[Congressional Record Volume 161, Number 168 (Monday, November 16, 2015)]
[House]
[Pages H8176-H8180]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
IMPROVING ACCESS TO EMERGENCY PSYCHIATRIC CARE ACT
Mr. PITTS. Mr. Speaker, I move to suspend the rules and pass the bill
(S. 599) to extend and expand the Medicaid emergency psychiatric
demonstration project, as amended.
The Clerk read the title of the bill.
The text of the bill is as follows:
S. 599
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Improving Access to
Emergency Psychiatric Care Act''.
[[Page H8177]]
SEC. 2. EXTENSION AND EXPANSION OF MEDICAID EMERGENCY
PSYCHIATRIC DEMONSTRATION PROJECT.
(a) In General.--Subsection (d) of section 2707 of Public
Law 111-148 (42 U.S.C. 1396a note) is amended to read as
follows:
``(d) Length of Demonstration Project.--
``(1) In general.--Except as provided in paragraphs (2) and
(3), the demonstration project established under this section
shall be conducted for a period of 3 consecutive years.
``(2) Temporary extension of participation eligibility for
selected states.--
``(A) In general.--Subject to subparagraph (B) and
paragraph (4), a State selected as an eligible State to
participate in the demonstration project on or prior to March
13, 2012, shall, upon the request of the State, be permitted
to continue to participate in the demonstration project
through September 30, 2016, if--
``(i) the Secretary determines that the continued
participation of the State in the demonstration project is
projected not to increase net program spending under title
XIX of the Social Security Act; and
``(ii) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such extension for that
State is projected not to increase net program spending under
title XIX of the Social Security Act.
``(B) Notice of projections.--The Secretary shall provide
each State selected to participate in the demonstration
project on or prior to March 13, 2012, with notice of the
determination and certification made under subparagraph (A)
for the State.
``(3) Extension and expansion of demonstration project.--
``(A) Additional extension.--Taking into account the
recommendations submitted to Congress under subsection
(f)(3), the Secretary may permit an eligible State
participating in the demonstration project as of the date
such recommendations are submitted to continue to participate
in the project through December 31, 2019, if, with respect to
the State--
``(i) the Secretary determines that the continued
participation of the State in the demonstration project is
projected not to increase net program spending under title
XIX of the Social Security Act; and
``(ii) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that the continued participation
of the State in the demonstration project is projected not to
increase net program spending under title XIX of the Social
Security Act.
``(B) Option for expansion to additional states.--Taking
into account the recommendations submitted to Congress
pursuant to subsection (f)(3), the Secretary may expand the
number of eligible States participating in the demonstration
project through December 31, 2019, if, with respect to any
new eligible State--
``(i) the Secretary determines that the participation of
the State in the demonstration project is projected not to
increase net program spending under title XIX of the Social
Security Act; and
``(ii) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that the participation of the
State in the demonstration project is projected not to
increase net program spending under title XIX of the Social
Security Act.
``(C) Notice of projections.--The Secretary shall provide
each State participating in the demonstration project as of
the date the Secretary submits recommendations to Congress
under subsection (f)(3), and any additional State that
applies to be added to the demonstration project, with notice
of the determination and certification made for the State
under subparagraphs (A) and (B), respectively, and the
standards used to make such determination and certification--
``(i) in the case of a State participating in the
demonstration project as of the date the Secretary submits
recommendations to Congress under subsection (f)(3), not
later than August 31, 2016; and
``(ii) in the case of an additional State that applies to
be added to the demonstration project, prior to the State
making a final election to participate in the project.
``(4) Authority to ensure budget neutrality.--The Secretary
annually shall review each participating State's
demonstration project expenditures to ensure compliance with
the requirements of paragraphs (2)(A)(i), (2)(A)(ii),
(3)(A)(i), (3)(A)(ii), (3)(B)(i), and (3)(B)(ii) (as
applicable). If the Secretary determines with respect to a
State's participation in the demonstration project that the
State's net program spending under title XIX of the Social
Security Act has increased as a result of the State's
participation in the project, the Secretary shall treat the
demonstration project excess expenditures of the State as an
overpayment under title XIX of the Social Security Act.''.
(b) Funding.--Subsection (e) of section 2707 of such Act
(42 U.S.C. 1396a note) is amended--
(1) in the subsection heading, by striking ``Limitations on
Federal'';
(2) in paragraph (2)--
(A) in the paragraph heading, by striking ``5-year''; and
(B) by striking ``through December 31, 2015'' and inserting
``until expended'';
(3) by striking paragraph (3);
(4) by redesignating paragraphs (4) and (5) as paragraphs
(3) and (4), respectively;
(5) in paragraph (3) (as so redesignated), by striking
``and the availability of funds'' and inserting ``(other than
States deemed to be eligible States through the application
of subsection (c)(4))''; and
(6) in paragraph (4) (as so redesignated)--
(A) in the first sentence--
(i) by inserting ``(other than a State deemed to be an
eligible State through the application of subsection
(c)(4))'' after ``eligible State''; and
(ii) by striking ``paragraph (4)'' and inserting
``paragraph (3)''; and
(B) by inserting after the first sentence the following:
``In addition to any payments made to an eligible State under
the preceding sentence, the Secretary shall, during any
period in effect under paragraph (2) or (3) of subsection
(d), or during any period in which a law described in
subsection (f)(4)(C) is in effect, pay each eligible State
(including any State deemed to be an eligible State through
the application of subsection (c)(4)), an amount each quarter
equal to the Federal medical assistance percentage of
expenditures in the quarter during such period for medical
assistance described in subsection (a). Payments made to a
State for emergency psychiatric demonstration services under
this section during the extension period shall be treated as
medical assistance under the State plan for purposes of
section 1903(a)(1) of the Social Security Act (42 U.S.C.
1396b(a)(1)).''.
(c) Recommendations to Congress.--Subsection (f) of section
2707 of such Act (42 U.S.C. 1396a note) is amended by adding
at the end the following:
``(3) Recommendation to congress regarding extension and
expansion of project.--Not later than September 30, 2016, the
Secretary shall submit to Congress and make available to the
public recommendations based on an evaluation of the
demonstration project, including the use of appropriate
quality measures, regarding--
``(A) whether the demonstration project should be continued
after September 30, 2016; and
``(B) whether the demonstration project should be expanded
to additional States.
``(4) Recommendation to congress regarding permanent
extension and nationwide expansion.--
``(A) In general.--Not later than April 1, 2019, the
Secretary shall submit to Congress and make available to the
public recommendations based on an evaluation of the
demonstration project, including the use of appropriate
quality measures, regarding--
``(i) whether the demonstration project should be
permanently continued after December 31, 2019, in 1 or more
States; and
``(ii) whether the demonstration project should be expanded
(including on a nationwide basis).
``(B) Requirements.--Any recommendation submitted under
subparagraph (A) to permanently continue the project in a
State, or to expand the project to 1 or more other States
(including on a nationwide basis) shall include a
certification from the Chief Actuary of the Centers for
Medicare & Medicaid Services that permanently continuing the
project in a particular State, or expanding the project to a
particular State (or all States) is projected not to increase
net program spending under title XIX of the Social Security
Act.
``(C) Congressional approval required.--The Secretary shall
not permanently continue the demonstration project in any
State after December 31, 2019, or expand the demonstration
project to any additional State after December 31, 2019,
unless Congress enacts a law approving either or both such
actions and the law includes provisions that--
``(i) ensure that each State's participation in the project
complies with budget neutrality requirements; and
``(ii) require the Secretary to treat any expenditures of a
State participating in the demonstration project that are
excess of the expenditures projected under the budget
neutrality standard for the State as an overpayment under
title XIX of the Social Security Act.
``(5) Funding.--Of the unobligated balances of amounts
available in the Centers for Medicare & Medicaid Services
Program Management account, $100,000 shall be available to
carry out this subsection and shall remain available until
expended.''.
(d) Conforming Amendments.--Section 2707 of such Act (42
U.S.C. 1396a note) is amended--
(1) in subsection (a), in the matter before paragraph (1),
by inserting ``publicly or'' after ``institution for mental
diseases that is'';
(2) in subsection (c)--
(A) in paragraph (1), by striking ``An eligible State'' and
inserting ``Except as otherwise provided in paragraph (4), an
eligible State'';
(B) in paragraph (3), by striking ``A State shall'' and
inserting ``Except as otherwise provided in paragraph (4), a
State shall''; and
(C) by adding at the end the following:
``(4) Nationwide availability.--In the event that the
Secretary makes a recommendation pursuant to subsection
(f)(4) that the demonstration project be expanded on a
national basis, any State that has submitted or submits an
application pursuant to paragraph (2) shall be deemed to have
been selected to be an eligible State to participate in the
demonstration project.''; and
(3) in the heading for subsection (f), by striking ``and
Report'' and inserting ``, Report, and Recommendations''.
(e) Effective Date.--The amendments made by this section
shall take effect on the date of the enactment of this Act.
[[Page H8178]]
The SPEAKER pro tempore. Pursuant to the rule, the gentleman from
Pennsylvania (Mr. Pitts) and the gentleman from Texas (Mr. Gene Green)
each will control 20 minutes.
The Chair recognizes the gentleman from Pennsylvania.
General Leave
Mr. PITTS. Mr. Speaker, I ask unanimous consent that all Members may
have 5 legislative days in which to revise and extend their remarks and
insert extraneous materials into the Record on the bill.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Pennsylvania?
There was no objection.
Mr. PITTS. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, the bill before us today extends and expands the
Medicaid emergency psychiatric demonstration project.
A longstanding policy under Medicaid, called the institutions for
mental diseases, IMD, exclusion, prohibits the Federal Government from
providing Federal Medicaid matching funds to States for services
rendered to Medicaid-eligible individuals aged 21 to 64 who are
patients in IMDs. IMDs are inpatient facilities with more than 16 beds
that primarily treat people with mental health and substance abuse
disorders. The original IMD exclusion is consistent with the goal of
treating severe mental illness in the least restrictive setting
feasible.
The IMD exclusion provided an incentive to shift the cost of care for
mental illness to other care modalities and facilities where Medicaid
matching funds were available. However, since the IMD exclusion was
included with the creation of the Medicaid program in 1965, our mental
healthcare system and overall healthcare system have evolved notably.
In recent years, we have seen a significant decrease in the number of
publicly funded inpatient psychiatric beds available for emergency
services. This has contributed to patients in need of critical mental
health services facing psychiatric boarding in general hospital
emergency departments.
Psychiatric boarding occurs when an individual with a mental health
condition is kept in a hospital emergency department for several hours
or admitted to medical wards or skilled nursing facilities without
psychiatric expertise because appropriate mental health services were
unavailable. This leads to potential serious consequences for
psychiatric patients and unnecessary hospital costs.
The Patient Protection and Affordable Care Act authorized a 3-year
demonstration program to study the effects of allowing Federal Medicaid
matching funds to pay for emergency psychiatric treatment for adults
that is otherwise prohibited by the Medicaid IMD exclusion. The
demonstration was funded with $75 million in FY 2011, and these funds
were available for obligation through December 31, 2015.
The HHS Secretary selected 11 States and the District of Columbia to
participate in the demonstration program in March of 2012, and the
demonstration program began July 1, 2012. Due to significant State
interest, patient need, and other factors, the demonstration project
exhausted its Federal funding in April and was forced to terminate
early.
S. 599 would temporarily extend the Medicaid emergency psychiatric
demonstration for States already participating in the demonstration
through September 30, 2016, if the chief actuary of CMS certifies that
this extension would not increase net Medicaid spending.
The bill also requires that, not later than September 30, 2016, the
HHS Secretary report to Congress on whether the demonstration should be
continued after such date and whether the demonstration should be
expanded to additional States. If the chief actuary of CMS certifies
that this extension would not increase net Medicaid spending, then the
demonstration may continue not beyond 2019.
While I have strong concerns with the President's healthcare law, S.
599 would let States and CMS continue to test the provision of critical
mental health services for patients in a manner that is responsible for
the Federal budget.
Mr. Speaker, I encourage my colleagues to support this commonsense,
bipartisan bill.
I reserve the balance of my time.
Mr. GENE GREEN of Texas. Mr. Speaker, I yield myself such time as I
may consume.
Mr. Speaker, I rise in support of S. 599, the Improving Access to
Emergency Psychiatric Care Act.
This legislation, sponsored by Senator Ben Cardin and championed in
the House by Representative John Sarbanes, will extend and expand the
Medicaid emergency psychiatric demonstration protect. Since the
creation of Medicaid 50 years ago, the program has excluded payment for
institutions for mental diseases, IMDs, a designation that includes
most residential treatment facilities for mental health and substance
use disorders with more than 16 beds.
The original IMD exclusion is consistent with the goal of treating
severe mental illness in the least restrictive setting possible.
However, there have been some unintended consequences of this
longstanding policy. States have an incentive to shift the cost of
treating mental illness to other care settings where Medicaid matching
funds are available. This contributed to a decrease in the number of
publicly funded beds available for inpatient psychiatric emergency
services. It also contributed to a rise in psychiatric boarding and
recidivism in hospital emergency departments.
To develop data on whether modifying an IMD exclusion can improve
health care for mental illness, the Affordable Care Act authorized $75
million over 3 years for the Medicare emergency psychiatric
demonstration project. Administered by the CMS Innovation Center, the
initiative aims to test whether the Medicaid program could provide
higher quality care at a lower total cost by reimbursing private
psychiatric hospitals for emergency care otherwise prohibited by the
Medicaid IMD exclusion. The demonstration project is currently
operating in 11 States and the District of Columbia.
This legislation extends the demonstration in a budget-neutral manner
so that the Secretary of Health and Human Services can complete an
evaluation and make an informed recommendation regarding its
continuation and expansion.
Medicaid plays a central and critical role in covering treatment for
individuals with mental illness. S. 599 holds promise for improving
access to quality psychiatric care for this underserved and vulnerable
population and the overall success of our mental healthcare system.
I urge my colleagues to support S. 599, and I thank the sponsors for
their commitment to this important issue.
I reserve the balance of my time.
Mr. PITTS. Mr. Speaker, I yield 2 minutes to the gentlewoman from
Indiana (Mrs. Brooks), a prime sponsor of the House companion bill and
a member of the Energy and Commerce Subcommittee on Health.
Mrs. BROOKS of Indiana. Mr. Speaker, I rise today to speak in support
of S. 599, the Improving Access to Emergency Psychiatric Care Act. The
bill is the companion to H.R. 3681, which I proudly introduced with my
colleague, Congressman Sarbanes from Maryland.
With the passage of this bill today, I am pleased that this
meaningful mental health reform will head to the President's desk.
Fortunately, this bipartisan, bicameral, and commonsense legislation is
a great step toward enacting meaningful reforms to an incredibly
challenging system.
Currently, CMS does not reimburse private psychiatric institutions or
institutions for mental diseases for the services provided to Medicaid
enrollees aged 21 to 64. Yet often serious mental illness manifests
itself in those in their twenties, and they are not allowed to go with
a severe psychiatric break to a psychiatric hospital.
Instead, they go and present at our ERs; and our ERs are already
overburdened. Many of them often lack the resources and sometimes the
expertise to deal with people who are suffering from a true mental
crisis. When they find themselves in the ERs, it is not uncommon for
them to have to sit for hours and for far too long while they are
suffering.
This commonsense legislation extends the existing demonstration grant
that lifts the IMD exclusion and will allow these important psychiatric
clinics to receive Medicaid reimbursement
[[Page H8179]]
while giving people access to short-term direct care in psychiatric
hospitals when they need it most.
I am proud to support the extension of this legislation that allows
people to get the treatment that they need. As a lawyer, I have dealt
with people who have been in a psychiatric crisis. Many of us have
family members who have dealt with a psychiatric crisis. They need the
help from the right experts at the right time.
I thank the gentleman for carrying this in the House, and I urge my
colleagues to support this legislation.
Mr. GENE GREEN of Texas. Mr. Speaker, I yield such time as he may
consume to the gentleman from Maryland (Mr. Sarbanes). He is also a
member of the Energy and Commerce Committee and a member of our Health
Subcommittee. I personally appreciate his commitment to mental health.
Mr. SARBANES. Mr. Speaker, I thank the gentleman for yielding and for
his leadership on the Health Subcommittee and on the Energy and
Commerce Committee.
I rise today in strong support of the Improving Access to Emergency
Psychiatric Care Act. I thank Representative Brooks of Indiana for her
support of this measure and certainly welcome the fact that this is a
bipartisan piece of legislation.
What this bill would do is it would extend a demonstration project,
as indicated, that ends the Federal prohibition on Medicaid matching
payments to community psychiatric hospitals for emergency psychiatric
cases. This demonstration project allows individuals with severe mental
illness who are a threat to themselves or to others, including those
with substance abuse disorders who have experienced overdoses, to get
emergency inpatient treatment.
The background of this is as follows:
There has been a longstanding Medicaid provision, dating back to
1965, called the institutions for mental diseases, IMD, exclusion.
Under that, the Federal Government is prohibited from providing
Medicaid matching funds and reimbursement for the care of eligible
individuals aged 21 to 64 if that care is provided in an inpatient
facility that primarily treats people with mental health and substance
abuse disorders and if that facility has more than 16 beds.
As was indicated, the effect of this exclusion has been to decrease
the number of inpatient psychiatric beds that are available for
emergency services. It has also been cited by the Government
Accountability Office as a factor in emergency department overcrowding,
which Congresswoman Brooks just indicated.
Community-based psychiatric hospitals could help relieve these
backups and provide much-needed emergency psychiatric care, but these
hospitals cannot receive Federal matching payments for these services.
In 2010, Congress authorized a 3-year pilot called the Medicaid
emergency psychiatric demonstration project, which expanded the number
of emergency inpatient psychiatric beds available in communities by
allowing Federal Medicaid matching payments to freestanding psychiatric
hospitals for emergency psychiatric cases.
{time} 1730
Eleven States, including my home State of Maryland, are participating
in this demonstration, and the preliminary data is very promising. Of
the total number of Medicaid beneficiaries admitted to these community-
based psychiatric hospitals, fully 84 percent had just one admission
during the entire first year of the demonstration. The average length
of stay was only 8.2 days, and in 88 percent of the admissions, the
beneficiaries were discharged to their homes or to self-care.
The demonstration project is set to end on December 31, 2015, but the
final evaluation of the project is not expected to be completed until a
year later.
In closing, Mr. Speaker, this bill would build upon the success of
the current demonstration project, which is providing timely and cost-
effective care. It would also extend the current demonstration project
by 1 year.
It would ensure budget neutrality by certifying that the extension is
not projected to result in an increase in net Medicaid program
spending, and it would allow the Secretary of HHS to extend the
demonstration project for an additional 3 years, provided that the
requirements regarding Medicaid spending are met.
The bill has already been passed in the Senate by unanimous consent.
While I am a little bit disappointed that a very small change was made
that is going to require it to go back to the Senate for
reconsideration, I am confident that it will be supported there again
with Senator Cardin's leadership.
I urge support of this bipartisan effort to extend a demonstration
project that allows individuals with severe mental illness and
substance abuse disorders to get emergency inpatient treatment at
community psychiatric hospitals.
Mr. PITTS. Mr. Speaker, I am prepared to close. I reserve the balance
of my time.
Mr. GENE GREEN of Texas. Mr. Speaker, I yield the balance of my time
to the gentlewoman from California (Ms. Matsui), who is also a member
of the Committee on Energy and Commerce, a member of the Subcommittee
on Health, and, again, a champion of mental health.
Ms. MATSUI. Mr. Speaker, I rise today in support of the Improving
Access to Emergency Psychiatric Care Act.
As we work to reform our broken mental healthcare system, it is
critical that we build upon programs that provide resources to
underserved and vulnerable populations at all points along the spectrum
of care.
Today, with the passage of this bill, we have the opportunity to
extend the vital Medicaid emergency psychiatric demonstration project.
This demonstration project, which recently expired, ensures greater
access to essential emergency psychiatric care for Medicaid patients.
This bipartisan bill will ensure that hospitals across our Nation
will be able to provide community members in need with inpatient
psychiatric beds.
In my home district in Sacramento County, this demonstration project
has provided great benefits to our system of care. Medi-Cal
beneficiaries have greater access to mental health services, and there
has been a reduction in readmission rates at local hospitals.
In fact, by the final year of the 3-year demonstration project, the
number of individuals rehospitalized within 30 days of their initial
stay decreased by 20 percent in Sacramento County.
The project has improved coordination of care for mental health
patients by streamlining planning efforts between inpatient and
outpatient providers. In addition, Sacramento County has been able to
reinvest savings generated by the project into programs that build
greater community alternatives for patients identified as high
utilizers of inpatient and emergency departments.
All of these improvements add up to a community mental health system
in California that is better able to focus on the whole spectrum of
care for underserved patients, from prevention to treatment to the
crisis stage.
There is still much more work to do to improve the mental health
system, but we must not reverse our significant progress by failing to
renew this demonstration project.
I urge my colleagues to vote ``yes'' on S. 599, the Improving Access
to Emergency Psychiatric Care Act.
Mr. GENE GREEN of Texas. Mr. Speaker, I yield back the balance of my
time.
Mr. PITTS. Mr. Speaker, I encourage my colleagues to support this
commonsense, bipartisan bill.
I yield back the balance of my time.
Mr. PALLONE. Mr. Speaker, I rise today in support of extending and
expanding the Improving Access to Emergency Psychiatric Care Act, which
has already passed the Senate and for which identical legislation, H.R.
3681 has been introduced in the House with bipartisan support.
This legislation would extend, and expand if appropriate, the
Medicaid Emergency Psychiatric Demonstration that was created by the
Affordable Care Act.
While I will not oppose this legislation based on process, I must
mention that I am not pleased that this legislation did not go through
regular order here in the House as it should have, and as it did in the
Senate. I also do not support a change made to require the $100,000 in
administrative costs in the bill to come out of unobligated funds at
CMS. To delay this legislation, slow it down even further and force the
Senate to reconsider the bill for a one word change and an amount of
money
[[Page H8180]]
that is less than the annual salary of any Member of Congress is a
waste of time. However, despite these reservations, I support this
legislation moving forward.
Since the enactment of Medicaid in 1965, so-called ``Institutions of
Mental Disease'', or IMDs, have been prohibited by statute from
receiving federal Medicaid matching funds for inpatient treatment
provided to adults ages 21 to 64. This prohibition was rooted in the
desirability of community-based care as an alternative to mass
institutionalization of the mentally ill, often in horrific conditions.
However, as our healthcare system has grown and changed, there has
been increasing concern about the perverse incentives created by the
wholesale exclusion of IMDs from treatment for Medicaid beneficiaries;
for instance, frequent boarding of psychiatric patients in emergency
rooms and non-psychiatric beds of general hospitals has been reported
to occur when specialized inpatient psychiatric beds are not available.
The days of mass institutionalization are over and we can never go
back to those days--at the same time, so-called ``boarding'' of the
seriously mentally ill in general hospitals, because the beds simply
aren't available, is not an acceptable alternative.
Those Medicaid beneficiaries that are seriously mentally ill need the
right treatment, at the right time. The demonstration project that we
are extending here today allows states to test incorporation of IMD
services for Medicaid beneficiaries in a way that insures other
community-based services do not suffer. This legislation, which also
aligns with CMS's recent proposal to allow for short-term IMD stays in
Medicaid managed care plans, is the appropriate way to responsibly
address the Medicaid IMD exclusion.
We've had immense success with this project thus far, and we can
still learn more from it, which is exactly why this demonstration
project must be extended and as appropriate, expanded. This legislation
will allow the Secretary to do just that, and I urge my colleagues to
support its swift passage.
The SPEAKER pro tempore. The question is on the motion offered by the
gentleman from Pennsylvania (Mr. Pitts) that the House suspend the
rules and pass the bill, S. 599, as amended.
The question was taken; and (two-thirds being in the affirmative) the
rules were suspended and the bill, as amended, was passed.
A motion to reconsider was laid on the table.
____________________