>> come to order the chair recognizes for purposes of an opening statement. >> today we convene to hold an oversight hearing on the mental health section on 21st

century cures act signed into law december 2016 on the anniversary of the house passage of 21st century cures act this subcommittee held a hearing on the sections of the law that the financial institute of health and the fda are implementing. today we have dr. mccance-katz assistance hhs secretary for substance abuse and mental health services to testify about the work the substance abuse and what they are doing to address our country's mental health needs. mental health title of 21st century cures act was based upon helping families of a mental health crisis reform act of 2016 passed the house by a vote for hundred 22/two prior to its inclusion in the 2t century cures act bill this legislative effort represents the most significant reforms

for the mental health system in more than a decade. the first provision to strengthen the leadership with the accountability of samsa to establish the position that dr. mccance-katz now holds one of her duties as assistant hhs secretary for substance abuse and mental health services to develop a strategic plan by the end of the fiscal year. twenty-first century cureslo act also strengthens existing programs the community mental health block plants services and substance abuse treatment lot granting given that each state and community is different this law provides flexibility to address their unique mental health needs and additionally the law authorizes the national mental health laboratory to carry out existing and new activities under the policy umbrella of mental health to promise service delivery and expending evidence-based programs.

access to mental health and substance use is vital to the overall health of our nation and according to the national alliance one out of five adults experiences mental illness and of those suffering a little more than 40% receive services in the past year title ix focused on promoting access to mental health disorder care the programs included authorizes several existing programs that previously were not in statute so they provide grants to eligible entries to provide mental health and substance abuse services to homeless individuals and jail diversion programs the title authorize the programs to further integrate primary care behavioral health services

notably the 21st century cures actt and expanded the population to include additional populations such as certain qualifying children and adolescents the cdc recently released a report that shows a risinged suicide rate across united states. in 2016 we lost 45000 lives to suicide 21st century cures act is to provide additional resources to codify the hotline and authorizing the resource center and the suicide prevention state grant the existence of all of these would be far less impactful without inadequate workforce therefore the entire subtitle directed to strengthen the mental behavioral workforce through grants and programs

and other means. here's establish several new grant programs such as mothers and children one program provides grants to support statewide or regional pediatric mental health care telehealth access programs such programs could be especially helpful and related to vacation treatment of mental health issues with school-age children and this is especially critical because 53% of allci chronic mental illness begins at age 1421st century cures act has long sought reforms and is a result of bipartisan legislation created over the course of severalat years this reflects on our diligence and commitment to improve the overall mental health work needs to be done.e. i healed back the balance of my time i recognize the ranking member of the subcommittee. >> thank you mr. chairman for

holding today's hearing for implementation of 21st century cures act today we will examine division c of the law focusing on mental health programs and activities administered by the substance abuse and mental health service administration samsa. thank you dr. mccance-katz assistant hhs secretary for substance abuse and mental health services for joining usr. this morning and acumen to of 2t century cures act december 2016 was a great achievement in a time of sharp partisanship and gridlock but the work started long before 2016 led by colleagues along with all of us on the committee but in 2014 we set out on a mission to do something positive with medical research and innovation to accelerate thearov discovery and development of cures and treatment to help prove public health after countlesss hours with hearings and drafts to have bipartisan

support and endorsements from over 700 organization that is intended to goo far to solve the problems of new treatments and to strengthen the nation's public health infrastructure and 21st century cures act help to program the implement of the programs by samsa to create new programs to make achievein organizations -- officer to promote best practices it further requires to develop a strategic plan every four years to develop priorities including a strategy for improving the recruitment training and retention of the mental health workforce 21st century cures act also created a national

mental health policy laboratory and interdepartment coordinating committee to issue a report to congress last december to address the needs of america suffering from serious mental illness and disturbances across federal agencies one of the most important f actions to help suffering from mental illness and emotional disturbance to ensure they have access to care indicated is the single largest payer in the united states and in 2015 medicaid covers 41% of mental illness and 26% of adults have serious mental illness i am concerned taken by the trumped administration to make it more difficult to receive medicaid by suspending risk adjustment patience and that will make it more difficult for americans suffering from mentalt mo illnesses and emotional

disturbances to receive the treatment that they need to live a full and healthy life and before i close the ongoing mental health crisis created by the trump administration regarding of separation of iochildren from their parents american academy of patriotic's says it causes irreparable harm to disrupt the brain architecture to affect his or her short or long-term health this prolonged exposure is serious toxic stress can lead to lifelong consequences for these children currently there are over 3000 children force to be separated by federal authorities we know how these are affecting the emotional health of thehe children and what action samsa is taking to help them recover from the trauma of the situation. thank you and i would be glad to healed my last-minute to someone who would like a minute.

nobody? i yield to my colleague from colorado. >> i just want to thank you dr. for coming today and look forward to hearing what samsa is doing to implement the 21st century cures act. this particularly the mental healthth aspect were issues this community -- committee worked on for many years to get it right i don't think we have it right but we are working in that directio direction. also i want to echo what my colleagues are saying about these kids at thean border. we are making progress to reunite them with their families but we need to double our efforts and make sure they get adequate mental health and i yield back to the gentleman from texas there is a vote on the floor but we will finish with opening statements before adjourning for theg vote and recognize the gentleman.

>> thank you very much we appreciate you convening this hearing with oversight on 21st century cures h act and those changes that are incorporated are not implemented i will think our colleagues on the committee and certainly dr. tim murphy who was a real leader in congress on mental health reform for his work as well these policies were the result of a mobile year and multimember bipartisan congressional effort based off of healthy families from jul july 2016 by a sweeping vote for 22/two and as an uprising that once we passed legislation is it working where can we approve what's not working? these provisions were folded into 21st century cures act signed into law december 13 of

2016 division b authorizes these reforms and they were long overdue when the committee first took this on there were 112 federal programs through eight federal agencies designed to address mental illness and they cost taxpayers $130 billion d annuallyneaxnn 112 programs eigt agencies 130 billion many had not been updated or reauthorized in years. with 21st century cures act under the leadership of the chairman at the time we streamlined these programs to bring them into the 21st century to prioritize access and best practices to make them available to providers across the nation granted states additional flexibility to administer block grants to address the specific needs of their population and increase oversight and accountability for these programs also made

progress of resources for prevention to many of us have friends have lost loved ones to suicide my dear friendve and colleague lost his son tragically to suicide one day before his 22nd birthday. i worked hard with the senator to have the original memorial act to provide information training suicide prevention and strategies for all ages i was proud to see this reauthorized in 21st century cures act but in a march funding bill now law i was provided critical funding for 30 sections of those provisions and this includes national traumatic child stress initiative and the training grants outpatient treatment and national suicide prevention lifeline. in addition it appropriated more than $2.3 billion of new

funding for mental health programs these are resources that mean the difference literally between life and death it is also worth noting the primary behavioral healthcare in the northeast part of my district and i have heard the success stories of providers to integrate the health center and the behavioral health services we know how it works but also there can be barriers to full integration and i appreciate hearing from our witnesses what you see from the federal level with integration of service and those devoted to substance abuse disorder last month support for patients and communities act the biggest legislativeun package to address the drug crisis in american history is started in this subcommittee and our work on substance abuse goes much

further back lead up of the comprehensive addiction act so this intersection is more clear more now than ever to set the table for our work to combat the opioid crisis thank you for joining us today with the work you are doing your position was created under the very law we came in today we are all eager to learn more about your work and programs to the federal government i yield back the balance of my time. >> the ranking member from new jersey. >> it is a critical function of this committee to conduct oversight to ensure legislation is working as intended it's important to hold hearings like these to direct the administration how policy is implemented president obama signed a

landmark 21st century cures act law into law that was truly a product of the hard work and bipartisan members of this committee 21st century cures act addressed a wide range of issues with the healthcare system today we are focusing on those provisions related to mental t health and thank you to ta to testify what is happening at samsa the mental health crisis act is part of tee11's port porton step to repairing the country's broken mental healthme system i like to highlight a provision to include in this legislation to those receiving psychiatric treatment and despite what was accomplished we all agree this work is far from complete them more needs to be done to improve access for mental health treatment the republican party which is

the single largest player in the country it only has it only chancema they have and to believe any progress made from the health crisis act is completely reversed if republicans ever succeed to repeal the affordable carere act and drasticallyhe cut benefits for lower individuals that could cause catastrophic harm to people with mentalth illness. i reminded this committee helping those in crisis because of the separation policy it recklessly moved ahead with the inhumane policy to address the long-term health implications for the children torn away from theirs parents for how to reunite them with her family this is a man-made disaster by the trump administration public health advocates and providers have formed how devastating

forcible separation can be to their overall development in mental health according american academy of pediatrics highly stressful experience of family separation can cause irreparable harm changing their architecture to affect his or her short and long-term health with exposure to toxic stress leads to lifelong consequences as i said at theat outset oversight is a critical function of this committee that the chairman has not been willing to have an oversight hearing on the family separation practice but we should be for the for the august recess so the majority is not as troubled by this crisis as some of them claim to be we must get to the bottom of how this happens to ensure it never happens again in reunite these families immediately although we cannot undo theirirun trauma the administration must take every step possible to prevent further harm i healed back

mr. chairman. >> there is under five minutes left in thisnd vote. there are four votes that should take us a little less than one hour to complete we are in recess until immediately after votes. [inaudible conversations] >> as we recessed we had opening statements the chair will remind those with the committee rules and they will be part of the record. thanks to the witness to be here today and stay with us through votes taking time to testify she will have the opportunity to give an opening statement followed by questions interview hereen from dr.. mccance-katz the assistant

hhs secretary for substance abuse and mental healthan servicesth we appreciate you being here with us today and you are recognized for five minutes. >> thank you for inviting me to testify 21st century cures act was signed into law thank you for your interest i leadership we have the services administration as the first assistant secretary that is created by 21st century cures act i take seriously my duties including leadership and accountability for behavioral health and

coordination across government and part of strength and leadership with a strong clinical perspective to codify the role of the chief medical officer by establishing and expanding the office of the chief medical officer to include two additionalo psychiatrist and a nurse practitioner. a new component of samsa with the national health laboratory has evidence-based practices in service delivery through models to benefit through further development expansion or replication it also provides leadership to identify and coordinate policies and programs related to mental disorders including policy changes. interdepartmental series of the coordinating committee was established by 21st century cures act to ensure coordination across the federal government to address the needs off adults with serious mental illness and children and youth with

serious disturbances and their families they have in working within five key areas of focus to strengthen federal court nation to improve care to close the gap what works and what is offered and to involve care for those in making it easier to have evidence base disorders to develop finance strategies to increase availability and affordability to reauthorize the community health services block grant to codify that if we could intervene early individuals are better able to combat these mental illnesses similar to other conditions and in 216965 americans died by suicide according to samsa over 1.3 million americans 21st

century cures act authorized national suicide prevention lifeline data shows the majority of individuals served following use of the lifeline reported the intervention stops them from completingif suicide long enough to keep them safe at the same time the highest rated suicide in america is amongaf adults age 45 to 64 years old and they are grateful to the adult suicide prevention program and cures the purpose is to implement invention programs focused on training of healthcare professionals to ask about suicide if they should endorse thoughts to end their life one of samsung one -- samsa role is the revelation of patient records and with those updates

in compliance with 20 -- 21st century cures act and then to obtain employment about implementation also the need for technical assistance and training the importance of integrating electronic health records also congress' commitment to address the opioid crisis the implementation to be awarded $500 million each year and the start state targeted funding on the country this supports a comprehensive program i feel strongly we need to provide congress and the highest quality service possible we have reconfigured the approach

of the robust technical assistance strategy emphasizing track -- on practices to communities acrossin the country much work has been undertaken to implement the cures act but this is far from over look forward to a strong partnership with congress to help american living with disorders and their families. >> this concludes the witness opening statement and they recognize myself for questions and i want to begin by placing into the record from texas tech university the hall professor in the executive

vice president at texas tech university to describe their program so let me pull some pieces out of this to provide school-based screening assessment that is typically struggling with mental health issues andal currently active in thee school districts to use telemedicine to link those remote schools and also to provide mental health recognition and training services to thehe resource officers with prompt referral it goes on to describe in some

detail how the program runs in the coordination that occurs between their staff and the staff of the school interesting to provide some statistics to have the annual enrollment around lovick texas where students are empowered to create a safe learning environment but of that number of 414 total 14 total referred by teachers and trained to recognizer those to be referred to the larger program to be triaged by telemedicine and 25 of those those have been removed from the school population by hospitalizations and arrest they believe they have averted tragic outcomes

starting others on a path to healing so it is an interesting program to develop for school safety and i'm interested in your thoughts how this integrates what you are doing with cures .mplementation >> thank you for bringing that forward this is a very important part not only of 21st century cures act but the commission we have had the opportunity to speak to a number of districts across the country and these innovative programs to better ensure a safe environment where they can learn to identify children early who may have mental health issues to be addressed and there are a number of ways to address those mental health service needs for either

integration or through a close relationship with other types of programs and what the cures actually do to directly affect those programs is that they reauthorize mental health programs oriented to children and samsa used implement those programs like project aware for infrastructure and the programs that teach about psychological to identify you early to get the care and services they need to authorize those programs and in addition talking about

integration of care the certify community behavior centers that congress established for us represents a model to provide those needed services to children referred from the schoold system. >> use of that model is important as i understand this is funded entirely from the university itself with those connections to encrypt all that is necessary to have those secure connections other forward to working with you and perhaps the white house as well to something that is very important i recognize five minutes for questions. >> welcome 21st century cures act was a landmark law

substance and then with that initiative then to focus on increasing access to trauma focused so can you explain how the network improves the lives of children impacted by traumatic stress that is a program established in large number off states to provide services around issues of traumatic stress. and not only trained practitioners and providers that s also to do a consultation within communities to address traumatic issues so this is a

highly regarded and valuable program. >> i don't have the grantees dedicated to memory but we can get you that very quickly. >> of those that are impacted the early intervention with the long-term health effects are those mitigated in any way? be my guest they can there is a fair amount of literature on this how trauma affects children and the ability to address those traumatic events in a therapeutic environment to mitigate the effects later in. >> responding to the recent eventset of the separation at the border as a result of the

trump administration zero-tolerance is the network utilized for services for children as a result of the family separation policy? >> what i would say is that samsa itself is not involved in those issues. that is dealt with by at different part of hhs and the office for refugee resettlement any provider with any jurisdiction can go to a national program and ask for resources that samsa is not directly involved. >> hhs is responsible for the children if you have any informationti on what is done with hhs with the network of these children to have a

document on the website that children can recover from dramatically's aberration to development culturally and linguistically and that their families including evidence-basedvi. that coordinating committee list five areas of focus increasing availability and affordable care. be denied health coverage by health insurance to have a pre-existing condition? >> that is not my area of

expertise at all feel comfortable commenting on the deed health health insurance. what i would say in that medicaid is one of the largest providers of mental health services their insurance programs and they serve millions of americans at this very momen moment. >> thank you mr. chairman i would also like to ask unanimous consent to place into the record a statement by the american had yet to idea psychiatric association opposing separation of children (and psychological association regarding the dramatic effects separate family and the national child traumatic stress network in those key points on that traumatic separation from refugee childre children.

>> without objection so ordered your time expired the gentleman from kentucky 54 question and i thank you for being here dr. mccance-katz so the cdc found that less than half of the abuse disorder patient with multiple mental health issues ever received treatment for mental health the commission suggests this is due to lack of access and discrimination and lack of motivation to seek treatment would you describe how you plan to encourage with the state using the state targeted response opioid money to help those with untreated disorders we have a very large population with the general public who needs awareness of the services. >> thank you for that question because we are very much engaged on that issue. the state targeted response to

opioid provides funding for technical assistance training within the state now that we have done it samsa and to put in place in february was to have a grantees whose requirement was to establish a routine with every state multiple teams those with larger geographic areas that they had to have addiction experts and other types of mental health for and physical healthcare expertise available so they could go into communities in those providers let the state know what kind of services and training and technical assistance they need and they provide that on the spot. we believe that will be way to establish evidence-based practice and we know the whole occurring rate is quite high so somebody has a substance

abuse disorder they must be screened and treating one and not the other will not solve those problems as are professionals, they are license within there's date and certified by the board to provide that technical assistance and training and they are doing that now in our communities. >> the new tv show that's out several characters seem to have addiction but at the very end of the show they have a public service announcement for tee5 i don't know if you knew about that so you getting any response from that? i was pleased they were trying to show people how to reach out if they have addiction issues.

so for guidance issues with the 21st century cures act samsa has released extensive guidance for consumers on how they can report. the concern does samsa have plans to offer additional pathways to address potential parity violations or concerns? >> we are very pleased he has a portal that consumers can you that they believe could have violations and getting for their mental health or substance problems. that portal will get them to the appropriate federal agency through treasury and we are about that. we also provide guidance. samsa last summer did a 38

policy where he trained on issues related to. he and how state can make sure appropriate attention is paid to the people of their states can get the services that they need to make those are my two questions i appreciate you being here and i yield back in the gentleman from new jersey. five minutes for questions. >> 21st century cures act included provision that physically addressed child, and as i noted in my opening statement i continue to have great concerns about the children forcibly separated from their parents or guardians as a result of the trump administration zero tolerance policy. so now whether those information of refugee settlement care have experienced trauma and my resolution of inquiry last

week to request the documents of the long-term health implications of the family separation policy on the children. as hhs leader on mental health issue samsa is qualified to speak to the impact of the long-term health implication so my question not just me raising concern about the health impact of this policy but this is been a goodbye numerous public health organization and child health advocate putting the american academy of pediatrics trust for america's health and national sensation of officials so the fact national child traumatic stress network says that separation from parents or primary figures is one of the most potent traumatic stressors a child can experience especially under frightening sudden chaotic or prolonged circumstances.

what is traumatic or toxic stress you don't mind? >> traumatic course toxic stress could be any number of things that an individual would experience as emotionally distressing in various individuals have different types of responses to that. in fact as you mentioned that has been reported to be separation but i would suggest to you there are lots of stressors these children have experienced in their travels to the united states not having indoor attributes with their distress might be about it is hard to say exactly what epidemiology of these individuals might be. >> but could you comment how the circumstances of separation increase the likelihood of toxic stress?

can i get is hard to say but if you were to look at the literature on pneumatic stress you would see depending on the study that you look at 43% will experience a experience a traumatic stress in her lifetime most of them do not go one to develop major mental disorders. when you mitigate that stressors need to recover people have an amazing amount of resilience that is why all of us who are exposed to some type of stressed-out developmental disorders but we cannot predict with reliability will. >> all the more reason to get the kids back together with their parents so they can recover. >> in our department is working very hard on that as secretary has spoken to that issue they are addressing it every single day. >> i guess the problem that i have is you mention that samsa

is not involved in the child separation issue but it is from zero tolerance policy. but the problem is that 21st century cures act requires to coordinate those services across the federal government do you think samsa as a leader of mental health care should play role to respond to this crisis at the border? samsa has defined responsibilities. one of those as you have mentioned in 21st century cures act is the national traumatic network and we do implement that work to make sure they are providing the services needed to serve those who are experiencing traumatic stress. it is also a decision by

others as to what agencies are specifically are specifically involved in the day-to-day activities of any particular so samsa does what it is required to do by the cure is actively standby to give additional assistance if requested to make it sounds like you are willing to help that nobody is asking you to you don't have to respond. i think it's clear these families must be reunited immediately and to ensure that they have access to the trauma prevention in order to recover to mitigate that experience as result of this policy in my time has run out. >> the gentleman from virginia for five minutes. >> thank you for being here today with a very important topic with 21st century cures act and mental health that is also important. i will ask questions that probably are not answerable in

the five minutes that we have i will give you an opportunity that recognize i would like you to come up with answers if you can and send them to acetylene or date in your testimony discussed concerns of the enforcement of parity protection of mental health and other medicines or treatment. meeting there was similar concerns from the department of labor they have horsemen's authority --em-dash enforcement authority but have difficulty on the enforcement side that so what tools are necessary? what suggestions would you have ensure compliance and the two are being treated. that is probably an hour lecture.

in my quick answer to that question is important that i would want to use the legal counsel he will be happy to give an answer. >> i would like the extended answer because they are all complex. in a world school and to say we can identify a child has issues and send him for evaluation with the current state of the privacy laws they cannot tell us what is going on we don't need to know everything that if there are some things we need to know like do they have a violent

with that emotional or mental issues? we could pay more attention or stop by the office to look in their bookbag every day to see if they are bringing in contraband and so the question is is there some way we can experience the knowledge base? we pass some bills that it still would not cover. and to get some answers back on that. so this is a topic that the president has asked us to look

at and i will further but part of this problem is that is that providers and teachers and administrators don't understand when they can communicate and if there is a threat already hipaa allows communication but this is not well understood what we have to do is we have to work very hard to get that information out for what they allow. >> my time has run out but here is the dilemma if there is a child who could be harmful if you think it is a developing problem don't think it covers now and then tumor

further with issues of mental illness that they have violent tendencies. they don't have a clue and then to flip one more. to deal with adult children and how the written get to be interacting if there's something we need to do in the code we want to help fix the problem but we don't want to give up those privacy rights.

>> that gentleman yields back. >> i guess i will ask the question. given samsa leadership on dramatic care and practice and the office of refugee settlement ensure the children held in their custody are receiving trauma and care? >> i can say two things about that. the office of refugee settlement ensures that they are getting both physical healthcare and regularly. >> quite frankly i was pretty shocked by your attitude that

they would get over to have congressman greene enter into the record those professional health organizations the psychiatric association american public health association, american academy of pediatrics, and the concern of the trauma. to add into the record some articles of people that that weighs in from long ago and those atrocities and so i ask

unanimous consent not separated me from my trauma lasts a lifetime and an article on anti-defamation league quotes hitting children of the holocaust open up about border situation and separating migrant children from parents and they are talking about the lifelong effect. >> i have an objection to article seven to compare what the nazis did to the current u.s. government policy in the

united states with certification i may remove my objection but to compare the nazi to united states of america i will not allow those to be submitted. >> and in defense of the anti-defamation league they issued a statement of a group of hidden children of the holocaust felt strongly compelled to propose the expanded zero-tolerance policy. >> i object to mr. chairman. >> i will ask for the yeas and in long nays will you recognize there is no comparison between united states government and the nazi?

>> i recognize there isn't but this is to separating children from their parents and the long-term effects. >> i read my objection. >> i appreciate that. >> i want to ask you about the no touching policy. i am having a hard time pinning down exactly what that is. is this a policy or his son with those particular staff and if it is a firm policy that i have heard of places for example with those articles that his sister was not able to embrace her younger brother. they were told they cannot touch each other and that may not children in great

distress. i wonder if those decisions are trauma informed? >> it's really not possible for me to comment i am not only with those details. >> you don't know about touching your physical comfort coming to mental health? >> what i'm not familiar with is the agency. >> i am asking a more general question of psychological study and positive touch in with if administered

regularly. and then to have detrimental effects as a maturity you agree with that? >> that is out of context. >> really? i am asking generally. and that you are and next for don? trauma informed care and so. >> deal agrees connect will the witness answer the question your time is expired.

>> thanks for being here first of all and i just want to say i am opposed to separating children from families in all of the sample size are but i wasn't going to bring up this subject but it seems like my colleagues are staying on message and everyone will talk about that i feel i would also. i am also concerned about the thousands of children coming in accompanied tracking thousands of miles bring bought when -- brought by the coyotes and drug cartels. many of whom have been assaulted or abused. i am concerned about them also.

and it is a tragic circumstance. and currently adult meals with children and then we are releasing them with ankle bracelets two or 300 of these people per day. because the cartel and the coyote helps to follow the law. or when we do follow a lot any with the past failed policies and with catch and release to send children thousands of miles by themselves.

. . . . neglected and suffering traumatic problems and we all know that is a difficult circumstance. that is all i'm going to say on that. section 605 requires a strategic plan every four years identifying priorities including a strategy for improving the mental health of the workforce.additionally the testimony mentionsengaging subject matter from across the country.macadamia hospitals , state consumers and for members to formal complex problems and

it is a compass problem. such as workforce challenges among other things. can you expand a little on what they are doing to address the workforce challenges? particularly in rural areas? related to mental health and let me just say this, i know because i was a healthcare provider before, one of the big challenges is financial support for this type of services. but can you expand on that a little bit? >> i can. and thank you, for the question. we have developed a new program that will be in place by september 30 through the end of the fiscal year. that sets up both specialized program around issues related to mental and substance abuse disorders. things like the teams dimension for the opioid crisis. we caught the state targeted response. we have one for veterans. with the national child traumatic stress initiative. we have a number of different types of topic related special

national programs. we have to do clinical support systems for serious mental illness that will address issues around serious mental illness. we also are establishing technical assistance and training programs within each of the 10 hhs regions. those, again, focused on localized needs of communities because we know every community is different. we also recently have established a relationship with the department of agriculture that does a lot of rural work and so, we are expanding our technical assistance to some of their initiatives into rural areas. telehealth is a big issue for the department of health and human services. we have behavioral health coordinating committee which includes the operating divisions and telehealth is a specific issue we are working on to provide additional guidance to states to try to expand the reach of practitioners that we have into

rural areas. >> thank you for that answer. i yelled back. >> the gentleman yells back to the chair recognizes the gentlewoman. >> thank you for joining us today. i'm pleased your hosting is hearing to discuss the mental health in the 21st century cures. i look forward to having an oversight hearing of the final section of the 21st century cures including health it and in operability. before i asked my questions about mental health, and curious. have to make a comment about the mental health of children separated from the family due to the presidents zero-tolerance policy. public health, mental health and pediatric experts including the american academy of pediatrics, american nurses association was concerned about the harm caused by the stress and trauma incurred by children. and forcibly separated from parents by the stress not only has immediate impact but it is also damaging long-term impact on child housing development.

the dr. knows that the impact of traumatic stress can last far beyond childhood and child trauma survivors or more likely to have long-term health problems including behavioral health and substance abuse disorders pay that is why this committee must act immediately to ensure that hhs is reunited children with their parents and to ensure that hhs long-term plans to mitigate the impact of trauma on these children. now, moving on to my legislative priorities of the 21st century cures. i also have title 11 the compassionate medication hipaa section of the bill. passed into law. these provisions seek to clarify confusion about the privacy rules as applies in mental health scenarios. the confusion for patients families, doctors and even administrators and lawyers about what information can and cannot be shared remains. they require that they

coordinate with relevant agencies to develop and periodically update programs to train healthcare providers, lawyers, patients and families on the permitted use and disclosure of the health information of individual seeking and receiving treatment for mental health or substance use disorders.doctor, as you know they released additional guidance on the topic back in december. what progress has been made to develop training programs? >> well, i have a few things to tell you. one is that we are working very hard with the civil rights office to coordinate those efforts and one of the things that we did just last week was to train attorneys, healthcare attorneys on issues around

hipaa and in fact, i brought a copy of the training and i will be happy to leave it if you like. >> that will be great, thank you. >> made a thousand attorneys on that webinar. that is the most that you can have in the american bar association which has possession of this and is continuing to disseminate it. the american bar association says they thought that we would have had 4000 because they have a committed everybody that wanted to learn about this topic. we also using this to develop something that i will just say will be a little simpler language for people like me who are practitioners. to do special training for practitioners on the privacy issues. but the thing that i think is most exciting is that yesterday, we were able to publish a funding announcement. will have a national center on privacy. hipaa and 42cfr and i think it will make a huge difference. >> help the other stakeholders and clinicians? will you be bringing them in

too as you develop this programs? >> absolutely. we will have a single grantee whose job it will be to train clinicians, to train administrators and often comedies will be lawyers that are involved in healthcare systems. but the other requirement that i put into the funding announcement is that we must put up materials for families and patients. >> that is very important because many times it is misunderstood. and so, if we set up this programs if we don't have a communication to even have some patients come in and parents coming to understand what the process is, because when a family gets into a certain kind of situation, people don't know what to do. and i would hope that we would keep these training sessions going because just because we have a certain set training does not mean that it is all

done. >> that is correct. and this will be a multiyear initiative. >> okay, thank you. -- >> thank you, mr. chairman. and thank you elinore mccance-katz for being here. as the first assistant secretary focused on these issues in this way and every answer you have given, your portfolio is so large about so many issues that our constituents care about and i'm having hard to figure out where to focus. but i have to tell you, as an attorney who practice criminal defense in the courts, as a former u.s. attorney someone has been very involved in criminal justice system, we know that the 21st century cure reauthorized programs regarding the job diversion grant programs. our jails are often just

overflowing and are often the largest institutions in many ways and counties that have those with mental illness. can you give us any updates on the successes that you've seen in the program so far? that we can have our local county jails and state prisons and so forth deal with this problem. >> yes. and this is really a great benefit of the act that these kinds of resources have been made available. what we have done is to fund mental health both for adults and youth who are experiencing mental illness from sometimes for the first time but it involves them in the justice system. we also are starting programs that divert people prior to arrest. this is really very important because people who have serious mental illnesses suffer from a

great deal of stigma and these things, when you have an arrest it makes it so much more difficult for you to be able to navigate in communities without problems. it makes it more difficult to get insurance, more difficult to get a job, more difficult to get housing. and so, we like the idea of pre-diversion programs and we have funding for some of those again, through the abilities given to us. >> and i apologize and i also think we just mentioned, the national center on privacy and the fact that many lawyers got on a call, i want to applaud the american bar association for encouraging that and i believe that many lawyers will participate in that kind of training. i want to encourage you getting the word out on that as well as my colleagues across the aisle. we talked about, what is the

best way for our constituents to learn about all of these grant opportunities which seem to be either so many new grants, so many new programs and quite frankly, we are having a hard time trying to direct all of our constituents. we had a school shooting in my district on may 25. we talk about teachers and educators wanting to learn more, that is one thing i have heard is that our teachers and educators are so concerned about learning more about whether mental health first aid you talked about, whether it is about identifying as congressman griffith brought up, how can, what can you share with us as the best mechanism we can provide our constituents to be educated or to pursue grant programs, particularly for mental health in the

schools. mental health in the communities. what are the best ways we should be communicating this? instead of just going to the website. i mean, how can we have better access to the tools to provide our constituents? >> and so, i would say that the website has the information and it is -- >> extensive. >> excuse me? >> extensive. >> and we are trying to make it easier to find things. we are also working on developing webinars on specific programs to talk to the public about what the programs are and about the funding opportunities available. the other thing that we will be using, the system of regionalized training is for these kinds of opportunities as well to make it easier for those who are taking advantage of those regional programs who know more about what the

opportunities are. so, if you have a transfer center for example in region one, the northeast. the technology transfer center also can make it easier for the communities and individuals in the communities to find out what the resources are. as it relates to addiction. will have one for substance abuse prevention and will also have one for mental health issues. we also are will be supplementing the mental health technology transfer centers to specifically work on issues related to school and children's needs. i'll be happening in the next fiscal year. and so, we hope that by regional lysing the programs that we can get down to the community level and communicate

better because you are so right. it is very difficult. >> thank you. i applaud all the work your office is doing. it is so critically important. i look forward to helping you with that. i yield back to request that your lady. >> doctor elinore mccance-katz, thank you for being here today. you have a very significant responsibility. as assistant secretary for mental health and substance use. anna want to thank you for taking on this very important assignment. i reviewed your bio. you have great experience and a number of degrees. from outstanding institutions. i think your expertise is going to be, it is needed here in this area. i want to ask you about the long-term mental health implications of child traumatic stress. caused by the family separation. you heard the concern from colleagues here today. we are reflecting the concern that we hurry back home across the country. i would like to ask you about

child traumatic stress caused by the family separation policy. the children that have been forcibly separated from their families. i know you cannot get into specifics. but based upon your extensive expertise i would like you to comment in general. at this point, many public health organizations have stressed that quote - the practice of separating children from their loved ones, and caregivers for an extensive period of time as a threat to public health inflicting serious trauma and threatening long-term, irreversible health effects. do you agree? >> this is a form of trauma. >> what are some of the serious long-term irreversible health effects that could result from family separation? >> so, i cannot speak to family separation per se. i do not know who might develop a mental disorder that will health-- that will have

long-term implications. >> that is counter to things we hearing from the little mental health organizations and public health organizations from across the country.>> the president has directed the families not be separated further. secretary -- these facilities. >> you would not recommend this would you? >> the -- >> if they came to as assistant secretary would you have recommended these policies? or did they ask you? were you asked? were you consulted? >> there are a number of different policy implications. and i am -- >> i am just curious.

i note secretary azar, i believe he said he was not consulted. were you asked as the assistant secretary for substance use and mental health? >> asked what? >> before the family separation policy was implemented? >> i was not consulted on that. >> we know there is a significant body of evidence detailing the public health implications of adverse childhood experiences. would you consider the forceful separation of children from their parents to be an adverse childhood experience? >> i would consider separation from parents to be an adverse experience. and i would also remind you that these children are getting physical healthcare and mental health care and they are getting that very regularly. >> thank you. it is likely that this forcible separation already compounds upon other adverse childhood experiences these children have faced in their home countries. such as witnessing domestic

violence or gun violence. do these experiences have a cumulative effect? >> depending on the individual. reality is, and the reality is that most people have a great deal of resiliency. and when they can get their mental health issues addressed, and these children are getting mental health care in the facilities, then we hope that they will not go on -- >> the cdc and kaiser permanente adverse childhood expenses study found many long-term health impact of adverse childhood experience. including the risk of disrupting neurodevelopment, social, emotional and cognitive impairment and heightened risk for disease, disability and social problems. can you explain some of the specific physical and mental health problems that can come

from adverse childhood experience? >> there are a variety of different types of mental disorders. that can be a result of adverse experiences. >> and their risk factors for behavioral health and substance use disorders. typically, correct? >> that is true. >> there was a recent news report. >> i believe the time has expired. >> i would ask courtesy most members have gone an additional 30 seconds. i just want to ask about -- there is a recent report that hhs has quietly dipped into tens of millions of dollars to pay for what has happened through family separation and the department has burned through at least 40 million in the past two months. i'm just wondering, has it impacted your shop at samsa? have you been asked to shift any monies out that were previously directed towards samsa?

>> samsa has not had any direct effect. >> the response is negative and the gentle lady yields back. you have five minutes. >> i'm sorry. thank you, very much. appreciate that mr. chairman. dr. elinore mccance-katz in accordance with section 13002 of cures, i understand that samsa last year conducted a public listening session on mental health. involving 15 and person groups with an additional 40 comments submitted via email and in writing. can you provide us with a summary of the comments, how were the comments addressed and samsa's action plan and do plan to host another meeting with industry stakeholders? >> the -- yes, we did hold that listening session. the comments that we received were around need for education around the parity act.

and how individuals experience what they believe to be. violations will get assistant they need and what are the responsibility of states and insurers around the issues. samsa is an issue of developing a guidance on that and that should be out before the end of this calendar year. that is what i was told before the meeting. i give me the information i have available to me. >> thank you, very much. in your testimony you mentioned over 7.4 million children and youth in the nation have a serious mental health disorder but only a certain percentage received treatment which leaves a vast majority untreated. the 41 percent are the ones that were identified. it could be even more than that. again, this is a serious issue and i'm glad that the chairman is holding this hearing and we

are taking this issue very seriously. it really is an epidemic and in addition to supporting systems of care, how is samsa working with industry to address workforce shortage issues? >> we are addressing -- when you think about what type or probably have, leave an urgent problem, we have an urgent need to get more services to americans living with these kinds of conditions. what is the fastest way to do that? by the way, it will not be by opening more medical schools. that will take too long. and when i think about this i have to think about, how can i get services to americans? i can do it by training and providing technical assistance that will prepare practitioners to intervene and to provide care and treatment for mental and substance use disorders. that is why i, so much

attention since i have come to samsa -- >> me talk about practitioners, ice, psychologist, psychologist or primary care physicians that would get additional training? >> all of the above. and so, we are setting up programs of regional training and technical assistance. we also have specialty programs.we are working very hard to disseminate this so clinicians and practitioners, psychologists, psychologist, nurse practitioner, physician assistants, counselors, social workers. and primary care doctors will be able to take advantage of these kinds of trainings. that allows him to get specialized kinds of skills. and provide service to their clients. the other thing i would say is that we are working to set up programs through our grants funded organization that will provide ways that practical assistance can be provided.

for example, in the state target response fund, that cures provided, the states can contract providers that provide specialized treatment services to also be grant program at samsa which is medication assistance. a way of fomenting medical assistant treatment. those programs provide practical experience. with the ability to provide classroom style webinar web based training. but then, the ability within regions of the country where people can go see this in practice. and we think that that is the way to better assure that practitioners will feel confident enough and able to use a new skill set to provide care when americans need it. we also continue to support programs called expert screening briefs and referral treatment. we also encourage primary care

to continue -- >> how does that work now? in the schools? how can we identify the kids that have these issues and is the burden going to be always on the teacher? and where you go next once they are diagnosed? i know it is very expensive. treatment centers and a lot of the insurance companies do not cover -- even if they do, the co-pays are so very high. the deductibles. i'm sorry. >> the genre from georgia has been waiting very patiently all day. perhaps this can be responded to in writing. the gentleman from georgia is recognized for five minutes. >> thank you, mr. chairman. dr. mccance-katz thank you for being here. thank you for what you do for the children particularly of our citizens. we appreciate that very much. i know a lot of this hearing is got a little bit off base but i want you to know that we appreciate what you are doing for us and our citizens here. i'm sorry to have to report to

you that george is not doing so good with mental health services. in fact, route we raised about 47/50 and that is one of the things that bothers me. it is estimated that we have less than 20 percent of the beds that we need for mental health services in the state of georgia as well. particularly when it comes to childhood mental health. we've got 159 counties in the state of georgia and only 76 of them have a license, 76 do not have a licensed psychologist. we've got again, hundred 59 counties. 52 of them have no licensed social worker. all of these figures are alarming to us and alarming to me in particular. because of the fact that in the state of georgia, for those children between the ages of 15 and 19, the second leading cause of death or suicide. between those of 10 and 14 the third leading cause of death or suicide. all that leads me to ask you,

they reauthorized the mental health initiative. it provided a lot of grants and a lot of assistance. and we are very appreciative to them for. i wanted to ask you, particularly in the state of georgia, we have a lot of rural areas between south georgia and my district.i am wondering, how do we get services to those areas?any suggestions on how we can improve services there? >> samsa has supported two types of integrated care programs. one is where behavioral health providers can participate in certain programs. the second is through programs such as certified community behavioral health clinics. they bring primary care directly into gabriel health setting. so a person can easily access all the care and services that they need in one setting. samsa, as you know, has limited

funds. we do demonstrations. we work closely in terms of establishing those demonstrations and then doing more technical assistance and training and trying to establish those on a national level. we talk with our colleagues at the centers for medicare and medicaid services. >> what about family medicine? or telemedicine? is that something we should be focusing more on? >> yes. i was just about to get to that. >> i'm sorry. [laughter] >> yes, telehealth is very important piece of it. particularly for areas that have a lot of large rural communities.>> right. >> telehealth can really extend the reach of a practitioner who may be in a more urban area but -- and so, department of health and human services has a committee that is working on telehealth guidance for the states. and in addition to that, is working with for example, the drug enforcement administration

around issues of prescribing. so that we can utilize the telehealth providers to the very best extent. >> right. other grants specifically for that? or are they included in the regular grants that you can use it for that purpose? >> we have at samsa, part of a larger grant program that our telehealth services come from. and i believe the other parts of hhs have specific funding for telehealth. >> another thing i want to talk about quickly is the opiate addiction and funds that have been going there, grants that have been going there. we've been very fortunate at the georgia department of health and develop mental disabilities. it has almost $12 million. i want to report back to because i been part of some of these programs. it is working well and being utilized well. in fact i've been, one of the cities, want to give them a shout out, pembroke georgia.

in my district. they've been very active in this and implement a number programs that have media campaigns, school partnerships. a number programs that have been very successful. can you elaborate quickly on what else we might be doing with all of that? >> for the opioid crisis, it is one of secretary azar 's parties. >> and this committees parties. >> yes. and we are very grateful to congress for the increase in funding to address these issues.but we have to do is work hard to integrate substance abuse treatment, opiate addiction treatment into primary care settings. in addition to having specialty care available. we know that people find it very difficult to access care and so, we want to broaden the number of providers that are willing to engage in care. and to use innovative practices

such as telehealth. this is why we are working with the dea to make it possible for clinician to have a greater reach and to reach americans in the areas of such difficulty accessing. >> right. thank you again for your work. i yield back. >> thank you. all members have had the opportunity to ask questions. i would think our witness for taking time to be here with us today. pursuant to committee rules i remind members have 10 business days to submit additional questions for the record. i asked our witness to submit responses within 10 business days upon receipt of those questions. without objections, the subcommittee is adjourned. [inaudible conversations]