will be releasing today i bipartisan staff draft of that legislation for public comment. .. on making sure the department of education implements that the way the congress wrote it and the way the president signed it. and we've done a lot of work reauthorizing higher education which expired at end of last year. we have number of bipartisan

proposals that will make it easier and simpler for students to attend college and more administrators manage our 6,000 colleges and universities. we have a lot we ought to be able to do this year and one of the most important of those items has to do with the mental health crisis that we're discussing today. i hope, and senator murray and i agree on this, we can move promptly to offer bipartisan recommendations on how to address the mental health crisis. we've already done a lot of work on it. we passed it in september the mental health awareness and improvement act that senator murray and i introduced. the senate passed that in december. senators cassidy, senator murphy have introduced legislation and senator murray and i are working with them. we hope to move promptly to bring combination of those recommendations to the full committee. not everything the senate may want to do is within our jurisdiction. so we're working with senator

blunt and senator murray runs the health appropriations subcommittee on ideas that senator blunt has proposed. we're working with senator cornyn on issues judiciary committee is considering and finance committee will probably have to be involved as well. we want to move promptly within the committee to have things promptly with our jurisdiction have them ready for the floor, to work with the leader to bring them to the floor if he chooses to do that. the reason there is such interest in the mental health crisis today, about one in five adults have a mental health condition the past year. according to the tall health services administration. that is nearly 10 million adults with illnesses such as schizophrenia, bipolar disorder, depression that interferes with major life activity. 60% of the adults didn't receive mental health services in 2014.

only half of ad deslengths receive treatment for their condition. conditions that remain untreated can lead to dropping out of school, incarceration, unemployment, homelessness and suicide. suicide is the 10th leading cause of death in the united states. 90% of those who die by suicide have an underlying mental illness. i hear that from many tennesseans. one out of five adults in tennessee reported having a mental illness. 4% had a serious mental illness. most recent data shows our rate of you side reached its highest level in five years a couple years ago. second leading cause of death. and our october hearing on mental health the committee herd from administration witnesses about the what the federal government is already doing address mental illness. we look forward to hearing from doctors, nurses advocates admin

slatetores who work with every day americans who struggle with a mental health condition, how the federal government can help patients mental health care providers communities to better address these issues. we want people to take advantage of the most innovative research. we heard some of that about the recent hearing about the rays study. we are interested to hear how the government supports evidence based treatment programs. that will require modernizing our leading federal agency for mental health t will require involvement from patients, families communities, health care providers kept departments law enforcement, state partners many others who are involved. look forward to hearing from our witnesses about the challenges we face and the solutions that they offer. senator murray. >> thank you very much, mr. chairman alexander. thank to ail of our colleagues here today.

i'm really glad we have the opportunity today to continue our discussion about ways to improve our mental health care system. we have really incredible group of witnesses joining to us share your expertise and experiences. so thank you all for coming. as i'm sure all of us do i hear far too many often from families in washington state about loved ones friends, neighbors struggling with mental illness, not getting support they need. it is heartbreaking when someone gets treatment and support it truly can make a difference. i recently heard from woman in seat tell, i will call amanda, she lived in a dumpster for fear of being abducted by aliens. case managers get her appropriate medication, housing care, supplemental security income benefits. today amanda is enrolled in school and pursuing her degree

with hopes of full-time employment. that is quite a change for her. my constituent jack's story is similarly powerful. jack is veteran from king county. he enrolled in outpatient support services after he was hospitalized several times for attempted suicide. he had serious addiction problems and was becoming alienated from his family. after being connected with support, he was able to find recovery even while being treated for cancer. he now lives independently and reconnecting with his teenage son. amanda and jack's story show that comprehensive, high quality mental health care can truly give someone their life back. but unfortunately a lot of stories don't end that way. in fact only 63% of the people with serious mental health illness received treatment in the past year. i'm focusing on a few challenges in particular today, ones which i believe our witnesses will have a lot to say about as well. the first is inadequate access to treatment.

far too many communities lack access to mental health professionals. in fact half of all u.s. counties don't have a single psychiatrist, psychologist or social worker. that means for many patients and families it is unclear where to turn for help. so we need to make sure communities have access to trained professionals who can intervene, treat and support those struggling with mental illness. in addition to strengthening our mental health workforce we need to make sure when someone presents in crisis or chooses to seek help there are providers who can take them in and meet their needs. no patient should be turned away, asked to wait in an emergency room for days or be left out on the street because there isn't available bed. miss blake, i'm sure this is problem you have seen all to often in the e.r. i think we can and must do better on this. i'm looking forward to hearing all of your thoughts. another issue i'm really eager to talk about today is the need

to truly enat that great mental and physical health care. the two stories i shared a minute ago have especially something in common. amanda just didn't need psychiatric help. she mead needed primary care. jack needed help with addiction and depression. during the course of his recovery he also needed treatment of cancer. silos exist between mental health care and physical care don't match patient realities and that needs to change. the legislation that senator murphy and cassidy have worked on together would take some very important steps to better integrate mental and physical headlight care. and i'm also interested in some innovative steps being taken at the state level. for example in my state the university of washington has a residency program that allows students focused on psychiatry to get experience working in physical health settings. dr. help burn, i know you are focused on this challenge and we're grateful for your

challenges today. if we are to confront the challenges i laid out today and many others within our mental health system we have to break down barriers that stigma creates for those suffering from mental illness. like dr. eaton and means raising awareness that those struggling don't feel they have to struggle alone. today nearly one in five people in our country experience mental illness in given year. far too many don't receive treatment when they need it and part of the reason is stigma gets in their way. mr. rahim, you worked over a decade to raise awareness and promote understanding of mental health in community across the country and you've been a inspiration to many people who otherwise might have not had the courage to seek help. i want to thank you for your work and i'm eager to hear what you think congress should do to

lend our voices to efforts like yours. we thank the witnesses today. we have a lot of urgent work ahead of us to make sure families and community have access to comprehensive, high quality mental health care they need and i look forward, mr. chairman, to work on bipartisan effort to strengthen our mental health system and if i have our patients opportunities to lead healthy and fulfilling lives. thank you. >> thank you, senator murray. we welcome the four witnesses. i thank you for arranging to be here. you have all busy schedules other things to be doing. we're grateful for that. i will ask senator mikulski to introduce one of you since she has a conflict which will requirer had to leave soon. >> thank you very much, senator alexander. and i i want to thank you for yr continuing progress here holding hearings on issue of mental health. i know this is the third hearing on the topic. i want to really salute you and senator murray for moving in that direction. the commerce, justice,

subcommittee on appropriations is holding a hearing on president obama's proposals on gun control and as the vice-chair i must be at duty station and have to excuse myself. i really wanted to be at this hearing because the fact, i'm a professionally trained social worker. we've been working on these issues all of my professional life. this is what i live for. this is why i came to the senate, to listen to good people with great ideas when how we could help our people. we have two dished marylanders here. one of course is dr. hepburn who headed up state of maryland's agency on health and mental health. himself a university of maryland trained clinician who went on to breathe mental health into a bureaucracy and bring care to our people in a state that mandates an affordable budget. so we're going to have some

great ideas. then we have dr. eaton here. dr. william eaton is professor of department of mental health at famous bloomberg school of public health. dr. eaton is a professor there and he chairs the department of mental health. it is the only department with a level one unit in a school of public health in the world. usually public healthys about vaccinations but dr. eaton thinks about how can we build resilient personalities and do preventative work. he will talk to you today about his work, his research, his recommendations. understanding, i believe the thrust will be everybody who has a mental health problem needs individual treatment but they live in a social world and we need to look at the social indicators, look at the social epidemiology and how can we strengthen anchor institutions of the family and the school.

you will learn a lot from him. i already learned a lot from him as i do from listening to the folks at john hopkins school of public health. i really look forward to where we're going on this issue of mental health. in a nutshell, when i got out of graduate school, senator alexander, while i actually went to graduate school, when national institute of health grant so that they were training community mental health social workers. president kennedy led the battle to establish community mental health centers, to get rid of the old snakepit type mental health hospitals. all the practitioners at the table remember that. mr. rahim, i'm sure you heard stories of that we welcome you here with your personal courage. maybe not that we need new ideas or new institutions. maybe we need to look with we thought we were going to do and we never did it. we never followed through on community mental health centers. maybe that is the way to go. we never followed through in

aggressive way to enforce the wellstone-domenici mental health parity act. maybe that is the way we need to go. speaking as a social worker along with nurses we know mental health requires a team approach. it is both the psychiatrist which we need but it's those trained in these matters. now i know my colleagues would never think i had a therapeutic personality but i look forward to working with you in the best way possible to advance ideas that will come forth and how we can really meet this crisis that's growing and expanding. thank you very much, mr. chairman. >> thank you senator mikulski. we'll hear from our witnesses and let me present them. again dr. hepburn has been mentioned. he is executive director of national association of state and mental health program directors which represent mental health service delivery systems in all 50 states. he's been a clinical associate

of professor of psychiatry at the university of maryland medical system for nearly 20 years. and he has cared for patients pour more than 20 years. the second witness, miss penny blake, registered nurse working in an emergency department in central florida. she has been a nurse for 40 years. worked in an emergency department for 15 years. she chairs the national advocacy advisory council for emergency nurses. dr. eaton, who senator mikulski mentioned is professor at bloomberg school of public health, an expert in the field, written hundreds of articles. much of his work has focused on the cooccurrence of mental health disorders and other chronic health issues like diabetes and heart disease. mr. hakim rahim is the ceo of live breathe. organization focused on mental health advocacy reducing stigma associated with mental health. he brings his own invaluable

perspective of his own journey of mental illness which began during his freshman year in college. we will enjoy hearing from all of you. if you summarize your remarks to five minutes. that will leave more time for senators to have conversation with you about your testimony. why don't we start with dr. hepburn. no thank you very much. -- thank you very much, chairman alexander, ranking member murray, senator mikulski. hard to think of maryland without senator mikulski so, thank you. >> [inaudible] >> thank you for the opportunity today to address this committee. on state services, for regarding mental illness. thanks go to this committee and its members. other members of the senate and the house who are working to find ways to support, strengthen and augment the country's mental

health system. i want to especially thank in addition to the chair and ranking member senators cassidy, senators murphy. and also senator franken. also want to congratulate senator franken on his second grandchild. that is where it all starts being a good grandparent. so, the, we appreciate the full congress passing senator cardin's legislation on imd demonstration. also we appreciate the support from congress on the first episode psychosis program. the organization which i represent the national association of state mental health program directors represents the state executives of the mental health authorities. representing agencies that have $41 billion in public mental health services and deliver services to 7.3 missions.

the mission is to work with the states and partners to promote wellness and recovery and resiliency. nastmhd integration of and prevention, trauma informed approaches, minimize consumer contact with police, develop the workforce, promote supported employment, supportive housing and decrease homelessness. support the use of data and health information technology. the state mental health authorities vary widely in terms how they're organized, however they share some common functions. planning and coordinate as comprehensive array of mental health services, submitting annual application to the block grant, educating the public, operating and funding inpatient services. this could be with state hospitals or could be buying

inpatient services in the private sector. the state mental health authorities work closely with the samsa which has been an excellent partner for us. the acting administrator is respected leader in the field. we appreciate having her as a leader and a partner. smsa provided strong leadership in promoting best practices for individuals with severe mental illness. the best example of that is first episode psychosis program. the first episode psychosis program started with research. the research showed that it was a best practice. ihm worked with smsa to promote first episode psychosis program. the implementation is across the country. it is an excellent way how the federal government wan work with the states and providers in order to promote a best practice. it is important to note that the role of the state mental health

authorities has changed over last 30 years. 30 years ago, states were promerrillly involved in state hospitals. 75% of the budget went to state hospitals. now 75% of the budget goes to the community. 30 years ago the private sector was not really addressing issues that are in the public sector. now it's hard to separate public sector and private sector. when it comes to admissions to state hospitals now almost all of the admissions are court-related. almost all the civil admissions which previously were uninsured individuals going to state hospitals, now those uninsured individuals get the same care as insured individuals and they go to the private sector. talking about, i want to say something about the funding for the state mental health authorities. basically the funding for most states is primarily from the states themselves.

so that the state budget and medicaid make up for almost all that's spent by, in the budget by the state mental health authority. the block grant accounts for less than 1% for the funding for mental health within the states. what are some additional actions that congress and the administration could take to support the state mental health authorities? one is as i indicated the first episode psychosis program, excellent program. the fact that you've agreed to move it from 5% to 10%, it's excellent. what we would ask for a change in the methodology. the smaller states are not able to move ahead with the first episode psychosis program the way the larger states are because of the block grant methodology. a second is to modify the medicaid institution of mental disease exclusion so that imds can get paid for taking care of individuals with medicaid who

are adults. at least to start with the private sector. we, in maryland we participated with a demonstration that showed that the average length of stay in the private psychiatric hospitals were 10 days. cost per episode was about the same as for the acute general hospital psychiatric units. we would ask to reauthorize the medicaid money follows the person. this has been a very important program in terms of helping to keep people -- >> could you wind down your -- >> i'm sorry. keep people out of institutions. promoting zero suicide. promoting technology. promoting smoking cessation and supporting mental health and addiction parity. with that i will stop. thank you very much. >> thanks, dr. hepburn. miss blake. >> chairman alexander, ranking member murray and members of the committee. thank you for inviting me to testify at this important hearing. i'm an emergency news working full time in the emergency department at good samaritan

hospital in west palm beach. it is an acute care community hospital. in addition to the work in the emergency department i'm the chairperson of the advocacy advisory council for the emergency nurses association which is the largest professional health care organization dedicated to improving emergency care. as a registered nurse for almost 40 years my career has been devoted to providing the best possible care to every person who comes into our hospital's emergency department. increasingly this involves treating patients who are suffering from mental illnesses. the emergency department at my hospital has capacity of 32 actual beds which can be expanded if necessary. it serves a very diverse community. excludes extreme poverty and some of the wealthiest neighborhoods in the entire country. since federal law prohibits hospitals turning away anyone seeking emergency care i see practically kind of every urgent medical condition but on a typical shift at least 10% of

our cases involve psychiatric patients. the reasons for the surge in mental health patients incrude increase in drug abuse, veterans returning from iraq and afghanistan who suffer from p it tsd and stresses created by weak economy and joblessness. my view the principle cause is lack of adequate treatment options and resources in the community. mental patients often find they have no place to turn for treatment so they go to the one place, emergency room, guaranteed to be open at all times and willing to care for every patient n florida a physician or law enforcement officer can invoke a state law that allows for involuntary hold for up to 72 hours for a person deemed to be a threat to themselves and others. after2-hour hold is put on a patient the emergency department physician must clear the patient of any physical illness. then the patient is placed in a 10-by 10 room until we can find a facility that can accept the

patient for evaluation by a psychiatrist. because at my hospital we do not have any psychiatrists on staff and we do not have a psychiatric unit. so all patients requiring inpatient care must be transferred to one of the four psychiatric facilities in palm beach county. i can not think of a single time in the past year that any of our patients has been accepted immediately when that request has been made. a mentally ill patient typically stays in our ed 12 to 24 hours before they're transferred to a psychiatric care facility. however two, three, four-days boarding in the emergency department is not unusual. this is also the case in other hospitals in palm beach county. it is made worse, the problem is made worse by lack of insurance coverage for people who suffer from mental illnesses. our experience is consistent with research conducted by the emergency nurses association that found that the average boarding time in the emergency department is 18 hours for

psychiatric patients versus only four hours for all other types of patients. inadequate community health services and extended boarding times are detrimental both for emergency departments and the care received bit mental health patient. for hospital eds mental health patients are resource and personnel intensive. not only do these patients stay in the emergency department much longer than other patients but they often require close supervision by multiple staff and personized medical attention. by necessity diverts nurses, doctors, technicians from treatment of other patients that come through our doors. whenever a patient is placed on a 72-hour hold, we have a certain protocol we must follow in order to insure that patient's safety. a security guard in our facility is placed at the door. for the patient who is are experiencing mental health crisis, the emergency department is far from the ideal place to receive care. eds are chaotic, often loud areas in the hospital. the nurses and physicians are

stretched to their limits in caring for the other patients. and our emergency physicians are understandably reluctant to prescribe psychoactive medications for these patients because it is not their area of expertise. so if a patient needs medication we usually give some form of anti-anxiety agent. they don't begin any kind of therapeutic interventions because there is no one there with professional psychiatric training to help provide it. imagine you're already stressed, anxious, possibly suicidal and or psychotic. perhaps having hallucinations and confined to a small base, all your belongings are taken away from you so you can't hurt yourself. a guard is at your door and there is constant chaos, noise and motion. because of shortage of inpatient beds or community based treatment psychiatric options this situation continues for many hours or even days. mentality health care patients would be better served in facilities that have specialized expertise. the most important thing that we feel is needed is that

communities must have the health care infrastructure and funding to provide resources needed to keep this population healthy. they need to have parity for insurance for the same kind of coverage that people with physical illnesses have. in high quality community-based mental health system which would acute and longer term care, access to community mental health clinics, inpatient and outpatient treatment and availability of a 24 hour crisis psychiatric care and services that will allow the patient to be more integrated more fully into society. i want to thank you for allowing me the opportunity to represent and speak for my fellow emergency nurses. we passionately care about providing best possible care to all of our patients. we strive for them to have the best outcomes possible for their illnesses. and that includes those who are most vulnerable in our society. a person who is suffering from mental illness. thank you. >> thank you, miss blake.

dr. eaton. [inaudible] >> can you hear me? can you hear me now? >> yes. >> thank you, sorry for the delay. i, senator alexander and senator murray and all the rest of the members of the committee i think you guys are doing great work and i appreciate the opportunity to speak to you. my orientation is from that of epidemiology, specialty of social epidemiology. one thing i wanted to, first point i wanted to make, we all feel, we all know somebody who has mental illness of one type or other and alcohol or drug abuse and we feel strongly. there has been develop ad new metric in the field of epidemiology called disability adjusted life years. kind of corny. but that metric allows us to

compare the disease burden of all the diseases, mental and substance abuse disorders as well as cancer stroke, all the physical diseases and when we do that comparison of population bases using epidemiological data, clearly shows mental and substance abuse disorders are the most important category of disease burden and depression is the single most important disease itself in terms of disease burden and so, the importance of mental disorders has been recognized many times in the past. in the past the surgeon general's report, new freedom commission and so forth but now we have a metric that establishes scientifically that mental and substance abuse disorders are the most important form of disease category. and one of the reince for this is that the mental disorders begin early in life and they're slow. so you talk to somebody who had onset of depressive disorder about it, it turns out it will have started 10 years earlier.

the consequences of that depressive disorder will not show up sometimes for another 10 years. so, the mental disorders, especially depressive disorder actually predicts onset of stroke, dementia, heart attack, diabetes. it predicts it more powerfully than the common risk factors we know. for example, a history with history of depressive disorder as three, four times risk of heart attack. that is higher risk than somebody with high blood pressure or family history of heart disease. these start early. take a long time and consequences for physical illnesses are very strong. and we need more research to figure out why these consequences are occurring. this argues as has been stated, for the integration of primary health care with psychiatric care because now the primary care doctor is interested in saving the life of his patient the way he should be and that

means he should screen for depressive disorder and other disorders probably and learn how to do it and we should make that technology available. i want to say that there are a range of prevention programs for mental and substance abuse disorders. there are many of them and they have beneficial outcomes prove have been years or even decades following the intervention. most of these prevention programs are social interventions early in the life course prior to the onset of the disorder. so, in the school system, for example, or even shortly after birth, those preventative interventions are one of the unused resources i guess i would say. around, as a tiny aside i would say there have been breakthroughs in genetics, so-called menthalen issue in

genetics, the tendency for a gene to operate or not operate is affected by the environment. so in the future we'll be studying the way genes and environment work together and when we study that we're likely to be oriented toward the social environment. the way the social environment works together with the genetic material is the way that mental disorders have their occurrence. the failure to help people with severe mental disorders is the most glaring problem in our mental health system and it turns out that severe mental illnesses like schizophrenia, bipolar disorder, you know this, senator alexander, they are associated with a shortened lifespan by even two decades. somebody with schizophrenia will die 20 years earlier. they're not dying from schizophrenia, but dying from preventative activities like we

receive for blood pressure or lipid-lowering drugs. that is almost a criminal issue that these folks are dying so much earlier. nobody chooses to be schizophrenic. it happens to them. so, it seems like we oh them that. in building, finally in building programs related to brain research i want to mention that the national institute of mental health has lost its focus on public mental health. and also it's abandoned what should be its natural interest in diagnostic categories. this, these new programs at the national institute of mental health basically confused a huge range of researchers and puzzled the international community. and this also has vitiated the probability of developing research-based prevention programs for mental and substance abuse disorders. so the orientation is, the action, from my point of view,

the action is prevention, preventative interventions early in the life course, mostly social. and, thank you for your time. >> thank you, dr. eaton. mr. rahim. >> chairman alexander, ranking member, murray, members of the health education and labor pensions committee, senators cassidy and murphy, thank you for taking these initial steps to improve the lives of millions impacted by mental illness. let me first share my journey with mental illness. it began in 1998 as a fresh man at harvard university. three weeks into my first semester i was struck by my first terrifying panic attack. my journey continued when i had my first manic episode and second one in the spring of 2,000. my next two weeks were filled with sleepless nights, i showered less frequently and eight sporadically. i had visions of jesus, heard cars talking, spoke foreign

languages. my parents rushed me to psychiatric hospital and i was diagnosed with bipolar disorder. the last 18 years of my life have been defined by mental illness yet through support, proper treatment, and persistence i have recovered and achieved wellness. there are millions of americans who are thriving in the face of mental illness. teachers who rise every morning to face their anxiety and their students full of, classroom full of students. veterans with lingering and visible scars of ptsd who will still provide for their families. many are thriving but many are not. to serve everyone living with mental illness we must take steps to address stigma access to medication and pier support. in 2012 i began speaking openly to my struggles with thousands of individuals with mental illness, their family members, law enforcement, faith based communities, teachers around mental health professionals

student. i've been a mental health illness presenter. i have made presentations to students. i have spoken to 20,000 students across this country. after one of my middle school presentation as petite young african-american girl walked up to me and started sharing she was self-harming. when i asked her if she told anybody. she said, no, i have not. then she lowered her shoulders. i told her that is okay. thank you for being brave and telling me. we walked her over to her school counselor, the same school counselor, friend am family member advised her not to go to. because she saw the importance of openly addressing stigma and that school saw the importance of openly addressing stigma the young girl's silence apt reticence was resolved and she was able to get the help she needed. awareness education is central to ending shame around mental illness. many parts of s-1945 address key

components breaking down barriers of treatment. for many medication is integral part of treatment. medication has an continues to play a key role in my life. i still take antidepressants and anti-pyschotics every morning. they're essential to my recovery and well-inness. finding right combinations of meds which at times was very harsh task for me. thankfully working with my doctor, i found the right combinations. the struggle to find the correct medication is arduous task for many. finding right medication can literally be the difference between life and death. paul, as i will call him, young man i know, went through 10 different diagnoses, convulsive therapy and at least 50 different combinations of medication. 20 years after his manic episode however he is now a mental health advocate. because he had access to medication he is helping others

working towards wellness. we must make medication accessible to those with mental illness. they must have the way to find right treatment because the wrong treatment leads to vicious cycle of hospital visits, substance abuse, exhaustive caregivers and even death. medication alone can not sustain wellness. another key component of bill is peer support. power of being able to relate to others going through similar experiences can not be understated. peer support group i interfaced with is quintessential example of power of the peer. on email chain of this particular support group a member mentioned he relapsed into depression. within an hour there were responses to his email. one member even saying that hey, i will come pick you up. they truly understood the power and emotional strength that support group. that emotional support can shatter the weighted chains of depression. i'm happy to say that this group

member is doing well and i is really doing well now. having language, codified what a peer specialist is and what peer support looks like is essential to standardizing a valuable component of mental well-ness ard peer support. mr. chairman, ranking member murray, members of the health committee, i'm testifying as voice of people living with mental illness. my journey however does not represent the full breadth of living with mental illness. my presence today gives a face to millions of americans who are struggling, striving and thriving in the face of mental health conditions. recovery from mental illness should be option for all. bill 1945 is pronounced step in that direction and i deeply, respectfully urge this committee to move forward on the strong bipartisan bill. i would say millions of people are depending on transformation of how we address mental illness in america. thank you so much.

>> thank you, mr. rahim. thanks to each of you. we'll now have a round of five minute questions for senators. mr. rahim, based on your experience, what advice would you have to someone who knows a person who may need help? how do you persuade them they should seek help, whether they're a family member, a friend, a student such as the ones you talked about? >> sure. i say i get that question all the time. i speak at support groups. na lbj family to family groups, dbsa. that is the bill dollar question i would say, we can't persuade anybody to do anything they don't want to do. >> what is your approach? what do you do? >> the key thing is education. we can't change anyone's behavior but we can change how we respond to people. so the key thing i say is educates ourselves and there are a lot of support groups and a lot of educational programs out

there if family members and people, say students can take and can change the way they interact with their friends or loved ones. thereby helping them understand what the loved one is going through. because especially, when i was in psychosis nobody could tell me that i was going through psychosis but my parents were fortunate enough to bring me to the hospital because they changed tear way of approaching my condition they were able to get me help. >> dr. eaton what is your experience? how do you persuade people who need help to seek help? >> i was going to say one thing that's possible in this area is a program in high schools. typically built into health curriculum. you can build into the curriculum without too much trouble a module on depressive disorder, psychosis so people are aware of these and think of them as illnesses just like any other illness.

that is part of the stigma reduction idea and they're less resistant. they are high school screening programs. the teen screen program was implemented in thousands of high schools aarp the country which you convene high school students, oriented a little bit toward depressive disorder. you mentioned suicide as being the 10th most important cause of death but for teenagers it is third most important cause of death. there are programs in high schools, that is what i'm saying to make sure people aware of issues around mental illness. >> you were critical of focus of nih. >> mih. >> institute that deals with mental health. >> right, national institute of mental health. >> our committee and the congress has increased funding for that. there is bipartisan interest doing more. if you were there what would

your focus being going forward? >> i'm completely supportive of more fund for mental health justified by the burden of disease as i mentioned. the orientation has been away from -- we no longer can apply for grants with diagnostic categories as outcome. it's silly. so i would change that orientation. and i think they really, you know, the smsa is a very important agency. i think to some extent the mih has disassociated itself from the public health orientation, partly because smsa is there but smsa doesn't have expertise to do public health research of mih. i didn't make comment here but in written comments i worked at sam is a two days last week, not one psychiatrist. not even one psychiatrist. as i left one psychiatrist joined the smsa.

only one epidemiologist at national institute of mental health. that is a failure in public mental health. >> dr. hepburn, i was, you mentioned 30 years ago in mental health. i was a governor at that time. i noticed that change. i just have a minute here but what advice would you have for states based on your experience and perspective about what the focus should be as they move ahead with the dollars that they have, both, state, federal and private? >> yeah. i think that's basic question that commissioners have to deal with on a regular basis. the, trying to take care of as many people as possible, as cost effective as possible, and what that means is moving further upstream towards prevention and early intervention so that you can take care of more people as they start to show symptoms or where they're at risk for symptoms. one of the problems that we had 30 years ago is that we were

waiting until people had severe mental illness before we started treating them. now with the health model we're trying to move further upstream to early intervention. so trying to spread dollars out, we obviously have to take care of people severely mentally ill but trying to get to people earlier as we are with the first episode psychosis and even earlier, trying to deal with kids and kids mental health. >> thank you, dr. hepburn. senator murray. >> thank you, mr. chairman. mr. rahim, thank you so much for sharing your story with this committee and for all of the works you've been doing with people across the country. it is very impressive. your message that people aren't defined by their mental illness is really powerful one and i appreciate that. >> thank you. >> i wanted to ask you, as you talk particularly with young people, what are the most common forms of stigma that you hear

about? >> some of the most common forms are, you know, i don't want my friends to know. i don't want my family members to know. even sometimes parents, students want to talk about what they're going through but their parents don't want to help them get the help. that is the case -- >> so they fear their parents will -- >> so they fear that their parent will, often times maybe there is guilt associated around, is my child broken or is my child sick. sometimes as parents when the students come to them, when their daughters and sons come to them they actually want to help but sometimes the parents are reticent not getting them help they need. students, a lot of them are open and willing to talk especially making it and putting that conversation out there. >> so, having somebody else besides your parents to talk to is critically important? >> that one of the things. >> persons in the community they feel comfortable accessing but i also hear from parents too, they don't know who to call when their child says, i mean who do

i call? my child is telling me they have this issue but they don't know who to call. what do you tell them? >> sure, well sometimes there is bridging the gap between what v. sources are out there and and what is actually known. key component is education component, is what is out there? what is available. knowing it is okay to seek the resources. your child is not broken. you're not wrong or bad if something happens to your child. really providing that bridge, that knowledge gap, listen, there are resources. it is okay to use them. >> okay, great. thank you very much. miss blake, let me turn to you, the work you do in the emergency department is critical part of our health care system. we all know that i know that the patients that come through your door are at the most vulnerable points of their life, otherwise they wouldn't be walking in that door. so once a patient is stablized and we know they need more

specialized care, we know there is acute shortage of inpatient psychiatric beds. you referred to that. certainly a critical issue in my home state. one study ranked my state 48th out of 50 on availability of psychiatric treatment beds. we're seeing a lot more press and discussion in that in moye state right now but i wanted to ask you, what happens to a patient in the emergency department if there are no psychiatric treatment beds? you mentioned this in your opening statement but what do you do? >> what we do is essentially keep them there in that room. we give them three meals. and, they are stuck there until we can either, a, find a psychiatric facility that is willing to take them. sometimes if the 72-hour hold has gone over 72 hours, our emergency room physicians have no choice but to allow that patient to go. >> so they goback out into the community. >> they go back out into the community. generally speaking what will happen, they will go from our

hospital to the next hospital is closest try to get in through that way, exactly. >> yeah. dr. eaton. >> can i just mention? i spent time in victoria, australia. they have a linked medical records system. someone shows up in emergency room they don't have bed in the hospital, they have an doing that for decades, they can dial up the nearest mental hospital bed in entire province in a few minutes. >> you do not have that access? >> we do not have that access where i am. in preparation coming for this i did informal poll of my colleagues throughout the country. this is not just a problem in florida or in washington. this is every single state in the country and, i would say this is the top issue in emergency departments right now across the country is holding on to these patients. one hospital, south part of palm beach county, i visited earlier this year, had 14 patients they were holding waiting for

psychiatric beds. >> so as mr. rahim pointed out people don't know who to ask, hospitals don't have a place to go and we have a huge hole in our system? >> exactly. and it's because there is not enough resources out in the community to be able to place these people, number one. to get them screened and get them into treatment programs. but number two, the follow-up from when they are released from that facility because they're put out back on the streets. if they don't have any place to go to follow-up, to get further treatment, their medications, to have someone they can go to if they're starting to have a problem. so many of these people are homeless. they get put back out, they have no place to go. they have no resources. they have no way to follow up with physician. they have no way to get their medications. so they show up back in our emergency room. vicious cycle. thank you, mr. chairman.

>> senator baldwin, senator cassidy, senator murphy. senator collins. >> thank you, mr. chairman. dr. hepburn particularly in rural states like maine, patients with seriously mental illness all too often lack access to the care that they need. as i look at federal policies, at times federal policies exacerbate the problem of access. we still don't treat mental illness the same way we treat physical illness in this country, from the perspective of federal reimbursement policies and perhaps. which is pretty stunning in this day and age. you mentioned that congress recently passed senator card dip's bipartisan bill, which

pleased to be cosponsor of which extends an important demonstration project that helps address the psychiatric bed shortage that ms. blake talked about and improved access to critical mental health care services and support. maine is one of the pilot states under that program and has already seen very promising results because federal medicaid matching payments are being allowed for free-standing psychiatric hospitals for certain emergency psychiatric cases. similarly the cassidy-murphy bill which i have cosponsored would go further by lifting the imd exclusion for psychiatric patients with an average length of state of 20 days for fewer. that should help more people get

the assistance that they need. could you talk a little bit more about this issue and how the restrictions on medicaid funding to freestanding psychiatric hospitals affect access to care. >> yes, thank you for the question. access is a major issue for following up on the previous discussion. there is a culture problem where individuals are expected to go into a psychiatric unit or a psychiatric hospital. if somebody is in the emergency room for another type of problem and there aren't beds for that particular discipline, they put them into an open, another open bed in the hospital. there isn't any reason that individuals with psychiatric problems couldn't go into a medical bed with a sitter. if some hospitals decide to do

that. that is one answer. the second is increased use of technology may be another way to reach the rural areas. the third, as you talked about, imd demonstration, has shown that private psychiatric hospitals have about the same cost per episode as acute general hospital psychiatric units. 30, 40, 50 years ago, the private psychiatric hospitals kept people for months, sometimes years. that has changed. the average length of time and cost per episode is about the same. there really is not a good reason from a financial standpoint or from a clinical standpoint to differentiate between private psychiatric hospitals and acute general hospitals with psychiatric units. >> i think you raised an excellent point at your last statement. it as if the practices of the past are dictating the reimbursements of today despite changed circumstances.

and as we have talked to administrators and psychiatrists and staff and families at one of the hospitals at a psychiatric hospital in maine as part of this pilot project they're seeing what you have said. they're not keeping people there forever or not abusing it but allowing people to get care that they need because it is being reimbursed for those individuals who are in the age span of 19 to 64 i think it is, that now can not get reimbursing. doctor. >> just another comment, emerging technology may be helpful. so we're talking about record linkage in victoria, australia. that will be coming in the united states. we'll be able to link records more easily probably but also, in baltimore 85% of the people with schizophrenia own a cell

phone. so there is a way of contacting these people and there are technologies being developed. they're not really therapies but they're locating devices. and devices that talk. i think that is in our future also. >> thank you. thank you, mr. chairman. >> thank you, senator collins. senator baldwin had to step out to another hearing so we'll go to senator murphy. >> thank you very much, mr. chairman. thank you to you and senator murray for taking this issue so seriously, for putting us on a path to a bipartisan product coming out of this committee and also a path to bring this to the floor, this year. i think this is one of our opportunities in 2016 to be able to move something substantive, something bipartisan, something that makes a difference on floor of the senate. i thank all of you for being here today. i think we've covered this question of capacity well. i thank senator collins for her specific questions related to imd exclusion. just for a minute let's think about how this would relate to

our lives. if we were to bring our child to the emergency room around dinnertime and we sat there with our child all evening, we sat with our child all overnight and we didn't get appropriate care for our child until noon the next day, we would call for people's heads at that institution. we would be outraged. that isn't the outlyer when it comes to people being admitted into the e.r. with mental health diagnoses. that's the average and yet we sort of have accepted it as commonplace but there's a reason why that's happening. we've closed down 4,000 mental health inpatient beds since 2007 in this country. in the last two years alone we went from 91 million americans living in an area that was designated as a mental health shortage jurisdiction for

outpatient services to 97 million americans. so we're going the wrong way on capacity as need is increasing. so it's no mystery as to why we're hearing these stores. as senator murray pointed out lack of coordination is. they're not talking to each other. for really complex patients it is not clear who is in charge for a child. is it the school? is it the mental health clinic? is it their primary care physician. so mr. rahim's story is captivating and you're courageous to tell about it. i want to ask you about the coordination. i want to ask you about the the barriers patients face in trying to find a quarterback for their care. the worry that's involved just trying to figure out which provider is the best place to

start. where do they haven'tly to to get care they need. how can we do a better job coordinating all of the good things happening in the system so it is easier for patients to navigate? >> right. so i can take a step back and share what happened with me about 17 years ago now. my parents were able to bring me directly to a hospital in queens. i was in the -- you talk about waiting area being chaotic. i thought that i had hallucinations in waiting area. i thought i saw jesus and prophets. . .

in fact the depression diagnosis alone doesn't put you in the top 5% of spenders. it's the combination. as you point out, if you have depression, if you have a mental health diagnoses you are much more likely to acquire another major and expensive physical health disorder. can you talk about the connection between a mental health diagnosis and a very expensive, very burdensome physical health diagnosis and what a little spending on the mental-health side prevent you

from spending a lot of money on the physical outside? >> i wish i knew more. that finding, predicting to diabetes or stroke or heart attack has been replicated 10 times. it's unquestionable and, therefore, the logic is very strong that on the one hand, treating a mental health disorder will almost certainly lower the risk for the physical disorder later on. but also preventing, moving upstream can't even farther from first steps of psychosis but if we can identify people at risk for psychosis, at least for depressive disorder, that will have these downstream consequences. the problem is it's complicated because it takes a long time. we haven't done enough studies to understand exactly how depressive disorder contributes to risk for stroke. we don't know that. in the united states we don't

have a tendency to do these longitudinal studies unfortunately. i don't think i've answered the question well, what i guess, i think we need longitudinal research to understand how it is that the body and the mind evolves over time from age 15 when someone is a resources on or depressive disorder until the age of 45 when they have four times the risk of having a heart attack because of that. >> thank you, senator murphy. senator cassidy. >> tremendous testimony. although a topic which is in a sense and nearly tragic. on the other hand, the fact senator alexander and murray and y'all are here gives us some room for happiness of optimism in the midst of this so thank you all. dr. eaton, let me ask, you describe in your testimony written and spoken about the lack of ordination between federal programs. i'm trying to, drawing from that

you feel there needs to be some change in how the programs coordinate or else we'll be spending federal tax dollars in an ineffective way, et cetera. your thoughts on that. >> in the written testimony, this is the part of the unknown. there's huge redundancy and epidemiological research related to mental disorders. i use them all. >> i have limited time. in a sense that would be better to have one person saying you shall do this and you shall do that as opposed everyone deciding on their own when we need you to? >> i think it would pay to study the coordination of those agencies. but it's a very difficult -- >> let me also ask. you brought up something tim murphy brought upon us consistently in the house of representatives site. that the samhsa really has a lot

of psychiatrists spent they didn't have anyone i was there. spent the principal agency didn't have a psychiatrist. >> it is amazing. >> i agree. the epidemiology, by the way i told dr. hepburn, osh has been regarding we need to start basing federal research on some objective criteria as opposed to intership using one example, it's like be still my heart. right nothing to talk about societal cost but you include the cost of incarceration in your societal cost? >> those dailies did not conclude that cost typically and that's something i didn't get into in my testimony, but really incarceration is a horrible, horrible problem. i think we now think, many of us think that the prison and jail system is the de facto mental health system in the united states.

>> my national association sheriffs association says these are the most active mental health provider in his parish. >> in cook county that's true also. we don't even have a good survey. >> let me stop you we heard testimony that the right drug is so necessary in order to keep somebody imbalance. i have learned when someone enters a jail they may become their medicines may be stopped or it may be a contract. it will be a drug substituted, et cetera. if we don't have some way to divert folks were mentally ill out of the jail it maybe they're going into a setting that would make a dadgumm yarmulke calm. super chaotic but either no medicine or different medicine because pashtun is that a fair statement to? >> that's one of the day concerns about not having a sequential intercept model that helps keep people out of being arrested and out of jail. the point you made, if somebody comes in on medication and that

medication isn't continued than it can have a negative impact on their ability to recover. >> thank you. mr. regime, again great testimony. tell me though, that you're speaking about peer groups as if it is something unique, maybe are just bragging on what you are involved i also got a sense from the testimony that the model needs to be expanded. that as good as it is we don't have peer groups proliferating across the country. this happens to be an exception of which you wish to speak of is that there? >> i know there are peer groups in the country and i think knowing the power that someone -- >> are they all over the place? >> i couldn't speak to that they are all over the place but no there are peer groups, certain organizations, they are based on peers and wellness. i do think that is a key component. if i knew that, when i was going

through the thick of my medication -- >> let me stop you because i'm out of time. anything that would increase the use of peer groups would probably be a good thing? >> 100%. >> last question. man, if we could put you in a bottle and sell you a whole world would be better off. but oftentimes those who are really ill will not take their medicine. the revolving door comes if you will, they stop taking their medication, they are back with ms. blake. what motivated you to take your medicine and what would you recommend for those who did not take their medicine, what would you recommend to kind of encourage them to stay on the path of recovery? >> medication does not define who you are. you are defined by your experience and noncommittal villas. mental illness, defining mr. ellis is how you think about yourself spend the appropriate mindset, number one. what else? >> number two is in finding the right medication, knowing that you have to go through a

combination. there is no one medication that is a panacea for meticulous and that's why more research is needed. so no such hotel accommodation, know that you're not defined by your medication or your mental illness, and having the ability to self report to your doctor. know how the medications are affecting you, how they're impacting your treatment as well as your body, and know that you will have weight gain. you have some sort of response or reaction. i think there's a key component. one, trial and error. there's going to be different combinations. know that 11 impact on your body. self-report come and know that they do not define who you are. mental illness does not define who you are. >> i yield back. >> senator warner. >> thank you, mr. chairman. today for most insurance plans mental health parity is the law but it sure doesn't feel that way for people who need help. 2015 survey conducted by the national alliance on mental illness found nearly 50% of

respondents had been denied coverage or mental or behavioral health care compared with only 14% tonight for physical health care. and i see way too many stories from people in massachusetts about how hard it is to get insurance coverage for the care that they need. let me start here. dr. hepburn, what do we really know about how many people are being denied services they need, why they're being denied? if you're filing complaints and if they ever end up getting the care that they need? >> yeah, it's an important issue. yesterday i called the maryland parity project because i wanted to get an update, and what they indicated was that it's very hard for them to know what the numbers are because when people look at how difficult it is to submit a request for review, it is so tedious and it is so detailed it's going to take

months to years to make a difference. so i asked for a recommendation and they said something has to change in the process. >> let's talk about that in a second but let's start with what you're saying. we just don't have even good data on this, on any of those four questions. mr. ring, if someone had trouble getting insurance coverage for mental health services, is there one place anyone in this country could report a problem and get some help? >> that i'm not sure of an -- >> i think that's information we need right there. that's part of the problem we've got. it's hard to fix any problem if we don't have reliable data. so connecticut creator and office of the health advocate to try to help people navigate the insurance system and this is what they were denied coverage. in 2014 that office returned nearly $7 million to consumers,

the most frequent places that the with every year, denials of mental health coverage. so my colleague from massachusetts, representative joe kennedy, introduced the behavioral health coverage and transparency act last month to try to create in a patient parity portal to provide consumers around the country a one stop shop for information about parity and a central place to submit complaints about coverage. let me ask you this, dr. hepburn, go back to the question about what to do about this. would a central place for people to go with problems about insurance coverage for mental health problems help consumers and give regulators better information about where to focus their enforcement actions speak was absolutely, yes. >> this is something that could make a real difference from what you are saying. good. i just want to say as of this

committee goes forward on mental health legislation i would like to work with you, chairman alexander and ranking member murray on making sure that consumers have a central place to turn to for help when they are denied coverage and a central place where we will get the information so that we can enforce the law that is currently on the books. thank you. thank you, mr. chairman. >> thank you, senator warren for the suggestion. senator franken. >> thank you, both the chairman, ranking member, for these series of hearings. dr. eaton come in your testimony you talk about the importance of preventing mental illness. so do, dr. hepburn. dr. eaton highlights programs such as the nurse family partnership program which has

been ineffective in identifying high risks, assisting birthing moms after birth. i really do believe convention is important that's why author and help advance the mental health and schools act which will increase access to mental health services in school settings. mr. eaton, what percentage of individuals with mental illness experience onset before the age of 18? >> it depends on which mental disorders you talk to. i think before taking for depressive disorder is probably, a full-fledged disorder is probably 20% but the beginnings of it are available, 50% of the people who will become depressive disorder full-fledged in a lifetime complexity before

the age of 35 already expressing symptoms at 15. and so they would be potentially identifiable, depending on if we can get the tools to do that. and it depends for schizophrenia, i think similar. schizophrenia has much more sudden onset at 18, 20, 25, something like that but the signs of psychosis and especially the negative symptoms are there at the age of 15 and 20. >> i think this is why if we expand enhanced mental health services in our schools, we will serve ourselves well. i want to ask about rural suicides, because the rate of study made by journal of american medical association

shows that rural adolescence commit suicide at approximately twice the rate of teenagers in urban areas. this disparity has increased over time. between 2004-2013 across all demographic groups suicide rates rose by 7%. in metropolitan areas, but by 20% in rural areas over the same period. the research shows that these differences are driven by the lack of treatment options in rural areas, provider shortages and stigma your aunt as a co-chair of the senate rural health caucus, i find this deeply concerning. dr. hepburn come yet previously served as a national suicide prevention lifeline advisory board, on that board, and now

represents state mental health program directors. can you explain why suicide rates have been driven up so dramatically in rural areas? >> i think you answered it, which is basically access issues. one of the things i think that's important is to look at how we can advanced technology to try and get to the rural areas. at a time when the internet is reaching people all around the world, there's really not a good excuse for being unable to reach kids, young people in the rural areas. one of the problems we sometimes get into is the lack of payment for thosfor the services that ae through telemental health. i think that's an important issue that needs to be addressed, that in this day and age elemental internet services should be made available on the same way that every other service is available. and by doing that you can increase access to those kids.

>> which is one of the reasons we need to make sure every area in america is wired. i mean, as the internet, because this is something i hear when i go to rural minnesota. i support programs that provide financial incentives to mental health service providers in rural areas, actually also, and i mean, we just need them in this country. we have a provider shortage, is that right? and would that be helpful to? >> absolutely. we have a work short -- workforce shortage but the average age of people in being able health in terms of providers and the workforce is 58. so we have to use technology as a way of compensating for that. >> thank you all for the work you are doing. i think we are beginning to understand how important this is in this congress and in this

country, and we've seen can we've seen some good things happen in this congress, beginning to happen at want to thank the chairman again and the ranking member. >> thank you, senator franken. senator whitehouse. >> thank you, chairman. follow up a little bit on senator warren's questions, it strikes me that one of the victories that we have achieved has been to bring mental health out of the shadows and be stigmatized it, not completely, not as much as it should be but there've been some real victories in that area that i want to commend my former delegation member, representative patrick kennedy on the work he did on the parity act which is really helped make that the law of the land as opposed to just a good social change that we made.

but in addition to the problem of trying to get insurance coverage, is there not also the underlying problem that our infrastructure for mental health treatment was basically built during a heavily stigmatized period when very few people came forward? and so it was designed to address a fraction of the real mental health problem. i don't know what you all see but in rhode island we have some of the best mental health facilities in the country. butler hospital and bradley hospital our best in show world-class facilities, and yet they kind of all our what they are. you get beyond that and to get into really difficult situations and very often there has to be a crisis you for simply can't get access to get into the mental health care system. not because the insurance company isn't reimbursing it but simply there isn't adequate

coverage, particularly in children's mental health. i see that as the case in rhode island. you all have a perspective their organizations nationally. do you agree that is a national problem as well? all heads are nodding, let the record reflect. >> i can also speak to that, i can speak come when i've spoken in 12 different schools can we get a study, a four-week follow-up. our students going to seek help? out of 2000 students, 184 action went to school social workers, school psychologist or a teacher because they said it's okay to talk about what i'm going through. if they are ready to seek -- if they're ready to seek out help, where do they go? so if people are ready to talk on this nation of young people, but where di do you do once youe ready for that health? >> our victory in the stigma area has now created a problem

in the infrastructure area, in my opinion. in the judiciary committee we will be considering a bill that is jurisdictional to the judiciary committee which is a comprehensive addiction recovery act which has overlaid with mental health issues, very often self-medication is the solution. not a good one but one that people use when they are really facing a mental health problem. could i ask as a question for the record if each of you would have a look, i think your organizations are probably already aware of the comprehensive addiction recovery act come if you wouldn't mind if you have an opinion on it we have a hearing will be coming up in the next couple of weeks and i would love to make sure we've got your organization position on the comprehensive addiction recovery act on the record here that i can take there.

in the last question i had has to do with emergency rooms. ms. blake, but your world you live in it. i have spent overnights in our emergency room just to witness what takes place, and it has enormous amount -- there is an enormous amount of health response deliver in the emergency room. people come in in the middle of the night, they really have is a mental health problem. the police taken to the er, bingo, now it your problem. er isn't really well-suited for dealing with that. so if you could just comment a little bit more on how big a role that task that you have been given place in your workload, and how much it is diminishing what else you can do. but also i'm interested in the extent you feel comfortable in which the electronic health

records you pull a plan to bring the person in or when they commend you, brought into you, are accurate and complete as to the mental health history of the individual, and how -- is that a good or bad thing? i get the feeling some of the protection we put in place to keep all this information private is keeping you from getting into electronic health records so that in the er you are not aware of -- >> i can give you an example of that. not too terribly long ago we had a 26 year old gentleman brought to emergency room. he was a heroin overdose. he was unconscious. we did know a lot about him except he had used heroin because he responded to narcan. we stabilized him and in the process of taking care of him, i got a phone call from a gentleman in virginia and who was tried to locate his son who had been sent down to our county

for treatment and rehab for substance abuse who had walked away from his rehab center. and it turned out, he gave me a sense that it turned out he was the patient i was taking care of. the problem was i could not tell him because of the hipaa law that we had his son in our emergency room, and one, because they patient was unconscious and unable to give me permission to do so. it turned out his son had a mental health issue as well. he was bipolar and he'd been off of his medications which was contributing to his problems. had we been able to release that information or pull that information up somehow, then it might would've changed the whole way that we treated this patient. but more importantly it broke my heart to not be able to tell this man back his son was safe in the emergency room and was going to be able to recover. so i think maybe if we look at some limited circumstances where

certain information could be released, and i certainly understand the privacy issue, but they would be very helpful. because in order to access someone's medical records you first have to get permission from them in order to do so. someone who might be in a mental health care crisis may not have the capacity to be able to be considered to sign permission for it. >> thank you. my time has expired but that was a terrific story and a terrific point. thank you. >> thank you, senator whitehouse. senator murray, do you have any further -- >> it's been an important that i really want to thank all of our witnesses today. clearly we have a lot of work ahead of us. we talked about making sure communities have access to mental health professionals can integrating the primary care with mental health care, existing research and breaking down barriers. that is a full plate. but it is an important one for us to tackle and i look forward

to working with you on moving his agenda forward. >> thanks, senator murray. ms. blake, thank you for that story. touching hipaa is like touching an electric wire, but maybe that's what we are paid to do sometimes. will look at our mental health legislation, we should consider that story and that circumstance. given the way we work on this committee, perhaps we can help with that. if you have a specific suggestion for the kind of exemption that that should become we would like to have it. maybe your organizations have that kind of proposal. >> as the chair of the council that is something we can put on our agenda to discuss and see what people would -- >> we are moving pretty fast here so we -- >> we have a meeting today. >> good.

[laughter] >> what senator murray and i hope to do is to move probably do this committee those issues that are within our jurisdiction, and do it at the same time that we are working with the enhanced judiciary committees and what senator murray and senator blunt's appropriation subcommittee so that we will be ready to deal with this issue. we have some very good work being done. i thank you for your testimony today from all four of you. the hearing record will remain open for 10 days. members may submit additional information within that time. the next hearing of this committee will explore issues related to generic drug user fee agreements and it will be on thursday january 28. thank you for being here today. the committee will stand adjourned. [inaudible conversations]

[inaudible conversations] >> we are live on this friday

morning as the u.s. conference of mayors is hosting its winter meeting this week in washington. the mayors immigration task force has a meeting on refugee resettlement. we would've been a mess of providence, rhode island, in anaheim, california, as well as the special assistant to the president for immigration policy, the head of refugee affairs and the head of health and human services department's office of refugee resettlement. this is live o on c-span2. it should get underway in just a moment. [inaudible conversations] okay. let's go ahead and get started. i want to quickly thank everyone for being here today. it is -- everyone else is

heading out of and going into washington. i appreciate you all being here. we are going to try to start on time and finish on time because i'm the authority of flights and what not just to catch to get out of town. my name is tom, the mayor of anaheim, california, about 350,000 people. one of the most ethnically diverse cities in the united states, and i am co-chair of the immigration task force of u.s. conference of mayors. we have, i have a new coach of this year, jorge elorza -- co-chair, the mayor come relatively new mayor of providence, rhode island, where he's a harvard graduate and decided to come back to his hometown of providence, and elected mayor just last year. he would've been your except he

feels he needs to be back intent to make sure that snow gets removed from the road so i applaud that. one thing in anaheim we don't have to worry about. [laughter] i got that going for me. we are both committed to bipartisan immigration reform. and anything we can do here at the u.s. congress of mayors to make that happen, i'm a republican, jorge is a democrat. as mayors of do, we do with these issues on the ground and anything we can do to move the ball forward to get immigration reform we will do. today we are going to discuss two important topics. the primary topic is the nation's refugee resettlement system. it became very clear this last fall at the tragic events in paris and in san bernardino that a lot of people don't know much about our refugee resettlement process. how individuals qualified to become refugees, how they are vetted and navigate into our

communities. we have key officials on three federal agencies that comprise that system and they will provide us with the primer of how the system operates. at first we will do from the president obama's special assistant for immigration policy who wil update us on the presidt welcoming communities initiative and then we will begin a discussion on refugee resettlement. i would like to first introduce, special assistant to the president for immigration policy, notes that present strategy for building a 21st century immigration system. working towards passage of meaningful comprehensive immigration reform legislation. before came to the white house she worked in the senate first for senator tom daschle and then for senator ken salazar. thank you for taking the time to be here and the floor is yours spent thank you so much and thank you to your commitment for

the task force can stay in town. i know you ought to get back to warm weather, warm and sunny weather center and for all your commitment over the years and haven't is what the president work and the congress were to pass immigration reform. we all know we are continuing to look for legislative action in that space. we had a good bill that went through in 2013 but were not able to get that the senate. or the house, sorry. we are continuing our efforts to focus on fixing as much of the system as a camp within the existing laws. and i'm going to say a bit about the welcoming committee's campaign but for that i would just remark that this was a week of coming terms of the president of executive actions that he's been working on them at some of you may know the supreme court is going to hear our appeal of the injunction was placed on a different action for parents of u.s. citizens programs, doctoral

program. window number of mayors that everyone, but a number of mayors did sign on to support the program because you all know just like with immigration reform bringing people out of the shadows actually helps with public safety, helps with economy, helps people feel more comfortable talking to law enforcement. we will see where the litigation goes but we expect in the spring for there to be a hearing, more amicus briefs that will be filed and then eventually the dishes in this june so we'll see where that goes. -- a decision in june. thank you all for all of you have been able to sign on to amicus brief. thank you for your support the entrance of the of executive action the president announced it we announced in november of 2014, the creation of a task force on new americans are really build on the work that's happening at the local level. and at the state level and some extent as well to really try to

create communities that are welcoming, speaking the immigrant immigration, making sure people are eligible not about the process and to make the decision on their own whether they want to apply, thinking about immigrants as important part of the economy. and it's an important part of the workforce. they create businesses. they are working in various industries and we want to continue to support them. the task force is focused on the economic integration of immigrants and refugees. and then finally it's also focused on the linguistic immigration of immigrants. we know that english is the language of opportunity. we want people to retain and, their language they come with but we also know that in order to up move the economic ladder it's important people learn english. there's a lot of work we've been doing with the department of education to promote best practices that are happening at the local level related to

linguistic integration. i was going to talk minute about the welcoming communities after we're doing which is another tier of work within the task force on new americans. the work we are doing is really a partnership with all of our federal agencies that are part of the task force on new americans but also nonprofits outside of government who have been working with cities and ngos and many others across the country to promote welcoming communities. we launched in september, last september but building welcoming communities campaign and its and effort to encourage folks that are already doing this work to take it to the next level, the strategic about the work they're doing by developing local immigrant and refugee immigration plans ever look across all sectors. we want education community, labor workforce and business community and fall.

we need to bring immigrant groups and refugee groups together. they don't always talk to each other but have similar barriers and concerns. also to create local plans that really work strategically and help can advance commuters. that's what we are continuing to support. we want other people to join if they can. we have 48 communities that are already part of the campaign and over the next several months we will be organizing around the country to highlight best practices of folks are already a part of our welcoming communities campaign but also encouraging others to come to the table as well. we will be having a meeting next week in los angeles. it's great the city of los angeles is involved but we know there's a lot of little towns and not so little towns in the area around los angeles so we want to encourage others to come to the table as well. as a major we're not doing this work alone. we are doing this work with cities that are already involved also national experts.

i would mention welcoming america, an organization that has been working over the last soviet to promote this work, is our formal national partner. i we have materials about the welcoming communities campaign. i have a map that's up on the white house website, so it's something where we are trying to make sure we are promoting the folks already with us. with a fact sheet and we have a commitment form for folks that want to either learn more are already interested in joining the campaign to come to the table and be a part of it. i would say that when we launched the campaign in november 2014 we were excited about it, but we didn't necessarily know what world events would bring in terms of really needing to promote this

work in a proactive way because of the negative rhetoric out of there. and with over the last several months with the attacks happened across the world in paris and other parts of the world and concerns about the refugee process and the question about whether we should still accept refugees really made us excited that we were, we vision nearly thought about creating the task force into things like that happened, that make people question whether we want immigrants and refugees in our communities. as we know there's a lot of negative rhetoric out of their at our job is to help people understand the facts about the refugee system an that about alf our immigration systems some clad my colleagues from across the administration argue to walk you through some of that. but also as we try to promote a more inclusive and welcoming climate we want to give people tools to proactively address

issues that bring people together rather than divide people which is really what the welcoming committee's campaign is about. so if you all are looking for things to do that are positive and proactive we encourage you to be a part of the welcoming communities campaign. with all of our federal agencies that are involved in the campaign, u.s. department of homeland security, department of labor, department of education, states, so many others that are trying to provide technical assistance and tools to people at the local level as they are grappling with whatever issue their grappling with, including crises that none of us can predict. i would just leave it at that for now and happy to answer more questions, really the start of the hour on my colleagues from the department of state and department of homeland security and health and human services that will walk you through the refugee resettlement process. and hopefully give you some good facts to take back that we know

there's a lot of rumors and myths. we want to make sure we're giving people the right information. i would just say the president has been very clear that he believes our country has to live up to its legacy as a nation of immigrants, a nation that welcomes those fleeing from persecution. we can do that at the same time we also make sure we are securing our country and securing american public from dangerous. so we believe we can do both. we can do come we all have to do as local governments, you all have to do 20 things at a time every day. the same applies for us so we want to make sure we give you all the tools to help you get folks back home information about the process. made i will turn it over to simon. >> very good but before we do that, any questions on welcoming communities? felicia, thank you so much.

let me go ahead and introduce the next three panelists. simon henshaw is a career officer with a u.s. foreign service, currently serving as principal deputy assistant secretary of the bureau of population, refugees, and migration. since he joined the state department in 1985 he is carried out a number of assignments and overseas postings here in washington. barbara strike to my left is a joint u.s. citizen, citizenship and immigration services as chief of the refugee affairs division november 2005. she manages the refugee core and headquarters staff to support u.s. refugee admissions, the admissions program. prior to that she worked in both public and private sectors directing project on immigration integration of the national integration for serving and apposite office as a form immigration and national station service working as counsel to the senate subcommittee and processing law and washington, d.c. firm.

bob kerrey also to my left directs the office of refugee resettlement for the administration for children and families in the department of health and human services. he came to a local or from international rescue committee where he held several key executive positions. most recent he was vice president of resettlement and migration policy and responsibly and agencies advocacy of refugee immigration's anti-trafficking in committee policy issues but before i served 10 years as vice president of resettlement overseeing fire season assistance to refugees. so why don't we start with simon? >> thank you very much. pleasure to be here. thank you for the warm introduction. and thanks to all of you for braving the weather. if any of you are from the north as i am and you're planning to stay the weekend, you are in for a treat las. [laughter] that are nearly 20 million refugees in the world. the vast majority will receive

-- in the country which they fled so they can voluntarily and safely return to their in fact i want to make this point though it's not the main point of today's meeting, the vast amount of effort of the united states government, my bureau and other elements and the u.s. government, vast effort we make when it comes refugees is supporting them overseas. a small number of refugees may be allowed to become citizens in the countries to which they fled, but an even smaller number, primary those were the most vulnerable, will be resettled in a third country. however, fewer than 1% of all refugees are eventually resettled in third countries of this 1%, u.s. takes over half. the crisis in syria is a dramatic illustration of humanity and situation refugees face. syrians are now the largest refugee population in the world numbering over 4 million.

another 7.6 million have fled their homes are trying to survive inside tents expect the government of turkey estimates it now hosts almost 2 million syrians. many more are spread over jordan, egypt, lebanon and iraq. in fact, 25% of lebanon's population now is syrian refugees. the united states has provided over $4.5 billion in humanitarian assistance for the region since the beginning of the crisis. and this includes essentials like food, health care and education. while our aim effort is supporting syrian refugees in the region we will resettle a small percentage in the u.s. and as i said before our program will be aimed at resettle in the most vulnerable members of this population as well as demonstrate our support for the countries in the region over burdened by high numbers of refugees. while maintaining the united

states leadership role in the humanitarian protection, and integral part of our mission is to ensure that refugee resettlement opportunities go only to those were eligible for such protection and who are not known to prevent a risk to the safety and secured of her country. our number one concern is the security. accordingly, the program -- detecting fraud among those seeking to resettle in the united states and applicants to the program are subject to more intensive screening and any other type of traveler to the u.s. in order to protect against threats to our national security. the department of state collaborates with the department of homeland security on this and also collaborates closely with the centers for disease control and protection to protect help of u.s. bound refugees and the u.s. public. are refugee resettlement program is premised on the idea that refugees should become economically self-sufficient as quickly as possible.

the department of state works domestically with agencies participating in the program to ensure that refugees receive services in the first 30-90 days after arrival in accordance with established standards. during and after this initial resettlement period, the office of refugee resettlement at the department of health and human services, led by mr. kerry, provides technical assistance and funding to state, addition of columbia and nonprofit organizations to refugees become self-sufficient and integrated into u.s. society. upon arrival of refugees are immediately eligible for employment and after one you are required to apply for a just status to th that of lawful permanent residents. five years after admission of refugees been granted lawful permanent resident status is eligible to apply for citizenship. the vast majority of refugees go on to lead productive lives,

receive an education and work hard. some serving u.s. military and undertake other forms of service for their communities and our country. while as we were all aware of the program has become controversial in some circles, in fact they continue to enjoy substantial support from state and local governments as well as community members in the vast majority of the locations where we work, which is in 48 states, 173 cities and towns, and 304 sites. as public-private partnership requires the support of american nongovernmental organizations, charities, faith-based groups, and thousands of volunteers and supporters of the program, in hundreds of communities across the country. we simply could not do this without their support. in closing let me thank you for your support. will start in life and in the united states may be daunting, it offers hope an unparalleled

opportunity. it is a chance not only to escape from violence and persecution but to start again. the assistance your communities provide helps newcomers find their footing and become a part of the committee. refugees are not the only one to benefit though. they add to america's vitality and diversity, and makes substantial contributions to economic and cultural life. thank you very much. >> thank you, simon. why don't we have, before we take individual questions why don't we go through the other guests. barbara. >> thank you for much. thank you so much for the invitation to be a today and meet with this conference and your guests. as the mayor mentioned in the introduction i work for u.s. citizenship and immigration services. we are an agency within the department of homeland security. and particularly with respect to refugee resettlement we are the operational partner with state department for the overseas

portion of refugee resettlement. one of the things i have learned to emphasize intellect but resettled in the last few months is the fact that simon describes the vast number of refugees in the world, and the very small numbers of refugees are able to avail themselves to resettlement or one of the things o are membr is really the united states decides which refugees we choose to offer resettlement to. it's really not a situation where the refugees themselves have the opportunity in most instances to say they would like to come to the united states. so in the first instance we are working with united nations refugee agency in terms of applying the criteria of who are the most vulnerable and/or the candidates for resettlement to the united states. what people in my office do most of them are based in washington but we work closely with the state department staff come and

we fan out around the world to locations where refugees live and we conduct in person interviews in those locations. we are typically in any quarter of the fiscal year we will be in 12-15 different locations around the world. we are in asia, africa, the middle east, europe. so we tried to go where the refugees are and where the need for resettlement is the greatest. we put a tremendous emphasis on the training that those officers receive. so they receive basic training and protectio protection law thy were also is a very detailed information about the particular population that they're going to be working with. i'm sorry, am i to close to the microphone? thank you. so what we're doing with those images is for high level is two things, determine is if the person of refugee under u.s. law or so ask questions about whether they have suffered persecution or have a well-founded fear of persecution. the other thing is checking on

whether they are admissible to the united states under u.s. immigration law. that deals with things like if someone has a criminal history, if you be a threat to national security, if they might have a communicable disease. there's a large number of grams of indivisibility so we explore the infinite entity with the refugee applicant. the other thing that we do in the background while we are also interviewing applicants is uscis and the state department should respond to the part of ministry the security checks that simon alluded to. and these security checks have been in place for refugee applicants since the immediate wake of september 11. there was a pause in refugee admissions back in 2001 while the white house, the national security council took a look at the security checks and they chose at that point the best set of confidence we can checks it can be accomplished at that point. but what we have done

collectively by represented here on this panel and many government agencies that are not here with us, those checks have been enhanced over time. so we added some things. we added department of defense fingerprint checks in 2007 when we started large-scale processing of the iraq applicants. that has since been expanded to applicants of all nationalities. we started working with the national counterterrorism center and we were able to add checks that let us check against a broader range of information held by the government. so that's been an iterative process of enhancing the checks as time goes on, and that is continuing today. we are committed to that. the other thing i did want to make it as well is there has been increased attention i think of refugee resettlement in many communities in many players who traditionally didn't have a high level of awareness of the program, and we realized that our public communication

material needed some attention as well. we have worked hard on our website now. we have nothing better information to help people understand who are refugees, what is refugee resettlement, and with the screen processes are that we take seriously before people travel. i did want to let you know that's a resource that is better. in general for education and some of it is suitable if you are having a came to the meeting, a stakeholder meeting. there's information that could be downloaded, printed and handed out to stakeholders who have an interest out what's happening in their communities. there's a short video narrated by secretary johnson from dhs, so we tried to enhance those public information tools and we be interested in hearing back if the are additional needs that you feel in your communities that would be useful if we can help communicate better. we are very interested in being partners with you on that public communication.

>> thank you, barbara. robert? >> thank you. and i want to start off by just thinking this group year, both my partners but also the mayors and your representatives. the u.s. refugee resettlement program is by much they public-private partnership but the most important work happens at the municipal pashtun municipal level and would not be possible without the support of countless volunteers and civic organizations that participate in the process. service the most mobile is central to the mission of the u.s. resettlement program and our success as a nation of immigrants is rooted in american values, quality and opportunity which secure a commitment to fully welcome and integrate newcomers into the fabric of our nation's. and these efforts benefit not only the refugees and their families but also the receiving communities. i think it's important remember refugees, bringing talent, try.

these are businesses at very high rates. they go to work quite quickly. they pay taxes. they become involved as members of society and they are an asset it's i think that's an important. they've been an asset. may bring vitality and renewed ideas and that's demonstrated throughout communities and economies. that's also very much they public-private partnership. the u.s. refugee program both the state department and the hhs components of it aligned closely and work closely with nonprofit organizations, bollinger or positions across the united states who bring to the process not only a large engagement of volunteers and religious institutions and civic organizations, but also community commitment to this long and important tradition.

the services that all or are that all or our provider closely coordinated coordinated in a very coherent fashion. it's important remember these things do not happen. in addition to the consultation process that is led by the processes that are led by the white house before the is a presidential determination as to the number of refugees to be admitted in a given year come in the coming year, that number is established in the curt geer at 85,000. there are also municipal and community-based organizations that counsel at the local level. orr has partners in each state. it is in each state a state refugee coordinator who is charged to coordinate the provision of services within that state and to ensure the coordination process takes place. there's also a state refugee health coordinator who ensures that health services within the state are coordinated to ensure

that refugees pursued both public health screening as they arrive. they are screened before admission but they're screened once again upon arrival to the united states it at any ongoing medical issues and services are provided in a coordinated and a sufficient fashion. refugees services include a short-term cash and medical assistance. the thrust of the program is, in the primary directive come is to ensure that refugees become self-sufficient as quickly as possible. so all of the self supportive services which are provided whether they the english language instruction, direct employment, psychosocial services, school adjustment speed we are going to lead this discussion from u.s. conference of mayors briefly for u.s. senate pro forma session. we will return on -- to the mayors discussion on refugee resettlement after just a brief

couple moments. the presiding officer: the senate will come to order. the clerk will read a communication to the senate. the clerk: washington, d.c, january 22, 2016. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable jeff sessions, a senator from the state of alabama, to perform the duties of the chair. signed, orrin g. hatch, president pro tempore. the presiding officer: under the previous order, the senate stands adjourned until 10:00 a.m. on tuesday, january 26, 2016.