Skip to main content

tv   Key Capitol Hill Hearings  CSPAN  January 20, 2016 4:00pm-6:01pm EST

1:00 pm
usually public health inks about oxidation. what dr. eaton thinks about is how can we do the preventive work senator mikulski: he will talk to you today about his work appeared everybody with a mental health problem needs individual treatment, but they live in a social world and we need to look at indicators and how we can make certain that institutions are with families and with goals. i have already learned a lot from him. and i have listened to the folks at the school of public health. i look forward to where we are going on this issue. when i got out of graduate went -- school, i went when they were training social
1:01 pm
health workers. president kennedy led the battle to establish community centers, to get rid of the old type of hospitals, everybody at the table remembers that. and i am sure you have heard stories. need newis not that we ideas, i mean institutions, maybe we need to look at thought we arewe going to do and we never did it. we never follow through on community health centers. maybe that is the way to go. we never follow through in an theessive way to enforce parity act. it may be that is the way to go. speaking as a social worker, we know that mental health harbors a team approach. it is on the part of the psychiatrist, but it is also others trained in the matter.
1:02 pm
my colleagues never thought i had a therapeutic personality, but i will look forward to working with you to advance ideas that will come forth and how we can really fix this crisis that is growing and expanding. : we will not hear from witnesses. again, dr. hitler and -- dr. hepburn. he is part of the system that represents the systems in all 50 states. professorn a clinical for nearly 20 years and he has cared for patients for more than 0 witnesses -- she has been a nurse for 40 years and worked in an emergency department for many years.
1:03 pm
dr. eaton, must -- most of his work has been done on chronic health issues. have the ceo of live thethe, this is focused on stigma associate with mental health care he brings his own invaluable perspective of his own journey through mental illness which began during his freshman year of college. we look forward to hearing from the 40 of if you'll each try to symbolize -- summarize your words so that we can have comments about your testimony. why don't we start with dr. hepburn. dr. hepburn: thank you very
1:04 pm
much. thank you chairman alexander and ranking member murray. thank you. thank you for the opportunity to just -- address this committee on state services regarding mental illness. thanks goes to this committee and members of the house and senate working to find ways to support, strengthen and augment the mental health system. i want to especially thank , andors cassidy, murphy also senator franken. i also want to congratulate senator franken on a second grandchild, being a good grandparent, that is where i will start. we appreciate the full congress passing the legislation on the
1:05 pm
imd demonstration. also, we appreciate the support from congress on the first episode psychosis program. the organization which i represent, the national association of the mental health program directors, this represents executives of the mental health authority, representing agencies that have $41 billion in mental health services and deliver services to people. we will work with state and partners to promote wellness and resiliency. members work to promote prevention and early intervention, integration of behavioral and physical health, trauma informed approaches, contact with police, developing the workforce, promoting
1:06 pm
supportive employment and decreasing homelessness. support the use of data and health information technology. the statement the health authority is very widely in terms of how they are organized, however they share common functions, planning and coordinating a comprehensive array of services, submitting annual application for grants, educating the public, operating and funding inpatient services, this could be with state hospitals or with buying inpatient services within the private sector. the state mental health wasorities work with samsa has been an excellent partner, the acting administration -- administrator is a respected leader in the field. we respect her as a partner. it has provided strong leadership in providing the best practices for individuals with severe mental illness.
1:07 pm
the best example of that is the first episode psychosis program, this program started with research. the research showed that with -- to promote the program. its implementation is now across the country. it really isn't so away of showing how the federal -- exc ellent way of showing how the state can work with providers on best practice. it is important to note that the role of the state mental health authorities has changed over the last 30 years. 30 years ago states were primarily involved in state hospitals and a 75% of the budget went to his hospital. -- state hospitals. now most of it goes to the community. the private sector was not really addressing issues in the public sector, now it is hard to
1:08 pm
separate them. when it comes to admissions to state hospitals, now almost all admissions are court related. almost all the civil admissions which were uninsured individuals going to state hospitals, now asy get the same care insured individuals and they go to the private sector. about -- i want to say something about the funding for the state mental health authorities, basically the funding for most states is primarily from the states themselves, so that the state foret and medicaid make up almost all of the expense in the budget by the state mental health authority. the block grant the tones -- atones for less than 1% of the mental health in the state. what are some additional actions congress and the administration could it take for the state mental health authorities? one is, the first episode
1:09 pm
psychosis program, an excellent program. the fact you have agreed to it is excellent. what we will ask is for a change in the methodology, the smaller states are not able to move ahead with the program the way to larger states are because of the block program methodology. modify sod is to mid -- that imd's can get paid for taking care of individuals with medicaid or adult. s. with theto start private sector. in maryland, we participated with a demonstration that showed the average length of stay in a private hospital for 10 days cost per episode was about the same as for the acute general hospital psychiatric units. we would ask to reauthorize the money for the program, this is
1:10 pm
an important program. chairman: could you lie down please?- wind down hepburn. : yes. ms. blake: thank you for inviting me to testify. i am an emergency nurse working full-time at good samaritan hospital in west palm beach, this is an acute care hospital. in addition to work in the emergency department, i am the chairperson for the council of emergency net -- nurses association, the largest professional health care association dedicated for emergency care. as a registered nurse for almost 40 years, my career has been devoted to providing the best possible care to every person who comes into the emergency
1:11 pm
department, increasingly this involves treating patients who are suffering from mental illnesses. the emergency department at my hospital has 32 beds. it serves a very diverse community, including extreme poverty and some of the wealthiest neighborhoods in the country. since the federal law prohibits hospitals from turning away anybody seeking emergency care, i see practically every kind of urgent medical condition. on a typical shift, at least 10% of cases involve psychiatric patients. thiseason for the surge in include the veterans who suffer from ptsd, drug abuse, and stresses brought on by weak economy and joblessness. but the possible cause in my view is the lack of adequate treating options in the community. mental health patients often find they have no or turn for
1:12 pm
treatment, so they go to the one place, the emergency room, that is guaranteed to be open at all times and willing to care for every patient. in florida, a physician or law enforcement officer can evoke a state law that allows for the voluntary hold of the 72 hours for a person who is deemed as a threat. after 72 hours, the emergency department must clear the patient of physical illness and then that person is placed in a 10 by 10 room until we can find a facility that will accept the patient. because at my hospital, we do not have any psychiatrist on staff. all patients requiring inpatient care must be transferred to one of the four psychiatric facilities in palm beach. i cannot think of anything -- of a single time in the past year that any of our patients have been accepted immediately.
1:13 pm
in mentally ill patient typically stays between 12-24 hours before they are transferred to a psychiatric facility, however 2-4 days boarding in the emergency department is not unusual. and this is also the case at other hospitals and it is made worse by the lack of insurance coverage for people who suffer from mental illnesses. our experience is consistent with research conducted by emergency nurses association that found that the average boarding time in the emergency department is 18 hours for psychiatric patients, versus four hours for other types of patients. inadequate health services and extended boarding times are detrimental, both for emergency departments and for the care of the patient. areal health patients personnel intensive care not only do they stay in the emergency department longer than other patients, but they often
1:14 pm
require close supervision and personalized medical attention. by necessity, nurses and , this takes away from other patients. whenever they are placed on hold, there is a protocol we must follow to ensure safety. a security guard is placed at the door. for the patients experiencing mental health crisis, the emergency department is far from the ideal place to receive care. they are chaotic, often loud areas and the nurses and physicians are stretched to their limit and carry for the other patients. and our emergency physicians are reluctant to prescribe psychoactive medication for these patients because this is not the area of their expertise. we usually give a form of anti-anxiety agent, they do not begin therapeutic interventions because there is no professional there to provide it.
1:15 pm
so imagine you are already stressed, anxious, possibly suicidal or psychotic and perhaps having hallucinations and you are confined to a small space. all the longings are taken away -- belongings are taken away and there is constant chaos and emotion. and because of the shortage of , the situation continues for many hours or even days. mental health care patients would be better served in facilities that have specialized expertise. the most important thing that we feel if needed is that communities must have the infrastructure and funding to provide resources needed to keep the population healthy. coverage andhave in a high quality mental system, which will provide care, access to mental health clinics,
1:16 pm
outpatient and inpatient treatment and the availability of a 24 hour crisis services that will allow the patient to be integrated fully into society. i want to thank you for allowing me the opportunity to represent and speak for my fellow emergency nurses, we passionately care about providing the best possible care to all of our patients. and we strive for them to have the best outcome possible for their illnesses. thank you. mr. chairman: thank you. dr. eaton? can you?: senator alexander and mary and the rest of the members of the
1:17 pm
committee, i think you for the opportunity -- thank you for the opportunities to speak to you. to first thing i want point out, we all feel, we all know some of you with mental illness of one type or another. and we feel strongly about this, but there have been developed a new metric in the field called disability adjustment, that magic allows us to compare the diseases, the mental and substance abuse disorders as well as cancer, stroke, all of physical diseases. and when we do a comparison of population basis using the data, it clearly showed that mental and substance abuse disorders of the most important category of disease burden. and depression is the single most important disease itself in
1:18 pm
terms of disease burden, so the importance of this has been recognized many times in the past. the surgeon general's report and so forth, so now we have a metric that will establish scientifically that depression is the most important disease category. and one of the reasons for this is that the mental -- begin early in life. detective somebody who just got depressive disorder and you find out and started 10 years earlier and the consequences of the disorder will not show up for another 10 years. so, the mental disorders, especially depressive disorder, predicts onset of stroke, dementia, heart attack, diabetes , it predicted more power play more powerfully than we know.
1:19 pm
somebody with depressive disorder has a higher risk for heart attack than those with diabetes. these start early. they take a long time and the consequences for physical illness are very strong. need more research to figure out why these consequences are occurring and also the consequences have been stated for primary health care for psychiatric care, because now the primary care doctor is interested in saving the life of this patient and that means he should screen for depressive disorder and other disorders and learn how to do it. we should make that technology available. i want to say that there are a range of prevention programs for mental and substance abuse disorders, many of them. and they have beneficial outcomes proven years or even
1:20 pm
decades following the intervention. most of these prevention programs are social intervention early in the life course prior to the onset of the disorder. in the school system for example, or even shortly after birth. those preventive interventions are one of the unused resources i would say. aside, there have been breakthroughs in genetics, especially the methylation issue the tendency for aging to operate or not operate is affected by the environment. in the future we will be studying how genes and environment work together. when we study that with them together, that will be a way to look at the social environment, the way it works with genetic material and that is the way that mental disorders have their occurrence.
1:21 pm
the failure to help people with severe mental disorders is the most glaring problem in our mental health system and it turns out that severe mental illness like schizophrenia, you know this senator alexander, they are associated with a shortened lifespan by even two decades. somebody with schizophrenia will die 20 years earlier, they are not dying from schizophrenia, they are dying because we are not taking -- paying attention to the prevention. like the boys lowering drugs -- lypod lowering drugs. nobody choices -- chooses to be schizophrenic. it happens to them. it seems like we go than that. them that. and building programs related to brain research, i want to mention that the national institute of mental health has
1:22 pm
lost its focus on public mental health. and also it is abandoned. the should be is natural interest -- be its natural interest. these new programs are basically confused, a huge range of researchers and puzzles the international community. has initiated the probability of developing research-based prevention programs for mental and substance abuse disorders. the orientation is the action from my point of view, the action is prevention, preventive intervention early in the life course, mostly social. and thank you for your time. mr. chairman: thank you dr. eating -- eaton.mr. irving ?
1:23 pm
mr. rahim: let me first share my journey of mental illness. it started three weeks into my first semester. i was struck with a panic attack. and thenfirst episode second in the spring of 2000. my next weeks were filled with sleepless nights and i ate sporadically. i had visions of jesus, spoke foreign linkages, my parents rushed me to a psychiatric hospital and are diagnosed with bipolar disorder. my years of life have been defined by mental illness, yet by proper treatment and persistence, i have recovered and achieved wellness. there are millions of americans who are thriving in the face of mental illness. teachers who rise every morning to face their anxiety and students.
1:24 pm
veterans with lingering and physical scars of ptsd who will still provide for their families, many are thriving, but many are not. to serve everybody living with mental illness we must take accesso address stigma, to medication and peer support. i began speaking in 2012 openly about my struggles to thousands of individuals with mental illness, family members, law enforcement, communities, teachers, and the students. since 2013, i have been talking about mental illness as a presenter. i have delivered presentations and i have spoken to more than 20,000 students across the country. after one of my presentations, a small african-american girl shared with me that she was -- when i asked if she told anybody, she said no, i have not. then she lowered her shoulders. i told her, that is ok.
1:25 pm
thank you for being brave in telling me -- we want her to her school counselor, the same that her family members advised her not to go to. because she saw the importance of openly addressing stigma, the young girl's silence was dissolved and she was able to get help that she needed. education is essential to ending the same around mental illness. many parts of -- 1985, addressed the components that would -- take down the barriers of mental illness. this is also part of the treatment. a medication has and continues to play key role in my life. i still think -- take antidepressants every morning. they are central to my recovery and wellness. finding the right combination of medications, which at times was very harsh, but thankfully by working with my doctor i found the right combinations.
1:26 pm
the struggle to find a correct medication is a difficult task for many. it can literally mean the difference between life and death. manunmanned and -- a young i know went to therapy and at least 50 different medications. 20 years after his first episode , he is now an advocate. toause he had access medication, he is now helping others work toward wellness. we must keep medications protected and affordable to people with mental illness. actors and patients must have a choice in finding the right treatment as the wrong treatment can lead to substance abuse, exhaustive caregivers and even death. however, medication alone cannot sustain wellness. another key component of this bill is pierce support. support. -- peer
1:27 pm
the power of relating to others cannot be understated. this is a quintessential example of the power of the fear -- pe er. a member mentioned in an e-mail chain that he had lapsed into depression. within one hour, there were responses to his e-mail, one member saying, i will come pick you up. they truly understood the power and emotional strength of the support group and that emotional support can shatter the weight of depression. i am happy to say that this member is doing well and he is really doing well now. quantifyingage, whatsit peer -- what peer support looks like is a component to mental wellness. mr. chairman, ranking member murray, and others, i am testifying as a voice for people who are living with mental illness. therade does not represent
1:28 pm
full breadth of living with mental illness. my presence here today gives a face to millions of americans , and is striving in the face of mental illness. recovery should be an option for all. step ina pronounced that direction and i am respectfully urging the committee to move forward on this bill and i would say that millions of people are depending on the transformation in how we address mental list in america. -- mental illness in america. mr. chairman: thank you. we will not have five-minute questions -- now have five-minute questions from senators. what advice would you have to someone who knows a person who may need help? how do you persuade them they should seek help, whether they
1:29 pm
are a family member or friend? question: i get that all the time. i speak at support groups and that is the billion-dollar question. we cannot persuade anybody to do anything they do not want to do. mr. chairman: what is your approach? mr. rahim: education fair we can change how we respond -- education. we can change how we respond to people. there are programs out there that students and people can take and it will change the way they interact with the loved ones and to thereby helping them understand what a loved one is going to read when i was -- going through. when i was in psychosis, because of the way my parents changed,
1:30 pm
they were able to get me help. mr. chairman: dr. eaton, what is your experience? thing is ar. eaton: one program in high schools that could be built into the health curriculum. you can build into the curriculum without too much trouble, a module on depressive disorder, psychosis, so that people are aware of these. they think of them as illnesses just as any other illness. then it becomes part of the stigma reduction idea. they become less resistant. schoolare also in-high screening programs. the teen screening program was implemented in thousands of high schools across the country, in which you screen high school students oriented toward depressive disorder. you mentioned suicide is being
1:31 pm
an important cause of death, for teenagers, it is the third most important cause of death. programs and high schools to make people aware of the issues around mental illness. >> you were critical of nih. nimh.ton: >> institute that it deals with -- the institute that deals with mental health. congress has increased funding for that. i hope there is a bipartisan interest in doing more. if you were there, what would be your focus? dr. eaton: i'm completely supportive of more funds for mental health. the orientation has been away from -- we can no longer apply for grants with diagnosed of that diagnostic categories. that is silly. i would it change that orientation.
1:32 pm
i think to some extent the nimh has shied away from mental health orientation. when i worked at the same so for week,sa for 2 days a there was not one psychiatrist there. as i left, one psychiatrist had joined. only one epidemiologist at the national institute of health. that is the failure. ago, imentioned 30 years was a governor at that time. what advice would you have for states, based on your experience , about the focus
1:33 pm
towards dollars, both federal and private? >> trying to take care of ms. many people as possible, as cost-effective as possible -- moving further upstream towards prevention and earlier prevention. you can take care of more people as they start to show symptoms, or where they are at risk for symptoms. is thatlem 30 years ago we were waiting until people had severe mental illness until we started treating them. now with the public health model, we are trying to move further upstream to early intervention. trying to spread the dollars out. we still have to keep taking care of those severely mentally ill. but trying to get to those earlier, as we are with the first episode psychosis. and even earlier, trying to deal
1:34 pm
with children's mental health. rahim, thankmr. you so much for sharing your story with this committee and all the work you have been doing with those across the country. your message that people are not defined by their mental illness is a powerful one. i appreciate that. i wanted to ask you -- as you talk with young people, what are the most common forms of stigma you hear about? mr. rahim: the most common forms are -- i don't want my friends to know, i do want my family members to know. or even sometimes parents, students that want to talk about it, but they have parents that don't want to help them get help. sen. murray: so they fear their parents will--? mr. rahim: oftentimes there is a guilt -- is my child broken,
1:35 pm
sick? sometimes when the students come to them, they actually want the help, but sometimes the parents are reticent in getting them to help that they need. a lot of students are willing and open to talk, especially putting the conversation out there. sen. murray: so having someone else besides her parents -- bes dieides your parents is criticay important. i also hear from parents too, they don't know who to call when their child says that. they say they have this issue, but they don't knew who to call. who do you -- what you do you tl them? mr. rahim: sometimes there is a bridging of a gap between resources and knowledge. the key component is what is
1:36 pm
available and knowing it's ok to seek those resources. you are not broken or bad if something happens to your child. it is providing that bridge to the knowledge gap. there are resources and it's ok to use them. sen. murray: great, thank you very much. blake, the work you do in the emergency department is critical to our health care system. under the patients that come mostgh your door or at the vulnerable points of their lives. once a patient is stabilized and we know they need more specialized care, we know there is an acute shortage of inpatient psychiatric beds. you refer to that, certainly a critical issue in my home state. wants that he ranked my state -- one study ranked my state 48th on psychiatric treatment beds. we are seeing more discussion on that in my state. what happens to a patient in the emergency department if there are no psychiatric treatment beds?
1:37 pm
you mentioned this in your opening statement. but what do you do? ms. blake: we essentially keep them there in that room. we give them three meals. they are stuck there until we can either a, find a facility willing to take them. sometimes at the 72 hour hold -- expired, hour hold has we have no choice but to allow the patient to go. and they go back into the community. generally speaking, they will go from our hospital to the next hospital that is closest. sen. murray: dr. eaton? dr. eaton: i spent time in the korea, australia. -- victoria, australia. they have a system, they can dial up and find the nearest mental hospital bed in the entire province in a few minutes. sen. murray: do you not have
1:38 pm
access? ms. blake: we do not have that access where i am. in preparation for this, i did an informal poll of my colleagues wrote the country. this is not just a problem in florida or washington, this is every single state in the country. i would say this is the top issue in emergency departments right now across the country, holding onto these patients. in the south part of palm beach county, they had 14 patients waiting for psychiatric beds. rahimurray: as mr. pointed out, people don't know who to ask, hospitals don't know who to take, and we have a huge hole in the system. ms. blake: there are not enough resources to place these people, get them screened and into treatment programs. but two, the follow-up when they
1:39 pm
are released from that facility. they are put back on the street. if they don't have any place to go to follow up to get further treatment -- their medications, to have someone they can go to if they start to have a problem -- so many of these people are homeless. they get put back out and they have no place to go. they have no resources. they have no way to follow up with a position. they have no way to get their medication. -- follow-up with a physician. alexander: idaho senator baldwin and -- i know have senator baldwin. sen. baldwin: in rural states like maine, patients with serious mental illness all too often lack access to the care that they need. as i look at federal policies, at times federal policies
1:40 pm
exacerbate the problem of access. we still don't treat mental illness the same way we treat physical illness in this country from the perspective of federal reimbursement policy. pretty stunning in this day and age. you mentioned to that congress passed senator cardin's bipartisan bill, which i cosponsored, which extends an important demonstration project that addresses psychiatric that shortage --psychiatric bed shortage this blake has talked about. maine is one of the pilot states under that program. it has already seen very promising results because
1:41 pm
federal medicaid matching payments are being allowed for pre-standing psychiatric hospitals for certain emergency psychiatric cases. similarly, the cassidy-murphy bill, which i cosponsored will go further by lifting the imd exclusion for psychiatric patients with an average length of 20 days or fewer. get should help more people the assistance that they need. could you talk a little bit more about this issue, and how the restrictions on medicaid funding to freestanding psychiatric hospitals affect access to care? yes, thank you for the
1:42 pm
question. access is a major issue. following up on the previous discussion, there is a culture problem. individuals are expected to go into a psychiatric unit. if someone is in the emergency room for another type of problem and there are not beds for that discipline, they put them into an another open that in the hospital. -- open bed in the hospital. there are no reason those with psychiatric problems could go into a medical bed with a sitter if some hospitals decide to do that. this i answer is an increased use of technology. the third, the imd demonstration, as shown private psychiatric hospitals have about the same cost per episode as acute general hospital psychiatric units. privatears ago, the psychiatric hospitals kept
1:43 pm
people for months, sometimes years. that has changed. the average length of time and the cost per episode is about the same. there is not a good reason from high financial standpoint or a clinical standpoint to differentiate between private psychiatric hospitals and acute general hospitals with psychiatric unit. sen. collins: i think you raise an excellent point. is that the practices of the past -- it is that the practices of the past or affecting the reimbursements of today. as we've talked to the administrators and psychiatrists, staff, families, and patients at one of the ne,chiatric hospitals in mai part of this pilot project, they are seeing exactly what you have said. they are not keeping people forever. they are not abusing it. they are allowing people to get
1:44 pm
the care that they need because it is being reimbursed for those ofividuals in the age span 19-64 that now cannot get reimbursement. comment.: just another emerging technology may be helpful. there is record linking in victoria, australia that is coming. we can link records more easily. in baltimore, 85% of people with schizophrenia own a cell phone. there is a way of contacting these people. technology is being developed. they are not really therapies, but locating devices. i think that is in our future also. sen. collins: thank you. chairman: senator baldwin have to step out so we will go to senator murphy. sen. murphy: thank you all for taking this issue so seriously,
1:45 pm
for putting us on a path to a bipartisan product out of this committee and a path to bring this to the floor this year. i think this is one of our opportunities in 2016 to be able to move something substantive and bipartisan on the floor of the senate. i thank all of you for being here today. i think we have covered the question of capacity. i thank senator collins for her questions. let's think about how this would relate to our lives. if we were to bring our child to the emergency room around theretime, and we sat with our child all evening. we sat with them all overnight and we didn't get appropriate care for a child until noon the next day, we would call for people's heads at that institution.
1:46 pm
we would be outraged. that is in the outlier when it comes to people being admitted to the er with mental health diagnoses. that is the average. [laughter] and yet we accepted as commonplace. -- accept it as commonplace. there is a reason that is happening. we have closed 4000 inpatient beds in the last 2 years alone. we went from 91 million americans living in an area designated as a mental health shortage jurisdiction to 97 million americans. we are going the wrong way on capacity as need is increasing. it is no mystery as to why we are hearing these stories. as senator murray pointed out, another failing of the system is the lack of coordination. we have so many people trying to do good things, but they are not talking to each other. and for complex patients, it is
1:47 pm
often not clear who is in charge. school,a child, is it the the clinic, the primary health physician? mr. rahim's story is captivating. you are courageous to continue. i want to ask you about coordination. about the barriers that patients face in trying to find a quarterback for their care. the worry that is involved in trying to figure out which provider is the best place to start, where they eventually go to get the care they need. how do we do a better job of coordinating all the good things that are happening in the system so that is easier for patients to navigate? mr. rahim: i can take a step back and share what happened with me about 17 years ago. my parents were able to bring my directly to a hospital in queens. you talk about the waiting area being chaotic. i had hallucinations in the
1:48 pm
waiting area. i thought i saw jesus and pro phets. i was able to get hospitalized tthahat night and get medication that night. i spent two weeks there. that early care is so critical. to speak to the larger issue, i think having that immediacy of care is critical. i know it was critical for me. eaton, i wanted to explore an issue that you raised. this realization that if we don't spend money on mental health, we are going to spend money somewhere else. the fact is that a diabetes diagnosis alone does not put you spenders in the medicare-medicaid system. in fact, the depression diagnosis alone does not put you
1:49 pm
in the top 5% of spenders. it's the combination of the two. as you point out, if you have depression, you are much more likely to acquire another major and expensive physical health disorder. talk a little bit about the connection between a mental health diagnosis and a very expensive and burdensome physical health diagnosis? and why and little bit of spending on the mental health side prevents from the spending a lot of money on the physical health side? dr. eaton: i wish that i knew more. that is been replicated 10 times. the logic is very strong. on the one hand, treating the mental health disorder will almost certainly lower the risk for the physical disorder later on. also moving upstream, even
1:50 pm
farther than first episode psychosis. if can identify people at risk for psychosis, or at risk for depressive disorder, not at the first episode. that will have downstream consequences. the problem is it is complicated because it takes a long time. we have not done a lot of longitudinal studies to determine whether depressive disorder contributes to risk for stroke. in the u.s. we don't have the a tendency to do these kinds of studies. i don't think i have answered the question well. but i think we need longitudinal research to understand how it is that the body and mind evolved over time from age 15 when somebody's at risk for suicide or depressive disorder, to the age of 45, when they are at 5 times the risk of a heart attack because of that. mr. chairman: thank you senator
1:51 pm
murphy. senator cassidy. topicassidy: this is a that is inherently tragic. but that all of you senators are here gives us some optimism in the midst of this. so thank you all. me ask -- you describe in your testimony about the lack of coordination between federal programs. i am trying from that -- drawing from that that you feel there should be changing how these programs coordinate with we will spend ourr we will tax dollars ineffectively. dr. eaton: there is huge redundancy in the it beating a logical research -- epidemiological research. organizations
1:52 pm
conducts a suvery. sen. cassidy: so it would be better-- to study: it would pay the coordination of those agencies. it is a very difficult-- you brought up some think that tim murphy brings up a lot. lack ofs aa psychiatrists. is amazing, i agree. sen. cassidy: i told dr. basing, we need to start federal research on i joked of -- on objective criteria instead of inertia.
1:53 pm
now, do you include the cost of incarceration in your societal cost? daily do notose include that typically. incarceration is a horrible horrible problem. many of us think that the prison and jail system is the de facto mental health system in the united states. sen. cassidy: my national sheriff's association says he is the most active mental health provider in his parish. dr. eaton: in cook county, that is true also. we don't even have a good survey. sen. cassidy: we have heard testimony that the right drug is so necessary to keep somebody in balance. i have learned that when some one enters a jail, their medicines may be stopped or on contract.it may be a drug
1:54 pm
substituted. if we don't have some way to divert folks that are mentally ill out of the jail, they might go into a sitting that would situation super chaotic. is that a fair statement? hepburn: the point you made, if psalmody comes in on medication and that medication is not continued, it can have a negative impact on their ability to recover. sen. cassidy: thank you. mr. rahim, great testimony. tell you though, the fact that you speak about your groups as if it is something unique -- peer groups as if it is something unique, i get the sense that it needs to be expanded. as good as it is, we don't have pure groups proliferating across
1:55 pm
the country. is this an exception for you? mr. rahim: i know there are peer groups across the country. sen. cassidy: are there all over the place, or no? mr. rahim: i can't speak to all of the place. but the depressive and bipolar support of line, they are based on peers and wellness. i do think that is a key component. if i knew -- when i was going through the stick of my medication-- sen. cassidy: let me stop you. anything that would promulgate peer groups would be great. mr. rahim: 100%. sen. cassidy: man, if we could put you on a bottle and sell you, we would all be better off. a lot of people start feeling well, they stop taking their
1:56 pm
medicine, and they are back with ms. blake. what motivated you to take your medicine. what would you recommend to others to encourage them to stay on the path of recovery? mr. rahim: medication does not define who you are. you were to find by your experienced -- you are the find by your experience. sen. cassidy: the appropriate mindset, number one. what else? two, knowingmber that you have to go through accommodation. there is no one medication that is a panacea for mental illness. that is why more researchers is needed. know that you have different, nations. you are not defined by your mental illness. having the ability to self reporting of dr., know how the medications are affecting you and your treatment as well as your body. know that you will have weight gain. you will have some sort of response in reaction. i think those are key components.
1:57 pm
one, trial and error. different, nations. -- different combinations. know that they do not defined who you are. you, i yield thank back my time. sen. warren: for a lot of plans, mental health parity is the law, but it sure does not seem that way. i survey by the national alliance on health found that 50% of respondents had been denied coverage for mental or behavioral health care compared with only 14% denied for physical health care. i hear way too many stories from people in massachusetts about how hard it is to get insurance coverage for the care they need. let me start here. dr. hepburn, what do we know about the number of those being denied services they need, why
1:58 pm
they are being denied, if they are filing complaints, and if they enter and of getting -- if they ever end up getting the care that they need. dr. alpern yesterd -- hepburn: yesterday i called the maryland perry project. it is hard for them to know what the numbers are. when they look at how difficult it is to submit a request for it is so, tedious it will take years. i ask for a recommendation. they said something will have to change. sen. warren: you are citing we don't even have good data on any of those four questions. mr. rahim, if someone had trouble getting health coverage for mental health services, is there one place that anyone in this country could report a problem and get some help from?
1:59 pm
that is the information we need right here. mr. rahim: i don't know. sen. warren: that is part of the problem we have. connecticut created an office of the health advocate to help people navigate the insurance system and assist when they were denied coverage. in 2014, that office returned nearly $7 million to consumers, the most frequent cases they deal with every year -- denials of mental health coverage. massachusetts,om joe kennedy, introduced the behavioral health coverage transparency act last month to try and create a patient parity portal to provide consumers run the country a one-stop shop for information about parity and a central place to submit
2:00 pm
complaints about coverage. let me ask you this dr. hepburn, would a central place for people to go with problems about insurance coverage for mental health problems help consumers and give regulators that are information about where to focus their enforcement actions? absolutely. sen. warren: this could make a real difference from what you are saying. good. as we move forward, i would like to work with you senator alexander and murphy, on making sure that consumers have a central place to turn to for help when they are denied coverage and a central place where we want get the information so that we can enforce the law currently on the books. thank you. thank you mr. chairman.
2:01 pm
mr. chairman: thank you senator warren for the suggestion. senator franken. bothfrnanken: thank you german and ranking member for this series of hearings. -- both chairman and ranking member for this series of hearings. -familyhlighted the nurse program assisting moms before and after birth. i believe prevention is very important. that is why i helped advance the mental health in schools act, which will increase back says -- increase access to mental health services in school settings. mr. eaton, what percentage of individuals with mental illness experience onset before the age
2:02 pm
of 18? whataton: it depends on mental disorder you are talking about. for depressive disorder it is about -- the full-fledged disorder is about 20%. the beginnings of it are available -- 50% of the people before 30e depressive are already experiencing symptoms at age 15. they would be potentially identifiable, depending on if we could get the to do that. -- to get the tools to do that. for schizophrenia, i think it would be similar. it has much more sudden onset at age 18-25, something like that. the signs of psychosis and negative symptoms are there at the age of 15 and 20.
2:03 pm
sen. franken: i think this is why if we expand and enhance mental health services in our schools, we will serve ourselves well. i want to ask about rural suicides. a study made by d journal of american medical association shows that rural adolescents commit suicide at approximately twice the rate of teens in urban areas. this disparity has increased over time. 2013, suicidejune rates rose by 7% in metropolitan areas, but 20% in rural areas over the same period.
2:04 pm
the research shows that these differences are driven by the lack of treatment options in rural areas, provider shortages, and stigma. as a cochair of the senate rural health caucus, i find this deeply concerning. dr. hepburn, you have previously served as a national service i'd prevention -- national suicide prevention advisory board. you represent the state program mental health directors. can you explain why suicide rates have been driven up so dramatically in rural areas? dr. hepburn: i think you answered it, which is basically access issues. one of the thing that is important is to look at how we can advance technology to get to the rural areas. edit time when the internet is reaching people all over the world, there is not a good excuse for being unable to reach
2:05 pm
young people in rural areas. a problem we sometimes get is the lack of payment for those services done through to let mental health. -- telemental health. in this day and age, internet services should be made available in the same way that every other service is available. by doing that, we can increase access to those kids. franken: which is one of the reasons we need to make sure that every area in america is wired. this is something that i hear when i go to rural minnesota. providing incentives to mental health service providers in rural areas also. we just need them in this country.
2:06 pm
we have a provider shortage, is that right? without the helpful? -- would that be helpful? dr. hepburn: absolutely we have a workforce shortage. the average age in the field is 58. we have to use technology as a way as compensating for the. franken: thank you all for the work you are doing. i think we are beginning to understand how important this is in this congress and this country. i think we have seen some good things happen in this congress. i want to thank the chairman and ranking member again. mr. chairman: thank you senator franken. senator whitehouse. ouse: following up on senator warren's questions, it strikes me that
2:07 pm
one of victories we have achieved has been to bring mental health out of the shadows and de-stigmatize it. not completely, not as much as it should be, but there have been some real victories. i want to commend my former delegation member, representative patrick kennedy of rhode island on the parity act, which has helped make that the law of the land as opposed to just a good social change. in addition to the problem of getting insurance coverage, is there not also the underlying problem that our infrastructure for mental health treatment was basically built during a heavily stigmatized period, when very few people came forward? it was designed to address a fraction of the real mental health problem.
2:08 pm
island, we have some of the best mental health facilities in the country. our best in show world-class facilities, and yet they are all they are. you get the on that -- get beyond that, and you have difficult situations. often there is a crisis before you get into the mental health care system. because there simply isn't adequate coverage, particularly in children's mental health. i see that is the case in rhode island. perspective from your national organizations. all heads are nodding, let the record reflect. mr. rahim: i can also speak to that. in 12 have spoken different schools, we did a four
2:09 pm
week follow up, are students ashley going to seek help? out of 200 students i talked to, 84 went to a teacher or school psychologist. they are ready to seek that help, where do they go? if people are ready to talk, especially the young people, where do you go once you are ready for that help? sen. whitehouse: our victory in the stigma era has created a problem in the infrastructure area, in my opinion. in the judiciary committee, we billbe considering a called the cumbrian sieve addiction recovery --comprehensive addiction recovery act. very often self-medication is a solution. not a good one, but one that
2:10 pm
people use when they face a mental health problem. record, ifor the each of you would have a look? i think your organizations are already aware about the cumbrian sieve addiction -- comprehensive addiction recovery act. a hearing is coming up in the next weeks. i would like to have your organizations opionions here that i can take there. the last question is about emergency rooms. ms. blake, you live in that world. i have spent overnight in our emergency room just to witness what takes place. there is an enormous amount of response delivered in the emergency room. people come in the middle of the night, the police have no else to bring them, they take
2:11 pm
them to the er, bingo, now it is your problem. the er is not suited for dealing with that. if you good comment a bit more taskw big a role that plays in your workload and how much it is diminishing what else you can do. but also i'm interested in how comfortable that the electronic health records of that person are accurate and complete as to the mental health history of that individual. is that a good or bad thing? thet the feeling that regulations for privacy are preventing information on these
2:12 pm
mental health records. ms. blake: we had a 26 rolled 6-year-old-- 2 gentlemen coming to the emergency room for a heroin overdose. him.abilized in the process of taking care of him, i got a phone call from a gentleman in virginia, who was trying to locate his son, who had been sent down to our county for treatment for rehab and substance abuse, who had walked away from his rehab center. it turned out it was the patient i was thinking -- i was taking care of. the problem was that i could not tell him because of hipaa, number one because the patient was unconscious and could not give me permission to do so. his son also had bipolar
2:13 pm
disorder, and had been off his medications. had we been able to release that information somehow, it might have changed the whole way retreated this patient. more importantly, it broke my heart to not be able to tell was safethat ihis son in the emergency room and will be able to recover. limitedwe look at some circumstances where certain information could be released. i certainly understand the privacy issue. but it would be very helpful. in order to access someone's medical records, you first need to their permission. someone who might be in a mental health care crisis may not have the capacity to be considered to sign permission for it. sen. whitehouse: thank you.
2:14 pm
my time has expired but that was a terrific point. senator murray? sen. murray: this has been an important hearing and i want to thank all of our witnesses today. we have a lot of work ahead of us. making sure communities have access to mental health professionals, integrating primary health care, breaking down barriers that stigma creates. that is a full plate, but an important one for us to tackle. i look forward to working with you on moving his agenda forward. ms. blake, thank you for bringing that up. touching hipaa is like touching and electric wire, but maybe that is what we are paid to do sometimes. as we look at our mental health decision, we should consider that circumstance.
2:15 pm
if you have a specific , weestion for the exemption would like to have it. maybe your organizations have that. ke: we can put that on our agenda. chairman: we are moving pretty fast here. ms. blake: we have a meeting today. [laughter] good.airman: we,ll,
2:16 pm
thank you for the testimony from all four of you. the hearing record will remain open for 10 days. members may submit additional information for that time. this committee will explore information to-- thank you for being here todya. the committee will stand adjourned.
2:17 pm
>> attorney general loretta lynch testified on capitol hill, saying president obama's step on gun violence are common sense and within his legal authority. the president announced the actions two weeks ago, including expanded back on checks on gun sales, in additional $500 million in federal funding for treating mental illness. that would likely need congressional approval. carries some of what the attorney general said. >> i have complete confidence that the common sense depth by the president are level. they are consistent with this
2:18 pm
supreme court and the laws passed by congress. for example, the gun control act lifts those who are not allowed to have firearms, such as felons, domestic abusers, and others. congress has required that back on checks be conducted as part of sales made by federally licensed firearms dealers to make sure that guns stay out of the wrong hands. the actions announced by the president, which focus on background checks and keeping guns out of the wrong hands, are fully consistent with the laws passed by congress. taken together, the new executive actions will bring progress on a number of front. lynch'sll of attorney appearances, and also gun control advocates at it :00 eastern on c-span. -- at 8:00 eastern on c-span. road to the white house coverage with lesser-known presidential candidates in manchester, new hampshire.
2:19 pm
that is coming up on c-span2 8:00 eastern. campaign 16 is taking on the road to the white house where the iowa caucuses. monday, february 1 at 7:00 p.m. on the c-span and c-span2, live pre-caucus coverage. at 8:00 p.m. eastern, live coverage begins on c-span of the republican caucus. and on c-span 2, live coverage of the democratic caucus. stay with c-span and join in on the conversation on c-span radio and on c-span.org. formerapitol hill today, u.s. ambassador's to unlock and syria said the u.s. should back its traditional persian gulf allies in a new cold war between saudi arabia and iran. he named saudi arabia egypt, turkey, and israel as u.s. allies of choice in the region. rocker is joined by the senate
2:20 pm
armed services committee by and philipn keane gordon. this is two hours and 40 minutes.
2:21 pm
2:22 pm
>> we continue our focus on strategy and policy in the middle east. i begin by saying we all look on the news that four americans that had been unjustly held captive in iran were finally released. their will be plenty of time to examine the circumstances of their original detention and ultimate release. four americans being united with their families is good news. now the u.s. must continue for the the release of the americans still missing work imprisoned in iran. we must push for the release of thousands of iranian political prisoners jailed by the iranian regime, which continues to
2:23 pm
possess -- suppress and undermined human rights. a previous generation of american leaders remember they creation" ofnt to the order that has been the source of unprecedented security for the u.s. in the world. the present trends continue. you may well november we were present at the unraveling of this international order. signs of this unraveling can be seen in europe and asia, but it is most visible in the middle east. we see a dangerous breakdown of state authority and the balance of power. as henry kissinger testified before this committee, there is a struggle for power within states of conflict, between states, a conflict between ethnic and religious groups, and an assault on the international system. as general petraeus told us last year, almost every middle eastern country is now a battleground in one or more
2:24 pm
wars. for the past seven years, the obama industries and has soft to scale back -- sought to scale back america's involvement in the region. assuming that a post america middle east will be good for the region, and that regional powers will step up to police the region themselves. results of this massive gamble should not be clear to us all. no new order has emerged in the least, only chaos. the power vacuum has opened up in the absence of america. it has been filled by the most extreme and insight american forces, sunni terrorist groups, or extremist such as the islamic republic of iran and its proxies. and the imperial conditions of vladimir putin. these challenges were always going to be present and difficult, but he did not have to be this way, this dangerous. instead of acknowledging his failures, as previous administrations have done, the
2:25 pm
administration has doubled down on its reactive incremental and inadequate policies. this is a testament to our civilian and military leaders. serious challenges remain. isil has lost some territory on the margin but has consolidated power in its core territories in both iraq and syria. it maintains control of key iraq cities like most will and falluja. -- like mosul and falluja. reports that sense isil's invasion of iraq in 2014, nearly 20,000 iraqi civilians have been killed. nearly 3500 people,
2:26 pm
predominantly women and children, are estimated to be isil slavces in iraw. it is no surprise that the training of iraq security forces has been slow. the building of support for sunni tribal forces even slower. in syria, there is no possible strategy to achieve isil's the feat on a timeline that would result in the tragic deaths of tens of thousands of syrians. there is still no ground force that is both willing and able to take cities, nor is the realistic prospect of one emerging soon. in the absence of a realistic strategy to create the conditions for the achievement of u.s. goals, the demonstration has fallen back on hope. the hope that diplomacy without sufficient leverage can convince russia and iran to abandon bashir al-assad and fight isil. yet we read just this morning that russia's air campaign
2:27 pm
continues to target moderate opposition groups, may be getting in traction in stabilizing the assad regime. meanwhile, isil continues to metastasize across the region in places like afghanistan, libya, lebanon, and egypt. , santtacks are now global bernadino, and most recently in istanbul. these should be a wake-up call that the threat to the homeland is real and growing. we need a strategy to destroy isil, not ultimately, but as quickly as possible. the administration cannot continue to assume that the time is on our side. one element of the administration's middle east policy clear from the beginning is its policy toward iran. instead of negotiating a deal to force iran to give up its nuclear program, the and menstruation signed a deal that said, as dr. kissinger
2:28 pm
went from prolonging proliferation to managing it. despite the talk, the islamic republic's behavior has not changed. rather than empowering iranian moderates, the nuclear deal appears to be doing the opposite. emboldening hardliners. iran as now conducted 2 advanced missile test since october in violation of the human security council by aleutians. it fired rockets within 1500 yards of u.s. aircraft carrier. iran seized 2 u.s. navy vessels , illegally detained 10 american sailors, and propagandized the entire incident in total violation of international law and centuries of maritime tradition. i must add, as a former navy person, that is the most humiliating thing i have seen.
2:29 pm
members of the u.s. navy subjected to in my or their lifetime. i am sure that the iranians use those pictures of american servicemen and women on their knees much to their great success throughout the world, as well as the region. shortly after the result, the release of 4 american hostages in iran, we learned that 3 americans were kidnapped in baghdad, apparently by in iranian backed shiite militia. i have no doubt the obama administration has pursued a new relationship with iran because it believed doing so would release sectarian tensions. but the reality is the in ministration has only exacerbated these tensions among our traditional sunni partners and allies, such as israel and turkey.
2:30 pm
this dynamic has only grown worse because the administration has been so slow to offer support to those allies and partners. as we have recently seen with delayed fighter aircraft sales to caught her and kuwait. -- to qatar and kuwait. to prevent competition from breaking down into open war. this is the responsibility that we are now advocating. we are being a very heavy price for doing so, that is only growing. i hope that our witnesses today can help us better understand the cost of our current course and contemplate a better alternative. senator viewed-- >> they have an extraordinary wealth of experience. this past weekend we saw a
2:31 pm
number of significant most notably,and implementation day of the joint comprehensive plan of action or the jcpoa, exchange of participating in the united states and iran. these are notable developments, but combined they to representntial an inflection point an opportunity to shift the course of the united states and iranian relationships, and the opportunity for these kinds of changes are rare indeed. usure the president upon hope for new opportunities, and share concerns about iran's he stabilizing actions in the middle east. iran will need to change its course. i hope the witnesses will ofvide their assessment
2:32 pm
these events and what opportunities and cautionary notes they would present for consideration to the committee. i recently returned from a visit to iraq. i had an opportunity to meet with the country's leadership, and our military commanders on the ground. by visit came on the heels of successful operation by iraq security forces to take and retake ramadi. the success which was enabled by the coalition air pod gave a significant confidence boost, and i hope this momentum will continue. in syria as a result of the violent agendas of the assad regime and isil, the humanitarian situation is increasingly dire and the human of conflict is staggering. our military has embarked on the campaign to ensure that isil is under increasing pressure. with respect to the overall conflicts in syria, secretary
2:33 pm
kerry is pursuing an ambitious agenda to facilitate a diplomatic pathway in the conflict and should be recognized for his persistence. i look forward to hearing from the witnesses on their assessment on whether the current peace talks might be approved. one other issue that struck me during my visit to the region was government efforts to information in the environment, an area where the administration is appropriately and necessarily try to breathe new life into interagency efforts on this front, creation of the global engagement center. it is adequately resourced and powered with necessary authorities. fromk forward to hearing our witnesses and what they hope to hear from the center, more we can effectively begin to win the information war, which isil has been so effective at. given that ambassador carter here, i will briefly mention
2:34 pm
afghanistan. security situation is challenging, but afghan national security officers remain responsive. further complicating the security situation has been the emergence of the so-called islamic state in the car is on province. -- in the province. from the political standpoint, the national unity government has held together through a difficult year, providing an opportunity for progress on key reform issues, including governance and corruption. evaluation and lessons learned for the past year may yield new ways in which the u.s. and coalition partners can improve our operations and political
2:35 pm
process by the afghans going forward. i'd be interested to hear from ambassador carter on what we should do and must do in this era. thank you, gentlemen. keene,ome, general chairman of the institute for the study of war, and the former vice chief of the army, and the dean and executive professor of the george bush's of government and public service. and the honorable phil h -- philip h that gordon, senior ,ounsel on foreign relations and white house middle east coordinator. general keene, due to your advanced age, we will begin with you. >> ok. thank you, chairman mccain, ranking member read. reed.i'm honored to provide testimony on the challenges of the middle east. this committee's persistence in keeping us focused on the unparalleled of people in the
2:36 pm
middle east is commendable. thank you for your hard work and much welcome reforms that are included in the national defense authorization act. i'm honored to be a part of this distinguished panel with the honorable phil gordon and particularly to be reunited with ambassador crocker, who remains today america possible successful and preeminent diplomat whose extensive service throughout the middle east is legendary. i was privileged to work with ambassador crocker during the afghanistan surges while assisting general petraeus. in previous testimonies before this committee i have purported details on how to defeat isis in iraq and syria and on russia possible involvement in syria. andy my focus is yours, what you have asked us to do, and that is to deal with overall u.s. policy and strategy in the region. i brought along a couple of maps for you to look at, and i think they will put them on boards when we reference them and you should have them at your seat as well.
2:37 pm
the middle east has experience one of the most tumultuous periods. in its history. radicalized islamists taking advantage of the political and social upheaval, and the islamic tote of iran using proxies achieve regional influence and control. some issues in the middle east have been simmering for some time, and are certainly underlying factors such as historical sectarianism, oppressive regimes, political and social injustice, and a lack of economic opportunity exacerbated now by the price of oil. one cannot simply blame these larger forces operating in the solve the united states of specific policy decisions that has had unintended adverse consequences. let's name a few. egypt. in 2010, the arab spring begins. were most arab countries
2:38 pm
in some form of pre-revolutionary phase, it was a strategic surprise. the united states in the face of major civil unrest in cairo abandoned mubarak, a multi-decade i like -- multi-decade ally. muslimult is the brotherhood, who move quickly without any u.s. opposition, to transition egypt to an islamic state. iran supports the muslim brotherhood. the muslim brotherhood quickly loses the support of the people and are deposed in a military coup. libya, in 2011 after gadhafi's deposed and killed, a newly elected moderate islamist regime requests support to train a national security force to repress the radical militants. the united states refuses. some of the same militants burned down the u.s. consulate, killed the ambassador and three others, forced the evacuation of a covert base, and the following
2:39 pm
year forced a u.s. retreat from libya. state, anow a failed breeding ground for radical islamists, and the largest isis presence outside of syria and iraq. 2003 -- whether the 2003 invasion was righteous, it are should in the first arab democracy in the middle east while giving rise to al qaeda in iraq, who was defeated in 2008. the new u.s. administration began to distance itself politically from iraq -- iraq, culminating in a total military pullout from iraq in 2010. the prime minister immediately begins a purge of political opponents and military leaders, and al qaeda reemerges that same year. syria's civil war growing out of the arab spring in 2011 is
2:40 pm
stalemated because the rebels initial games are thwarted by iranian proxies. shiaezbollah and iraqi militias and much-needed supplies and equipment from russia and iran. the rebels in 2011 and 2012 seek assistance from the united states, which is recommended by secretaries clinton and panetta, general dempsey and director contrasts. the united states refuses. al qaeda in iraq is incentivized by the protracted civil war in syria. moves out of a rock with several hundred iraqi fighters, establishing a sanctuary in northeastern syria, and grows a terrorist army of some 30,000 to 40,000. this decision baghdadi made is influential for him and the most critical decision has made since being the leader of al qaeda in iraq. two years later, isis invades
2:41 pm
iraq and expands its territory in syria. isis as we know it today would not exist without the opportunity that syria provided. red013, a chemical weapons line is crossed, the united states does not respond as promised, arab allies are dismayed and dissolutions. ssad continues to conduct a comprehensive depopulation campaign, killing 250,000 civilians, displacing 11 million in thousandsting of syrians joining tidal waves of others in the region to migrate to europe. in yemen, iranian backed houthis in 2014 forced the u.s.-backed yemen government to topple. the much touted u.s. counterterrorism operation is in full retreat with the closing of u.s. military operations and the united states embassy in yemen. an extraordinary
2:42 pm
chronology of events, where u.s. policy will not necessarily the primary cause of these disturbing events, was a least a factor and further destabilizing the middle east and losing the confidence and trust of our allies in the region. ismuch so that russia seeking to replace the united states as the most influential out of region nation, and many of our allies are listening. most critical policy failures are essentially strategic, and therefore have the most profound impact. simply stated, they are the united states and allies strategic failure to organize, plan, and defeat radical islam, and to successfully counter iranian regional hegemony. yearsradical islam, 23 after the first world trade center bombing in 14 plus years still have no comprehensive strategies to defeat radical islam. radical islam is morphing into a
2:43 pm
jihad, with expansion of al qaeda and the extraordinary success of isis, which has rapidly become the most successful terrorist organization in history. 2000 per month, and expanding into affiliate organizations throughout the middle east, africa, south and southeast asia, and developing a whereide following believers are willing to kill their fellow citizens, foam in and paula unrest, and risa population between muslims and non-muslims. by the map provided institute for the study of war, toch depicts isis' desire expand into affiliates in the near abroad in orange, and the far abroad in yellow. with the number of current affiliates as represented by the black stars, and affiliates in process of approval in blue
2:44 pm
stars. most of the far abroad will not have affiliates but rather radicalized followers who are inspired by isis to act, either as individuals or small cells. the united states strategic failure arrives not from -- derived from not understanding the nature of the conflict. the bush war on terror, and the obama counterterrorism war are simply tactics. the battle is within islam the arab world is intersecting with authoritarian regimes and family monarchies, failure, politically reform and to adjust to the needs of their societies. therefore we are fighting a political and religious ideology which draws its origin from the very strict interpretation of the koran, as well as the intolerance of wahhabism. political leaders such as lcc and king abdullah have referred
2:45 pm
to it as a religious revolution, yet the current u.s. administration fails to define radical islam or explain it -- nor explain it, nor understand it. how can we possibly defeat radical islam if we don't understand it? knowing the kind of war you are fighting is the first ird of a national or military leader. given this purposeful misunderstanding, or self-deception at best, by not acknowledging this narrowly focused islamic ideology, it creates an unnecessary condition where all muslims are brought under suspicion. law-abiding, faith-based, traditional or modern muslims who would do no harm to the fellow man and resent any association with radical islam deserves better treatment than that. a 21st century, generational, ideological struggle someone from the 20th
2:46 pm
century -- the 9/11 commission recommended a global alliance design a strategy and to work together to defeat radical islam. isg solomon of saudi arabia organizing a 34 member alliance to combat radical islam. it remains to be seen if it amounts to anything substantive. i do know it begs for the united states to play a leadership role. the next president of the united states will likely defeat isis theraq and syria having resources necessary to do the job. isis and radical islam is a global movement. it's not a question of whether we want to combat radical islam, is unavoidable. the only question is how. i believe global alliance members should design a strategy and not the united states. there are some elements that are obvious and critical. leaders and muslim
2:47 pm
clerics must undermine the political and religious ideology with not just what is wrong, but what is the right thinking and ideology. arab-muslim countries must change the levels of intolerance and the influence of wahhabism. clinical reform and social justice are essential. financial and economic support must be countered. countries permitting such behavior by the citizens should be held accountable. intelligence technology and selected equipment should be shared. partnering for training and military education is essential to raise the level of operational confidence. there is no substantive for an effective ground force. airpower is an enabler, it is not a defeat mechanism. is about alliance members providing the predominant military response. it's not the united states military. the united states military would provide a certain level of support.
2:48 pm
combatant should be pursued aggressively and ruthlessly. destroy and defeat radical islamic sanctuaries, sanctuaries are safe havens by themselves, protract the conflict and drive up the casualties. syria is a sanctuary. for 14 years has and has two sanctuaries unnecessarily protracted that wa r. iran iran, in 1980 declared the united states as a strategic enemy with its stated goal to drive the united states out of the region, achieve regional hegemony, and destroy the state of israel. proxies, primarily as the world's number one state sponsoring terrorism, and to fight proxy wars. beginning in the early 1980's, it began jihad against the united states by bombing the
2:49 pm
marine barracks, united states embassy, and the annex in lebanon, something our ambassadors intimately familiar with, united states embassy in kuwait, the air force towers in and attacking the united states military in iraq using shia militias trained in iran with advanced [indiscernible] iran began an0's, aggressive kidnapping and assassination campaign which resulted in numerous american hostages and the death of cia station chief buckley. a policy of hostage-taking for political gain continues to this day, as we are very much aware of. u.s.te, the result is troops left lebanon, saudi arabia, and initially iraq while changing middle east maps in red, has direct influence and some control over lebanon, gaza, syria, iraq, and
2:50 pm
lemon, while strategically desiring to influence not only the major shipping in the gulf, but the shipping entering and departing the suez canal. when you talk to a leader in the middle east, and arab sunni leader, this is what they think of when they think of iran. iran andow they see what it is doing in terms of their future security of stability. excuse me. isthere any doubt that iran on the march and systemically moving towards the regional hegemonic objectives? ise suggest that iran agreeing to a delay in a threshold capability towards a nuclear weapon is a transforming event. joining lead to iran the community of nations seeking stability and security. given a return of 100 dollars and sanction relief funds and a
2:51 pm
proven track record of belligerence and armed violence pursue its goal, a tough-minded skepticism is in order. to force compliance on the senator reid as mentioned, and finally, once and for all, the first development of a regional strategy to counter iran. a remarkable fact is that since the killing of americans and astage-taking by iran, and proxy wars began in the 1980's, no american president, democrat or republican, is ever counted iran's regional strategy. --more than ever with iran now more than ever with iran developing a ballistic missile capability and likely to cheat on the conditions of the nuclear it can, it is an imperative to join with israel our arab and european allies to counter iran's strategy of
2:52 pm
regional hegemony. a part of that strategy is concrete steps should be taken. in syria, the reverse of the stay,on that assad can which guarantees there will never be a negotiated peace, a theession, i believe, to russians just to get them to participate. establish safe zones and no-fly zones in syria to change the momentum against the assad regime. move eventually to a transition government, and eventually independently observe national actions. in iraq, establish a key political objective to reduce in to gain thece prime minister's strong political, military, and for the sunnirt tribes and kurds. dispatch ambassador crocker to iraq to was again assist and in achievingent
2:53 pm
political unity, something i've been saying publicly since the 2014 invasion. and the gulf states against pushing against the intelligence targeting and striking targets if necessary. ballistic missile testing, maligned regional behavior, hostage-taking, and of course any nuclear deal violation should all be met with tough, unrelenting economic sanctions. failure to counter iran's m aligned influence is encouraged their aggressive and destructive behavior for.36 years -- 36 years. the united states should return to its historical role as the major out of region power pumping out allies to secure a stable and prosperous middle east. the united states major policy
2:54 pm
challenges in the middle east surround the development of comprehensive strategies to defeat radical islam, and to counter iranian aggression and maligned behavior. if these competencies are not addressed, the middle east will continue to be in freefall, as the middle east problems become problems and confronting global jihad. the potential of middle east war between the kingdom of saudi arabia and iran, and supported real.ir allies, is and nuclear middle east proliferation leading to the car of the world's first nuclear exchange is real, which is secretary kissinger's major concern as a result of the nuclear deal. the risk has always been high in the middle east, and the challenges certainly complex, but now in adequate strategies and misguided policies are driving up that risk exponentially. you, and i appreciate you giving me an extra few minutes
2:55 pm
to explain that. >> thank you. ambassador crocker? crocker: it's an honor to be with you this morning. you have my written testimony, i believe, mr. chairman. remarksake a few brief so we can get on with the questions. teenld start where general left off, in a region experiencing unprecedented to mold in its 100 year modern urgent needre is an for a reassertion of u.s. engagement and leadership. i will have some specifics, i was just in the middle east last longtimeking to some friends and lebanon with saudi's , with some syrians.
2:56 pm
there is a perception that the united states is absent and maligned forces are therefore having a field day out there. our friends are uncertain and scared, our adversaries are .aining ground you need to make this clear that what happens in the middle east is of vital national importance to us. at a time when states are failing and nonstate actors are rising, it has become all too friend andas my good former wingmen data try us has said, what happens in the middle east does not stay in the middle east. that was the lesson of paris. we have an urgent national security imperative here. let me say briefly on iran,
2:57 pm
since that is the issue of the hour around town, some pretty momentous developments. i think the implementation of is important, for regional security and global security. we are going to have to be very vigilant to see that iran follows through. we are delighted that our hostages have come home. this over the sweep of recent history, these are transactions. they are not transformations. i'm reminded of our arms control agreements with the soviets in the 1980's. he made the world a safer place with a nuclear power, not just an aspirant nuclear power, but they did not transform anything. continued, we continue to stand against the evil empire in spite arms
2:58 pm
control transactions. when some ofnon our hostages were taken, and i was in lebanon when they came home. i loaded the remains of my former ambassador onto the helicopter. the syrians were also instrumental in holding those hostages, as was iran and hezbollah. they're released to not transform anything, did not transform a relationship with syria. syria remained on our list of state sponsors of terrorism, as it should have. what has happened. in this past week i think is important. it is transactional. point is that we are
2:59 pm
witnessing in the midst of these hot conflicts a middle eastern cold war. iran is on the move. militia thathia hezbollahhem in iraq, working with the revolutionary guard to support assad in syria, we need to stand clearly not in the middle of this cold war, we need to stand on one side of it. and that in my view is with our traditional allies. other gulfa and the states, with turkey, with israel, with egypt. we have differences with some of
3:00 pm
them, particularly with saudi arabia over yemen. but we have to take a stand here, mr. chairman. the russians have taken a stand and they are all in with iran and assad. i think we all know they are not there to fight islamic state. they do not care about islamic state, nor does iran. they care about shoring up assad. that axis, damascus, tehran, moscow, is perceived in the region as an axis. the more we don't take sides. take sides,we don't the more that perception takes hold among the sunni arabs, the considerable minority of the population of that volatile region. the more islamic state can make may out of it -- hay out of it. you i would mention several specific steps we need to take.