he is having the hearing. we are entering this discussion , with no agenda other it then to learn what needs to be done. we have as the chairman said, we've had not had a mental health hearing in a while, -- we have not had a mental health hearing in a while, so i'm here to do some listening. i remember telling people in the department that i thought i was going to a hearing but in fact, it was a talking because the senators did all the talking and the witnesses did most of the listening. i hope this will be more of a hearing instead of talking, and i will do my best to make it that way. seems to me that the question before us is -- who needs help? and who is there to provide the

help? we could hone in on that question and see what the federal government can do to improve our ability to determine who needs help and our ability to identify the person or agency whose job it is to provide the help, and then we will have provided some service. it helps to put a face on who needs help. as a former governor, i look at things from my background and perspective, as i know most of us do. about 22% of tennesseeans reported having a mental illness last year. that is more than 1 million people. this is according to our state department of mental health. about 5% had a severe mental illness. that is nearly 250,000 tennesseeans. that is a lot of people.

about 40,000 had a major depressive episode. the funding that helps meet the needs for that comes in some part from the federal government. about 22% of what tennessee spends, i'm told, is federal dollars. the rest is state dollars. in community services, state appropriations are about 70% of the mental health fund. while the state government has a role, it is a support role, and it ought to make things easier instead of harder. in preparing for this, it seems to me that putting a face on the individuals that need help -- one group would be a 9-year-old boy, who has always been pleasant but suddenly started defying his teachers. his grades slipped, and he did not want to go to boy scouts, did not want to play with his friends, so they reached out to a pediatrician who was able to

get professional assistance. he was diagnosed with a mood disorder, and he began to improve and was sleeping better, so it was a success story. another case might be a 17-year- old who had no behavioral issues growing up. he started noticing lights in the bathroom. sounds of water irritating him. he began having trouble sleeping. he began to hear voices telling him to throw rocks at people. he was finally diagnosed with schizophrenia, but only after he had multiple episodes. those boys represent two of the largest groups that need help, and i will be interested in finding out from our witnesses how well we are doing in helping them get the help. finally, i will be especially interested in asking federal agencies as well as state and local witnesses that are here what we can do at the federal level to make things easier to identify who needs help and who

can provide the help. are there administrative things we can do? are there funding things we can do? are we putting up roadblocks that make it harder for you to provide services? if we are, this is the place to identify them and see if we can correct them. mr. chairman, i look forward to this, and i thank you for holding the hearing. >> thank you very much so, senator alexander. now we will turn to our witnesses. on our first panel, we start with pamela hyde, the administrator of the substance abuse and mental health services administration. ms. hyde was nominated by president obama and confirmed by the u.s. senate in 2009 as the administrator of samhsa. she has served as a state mental health director, state human

services director, city housing and human services director, as well as ceo of a private, nonprofit managed behavioral health firm. she is a member of or has served as consultant to many national organizations including the john d. and catherine t. macarthur foundation, the american college of mental health administration, and the united states department of justice. our second witness is no stranger to this committee. dr. thomas insel, director of the national institute of mental health at the national institutes of health. he has been director since the fall of 2002. prior to that, he was professor of psychiatry at emory university, and he was the founding director for the center of behavioral neuroscience, one of the largest science and behavioral centers funded by the national science foundation. he has published over 250

scientific articles and four books, including "biology of parental care" in 2003. he is a fellow at the college of narrow psychopharmacology -- neuropsychopharmacology -- there i said it. we thank you both for your background, for what you have done in this area of mental health, both in research and practicality, and your statements will be made part of the record in their entirety. i would ask -- we will start with ms. hyde. i will ask if you could sum it up in five, seven, eight minutes, something like that. then we will get to questions. >> thank you for holding this hearing today. it is an important day. you will hear today about the prevalence and burden of mental illness and the critical needs

in our country for understanding treatment and support services for those who experience mental health conditions. samhsa's mission is to reduce the impact of substance abuse and mental illness on american communities, and there is significant overlap between those sets of conditions. they currently exist largely outside the mainstream of american health care with different histories, structures, funding, incentives, practitioners, and even in some cases, different governing loss. it is time that changes. behavioral health is really essential to health, that mental and emotional health and freedom from substance abuse and addiction are necessary for an individual, a family, or a community to be healthy. almost half of all americans will experience symptoms of mental or substance abuse disorders in their lifetime, and yet, of the 45 million adults

with any mental illness in a given year, only 38.5% of them receive the treatment they need. of the almost 22 million adults with substance abuse disorders, only 11% receive the treatment they need. for children and adolescents, only about one in five receive the treatment they need. cost, access, and recognition of the problems this treatment -- are the primary reasons this treatment is not received. but it does not have to be this way. treatment is effective, and people do recover. the institute of medicine reported in 2009 that half of adult mental illness begins before the age of 14, and 3/4 before the age of 24. we can and must intervene early to address these issues for our young people and for our nation. behavioral health is a public issue, not a social issue, and it can be tackled and addressed in an effective public health approach, driven by data, focus

on prevention, and support of policies that treat and restored to health. i would like to talk about the affordable care act for a minute because it will provide one of the largest expansions of mental health and substance abuse coverage in a generation, by helping over 65 million americans have access to additional behavioral health benefits that they do not have now. they have already prescribe it -- it has already provided screening for depression, suicide, and added many programs in its quality measures and has added additional coverage opportunities for youth. it will ensure that insurance plans offer coverage at parity with other benefits and as one of the 10 essential health categories. as part of the president's plan to protect children and communities, he outlines specific actions and initiatives to help ensure adequate coverage of mental health and addiction services. the administration issued a letter to state health officials, making it clear that

medicaid expansion plans must comply with the parity requirements of the mental health parity and addictions equity act of 2008. in addition, the administration will issue final regulations governing how existing health plans that offer mental health and addiction services must cover them at parity. the president's initiatives to ensure students and young adults receive treatment for mental health issues includes samhsa- lead proposals such as a new program called project aware, which would bring together state officials, schools, communities, families, and youth, to promote safety, prevent violence, and identify mental health conditions early and provide treatment. a proposed new grant program would provide a pilot to model innovative state and community- based initiatives and strategies, supporting young people ages 16 to 25.

the president's workforce proposal would provide training for more than 5000 additional mental health professionals to serve students and young adults. finally, with the department of education, hhs will soon launch what we are calling a national dialogue on mental health to help change the conversation and galvanize action about our children's mental health. we have come a long way in the prevention, treatment, and recovery support for mental and addictive disorders, but we have a long way to go, and we can do better. thank you for your time today, and i would be very pleased to answer any questions you may have. >> thank you very much. now we will turn to dr. insel. welcome, once again. please proceed. >> thank you, mr. chairman, ranking member alexander, and members of the committee. it is a real honor to be here, and it is a real pairing to have hyde -- administrator hyde and

me on the same panel. as a person coming to you from the national institute of mental health and the national institutes of health, my role is around the research related to mental illness and thinking about how to come up with the science that will lead to better diagnostics, better therapeutics, a better understanding of what you called a silent epidemic, and that is an interesting term for this. i know we have not met for some years to talk about this, so it is particularly for us important to get this out on the agenda. it is clear that in some ways this is a response to the -- response to the tragic event that happened in december in newtown, connecticut, and if it takes an event like that to focus the nation's attention on the needs of those with mental illness, it is terrible to say that, but at least perhaps one of the opportunities that can be taken now is to think about how we do better by those with mental illness and how we make sure that events like this do

not happen again. i will not read my testimony, and to save time, i think we are both eager to get to your questions, but perhaps to preempt some of those questions, let me take a couple of minutes to discuss what might help in terms of how we think about mental illness -- some of the definitions and science as we understand it. first of all, very common disorders -- depression, ptsd, eating disorders, and many others -- there are about 10 or 12 that we focus on -- these are real illnesses with real treatments, and they affect about one in five americans overall, including youth, as we will say in a moment. today, we will probably talk seriously about serious mental illness, a term for those people that are severely disabled, often by a psychotic illness, which occurs perhaps in about

one in 20, so it is not quite as common, but it is an important piece of the story we need to talk about because these are the people who are most severely impaired. as pam mentioned and was already mentioned by you, senator, it is critical to understand that unlike talking about cancer and diabetes and heart disease, when we talk about mental illness, we are talking about illnesses that began early in life. these are in fact chronic disorders of young people, and it requires a different mindset when you think about how you detect, intervene, make sure that you can make a difference. that is one of the reasons these disorders have the highest disability rating or the highest morbidity overall -- because they start early and tend to be chronic. we know these are treatable disorders, but there is a significant delay in getting treatment, and even those young people who have these most severe illnesses like schizophrenia -- on average, the

delay between the onset of symptoms and when they get diagnosed and treated is somewhere between one or two years, which seems extraordinary because you are talking about a sentence that seem disabling and obvious. it is especially unfortunate because we've learned that the secret to having the best outcomes is early detection and early intervention. that is what biomedical research has taught us. you have to get early -- you have to get there early in the process if you want people to have the best outcome, and we do not do that here. one of the things we need to talk about, going back to your comments about who needs help and who will be responsible for providing help, is why the delay? how do we do better in making sure people get involved earlier in the process? just a comment about violence and mental illness because it will come up, i think -- it is on a lot of people's minds -- most violence has nothing to do

with mental illness, and most people with mental illness are not violent. in fact, we generally worry more about people with mental illness being the victims, not the perpetrators of violence. the science certainly supports that. there are two conditions where we do need to think about this. violence and mental illness will intersect. one of those is the psychotic illnesses like schizophrenia that start early, usually adolescence. people who have not received treatment are at greater risk for violence, either because they are paranoid and rationally feel they are under attack, or sometimes because of hallucinations or voices telling them to do something horrific, as you mentioned with your example, senator alexander. far more common is the second issue, violence against the self. suicide is a far more common

problem. 38,000 suicides in the country each year -- that is more than one every 15 minutes. 90% of these involve mental illness. by contrast, there are less than 17,000 homicides with less than 5% involving mental illness. when we talk about violence and mental illness, when we talk about safety and security, when we talk about access to means or duty, the primary objective is protecting people with mental illness, appears, and community. there's a lot to be done. it is more still art than science, and i would say that is true, by the way, of heart attacks as well as cancer. but even without being 100% certain on the predictions at the individual level, we can do a lot towards prevention, and you will hear about that in the

conversation today. at nimh, we spent much of our investments focusing on mental illness before psychosis' begins, the way we do today with cancer and heart disease and thinking about how to intervene early. i will stop there, except to say that this is an extraordinary time in terms of the science of mental illness. we are in the middle of a revolution because of what we are learning about the brain. we think of each of these disorders as brain disorders. we think about our interventions in terms of how they affect individual brain circuits. we have made tremendous strides over the last 50 years -- you cited president kennedy's launching of the community health program, which began with congress on february 5, 1963. we are almost exactly at the 50-year anniversary. a lot has happened at that time, but we have a long way to go. i look forward to your questions

about how we can do better going forward. thank you. >> i will start a round of five- minute questions. i just want to again focus on the mental health parity addiction equity act, signed in law, 2008. major accomplishment -- concern because the interim final will published in 2010 left some implementation details unresolved. when the administration publishes a final rule, how will you address issues such as the scope of services that must be covered so that insurers have the detailed guidance they need to implement the law? >> thank you for the question, senator hyde -- harkin. part of what was requested from the public was input on several topics. that was one. in the meantime, we've issued four or five sub-regulatory guidances', frequently asked questions, and we've been

meeting with stakeholders in with the industry trying to understand how the implementation is happening. we are ready to produce final legislation -- final regulation, and we are in the process now. >> dr. insel, i have some concerns, and i know others have also, and i've read a lot about these concerns, and i hear them from constituents and people who talk to me, about the use of pharmaceuticals, particularly the use of anti psychotic medications in children -- anti- psychotic medications in children. from what a year, a kid acts up, does something, get him a drug -- the use of anti-psychotic medications in children. from what i hear, when a kid acts up, does something, they get him a drug. what might work in an adult --

you say we will reduce the dosage. that sometimes does not always correlate. i do not want to practice medicine without a license, but unless we know that to be a fact, what do we know about the long-term safety of these kids, and what areas require further research and study? >> in fact, there is a real concern because the use of anti- psychotics in children has gone up markedly over the last decade. we know that children are more sensitive to the side effects, particularly the metabolic side effects, and that is a real concern because often these drugs are used long term. so there is an issue -- a real issue about practice and improving the quality of practice in this regard. i should say that some of this may be related to reluctance from many clinicians to use anti-depressant, which are probably somewhat safer, but there are concerns about suicide and violent behavior. the curious thing to note is if

you look at the other side of this, we are not talking about young children, but when we talk about adolescence and the example that senator alexander used about the 15 or 16-year-old beginning to hear voices and going down the path of psychosis -- what tends to happen most often is not that people are getting over treated with medications, but they are not getting diagnosed or treated at all. specifically with respect to concerns about violent behavior, we know that treatment reduces that. the most important thing you can do if you want to prevent new events like this, the ones we have often talked about over the last five or six years, is to ensure that people who are on this path -- becoming psychotic and paranoid and grandiose and perhaps dangerous -- are treated. the risk of violence is 15-fold higher prior to treatment. medication is not the whole treatment, but it is part of

making sure that people who are developing a psychotic illness are actually not going to become a risk to themselves or others. >> we will hear testimony later from the next panel about approaches such as mind/body connections and things like that. in terms of -- especially as we get into prevention and we start recognizing in young children in school and other places certain types of behavior, maybe early- on interventions with family counseling and therapy might be more successful than just giving them an anti-psychotic drug. do you have comments on that? >> there are only a few reasons to use an anti-psychotic drug in a young child. probably the most common and the one approved by the fda is in autism, where there are forms of

irritability and what you might call to pretend trends in which children might hurt themselves or hurt somebody else -- in that case, the fda has approved the use of anti-psychotic drugs. for the most part, the ones that seem to show the greatest efficacy are in other classes, particularly for children who have for instance attention deficit hyperactivity disorder where the site the stimulus have been shown over and over again over the last four decades not only to be high efficacy but high safety as well -- where the psychostimulants have been shown to be high efficacy and high city. there are all kinds of intervention that are being developed and that are still being developed that may be far more effective be on medication. so this is just a part of the story. >> thank you. my time is up.

>> i just was going to say that from a population-based point of view, for young children, there are interventions, not for people who have been identified with an issue, but in classrooms for example, a program we support called the good behavior game, which has shown a remarkable ability for teachers to manage behavior in classrooms that has shown an impact. >> thank you, mr. chairman. ms. hyde, it looks like, just looking at tennessee, may be 1/4 four 1/3 of the funds -- maybe 1/4 or 1/3 of the funds are available for mental illness. does that sound right? most of it goes through two big block grants -- or one big one and one smaller one. does that sound right? >> sauerbrey rule of thumb, --

sort of a rule of thumb, somewhere around 1/4 of the nation -- i do not know about tennessee in particular. >> for the nation, that sounds about right? >> it sounds about right if you take the medicaid dollars. each state has a different match, of course, so that changes how much is state dollars and how much is not. about half the dollars that go for the behavioral health of the country as a whole are federal dollars, public and state. >> do you regularly consult with state mental-health directors about your two block grants and how they are administered and how the money is -- how you might improve the process of applying for that money and make it easier for them to help the people who need help? >> absolutely, senator. we put out a block grant application that makes it easier for states to apply for the funding. we go through a public process as well as informal process of

asking for input from the states, and the two state associations that represent state agencies in that process. >> i heard the statutory deadline for the grants is in the fall -- september and october -- but you have indicated that you have moved that up to the spring, and that is causing some states to have concern about being able to get ready for the applications because of the legislative sessions, and that there's some confusion about how much information is requested. and if as much is requested as appears to be, that it might be burdensome. >> interestingly enough, we changed that date initially in consultation with some states. we were trying to push up the date so that they could do their planning during their legislative process, so as their legislature decided match money's or what we call maintenance of effort monies, it

could be tied to the block grant dollars -- as their legislature decided match monies. >> could i encourage you to take a look at that and make sure that it is not a burden on the states? >> absolutely. >> you mentioned the mental health parity letter that came out earlier this month. did the mental health parity law apply to medicaid by its terms, or does it apply to medicaid by the terms of the new health care law? or is the letter something that expands the application of mental health parity to medicaid? >> the letter just explains and provides guidance to states about how the federal law about parity applies to certain portions of the medicaid program.

medicate benchmark plans and benchmark equivalent plans or alternative plans are subject to the law, where is the basic underlying medicaid program in the states are subject to others. >> so it should not be a surprise to governors who are evaluating the cost of mental health expansion that the mental health parity law applies to medicaid? >> sir, i do not know if it is a surprise, but it, in fact, applies to certain portions. >> that is helpful. i've heard from a number of governors who have made decisions -- to have not made decisions about medicaid expansion that it is hard for them to make that decision. for example, in our state, it was 8% when i was governor, and it is 26% today.

did you detail in your letter with the added cost would be as a result of the application of mental health parity to medicaid? >> no, the letter was not about cost, although as congress went through the process of passing the mental health parity and addiction equity act and a significant discussion about cost and all the studies that occurred have indicated that the cost is negligible. in fact, it does allow a plan to request an exemption if their costs go over a certain amount. so that is part of the law. >> thank you. >> thank you, senator alexander. it has been a tradition or rule of this committee that the center -- senators are recognized in order of appearance. we will go back and forth.

>> thank you very much for holding this very important hearing. i think it is especially important to note, obviously the issue of newtownfolk is everybody on it, but this is an issue a lot of us have been working on for quite some time -- obviously the issue of newtown focused everybody on it. i look forward to working with you and all of our new members. there's a lot of great talent here, mr. chairman, and i think we will be able to do some really good things with committee -- with this committee. thank you so much, and i want to thank the panelists as well. i do want to go back. in the president's recently released gun violence package, he issued three parity provisions, one clarifying parity for medicaid-managed care plans, one saying that a parity

provision would be included in the final central health benefits rule, and one that committed to issuing the final rule on the mental health parity and addiction equity act, which you have mentioned, but it did not make clear and you have not yet made clear when we will actually see that. if these plans are supposed to be ready to go into exchange starting in october, it is essential that we see a final rule on this before april. let me go back to the question that senator harkin asked and asked you to be specific about a date when we will see this final rule in place -- ask you to be specific. >> the indication was the essential health benefits rule would be out next month. we are working on the mhpaea final reg, and it will go through the regulatory process and is in the process now. i cannot give you a specific date. >> will we see it by april?

>> i cannot tell you what the specific date is, but we are on it now. >> it is essential because states are working on these exchanges, and they need that clarity to move forward. i cannot urge you strongly enough that that date is critical. one of the issues i have focused a lot on is our military families. i just continue to believe we have to do everything we can for our veterans and service members as they transition, especially during difficult periods of redeployment and returning home, transitioning back into the civilian world. the focus also has to be on the families of these veterans, and i'm certain that is the same throughout all of the mental health areas you are talking about. the mental health access act that we wrote included provisions to expand some of the va mental health services to

family members. can you tell me how you have been progressing in implementing the military families initiative? >> yes, senator. you may recall the president issued an executive order in the fall asking hhs and dod and va to collectively work on improving mental health access for service members and veterans. we are actively working on that together, the three departments. part of the way we are trying to get at the whole family and the whole needs of the individual is looking at partnerships between community health centers, community mental health centers, and va organizations. there are times when family members cannot access veterans administration, but they can access the mental health center down the road, or vice versa. we have been trying to look at pilots. the executive order called for working on pilots, and we have been doing that. we have also been working on

stakeholder groups, and some of those have been families of veterans, service organizations, and others giving us their input about the best way we can provide that. we have a report due to the president by the end of february, so we are actively engaged in the process. >> i look forward to seeing that. senator sanders is taking over the veterans administration, and he is really focused on that as well. dr. insel, thank you so much for reminding all of us that mental health does not mean that someone is violent. i think that is important to remember as we go through this, and we do need to focus on the population that has the potential for becoming violent, particularly at younger ages. i think that is why this hearing is so essential, and i appreciate and look forward to hearing the testimony of the rest of the panel. thank you.

>> thank you, mr. chairman. i want to congratulate senator alexander, who gave up a leadership position on our side in order to be ranking member on this committee. it shows his dedication to health and education and workplace safety and training and pensions, and i know he will do an outstanding job. i appreciate you holding this hearing on mental health. my first question is for administrator hyde. i want to know more about the coordination and collaboration of agencies at the federal, state, and local level. within your appropriate role as a federal agency, what needs to be done to better enhance that coordination and collaboration of agencies at the federal, state, and local level? >> thank you for that question. we've been trying very hard to recognize the relationship between states and local communities because the state

often will create laws, rules, regs that the community has to respond to. when we provide grants, for example, to our communities, we are trying to ask how it relates to the state's plan of direction. likewise, we want to ask how they are bringing communities into the process. we are trying to bring them together through our community block grant application process. we are also asking how these things relate to what is going on at the community level. we have been providing significant technical assistance because there's a lot of change going on in the health delivery system to both our states and our provider agencies, which provide the basic community infrastructure. we also have a county-based programs that we do a significant amount of work with -- we also have county-based programs. i've had the opportunity to work

at the city, county, state, and now federal level, and sometimes, what you feel is where you sit, but i understand only too well how much those relationships matter, so we are working on them significantly. >> thank you. i look forward to any suggestions you might have. dr. insel, what do we need to do to close the gap between research and real-world practice to make sure that treatments are available in the community service settings? >> thank you. that is a discussion we had discussed a lot at nih, not just in the mental health arena, but across all of the diseases for which we are responsible for providing better science. the response to your question or typical assumption behind it is there is a 17-year gap between discovery and implementation, so what we used to talk a lot about was how you move from research to practice. interestingly, i was set in the last two years, there's been a

transformation in terms of how we talk about this -- i would say in the last two years. how do we move from practice to research? how do we make sure we develop health care systems but learning health care systems that are involved in the research care process itself? at nih, we have created several efforts to do that, involving millions of patients through a large health-care system like kaiser and many others, in which we are doing research for doing actual practical trials in these very large groups -- or doing actual practical trials. the advantage is you are making discoveries in the place where they will be implemented, rather than doing it, for instance, in an academic center where they meet -- where there may be a gap between development and getting it to the community. there's also bringing in the community at the get go and

making sure the kinds of questions asked will give you the kinds of answers that people in the community are looking for. >> reinvention is always appreciated for both of you. what type of oversight or financial controls are in place to ensure that federal funding is being used effectively to prevent and treat substance abuse, use, disorders, and mental illnesses? what needs to be done? what changes are needed? >> i will start with that question. for almost all of our programs, we do an evaluation to see what kind of outcomes we are getting and what the results are. we try to use those evaluation results in how we do the next round of activities. we also provide some of the largest amount of surveillance data in the area of behavioral health, substance abuse, and mental health. we are trying increasingly to use that data to help us understand where we need to go. we are working on something

called the national behavioral health quality framework, which is a second step from the national quality strategy that was called for in the affordable care act. in that, we will be laying out the framework for quality direction for behavioral health as a whole at different levels. we also obviously collect information and data from each of our grantees, and we are trying to improve that by streamlining our data collection systems. we have multiple systems now. we are trying to put them into one that we hope is more effective and easier for states and communities to report into, so there's a number of activities we are going through around accountability and innovation, and we work very well with nimh, nida, niaaa on their research and how we can bring that into our practices as well. >> my apologies -- i have used

up more than my time. dr. insel will answer that in writing. i will also add a question about duplicate information between all agencies. >> thank you. >> thank you, mr. chairman. i am delighted to join the community and very pleased that the first hearing in this committee this session is developed to this incredibly important topic. insuring access to quality and affordable health care has been and will always continue to be a very high priority of mine. when i say health care, i do not distinguish between physical health and mental health because to me, they should be viewed as one and the same. the mental health parity act and the affordable care act both take important steps to make this a reality.

together, those two laws will expend health-care insurance coverage to millions of previously uninsured americans and increase access to mental health care for millions more who have health insurance coverage. my first question relates to increased access to insurance coverage. as we speak, governors across this country, including in my home state of wisconsin, are grappling with the decision of weather to expand medicaid coverage -- whether to expand medicaid coverage under the affordable care act. in my home state, around 200,000 could gain medicaid coverage under the affordable care act -- medicaid expansion -- should our governor make that expansion. ms. hyde, i want to appreciate the fact that in your testimony, you point out that medicaid is

currently the no. 1 paper for mental health services in the united states -- the number one payer. we know many americans currently do not qualify for medicaid coverage. in your opinion, how might states grappling with this decision, states choosing to expand medicaid coverage under the affordable care act, improves mental health outcomes for their most vulnerable citizens? perhaps alternatively, what variation might you expect to see between states that expand -- choose to expand medicaid and those that do not with regards to treatment of mental illness? >> thank you, senator, and welcome. >> thank you. >> we are very optimistic that as states go through their processes, that they will come to the decisions to provide opportunities for coverage to their citizens. in that process, obviously, each

state looks at its own medicaid program. however, the letter that we just recently put out was an attempt to try to help states understand how they should be looking at mental-health and substance- abuse treatment within those contexts. there are certainly substance -- there are certainly treatments we know can work. we are working closely with the mental health agency in cms and putting out information on how states can give the medicaid program increased access and do better for behavioral health. we are working with them to do that. we also are working on the enrollment and eligibility process with the department as a whole because we know people with behavioral health needs, typically even after a full recovery, have a harder time saying covered. we are trying to get access to the type of service or the a ray of services that might be provided and just trying to provide information in helping

states understand the most effective way to provide these services -- the array of services that might be provided. >> thank you. one of the ways that we have already seen expansion of access to care -- you were talking in your testimony today about the barriers being cost and access, etc. is the provision in the affordable care act that allows young people to stay on their parents' health insurance until they are 26 -- something i am particularly proud of because i worked very hard on that and was pleased to see it in the final act. i'm wondering, especially given that your testimony talks a lot about the age of onset of many profound mental illnesses, being between 16 and 25, weather you

are already observing the positive impact -- whether you are already observing the positive impact of that increase insurance coverage. >> the provision to allow young people to stay on their parent'' insurance and the provision to prohibit the exclusion from pre- existing conditions -- both help young people with mental health and substance abuse disorders stay on and keep insurance or be able to get access to insurance when they may not have access to it otherwise. millions of young people are covered through that process already, and we know -- i do not have a specific number, but we know the young people who have these disorders are part of that group. >> thank you. >> thank you, mr. chairman, and i join the rest of my colleagues in thanking you for calling this hearing on a very important subject. i'm told by my staff that we

have not had a hearing in the health community on mental health issues since 2007, which is way past time. thank you for your attention to this. i have been focused on the issue of suicide for years now, particularly youth suicide in this country. in my state, we have troubling statistics in areas, but the one i find most disturbing is statistics when it comes to youth suicides. in the country, the rate was 11.5 suicides per 100,000 people. in alaska, we look at a suicide rate of exactly double that. even worse are our statistics as they relate to our alaska native young men -- those between the ages of 15 and 24 have the highest suicide rate of any

demographic in the entire country at a rate of 141.6 suicides per 100,000 people per year, and this is between 2000 and 2009. for us, it is staggering. it is something i find so troubling. for everything that we do, we cannot seem to make inroads here. i have long been focused on it. i just introduced legislation that will help to address the youth suicide -- this is the garrett reid smith memorial act reauthorization -- the garrett lee smith reauthorization. also, in addition to providing these grants to tribal organizations and to colleges

and universities as well. the question that i would have for you as director is how we can do more within our colleges and within our universities to provide for identification, early treatment, early intervention, and the treatment services that might make a difference with our young people in our universities. we see these documented mental health needs. i am concerned that we do not have sufficient flexibility within the programs that currently exist to help address this need. can you speak to your observations and what we could be doing better to address those? >> thank you for the question. as you know, the surgeon general, along with a very

strong public-private partnership last september, put out a national strategy for suicide prevention. in that strategy, there were several high-priority things identified. i do not have the time nor memory to go through all of them at the moment, but there were some very key things like identifying, even as we have been talking about issues in the age group, raising awareness so people know what to look for. having people be able to get help better, in gauging -- engaging after care so when people do have risk of suicide or make a suicide attempt, then follow up to make sure there is adequate follow-up. providing clinical standards so that clinicians know how to do the screening. that includes campus-based programs. we are proud to administer the garrett lee smith program, and we are seeing great results in

terms of raising awareness. part of the president's proposals also include the idea of a mental health first aid approach and trying to get people more aware -- especially focused on youth -- of what to look for, how to get help. >> this is a key issue for us. it has been noted by my colleague, senator baldwin, that the identification of mental illness in terms of recognizing what we are dealing with -- ansett is as early as age 14, and that the early identification can really help with improving outcomes -- onset is as early as age 14. yet, most of our primary care providers out there are probably not adequately prepared to

identify mental illness at its earliest stages or provide for that appropriate care. what can be done? what is the administration doing to support primary care, improve these training opportunities so that we can do that early intervention, that early identification? >> such an important question because, as we talked about earlier in the hearing, the lesson we have learned over and over again by medical research is that early detection and early intervention give you the best outcomes, so we do need to do better at this. it is challenging in this sphere because we do not have by no markers the way we do for heart disease or cancer or many other diseases -- we do not have biomarkers the way we do for heart disease or cancer or many other diseases. nih is invested heavily in developing those kinds of tests, weather they are cognitive or biological -- whether they are

cognitive or biological, to know who is in a high-risk state. i do not think we can wait to make sure there is better awareness and better community support. one of the things that you have heard, and pam has already spoken to this, is project aware, which was announced by the president last week, which is an attempt to go out and increase awareness in schools and communities about the challenge we face, the need to be able to detect the earliest signs, at the same time recognizing that there are a lot of teenagers who are struggling. you do not want to label every one of them as having an illness. you need to be sensitive to getting better and better, more precise measures about who really is at risk and knowing who to intervene with. we have got to find the right balance, and, hopefully, science will bring us better tools for that. gone over time. i apologize, mr. chairman. >> thank you, mr. chairman.

like all members of this committee, we thank you for calling this committee. i want to welcome senator alexander as our new ranking member. i look forward to working with you. like everyone on this committee, i was devastated by the tragedy in newtown. in the wake of the tragedy, there's been a new focus on mental health issues, which i've been working on for a long time. paul wellstone held the seat that i hold, and i, too, share the sense of urgency. while i am glad we are focusing on mental health, i think it is

important not to stigmatize people with mental health or generalize about the connection between mental illness and behavior. most people who are violent do not have a mental disorder, and most people with mental disorder are not violent, as ms. hyde said in her testimony, and, dr. insel, you said essentially the same thing. we should ensure that everyone has access to the mental and behavioral health services that they need, because it would make our communities and families and them healthier and happier, but again, i think it is absolutely vital that we not stigmatize mental health in the process. it would be not only counterproductive, but counterfactual. i will be introducing the justice and mental health collaboration act, which is

really a reauthorization of -- an improvement, i hope, upon a previous bill about when people with mental health issues encountered the criminal justice system. i have seven republican sponsors on that. i will also be introducing the mental health in schools act, which dovetails with project aware. this is where, doctor insel, your testimony -- and your testimony, too, ms. hyde, is so important. it is about schools, identifying and treating and giving access to treatment to kids. the statistics you mention -- only one in five of children who

have a mental health issue get seen or treated. my legislation will allow schools to collaborate with mental health providers, law enforcement, and other community-based organizations to provide expanded access to mental health care for their students. it will also support schools in training staff and volunteers to spot warning signs in kids, and to refer them to the opprobrious services. i am glad that project aware has the same kind of focus. i want to ask about the evidence. with the caveat that both of you made about not stigmatizing mental illness and associating it with violence, that if mental

health issues go untreated, does that increase the chance that someone in a certain subset of mental illness will become more violent or has a higher chance of becoming violent. >> within that narrow band of the people we are talking about, which is a small, small segment of the population of people with mental illness, but those who have what we call first episode psychosis -- we know that the duration of untreated psychosis is related, in fact, to the risk for having a violent act. that has been studied quite carefully, and there is a real correlation. closing that gap is one of the things we can do to increase safety. >> in a sense, newtown did prompt this.

and that was one of a number of horrific occurrences where i think that no one would that in, newtown, we are talking about someone that is deranged. and had that person been able to get some kind of treatment to identify and treat children early on with the tragedy that brought us here. >> i will not speculate on individual cases, but the published data is quite clear. a severely violent acts at

those that are and treated was 15 fold. it is something that is effective. >> center murphy has left right now. -- senator murphy has left right now, senator sanders. >> thank you very much, senator sanders, i have a meeting with senator shelby t. that will take me to the questions with the doctors. whether it is autism or chronic schizophrenia, it is research, treatment, and the work force.

my question to each one of you, if we take the issue of research, what will be the consequences of sequester with the national institutes of mental health? you talked about this outstanding work you're doing. what would happen? lookingis point, we're at a 6.4% reduction in the 2013 budget. it will come, if it happens, sometime in march or april. there will be certain studies that will not be done with that budget. one of the major project is highly relevant to this discussion today that has to do with how we ensure that we have the kinds of predictors for early psychosis? we have a large national study

that we would like to scale up. that is not going to be done if we don't have the funds to expand what we are currently doing. >> 1 but said the operation under your organization, what would be the consequence? you can't have mental health without mental health practitioners. what a sequester have an impact on health force issues? >> a sequester that was not intended to happen, we hope it doesn't happen. we have a lot of technical assistance and training. we have materials and practice improvement for the work force. to the extent that we don't have

the same number of resources to do that, less of that will certainly be able to be done and less of the grants that we put out as well. >> it will have a direct impact on training? >> it could. we have a fairly significant portfolio in providing what i call replace or practice improvement efforts. it includes training, technical assistance, materials, and access to resources. that is what it takes resources to do. >> i have a picture and we will be coming back for more detailed questions. this threat is severe. it has a tremendous impact on morale. senator sanders, i appreciate it. i know you are keenly interested

as well. the reason i asked about the training, this 1963 bill was signed for mental health centers, i was a social worker working as a child abuse workers. because of that, i was able to go to graduate school and get a master's in social work. i also specialized in community and mental health. you may not think i have a therapeutic personality. [laughter] but i learned a lot, and then make a difference in lives, the consequences of untrained people and what they produce in society is important. >> we hope you're training is successful in the appropriations process. >> thank you very much, mr. chairman.

newtown and other events have highlighted the importance of this issue and i very much appreciate you holding this hearing. i am going to approach the issue and a little bit different way that some of our colleagues do. the united states of america is the only country that does not have a national health-care system. in my view, in the midst of a major health care crises in this country including 50 million people today without insurance and hopefully that number will be significantly reduced. when you don't have a system, you're not prioritizing. that means not only are we not paying adequate attention to mental-health in general, but the disparities based on in, and where you live are also enormous. the center mentioned the problems can roll up -- the

senator mentioned the problems in rural alaska. if i am making $500,000 a year living in new york city and my kid has problems. the the likelihood is that i will be able to get reasonable mental health treatment for that kid. on the other hand, if i live in vermont, and i make $25,000 a year, i am going to have a very difficult time accessing the mental health care that my kids need. that is true in tennessee and all over america, i suspect. the reality is that we have a primary health care system which is a disaster. whether it is physical illness or if we do well with mental health when they can access the system when they need it. i feel calls in vermont where

family members say that i have my kid, my husband, a serious problem and i can't find a mental health treatment now. let me ask you a simple question. if our goal is to make sure that mental-health care is available to all people that need it, how many thousands and thousands of mental health practitioners does this country needs? how do we get them? >> i am going to turn to my colleague that is just completing the work force, so she looked very carefully at this issue. >> we don't have good studies that say how many we need. we have lots of data that tell us what we don't have. we have lots of data that give us comparisons between certain

areas and certain types of practitioners. it will be ready. >> before we get to the report, we need better data. is it fair to say that if i am a low income person living in rural america or urban america, today i am going to have a difficult time finding mental health care for my loved one? >> thank you for the question, it is not even so much but clearly in certain areas, we don't have enough. i come from new mexico, so we have major rural areas in new mexico and there are counties that don't have any practitioners. none. the psychiatrists are in waco the rio grande corridor -- what

we call the rio grande corridor. it's more urban. >> we don't have a lot of time, so my question is, if i may working-class person, is it a fair statement to say that it would be hard for me to access to affordable mental health care? >> i did it is fair to zero areas have a difficult time, there are centers that have been exposed -- >> let me interrupt, i apologize. i work very hard to double the fund, i think we made progress. would you agree that we have a long way to go to expand beyond where we have gone? >> i would agree that we need more practitioners. >> is not only across the board

but particular areas needing attention. one of them is children. child psychiatry is way underemployed. it is incredibly important to of the bill the work force. >> i think it is a clash -- a class issue, too. i think a psychiatrist is something accessible for urban and upper income folks, not accessible for low-and, and rural folks. i think we have to look at geography and we have to make sure that mental health is available to all people regardless of income all over this country. >> since i focused so much on prevention, school psychologist. the national average is 1500 to one. the recommended ratio is 700 or

800 students per psychologist. we need to double that to meet the recommended level of kids in school. welcome to the committee. [inaudible] >> i want to apologize for coming in late. i have the best possible excuse, introducing my senior senator to the senate foreign relations committee. i believe that will not be a recurring event. >> if that is your way of saying you will soon be the senior senator from massachusetts -- [laughter] >> it is. i thank you. i would like to start in the same place. i have a very similar interest in the question about research,

evidence-based medicine, accountability, funding for research. i would like to start with you, if you would. i asked you to do two things. the first is paid a bit of a picture on what we can do with research in the mental health field. if we get good research, what can we learn that we don't know? and talk a little bit about what funding levels are doing to research. >> i usually don't get an opportunity to talk about this and i promise i will do it very quickly. you are asking the question at a critical moment in time. we are in the case of understanding mental illness and where we were in some ways for studying cancer 20 or 30 years ago. we are on the cusp of a revolution because we have extraordinarily -- extraordinary

tools now. it gives us a kind of precision that we have never even imagined we can have. the reason that is so important is because for behavioral problems, whether they are parkinsons' disease or alzheimer's, the behavior symptoms are a very late advent. we believe the psychosis of schizophrenia. as we define these as behavioral disorders, but they are brain disorders. the changes are probably occurring years earlier. the same way we have done in other areas of medicine. the science is taking us to were the fundamental biology. we have not been there before, we have a simplistic approach. the good news is that we have

better tools to be able to come back this. the question was about the funding. it is a challenge. there are lots of questions and things you would like to answer. i like to say that the chef has largely been to lose much of our funding to people that were studying cancer and heart disease that are now joining us. these are the places we are going to make the big breakthroughs. about 1 and 5 grant gets funded. i hope i am smart enough to pick the best 20%. if i could do 30%, i would probably have a much better hit rate.

that is always the challenge, you never have the funding you want to do all of the science, some of which is spectacular, sitting in front of you. >> can i ask you to expand on that in one more dimension? if you really hit on some of these studies on is alzheimer's, autism, can you speak briefly about the financial impact for the country? >> we know that in the case of alzheimer's, if we can just forestall the dementia by a matter of one year or two years, it is certainly within our grasp as we have gotten a better understanding of how to predict and look at ways of intervening. we're talking about billions of dollars that will not have to be spent that are now going into the care of people with dementia. it comes down to a question of if you want to invest early or pay later. enough.you don't knowautism, cu

i think we have tended to decide we will pay later instead of making the early investments to make sure that we come up with better solutions. >> my time has expired, but if you have a comment to add. >> these disorders have profound impact on our justice systems, school systems, public welfare, child welfare. there are profound dollars being spent there because we are not intervening early because we are not providing the kind of support to young people and their families. >> i was on the floor with my senior center. -- senator.

i will submit some for the record if that is ok with you. i want to thank you very much for holding this hearing and dialect to join the center frankland and say how delighted i am to see senator alexander here. and finally, to welcome our new colleagues. it is wonderful to see you here. >> i think our first panel for being here. i will call the second panel. dr. hogan, george, and mr. murray.

>> our next panel, i will first introduced dr. michael hogan. the former commissioner of the new york state office of mental health and the new freedom commission on mental health. his capacity of overseeing the public mental-health system. he previously served as the ohio director of public health and the commissioner of the connecticut department of mental health. for purposes of introduction, i turn to senator alexander. >> i am delighted to welcome robert viro of tennessee.

he has done work at the behavioral health care field for a long time, 40 years. he is chief executive of the company, and non-profit organization. they have more than 50 facilities, 160 partnership locations serving 50,000 people of all ages each year. his distinguished background includes work at vanderbilt, he is a clinician and he has been consulted by many for his expertise in his field and i look forward to his insights about the need to tell and how we can do a better job of making sure that they have helped. >> thank you, center alexander.

>> it is a great privilege to introduce george to the committee. he currently serves as the chief executive officer of the colorado behavioral healthcare council. it is a statewide network comprised of 28 behavioral health organizations that provides treatment and other services to 120,000 people each year. he became as a site that -- he began as a psychotherapist and has been promoted to a program developer before ultimately moving in the senior management. before leaving the health care council, he served as the executive director of mental health centers in the valley and in wyoming. throughout his career, he has work to develop integrated treatment approaches to mental health. he is working to expand the first aid program in colorado.

to include prevention, early identification, and access to health. his decades of experience gave him a unique perspective. i look forward to his testimony. >> we have a senior consultant at the national council for behavioral health. he is also director of the appalachian consultant group and a deputy director of the center for integrated health solutions. he will share his firsthand account of recovery from mental illness and substance abuse. as with the last panel, your statement will be included in the record. i would just ask you to sum up in five or six minutes or so. and we can get to a round of questioning. i read all of your testimony,

they are just excellent. everyone of them. i remember dr. ho been talked about separate but equal mental health from regular health. please proceed. >> i have to start by expressing appreciation on behalf of our community for focusing on this. it has been quite a while, but the timing right now for reasons i will explain, i think make it the right time and we are particularly appreciative that this focus happens on the first meeting as ranking member. i would start my remarks by focusing on something that is subtle and often not a parent with respect to health care is

provided. that is to say the mental health system started in asylums run by states. without the support or involvement of the federal government in any way. to some extent as we focus on a movement from asylum to community, there was attention to the locus of care that was being transformed. what escaped the attention was that care in separate programs and systems was still separate. that is changing before our eyes, right now. it is changing and accelerating in ways we can't even see because of legislation that has already been discussed. to say that mental health care had to be part of health care, no longer separate. and the affordable care act took that legislation and debate

it into all the changes in health care going forward. we are at a time when it is increasingly going to be part of health care. this raises two major questions. will we take time and attention to make sure that we get that the health right? we are fumbling at that right now. the second, as we move away from the separate system, where will we pay enough attention to it to ensure that there is sufficient storage shed for it? it is primarily a state problem, or will we recapitulate the institution by walking in another direction that is well intended but forgets the people with the most serious needs? those are the major challenges that we face. having said that, i want to touch on a couple of points briefly.

the first has to deal with the imperative of figuring out how to help primary care providers to deliver basic health care. most primary care providers with a little bit of help can do an excellent job with most of the mental health conditions that people walk into their offices with. but they can't do it on their own. they have to have a social worker or nurse or someone that can spend time with people. thatare still doesn't do very well. we have to take steps toward integrated or collaborative care to make sure that we provide that primary care. more people get something for their mental health problems than get it from the entire separate mental health system. it tends to be a day late and a dollar short.

your chances of getting enough treatment to make a difference are about 15%. but with a little bit of attention, that problem can be resolved. i won't comment much of the prominent -- the problem of protecting the safety net, but i think what i would say is, the attention might be focused on whether there are adequate standards for mental health care as the system goes forward. increasingly, when you're concerned about mental health, you talk to the medicaid director. and if they have this on their radar screen is sort of a coin flip. federal standards there would help. the committee has already talked significantly about children's issues and senator alexander's example of the 17-year-old with an early psychotic symptoms is

something else i want to comment on. we know how to address those problems today. we know how to engage people with an early psychotic problem. as we would, in a modern cancer center. family would be welcome. we would stick with people to try to find something that is acceptable to them as opposed to waiting until they deteriorated and letting them leave with a referral that is not going to work. two other points i have addressed in my written testimony. my time is up so i won't comment on them except that i want to underline what senator macao's he has said about the problem of suicide. the surgeon general has really stepped up on this. the department of defense and veterans affairs are moving on this. the rest of the government should pay more attention

because it is costing us more lives lost from suicide every week that military suicides the entire last year. >> thank you very much, dr. hogan. >> on behalf of my colleagues, i want to echo how much we appreciate the attention on health care in general being received as part of this hearing. i hope that when i share will assist this committee truly as you seem to get an understanding of the opportunities to address the gaps and barriers that currently exist in the mental health system. it has been echoed several times this morning. we know our country absolutely suffered a devastating loss of 28 precious lives.

20 in a sense, and a mentally ill young man that did not get the care that he needed and his mother who did not get the care or the information that she needed. this tragedy along with those in colorado, arizona, they have thrown an invaluable spotlight on community mental health, mental illness, and this entire discussion. to work in this area of community mental-health is an extraordinary privilege. it is a tremendous responsibility. i have been fortunate to participate in a variety of perspectives as a critical incident responder, a faculty member, research collaborator, patient, and ceo. i have seen what the research shows. it affects everyone in treatment is effective. health centers do a tremendous

job for the people we serve. we help people build a strong and healthy resilience individuals and strong and healthy resilience communities. there are several significant barriers and the gaps that make it difficult for local agencies to serve the safety that they were intended to serve by president kennedy more than 50 years ago. most significant is the availability of quality mental health services. we lack a federal definition of what services it should offer. many towns and cities do not have access to a continuum of care that covers the life span. since 50% of mental ellises occur before the -- before the age of 14 and three out of four people experience the onset by the time they reach young adulthood, the lack of early intervention can have tragic and

lasting effects. congress is encouraged to pass language included in the mental health act the finding that a community behavioral health provider must provide a a continuum of services across a life span. in particular, we wish to thank others for their tireless leadership. there are several ways to address the barriers for providing quality health services. banks to grant funding, we have been able to deliver home and school-based services within both urban and rural areas. these programs have been proven clinically effective and likewise 0 -- offset educational costs. increasing federal funding to effectively deliver prevention and early education services. congress could ensure that services to children and youth targets the entire family. research shows that programs

that engage the whole family are the most effective programs. have adequate insurance coverage often becomes the barrier to engaging the entire family. incredibly, not all states, counties and health centers offer formal crisis services. especially the services that are delivered seven days a week, 24 hours a day, 365 days a year. it would also require the prevention of these crisis services. technology also prevents another barrier. there have been tremendous advances of creating standardize communication guidelines. since mental health was left out of the act, we have not been able to fully benefit from these advances.

strong bipartisan bills like those that have been introduced by representatives murphy, blackburn, and collins with behavioral health ip, this is what community behavioral health will be able to do. we can effectively share information for care including treatment plants with primary care providers. we would prevent some of the drug interactions that occur because of a lack of shared information and hopefully prevent over prescribing. we can also effectively track outcomes overtime. there is a great need for integrating physical and mental health care. we hear a lot about the fragmented and broken health care system. the consequent at best is costly and at worst, dangerous and often deadly. people with serious mental illness on average a died 25 years earlier and then they're

not mentally ill contemporaries. is it because of their illness? no, it is because of the impact of their home and work conditions. health centers are key to improving physical health care by simultaneously lowering overall health-care costs. our expertise is part of the solution to meet the travel and of health care. reduce costs, improve health and quality outcomes. launchedteful that it primary-care and behavioral health integrated care programs. and since has launched 94 programs across the country. to have happened to land at center stone. and reducing the total health care costs by making sure services for behavioral health and physical health are

provided at the same location. we have a substantial and complex task before us. we cannot solve these issues alone as providers. this is a watershed moment that the man's courage and action. everyone in this room shares responsibility for the future of community and a mental health. health centers stand ready to work with you. elected representatives and officials to make a difference in the u.s. mental health care system. >> please proceed. >> thank you for always being there for us for mental health. it is interesting. as i hear the discussions happening around the room.

i think you may be surprised about how many people are watching c-span today from around the country because they are so excited about the opportunity to discuss this matter in the kind of detail we are hoping for. i would like to share with you that if i can take a video of today and the comments you all were making of their and comments made down here today, if we can encapsulate it and play it to the public, we would not have to be here today. i think people would be greatly moved by what was brought here today and what you're saying about our area of health care and how important it is to address substance disorder. there were several of you that said to tell us about what we might be able to do to intervene or what we can do earlier. i want to make sure to tell you that there are a couple of

things that can be done. with the shortage of funding that has been in the area of mental health and substance abuse, the funding available has been focused on people that have already diagnosed conditions or already significantly ill. we need to ensure that we continue to provide care in those areas. but we're having problems when we do prevention work in both physical and behavioral health area, often the funding is not available. you have to take it out of your own pockets to try to get some of the necessary prevention and early intervention services and support that they need to keep them from getting to that point. this is a problem in the area of medicare. today, we have not talked very much about the elderly. people think that when they get older, they will naturally be depressed and it is really not

the reality. many people are aging in doing well but sometimes there will be depression or substance abuse disorders like anybody else. it needs to be preventive and also get the treatment. no. what is that we saw the opportunity for mental-health to get out to the citizenry and be able to talk about mental health itself an increase their literacy and understanding and recognition of the signs and symptoms of common mental health diseases like a bipolar, major depression, psd, and anxiety disorders. it also provides a crisis de escalation technique for people that take the class. it helps you manage something where it is a splendid if there is a broken leg. had there is an action plan to get persons in distress

referred to a mental health providers. the comprehensive program, in the wake of the summer that we had, we know about aurora and we had a major fire is this past year that a lot of people lost their homes and some loss of life. it was one of the most depressing summers in colorado. we found that by using mental health first aid, people began reaching out for help themselves and help their family members understand more about what is going on with them and what is happening in the world around them. talking about the common mentald a mental health, how they looked up and said, we need a program to help us identify things for family members and friends. let us tell you about mental health, first aid, and it became a real charge for us in

colorado. we have also done training with department heads and middle managers and many state agencies. there is a consideration that all state agencies or state employees. they have trainers' and corrections officers. i can go on and on about the number of people that have received this. i want you to know there is great news coming out of washington on this. the last week, the representative barber introduced the mental health aide act of 2013. as you know, he was wounded in a tragic incident. as they are recovering from their tragedy there, they have it on good authority that they

will anticipate a bill with bipartisan support coming through the senate. i asked the consider supporting this as a committee and providing funding that we necessarily need in our community. what a tremendous opportunity to be here today to speak on behalf of this area of health care. >> welcome, please proceed. >> thank you, chairman harkin. it is an honor to be here, and honor that we are getting this sort of focus on those of us that have experienced mental ls and addiction. i would like to address three topics today. first, stigma and discrimination that surrounds health disorders. second, the critical role of

peer support and a new work force that promote recovery. and the importance of whole health. my body has been huge in my recovery. those of the three topics i would like to address. first of all, i am recovering from bipolar illness and clean and sober 28 years. i can tell you and my peers can tell you that we fight to battles. we fight the illness and we also fight the stigma. we have a saying in our movement, what you believe about mental ls maybe more disabling than the illness itself.

and yet, as a society, will largely remain ignorant about the signs and symptoms of mental ls and we ignore our role as supported community members to help those of us experiencing those illnesses. i was hospitalized three times in the '80s. i fell in the category of serious mental illness. in the back of a deputy's car, is a humiliating experience. i spent the day in jail until family and friends intervened and got me hell. i attempted suicide. it is humbling to be here today and have the chance to talk about this. the stigma is so significant that we often internalized it, it takes over our lives, not

only the diagnosis, it becomes the prognosis that your life is over as you have known it. and today, i live a full and meaningful life. i have a wonderful wife, i have a life in the georgia mountains. and the key to that was learning self management skills. those of us in recovery, we know about self management to stay well. pierre support is huge, having somebody you can relate to. and also receiving services. i just want to say that learning about sleep deprivation and its role was huge for my recovery. the former director introduced

me to that. i manage my bipolar illness largely by managing my sleep patterns. this new work force is certified appear specialists. the 13 years i served on the management team, there are the fastest-growing work force in our state, we trained 1000, probably 12,000 across the country. we focus on strength-based recovery, we are able to deliver services. and research on the effectiveness of specialists have been so positive that in 2007, the center's issued guidelines for wanting to build

your support services, proclaiming them as a model of care. research shows we have a unique ability to promote health. i warn that medicaid's focus on necessity makes it tough because we are strength based and we look at unlocking hope and self management. it is stuck to find under medical necessities. the respite center is coming out across the country, early warning signs, you can go land and in georgia, we have three. you can spend seven nights surrounded by peers and is keeping people out of hospitals. we're having tremendous success of the department of justice settlement.

this is a service that we had that is really starting to pay off. addressing the mind, body, health care. there can be no health without mental health. we cannot care for people with addiction disorders without addressing the existing disorders. research indicates people with severe mental ls that serve the public health care system have an average life expectancy 25 years less than the general public. we have heard that already. i just want to thank samhsa for offering basic primary care screenings and referrals as part of primary care behavioral health integration programs. care managers, care

specialists, and other professionals now working at 94 sites for a weight gain, and blood levels, cholesterol, and although data is still being collected, early results indicate this program has been successful helping people with behavioral health conditions maintain and reduce their weight, cholesterol, blood sugar, and other risk factors. i urge the committee to support this grant program. in closing, i would like to say that after three decades of experience, it has taught me that the greatest potential for promoting recovery comes from within the individual. and with the support of family and community, my recommendation is to drive this potential, but in the center of all services and building on the strength and

support. >> i think your testimony really does summarize what we are all here about today. providing the kind of interventions and support so people can successfully deal with an ls does likely deal with every other ls and you are a prime example of that. from my limited experience, i could not agree with you more. the most important element, it comes from within and how we build that system. we talk about providers for support and tell you is extremely important. self management skills need to be taught. sometimes it comes from just a drug and it also recognizes and

kind of get back to dr. vera on this. they are intricately intertwined. at the risk of practicing medicine without a license, i have been involved in this for 30 years now. from this standpoint, i think we have adequate data to show that so many physiological conditions have their genesis in psychological conditions. and we attempt to treat the physiological conditions. and sometimes it makes it even worse. we have a hearing last year on pain. all the pain clinics that have come out. we had one witness, a very

distinguished doctor that wrote a lot of books about this. you can't make everything total, but for the vast majority of these and afflictions, it has agenesis with and psychological problems. anxiety, stress, they manifest themselves. and yet they go to clinics to get a shot or some kind of medicine. or a back operation. i'm always cautious to say that it is not 100%, but the vast majority, i don't think we recognize that. intricately intertwined between mental health and physical health. a took a lot of my time talking doctor, youn't, but talked about getting it right.

tell me about the accountable care organizations that are springing up. they will have the guidelines for what these entities have to provide. but i don't think we have any kind of instructions to than. are you suggesting we need to instruct these accountable care organizations that they also need to structure this? >> absolutely. they will learn this sooner or later. >> we can't wait until later. >> exactly. if you have diabetes, hypertension, cancer, or one of these medical problems, your medical costs are going to go up between 50% and 75%. if you treat depression, it allows the person to be an active player in the management of their health.

cope with the depression goes away, you have to diagnose it and provide treatment. the data shows that a relatively small investment in the primary care setting is going to reduce total cost because people will be better able to take care of themselves. >> you mentioned the organizations, do you have an elaboration? dodge the element to apply would be the accountable expectations. that act will allow us to set some clear expectations for performance. what is expected in terms of improving the health care outcomes. the agreement between the provider system, we are beginning to target the key health care indicators on the behavioral health side that will work together to try to truly

improve overall outcomes. >> there is a barrier of insurance coverage. in this area, there are very few in-network that the health providers. i got a look at that and wondered why. i am amazed at how few are in the network. i looked at it a little longer and started thinking the taxpayers, through federal programs and other programs gave these practitioners when they were going to medical school or when they were going to their specialty is. and when they were going into

their residencies. the accumulated a lot of that and they got these guaranteed government loans and low interest rates. shouldn't we expect a little more of them? they don't get reimbursed enough so they are out of that work? -- network? if you have the money and can afford it, you are fine. you can be paying a lot, still not have the coverage for mental health and you have to pay out of pocket for that. >> thank you for making that comment because it is something, the proverbial elephant in the room that people do not talk about. it has been surprising to me how insurance companies have not been able to put together the savings on the physical health side if they provide more care

on the behavioral health side. they don't necessarily look at the long run. the head is not connected to the body. it looked at the physical health costs separately from the behavioral health costs. one of the plusses you were talking about is the opportunity to bring together the funding to put the right service, the right place, the right time, the right cost, the right payment together. it brings those pieces together where you are saving money on the physical health side and you can move that money over there as needed. it is really important. that has fallen greatly on the

federal government and on our states with the indigent care programs and the medicaid programs. people shift to the public side because they don't have the behavioral health coverage on the physical health side. it is a quagmire that i think we are on the verge of making changes. >> we have to make sure these organizations have that model. hopefully we can do this committee the other is impress upon them. i have run way over my time, i apologize. >> it was very interesting. mr. chairman, thank you for coming today. i would like to listen to what

you have the say so i will ask each of you a question. if you can think of one thing that the federal government could do to make it easier for you to spend the money that we now spend more effectively, primarily through big block grants and through medicaid is the way i gather it goes to mental health. what will be the one thing that we can do to make it easier for you to do that? you can start and i would like ask this additional question. you mentioned the importance of a continue on that makes sense. you are one of the largest operators for the mental health centers. would that be an additional cost if it did back? who would pay for that? if the federal government were to require that, how much would

it cost and how much would we have to appropriate for that without paying for it? that is sometimes what we do around here. who would pay for it? >> wheat talk about this continuance of care over the age span. when you are a governor of tennessee, we built out a statewide, therapeutic preschool program. we had preschools in every single one of our community health centers across all 95 counties. those schools were there to deal with the most vulnerable children with whom we were seeing early indications par, the onset of severe mental and illnesses, those children as we have reference several times today. what happened?

very few of those programs exist. we are so fortunate. it is not in the classroom any longer. that model is no longer affordable. it has been suggested to -- as we manage medicaid programs, we are part of a health care system that is continue to look at susan or the provider might become aware the contact is, and what the services. the requirement dropped. those preschool programs were lost. we took our preschool program and moved it into the community. we were only able to serve about 48 of those children a

year. it is a high-cost program. they had a hard time understanding what the role was. in addressing the health care needs of the children, why there were also receiving vital education services. one thing we need to do is remove the barriers that oftentimes do not allow us to bring our systems together, education, crime and justice, mental health, in a cooperative way for the sole purpose of addressing our health care crisis. we spend too long arguing over what part of the day education should pay for, and we have to address those conversations immediately if we will make any difference in the conversation we are having today. >> i would like to work with you and i will ask my staff to follow up and give specific examples. was that part of the healthy children initiative?

>> yes. >> i will tell my wife. my wife was the head of that. my time is about up. if there is one thing we could do that would change the existing law or practice to spend the money we now spend better, and you can follow that up with writing, is there one thing you would like to briefly mentioned? >> i would like to make the recommendation that you allow the services you currently pay for be opened up to provide more services at the front end to provide more prevention, and to

let the creativity and country and allow us to do the right thing. >> any other comment? >> we keep talking about access, the shortage of psychiatrists. we have been providing tell a psychology services since 2002 in the state of tennessee. those services are getting out to counties where we cannot hire physicians. it is 2014 as we did here today -- sit here today. we are not permitted in the state of tennessee, and i know elsewhere, to provide teller counseling services.

i can have a psychologist talk to a child and interviewed the child and provide services and work alongside a practice to share -- a practitioner. i cannot provide counseling services remotely and get reimbursed. it is 2014. we have 12 years of experience on the psychiatrist's side and we cannot seem to move out of the current limitations around those services. >> thank you. >> thank you. thank you all. doctor, you know in your written testimony there are a number of barriers to access to children's mental health services. you recommend grant funding streams had encouraged existing centers to expand their service

continuinum. i am introducing the mental health in schools act, which does that exactly. can you explain why this is so important to students? >> let me thank you for moving the bill forward again this year. i think it is rather simple. we know most of the disorders we see in children are first identified, not in the office of pediatricians, or a family practitioner. but instead by their school teachers. some as early as preschool teachers who see this behavior. they are well trained in normal child development. typically no what is expected of

that age group. when they see unusual and these are -- and bizarre behavior, they need to bring that to the attention. those teachers have the competencies' to help us identify the children who need early intervention. we are 160 schools currently in d.c. those are partnerships that work. i have licensed partnerships in the school providing the care you are addressing. >> i was just in minnesota. we had a round table there. a couple. one is specifically on integrating the schools with community mental-health. you talked in your testimony about how this is a family disease. a family matter.

we had three mothers testify. the kids were turned around completely to the good. a woman who, because of the school system having integrated the system, with community health, and they had a mental health partner, a professional who took their case, had a caseload, we had one woman there, i think she was 26. she had an 8-year-old child. completely turned around. 3-year-old child. a completely single mom. she was not wealthy living on fifth avenue. this woman had such a joy in describing her son, who had been

a complete turnaround. he was diagnosed with as a murderous -- with kasper's -- with as burris -- with asperger 's. when i was doing research for that, i was talking a lot to rehab counselors hicks and i want to ask you about this. the shocking ignorance about this about alcoholism. the teacher is -- pediatricians,

what they do not know about this is pretty remarkable integrated care is so important. it is something we do pretty well in minnesota. we have accountable care organizations. they become pioneers. what can you say about the training of doctors and medical school that we should be doing and we are not doing, or have we gotten better? >> thank you. i want to comment very briefly on your point about children. the senator has been closely -- closely connected to and

followed an extraordinary national program for young people who have got a developmental disabilities. if you have got a significant developmental disability, you are basically entitled foto some care for your family. we have an average weight of nine years until we find out about it. tenants -- wait of nine years until we find out about it. this is of profound importance. training around these conditions, there is too much they have to cover in medical school. but it is not a problem that can be fixed by draining doctors better. primary doctors thought 7, 8, or

10 minutes. the only way this care can be delivered is if one of our types is parachuted into that practice. if the patients, as a screen in the waiting room, the doctor can then say, i see you have concerns about sleeping and you are feeling depressed. i would like to ask mrs. jones to come in. she can then spend the time it takes to talk through the system -- through the symptoms. these programs that go under a rubric of collaborative care, there has got to be a team approach. that can discuss -- that can be thwarted by two things. i will argue in a way that may seem reversed. if you keep the insurance plan and only pay it through mental health specialists, it will not help the primary-care doctor. if you give it to the mainstream

insurance plan and do not make the measure it, did you ask about depression? did you start people on treatment? did they improve? unless we do that, we cannot get results, either. i will say as important as it is, it is less critical now than figuring out how to crack this problem of primary care. they have got have training -- >> i see a lot of nodding. there are primary care physicians who do not understand that the terahertz and do not

understand they are seeing something that is really comes from something else. i am way over my time >> thank you for being here today. there is a part we have not talked about. millions of people who have serious mental health issues on not seeking care. you have talked in different ways about why that is so. you are describing different parts of the animal. we talk about stigma and why people do not ask for taylor -- care. how we might deal with that with pure specialists, community health care centers, and

doctors' offices. we talked a little bit in the early panel about research, so we get better treatment, how we get better outcomes at lower costs. the one i want to focus on, all the other things are there but they feel like they cannot afford it or go out of pocket. what i would like to hear from you is about the impact, about what that means when people deny care themselves, to their children, to spouses, others in their families. and just what happens then. describe that in human terms or financial terms. in financial terms for the family or the whole system. i would be grateful if you talked about that.

maybe he would like to start. >> in rural communities like mine, it is so obvious about the stigma. you parked out front, in public health. mental health, you park around back. you do not want and neighbors seeing you. when we integrate, we will help fix that. everybody can go through the debt -- the same door and same parking lot. it is hard to explain the devastation that occurs from the stigma. the act of discrimination, it goes beyond. in point is a huge factor --

employment is a huge factor. housing, they are discriminated against. a lot is almost a civil rights issue. it is a human rights issue. i am hoping integration helps that. families are torn apart by it. i am fortunate to have had a very fortunate family. the stress and strain economically will bust up families. you are right on it. think -- thank you for your acknowledgement. >> i think it is interesting families would not hesitate to get a family matter cannot -- family member help for appendicitis or any other problem but often have a difficult time reaching out to

get the behavioral health and the substance seized disorder treatment they need. the bottom line is it is often seen that you have a character problem or a bad mom or dad or something along those lines, rather than, for many people, if they have a brain disease. there is a lot of education still to come and a lot of support we need at several levels for people to be able to move forward and raise their hand and come out and get help. i can also say we need to stick our head up and be proud of the fact that the area of health care we provide care in and we are not and in a month. let's take the cloak off of this and talk about what it really is, how people can recover and become remarkable members of our community. >> could i ask the doctor to add your comments?

>> thank you. i will answer from both the human and financial sides. we cannot afford not to treat these illnesses we identify, especially those we identify early. they simply get worse. mental illness is a systemic family disease. we know that when we look at addition -- addiction disorders. alcohol. there may be one in the family with and how a whole addiction. the entire family can pick up signs and symptoms of that illness. there is disfunction throughout the family carried the same things occur when people have severe and persistent mental illness. it is the leading cause of disability in the united states. that cost alone should alarm us all. we have to start treating this

area >> thank you. >> i will conclude on the same point. the total cost of mental illness, the total cost of cancer, the second to heart disease, what is striking about the statistics is the cost of cancer and heart disease and the cost of providing care, the cost of mental illness is the cost of not providing care, the cost of year's loss of life due to suicide, not being able to function fully at work, children not graduating because they were not able to sit in their seat long enough and they dropped out in high school. if we could reverse this just a little bit and provide effective treatment, maybe we could slip back from numbertwo two numberthree. >> thank you. >> i just want to think this

panel very much. both for the work you do and the testimony you have offered today. it is the reason why we wanted to start off the congress with this kind of hearing. simply for the reasons many of you expressed one way or the other. we cannot really get a handle on a health-care system in america until we get a handle on integrating the mental health with physical health. i would lean a little bit more towards the side on looking at this mine body connection. hogan, they have

got to remember a lot of stuff from medical school. it seems to me that systems have to be built where you have a collaboration. i have seen these. they are around the country. if you go in, and you have electronic records, and you have some element, you come in to see a primary care practitioner about, whether it is a community health center or someplace else, there is a collaboration. with the primary care physician, a physical therapist, a psychiatrist, psychologist, or both, take a look. what is really affecting this person? is it a physical ailment or manifesting from a psychological problem? or is it something else?

could a qualified therapists work with them and their family? rather than a prescription for a medicine? it seems as we move ahead with the affordable care act and all these changes, we have an opportunity, i hope, and with the expansion of the community health centers around america, and that is where we will be in touch with you more about what you have done in tennessee, because i think there is a model for what we will do with community health centers in the future and how they are integrated into the system, that is why i think this hearing is so important. you just said the cost of mental illness now outstripped the cost

of cancer in our country. we do not pay attention to it. hopefully this will set the stage for a lot of good bipartisan work and integration here of this committee looking to what we need to do to provide an integrated model. in this new health care regime we seem to be embarking on in the near future. i thank you very much. i am certain our staffs or us will be in touch with you. for further enlightenment and suggestions. and recommendations you might have. senator? >> i want to set -- i want to thank the senator for this and the witnesses for coming. i look forward to following up. this is a committee on which we

can have a very profound differences of opinion, when we are talking about new laws, new spending, new policies, but it seems to me a lot of what we fail to do is look at what we are already doing and ask people who are doing it, how can we take the programs we have got and the money we have got and make it easier for you to do what you need to do? you have given us a long list of things today you have suggested that would improve your ability to identify the person to provide the help. while we may argue about some things, there is no need to argue about those things. we can work together and i would look forward very much to the offspring -- to that opportunity and your specific objections

about laws, regulations, and practices you think ought to be changed. we will see if we can do this in a bipartisan way. >> thank you. i request the record remain open for 10 days for members to make additional statements for the record. thank you all very much in the committee will stand adjourned. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> here is a look at our prime- time schedule. starting at 8:00 p.m. eastern on c-span, senator john kerry testifies on his nomination to be the secretary of state. on c-span2, leon panetta on women in combat. on c-span 3, remarks from secretary napolitano on cyber

security. on the next "washington journal," william kristol. then kevin cathcart looks at the state of gay-rights in the u.s. then hubert hamer discussing the drought. >> contact. glad to see you. >> it is hard to realize now, 25 years after, what the climate

was like back then. in a way, after the stalin years and khrushchev pounding with his shoe and all that sort of thing, soviets were very foreign to us. but after some of the things that happened, we thought they were pretty aggressive people and i will not say monsters. they probably thought we were monsters. we very quickly broke through that. when you deal with people who are in the same line of work as you are, and you are around them for a short time, you discover they are human beings. >> this weekend, oral

histories, apollo-soyuz. sunday at 3:00 p.m. eastern on c-span3. c-span, created by america's cable companies in 1979, brought to you as a public-service by your television provider. >> earlier today, california senator dianne feinstein introduced new legislation. here is part of that.

>> today, my colleagues and i are introducing a bill to prohibit the sale, transfer, manufacture, and importation of these feeding devices that can accept more than 10 rounds. let me describe the legislation. we prohibit 158 specifically named military-style firearms. since the 1994 law expired, there has been an influx of new models of assault weapons. these models are more powerful, more lethal and more tech technically advanced they were in 1993. our bill also prohibits other semi-automatic rifles of shotguns and rifles that can accept a detachable magazines. one criticism of the 1994 law was that it was a two characteristic test that defined it and that was too easy to work around. manufactures could remove one of the characteristics and the firearm was legal.

the bill we're introducing today, will make it much more difficult to work around by moving a one characteristic test. the bill also prevents and prohibits specific loopholes, such as the slide iron stock which can be added to an ar15. which will make it mimic automatic weapons and it is legal. bullet buttons, these are modifications can make it easy for manufactures to avoid the law. the bill prohibits semi automatic rifles and handguns with a fixed magazine that can accept more than 10 rounds. a ban on importation of assault weapons and large capacity magazines. elimination of the 10 year sunset. let me tell you what to be will not do. it will not affect hunting or

sporting firearms. instead the bill protects hunters and sportsman by protecting 2,200 specifically named weapons used for hunting or sporting purposes. they are by make and model

exempt from the legislation. when we did this bill in 1993, there was 375. today there are 2,200. it includes grandfathered weapons to a background check. we have tried to learn from the bill. we have tried to recognize legal hunting rights, we have tried to recognize legal defense rights. we have tried to recognize the right of a citizen to legally possess a weapon. no weapon is taken from anyone. the purpose is to dry up the supply of these weapons over time. therefore, there is no sunset on this bill. >> this would not then more than 2200 firearms used for hunting or other sport. you can see this briefing in its entirety tonight on c-span two or any time in our video library at c-span.org. jerry brown delivered his address today.

this is 25 minutes. >> thank you. [applause] thank you. they do fellow constitutional officers. and all my friends gathered here this morning. the message this year is clear. california, we have brought in just two years a solid budget. by god, we will preserve and keep it that the -- that way for years to come. [applause]

my longest speech. we will not get out of here if we do not keep moving. against those who take pleasures, california did the impossible. you did it. you cast difficult votes. you reform and reduced the state's long-term liabilities. then, the citizens of california, using their inherent political power, under the constitution, finished the task. 55-44% terahertz members of the legislature, i salute you for your courage for wholeheartedly

throwing herself into the cause. i salute the unions, the members, and leaders, and you show order night -- ordinary people can do. i salute the leaders in california business and the individual citizens who proudly stood with us. i salute the whole school community. as oliver once said, feeling the gets feeling and great feeling the gets a great feeling. use third yourself to action and victory was the outcome. that was 2012. what a year. 2011 and 2012 were remarkable. you did great things. the reformers workers'

compensation, the organization of state government, reforming our welfare system, and watching the nation's first high-speed rail system. of course, governing never ends. we have promises to keep. . the most important one is the one we kept to people -- we made to people. this means living within our means and not spending what we do not have. fiscal discipline is not the enemy of our good intentions but the basis for realizing them.

expanding good programs, only to cut them back when the funding disappears. that is not progress; it is not ahead. drive a hole in the budget. decade of deficits. then the lean cows ate up thethe pharaoh could not interpret were

seven years of great plenty immediately follow.

the pharaoh took the advice of years of plenty. when famine came, egypt wasthe people have given us seven years of extra taxes. let us follow the wisdom of joseph, pay down our debts and store up reserves against the leaner times that will surely come. in the midst of the great depression, franklin roosevelt said -- "there is a mysterious cycle in human events. to some generations much is given. of other generations much is expected. this generation has a rendezvous with destiny." we --right here in california-- have such a rendezvous withall around us we see doubt and skepticism about our future andbut what we have accomplished together these last two years, pessimism. orders were issued to jose de monterey for god and the king of spain. gaspar portola and a small band of brave men made their way slowly north, along an recognize the bay in the denseundaunted, portola sent for along what was to become el camino real, the kings highway. this time, father serra joined

the rest is history, a with even greater success. of gold, the coming of the hundreds of thousands. land grant colleges, followed by the founding of the university of california. and oil production, movies, an aerospace, the first freeways, grand water projects, jet propulsion laboratory, venture capital, silicon valley, hewlett packard, apple, qualcomm, google and still just imagined. what is this but the most diverse, creative and longest history of the world.

that is california. and we are her sons and daughters. this special destiny never ends. it falters. it goes off track in ignorance and prejudice but soon resumes again -- more vibrant and more stunning in its boldness. the rest of the country looks to california. but for what is necessary -- necessary to keep faith with our courageous forebears. what we have done together and a more abundant california. as legislators, it is your duty and privilege to pass laws. but what we need to do for our each year. and fixed and immutable laws.

simplest, and most general -- and i even think that it would be better to have none at all than to have them in such numbers as we have." constantly expanding the coercive power of government by adding each year so many minute detailed and turgid legal system public service. individual creativity and direct leadership must also play a part. we do this, not by commanding through a new law but by tapping into the persuasive power that can inspire and organize people. lay the ten commandments next to content from that which

forms the basis of our legal system. education -- the early fashioning of character and the formation of conscience -- comes before legislation. our future than how we teach our children. if we fail at this, we will sow rectify. there are six million students, regulations.

the classroom, we have a principal in every school, a superintendent and governing board for each school district. then we have the state superintendent and the state board of education, which makes rules and approves endless waivers -- often of laws which you just passed. then there is the congress which passes laws like "no child left behind," and finally the federal department of education, whose rules, audits and fines reach into every classroom in america, where sixty million children study, not six million. add to this the fact that three million california school age children speak a language at home other than english and more than two million children live in poverty. and we have a funding system deeply inequitable.

accountability data. a ahead regurgitated at regular computers. performance metrics, of course, are invoked like talismans. whip, demanding quantitative every child. is a thing -- like a vaccine -- children. butler yeats said, "education is not the filling of a pail but the lighting of a fire." [applause] this year, as you consider new education laws, i ask you to consider the principle of subsidiarity. subsidiarity is the idea that a central authority should only perform those tasks which cannot be performed at a more immediate

or local level. in other words, higher or more remote levels of government, like the state, should render assistance to local school districts, but always respect their primary jurisdiction and the dignity and freedom of teachers and students. subsidiarity is offended when distant authorities prescribe in minute detail what is taught, to be measured. i would prefer to trust our teachers who are in the classroom each day, doing the young minds. [applause] my 2013 budget summary lays out the case for cutting categorical programs and putting maximum authority and discretion back at the local level -- with

schooli am asking you to approve a brand new local control funding formula which would distribute supplemental funds -- over an extended period of time -- to school districts based on the real world problems they face. this formula recognizes the fact that a child in a family making $20,000 a year or speaking a requires more help. justice. -- equal treatment for children in unequal situations is not justice. [applause] with respect to higher education, cost pressures are relentless and many students cannot get the classes they need. a half million fewer students this year enrolled in the

community colleges than in 2008. graduation in four years is the exception and transition from one segment to the other is difficult. the university of california, the cal state system and the community colleges are all working on this. the key here is thoughtful change, working with the faculty and the college presidents. but tuition increases are not the answer. i will not let the students become the default financiers of our colleges and universities. [applause] california was the first in the nation to pass laws to implement president obama's historic affordable care act. our health benefit exchange, called covered california, will begin next year providing insurance to nearly one million californians. over the rest of this decade, california will steadily reduce the number of the uninsured.

today i am calling for a special session to deal with those issues that must be decided quickly if california is to get the affordable care act started by next january. the broader expansion of medi- cal that the act calls for is more time. working out the right relationship with the counties will test our ingenuity and will not be achieved overnight. given the costs involved, great prudence should guide every step of the way. california lost 1.3 million jobs in the great recession but we are coming back at a faster pace than the national average. the new office of business and economic development -- gobiz -- directly assisted more than 5,000 companies this past year. one of those companies was samsung semiconductor inc. headquartered in korea. working with the city of san

jose and santa clara county, gobiz persuaded samsung to locate their only research and world here in california. the new facility in san jose will place at least 2,500 people in high skill, high wage jobs. we also leveled the field on internet sales taxes, paving the way for over 1,000 new jobs at new amazon distribution centers in patterson and san bernardino and now tracy. the enterprise zone program and the jobs hiring credit. they aren't working. we also need to rethink and streamline our regulatory procedures, particularly the act. our approach needs to be based more on consistent standards that provide greater certainty and cut needless delays. [applause]

california's exports are booming and our place in the world economy has never been stronger. our ties with the people's republic of china in particular are deep -- from the chinese immigrants crossing the pacific in 1848 to hosting china's next president in los angeles last february. this year we will take another step to strengthen the ties between the world's second and ninth largest economies. in april, i will lead a trade and investment mission to china with help from the bay area council and officially open california's new trade and investment office in shanghai. water central to the life of our state is water and one sixth of that water flows through the san joaquin delta.

silicon valley, the livermore valley, farmers on the east side of the san joaquin valley between fresno and kern county and farmers on the west side between tracy and los banos, urban southern california and northern contra costa, all are critically dependent on the delta for water. if because of an earthquake, a hundred year storm or sea level rise, the delta fails, the disaster would be comparable to hurricane katrina or superstorm sandy -- losses of at least $100 billion and 40,000 jobs. i am going to do whatever i can to make sure that does not happen. my proposed plan is two tunnels 30 miles long and 40 feet wide, designed to improve the ecology of the delta, with almost 100 square miles of habitat restoration. yes, that is big but so is the problem. the london olympics lasted a short while and cost $14 billion, about the same cost as this project. but this project will serve california for hundreds of years. think about california'sinwhene

future, no long term liability presents as great a danger to our wellbeing as the buildup of carbon dioxide and other greenhouse gases in the atmosphere. according to the latest report from the world bank, carbon dioxide emissions are the highest in 15 million years. at today's emissions rate, the planet could warm by more than 7 degrees fahrenheit by the end of the century, an event unknown in human experience. california is extremely vulnerable because of our mediterranean climate, long coastline and reliance on snowpack for so much of our water supply. tipping points can be reached before we even know we have passed them. this is a different kind of challenge than we ever faced. it requires acting now even though the worst consequences are perhaps decades in the future. again california is leading the way. we are reducing emissions as

required by ab 32 and we will meet our goal of getting carbon emissions to 1990 levels by 2020. key to our efforts is reducing electricity consumption through efficiency standards for buildings and appliances. over the last three decades, these pioneering efforts have saved californians $65 billion dollars. and we are not through yet. we are also meeting our renewable energy goals -- more than 20% renewable energy this year. by 2020, we will get at least a third of our electricity from the sun and the wind and other renewable sources -- and probably more.

transportation and high speed rail in the years following world war ii, california embarked on a vast program to build highway, bridges and roads. today, california's highways are asked to accommodate more vehicle traffic than any other state in the nation. most were constructed before we knew about climate change and the lethal effects of dirty air. we now expect more. i have directed our transportation agency to review thoroughly our current priorities and explore long- term funding options. last year, you authorized another big project -- high speed rail. yes, it is bold but so is everything else about california. electrified trains are part of the future. china already has 5000 miles of high speed rail and intends to double that. spain has 1600 miles and is building more.

more than a dozen other countries have their own successful high speed rail systems. even morocco is building one. the first phase will get us from madera to bakersfield. then we will take it through the tehachapi mountains to palmdale, constructing 30 miles of tunnels and bridges. the first rail line through those mountains was built in 1874 and its top speed over the crest is still 24 miles an hour. then we will build another 33 miles of tunnels and bridges before we get the train to its destination at union station in the heart of los angeles. it has taken great perseverance to get us this far.

i signed the original high speed rail authority in 1982 -- over 30 years ago. in 2013, we will finally break ground and start construction. this is my 11th year in the job and i have never been more excited. two years ago, they were writing our obituary. well it didn't happen. california is back, its budget is balanced, and we are on the move. let's go out and get it done. thank you.

[applause] >> on the next "washington 0, journal," william kristol. kevin cathcart, and a discussion of the effect of the ongoing drought is having on food prices. live at 7:00 a.m. eastern on c- span. up next, president obama's pick