect on mental health for 
communities of color, mothers, and essential workers.\10\ The AAFP is 
supportive of efforts to expand access to mental health services via 
telehealth and encourage Congress to address the legislative barriers 
outlined in our previous testimony and Joint Principles for Telehealth 
Policy. In particular, the AAFP strongly believes that the permanent 
expansion of telehealth services should be done in a way that advances 
care continuity and the 
patient-physician relationship. Telehealth for mental health can help 
address the shortage of over 6,000 mental health professionals in the 
U.S., particularly for rural and underserved areas that face a 
disproportionate impact of the shortage.\11\
---------------------------------------------------------------------------
    \8\ Koonin LM. Trends in the Use of Telehealth During the Emergence 
of the COVID-19 Pandemic--United States, January-March 2020. MMWR Morb 
Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6943a3.
    \9\ Panchal N, Kamal R, 2021. The Implications of COVID-19 for 
Mental Health and Substance Use. KFF. Published February 10, 2021. 
Accessed June 17, 2021. https://www.kff.org/coronavirus-covid-19/issue-
brief/the-implications-of-covid-19-for-mental-health-and-substance-
use/.
    \10\ Ibid.
    \11\ Mental Health Care Health Professional Shortage Areas (HPSAs). 
KFF. Published November 5, 2020. Accessed June 17, 2021. https://
www.kff.org/other/state-indicator/mental-health-care-health-
professional-shortage-areas-hpsas/.

Trauma-informed care, an approach to engaging individuals with a 
history of trauma that recognizes their traumatic experiences, and how 
it affects their lives, is a promising practice that may facilitate 
healing and help prevent the consequences of exposure to trauma.\12\, 
\13\ An estimated 60% of adults in the U.S. have experienced a 
traumatic event at least once in their lives.\14\ Exposure to trauma, 
such as intimate partner violence, sexual abuse, rape, neglect, 
terrorism, war, natural disasters, and street violence predisposes 
those affected to poor physical and mental health outcomes.\15\ The 
principles of trauma-informed care include: realizing that there is a 
high prevalence of trauma and it has serious effects; recognizing the 
signs and symptoms of trauma; responding to the high prevalence by 
integrating knowledge about trauma into practices, procedures, and 
policies; and avoiding retraumatizing individuals by using best-
practices in screening and history taking.\16\
---------------------------------------------------------------------------
    \12\ Oral R, Ramirez M, Coohey C, et al. Adverse childhood 
experiences and trauma informed care: The future of health care. 
Pediatr Res. 2016;79(1-2):227-233.
    \13\ Decker MR, Flessa S, Pillai R V., et al. Implementing trauma-
informed partner violence assessment in family planning clinics. J 
Women's Heal. April 2017:jwh.2016.6093
    \14\ National Council for Behavioral Health. Trauma-informed 
approaches learning communities. Accessed January 22, 2018.
    \15\ Agency for Healthcare Research and Quality. Trauma-informed 
care (https://www.
ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/trauma.html). 
Accessed January 22, 2018.
    \16\ Ibid.

Disparities are pervasive in all aspects of health, including mental 
health conditions. While mental health conditions can affect everyone, 
regardless of culture, race, ethnicity, gender or sexual orientation, 
---------------------------------------------------------------------------
some populations experience those conditions at a higher rate.

      American Indian and Alaska Natives (28.3%) experience higher 
rates of mental illness than white (19.3%), black (18.6%), Hispanic 
(16.3%), or Asian (13.9%) adults.\17\
---------------------------------------------------------------------------
    \17\ National Alliance on Mental Illness. Mental health by the 
numbers (https://www.nami.org/mhstats). Accessed January 22, 2018.
---------------------------------------------------------------------------
      Individuals from the lesbian, gay, bisexual, transgender, and 
questioning (LGBTQ) community are two or more times as likely as 
heterosexual individuals to have a mental health condition, and LGBTQ 
youth are two to three times more likely to attempt suicide than 
heterosexual youth.\18\
---------------------------------------------------------------------------
    \18\ Ibid.
---------------------------------------------------------------------------
      Nearly one-fifth (18.5%) of the veterans who returned from 
serving in either Iraq or Afghanistan suffer from either major 
depression or post-traumatic stress disorder.\19\
---------------------------------------------------------------------------
    \19\ Tanielian T, Jaycox LH, Schell T, et al. Invisible wounds. 
Mental health and cognitive care needs of America's returning veterans. 
RAND Corporation. 2008. Accessed January 22, 2018.
---------------------------------------------------------------------------
      The prevalence of mental illness is similar for individuals 
living in either rural or metropolitan areas, but the mental health 
care needs are more often unmet in rural communities due to inadequate 
services.\20\
---------------------------------------------------------------------------
    \20\ Substance Abuse and Mental Health Services Administration. 
Results from the 2015 National Survey on Drug Use and Health: Detailed 
Tables (https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-
2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf). Prevalence estimates, 
standard errors, P values, and sample sizes. 2016. Accessed January 22, 
2018.

Disparities in mental health illness and mental health care are related 
to coverage and availability of care, quality of care, rates of health 
insurance, stigma, cultural insensitivity, racism, bias, homophobia, 
discrimination in treatment settings, and language barriers.\21\
---------------------------------------------------------------------------
    \21\ National Alliance on Mental Illness. Mental health by the 
numbers (https://www.nami.org/mhstats). Accessed January 22, 2018.

College students face unique mental health concerns, such as non-
suicidal self-
injury and serious suicidal ideation.\22\ There are approximately 20 
million students enrolled in U.S. colleges and universities, and the 
rates of serious mental health concerns is rising in this 
population.\23\,\24\ According to the Center for Collegiate 
Mental Health's 2017 Annual Report, 52.7% of students attended 
counseling for mental health concerns; 34.2% took a medication for 
mental health concerns; 9.8% were hospitalized for a mental health 
concern; 27% purposely injured themselves without suicidal intent; and 
34.2% seriously considered attempting suicide, with 10% making a 
suicide attempt.\25\ In fact, some data suggest that suicide may be the 
most common cause of death in college students.\26\
---------------------------------------------------------------------------
    \22\ Center for Collegiate Mental Health. 2017 Annual Report 
(https://sites.psu.edu/ccmh/files/2018/01/2017_CCMH_Report-
1r3iri4.pdf). Accessed January 22, 2018.
    \23\ Ibid.
    \24\ National Center for Education Statistics. Fast facts. Back to 
school statistics (https://nces.ed.gov/fastfacts/display.asp?id=372). 
Accessed January 22, 2018.
    \25\ Center for Collegiate Mental Health. 2017 Annual Report 
(https://sites.psu.edu/ccmh/files/2018/01/2017_CCMH_Report-
1r3iri4.pdf). Accessed January 22, 2018.
    \26\ Turner JC, Keller A. Leading causes of mortality among 
American college students at 4-year institutions. Conference Paper: 
American Public Health Association 139th Annual Meeting and Exposition. 
Washington, DC 2011. Accessed January 22, 2018.

Attention-deficit/hyperactivity disorder (ADHD) is another prevalent 
disorder in college students that family physicians may encounter. 
ADHD's prevalence is estimated to be between 2-8% among college 
students, and this condition is frequently associated with other 
psychiatric comorbidities and increases individuals' risk of 
psychosocial and substance-use problems.\27\
---------------------------------------------------------------------------
    \27\ Unwin BK, Goodie J, Reamy BV, Quinlan J. Care of the college 
student. Am Fam Physician. 2013;88(9):596-604.

Tobacco use is prominent among individuals living with mental illness. 
Thirty-six percent of adults with any mental illness use tobacco 
products, compared with 25.3% for adults without a mental illness.\28\ 
In addition, people who have any mental illness are only half as likely 
to quit smoking compared to individuals without a mental illness.\29\ 
One study found that nearly half of all deaths were tobacco-
related for persons who received substance abuse services, or who 
received both substance abuse and mental health services.\30\ 
Therefore, addressing tobacco addiction among individuals living with 
mental illness is an important strategy for decreasing preventable 
mortality and morbidity among individuals living with a mental illness.
---------------------------------------------------------------------------
    \28\ Centers for Disease Control and Prevention. Tobacco use among 
adults with mental illness and substance use disorders (https://
www.cdc.gov/tobacco/disparities/mental-illness-substance-use/
index.htm). Accessed January 22, 2018.
    \29\ Centers for Disease Control and Prevention. Vital signs: 
Current cigarette smoking among adults aged  18 years with mental 
illness--United States, 2009-2011. MMWR. 2013;62(05):81-87.
    \30\ Bandiera FC, Anteneh B, Le T, Delucchi K, Guydish J. Tobacco-
related mortality among persons with mental health and substance abuse 
problems. PLoS One. 2015;10(3):e0120581.

The AAFP has position papers that detail substance use disorders and 
---------------------------------------------------------------------------
addiction and tobacco prevention and cessation.

Payment for primary care physicians has historically been inadequate 
for office visits for mental health diagnoses. This limitation in 
reimbursement interfered with the family physician's ability to offer 
comprehensive care and management of mental health conditions, as well 
as the ability to integrate, from a business perspective, with 
behavioral health services. However, new coverage policies adopted by 
the Centers for Medicare and Medicaid Services (CMS) are more promising 
and may incentivize primary care physicians to provide treatment for 
mental and behavioral health conditions.\31\ These policies, effective 
January 1, 2017, emphasize collaborative care, where primary care 
physicians are expected to work in partnership with a behavioral health 
care manager, and consult with mental health specialists. While 
targeting populations with Medicare, these policies may also encourage 
private insurers to offer similar options and may incentivize more 
family physicians to offer behavioral and mental health care to other 
populations.
---------------------------------------------------------------------------
    \31\ Press MJ, Howe R, Schoenbaum M, et al. Medicare payment for 
behavioral health integration. N Engl J Med. 2017;376(5):405-407.

Health care for all people with mental illness should be ``affordable, 
nondiscriminatory, and includes coverage for the most effective and 
appropriate treatment.''\32\ Coverage for mental illness should be 
equal in scope to coverage for other illnesses and all clinically-
effective treatments appropriate to the needs of individuals with 
mental illness should be covered.
---------------------------------------------------------------------------
    \32\ National Alliance on Mental Illness. Public policy platform of 
the National Alliance on Mental Illness (https://www.nami.org/
getattachment/learn.more/mental-health-public-policy/public-policy-
platform-december.2016(1).pdf). Twelfth Edition. 2016. Accessed January 
22, 2018.

Thank you for the opportunity to provide testimony on this important 
issue. For further questions, please contact Erica Cischke, Senior 
---------------------------------------------------------------------------
Manager, Legislative and Regulatory Affairs at [email protected].

Sincerely,

Gary L. LeRoy, M.D., FAAFP
Board Chair

End notes

https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/telehealth/
TS-SenateFinanceCmte-DavisTelehealth-051921.pdf.

https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/telehealth/
LT-Congress-TelehealthHELP-070120.pdf.

https://www.aafp.org/about/policies/all/substance-use-disorders.html.

https://www.aafp.org/about/policies/all/tobacco-
preventingtreating.html#::text=
The%20AAFP%20opposes%20all%20forms,of%20tobacco%20products%20to%20chil
dren.

                                 ______
                                 
                     American Hospital Association

                          800 10th Street, NW

                       Two CityCenter, Suite 400

                       Washington, DC 20001-4956

                             (202) 638-1100

On behalf of our nearly 5,000 member hospitals, health systems and 
other health care organizations, our clinician partners--including more 
than 270,000 affiliated physicians, 2 million nurses and other 
caregivers--and the 43,000 health care leaders who belong to our 
professional membership groups, the American Hospital Association (AHA) 
appreciates the opportunity to submit this statement for the record.

America's hospitals and health systems play a central role in 
delivering behavioral health care and are uniquely positioned to help 
patients navigate the behavioral health resources that are available in 
communities. Psychiatric and community hospitals are a vital source of 
care for behavioral health patients, providing treatment for a full 
range of psychiatric and substance use disorders (SUD) by stabilizing 
patients, establishing and providing quality treatment regimens, and 
transitioning patients to outpatient and community-based services. The 
AHA strongly supports efforts to increase access to, and improve the 
quality of, behavioral health care.

Even before the COVID-19 pandemic, one in five American adults was 
estimated to have a behavioral health condition, and nearly 60% of 
adults with behavioral health disorders reported not receiving services 
for their conditions. But the nation's level of unmet behavioral health 
needs has been exacerbated by the COVID-19 pandemic. As of June 14, the 
Centers for Disease Control and Prevention (CDC) reports that more than 
33 million Americans have been infected with COVID-19, and, of those, 
more than 597,000 have died.

The effects of high unemployment, anxiety over the risk of contracting 
COVID-19, grief over the death of loved ones, isolation from neighbors 
and friends, and an increase in domestic violence and child abuse are 
all increasing the incidence and prevalence of mental health conditions 
and substance use disorder. For example, one in three adults reported 
symptoms of an anxiety disorder in 2020, compared with one in 12 in 
2019.

In addition, the inability to access in-person group therapy and 
medication-assisted treatment (MAT), in part because of social 
distancing requirements, has led many with substance use disorders to 
relapse. According to the CDC, overdose deaths spiked after the start 
of the pandemic, driven by synthetic opioids such as fentanyl.

Further, the behavioral health effects of COVID-19 are manifesting at a 
time when the nation's behavioral health care system is ill-prepared to 
meet the nation's needs. According to the Substance Abuse and Mental 
Health Services Administration (SAMHSA), only 43% of U.S. adults with 
mental illness received treatment in 2018, and a JAMA study found that 
50.6% of U.S. youth aged 6-17 with a mental health disorder received 
treatment in 2016.

Unfortunately, due to financial pressures, hospitals' capacity to care 
for behavioral health patients has been significantly diminished, 
exacerbating a trend that began decades ago. The number of state-funded 
psychiatric beds per capita decreased by 97% between 1955 and 2016, 
with the per capita psychiatric inpatient bed count approximately 70% 
lower than the average among developed nations, as noted by a March 
2019 National Association for Behavioral Healthcare report. Lack of 
access to psychiatric inpatient services and resources will exacerbate 
existing sever shortages in psychiatric beds nationally. This trend, 
combined with new closures, will result in more preventable deaths from 
psychiatric and substance use disorders and more cases of emergency 
room boarding. As the number of psychiatric beds has declined, the 
demand for inpatient services has continued to increase, and 
correspondingly, wait times for those beds has increased dramatically 
as well.

To address the urgent need for greater access to behavioral health 
services, the AHA offers the following recommendations to the Committee 
on Finance.

ADDRESS PHYSICIAN SHORTAGES

At the core of our health care system is a well-trained, diverse 
workforce. But critical physician shortages deprive many communities of 
access to needed care. The Association of American Medical Colleges 
estimates that the United States faces a shortage of between 54,100 and 
139,000 physicians by 2033.

In the 1997 Balanced Budget Act, Congress froze the number of Medicare-
funded residency slots at 1996 levels, based on projections that the 
nation would soon have a surplus of physicians. Over the past 24 years, 
millions more Americans have attained health insurance, the nation's 
population has grown and aged, and more physicians are retiring--
leading to a crisis in physician access. The shortage is even more 
acute for substance use disorder providers. A recent report from the 
National Academies of Sciences, Engineering and Medicine highlighted 
the dearth of clinicians with specialized training in MAT, and SAMHSA 
has estimated that only 10% of the 22 million Americans with an SUD 
receive treatment.

Last December, Congress lifted the cap on Medicare-funded residency 
positions, allowing growth for the first time since 1997. That 
provision, in the Consolidated Appropriations Act, 2021, created 1,000 
new slots that will begin to be distributed in fiscal year (FY) 2023. 
Increasing the number of Medicare-funded slots would help ease current 
shortages, and bolster the foundation of our health care system.

The AHA supports the Opioid Workforce Act of 2021, introduced by 
Senators Margaret Wood Hassan and Susan Collins, which would help abate 
the national shortage of opioid treatment providers by increasing the 
number of resident physician slots in hospitals with programs focused 
on SUD treatment. Existing shortages of SUD treatment providers have 
led to lengthy waiting periods for treatment and increased mortality 
from opioid misuse and addiction. The Opioid Workforce Act would help 
address existing shortages by adding 1,000 Medicare-funded training 
positions in approved residency programs in addiction medicine, 
addiction psychiatry or pain medicine. These new slots would constitute 
a major step toward increasing access to SUD treatment for communities 
in need. We look forward to working with you to ensure passage of this 
important legislation.

REPEAL THE IMD EXCLUSION

Since 1965, the Institutions for Mental Diseases (IMD) exclusion has 
prohibited federal payments to states for services for adult Medicaid 
beneficiaries between the ages of 21 and 64 who are treated in 
facilities that have more than 16 beds, and that provide inpatient or 
residential behavioral health treatment. The discriminatory IMD policy 
was established at a time when behavioral health conditions were not 
considered medical conditions on the same level as physical health 
conditions, state-operated psychiatric facilities were a primary 
setting for behavioral health care, and patients were admitted for 
longer-term stays.

We know that successful treatment requires access to the full continuum 
of care--namely, inpatient care, partial hospitalization, residential 
treatment and outpatient services. Different types of patients require 
different clinical services from across the care continuum. Investing 
only in outpatient care and failing to provide states with relief from 
the IMD exclusion would continue to deny many of these patients access 
to the most clinically appropriate care. Additionally, advances in 
behavioral health care have allowed for shorter inpatient stays and 
more outpatient treatment options, while funding challenges have led to 
a decline in the number of inpatient psychiatric beds. Repealing the 
IMD exclusion would help reverse this decline.

 ELIMINATE MEDICARE'S 190-DAY LIMIT ON INPATIENT PSYCHIATRIC TREATMENT

Medicare covers only 190 days of inpatient care in a psychiatric 
hospital in a beneficiary's lifetime. This discriminatory limit erects 
a barrier to accessing care for individuals who have gone beyond their 
190-day limit, particularly those with a chronic mental condition.

As the nation looks to recover from COVID-19 pandemic, an even greater 
mental health crisis awaits. Medicare beneficiaries who did not seek 
inpatient care during the pandemic because they hesitated to leave 
their homes or because they have conditions that were exacerbated by 
the pandemic will need inpatient services. Further, as the nation's 
elderly population continues to grow and life expectancy continues to 
rise, the 190-day limit will severely affect access to needed care. To 
effectively address the needs of America's seniors, Congress should 
repeal Medicare's 190-day limit on inpatient psychiatric care.

MAKE TELEHEALTH FLEXIBILITIES PERMANENT

Telehealth services, including for mental health and SUD treatment, 
have improved access to care. The increased use of telehealth since the 
start of the public health emergency (PHE) is producing high-quality 
outcomes for patients, enhancing patient experience, and protecting 
access for individuals susceptible to infection. With the appropriate 
statutory and regulatory framework, this beneficial shift in care 
delivery could continue to improve patient experiences and outcomes and 
deliver health system efficiencies beyond the pandemic. The AHA urges 
the Committee to consider making these flexibilities permanent.

Additionally, telehealth policies should work together to maintain 
access for patients by connecting them to vital health care services 
and their personal providers through videoconferencing, remote 
monitoring, electronic consults and wireless communications. We support 
the following: elimination of the 1834(m) geographic and originating 
site restriction; coverage and reimbursement for audio-only services; 
an expanded list of providers and facilities eligible to deliver and 
bill for telehealth services, including rural health clinics and 
federally qualified health centers; a national approach to licensure so 
that providers can safely provide virtual care across state lines; and, 
adequate reimbursement for the substantial costs of establishing and 
maintaining a telehealth infrastructure, among others.

PROMOTE INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH

The use of electronic health records (EHR) can promote the integration 
of physical and behavioral health care. Yet, significant barriers 
remain for the adoption of EHRs by behavioral health providers. The 
2009 HITECH Act incentivized EHR adoption with payments for providers 
who participate in the Medicare and Medicaid Promoting Interoperability 
Programs; however, psychiatric hospitals are ineligible for these 
programs. In addition to this financial pressure, the nature of 
behavioral health records--that is, that they are often narrative or 
follow a different structure than physical health records--as well as 
conflicting regulatory requirements regarding information sharing has 
led to far lower adoption of EHRs in psychiatric hospitals compared to 
general acute care hospitals. We urge the Committee to create 
opportunities for behavioral health providers to acquire interoperable 
electronic health records that enable improved information sharing 
among providers and with public health and other government agencies.

CONCLUSION

The AHA is encouraged that the Committee is examining ways to improve 
Americans' access to mental health and substance use disorder 
treatment. We stand ready to work with the Committee as you consider 
legislation to expand vital behavioral health services to patients and 
families.

                                 ______
                                 
                   American Psychological Association

                          750 First Street, NE

                       Washington, DC 20002-4242

                              202-336-5800

                            202-336-6123 TDD

                          https://www.apa.org/

  Statement Submitted by Katherine B. McGuire, Chief Advocacy Officer

The American Psychological Association (APA) thanks the Committee for 
the opportunity to offer solutions to strengthen the nation's mental 
health system, which even prior to the COVID-19 pandemic could not meet 
the needs of people in need of care. 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 in psychological science.

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 single solution to addressing this 
crisis, and the Committee and its members will need to improve policies 
in multiple areas, including the following:

      Preserve Recent Expansions in Medicare Coverage of Mental and 
Behavioral Health Services Furnished by Telehealth. Congress's and 
CMS's 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 
this Committee will help avoid this ``access cliff'' and permanently 
authorize Medicare to cover audio-only telehealth for mental, 
behavioral, and substance use disorder services. Specifically, we urge 
the Committee to approve legislation such as the bipartisan bill H.R. 
3447, introduced by Reps. Jason Smith and Josh Gottheimer. This bill 
would permanently establish Medicare coverage of mental, behavioral, 
and substance use disorder services furnished via audio-only 
telehealth, provided that the patient has at least one in-person or 
audio-video telehealth visit within the past 3 years.

     Additionally, while APA supported Congress's decision to eliminate 
certain site-of-service requirements on Medicare tele-mental health 
coverage in the year-end budget and COVID package (Pub. L. 116-260), we 
are concerned that the new six-month in-person service requirement will 
inequitably limit access to services. Accordingly, APA asks the 
Committee to take up and pass the bipartisan Telemental Health Care 
Access Act (S. 2061) sponsored by Senators Cassidy, Smith, Thune, and 
Cardin, which removes this arbitrary and unnecessary barrier to 
coverage of tele-mental health services. AP A also hopes that members 
of this Committee will consider introducing a Senate counterpart to 
Representative Matsui's Telemental Health Care Access Act (H.R. 4058), 
which in addition to removing this in-person service requirement, will 
also eliminate the aforementioned site-of-service requirements for 
behavioral health services.

     Finally, we hope this Committee will support a bipartisan bill co-
sponsored by Senator 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. We hope 
members of this Committee will also consider long-term measures to 
address the inequities in reimbursement between care furnished in 
person and care furnished via telehealth.

      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 Committee to advance similarly innovative approaches 
to this crisis, such as those outlined in: (1) the bipartisan Medicaid 
Reentry Act (S. 285), co-sponsored by Senator 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) S. 854, 
legislation introduced by Sen. Grassley to designate methamphetamine as 
an emerging drug threat; and (4) S. 1457, the STOP Fentanyl Act of 
2021--introduced by Senators Warren, Whitehouse, Baldwin, and Booker--
that, among other provisions, would 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).

      Allow Clinical Psychologists to Practice Independently in All 
Medicare Treatment Settings. Current law requires physician supervision 
of psychologists' treatment of Medicare patients in certain settings, 
such as partial hospitalization programs, surgical centers, and 
community mental health centers. Medicare is the last health insurer 
that requires physician supervision of psychologists. Unlike Medicare, 
all other health insurers and state licensure laws allow psychologists 
to practice independently in all treatment settings.

     Most older Americans with mental disorders do not receive mental 
health treatment from a mental health specialist, and older Americans 
are much more likely to be prescribed psychoactive drugs--even without 
an established diagnosis for a mental disorder-than to receive 
psychotherapy or other behavioral health services, despite the ongoing 
opioid epidemic and concerns about overmedication in nursing homes and 
other facilities. Allowing clinical psychologists to practice 
independently in all treatment settings, as they can do through other 
health insurance programs, would contribute to reversing this trend. 
Medicare patients would benefit from improved access to psychologists' 
services, including psychological and neuropsychological assessments, 
psychotherapy, and health and behavior assessments and interventions.

      Incentivize Adoption of a Broad Array of Integrated Care Models. 
APA appreciates the Committee's discussions around the integration of 
primary care and mental health services. Integrated care is an 
innovative way of improving patient outcomes and satisfaction with 
care, as well as reducing overall treatment costs, but it requires 
significant changes to primary care practices' physical offices, 
information technology systems, management procedures, clinical 
staffing and policies, health records and data tracking practices, and 
provider education and training. With these challenges and given 
differences in patient populations and the goals of the integration 
effort, there is no ``one size fits all'' approach to effective 
integrated primary care. As stated in a recent review, ``[t]here are 
several models and differing levels of integration described in the 
literature, suggesting that approaches to integration should be 
responsive to the needs and context of the community'' (Vogel et al., 
2017, p. 81).

     We urge the Committee to provide support for the implementation of 
integrated care programs by primary care providers that gives them the 
flexibility to blend services, models, and interventions in a way that 
best meets the needs of their patient populations and reflects the 
healthcare workforce in their community. Support should be made 
available for all evidence-based integrated care programs meeting the 
following four criteria:
        A multi-professional approach to patient care;
        A structured management plan;
        Scheduled patient follow-ups; and
        Enhanced inter-professional communication.

      Support Programs that Strengthen Access to School-Based Mental 
Health Services. 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 
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. 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).

     To aid the nation's school-age children in recovering from the 
mental, social, and educational impact of the COVID-19, we ask that 
members of the Committee support the following pieces of legislation:
        The Increasing Access to Mental Health in Schools Act (S. 
1811), introduced by Sen. Tester (D-MT), which would expand mental 
health services in low-income schools by supporting partnerships 
between institutions of higher education and local education agencies 
to increase the number of school-based mental health professionals;
        The Mental Health Services for Students Act (S. 1841), 
introduced by Sen. Tina Smith (D-MN), which would build partnerships 
between local educational agencies, tribal schools, and community-based 
organizations to provide school-based mental health care for students 
and provide resources for the entire school community on warning signs 
of mental health crises; and
        A Senate counterpart to the Comprehensive Mental Health in 
Schools Pilot Program Act (H.R. 3549), which would create a new 4-year 
grant program to help schools that predominantly serve low-income 
students with building their capacity to address students' mental and 
behavioral well-being.

      Address Inequities in Access to Mental and Behavioral Health 
Services. 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, AP A hopes this Committee will take up and pass H.R. 1475, 
the Pursuing Equity in Mental Health Act adopted by the House last 
month. 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.

APA stands ready to assist the Committee in finding impactful 
bipartisan solutions to expand the nation's mental and behavioral 
health system to serve all in need of these services. Please contact 
Andrew Strickland, J.D. at [email protected] if our association can 
serve as a resource.

REFERENCES

Ahmad F.B., Rossen L.M., 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.

Vogel, M.E., Kanzler, K.E., Aikens, J.E., and Goodie, J.L. (2017). 
Integration of behavioral health and primary care: Current knowledge 
and future directions. Journal of Behavioral Medicine, 40(1), 69-84.

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.

                                 ______
                                 
             Association for Behavioral Health and Wellness

                      1325 G Street, NW, Suite 500

                          Washington, DC 20005

                           https://abhw.org/

                             June 15, 2021

Dear Chairman Wyden and Ranking Member Crapo:

The Association for Behavioral Health and Wellness (ABHW) appreciates 
the opportunity to provide comments for the record on the hearing: 
``Mental Health Care in America: Addressing Root Causes and Identifying 
Policy Solutions'' that took place Tuesday, June 15, 2021. We 
appreciate the Committee's leadership on and dedication to addressing 
behavioral health issues.

ABHW serves as the national voice for payers that manage behavioral 
health insurance benefits. ABHW member companies provide coverage to 
approximately 200 million people in both the public and private sectors 
to treat mental health (MH) and substance use disorders (SUDs), and 
other behaviors that impact health and wellness.

Overarchingly, our organization's goals aim to increase access, drive 
integration, support prevention, raise awareness, reduce stigma, and 
advance evidence-based treatment and quality outcomes. Furthermore, 
through our policy work, we strive to promote equal access to quality 
treatment and address the stark inequities created by systemic racism. 
We are deeply concerned about health disparities in this country in the 
areas of MH and SUD services and are committed to addressing systemic 
racism in the healthcare system. We applaud the Committee's commitment 
to health equity and look forward to working with you to improve 
behavioral health services in this country.

Behavioral health services have become increasingly important as a 
result of social isolation, job loss, illness and death, and domestic 
violence related to COVID-19 and we suspect the utilization of such 
services will continue long after the public health emergency (PHE) is 
lifted. Addressing the following issues can play a critical role in 
expanding access to MH and SUD services and provide long lasting 
improvements to our nation's behavioral health system.

      Expand the use of telehealth for MH and SUD services.
      Increase access to medication-assisted treatment (MAT).
      Support suicide prevention efforts and increase focus on crisis 
services.
      Eliminate the Institution for Mental Diseases (IMD) Medicaid 
exclusion.
      Develop a clear, universal compliance standard related to mental 
health and addiction parity.
      Ensure health coverage for individuals released from jails and 
prisons.
      Align 42 CFR Part 2 with the Health Insurance Portability and 
Accountability Act (HIPAA).

As you further examine behavioral health issues, we urge you to 
consider and include the following:

Expand the use of telehealth for MH and SUD services. We appreciate the 
current guidance and flexibilities in response to the PHE and request 
that the flexibilities continue for at least one year after the PHE is 
lifted. These long overdue changes to telehealth policies have allowed 
payers and providers to ensure people can access necessary MH and SUD 
services in midst of physical distancing. ABHW members support 
extending flexibilities past the PHE and simultaneously collecting and 
analyzing data before making permanent changes. As the need for 
behavioral health services continues to grow, we urge Congress to 
support the following policy changes:

      Eliminate the new in-person visit requirement for mental health 
services: We applaud the recent changes made to remove geographic and 
originating site restrictions on originating sites for mental health 
services, allowing beneficiaries across the country to receive virtual 
care from a location of their choosing. However, these changes were 
accompanied by a new requirement, mandating that an individual must 
have an in-person visit no less than six months before he or she is 
eligible to receive mental health services via telehealth. Given that 
many individuals with mental health issues may not physically be able 
to leave the home, we urge you to support the Telemental Health Care 
Access Act, S. 2061/H.R. 4058, which removes the in-person requirement 
visit prior to receiving Medicare telehealth services for mental 
health.

      Expand cross state licensure: During the pandemic, all 50 states 
have used emergency authority to waive certain aspects of state 
licensure laws, thus providing widespread access to care. We encourage 
efforts for states to foster cross state licensure reciprocity to 
support increased access to services. We also propose convening a task 
force of federal and state leaders to examine this issue and outline 
recommendations on changes that would increase access to behavioral 
health services.

      Examine audio-only telehealth services. ABHW supports patient 
access to audio-only behavioral health services for the duration of the 
PHE. However, before audio-only services are made permanent, ABHW 
strongly suggests that the appropriate regulatory agencies conduct 
research as to whether or not behavioral health services provided via 
audio-only are an effective long-term strategy to provide quality, 
evidence-based, and clinically appropriate care. One way to do this 
would be to create an audio-only modifier so that it can be used in 
effectiveness research to differentiate between audio-visual and audio-
only services.

     Currently, it is unclear whether audio-only is appropriate for all 
behavioral health treatments. Specifically, ABHW advocates for audio-
only services to be evaluated in partial hospitalization programs, 
applied behavioral analyses, psych testing, and group therapy before 
they are reimbursed permanently. Ultimately, audio-only behavioral 
health treatments should have safeguards built around them and should 
not be a primary or default avenue for care. Post PHE, audio-only 
should only be used after it has proven to be effective and is deemed 
to be in the individual's best interest (for example, the patient has 
limited broadband access and difficulty accessing video technology).

Increase access to medication assisted treatment (MAT). Research has 
shown that MAT is the most effective intervention to treat opioid use 
disorders (OUDs) as it significantly reduces illicit opioid use 
compared to nondrug approaches and increased access to MAT can reduce 
overdose fatalities.\1\ As such, ABHW supports the following policy 
changes to increase MAT access.
---------------------------------------------------------------------------
    \1\ Medication-Assisted Treatment Improves Outcomes for Patients 
with Opioid Use Disorder, Pew Fact Sheet, November 22, 2016.

      Eliminate the X-waiver. During the COVID-19 pandemic, overdoses 
and related deaths continue to rise, making access to MAT crucial. HHS 
recently published a Notice which allows providers to treat up to 30 
patients using MAT without first obtaining the X-waiver. While this is 
a step in the right direction to treat OUDs, more must be done. As 
such, we ask that Congress pass the Mainstreaming Addiction Treatment 
(MAT) Act, S. 445/H.R. 1384. This bipartisan legislation would remove 
the federal rules established by the DATA 2000 Act that require health 
care practitioners to obtain a waiver (X-waiver) from the Drug 
Enforcement Administration (DEA) before prescribing buprenorphine to 
treat OUDs. The legislation would remove a major hurdle to prescribing 
MAT, impact existing nationwide shortage of treatment providers, and 
---------------------------------------------------------------------------
expand access to OUD treatment.

      Eliminate the in-person evaluation requirement. Given that not 
all individuals with SUDs are able to have an initial in-person visit 
with a provider due to behavioral health provider shortages or physical 
difficulty traveling, ABHW advocates for actions which would eliminate 
the in-person evaluation requirement before a provider can prescribe 
MAT via telehealth. The Ryan Haight Act, originally passed to combat 
the rise of rogue online pharmacies, requires an in-
person evaluation before a provider can prescribe MAT via telehealth. 
This safeguard likely suppresses the use of MAT because under current 
law, the evaluation requirement cannot be fulfilled via a telehealth 
visit.\2\ While the Ryan Haight Act allows for providers to use 
telemedicine when engaged in the ``practice of medicine,'' it is nearly 
impossible for providers to do so. The definition of ``practice of 
telemedicine'' includes seven categories in which a provider could meet 
the in-person requirement through a virtual care platform, including 
under a special registration granted by the DEA. However, the DEA never 
created that registration process. With the Special Registration for 
Telemedicine Act of 2018, which was part of the Substance Use-Disorder 
Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act, 
the DEA had until October 24, 2019, to outline rules for providers with 
a special registration to prescribe controlled substances. That 
deadline passed without action, severely impeding those with OUDs from 
receiving the care they need.
---------------------------------------------------------------------------
    \2\ Kayla R. Bryant, Health Law Daily Wrap up, Strategic 
Perspectives: States Fail to Fully Use Telemedicine to Fight the Public 
Health Crisis, Wolters Kluwer (September 28, 2018), p. 2.

     As such, we recommend that Congress urge the DEA to move forward 
with promulgating the telemedicine special registration process rule, 
as mandated by federal law, to enable providers to prescribe MAT to 
---------------------------------------------------------------------------
patients with SUDs by employing telemedicine.

Support suicide prevention efforts and increase focus on crisis 
services. Last year Congress passed the National Suicide Hotline 
Designation Act of 2019, making the National Suicide Prevention 
Lifeline an easy to remember three-digit number, 9-8-8. The need for 
Americans to have readily available access to mental health crisis 
services through a ubiquitous number like 9-8-8 is more urgent than 
ever. We urge Congress to work with the Federal Communications 
Commission (FCC) to ensure the timely implementation of 9-8-8 by July 
2022. Incidences of mental health crises and suicide attempts have been 
increasing annually, and are exacerbated by the COVID-19 pandemic.

In addition to swiftly creating the crisis line, it is equally 
important that the crisis line have adequate resources so that it can 
operate effectively and ensure that all Americans can access it. Since 
demand will undoubtedly increase for services of the crisis line, there 
will need to be significant investment after the initial implementation 
to expand capacity and provide services consistently for mental health 
crises. Therefore, we ask Congress to pass H.R. 2981, the Suicide 
Prevention Lifeline Improvement Act of 2021. This legislation would 
require increased coordination, data sharing, and provide more funding 
to support community-based crisis service delivery. ABHW supports an 
evidence-based continuum of crisis care for individuals experiencing a 
behavioral health crisis, and look forward to working with Congress to 
promote access to quality crisis services.

Eliminate the Institution for Mental Diseases (IMD) Medicaid exclusion. 
We urge Congress to remove policy barriers that limit beneficiary 
access to needed and appropriate MH and SUD care. This includes ending 
the IMD exclusion, which prohibits Medicaid reimbursement for adults 
under the age of 65 in residential behavioral health facilities with 
more than 16 beds. Although the IMD exclusion cannot be fully 
eliminated without Congressional action, the Administration could 
increase access and improve appropriate care through expanded use of 
waivers under section 1115, which would enable states to more broadly 
cover IMD services. Further, as we have witnessed, national hospital 
capacity has been pushed to its limits during the COVID-19 pandemic. 
Waiving the IMD exclusion to Medicaid funding for inpatient behavioral 
health treatment would free up beds in local hospitals, allowing them 
to better manage the surge capacity in both inpatient and emergency 
departments to care for COVID-19 patients. Additionally, new 
legislation was introduced this year by Representative Napolitano, the 
Increasing Behavioral Health Treatment Act, H.R. 2611. This legislation 
would remove the IMD exclusion for states that have submitted a plan 
to: increase access to outpatient and community-based behavioral health 
care; increase availability of crisis stabilization services; and 
improve data sharing and coordination between physical health, mental 
health and addiction treatment providers and first-responders. We urge 
Congress to pass this important legislation.

Develop a clear, universal compliance standard related to mental health 
and addiction parity. ABHW member companies continue to invest 
significant time and resources to understand and implement Mental 
Health Parity and Addiction Equity Act (MHPAEA). Our member companies 
have teams of dozens of people working diligently to implement and 
provide MH/SUD parity benefits to their consumers. We have also had 
numerous meetings with the regulators to help us better comprehend the 
regulatory guidance and to discuss how plans can operationalize the 
regulations.

While parity has progressed since its adoption in meaningful ways and 
access to MH and SUD treatment providers has greatly expanded, systemic 
issues continue to be a challenge due to other non-parity factors such 
as the looming shortage of physicians (both psychiatrists as well as 
other MH and SUD providers). Examples of key changes since the parity 
law and regulations were enacted include: the fact that routine MH 
outpatient treatment no longer habitually requires prior authorization 
or has explicit quantitative treatment limits; evidence-based levels of 
care for MH conditions are no longer subject to blanket exclusions 
(e.g., residential treatment for eating disorders); and transparency, 
documentation, attention to medical necessity criteria all have 
improved.

However, despite these gains and the parity language in the 21st 
Century Cures Act, aspects of the law and regulations remain overly 
complex and technical. As a result, compliance has become a moving 
target through a patchwork of conflicting and changing guidance. There 
is new parity language in Section 203 of the recently passed 
Consolidated Appropriations Act of 2021, and we hope that the 
regulations related to these parity provisions will provide the clarity 
payers need to appropriately implement MHPAEA. We strongly support the 
flexibility built into the law, yet there has been a proliferation of 
different compliance approaches, tools, and interpretations, which 
continues to lead to confusion in implementation, is costly for 
stakeholders, and ultimately hinders patient care. We believe this 
Administration can re-invigorate efforts to clarify and improve the 
application of the law for the benefit of all.

Strengthen and expand the behavioral health workforce. We appreciate 
your support to expand access to care, and address ongoing workforce 
shortages across the country in order to help ensure people who need MH 
and/or SUD treatment get the care they need. As one first step, we ask 
that the Administration and Congress work to increase funding to 
behavioral health providers so that we have an adequate workforce to 
meet the increasing need for MH and SUD services. We recommend 
expanding eligible Medicare providers to include marriage and family 
therapists (MFTs), mental health counselors (MHCs), and certified peer 
support specialists.

      Medicare coverage of mental health counselors and marriage and 
family therapists. Recognition of MHCs and MFTs as Medicare providers 
would increase the pool of eligible mental health professionals by over 
200,000 licensed practitioners. Studies have shown that these providers 
have the highest success and lowest recidivism rates with their 
patients as well as being the most cost effective.\3\ We encourage you 
to work with Congress to pass the Mental Health Access Improvement Act 
(S. 828, H.R. 432), which recognizes MHCs and MFTs as covered Medicare 
providers, helps address the critical gaps in care, and ensures access 
to needed services.
---------------------------------------------------------------------------
    \3\ D. Russell Crane and Scott H. Payne, ``Individual Versus Family 
Psychotherapy in Managed Care: Comparing the Costs of Treatment by the 
Mental Health Professions,'' Journal of Marital and Family Therapy 37, 
no. 3 (2011): 273-289.

      Medicare coverage of peer support services. Certified peer 
support specialists can be vital in providing support to people living 
with mental health conditions and SUDs. These paraprofessionals are 
individuals with lived experience of recovery from a MH disorder or 
SUDs. This evidence-based practice helps individuals navigate the 
often-confusing health care system, get the most out of treatment, 
identify community resources, and develop resiliency. Due to the COVID-
19 pandemic, engagement with treatment and care has been disrupted, but 
finding and utilizing support in a timely manner can help mitigate 
negative health outcomes of the disruption. Recently, the Promoting 
Effective and Empowering Recovery Services in Medicare (PEERS) Act of 
2021, H.R. 2767/S. 2144, was introduced. This legislation is an 
important step in recognizing the unique role of peer support 
specialists in helping individuals better engage in services, manage 
physical and mental health conditions, build support systems, and, 
---------------------------------------------------------------------------
ultimately, live self-directed lives in their communities.

Ensure health coverage for individuals released from jails and prisons. 
ABHW strongly supports H.R. 955/S. 285, the Medicaid Reentry Act of 
2021, to grant Medicaid eligibility to incarcerated individuals 30 days 
prior to their release to promote the health care needs of individuals 
transitioning back into communities. According to the Bureau of Justice 
Statistics, more than half of those in the criminal justice system 
suffer from a mental illness. Of those with serious mental illness, 
approximately 75 percent also have a co-occurring SUD. Allowing 
incarcerated individuals to receive services covered by Medicaid 30 
days prior to their release from jail or prison will expand access to 
vital mental health and addiction services. Equipping individuals with 
timely access to addiction, mental health, and other health-related 
services before release, will facilitate the transition to community-
based care upon release that is necessary to help break the cycle of 
recidivism. This is even more critical in the midst of the COVID-19 
pandemic.

Issue regulation for 42 CFR Part 2. We look forward to the promulgation 
of the next 42 CFR Part 2 (Part 2) rule pursuant to the Coronavirus 
Aid, Relief, and Economic Security (CARES) Act of 2020. Part 2, which 
governs the confidentiality of SUD records, sets requirements limiting 
the use and disclosure of patients' SUD records from certain substance 
use programs, including the cumbersome requirement of a signed consent 
by the patient each time the SUD record is to be shared. The CARES Act 
brings Part 2 into significant alignment with the Health Insurance 
Portability and Accountability Act of 1996 (HIPAA). Changes in the 
CARES Act permit a patient to provide one written consent to disclose 
their Part 2 information for all future treatment, payment, and health 
care operations (TPO), unless the patient revokes consent. 
Additionally, under the CARES Act, breaches in a Part 2 program trigger 
patient notification, Part 2 programs are now subject to HIPAA civil 
and criminal penalties, and discrimination against Part 2 program 
patients is prohibited. This legislation culminates years of work from 
a broad range of organizations, and it represents a number of critical 
compromises.

Attached you will find recommendations from the Partnership to Amend 42 
CFR Part 2 (Partnership), which we have previously shared with the U.S. 
Department of Health and Human Services (HHS), the Substance Abuse and 
Mental Health Services Administration (SAMHSA) as well as the Office 
for National Drug Control Policy (ONDCP). The Partnership, founded by 
ABHW, brings together a broad spectrum of the healthcare industry to 
advocate for aligning Part 2 with HIPAA. We urge HHS to ensure that the 
requirements for Part 2 stated in the CARES Act are reflected in the 
next Part 2 Rule.

Thank you for the opportunity to provide suggestions to address 
important behavioral health policies. If you have any questions or 
would like to discuss ABHW's policy priorities please contact Maeghan 
Gilmore, Director of Government Affairs, at [email protected] or 202-
503-6999.

Sincerely,

Pamela Greenberg, MPP
President and CEO

                                 ______
                                 
                        Center for Fiscal Equity

                      14448 Parkvale Road, Suite 6

                          Rockville, MD 20853

                      [email protected]

                    Statement of Michael G. Bindner

Chairman Wyden and Ranking Member Crapo, thank you for the opportunity 
to submit these comments for the record.

It seems like we covered this ground last month in the subcommittee, 
but looking at the budget comments and appropriations history, I see 
that there is much to pull together. This is a very ambitious title. 
While I can trace my mental illness to an adrenal tumor and some have a 
genetic predisposition to disease, while others arrive at dysfunction 
through abuse, neglect or drug use, I suspect we won't cover everything 
in the 90 or so minutes that this hearing will last.

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.

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.

During the pandemic many mentally ill SSDI beneficiaries were not going 
out much and did not have many places to go. Libraries and movie 
theaters have been closed. Some were working in tense situations and 
need a vacation. Those of us receiving SSDI benefits are spending more 
on food of late. Let me illustrate.

Even before the pandemic, my SSDI was inadequate for food, medicine, 
clothing and cable. If I owned a vehicle, there is no way I could 
maintain it or even buy gas. I have an above average benefit, high 
enough to be ineligible for SNAP or Medicaid. Many are not so lucky, 
even on a good day.

In the last few months, days have not been so good. Were it not for 
stimulus payments, I would be running out of food as I write this and 
would not have just bought new clothes, from socks and underwear to a 
jacket I can wear when the Committee finally asks me to testify in 
person. As it is, I will need to use the last $600 from my December 
payment (which should have come through Social Security) to attend my 
upcoming high school reunion. While I have wifi, I cannot afford cable 
and a car is still out of reach.

Let me underline a point. In most months, new underwear is not an 
option, I rely on free bus rides due to the pandemic and subsidies from 
Ride On and there is never enough money in that last week before the 
check comes. When it does arrive, the cupboard is bare.

Double underline: food prices are skyrocketing. Part of the problem may 
be too much money chasing too few goods, but retirees and the disabled 
find (our)selves between a rock and a hard place. We need a COLA and we 
need it now. Most of us cannot even afford cola. Because this is a 
short term emergency due to the Pandemic, it should be funded out of 
the general fund until the normal process kicks in for next year.

The important point is that, if wage growth is considered inflation, 
the retired and disabled can be given not only a Cost of Living 
Adjustment, but also have their income history rebased for inflation. 
Even with Chained CPI, such an increase will take the financial 
pressure off of many such households, including mine.

Home and Community-Based Health Care are addressed in the President's 
Budget. Home and community-based care should be funded by goods and 
services taxes as part of a newly created Medicare Part E. Senior 
Medicaid should be entirely federalized, with other clients insured 
through the President's proposal for a public option.

President Reagan's New Federalism proposal would have removed Medicaid 
from state budgets in exchange for ending or block granting other 
federal programs. This was a good idea then and a better idea now. 
Medicaid Part E should be created to both relieve states and the 
District of Columbia (or Washington, Douglass Commonwealth) from 
providing Medicaid for seniors and the Disabled and seeing to the 
enforcement of practice standards for nursing homes who receive these 
funds.

For workforce development and general recovery, Psychiatric 
Rehabilitation Programs, such as the Center for Behavioral Health in 
Rockville and Cornerstone Montgomery in Gaithersburg are essential. To 
make them more attractive, and to increase our ability to manage--
especially in the period before disability programs kick in, 
participation should be paid at the minimum wage.

People will participate in this care more frequently if their 
opportunity costs are met. Those with less than a full education should 
receive it through public and private providers and also be paid to do 
so.

Health care currently provided through Medicaid should be dual eligible 
for everyone, regardless of income and before it kicks in entirely be a 
public option. Instead of using a larger system, clients should have 
the option of receiving coverage through the PRP provider's employee 
plan.

Low wages are endemic among the mentally ill. We need a raise, along 
with the rest of the working poor (and not so poor--who make more when 
the minimum goes up). The Minority proposed a $10 wage as a counter-
offer to $15. A $12 wage for a 40 hour week puts us at parity to 1965, 
when the wage peaked and the war over wages started with the Kennedy-
Johnson tax cuts. An $11 wage with a 32 hour week is also acceptable. 
With increased productivity, the work week should be shorter. The 
minimum wage should be indexed to inflation, including during any 
transitional period--which should have the goal of $18 per hour ($15 is 
a 20th Century goal).

Not raising minimum wages has been justified by the reactionary sector 
that claims that in the end, the market will sort everything out. The 
perception that doing the right thing makes a business non-competitive 
is the reason we enact minimum wage laws and should require mandatory 
leave. Because the labor product is almost always well above wages 
paid, few jobs are lost when this occurs. Higher wages simply reduce 
what is called the labor surplus, and not only by Marx. Any CFO who 
cannot calculate the current productive surplus will soon be seeking a 
job with adequate wages and sick leave.

The requirement that this be provided ends the calculation of whether 
doing so makes a firm non-competitive because all competitors must 
provide the same benefit. This applies to businesses of all sizes. If a 
firm is so precarious that it cannot survive this change, it is 
probably not viable without it.

Mentally ill people deserve to have families, just as others do. 
Increasing the child tax credit is as essential to us as to anyone. The 
child tax credit level passed in the American Recovery Act should be 
made permanent and doubled, with distribution through private sector 
payrolls, unemployment insurance benefits, emergency benefits for 
families and paid participation in educational programs.

There are two avenues to distribute money to families. The first is to 
add CTC benefits to unemployment, retirement, educational (TANF and 
college) and disability benefits. The CTC should be high enough to 
replace survivor's benefits for children.

The second is to distribute them with pay through employers. This can 
be done with long term tax reform, but in the interim can be 
accomplished by having employers start increasing wages immediately to 
distribute the credit to workers and their families, allowing them to 
subtract these payments from their quarterly corporate or income tax 
bills.

In recent decades, the problem of veteran disability determinations has 
remained troubling, with the Pandemic complicating processing. When a 
job gets too big to manage with staff, two options remain--contract out 
as much work as possible, including consolidating case files and making 
easy determinations--and sharing responsibility for processing with the 
Department of Defense. The handoff from DoD to DVA should be seamless.

The mental health and housing needs of veterans, both recent and 
lingering, is endemic. This is another area where coordination with DoD 
would prove helpful. This help must go beyond management and computer 
systems and include the human element of soldiers, veterans using 
services and those who need services can interact on a less formal, but 
not unprogrammed basis.

The DVA and DoD must both actively facilitate this and join state and 
local governments in reaching out to those who suffer, from active duty 
soldiers to veterans both receiving and in need of services. For those 
mentally ill or addicted veterans who do not trust the system, less 
restrictive systems should be developed--including providing camping 
supplies and a place to camp and a more permissive attitude to active 
drinking and drug use until help is sought. Such systems do not 
encourage use. No addict needs encouragement. They build the trust that 
makes recovery possible.

The largest provider of mental health services (including to veterans) 
is the correctional system. Job one is to shift from correctional 
modalities to new methods featuring mental health, education (including 
ESL programs) and addiction medicine. Warehousing young males of any 
race, but particularly African-Americans multiplies societal 
pathologies. While some forms of illness, such as sexual violence and 
physical violence or murder may require higher security, others can be 
treated as patients rather than criminals.

The Department of Justice can take the lead in both practice and in 
developing best practices for state correctional systems. Part of this 
would be specialized facilities based on the type of crime committed.

For example, sex offenders would be in facilities of their own. Those 
who remain dangerous post-sentence would still be detained until they 
are no longer dangerous. Such decisions must be based on science, not 
the desire for further punitive measures.

This change would migrate to local law enforcement, i.e., policing.

A pilot program could be developed to respond to certain incidents 
(especially those involving mental illness or alcohol) with immediate 
dispatch of emergency medical teams. This would require more 
ambulances, more mental health facilities and a pause in applying 
restraints until medical personnel arrive.

Funding more hospitals and ambulances would be part of this, possibly 
with some form of federal grant program. Private corrections facilities 
can also be transformed into contracted medical facilities with 
security contracting provided as a subcontract to mental health 
systems, both secular and religious. Catholic Health Association 
members come to mind. Both public and private educational systems would 
be an integral part of such facilities and be treated as an essential 
function, rather than the first item cut when states wish to minimize 
their spending by essentially torturing (and dehumanizing) inmates.

New standards of individual and societal protection must be developed. 
Improved standards of care and security will require much more funding 
than state and local governments are willing to commit to. This simply 
drives the problem to the correctional system, which is the largest 
provider of mental healthcare in this nation. The term for this 
practice is pennywise and pound-foolish.

It is too easy to get out of treatment and too hard to get it. 
Hospitalization for medication management is sometimes needed but 
rarely given. Often, people are released before a stable routine is 
established, including management of side effects. It is hard to create 
a good care plan in a five day hold. For both mental illness and 
alcoholism, it must be harder to simply sign out without a real 
prospect for long- term recovery. Again, the term is penny wise and 
pound foolish.

A final reform, which will save money and resources, is to create a 
plea in criminal cases of guilty by reason of insanity. Those who enter 
this plea would be confined in the facilities detailed above for at 
least the minimum sentence for their offences, with no release after 
that if the subject remains a danger to society.

If relapse occurs or treatment protocols are evaded after release, 
rehospitalization must be automatic and last until a treatment program 
is more deeply ingrained. There should, of course, be protections on 
both sides in the decision to release subjects--both for the protection 
of the rights of subjects who made be held for punitive, rather than 
hygienic reasons and, as importantly, the interests of the victims of 
crime, including but not limited to the possibility of physical danger. 
Sometimes, exile should be a part of release.

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

Statement of Allison Ivie, MPP, MA, Government Relations Representative

Chairman Wyden, Ranking Member Crapo, and members of the U.S. Senate 
Committee on Finance, thank you for holding this important hearing 
entitled, ``Mental Health Care in America: Addressing Root Causes and 
Identifying Policy Solutions'' 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.
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    \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/report-economic-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, Pand 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 Recovery              Ballwin, MO
 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 Disorders                  Pekin, IL
 Professionals
 
International Federation of Eating Disorders                  Dallas, TX
 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 Nervosa                 Chicago, IL
 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 St., NW, Suite #500

                          Washington, DC 20510

June 21, 2021

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

Dear Chair Wyden and Ranking Member Crapo:

On behalf of the Healthcare Leadership Council (HLC), we thank you for 
holding a hearing on, ``Mental Health Care in America: Addressing Root 
Causes and Identifying Policy Solutions.''

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 healthcare 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, home care 
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 created significant 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.\1\ The impact of COVID on mental health is 
expected to continue to be a challenge in the coming years. We applaud 
Congress for providing over $4 billion in the Consolidated 
Appropriations Act and $3.8 billion in the American Rescue Plan Act for 
mental health services. These investments will provide much-needed 
assistance to struggling communities.
---------------------------------------------------------------------------
    \1\ 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/.

We encourage the Committee to examine ways to improve access to mental 
health services, particularly via telehealth options. A recent survey 
found that approximately 50% of patients using telehealth services were 
seeking behavioral health treatment.\2\ Providing mental health 
treatment via telehealth provides a unique opportunity to reach 
underserved patients. Estimates have found that up to 60% of patients 
do not arrive for their behavioral health appointments.\3\ By using 
telehealth solutions to deliver such care, providers have been able to 
deliver much needed assistance to patients in their homes. Patient 
satisfaction in receiving behavioral health treatment via telehealth 
\4\ has shown that providers can innovate in care delivery without 
sacrificing quality.
---------------------------------------------------------------------------
    \2\ Shira Fischer et al., The Transition to Telehealth During the 
First Months of the COVID-19 Pandemic, RAND Corporation (January 8, 
2021), https://link.springer.com/content/pdf/10.1007/s11606-020-06358-
0.pdf.
    \3\ Eric Berger, No-Cancel Culture: How Telehealth Is Making It 
Easier to Keep that Therapy Session, Kaiser Health News (May 24, 2021), 
https://khn.org/news/article/no-cancel-culture-how-telehealth-is-
making-it-easier-to-keep-that-therapy-session/.
    \4\ Joe Gramigna, Patient satisfaction high for psychiatric 
telehealth platforms in partial hospital program, Healio (March 25, 
2021), https://www.healio.com/news/psychiatry/20210325/patient-
satisfaction-high-for-psychiatric-telehealth-platforms-in-partial-
hospital-program.

The COVID-19 health pandemic has also 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.\5\ Preliminary data expects 
2020 to be the worst year on record for drug overdoses.\6\ 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 medications through the duration of the public health 
emergency (PHE) while maintaining robust safety and monitoring 
programs.
---------------------------------------------------------------------------
    \5\ 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/.
    \6\ 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/.

HLC appreciates your work on improving mental health outcomes for 
patients and looks forward to working with you on future solutions. 
Please feel free to contact Tina Grande at 202-449-3433 or 
---------------------------------------------------------------------------
[email protected] with any questions.

Sincerely,

Mary R. Grealy
President

                                 ______
                                 
     HR Policy Association, American Health Policy Institute, and 
          National Alliance of Healthcare Purchaser Coalitions

June 15, 2021

The HR Policy Association, the American Health Policy Institute, and 
the National Alliance of Healthcare Purchaser Coalitions appreciate the 
Committee holding this important hearing on behavioral and mental 
health care issues.

The HR Policy Association is the leading organization representing 
chief human resource officers of over 390 of the largest employers in 
the United States. Collectively, their companies provide health care 
coverage to over 20 million employees and dependents in the United 
States. The American Health Policy Institute, a part of HR Policy 
Association, examines the challenges employers face in providing health 
care to their employees and recommends policy solutions to promote 
affordable, high-quality, employer-based health care. The Institute 
serves to provide thought leadership grounded in the practical 
experience of America's largest employers.

The National Alliance of Healthcare Purchaser Coalitions (National 
Alliance) is the only nonprofit, purchaser-led organization with a 
national and regional structure dedicated to driving health and health 
care value across the country. Its members represent private and public 
sector, nonprofit, and Taft-Hartley organizations, and more than 45 
million Americans, spending $300 billion annually on healthcare.

The National Alliance, HR Policy Association and the American Health 
Policy Institute are also part of The Path Forward initiative to 
execute a disciplined, private sector approach to systematically and 
measurably improve five established best practices of mental health and 
substance use care. Below are our policy recommendations to improve 
access to behavioral and mental health care services.

Sincerely,

D. Mark Wilson                      Michael Thompson
President and CEO, American Health 
Policy Institute                    President and CEO
Vice President, Health and 
Employment Policy                   National Alliance of Healthcare 
                                    Purchaser Coalitions
HR Policy Association               1015 18th Street, NW, Suite 705
1001 19th St. North, Suite 1002
Arlington, VA 22209                 Washington, DC 20036

Collaborative Care Model (CoCM)

While employer health plans and Medicare reimburse providers in 
collaborative care practices, behavioral health is not broadly 
integrated with primary care. Because behavioral health conditions 
often initially present themselves in primary care settings, this lack 
of integration leaves patients with undiagnosed or poorly managed 
behavioral health conditions. Increasing the number of collaborative 
care practices would improve access to behavioral health services, 
increase the effectiveness of treatment, and reduce disparities in 
identification of behavioral health issues. Over 70 randomized 
controlled trials have demonstrated collaborative care models are more 
effective and cost efficient than usual care.\1\
---------------------------------------------------------------------------
    \1\ https://www.chcs.org/media/
HH_IRC_Collaborative_Care_Model__052113_2.pdf.
---------------------------------------------------------------------------
Policy Recommendations
    1.  Allocate funds to support a change effort to provide technical 
assistance, training and startup funds to allow for large scale 
adoption for collaborative care across the country. Collaborative care 
can be delivered virtually or by in person care managers meaning this 
model can deliver to large medical groups or small and rural primary 
care practices.

    2.  CMS should establish a national Technical Assistance (TA) 
center and regional extension centers to assist primary care practices 
in implementing the CoCM.

    3.  Incentivize behavioral health care providers to adopt 
electronic health record technology that is interoperable with general 
health care providers into their practices.

    4.  Expand research on promising integrated care models.

TeleBehavioral Healthcare (TBH)

    Background--During the COVID-19 pandemic, Medicare rules related to 
TBH have been liberalized resulting in an exponential growth in the use 
of TBH, including enabling cross-state care which has been critical to 
underserved areas and rural communities. However, the requirements for 
employer health plans around how TBH is provided and reimbursed remain 
far too restrictive and result in access and quality disparities. TBH 
has the potential to overcome patient stigma and improve access and 
efficiency of care for BH services. We know that since the COVID-19 
public health emergency, there has been a significant increase in 
patients keeping their appointments. 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. Research also 
suggests that TBH results in better medication compliance, fewer visits 
to the emergency department, fewer patient admissions to inpatient 
units, and fewer subsequent readmissions. However, 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 racial/ethnic and low-income communities 
lack access to broadband or video-enabled devices, which only expands 
the health inequities in the U.S.

Policy Recommendations

    1.  Eliminate cross-state border restrictions on TBH on a permanent 
basis for Medicare, employer and commercial plans. Licensing 
requirements should be based on the location of the provider not the 
patient.

    2.  Enable patient access to TBH without having the first provider 
appointment be in person.

    3.  Make permanent the allowance of first-dollar coverage of 
telehealth in high deductible health plans. Specifically, Congress 
should pass the Telehealth Expansion Act of 2021 (S. 1704).

    4.  Allow employers to offer standalone ``excepted benefit'' 
telehealth benefits.

    5.  Adopt technology-neutral requirements, permitting use of 
different types of technology platforms for telehealth services.

    6.  Establish a uniform set of rules for multi-state telehealth 
benefit plans to eliminate state restrictions that block patients from 
telehealth benefits.

The HR Policy Association, the American Health Policy Institute, and 
the National Alliance welcome any opportunity to provide input and 
speak in further detail about improving access to behavioral and mental 
health care services. We look forward to working with you on this 
important topic.

                                 ______
                                 
                 The Partnership to Amend 42 CFR Part 2
April 13, 2021

Robinsue Frohboese
Acting Director and Principal Deputy
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201

Dr. Neeraj Gandotra
Chief Medical Officer
Substance Abuse and Mental Health Services Administration
5600 Fishers Lane
Rockville, MD 20852

Re: 42 CFR Part 2--Recommendations for Next Rule

Dear Ms. Frohboese and Dr. Gandotra,

The Partnership to Amend 42 CFR Part 2 (Partnership), writes to provide 
recommendations for the U.S. Department of Health and Human Services' 
(HHS) Office for Civil Rights (OCR) and the Substance Abuse and Mental 
Health Services Administration (SAMHSA) to consider when drafting the 
new rule for the 42 CFR Part 2 (Part 2) provisions in the Coronavirus 
Aid, Relief, and Economic Security Act (CARES Act). We have appreciated 
working with HHS and SAMHSA on Part 2 in the past and welcome the 
opportunity to partner with both SAMHSA and OCR on this important issue 
moving forward.

The Partnership is a coalition of nearly 50 organizations committed to 
aligning Part 2 with the disclosure requirements of the Health 
Insurance Portability and Accountability Act (HIPAA) for the purposes 
of treatment, payment, and health care operations (TPO).

This is a time of unprecedented urgency. First, the Centers for Disease 
Control and Prevention's preliminary estimate is that more than 81,000 
Americans died of drug overdose in 2020. Second, federal health 
officials believe the drug crisis is only being amplified by months of 
social isolation, high unemployment, and diversion of public health 
resources, all a result of the COVID-19 pandemic.\1\ Given this 
alarming correlation, an important part of responding to the COVID-19 
pandemic will be to simplify coordination of care for substance use 
disorders (SUDs), which ultimately will prevent gaps and expand access 
to care. Furthermore, we anticipate SUDs may continue to rise even 
after the COVID-19 pandemic is over, reflecting the extreme toll it has 
taken on Americans. As such, we believe quickly issuing the proposed 
rulemaking, as required by section 3221 of the CARES Act, will both 
help curb the SUD epidemic and also strongly supports the incoming 
Biden-Harris Administration's Build Back Better strategy.

    \1\ Dan Goldberg and Brianna Ehley, Biden's other health crisis: A 
resurgent drug epidemic, Politico, November 28, 2020.

Previous requirements in the Part 2 regulation led to segmented data, 
interrupted flow of that data, and ultimately hindered informed 
diagnosis, treatment, and implementation of an individual's care plan 
and access to care. The CARES Act takes great strides to remedy these 
issues by promoting partial alignment between Part 2 and HIPAA, though 
the two privacy frameworks remain distinct, particularly for consent 
purposes. Nevertheless, the law clearly strives to bring Part 2 in line 
with HIPAA, a fact being embraced by industry thought leaders. For 
example, the Medicaid and CHIP Payment and Access Commission (MACPAC) 
noted during its December 2020 meeting that the CARES Act 
``[p]ermanently aligns 42 CFR Part 2 and HIPAA.''\2\
---------------------------------------------------------------------------
    \2\ Aaron Pervin and Erin McMullen, Promoting Behavioral and 
Physical Clinical Integration Through EHRs, 2020. https://
www.macpac.gov/wp-content/uploads/2020/12/Integrating-Clinical-Care-
through-Greater-Use-of-Electronic-Health-Records-by-Behavioral-Health-
Providers.pdf, last visited April 1, 2020.

Additionally, and most importantly, the Partnership staunchly supports 
patient privacy. We are acutely aware that even if the sharing of 
information is made easier, it has limited utility without continued 
strong protections for patient privacy. Without trust, patients may not 
seek the care they need to treat SUDs. We are also aware that 
individuals may be concerned that SUD records will be used against them 
---------------------------------------------------------------------------
by law enforcement.

These are significant concerns. However, the CARES Act protects patient 
rights in two important ways. First, it allows an individual to revoke 
his or her consent to sharing SUDs records, giving patients control 
over their information.\3\ Second, SUD records are expressly prohibited 
by law from being used in civil, criminal, administrative, or 
legislative proceedings against a patient by any government authority 
(unless authorized by court order or patient consent). Furthermore, SUD 
records specifically cannot: (a) be entered into evidence in criminal 
prosecutions or civil actions; (b) form part of the record for a 
decision or otherwise be taken into account in government agency 
proceedings; (c) be used by a governmental agency for law enforcement 
purposes or investigations; or (d) be used in a warrant application.\4\ 
As such, we believe the changes made to Part 2 by the CARES Act will 
allow for smoother care coordination while simultaneously strengthening 
patient privacy.
---------------------------------------------------------------------------
    \3\ Coronavirus Aid, Relief, and Economic Security Act (CARES Act), 
Pub. L. No. 116-136, section 3221(b)(1)(C).
    \4\ Id. at section 3221(e).

As you begin drafting the next Part 2 rule, we submit the following for 
---------------------------------------------------------------------------
your consideration:

Original Consent Process. While the Confidentiality of Substance Use 
Disorder Patient Records Final Rule (final rule) issued in July 2020 
takes an important step forward to address the issue of patient 
consent, we believe more needs to be done in this regard. The final 
rule allows an entity, instead of an individual, to be specified as the 
recipient of Part 2 records, which broadens the scope of the consent 
and incrementally relieves the burden on patients and providers. 
However, this is not enough because a new patient consent is needed 
each time there is a new entity where the Part 2 record needs to be 
disclosed.Fortunately, the CARES Act further simplifies the process by 
requiring only one consent, after which the Part 2 record can be used 
or disclosed by a covered entity or business associate for the purposes 
of TPO in accordance with the HIPAA regulations.

Additionally, please note that although the initial consent requirement 
was amended under section 3221 of the CARES Act to allow a general 
designation (instead of a specific practice), there still remains a 
roadblock in practice: the list of disclosures requirement in Part 2. 
Specifically, section 2.31 of Part 2 mandates that ``upon request, 
patients who have consented to disclose their patient identifying 
information using a general designation must be provided a list of 
entities to which their information has been disclosed pursuant to the 
general designation'' [emphasis added]. Due to the list of disclosures 
requirement, practitioners are often uncomfortable attempting to use 
the general designation in the consent.

Recommendation: Ensure that the consent requirements in the next rule 
are simple and straightforward so additional administrative processes 
are not imposed on patients, providers, or payers (including health 
plans and their subcontractors). The consent process should be easily 
folded into existing HIPAA compliance processes, preferably with the 
patient's acknowledgement of HIPAA practices and the patient's Part 2 
consent incorporated into the same document at intake where feasible. 
Furthermore, include language to address the conflict with Part 2's 
list of disclosures requirement.

Transmission and Retransmission of Data. The CARES Act plainly states 
that once written consent is obtained, a Part 2 record may be 
transmitted and retransmitted for TPO in accordance with HIPAA 
regulations. No further consent should be required for TPO unless the 
patient revokes consent.

Recommendation: Include specific language directing covered entities 
and business associates to disclose and redisclose data in accordance 
with HIPAA regulations.

The final rule also requires physically separating records with Part 2 
data. However, such physical separation is difficult once the data is 
transmitted, as very few integrated systems or Health Information 
Exchanges (HIEs) can manage the consent process for a completely 
separate database for Part 2 records. The separation of data not only 
creates an administrative burden, but also makes the data difficult to 
obtain by subsequent treating providers, ultimately hindering patient 
care. For example, we have heard anecdotes of physicians physically 
carrying two separate laptops for the purposes of compliance with the 
data segregation requirements.

Recommendation: Specify that once Part 2 data is transmitted or 
retransmitted with patient consent, there is no requirement to 
segregate a patient's Part 2 data from the rest of a HIPAA database, 
with the regulatory requirement for data segmentation terminating upon 
transmission or retransmission.

Revocation of Consent Provisions. The patient's ability to revoke 
consent is an important privacy protection supported by the 
Partnership. However, serious administrative issues arise when there is 
an expectation that a revocation be retroactively effective. 
Specifically, practices are now required, under the Promoting 
Interoperability program, to incorporate information from outside 
sources for medications, allergies, and other problems. If revocation 
is mandated to be retroactive, there is technically no way to go back 
and isolate this data from a patient's overall clinical record.

Furthermore, it is critical that the responsibility for managing the 
revocation remain with a designated entity. We believe that the 
management of the consent revocation should be the responsibility of 
the Part 2 treatment entity that contributed that data and that program 
would be responsible for seeing that the Part 2 data is not being 
transmitted either to another covered entity or business associate.

Recommendation: Specifically state that the revocation of consent for 
Part 2 data transmission is effective only from the point of revocation 
going forward and that responsibility for the revocation should be 
limited to those who are so notified by the patient and their 
respective actions.

Scope of Part 2 Consent Process. SAMHSA's current guidance seems to 
indicate that a Part 2 consent should not impede the transmission of 
behavioral health data that does not originate with a Part 2 program. 
However, this is very different in practice as there is much confusion 
on how to handle behavioral health data. Providers hesitate to share 
behavioral health data because they are concerned that they may be 
violating Part 2 requirements related to consent.

Recommendation: OCR and SAMHSA should explore, in partnership with 
stakeholders, how to exclude behavioral health data from the Part 2 
data and incorporate the findings into the rule and any subsequent 
frequently asked questions or guidance. Similarly, OCR and SAMHSA 
should explore, in conjunction with the States and stakeholders, policy 
mechanisms for promoting the use of behavioral health data for care 
coordination purposes when state privacy laws may impose restrictions 
beyond both Part 2 and HIPAA.

Research. The final rule permits disclosures for the purposes of 
research under Part 2 by a HIPAA covered entity or business associate 
to non-HIPAA covered individuals and organizations. However, the CARES 
Act does not specifically address disclosures for the purpose of 
research.

Recommendation: Include a provision in the next rule, consistent with 
the last rule, to ensure that disclosures for the purposes of research 
from a HIPAA covered entity to a non-HIPAA covered entity are 
permissible.

Patient Rights. The final rule does not address patient rights. 
However, in Section 422(j) of the CARES Act, it is stated that nothing 
in that section can be construed to limit patient rights related to 
privacy protections for protected health information as defined under 
Section 164.522 of the HIPAA Privacy Rule.

Recommendation: Include specific language to ensure that patient 
privacy rights are protected in accordance with the CARES Act and 
HIPAA.

Claims Data Access. Currently, HHS provides patients' claims data 
through various initiatives, including to organizations participating 
in alternative payment models. Accountable care organizations, for 
example, are provided claims data at least monthly, and sometimes 
weekly. But these data lack SUD-related information because of limits 
of Part 2.

Recommendation: We urge HHS to start providing SUD-related claims data 
to providers practicing in alternative payment models to help support 
their work in population health management.

Thank you for your time and consideration on this crucial issue. Please 
feel free to contact Deepti Loharikar, Director of Regulatory Affairs, 
Association for Behavioral Health and Wellness, at [email protected] 
or (202) 505-1834 with any questions.

Sincerely,

Maeghan Gilmore, MPH
Chairperson, Partnership to Amend 42 CFR Part 2

                       Members of the Partnership

        Academy of Managed Care Pharmacy  Alliance of Community Health 
        Plans  American Association on Health and Disability  
        American Health Information Management Association  American 
        Hospital Association  American Psychiatric Association  
        American Society of Addiction Medicine  American Society of 
        Anesthesiologists  America's Essential Hospitals  America's 
        Health Insurance Plans  AMGA  Association for Ambulatory 
        Behavioral Healthcare  Association for Behavioral Health and 
        Wellness  Association for Community Affiliated Plans  
        Association of Clinicians for the Underserved  Blue Cross Blue 
        Shield Association  The Catholic Health Association of the 
        United States  Centerstone  College of Healthcare Information 
        Management Executives  Confidentiality Coalition  Employee 
        Assistance Professionals Association  Global Alliance for 
        Behavioral Health and Social Justice  Hazelden Betty Ford 
        Foundation  Healthcare Leadership Council  InfoMC  The Joint 
        Commission  The Kennedy Forum  Medicaid Health Plans of 
        America  Mental Health America  National Alliance on Mental 
        Illness  National Association for Behavioral Healthcare  
        National Association for Rural Mental Health  National 
        Association of ACOs  National Association of Addiction 
        Treatment Providers  National Association of Counties  
        National Association of County Behavioral Health and 
        Development Disability Directors  National Association of 
        State Mental Health Program Directors  National Rural Health 
        Association  Netsmart  OCHIN  Opioid Safety Alliance  
        Otsuka America Pharmaceutical, Inc.  Primary Care 
        Collaborative  Pharmaceutical Care Management Association  
        Premier Healthcare Alliance  Population Health Alliance  
        Smiths Medical  Strategic Health Information Exchange 
        Collaborative

                                 ______
                                 
              Office of the United States Surgeon General
The Honorable Ron Wyden
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20510

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

Dear Chairman Wyden and Ranking Member Crapo,

Thank you for your leadership and dedication to this critical issue. As 
you mention in your letter, the COVID-19 pandemic has not simply 
created a new mental health crisis, but rather exacerbated a 
longstanding crisis that continues to affect people across this 
country. I was deeply concerned about the mental health of our country 
before the pandemic, and my concerns have grown over the past year.

Before COVID-19, mental health conditions were widespread in the United 
States, and there was significant unmet need for mental health 
diagnosis and treatment among young people and adults. Drivers of this 
crisis before the pandemic included stigma, shortages in the mental 
health workforce, health disparities, limited investments in 
prevention, and treatment services that were too limited and 
insufficiently integrated with primary care. And the cost of this 
crisis is accumulated in both human suffering and financial losses, as 
people with mental illness incur higher health care spending for non- 
mental health associated conditions and billions of dollars in lost 
earnings per year.

The pandemic has added urgency to these challenges. Millions of people 
have experienced the trauma of family, friends, and neighbors dying or 
being hospitalized with COVID-19. Working people have lost jobs or had 
their hours cut. Parents, disproportionately mothers, have endured 
significant stress in caring for their children and adapting to virtual 
schooling. An estimated 40,000 children in America lost a parent to 
COVID-19, and millions of children have been isolated from their 
friends and supportive school environments. Patients dealing with 
anxiety, depression, addiction, and other illnesses have had their 
access to treatment disrupted. And health care workers have gone 
through unimaginable pain watching, in some cases, dozens of their 
patients die of this terrible disease. The statistics on substance 
misuse, which so often occurs alongside mental illness, are also 
heartbreaking:

More than 87,000 of our neighbors, friends, and family members died of 
a drug overdose over the past year--the highest number of yearly drug 
overdose deaths in recent memory.

Mental health has been an important issue for the Office of the Surgeon 
General dating back to 1999, when my predecessor, Dr. David Satcher, 
released the landmark Surgeon General's Report on Mental Health. As a 
nation, we've come a long way since then in raising awareness about 
mental health, helping reduce stigma and shame, and expanding access to 
mental health treatment.

But the pandemic has reminded us just how much more remains to be done.

We must expand access to mental health services, by supporting mental 
health telehealth programs, training more mental health professionals, 
enforcing the 2008 Mental Health Parity and Addiction Equity Act, and 
integrating mental health services with primary care. We must do more 
to protect our children, who at times struggle for years with 
undiagnosed mental illness, by increasing access to mental health 
diagnostic and treatment services and by investing in evidence-based 
social emotional learning programs. We must extend further help to 
those at risk for suicide, including transitioning to full national 
availability of 988 as the new national suicide prevention and mental 
health crisis number. And we must target our efforts to communities 
that have struggled with high rates of depression, anxiety, and 
suicide--including health care workers whose alarmingly high rate of 
mental illness and burnout poses a threat to our ability to provide 
care to people throughout our nation. In all this work, we must 
prioritize equity, as we know that rural communities and communities of 
color face higher rates of mental health stigma and less access to 
treatment.

Perhaps most challenging of all, we must change the way we think about 
mental health. For too long, mental illness was a source of shame, and 
that shame prevented people from seeking help and compounded their 
suffering. Through our words, our actions, and our example, we can help 
people recognize that you are not broken or deficient if you are 
struggling with your mental health. Each of us can play a role in 
providing support to those who are suffering and in affirming their 
humanity. When we treat mental health with the same importance and 
urgency as physical health, when we apply ourselves as much to 
prevention programs as treatment efforts, when we set bold goals and 
hold ourselves to account, then we will see the change our nation 
needs.

We have many reasons to be hopeful. We have evidence-based programs, 
such as the Certified Community Behavioral Health Clinics, that are 
well-positioned to provide critical behavioral health services and 
expand access to care across the nation. We have school-based programs 
which have demonstrated their ability to reduce rates of mental illness 
and substance use disorders in a cost- effective manner. And we have 
millions of people across America whose lives have been touched by 
mental illness and who now want to be part of the solution. We can use 
this opportunity during the COVID-19 pandemic, when more people are 
talking about mental health and increased funding is being directed to 
address mental health issues, to act and take bold steps to improve the 
mental health of our country.

Responding to the mental health needs across America should be a 
central focus both during and after this pandemic, and I appreciate the 
attention you and others in Congress have brought to this issue. I know 
the road ahead is steep. We have much work to do. And we are still 
making our way through a difficult pandemic. But the progress we have 
made gives me faith in what is yet to come.

As the Committee moves forward under your leadership, HHS is committed 
to working with the Senate Finance Committee--and all of Congress--to 
address America's mental health crisis. Thank you for the opportunity 
to weigh in on such an important issue. I look forward to learning from 
you and partnering with you in the months ahead to tackle the nation's 
mental health crisis.

Sincerely,

Vivek Murthy, M.D., M.B.A.
U.S. Surgeon General
Vice Admiral, U.S. Public Health Service

                                   [all]