to go forward to do whatever it wants even if it inconveniences special counsel but you don't want to inadvertently interfere with that investigation. if our equities and priorities are such that it's an inconvenience to special counsel, it should go ahead, that's additions and to make. >> go ahead and do what? what would you do? >> have public hearings for the record so that depending on how far away you could have both public awareness of what was going on and potentially it adds to the battery of evidence for the house to take up an impeachment resolution. >> okay. >> we have time to ask you one more? >> sure. >> i always invite people -- >> we leave this program at this point as we had live with during on mental health care for the senate health committee hears from the hhs

secretary for mental health this morning. live coverage on c-span2. >> senator murray is not here today so she sent senator murphy to go fill in for her. i've asked senator cassidy to chair the hearing. i will come back at 1145. especially with their leadership in enacting the legislation last year. after our witness testifies, senators will have five minutes for questions. sean luster is a typical busy, nashville young adult with a full-time job who also attend college. in june 2014, 2 days before his 25th birthday, he experienced his first schizophrenic experience.

since then he has been admitted to the hospital five times, spending ten weeks receiving psychiatric treatment. he recently wrote me saying this may seem slightly depressing, but my story does not end there. the doctors and staff i encountered at the clinic taught me too live productively in society. i have been free of the hospital for a year. during that time i've taken medication, return to work and even paid off a car. i am enrolled at tennessee state university as a junior, pursuing a degree in psychology. he is one person out of 10 million in the u.s. with a serious mental health condition. without this treatment history could've had a different outcome. in tennessee, about one in five adults have a mental illness according to the tennessee department of mental health and substance abuse. that is more than 1 million tennesseans. over 200 30,000 have what is

considered a serious mental illness. over the past few years, this committee has worked in a bipartisan way to update parts of the federal mental health system including systems of substance abuse and mental health services administration. for the first time in over a decade this effort was championed by senators cassidy and murphy. the reform act that pass this committee on march 16, 2016 and they were included in the curious act which majority leader mcconnell called it the most important legislation congress passed last year. today is the third hearing on the implementation of the cures legislation. we hope the updates will help more americans access quality evidence-based mental health care. as i said, when we began

hearings on the every student succeed acts, the law is not worth the paper it's printed on it does not implement it properly. i intend to ensure that this is fully and properly implemented as well. our focus is to hear how the program is implementing the mental health provisions in cures. of the 10 million americans with a mental health illness, including severe schizophrenia, bipolar disorder, major depression, millions go without treatment as family struggle to find care for loved ones. most of the services and treatments for people with mental illness are provided by the private sector such as programs run by the state. the largest role in the federal government is the amount of money spent through medicaid in partnership with the states. the federal government also plays a role through samsara which while relatively small compared to medicaid and responsibilities states have is critically important to improving the availability and

quality of prevention screenings early intervention and treatment programs and recovery services. tennessee received over 80 million in grants last year. prior to our work, federal mental health programs had not been updated in over a decade and the coordination between federal agencies was not as effective as (i hope today we will learn more about how implementation of those provisions is going, how has coronation improved among federal agencies on the best way to assist those with mental illness, for example we hope that promising research and early intervention programs at the national institutes of health would translate into clinical applications for patients. we also include updates to the block grants to states to ensure the funding is best meeting the needs of those suffering from mental illness. in addition to improve the care patients received, we

encourage the adoption of proven scientific approaches to treatment. i would like also to hear how the agency started to incorporate more evidence-based approaches for treating mental health. we also hope the reforms would help increase integration between primary care and mental health care, ensure that insurance coverage for mental health disorders is comparable to insurance coverage for other medical conditions and strengthen suicide prevention efforts. our witness today serves as the first assistant secretary for mental health in substance abus abuse, a position we created in the 21st century. she has new authorities to work with state and federal agencies and help more americans receive the treatment they need. i look forward to hearing about the progress being made to ensure more people can receive the healt help they need and have a positive outcome. i would now like to turn the chair of this hearing over to senator cassidy's and senator

murphy will make an opening statement. then senator cassidy will make an opening statement and then senator cassidy, you can take it from there. >> thank you very much. >> thank you very much chairman alexander. thank you to you for holding this important hearing and senator murray for allowing me too sit in her place and senator cassidy for her years of our partnership on this issue. it is indeed fitting that we are holding this hearing on the one-year anniversary of president obama signing the legislation that established this new position. he is the very first secretary for mental health and substance abuse. a position long overdue. at some of five years to the day since the terrible tragedy at sandy hook elementary school when a young man with serious mental illness killed 20 first-graders and six adults. let's be clear, there is no inherent connection between mental illness and violence. america has no more mental

illness than any other country and yet we have a gun violence that is 20 times higher. we also know when people fall through th the crooks of our mental health system it can have a devastating impact. in the aftermath of that traged tragedy, republicans and democrats were able to come together to pass mental health reform act which was part of the 21st century cures act. it represents the first comprehensive reauthorization of our mental health laws in a generation. it can't equal support from both parties that cannot happen without the bipartisan ship of this committee which is of course a testament to chairman alexander and ranking member murray. >> i think legislation's most important provision is the part that builds upon the mental health parity and addiction equity act by strengthening enforcement of that law and making it more

transparent for americans but there are two recent reports that illustrate how far we still need to go to fully achieve that vision. a couple weeks ago, they respect third nationwide parity report which found that more than one out of three respondents with private insurance had difficulty finding a mental health therapist compared with only 13% reporting difficulty finding a medical specialist. similarly, a study was released that found that insurance pay primary care providers 20% more for the same types of care that they pay addiction and mental health specialists including psychiatrist. in many states, the disparities in payment rates for 2 - 3 times greater rates higher for medical doctors, for people practicing medicine below the neck than those who are practicing medicine above the neck. fortunately the 21st century cures law provides additional authority to the trump administration and i hope they will begin to see these provisions implement it soon.

it also created the assistant secretary, this is an important step to make sure there is one person at the top of the leadership was solely focused on these issues. we also codify the role of the chief medical officer to work closely with you. other provisions include several grant programs to include coordination of mental health treatment, the creation of the first ever early mental health brands and workforce development and after hearing from consumers and providers about how there was confusion around hipaa and when it was allowable to share personal health information, we included new authorization for hhs to develop educational materials to help patients and clinicians and family members better understand when these disclosures can take place. >> there are other elements that will likely come up today. we have to remember none of the programs we authorized in this bill matter if we don't fund them. congress has an awful habit of talking a really good game on mental health and addiction, but then never being willing to actually meet our rhetoric

with resources. the current labor hhs appropriations bill doesn't yet include funding for the new programs in the bill we passed last year. even worse, the health repealed bill that was tried to push through the senate earlier this year would have cut medicaid by $800 billion. medicaid is the nation's primary payer for mental health treatment. but, the legislation we passed as. the 21st century cures act. it is still groundbreaking. if properly funded, it will save lives. i'm deeply thankful again to the committee for their work in making this bill possible and calling this hearing and lastly i would like to ask unanimous consent that murray statement be placed in the record. >> without objection. >> as many of you know, i am a physician who worked for 25 years in louisiana's charitable hospital system and i learned a couple lessons, one when the patient has the power to set the mines up to serve the patient where he or

she needs, but what i've also observed is that those with serious mental illness have no power. they are, their ability to act upon the resources that are available are lost by the disorder which is in their mind. this is not just an experience for a fellow who has worked in a public hospital for the uninsured. it's the experience of us all, whether it's family member, an associate, someone we went to high school with, we all know someone who seem to have such promise and that promise was snuffed out by serious mental illness. their ability to execute power totally lost because of that. now, government has a role, and government has a role to help those who are most vulnerable. there's been a tangle of efforts by government to attempt to help those who have serious mental illness. i was so privileged to work with senator murphy and others on this bill in 2016.

it creates the authority to untangle this mess and to somehow take this whole mishmash, some effective, some not, some would be effective if coordinated of government programs and line them up to help those with serious mental illness. we are now at about the one-year anniversary of that builds signing and this is a hearing to look at the effectiveness of this. let me say, sometimes these committees are compensated for this is about collaboration and cooperation, how do we work together with this newly created position so that we can better serve those folks who have lost their power because of serious mental illness. my goal is that when that 24-year-old has her first psychotic episode it is her

last psychotic episode and when she's 50 years old she does not look back upon that single event as a life defining event leading up to the breakup of her marriage, loss of her children, loss of her health, but rather she looks back upon it as a distant memory from which she grew and actually became a better person. that is the goal of all of us. we look forward to your testimony today as to ultimately how we restore wholeness and return power to that patient. thank you for being here and now i will make your introduction. >> am very pleased to welcome eleanor to today's hearing. she is the assistant secretary for mental health and substance use at the substance abuse and mental health services administration. the 21st century cures act created the office of assistant secretary for mental health and substance use replacing the role of the

administrators. she formally served as the chief medical officer for the rhode island department of behavior healthcare, developmental disabilities and hospitals. before that she served as chief medical officer. welcome again. you have five minutes to give your testimony and we shall hear from you now. >> thank you so much. thank you for inviting me to testify at this important hearing today. one year ago today, the 21st century cures act was signed into law and the services administration has been actively implementing its provision in concert with our colleagues of the department of health and human services, tribal entities and other peaceful holders. for over 25 years i have served people with serious mental illness and serious substance abuse disorders.

it is such a privilege for me and an honor for me too serve as the first assistant secretary for mental health and substance use. as the assistant secretary, i take my duties seriously. the cures act has asked that the assistant secretary look at disseminating research findings and evidence-based programs to ensure that grants are subject to performance and outcome evaluations, consult with stakeholders to improve services for those with serious mental illness and children with serious emotional disturbances. part of strengthening leadership and accountability at samson includes a strong clinical perspective at the agency. the cures act describes the role of the chief medical officer and we've expanded it. a new component created by the cures act as the national mental health and substance use policy laboratory. the policy lab will promote evidence-based practices and service delivery models to evaluate models that would

benefit from further developments across a wider area. the interdepartmental urinating committee, it was established by the cures act to ensure better coordination across the federal government to address the needs of individuals with serious mental illness and serious emotional disturbances as well as their families. i was pleased to chair the first meeting in late august which was attended by key leaders and federal government as well as 14 highly qualified nonfederal members. it has been working with in five key areas of focus, strengthening federal coordination to improve care, closing the gap between what works and what offered, reducing justice involvement and making it better to obtain healthcare and developing finance strategies to increase availability and affordability of care. as required, the report will be delivered to congress today. i just show you this. we are very pleased to bring it too congress on time and

it's our hope that you will be pleased with it. >> i will scratch that question off my list. >> it reauthorize the community mental health's plan and set aside it's vitally important to ensuring that individuals developing receive timely and appropriate treatment. if we can intervene early with needed treatment, people are better able to live with their illnesses. i strongly support the reauthorization of the cures act of assisted outpatient treatmen treatment. in fiscal year 2016 they implemented a grant program and awarded 17 grants. they have partnered with the assistant secretary for planning and evaluation to implement a crass site evaluation which will assess the effectiveness and impact of this program. one very important area addressed with suicide prevention. in 2015 over 44000 americans

died by suicide and there are over 1.1 million suicide attempts annually in the united states. it authorized the existing national suicide prevention lifeline. in 2017, the lifeline has already answered over 1.67 million calls. those recorded for all of 2016 and we are not done with 2017 yet. suicide remains the second leading cause of death for individuals 15 - 24 years old. the cures act reauthorize the memorial act which provides grants to states and tribes to reduce suicide and suicide attempts. at the same time, the highest rate of suicide in america is among adults 54 - 65 years old. priors to the cures act there was no authorized suicide prevention program for adults. we are grateful for the authorization of the suicide prevention program and for

congress is funding of the program in fiscal 2017 as a result we have awarded grants for zero suicide which is a program that implements suicide prevention and intervention programs within health systems. ensuring children and adolescents at risk and living with the key element of the cures act. the national child traumatic stress initiative was reauthorized and has provided resources to communities and individuals in other dramatic events affecting the mental health of all americans. as directed by the cures that they are working collaboratively with the hhs office of civil rights on guidance that would clarify permitted uses and disclosures of protected health information by healthcare professionals under hipaa to improve communication with caregivers of adults with serious mental illness in order to facilitate treatment. with the passage of the cures act, we continue to recognize the critical role of behavioral health parity in ensuring high-quality health care for all americans.

they have conducted to parity academies to improve parity implementation in the commercial insurance market, medicaid of the children's health program. the parity website has been updated to include information from a public listening systems session as has the portal which provides information for individuals who have may received a violation. much work has been undertaken to implement the cures act but we know this work is far from over. there are many more individuals and families struggling with mental and substance use disorders that need help. i look forward to continuing a strong partnership with congress to help these people and their families and answer any questions. >> thank you. >> senator murphy, would you like to go first? >> thank you, mr. chairman. enqueue. we are very excited that you are doing fantastic work in this position. you've got a lot on your plate.

we are excited about some of the early deliverables but i wanted to ask you to talk a little bit more about this question of integration you referenced it in your testimony. like you to talk more about the work that can be done are hhs and through cms to bring together our behavioral health system and the rest of our healthcare system. whether the proper way to do that is working through state government or whether there are new payment mechanisms we could develop through cms to try to marry together these systems, it's the idea that we have one system of healthcare for your neck down and then you have to walk across town to find someone that will treat the rest of your body. it is a slow progress, slow progression to fix that in part because of the way that we fund mental health and mental health services.

there's at least one grant program that is designed to take this on, but tell me what you been doing since you been on the job to try to promote integration. >> thank you for that question. i think we are doing a fair amount. we have funded programs that are bidirectional and that was through the cures act so that behavioral healthcare can be put into primary care settings and primary care into behavioral health settings. we also have a program that congress brought into being a couple of years ago and is now in the process of implementation, and that is for the certified community behavioral health centers. these are programs that are focused on behavioral healthcare but require that both serious mental illness treatment and substance use disorder treatment as well as physical healthcare can be in

the same setting for individuals primarily diagnosed with mental disorders. that is very important. we work collaboratively with cms, we are talking with them about what kind of innovations they might be able to look at in terms of ongoing funding. i will personally advocate for the continuation of the community behavioral health program because, even though we have an evaluation out, we know they work very well because they integrate care and they pay for that care and that's the other thing about this. we have cms that is providing the payment for services. i think that will be very important to establishing these kinds of sensors. we also work collaboratively with other operating divisions that provide direct care including herself which is a

much larger organization than we are and we provide a lot of technical assistance and opportunity for training on behavioral health issues, same with the health service. i have also, since i started had my chief medical officers establish a relationship with the indian health service to make sure these things move forward. >> often states regulate behavioral healthcare centers and their primary care or federal qualified health centers through different agencies, and so, when they tried to combine, they often have simple regulatory hurdles like the number of fired drills are different in the two different locations. when they go on to one site, there often being overregulated. i hope that is something you will help states try to overcome. one final? hepa, a lot of confusion out there on what clinicians can

share with you my members and caregivers. we gave you the ability to develop some new guidance to try to make it clear to providers about when they are able to share information with a mom or a dad or a caregiver. i know you are working with the office of civil rights within hhs. i just wanted you to give us some insight on when you might see that come forward. it would be helpful to everyone in the community. >> indefinitely, on that. for one thing i think you will get a series of informational documents from the office that further clarifies when information can be shared. i spoke with the hh hhs about

it yesterday. a few weeks ago, the office of civil rights put out a guidance to practitioners about what can be shared in emergency settings. one of the big sources of confusion has been when a person comes into an emergency department, for example emma with an opioid overdose, can that information be shared with loved ones and caregivers. it often that has been shared because mistakingly they think it's covered by the statutes related to substance abuse treatment. this is not substance abuse treatment practices treatment of a medical emergency and under hipaa we are able to share that. there are exceptions and so we have had one guidance go out to practitioners about what they can share under emergency situations.

that one out in november. we are working on another document that will further clarify hepa and 42 cfr in the same document. i like these to be short and easily digested by practitioners. last week i was at a national meeting of substance abuse providers and the issue of sharing information was one of their main issues. i'm really grateful to congress for the direction on the. >> thank you for taking it so seriously. >> i'm going to ask you to be tight with your answers because i have a lot to ask you. let me follow up quickly with what senator murphy just asked about. that is great that you are coming out with this guidance. is there any plan, do you have the ability to turn this into an education credit or legal credit or nursing credit? i find those sorts of things can be trees in a forest but if you make it as a ceu right before the end of the year

when everybody needs to get their credits in, it has a little more bank. >> exactly. we have a number of training programs. they address a wide variety of topics. : we have the addiction technology -- >> you have to give your continuing legal credit. it will be the lawyer their calling in the middle of the night saying listen, can i share information and if the lawyer says no they will not do it. >> you are exactly right about that at some of his work in the hospital setting i can tell you they can be a a very big barrir to sharing information. >> as a lawyer i can imagine, but anyway. >> our chief medical officer one of the things she is working on is developing a network with

hospitals and the hospital of national hospital associations to exactly addressing these issues. >> let me go on. in our legislation collectively hours, we have reported -- reporting requirements. clearly you have to measure or else it could be money which is wasted. so first as samhsa put those requirements in place for these fiscal year 20 can block grants, how you are measuring compliance by the states in terms of reporting, and how does sam should take into compliance with reporting section and how wealtl states are performing when they decide to award a grant? >> so we have a required government reporting system that is used by all of our grantees including the states and block grants funding. i will tell you i'm not satisfied with the data as it is currently collected.

i think that we could do a a mh better job of getting information, that requires a certain set of steps we need to go through. but i will tell you since i've started we've made good progress on that and will be approaching omb to further hone those questions that would be more informative about programs. >> let me ask as well because i bakley spoken to colleagues about this. medicaid is not required to robustly report dated the understand what it comes to mental health there's abrading. pics samhsa block grants with medicaid dollars with medicare dollars et cetera. it's all put together for a package. cms has one set of reporting requirements and samhsa has another. has the been any initiative between samhsa and cms to coordinate these reporting requirements perhaps to unlock some of what cms holds that samhsa could use?

>> i see where you're going with it. what i can tell you is this. part of the role of the assistant secretary position is to reach out to other divisions, other agencies, other departments. and so i've asked for a meeting with cms. that will be happening soon and this is one, one of several topic areas we will be addressing. i have talked to folks at samhsa about this. they say this is a big hurdle, that they do not know way we could right now. those data. i do understand what you're getting at what i'll be talking with cms about that and see if we can't bring people together. >> let me say again, this is about collaboration and cooperation. i would suggest, i suspect senator murphy, my staff would love to meet with your staff as to how we facilitate that. right now we are paying a lot of money for medicaid and with some pretty poor outcomes in medicaid. medicaid. when you control for everything you still have four outcomes. and so when you get better reporting requirements, and if it takes a statue to make that

happen or some sort of oversight, sometimes that makes it work better. so want to work on that. so at least murphy and cassidy staff would like to meet with your staff regarding that. >> got it. >> okay. i have some of the questions but i'm almost out of time so now i think i go to senator franken. >> thank you, mr. chairman. good to see it again, doctor. when a new with people in minnesota who are struggling with mental illness and substance use disorders eye-opener about the stigma, people experience mental illnesses are often regarded as physical conditions, rather sometimes seen as moral failings. we'll know that's just not the case. my predecessor senator wellstone made it his life story to fight for people with mental illness, pushing for mental health parity. one of my greatest honors as senator from minnesota has been to carry forward his work on

mental health and championing policies that promote parity. i'm proud that the affordable care act expanded projections to people who have employer-sponsored coverage, and seek care through the individual market. the 21st century cures bill extends these efforts by called on the federal government and other key stakeholders to generate an action plan to improve enforcement of mental health parity laws. dr. mccance-katz, in your testimony you referred to all listening session that the administration held this past july, haitians, advocates and providers explained that many times people cannot find in network providers face high out-of-pocket costs and have to fight with insurance companies just to get services covered. stakeholders call for more enforcement, transparency from insurance companies, and agency guidance. the actions the administration has taken thus far fall short of

these demands. what will you do, commit to doing, in your new role to improve transparency from insurance companies and transform the parity portal into a meaningful resource for consumers? >> yes. thank you, senator franken, and i will tell you that is a work in progress. so one of the things, one of the reasons that i agreed to come back into federal service is because i want to advocate for people living with mental and substance use disorders. some going to be an advocate for his long as i'm in this position. one of the things that i think is very important is for people to be able to get access to care. and when they have barriers that put in place by arbitrary insurer limits, it's unfair. so i am working with people at hhs around this parity portal to try to make it something that

will be more functional for consumers. right now it has been updated so that at least people will be shunted to either department of labor dipping of what the problem is. but i would like to see this be something much greater and something that consumers can actually used to get information. but it will take them. >> i'm so glad to hear you say that. for years we've heard growing and urging try for help from clinicians and tribal leaders about the opioid epidemic and a particular its impact on indian country. that's why in the indian affairs committee i asked indian health service acting director admiral how the administration could address this issue and the opioid epidemic in indian country more broadly. he recommended that we first bring tried to the table,

second, consider community and culture specific drug prevention programs. i push for language and the 21st century cures cures act to ensure leaders at samhsa considered unique needs and circumstances of vulnerable subpopulations including native americans in the programs. what are you doing to support and expand culturally-based treatment programs for individuals living in indian countries, special the supping with opioid addiction and other substance disorders? as part of your answer can you describe how you engaging with tribal communities and working to develop and have of it these culturally specific programs? >> yes. so we have an ongoing, we actually have the office of tribal affairs at samhsa. we have ongoing meetings with tribal leadership. when i came to samhsa, i learned that one of the addiction technology transfer centers that was specifically put in place to assist tribal nations was going

to end. that has now been funded. there is a funding announcement out and we will choose a grantee who will work with tribes and meet their culture needs as well as their substance abuse needs. we also work as i as a mentionh the indian health service. we have our chief medical officers meeting with bears and working with them around what kinds of technical assistance and training needs, do they recognize that santa can help them with. we have, i will take a lot of time but we have a lot of training programs that really are quite good and -- >> thank you. because i am at a time and before the hearing i spoke to you also about support of housing and a want to continue that conversation with you, even as i leave this body. because i think that's very

important that people with mental health disorders and with addiction gets support of housing and wraparound services. so thank you for engaging that conversation before the hearing. thank you, mr. chairman. >> senator whitehouse. >> thank you, chairman. appreciate it. dr. mccance-katz, welcome. good to see you again before the committee. >> thank you. >> we in the negotiation around the cures act got a commitment, bipartisan commitment for extra billion dollars to be spent on opioid treatment. the first half of that was already distributed, and we hope and expect that the second half of it will come through at the end of this year, funding measure, whatever that ends up looking like we are very much counting on that. in the last one, the measure by

which the funding was distributed to states didn't correlate to the rate of the opioid epidemic, the intensity and severity of the opioid epidemic in that state. nor did it connected recently passed cara bill here i'm hoping that as we move forward on this, you'll be in a position to structure the grant process for the second half billion in such a way that it more accurately addresses the high impact states, and that it's better k'nex to the cara bill. i think you can probably do that in the terms of the grant application request that you structure from samhsa, and i just wanted to hear from you where you plan to go with that. because the high impact states kind of got not treated so well. >> so my understanding of this

situation is that if we make any kind of changes to the previous funding announcement, then all states would have to reapply for the money. i can just tell you that we have been hearing from lots of states about their concerns in having to reapply for the money and the decision was made to not have any substantive changes in the second year funding for that two years, that billion dollars, 500 million each year. >> so for the sake of the process convenient for all, the high high-intensity states are going to pay the price? >> so, so i was a couple of things. one, when the decision was made i did go back and we looked very hard and we did find one and we put a new funding announcement out that does prioritize of those states that a been hardest hit by the opioid epidemic. i will continue to do that.

in addition, the other thing that i been able to do is to reallocate funding so that we are building a new technical assistance program that will be individualized to every state. so the states that a hardest hit who have certain types of special needs, we will have local technical assistance available to them that we think will be important to helping them implement as efficiently and as effectively as possible. going forward from that two years of funding, whatever congress and the president decide upon, we will look at that and we will be very much aware of the kinds of issues you just raised. >> and please also be an advocate for additional spending in this area in the cara programs in particular. i think we were able to get $170 million in the last funding

measure. that's 2% of the $8.6 billion that the pharmaceutical industry makes selling just the prescribed opioid products, setting aside the illicit stuff that comes over the border. so 2% up against the devastation we are seeing in the context of a multibillion-dollar industry, i would consider a beachhead, not a victory. i hope you agree. >> yes, sir. >> last quick thing. this is a rhode island specific thing. the health insurance commissioners you know in rhode island is taking a look at the parity compliance of the insurance companies in rhode island, and i know you're looking at that at the national level. can't i just make sure you got somebody on your staff coordinating with rhode island to make sure that your supporting their work and everybody's pulling smoothly together on perry disclosure and

enforcement? >> yes. -- parity. two things, samhsa has developed a parity toolkit for commissioners we've made available to all the states, and number two, we have an office of around health care reform issues, and that, we have a person who works individually with the states and the insurance commissioners within the states so we will make sure that happens. >> times up. thank you. appreciate it. >> chairman alexander. >> thank you. dr. mccance-katz, welcome. i want to follow up with senator whitehouse is questions if i remember right it was his language that we put into the cures act to try to make sure that the money distributed took into account high impact states, am i not correct about that? >> at least -- >> the problem is that it was

based as i understand it on the number of opioid deaths among other speedy right but we did the language -- >> you have a big number but it doesn't necessarily mean that's a big impact. >> so our intention, dr. mccance-katz, was to recognize the importance of, was to distribute money to high impact states. that was our intention and doubly senator whitehouse -- >> it was not accomplished. >> so what do we need to do to accomplish our intention? you are saying that it would be impractical to cause all the states to reapply again. i can see that, but there would be more money coming for opioids. we don't know yet when or where or how much, but is it the language about the difference between high impact states? i mean, a number of total deaths and the number of per capita deaths, is at the issue of what

kind of language would you recommend that we include in any new funding so that we direct money with a particular sensitivity to high impact states? >> so senator alexander, i was not here in the previous administration when the decision was made. however, my guess would be that they were trying to implement as congress directed, and i don't know that speedy what would be a better way? i'm not trying to criticize them. i just try to say if you are doing it today, how would you do it? >> yes. and for the new funding announcement that we just put out, what we said was we were looking at the rate of opioid overdose deaths within the state, and the rate of increase year over year. that tells you how hard estate is being hit. >> does not go into effect the second round of funding? >> when the second round of funding comes forward,

absolutely we would be looking at different -- >> a reapplication? >> if it's a new source of funding, no, everybody have to apply for that funding and then -- >> wait a a minute. the second round -- >> second. >> the second half billion dollars what you just described is that apply to the second half billion dollars? >> no. >> but you would recommend that what you just said would apply to any new money? >> exactly. >> would you work with our staff so that if we write that properly and are intention is to recognize high impact states that we do it in a a correct wy so we don't get surprised by -- >> i absolutely will do that, yes. >> let me ask you this. in 2014 congress required states, i remember a discussion with senator whitehouse and want to see that his, we tried to implement his intention and we can keep working on that. >> i'm just so grateful that you

follow up that way, chairman. i appreciate it. >> in 2014 congress required states to set aside 5% of community mental health block grant funds for serious mental illness. the cures act increase the requirement to ten. now, that sounds good but that reduces the flexibility that states had to address what might be different in rhode island and california. what's your opinion about the increase from five to 10%? does that it help or hurt the y of states to respond to needs of those with serious illness? >> the vast majority of payment for the services delivered to people with serious mental illness is not from samhsa. a block grant having the increase of 10% causes a focus on something that is actually afford, that is early identification of first episode psychosis. we know that the longer a person goes without having their psychotic thinking detected and

treated, the more refractory their illness becomes overtype. all so that 10% in that block gt does a tremendous amount of good in terms of raising awareness of this important issue. >> how does that encourage early prevention? the language is to focus on service mentor illness, isn't it, or does it say something about early? >> it talks about early identification of -- >> early identification of serious mental illness pixels so it's not that serious. it's the early that is key to really to effective treatment? >> that we consider psychosis to be indicative of serious mental illness. >> so you think the 10% helps? >> i absolutely do. >> because the push towards early identification of serious mental illness? >> yes. and we know that the onset of most psychotic disorders is in

adolescence and transitional issues. this is really very important to the lies that these folks will be able to live going forward. >> thank you, mr. chairman. >> thank you very much, senator cassidy. and mr. chairman, thank you for holding this hearing. and dr. mccance-katz, thank you so much for being here and for the work you do. i want to follow up on a conversation we were just having about funding for those of us who are from states that have been incredibly disproportionally impacted by horrible epidemic that has taken less obvious it across our country, but in new hampshire carfentanil heroin and opiate epidemic is referred that way because it is fentanyl that is killing people in my state at one of the highest if not the highest per capita death rate in the country. we have been targeted by fentanyl dealers. i was a funeral saturday were a family buried their second

daughter from an overdose. women had been in recovery and have been working really hard at it, and this disease is take all of our efforts and i'm very, very grateful to everybody on this committee. but i will add my concerns and frustrations to what you are from senator whitehouse. i've expressed them directly to the secretary. i think the fact that states are uncomfortable out reapply is a non-excuse in terms of the decision that was made in the second round of this funding. towards that end, , senator alexander, senator capito, senator coons, my seven senator manchin have a built in call the targeted opioid funding act that would change the formula and make clear what kind of priority we could give to per capita death rates and i love the committee's attention and collaboration on the bill. but even if we fix this for me under the cures act we know that the cures act, , money right now

is only for two years. and we know there's no quick fix for this epidemic. we desperately need funds to fight this epidemic. we need the administration to tell us what supplemental resources it's proposing to turn the tide, and i was appreciative of being at the white house in october when the president declared this eight public health emergency. but so far we haven't seen any follow up to that declaration and we have seen no proposal from the administration for the funds that we need to tackle this epidemic everywhere in our country, and epidemic that is not only taking lies but in new hampshire i think they year was 21442015 cost us over $2 billion in our economy. so dr. mccance-katz, have you had conversations about the need for additional funding with hhs in the white house? why hasn't this administration called for additional funding or propose additional funding so we

can get the dollars and the resources to the front lines where it so needed? >> senator, i think that there are many conversations going on about what the needs are and lots of efforts to look at the data that is available. information that's available. it's my understanding that the administration is very interested in working with congress on developing those ideas that might be something that both the president and congress can't agree upon to bring more resources to bear. >> well, , this congress has mae very clear that we support additional funding to fight this, but we really need a partner and and administration to stop talking and start funding. and so i would look for to continue those conversations. i i also wanted to follow up wih another question, because we know how complex the opioid use

disorder is. it's often accompanied by a variety of mental health disorders, including for example, post-traumatic stress disorder. this leads to complex and sometimes very dangerous outcomes. veterans and other populations with ptsd and co-occurring pain conditions are often prescribed higher doses of opioids putting them at a greater risk for accidental overdose and deaths. it's imperative that we were to ensure that patients have access to comprehensive treatment to address both substance use disorders and the health needs. doctor come has a a mental heah proficient in a 21st century cures act help samhsa nsd visibly of evidence-based treatment programs for dual diagnosis of mental health disorders and opiate use disorder? >> yes, i believe they have. specifically, i can speak to the issue around department of defense and veterans affairs which cures addressed, and which

has developed into a very strong relationship where samhsa works collaboratively in an ongoing way, and we specifically addressed the issues of mental disorders and opioid epidemic as well as suicide. those are the big issues that we are working on right now. and we also can use the information that we learn from the va, which actually does a lot of research of its own, and we share this and we promulgate it to communities. >> i thank you for that and i thank you for the division of integrated healthcare in this area. i am most concerned that we are delaying some of our work that would be made possible with extra funding because of the stigma attached as many of the other speakers, standards have reference and appreciate very much your efforts. >> thank you. >> doctor, good to see you. good to see. i read a book some months ago by

sebastian junger, a small little book called tribe. he discusses in the book the challenges our veterans face as he tried to reintegrate back in society. makes the point, evolutionary standpoint for more, we are more comfortable in tribal societies, like military platoons embedded in a military structure. then we are in the current atomized society where people tend to feel lonely. there are challenges of reintegration and adaptation. so he turns on its head the challenges our veterans are facing. the problem is not per se with the pattern but it may be with the broader society. it's a really interesting read. and when i laid that line of argument, that analysis, on top of the study, the depths of

despair study that indicates we see increasing rates of morbidity among middle-aged men, white men in this country, and the reason for the deaths is heightened suicide, , i'll call use and so forth. start to think that loneliness is really driving so many of the mental health issues in our country. could you just give me your assessment of that perhaps popular reading of the literature? >> so i do think that those are important points, and i actually think that there's actually researching data that says that people who are isolated, who will endorse loneliness and feeling ostracized within their communities have, die at much younger ages. ..

what intervention? >> yes, so senator, this is a topic in evolution. i do think there is accumulating evidence for the value of recovery supports as they relate not only to substance use disorders, but to mental disorders. one of the things i'm working on and this is one of my priorities actually is to bring psychiatric medicine and into closer contact and collaboration with community recovery supports. it is not enough to just provide medical care and psychiatric medical care.

people need does recovery support in their communities. they can be better in based. they can be faith-based. so you get where i'm going with that. and i think that will go a long way towards assisting people to lead the fullest life. >> it just seems consistent with common sense that there is more needed den medicating these problems away. people in a genuine human contact. they need relationships that are meaningful to them. they feel like they are part of a broader community, a meaningful part. i just have a couple minutes left. if we could turn to have the federal government incorporates or fails to incorporate feed back loops in terms of addressing mental health and the policies we have. there's everything governing mad entre magazine article at

harvard medical school for a tiered evidence approach to allow for scaling up of evidence-based approaches while concurrently approaching field generated innovation. have you considered including evidence approach and some of your programs, said the national mental health substance use policy lab? >> thank you for that question, senator. we spoke about this when i was going through the confirmation process. >> i want to publicly speak about that. >> the answer to your question is yes we are. i'm happy to be able to tell you the policy lab is being stood up now. we heard a direct or who i think it's a very experienced and knowledgeable person who is going to do exactly that kind of work. >> you to continue to have great interest in us and we will be following up with you and your

staff supported for my legislative standpoint. thank you, mr. chairman. >> senator franken. thank you, mr. chairman. i was glad to hear you talk about recovery supports. we have her back boss from rhode island. i know you're from rhode island. >> i used to work for her. >> she's been unbelievable work in right now in rhode island they have recovery coaches what they are called to do exactly what you're talking about getting into the community. one of the things in the 21st century is more crisis intervention training for police. we talked before, hearing about judge stephen lichtman in miami dade who has implemented a system where people with mental illness and substance abuse who

get arrested instead of going to jail, which they used to do and cost tremendous amount of money were going to emergency rooms, which also costs a lot of money is getting housing and getting wrapped around services and that is sent and then i think, you know, i'm a know that senator jan and i have talked about housing and weak doneness in hennepin county in minnesota as well, but that is something that i want senator jan and others on the committee to keep advocating for and keep outside. i want to talk about indian country again. and senator hasan talked about ptsd and trauma.

we see a tremendous amount of trauma in indian country, not just the historical trauma, but the trauma of extreme poverty, domestic violence, drugs and sexual abuse in all of those things. and so, that is why we see such high in the days of opioid death in indian country. i went to a rehab for teenagers in northern minnesota a couple years ago and i've visited a number of rehabs and i never mean such hopelessness in a rehab. usually when you go to rehab their south at a certain point. what i really thought was that these kids, most of them had started with use of their parents in the hopelessness that

i saw was what they were going back to and they seem to be going back and this is true also in indian country. and they'd gotten treatment, fell back in with the old crowd and is now gone. again with housing. maybe piloting this. a sober living housing in indian country where is that of going back to where you are living, going to a facility that has people like you, you know, having to be very close to the reservation or on a reservation,

but where you are getting continuous support and fellowship of the people they are living sober, too. especially opioid, and this is a long, long term thing. it is than 25 days of detox and then 28 days. it is a much longer thing they have not. that is something that i would really like to advocate for going forward. one last thing about culturally specific in indian country think it's very important, but i did a roundtable in minneapolis in one of the providers they are, one of the counselor said to me what does that mean? culturally specific? when one of the indian women sees me as a counselor because

i'm indian, she knows that i know what she's been through. so i think culturally specific means more than just -- it means in indian country, making sure we train the providers. so come a thank you. >> yes, and i agree with you. you're quite right. >> senator warren. thank you, mr. chairman. dr. mccance-katz, one of the most important things we did send to resist to create the office health and mental substance abuse is what you've been nominated to head up. we need to ramp up to the opioid epidemic and that means using every single tool in the toolbox. one tool is to put more resources into mental health. can i ask you to tell us why it

is so important that we express mental health if we want to beat back the opioid crisis? >> yes, thank you for that question. there is such a high rate of co-occurring mental disorders with substance use disorders and the genesis of these mental disorders often predate the disorder itself. we also know if we do not address bowa. treating one does not treat votes. that's a very succinct way to put it. it is clear making process on the opioid crisis means putting resources into mental health disorders. medicaid is the largest funding mental health service, but samhsa has others not covered through private health

insurance. the block grant and of other grant programs called regional and national significance are the main mental health programs providing funding for all 50 states and supporting the work of mental health agencies of local governments and nonprofits working in this area. these programs are absolutely critical to improving mental health in this country and they serve millions of americans. let me ask you, doc or mccance-katz, is ever on him is mental health care able get that right now? >> i would say the short answer to that is no. >> why not? >> a variety of reasons. a lot of people who we would say need this kind of assistance don't want it. but they are also barriers that prevent people from getting the

care and treatment they need. it can be very difficult to access care. >> given estimate how many people need to have been unable get it? >> are data told us about 12, 13 million people. >> that is a really stunning number. >> the mental health services block grant significant are samhsa's programs combined with less than a billion dollars a year on those programs. let me ask you economic advisers released the cost of the opioid crisis to this country, do not figure they came up with? >> i'm guessing it was pretty high. the mac is pretty high. $504 billion. >> think about that. the cost of the opioid crisis atop a trillion dollars.

that is 2015 alone. we are investing only one fifth of 1% of that amount in helping samhsa tackle the mental health piece of this program. we need to do more in knots i've called for an additional billion dollars of fun being in next year's budget that would double the samhsa budget. what they put into the two largest mental health programs. yesterday the national council would represent 2900 mental illness and addiction organizations wrote a letter and i want to quote what they said. now is the time to support the highest possible levels of funding for health care programs in the federal budget and today this morning the massachusetts association for behavioral health care segment separate letter requesting congress

doubled the funds. i could not agree more doubling the funds for these mental health programs would give millions more americans access to the treatment that they need and would start making it dent in the ouster nonlocal cost that the opioid crisis is imposing on our country. thank you for being here. thank you, mr. chairman. thank you, mr. chairman. good to have you with us, dr. mccance-katz. i hear from my law enforcement community intersection between mental health in people who are in jails and prisons who shouldn't be. i have a lot of tough sheriffs, teflon first met sheriffs and police chiefs who lament the fact that their jails are filled with people who have diagnosed untreated or sometimes undiagnosed mental health and these people shouldn't even be in jail but if they're not treated, they will harm themselves or others.

they feel like they are being asked to be the mental health provider for society that doesn't find mental health services and mayfield started a compassionate anger but also makes it harder for them to do their job. i really want to ask about that. i also talked to police chiefs sometime after high-profile incidents and that bottom, some of this was the police approached and we are not not completely train not completely trained on none of it spiraled into something worse than that can become a flashpoint for community anger but at the bottom of it there was an untreated mental health issue. that's what i want to talk to you about. the 21st century cares act has some important provisions about criminal justice system including an interdepartmental coordinating committee. the provision that called for the attorney general to establish a pilot program to determine the effect of

ms. encumbered an eligible offenders to the federal courts system into drug and mental health court. can you tell us a little bit about what they are doing in conjunction with the criminal justice system and has the attorney general the department of justice than in the department of justice that has supported these efforts? >> so, a lot of questions there. but yes, so the interdepartmental series coordinating committee, as you know this is a five-year process. and the issues around the interface between serious mental illness and the justice system is one of the primary areas of focus within the report.

i will tell you also we have programs at samhsa dedicated to diversion, mental health court, programs for offender reentry so they don't get lost through the cracks because they are next. having hospital system in rhode island where he worked with the department of correction was that we frequently would get folks back because they didn't get into appropriate outpatient care at the time they were leaving and even though we might provide treatment, and the idsmcc has addressed this and i hope you'll be pleased. >> i very much look forward to reading it. the thing i'm most familiar with this use of mental health courts which are significant. can you talk about how the mental health system is working at the federal level, some of the things we might be reading in the idsmcc report about that. >> you will be reading more of

these programs and these programs are very effective in diverting people away from into treatment appropriate care including medication because a lot of these individuals need medication and have not gotten it and that's also part of what the committee has recommended that the issues around civil commitment laws to try to maintain a person in care once they leave. also, the other thing we talk about in the report is the use of a crisis center specifically geared to the treatment of people with substance use and mental disorders rather than an emergency department which is not an appropriate placement in one person often get stuck. so these kinds of interventions can be helped: freeing up law

enforcement in getting people to care they need. >> one more question if i could ask it if others want to jump ahead, go ahead. i want to ask about co-prescription of the locks on. many have been about opioid issues. i've worked with colleagues to introduce a co-prescribing act which was incorporated partially and i was pleased to see that was a very bipartisan effort. how much progress has been made in terms of making more available to at-risk populations and can you speak to the availability of prescribing guidelines? >> prescribing guidelines we have opioid overdose prevention toolkit that speaks to all of the available formulations in the process of being updated because there's been some approved formulation. so that is available.

we also encourage co-prescribing. we train on co-prescribing and we have programs available that train first responders and also provide funding for no locks on. >> kind of a follow-up not only to what i asked earlier, but a previous hearing where you were. the previous line of question is asking about hardware monitor outcomes. last committee hearing asked heavily monitor a specific program if we had treatment programa, b. with a high recidivism rate and a lot of folks being perhaps overdose in an emergency room two weeks program b. where they have a more vivid approach and we don't see that sort of thing building

data however. i asked you last time if they were having processes the data great idea at this point. in relation to what i asked earlier, is it possible to do that with cms, to look at data to see if there's recidivism, for example, emergency room visits a week after discharge. i'm trying to get out how to effectively look at programs treating addiction to know whether those programs or affect the taxpayer get the best deal for her dollar but more importantly the patient gets the best outcome relative to recovering for addiction. bob. >> the issue about cms than the billing date is one we have to work on. i am reviewing all of samhsa's

programs right now and we are going to be making the data publicly so it's not just a matter of programs we are funding. but it's not just another click data so we can see whether they are good, but making it available to the public. we are working with her center to look at means by which we can make the data more available. i will tell you for the fcr program. i'm sorry, the str. i love clinical work. i am meeting about every single grade c. they are all doing it differently. >> in follow-up, is there a common way you can see, because

absent elaine dodd, it can be very difficult to evaluate recidivism rate. it is that a geographic distance if there is a way, one is that exist in promulgating this, one shoe to evaluate and do so. >> just come in answer to your question is we have several evaluations of the program of ongoing and we're monitoring the states to make sure they are using evidence-based this. one of valuation being done by cdc and another being done by a contract or any data will be made available publicly. that is an ongoing project. >> either way, i don't think the data should be used punitively. >> the other thing we do is because we're working so close

he and a new program of technical assistance, we will also be asking state to bring forward data on their programs because they have the abilities. >> i don't know the exact answer but i will find out and get to you without. >> thank you for the follow-up questions. 21 the challenger broadening. senator kaine accurately talked about converting individuals out of the criminal justice system. first it happens at school. many kids with mental illness will misbehave at school, will run into a police officer and be into the criminal justice system never to emerge. we talked about mental help aid

training. to the extent schools have police officers on site, shouldn't every officer have some basic illness so they can divert kids away from jails. >> without endorsing a particular program i believe that is the best way to approach the issue. absolutely. >> tell me about train samhsa's work to develop your capacity. it appears to occupy a various pacific wall and emerging data for many people in recovery that peer connection is what matters most. give me an initiative samhsa is working on to broaden and improve the quality of peers in our system today.

>> samhsa has had a role in the development of the workforce. however, it is my view no government agency should be in the business of trying to figure out how to accredit a particular title is holy spirit so what we are doing for consumers and families working with the national organization on developing criteria. they do it differently, so we are working with dave and stakeholders to move the process along. i believe peers need to be integrated into the health care team because it is so important to not just give medical care but services and that is what we are working towards. >> a conversation you're having a senator cassidy. you are not satisfied with the

data you are receiving from states. that is in relation to the block grant. can you tell us why you are not satisfied with the data you are getting? is it the amount of data or the quality of data? what is the problem you are seeing? >> because the data does not tell us anything about diagnoses and it doesn't tell us anything about basic standard of care issues like that a person get medication assisted treatment? i don't even know they got the standard of care. mccance-katz what are you getting right now? >> number of people served. they approximate certain types of diagnoses. did you feel sad? do you use certain substances? that is not enough to tell us what these programs are doing,

for who. >> thank you for your focus on negra senator cassidy asked that we can avoid duplication is something we should work together on. >> codec of adding think the administration because you seem is irritated about something same irritated about and they are good names to be irritated about. i want to finish by thanking senator alexander murray and murphy for calling, convening in participating in this. thank you, dr. train to afford hearing. it will remain open for 10 minutes. members may submit within that time if they would like. thank you for being here today. the committee stands adjourned.

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[inaudible conversations] >> and a fair number of filtering today, covering several of them. later today, house and senate conferees are meeting to negotiate to talk about tax reform. live coverage of that coming up at 2:00 p.m. eastern on c-span 3. you can listen live on the free c-span radio app. president trump today talking about tax reform working its way through congress. having lunch first of the lunch first with the conferees in speaking about it at 3:00 p.m. eastern also on c-span 3 and c-span.org. senate democratic leader chuck schumer today called on republican leader mitch mcconnell o