[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
WHERE HAVE ALL THE PATIENTS GONE? EXAMINING THE PSYCHIATRIC BED
SHORTAGE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
MARCH 26, 2014
__________
Serial No. 113-130
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
RALPH M. HALL, Texas HENRY A. WAXMAN, California
JOE BARTON, Texas Ranking Member
Chairman Emeritus JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky Chairman Emeritus
JOHN SHIMKUS, Illinois FRANK PALLONE, Jr., New Jersey
JOSEPH R. PITTS, Pennsylvania BOBBY L. RUSH, Illinois
GREG WALDEN, Oregon ANNA G. ESHOO, California
LEE TERRY, Nebraska ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
PHIL GINGREY, Georgia JIM MATHESON, Utah
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio JOHN BARROW, Georgia
CATHY McMORRIS RODGERS, Washington DORIS O. MATSUI, California
GREGG HARPER, Mississippi DONNA M. CHRISTENSEN, Virgin
LEONARD LANCE, New Jersey Islands
BILL CASSIDY, Louisiana KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky JOHN P. SARBANES, Maryland
PETE OLSON, Texas JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia BRUCE L. BRALEY, Iowa
CORY GARDNER, Colorado PETER WELCH, Vermont
MIKE POMPEO, Kansas BEN RAY LUJAN, New Mexico
ADAM KINZINGER, Illinois PAUL TONKO, New York
H. MORGAN GRIFFITH, Virginia JOHN A. YARMUTH, Kentucky
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Missouri
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina
Subcommittee on Oversight and Investigations
TIM MURPHY, Pennsylvania
Chairman
MICHAEL C. BURGESS, Texas DIANA DeGETTE, Colorado
Vice Chairman Ranking Member
MARSHA BLACKBURN, Tennessee BRUCE L. BRALEY, Iowa
PHIL GINGREY, Georgia BEN RAY LUJAN, New Mexico
STEVE SCALISE, Louisiana JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
PETE OLSON, Texas KATHY CASTOR, Florida
CORY GARDNER, Colorado PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York
BILL JOHNSON, Ohio JOHN A. YARMUTH, Kentucky
BILLY LONG, Missouri GENE GREEN, Texas
RENEE L. ELLMERS, North Carolina HENRY A. WAXMAN, California (ex
JOE BARTON, Texas officio)
FRED UPTON, Michigan (ex officio)
C O N T E N T S
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Page
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 3
Hon. Diana DeGette, a Representative in Congress from the state
of Colorado, opening statement................................. 5
Hon. Henry A. Waxman, a Representative in Congress from the state
of California, opening statement............................... 7
Witnesses
Lisa Ashley, parent of a son with serious mental illness,
Sacramento, California......................................... 9
Prepared statement........................................... 12
Jeffrey L. Geller, M.D., M.P.H., Professor of Psychiatry and
Director of Public Sector Psychiatry, University of
Massachusetts Medical School, Worcester, Massachusetts......... 17
Prepared statement........................................... 19
Answers to submitted questions............................... 120
Jon M. Hirshon, M.D., M.P.H., Ph.D., FACEP, Task Force Chair,
2014 American College of Emergency Physicians National Report
Card on Emergency Care, and Associate Professor, Department of
Emergency Medicine, University of Maryland School of Medicine,
Baltimore, Maryland............................................ 37
Prepared statement........................................... 39
Answers to submitted questions............................... 176
Michael C. Biasotti, Chief of Police and Immediate Past President
of New York State Association of Chiefs of Police, and parent
of a daughter with serious mental illness, New Windsor, New
York........................................................... 51
Prepared statement........................................... 53
Answers to submitted questions............................... 178
Thomas J. Dart, Sheriff, Cook County Sheriff's Office, Chicago,
Illinois....................................................... 65
Prepared statement........................................... 68
Steve Leifman, Associate Administrative Judge, Miami-Dade County
Court, Eleventh Judicial Circuit of Florida, Miami, Florida.... 74
Prepared statement........................................... 77
Gunther Stern, Executive Director, Georgetown Ministry Center,
Washington, D.C................................................ 97
Prepared statement........................................... 99
Hakeem Rahim, Ed.M., M.A., Speaker and Mental Health Educator and
Advocate, Hempstead, New York.................................. 103
Prepared statement........................................... 105
Lamarr D. Edgerson, Psy.D., LMFT, NBCCH, Clinical Mental Health
Counselor, Director at Large, American Mental Health Counselors
Association, Family Harmony, Albuquerque, New Mexico........... 107
Prepared statement........................................... 109
Arthur C. Evans, Jr., Ph.D., Commissioner, Department of
Behavioral Health and Intellectual Disability Services,
University of Pennsylvania, Philadelphia, Pennsylvania......... 129
Prepared statement........................................... 131
Answers to submitted questions............................... 181
Submitted Material
Article entitled, ``Dashed Hopes; Broken Promises; More Despair:
How the Lack of State Participation in the Medicaid Expansion
Will Punish Americans with Mental Illness,'' by the American
Mental Health Counselors Association, submitted by Mr. Waxman
\1\
Letter of March 26, 2014 from the National Association of
Psychiatric Health Systems to the subcommittee, submitted by
Mr. Murphy..................................................... 163
Articles submitted by Mr. Burgess................................ 165
----------
\1\ The article is available at http://docs.house.gov/meetings/
if/if02/20140326/101980/hhrg-113-if02-20140326-sd004.pdf.
WHERE HAVE ALL THE PATIENTS GONE? EXAMINING THE PSYCHIATRIC BED
SHORTAGE
----------
WEDNESDAY, MARCH 26, 2014
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:02 a.m., in
room 2123 of the Rayburn House Office Building, Hon. Tim Murphy
(chairman of the subcommittee) presiding.
Present: Representatives Murphy, Burgess, Blackburn,
Harper, Griffith, Johnson, Ellmers, DeGette, Braley,
Schakowsky, Butterfield, Castor, Tonko, Green, and Waxman (ex
officio).
Staff present: Leighton Brown, Deputy Press Secretary;
Karen Christian, Chief Counsel, Oversight and Investigations;
Noelle Clemente, Press Secretary; Brad Grantz, Policy
Coordinator, Oversight and Investigations; Brittany Havens,
Legislative Clerk; Sean Hayes, Counsel, Oversight and
Investigations; Alan Slobodin, Deputy Chief Counsel, Oversight;
Sam Spector, Counsel, Oversight and Investigations; Tom Wilbur,
Digital Media Advisor; Jessica Wilkerson, Legislative Clerk;
Brian Cohen, Democratic Staff Director, Oversight and
Investigations, and Senior Policy Advisor; Hannah Green,
Democratic Staff Assistant; Elizabeth Letter, Democratic Press
Secretary; Karen Lightfoot, Democratic Communications Director
and Senior Policy Advisor; Anne Morris Reid, Democratic Senior
Professional Staff Member; and Stephen Salsbury, Democratic
Investigator.
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Murphy. Good morning. I now convene this morning's
hearing entitled ``Where Have All the Patients Gone? Examining
the Psychiatric Bed Shortage.''
Right after the December 14, 2012, elementary school
shootings in Newtown, Connecticut, the Subcommittee on
Oversight and Investigations began a review of federal programs
and resources devoted to mental health and serious mental
illness. Recent events have shown the continuing importance of
this inquiry, including the September 2013 Navy Yard shooting
just a couple of miles from where we sit this morning, in
Washington, D.C. Other tragic cases, like Seung-Hui Cho, James
Holmes, Jared Loughner, and Adam Lanza, all exhibited a record
of untreated severe mental illness prior to their crimes. It is
a reflection of the total dysfunction of our current mental
health system that despite clear warning signs, these
individuals failed to receive inpatient or outpatient treatment
for their illnesses that might have averted these tragedies.
And they all leave us wondering, what would have happened if--
--
What would have happened if Aaron Alexis was not just given
sleeping pills at the VA hospitals, or if there was hospital
bed or outpatient treatment available for others who later
became violent, involved in a crime, unable to pay their bills,
or tossed out on the street?
Part of the problem is that our laws on involuntary
commitment are in dire need of modernization. It is simply
unreasonable, if not a danger to public safety, that our
current system often waits until an individual is on the brink
of harming himself or others, or has already done so, before
any action can be taken. The scarcity of effective inpatient or
outpatient treatment options in the community, as illustrated
by the premature release of Gus Deeds, son of Virginia Senator
Creigh Deeds, from emergency custody because of the lack of
psychiatric hospital beds, is also to blame, and it is a sad,
sad ending. In our heart we cannot begin to imagine a parent's
grief when told there is no place for your son or daughter to
get help.
Nationwide, we face an alarming shortage in inpatient
psychiatric beds that, if not addressed, will result in more
tragic outcomes. This is part of the long-term legacy of
deinstitutionalization, the emptying out of State psychiatric
hospitals resulting from the financial burden for community-
based care being shifted from the State to the Federal
Government. With the deinstitutionalization, the number of
available inpatient psychiatric beds has fallen considerably.
The number of beds has decreased in the 1950s from 559,000 to
just 43,000 today. Back in the 1950s, half of every hospital
bed was a psychiatric bed. We needed to close those old
hospitals that had become asylums, lockups and, quite frankly,
they were dumping grounds.
But where did all the patients go? They were supposed to be
in community treatment. They were supposed to be on the road to
recovery. But for many, that simply did not happen.
The result is that individuals with serious mental illness
who are unable to obtain treatment through ordinary means are
in too many cases homeless or entangled in the criminal justice
system, including being locked up in jails or prisons.
Right now, the country's three largest jail systems in Cook
County, Illinois, Los Angeles County; and New York City have
more than 11,000 prisoners receiving treatment on any given day
and are, in fact, the largest mental health treatment
facilities in the country. These jails are many times larger
than the largest State psychiatric hospitals.
Not surprisingly, neither living on the streets nor being
confined to a high-security cellblock are known to improve the
chances that an individual's serious mental illness will
stabilize, let alone prepare them, where possible, for eventual
reentry into the community, to find housing, to find jobs, and
to find confidence in their future.
It is an unplanned, albeit entirely unacceptable
consequence of deinstitutionalization that the State
psychiatric asylums, dismantled out of concern for the humane
treatment and care of individuals with serious mental illness,
have now effectively been replaced by confinement in prisons
and homeless shelters and tied to hospital beds.
What can we do earlier in people's lives to get them
evidence-based treatment, community support, and on the road to
recovery, not the road to recidivism? Where is the humanity in
saying there are no beds to treat a person suffering from acute
schizophrenia, delusions, agitation, and aggression and what
they are offered is sedation and being restrained in ER
hospital bed for days?
This morning, to provide some perspective on the far-
reaching implications of the current psychiatric bed shortage
and to hear some creative approaches to address it, we will be
receiving testimony from individuals with a wealth of
experience across the full range of public services consumed by
the seriously mentally ill across our Nation. These include
Lisa Ashley, the mother of a son with serious mental illness
who has been boarded multiple times at the emergency
department; Dr. Jeffrey Geller, a psychiatrist and co-author of
a report on the trends and consequences of closing public
psychiatric hospitals; Dr. Jon Mark Hirshon, an ER physician
and Task Force Chair on a recent study of emergency care
compiled by the American College of Emergency Physicians; Chief
Mike Biasotti, immediate past President of the New York State
Association of Chiefs of Police and parent of a daughter with
serious mental illness; Sheriff Tom Dart, of the Cook County,
Illinois, Sheriff's Office, who oversees one of the largest
single site county pre-detention facilities in the United
States; the Hon. Steve Leifman, Associate Administrative Judge,
Miami-Dade County Court, 11th Judicial Circuit of Florida;
Gunther Stern, Executive Director of Georgetown Ministry
Center, a shelter and clubhouse caring for Washington D.C.'s
homeless; Hakeem Rahim, a Mental Health Educator and Advocate;
LaMarr Edgerson, a Clinical Mental Health Counselor and
Director at Large of the American Mental Health Counselors
Association; and Dr. Arthur Evans, Jr., Commissioner of
Philadelphia's Department of Behavioral Health and Intellectual
DisAbility Services. I thank you all for being with us this
morning and giving us so much of your time.
[The prepared statement of Mr. Murphy follows:]
Prepared statement of Hon. Tim Murphy
Right after the December 14, 2012 elementary school
shootings in Newtown, Connecticut, the Subcommittee on
Oversight and Investigations began a review of federal programs
and resources devoted to mental health and serious mental
illness.
Recent events have shown the continuing importance of this
inquiry, including the September 2013 Navy Yard shooting just a
couple of miles from where we sit this morning, in Washington,
D.C.
Other tragic cases, like Seung-Hui Cho, James Holmes, Jared
Loughner, and Adam Lanza, all exhibited a record of untreated
severe mental illness prior to their crimes. It is a reflection
of the total dysfunction of our current mental health system
that despite clear warning signs, these individuals failed to
receive inpatient or outpatient treatment for their illnesses
that might have averted these tragedies.
They all leave us wondering what would have happened if.
What would have happened if Aaron Alexis was not just given
sleeping pills at the VA? Or if there was an available hospital
bed or outpatient treatment available for others who later
became violent, involved in a crime, unable to pay bills, or
tossed out on the street?
Part of the problem is that our laws on involuntary
commitment are in dire need of modernization--it is simply
unreasonable, if not a danger to public safety, that our
current system often waits until an individual is on the brink
of harming himself or others, or has already done so, before
any action can be taken. The scarcity of effective inpatient or
outpatient treatment options in the community, as illustrated
by the premature release of Gus Deeds, son of Virginia senator
Creigh Deeds, from emergency custody because of the lack of
psychiatric beds, is also to blame. A sad ending that in our
heart we cannot begin to imagine a parent's grief when told
there is no place for your son to get help.
Nationwide, we face an alarming shortage in inpatient
psychiatric beds that, if not addressed, will result in more
tragic outcomes. This is part of the long-term legacy of
deinstitutionalization, the emptying out of state psychiatric
hospitals resulting from the financial burden for
communitybased care being shifted from the state to the federal
government. With deinstitutionalization, the number of
available inpatient psychiatric beds has fallen considerably.
On the whole, the number of beds has decreased from 559,000 in
the 1950s to just 43,000 today. We needed to close those old
hospitals that had become asylums, lock-ups, and dumping
grounds.
But where did all the patients go? They were supposed to be
in community treatment--on the road to recovery--but for many
that did not happen.
The result is that individuals with serious mental illness
who are unable to obtain treatment through ordinary means are
now homeless or entangled in the criminal justice system,
including being locked up in jails and prisons.
Right now, the country's three largest jail systems--in
Cook County, Illinois; Los Angeles County; and New York City--
have more than 11,000 prisoners receiving treatment on any
given day and are, in fact, the largest mental health treatment
facilities in the country. These jails are many times larger
than the largest state psychiatric hospitals.
Not surprisingly, neither living on the streets nor being
confined to a high-security cellblock are known to improve the
chances that an individual's serious mental illness will
stabilize, let alone prepare them, where possible, for eventual
reentry into the community, to find housing, jobs, and
confidence for their future.
It is an unplanned, albeit entirely unacceptable
consequence of deinstitutionalization that the state
psychiatric asylums, dismantled out of concern for the humane
treatment and care of individuals with serious mental illness,
have now effectively been replaced by confinement in prisons
and homeless shelters.
What can we do earlier in people's lives to get them
evidence-based treatment, community support, and on the road to
recovery not recidivism?
Where is the humanity in saying there are no beds to treat
a person suffering from schizophrenia, delusions, and
aggression so we will sedate you and restrain you to an ER bed
for days?
This morning, to provide some perspective on the far-
reaching implications of the current psychiatric bed shortage
and to hear some creative approaches to address it, we'll be
receiving testimony from individuals with a wealth of
experience across the full range of public services consumed by
the seriously mentally ill. These include:
Lisa Ashley, the mother of a son with serious
mental illness who has been boarded multiple times at the
emergency department;
Dr. Jeffrey Geller, a psychiatrist and co-author
of a report on the trends and consequences of closing public
psychiatric hospitals;
Dr. Jon Mark Hirshon, an ER physician and Task
Force Chair on a recent study of emergency care compiled by the
American College of Emergency Physicians;
Chief Mike Biasotti, Immediate Past President of
the New York State Association of Chiefs of Police and parent
of a daughter with serious mental illness;
Sheriff Tom Dart, of the Cook County, IL Sheriff's
Office, who oversees one of the largest single site county pre-
detention facilities in the U.S.;
The Honorable Steve Leifman, Associate
Administrative Judge, Miami-Dade County Court, 11th Judicial
Circuit of Florida;
Gunther Stern, Executive Director of Georgetown
Ministry Center, a shelter and clubhouse caring for Washington
D.C.'s homeless;
Hakeem Rahim, a mental health educator and
advocate;
LaMarr Edgerson, a clinical mental health
counselor and Director at Large of the American Mental Health
Counselors Association; and
Dr. Arthur Evans, Jr., Commissioner of
Philadelphia's Department of Behavioral Health and Intellectual
DisAbility Services.
I thank them all for joining us this morning.
# # #
Mr. Murphy. I would now like to give the ranking member an
opportunity to deliver brief remarks of her own. Ms. DeGette.
OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thank you very much, Mr. Chairman. I want to
thank you for having this hearing and also for your continued
leadership on the important topic of mental health. I want to
thank all of the witnesses for appearing before us today. I
think this sets a record as the biggest panel we have ever had
in this subcommittee, and I am looking forward to hearing each
one of your perspectives. It is rare we ever get so much
knowledge and such a breadth gathered in one place.
Mr. Rahim, I am especially glad that you are here with us
this morning. This is our fourth hearing in this subcommittee
on mental health during this Congress, but this is the first
time we have ever heard directly from somebody who can share
his own personal history with mental illness and sit before us
as a testament to the possibility of recovery. I know it takes
a lot of courage to tell these personal stories in public, and
I want to commend you for being here.
I also want to commend Ms. Ashley and Mr. Biasotti for
being here today as parents because I have been approached by
so many parents in my district who know that I am working on
these issues, talking to me about the heartbreak of having
young adults or teenagers who are dealing with these issues and
what it is like as a family member. All of you can add really
good perspective to this, and I want to thank you.
The question for this hearing, where have all the patients
gone, is a very important one. Individuals with serious mental
illnesses like bipolar disorder or schizophrenia are showing up
in emergency rooms, encountering the criminal justice system
and becoming homeless far too often. One reason why this
problem is getting worse is because of budget cuts for mental
health and addiction services at the State and local level. The
American Mental Health Counselors Association reported that
between 2009 and 2012, States have cut nearly $5 billion in
mental health services.
Mr. Chairman, I am concerned about the impact of these
cuts, and I hope that we can address them today, and also as we
continue our joint efforts to work towards comprehensive mental
health legislation, how we can address these cuts because, to
be honest, if there are no beds for folks to go to, then
anything we can do is going to be useless, and so we are going
to have to work with State and local governments to figure out
how to fund the appropriate amount of beds that we need.
It is also important to address the issue of patients with
mental illnesses showing up in the ER, which we all know is
less effective and more expensive to receive treatment than
other alternatives, but I do think if these folks do show up in
the ER, there are ways to improve the way they are treated
there.
But I also want to focus our attention on an even more
important question: how can we keep people with serious mental
illness out of the emergency room in the first place? When
people show up in the ER, it means that they have reached a
crisis point and that represents a broader failure of our
mental health system in this country. Our goal should be
preventing crises from arising in the first place by investing
in approaches to identify the early signs and symptoms of
mental illness and to make sure that patients have quality
health insurance and can get timely and effective mental health
treatment and support services, and I will bet you every single
provider, parent and patient in this room would agree with what
I just said.
I don't want to downplay the concerns about the lack of
inpatient beds for patients who need them. Despite our best
efforts, there still will be instances where more intensive
interventions are needed. But I hope that we can agree that
these should be exceedingly rare occurrences and that having
more inpatient beds is only a partial solution. The benefits
provided by the Mental Health Parity and Addiction Equity Act
and the Affordable Care Act will help prevent these ER crises
if implemented correctly. They will provide millions of
Americans with access to quality, affordable health insurance
that includes coverage for mental health services. We need to
build from these laws to support the continuum of mental health
services at all levels of government, and I must say, I was
very proud that we were able to include mental health parity in
the Affordable Care Act. This will be very important for
patients.
We also need to remember that recovery, even for
individuals living with serious mental illness, is possible, or
certainly at least management. Mr. Rahim is proof that
individuals with access to the right range of services not only
can we greatly reduce the number of individuals in crisis
winding up in prisons or emergency rooms but we can produce
hardworking, contributing members of society as well. As well
as your bill that you have introduced, Mr. Chairman, there is a
lot of other legislation out there, and I know we intend to
continue working together to try to have some kind of
comprehensive legislation that will begin to address all of
these issues.
Thank you so much, Mr. Chairman.
Mr. Murphy. I thank the gentlelady for her comments, and
yes, we will continue to work together.
I now recognize the gentlelady from North Carolina, Mrs.
Ellmers, if you want to make an opening statement.
Mrs. Ellmers. Thank you, Mr. Chairman. I just want to make
a brief statement, especially due to the size of our panel, and
I am very anxious to hear from all of you on these issues.
You know, I served as a nurse for 21 years before coming to
Congress, and there is nothing that is more heartbreaking than
when you see a situation of mental illness and a family who is
struggling to deal with that. I just want to say thank you to
all of you. I want to take that opportunity because you coming
forward will help us to finally deal with the situation, and it
is a multifaceted situation and we all have to come together.
This is not a political one, this is not one that we can't
reach across the aisle and work together on.
So thank you to all of you, and God bless all of you.
Mr. Murphy. The gentlelady yields back. Anybody on this
side want any more of the remaining time? If not, we will now
recognize the ranking member of the full committee, Mr. Waxman,
for an opening statement, 5 minutes.
OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Mr. Waxman. Thank you very much, Mr. Chairman.
Today's hearing addresses an important issue affecting
treatment and outcomes for patients with mental illnesses. We
will hear today that budget cuts and other factors have
resulted in a lack of inpatient beds for intensive psychiatric
treatment, meaning that patients with serious mental illness
who show up to the emergency room at a crisis point are forced
to wait far too long, for days at a time, for an inpatient
psychiatric bed.
This is a growing problem, but it is not a new one. A
decade ago, as ranking member of the Oversight Committee, I
released a report finding that all too often, jails and
juvenile detention facilities have had to provide care for
individuals with mental illnesses. This report found that due
to lack of available treatment, youth with serious mental
disorders were placed in detention without any criminal charges
pending against them. In other cases, youth who had been
charged with crimes but who had served their time or were
otherwise able to be released remained incarcerated for
extended periods of time because no inpatient bed, residential
placement or outpatient appointment was available. That
investigation found that two-thirds of juvenile detention
facilities were holding youth waiting for mental health
treatment, and that in one 6-month period, nearly 15,000
incarcerated youth were waiting for mental health services.
Mr. Chairman, I share your desire to end these practices.
That is why I supported the Affordable Care Act, which provides
health insurance coverage, including coverage for mental
illness, to millions of Americans, and that is why I have
opposed Republican efforts to repeal this law and take this
coverage away. It is also why I hope that this hearing does not
ignore the elephant in the room: the impact on millions of
Americans with mental illnesses of the failure by 24 States to
expand their Medicaid programs under the Affordable Care Act.
Last month the American Mental Health Counselors
Association released a new study titled ``Dashed Hopes, Broken
Promises, More Despair,'' and I would like to ask that this
report be made part of the hearing record.
Mr. Murphy. Without objection, yes, it will be included.
[The information appears at http://docs.house.gov/meetings/
if/if02/20140326/101980/hhrg-113-if02-20140326-sd004.pdf.]
Mr. Waxman. Dr. Edgerson is here today to testify on behalf
of the organization, and I appreciate him joining us.
The report found that the failure by states to expand their
Medicaid programs is causing nearly four million people who are
in serious psychological distress or have a serious mental
illness or substance disorder to go without health insurance.
That is four million Americans in need who are left without
coverage, largely because of Republican governors' ideological
obsession with rejecting everything associated with the
Affordable Care Act.
Mr. Chairman, this includes over 200,000 people with mental
illnesses in your home State of Pennsylvania.
The report described the impact of this lack of coverage,
finding that ``The lack of health insurance coverage keeps
people with mental illness from obtaining needed services and
treatments and follow-up care with the goal of achieving long-
term recovery and quality of life.''
This is a tragedy and a shame. If these four million
Americans obtained coverage, they would receive better ongoing
treatment and care, and they would be less likely to end up in
a hospital emergency room, or worse, a prison, with a mental
health crisis.
Mr. Chairman, I know you want to help individuals with
mental illnesses. We have both introduced mental health
legislation, and I hope that as we move forward, we can find
common ground with these bills.
But the biggest and easiest step we can take to improve
care for those with serious mental illnesses is to make sure
they have health insurance. The Medicaid expansion is a good
deal for the states, and it is desperately needed by millions
of Americans. This committee should be working together to make
sure that regardless of where they live, Americans in all 50
states can obtain this coverage.
I yield back the balance of my time.
Mr. Murphy. The gentleman yields back. Thank you.
I also have a letter from the National Association of
Psychiatric Health Systems, also commenting on this topic today
of psychiatric beds, and so I ask without objection to include
that in the record as well.
[The information appears at the conclusion of the hearing.]
Mr. Murphy. I have already introduced all of our witnesses
today, so I am now going to swear you in. So you are aware, the
committee is holding an investigative hearing, and we have the
practice of taking testimony under oath. Do any of you object
to taking an oath? All right. The Chair then advises you that
under the rules of the House and the rules of the committee,
you are entitled to be advised by counsel. Do any of you desire
to be advised by counsel during your testimony today? It
shouldn't be an issue. Thank you. In that case, if you would
please rise and raise your right hand, and I will swear you in.
[Witnesses sworn.]
Mr. Murphy. You may now sit down, and you are under oath
and subject to the penalties set forth in Title XVIII, section
1001 of the United States Code. We will now recognize each of
you to give a 5-minute opening statement.
I recognize first Ms. Ashley. Make sure your microphone is
on and it is pulled close to you. Thank you.
TESTIMONY OF LISA ASHLEY, PARENT OF A SON WITH SERIOUS MENTAL
ILLNESS, SACRAMENTO, CALIFORNIA; JEFFREY L. GELLER, M.D.,
M.P.H., PROFESSOR OF PSYCHIATRY AND DIRECTOR OF PUBLIC SECTOR
PSYCHIATRY, UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL,
WORCESTER, MASSACHUSETTS; JON M. HIRSHON, M.D., M.P.H., PH.D.,
FACEP, TASK FORCE CHAIR, 2014 AMERICAN COLLEGE OF EMERGENCY
PHYSICIANS NATIONAL REPORT CARD ON EMERGENCY CARE, AND
ASSOCIATE PROFESSOR, DEPARTMENT OF EMERGENCY MEDICINE,
UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE, BALTIMORE, MARYLAND;
MICHAEL C. BIASOTTI, CHIEF OF POLICE AND IMMEDIATE PAST
PRESIDENT OF NEW YORK STATE ASSOCIATION OF CHIEFS OF POLICE,
AND PARENT OF A DAUGHTER WITH SERIOUS MENTAL ILLNESS, NEW
WINDSOR, NEW YORK; THOMAS J. DART, SHERIFF, COOK COUNTY
SHERIFF'S OFFICE, CHICAGO, ILLINOIS; STEVE LEIFMAN, ASSOCIATE
ADMINISTRATIVE JUDGE, MIAMI-DADE COUNTY COURT, ELEVENTH
JUDICIAL CIRCUIT OF FLORIDA, MIAMI, FLORIDA; GUNTHER STERN,
EXECUTIVE DIRECTOR, GEORGETOWN MINISTRY CENTER, WASHINGTON,
D.C.; HAKEEM RAHIM, ED.M., M.A., SPEAKER AND MENTAL HEALTH
EDUCATOR AND ADVOCATE, HEMPSTEAD, NEW YORK; LAMARR D. EDGERSON,
PSY.D., LMFT, NBCCH, CLINICAL MENTAL HEALTH COUNSELOR, DIRECTOR
AT LARGE, AMERICAN MENTAL HEALTH COUNSELORS ASSOCIATION, FAMILY
HARMONY, ALBUQUERQUE, NEW MEXICO; AND ARTHUR C. EVANS, JR.,
PH.D., COMMISSIONER, DEPARTMENT OF BEHAVIORAL HEALTH AND
INTELLECTUAL DISABILITY SERVICES, UNIVERSITY OF PENNSYLVANIA,
PHILADELPHIA, PENNSYLVANIA
TESTIMONY OF LISA ASHLEY
Ms. Ashley. Hello, and good morning, Mr. Chairman and
members of the subcommittee. Thank you for inviting me here to
tell my son's story with the emergency room department in my
vicinity.
I am a Nurse Practitioner with a master's degree. I have
been in pediatric practice for 38 years, but that is not why I
am here today. I am here as a mother of a son who is now 27 and
diagnosed with paranoid schizophrenia 2 years ago. It has been
a long and difficult story which I share with many parents.
My son was about 20 or 21 years old when I knew something
was wrong but it wasn't until he went homeless when he was in
L.A. and went missing for 3 weeks that I knew for sure. Of
course he saw nothing wrong. When I was finally able to locate
him, I brought him back to Sacramento. He was delusional,
thinking the FBI was watching him, there were satellites in the
sky monitoring his thoughts, having auditory hallucinations,
could not have a conversation, laughing to himself, and not
caring for his hygiene. Prior to this, my son was extremely
bright, received 740 out of 800 on his math SATs, and was
accepted to seven universities for mechanical engineering. His
bizarre behavior went on for months but he refused to see a
psychiatrist. He was bonded to his primary medical provider,
who saw him several times trying to get him on a hold. I felt
helpless and extremely frustrated. Even calling the police did
not help because they did not feel that he was a harm to
himself or others.
I am specifically going to tell a story regarding his
hospital emergency department stays three times over a 2-year
period. Each time, I struggled with pain and anguish to see my
beautiful son taken into custody, especially for the first
time, because he didn't know how sick he was and how very
confused as to why he could not go home with me, and I cried my
heart out.
The first time was in May 2012. He had been sick over a
year before I was able to get him some help. His first time in
the emergency room was approximately 12 hours. I couldn't
believe they had to hold him there that long, not knowing there
was a shortage of psych beds in the county. He was then
transferred to a psych facility locally and remained 2 weeks,
just as long as my insurance would allow him. Although it was
very difficult to have my son hospitalized, I know he was in
good hands and it relieved some of my anxiety, but still, it
was nothing like I had ever been through and having to trust a
system that was so foreign to you and difficult, I worried
every minute.
The second time was not quite as smooth. In January of
2013, my son asked voluntarily to be taken to the hospital
because his head felt like it was on fire. He was anxious and
very distressed. I dropped everything, knowing that he was
asking to go, he must have felt pretty bad. I brought him to
the same emergency room that morning, we reached the triage
nurse. I identified myself as an employee and a nurse
practitioner. I explained my son was a paranoid schizophrenic
and he was in psychosis. I tried to remain calm as the triage
nurses took his blood pressure and temperature and then
assigned him to a gurney in the hallway with at least eight
other patients, which included children, all waiting to be seen
by a doctor. It was not long before my son started to get
agitated and wanting to leave. The R.N. called the social
worker to help intervene. She could not quiet him down. As he
tried to approach the exit, the emergency room policeman tried
to stop him by holding him back. His behavior escalated. My son
was screaming at him not to touch him. When schizophrenics are
in psychosis, they do not want to be touched. In front of all
the children and adults waiting in the hallway, the police
officer wrestled him to the ground and handcuffed him.
I tell you this because I brought him to the hospital for
medical treatment, not for police handcuffing him, and their
intervention escalating his psychosis made it worse. If he had
been able to go to some kind of psych facility, he would have
gotten medical attention rather than police detention. Doctors
would have known how to deal with him, calm him down, isolate
him from others. The emergency room is not a quiet place and
they are not trained to deal with psychiatric illnesses and
certainly not serious mental illness.
They then placed him on a gurney and put him in four-point
restraints and then medicated him. He was there on a Friday
morning the whole day, all day Saturday, all day Sunday and all
day Monday afternoon because they could not find a psych bed
anywhere. He stayed in a room tied to his bed for four days,
heavily medicated. Seeing him helpless tied to a bed for days
was like a nightmare. This was my son, and I was helpless
except to keep him company and try to reassure him things would
be all right. I was angry they couldn't find him a place. Does
it really take that long to find a psych bed?
Finally, on Monday, I was told there was an opening at a
hospital in San Francisco, which is 100 miles east of
Sacramento. They finally took him there later that day. I was
unable to be involved in his care because he was so far away
except for weekends. It was very frustrating. I didn't
understand why he needed to go so far away from his family
member, who cared for him and loved him.
By the way, if I hadn't had private insurance, he never
would have gone to that hospital because they don't accept
public monies, so because I had private insurance, they took
him. Otherwise, who knows? He might still be there.
The third time was in November. Again, his head was burning
and voices were screaming at him. I took him back to the
hospital. They put him on a gurney in the hallway again. I was
able to be proactive and talk with other providers prior to
this, and set up a plan so that the second intervention would
never, ever happen to him again. I was able to make some phone
calls, and after two days get him into a local psych facility,
where he stayed another 3 days.
My son is fairly stable since that time in November. He has
not required any additional hospitalization but he attends
regular psychiatric visits and takes his medications regularly,
and I pray every day that he continues to stay out of the
emergency room because there are no other alternatives for him.
Thank you.
[The prepared statement of Ms. Ashley follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Ms. Ashley. I appreciate your moving
testimony.
I forgot to mention at the time to keep your comments to 5
minutes, so if you hear my gavel tapping, that is why.
Doctor, you are next.
TESTIMONY OF JEFFREY L. GELLER
Dr. Geller. Mr. Chairman, Representatives, ladies and
gentlemen, good morning. I am Dr. Jeffrey Geller, a board-
certified psychiatrist, currently Professor of Psychiatry at
the University of Massachusetts Medical School, Medical
Director of the Worcester Recovery Center and Hospital, and
Staff Psychiatrist at the Carson Community Mental Health
Center.
I have consulted public mental health systems and State
hospitals in one-half of the States in the United States, the
District of Columbia and Puerto Rico. I am the author of 250
publications in the professional literature, and the book,
``Women of the Asylum.'' I serve on many professional boards
but I come here today representing only my own experience
taking care of patients with serious mental illness for 40
years.
Just yesterday, there were 22 psychiatric patients in a
general hospital emergency room in a city of 150,000 not far
from here waiting for disposition. Why? What is to be done?
On May 3, 1854, President Franklin Pierce vetoed a bill
that would have made the Federal Government responsible for
America's population with serious mental illness. His veto
message includes the following beliefs of his: State hospitals
or public psychiatric hospitals are meritorious institutions
doing good. They fulfill a historic role belonging to the
States, meeting the needs of a population outside the purview
of the Federal Government and susceptible to becoming the
responsibility of the Federal Government if the Federal
Government provided any opportunity to the States to shift the
burden.
The Federal Government left the care of the serious
mentally ill to the states until Congress passed and President
Kennedy signed the Mental Retardation Facilities and Community
Mental Health Centers Construction Act of 1963. From then until
now, federal actions such as Medicaid, Medicare, the IMD
exclusion and many others have resulted in the unintended
consequences of massive proportions, not the least of which is
deinstitutionalization. We created the perfect formula for the
current debacle: an expanding array of fiscal incentives for
States to move people out of state hospitals, inadequate
resources to meet the needs of State residents with serious
mental illness in the community, no beds in State hospitals to
meet the needs of former State hospital patients, who did not
find the community the panacea promised by the Supreme Court
and were dangerous outside of hospitals, no beds to meet the
needs of new cases of serious mental illness requiring a
hospital level of care, and a public more willing to build
jails and prisons than hospitals because they found no solace
in a state system they saw as pushing ill-prepared folks with
mental illness into their neighborhoods.
How did this lead to individuals waiting in hospital
emergency departments, or EDs, for weeks, sometimes a month?
Pick any State. There are no available beds in the State's
public psychiatric hospitals because there are too few beds. A
patient on the psychiatric unit in a general hospital has been
approved for transfer to the State hospital but cannot be
transferred because there is no available bed. Thus, the
general hospital psychiatric unit is populated by some patients
who are stuck there awaiting state hospital transfer. An
individual is brought to the general hospital's emergency
department by police, family, ambulance, or comes on her own.
The individual was assessed and determined to need
hospitalization. The individual cannot be admitted to the
psychiatric unit in the same hospital as the emergency
department because there are no beds there.
What happens next is, a hospital emergency department staff
or a member of a contracted crisis team starts a bed search. A
bed search means calling every hospital in the State seeking a
bed. Frequently, the bed search is fruitless. There are no beds
available anywhere because all the hospitals are in the same
situation as the psychiatric unit in the hospital the worker is
calling from. So the individual remains in the emergency
department waiting for an available bed. The days waiting
benefit no one. The ED becomes overcrowded. The patient is a
patient in name only. He is not getting treatment except that
he is receiving food, a bed or gurney, and maybe some
medication. He might as well be waiting on a bench in a train
station. Or the individual is simply released from the
emergency department because there is no place else for her to
go. The threshold for holding somebody in the emergency
department awaiting admission keeps creeping up. Many released
folks are picked up by the police, processed through the
courts, sent to the State hospital for a forensic evaluation,
further decreasing available beds to the person awaiting a bed
in the emergency department.
Congress can enact measures to ameliorate the problems of
boarders in emergency departments. These include: provide
States with opportunities to obtain IMD exclusion waivers with
maintenance of effort; make SSI and SSDI payments to eligible
individuals independent of where they reside and require their
contribution for room and board to be the same in all locations
including jails and prisons; individuals keep their Medicaid
and Medicare in all settings. Improve the federal grant process
for research into prevention and early intervention; provide
grants to States to create or expand crisis intervention teams
so that such a program is available in every city and town; set
fair and reasonable Medicaid payment rates for psychiatric
services at community mental health centers and Federally
Qualified Health Centers; incentivize States to actually use
the assisted outpatient treatment statutes they have; define
Medicaid and Medicare payments to clubhouses in ways that do
not destroy the mission of clubhouses; incentivize States to
establish mental health courts.
Mr. Chairman, Representatives, it is time the Federal
Government took explicit action through bipartisan, bicameral
efforts to remedy the calamitous state of the public care and
treatment of persons with serious mental illness in the United
States today.
Thank you.
[The prepared statement of Dr. Geller follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Doctor.
Dr. Hirshon, you are recognized for 5 minutes.
TESTIMONY OF JON M. HIRSHON
Dr. Hirshon. In emergency departments throughout the
country, we emergency physicians expect the unexpected. This is
what we are trained to do. Even so, there is one thing that we
all know is happening: increasing demand by patients in need of
acute psychiatric care.
Mr. Chairman and members of the subcommittee, thank you for
this opportunity to testify today on behalf of the American
College of Emergency Physicians. ACEP is the largest specialty
organization in emergency medicine with more than 32,000
members in all 50 States and the District of Columbia.
My purpose today is to help you understand that we are in
the midst of a national crisis, facing a dramatic increase in
vulnerable mental health patients seeking emergent and urgent
care. America's mental health services are experiencing
increasing demand while concurrently receiving decreased
funding, which drives psychiatric patients to the ED, or
emergency department.
In 2000, psychiatric patients to the ED accounted for only
5.4 percent of all ED visits, but by 2007, that number had
risen to 12.5 percent, well over a doubling of the number of
psychiatric patients. Until more services and funding are made
available to address this crisis, EDs will be the safety net
for these patients. This is due in large part to the federal
Emergency Medicine Treatment and Labor Act, EMTALA, which
mandates medical screening evaluation and stabilization for
anyone seeking care in an ED. Additionally, unlike many other
health care settings, EDs are open 24 hours a day, 7 days a
week every day of the year.
Emergency physicians do their best to provide care to
patients with psychiatric conditions but the ED is not the
ideal location for these services. ED crowding leads to delays
in care and have been associated with poor clinical outcomes.
For patients with mental health and/or substance abuse
problems, prolonged ED stays are associated with increased risk
of worsening symptoms. Without available appropriate inpatient
resources for admitted patients, these patients wait or are
boarded in the ED until an inpatient bed becomes available or
an accepting facility can be found.
When the normal capacity of the ED is overwhelmed with
boarded patients, there remains absolutely no room for surge
capacity, which would be critical in the event of a manmade or
natural disaster.
In a recent ACEP survey, 99 percent of emergency physicians
reported admitting psychiatric patients daily while 80 percent
said that they were boarding psychiatric patients in their EDs.
Acutely ill psychiatric patients require more physician, more
nurse and more hospital resources. ED staff spends more than
three times as long looking for a psychiatric bed as they would
for a non-psychiatric patient.
Other factors contribute to the extended ED boarding times
for psychiatric patients including defensive medicine or threat
of legal action, required preauthorization for inpatient
services, medical clearance prior to psychiatric evaluation,
substance abuse-related issues, and inadequate outpatient
services. As communities have seen, many of these issues are
systems issues and beyond the control of the clinician. It is
imperative that access to high-quality inpatient and community
mental health care be a priority.
I go into further detail on suggested solutions in my
written testimony but some important ones include full capacity
protocols to improve the movement of admitted patients to
inpatient floors, separate psychiatric ED and behavioral health
annexes to help address urgent and emergent psychiatric needs,
regionalized care and telemedicine to help efficiently and
effectively address increasing demand, as well as the
elimination of out-of-network insurance issues and community
and State mental health buy-in.
Let me leave you with this: the increasing burden of mental
illness in this country combined with a lack of resources to
care for these individuals is a national crisis. Mass
deinstitutionalization of mental health patients over the past
few decades did not result in successful community integration
of individuals needing psychiatric services, in part because
the necessary services and funding were not put in place for
adequate community support.
Systematic changes are needed in the way we care for these
individuals with mental illness in this country. How we deal
with these vulnerable individuals is an important measure of
who we are as a society. Necessary resources must be made
available for additional inpatient and outpatient treatment
beds with the corresponding professional staff as well as for
critically needed research. Otherwise mental health services
will continue to deteriorate and these individuals, often our
family members, will continue to be at risk for abuse and
neglect, seeking care in EDs for lack of any other support.
I thank you for your attention to this alarming problem.
[The prepared statement of Dr. Hirshon follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Doctor.
Chief Biasotti, you can pull that microphone right up next
to you, please. Thank you.
TESTIMONY OF MICHAEL C. BIASOTTI
Chief Biasotti. Good morning, Chairman Murphy and Ms.
DeGette. I am the immediate past President of the New York
State Association of Chiefs of Police and Chief of Police in
New Windsor, New York. I am in my 38th year of service.
My wife, Barbara, who is a psychologist, is here today with
me. We have a daughter with schizophrenia who has been
involuntarily hospitalized in excess of 20 times. Barbara and I
met when she, like many moms, turned to the police for help
when her, now our daughter became psychotic, disruptive and
threatening. She was self-medicating, unemployed and
deteriorating, despite my wife's heroic efforts to help her.
Then she went into assisted outpatient treatment. It saved her
life.
In 2011, while at the United States Naval Postgraduate
School's s Center for Homeland Defense and Security, I
published a survey of over 2,400 senior law enforcement
officers titled ``Management of the Severely Mentally Ill and
its Effects on Homeland Security.'' It found that the mentally
ill consume a disproportionate percentage of law enforcement
resources. Many commit low-level crimes. One hundred and sixty
thousand attempt suicide, 3 million become crime victims, and
164,000 are homeless each year.
The survey essentially found that we have two mental health
systems today, serving two mutually exclusive populations.
Community programs serve those who seek and accept treatment.
Those who refuse, or are too sick to seek voluntary treatment,
become law enforcement responsibilities. Officers in the survey
were frustrated that mental health officials seemed unwilling
to recognize or take responsibility for this second more
symptomatic group. Ignoring them puts patients, the public and
police at risk and costs more than keeping care within the
mental health system.
As an example, there are fewer than 100,000 mentally ill in
psychiatric hospitals but over 300,000 in jails and prisons.
The officers I surveyed pointed out the drain on resources it
takes to investigate, arrest, fill out paperwork and
participate in the trials of all of them. Add to that the
sheriffs, district attorneys, judges, prisons, jails and
corrections officers it takes to manage each of them and you
see the scope of the problem.
Many more related incidents, like suicides, fights and
nuisance calls take police time, but don't result in arrest or
incarceration. Overly restrictive commitment standards and the
shortage of hospital beds are major sources of frustration for
officers. Hospitals are so overcrowded they often can't admit
new patients and discharge many before they are completely
stable. They become what we call round trippers or frequent
flyers. One officer referred to it as a human catch and release
program. Anyone who asks for help is generally not sick enough
to be admitted, so involuntary admission, that is, being a
danger to self or others, becomes the main pathway for
treatment. Officers are called to defuse situations and then
have to drive in some cases hours to transport individuals to
hospitals and then wait hours in the emergency rooms, only to
find the hospital refuses admission because there are no beds
or that the commitment standard is so restrictive. The only
remaining solution for our officers is to arrest these people
with serious mental illness for whatever minor violation
exists, something that they are loathe to do to sick people who
need medical help, not incarceration.
Finally, while everyone knows that everyday mental illness
is not associated with violence, untreated serious mental
illness clearly is. The officers in the survey deal with that
reality every day. You in Congress dealt with it when Ronald
Reagan and Gabrielle Giffords were shot; two guards in the
Capitol building were killed, and the Navy Yard shooting
happened. Representatives DeGette, Gardner and Griffith have
experienced the worst of the worst in their States.
We have to stop pretending that violence is not associated
with untreated serious mental illness. We have to stop
pretending that everyone is well enough to volunteer for
treatment and then self-direct their own care; some clearly are
not.
As I wrote in the intro to the survey, police and sheriffs
are being overwhelmed dealing with the unintended consequences
of a policy change that in effect removed the daily care of our
Nation's severely mentally ill population from the medical
community and placed it with the criminal justice system. This
policy change has caused a spike in the frequency of arrests of
severely mentally ill persons, prisons, and jail populations as
well as the homeless population and has become a major consumer
of law enforcement resources nationwide.
If I could make one recommendation, it would be to prevent
individuals from deteriorating to the point where law
enforcement becomes involved. Return care and treatment of the
most seriously ill back to the mental health system. Make the
seriously mentally ill first in line for services rather than
last. As a law enforcement officer and a father, I know that
treatment before tragedy is a far better policy than treatment
after tragedy.
Thank you so much.
[The prepared statement of Chief Biasotti follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Chief.
Mr. Dart, you are recognized for 5 minutes.
TESTIMONY OF THOMAS J. DART
Sheriff Dart. Thank you, Mr. Chairman and the committee,
for having me here today.
I am the Sheriff of Cook County, and as the Sheriff, I run
the Cook County Jail, which is the largest single site jail in
the country. My office is in the jail. Our average daily
population is between 10,000 to 12,000 inmates and it costs
about $143 a day to house someone there.
Since becoming Sheriff in 2006, I have seen an explosion in
the percentage of seriously mentally ill individuals housed in
the jail. I have seen firsthand the devastating impact cuts to
mental health programs and services have had on the mentally
ill in Illinois. This is a crisis we must all care about
because it affects all of us. I find it ironic that in the
1950s we thought it was inhumane to house people in state
hospitals but now in the 21st century we are OK with them being
in jails and prisons.
On any given day, an average of 30 to 35 percent of my
population suffers from a serious mental illness. The diagnoses
fall into two main categories: mood disorders such as major
depressive disorder or bipolar disorder, or a psychotic
disorder such as schizophrenia. While some mentally ill
individuals are charged with violent offenses, the majority are
charged with crimes seemingly committed to survive, including
retail theft, trespassing, prostitution and drug possession.
A cursory review of our statistics tells the story. Last
year in one of my living units, 1,265 men were in that dorm on
low-level drug-related offenses. The average length of stay was
87 days. At $143 a day, it costs over $12,000 just to house
these individuals pretrial because they cannot afford to post a
minimal bail or have nowhere to live. Many of these inmates
ultimately are sentenced to probation, more often than not, or
sentenced to time while they were sitting with me.
The unfortunate and undeniable conclusion is that because
of dramatic and sustained cuts in mental health funding, we
have criminalized mental illness in this country and county
jails and State prison facilities are where the majority of
mental health care and treatment is administered.
Three recent case studies illustrate this. J.J. was
arrested by the Chicago Police Department last May after a
failed attempt to steal sheets or towels from a local Walgreens
drug store. When we spoke to him shortly after his arrest, he
explained that he took the items off the shelf and as he walked
past the cashier and he asked her to charge him. He was
arrested and charged with retail theft. The value of the items
he stole were $29.99. He spent 110 days in my jail before being
sentenced to probation. During his custody, he was stabilized
on medication and received drug and mental health treatment.
The taxpayers of Cook County spent close to $16,000 after his
failed attempt to steal $29 worth of sheets.
J.D. suffers from a psychotic disorder and has visions that
terrify him. He was arrested in California on a warrant from my
county. While in custody in California, he removed one of his
eyeballs in an attempt to stop seeing his visions. He lost
sight in that eye. So we were alerted to this issue. He was
transferred to our custody 2 weeks ago and recently attempted
to remove his other eye. While staff acted quickly, we were
able to stop that from occurring. We presently have him where
he wears a helmet and face mask and has gloves on his hands.
T.A. was arrested over 100 times. Her most recent arrest
came after she attempted to steal $20 from a person's purse
during a church service. She is a chronic self-mutilator. She
attacks her arms with her own fingernails or any objects she
can find. To keep her safe while in our custody, we make
special mittens for her that go up to her armpits. Incredibly,
she was sentenced to a prison term and recently was transferred
to a state hospital. We are awaiting right now her imminent
return to Chicago. She has cost us, the taxpayers,
conservatively, over a million dollars for all of her custody.
What we have done in our county now is my staff interviews
every detainee before they appear in bond court regarding their
mental health history. Those who admit to a history are
identified for the public defender's office and then we make
efforts to try to appeal to the judges for alternative
programs. Unlike State prisoners who have fixed release dates,
pretrial detainees may be released at any time, which
significantly complicates our ability to provide discharge
planning. The inmates are offered written information on
available community resources and enrollment in County Care and
allowed access to a telephone to contact someone to arrange for
transportation home or to identified housing. If the inmate
requires discharge to a facility in the next day, we will
shelter them overnight before we will try to get them to a
hospital. If the inmate requires assistance with transportation
to his or her home or a shelter, we will drive them there. If
the inmate is stable, coordinated releases are typically
initiated by our health care provider and the steps are
followed. Additionally, we communicate with the party the
inmate is being released to. Once it is confirmed the party is
outside the jail, someone from our records unit will go out
there to make sure that person is there. The past practice
always had been, we released them out to the street where they
would wander around aimlessly for hours, if not days.
If the inmate is unstable and in need of psychiatric
hospitalization in the community, he or she is petitioned by a
licensed mental health professional. A certificate for
involuntary hospitalization is completed by psychiatrists and
accompanies the individual to the receiving hospital.
Finally, in August, I launched the Mental Health Help Line.
It is a 24-hour help line dedicated to assisting former
mentally ill detainees or families of mentally ill detainees.
The phone line is manned by members of my policy team and
supported by our mental health staff. It has been an invaluable
resource to the families who communicate with us through this
help line. We receive calls on this help line 24 hours a day, 7
days a week.
In conclusion, we are in an unsustainable position. I often
refer to the jail as the last car on a long train. Every single
day and at every step before a person comes in to the jail,
there is discretion: discretion to arrest, to charge and to set
bond. But as custodian, I am obligated to care for those
individuals. Every day I am faced with the mental health crisis
in this county and in the country. I see the pain of those
suffering from mental illness and the pain of their families
who have struggled to care for them and provide them with
resources. The question that plagues me, that keeps me up at
night, is where do we go from here?
As that question is debated, I will continue to do all I
can to care for, protect and advocate for increased funding to
address mental illness in our country and I will continue to
provide the best care I can for the mentally ill. This is truly
a crisis that we can no longer ignore.
Thank you.
[The prepared statement of Sheriff Dart follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Sheriff.
I now recognize Judge Leifman for 5 minutes.
TESTIMONY OF STEVE LEIFMAN
Mr. Leifman. Thank you very much, Mr. Chairman, members of
the subcommittee. My name is Steve Leifman. I am a Judge for
Miami-Dade County and I chair the Florida Supreme Court Task
Force on Substance Abuse, Mental Illness and Issues in the
Court.
You asked where have the patients gone. Sadly, the answer
is jail and prisons, and this is an American travesty. As you
already stated, in 1955 there were some 550,000 people in State
psychiatric hospitals around this country. If nothing had
changed and we use today's population, there would have been
about 1.5 million people in State psychiatric hospitals today.
Last year, 1.5 million people with serious mental illnesses
were arrested in this country. On any given day in the United
States, we have approximately 500,000 people with serious
mental illnesses in jails and prisons and another 850,000 in
the community on some type of community control or probation.
Since 1955, we have closed 90 percent of the hospital beds in
this country and we have seen a corresponding increase of 400
percent of the number of people going to jail with mental
illnesses, and because jails are not conducive to treatment and
courts do not know what to do with this population, people with
mental illnesses generally stay four to eight times longer in
jail than anyone else with the exact same charge who does not
have a mental illness and costs seven times more.
I had no idea that when I become a judge I was actually
becoming the gatekeeper to the largest psychiatric facility in
the State of Florida, and tragically, that is the Miami-Dade
County Jail. I see more people on any given day with mental
illness than most psychiatrists see in a month.
People with mental illnesses in this country are three
times more likely to be arrested than to be hospitalized, and
in my State, it is nine times more likely. The closing of the
hospitals is not the only and primary reason all these
individuals had ended up in hospitals. It is a combination that
created the perfect storm. It includes the IMD exclusion. It
includes what Medicaid pays for its services. It includes the
war on drugs. It includes the reduction of hospital beds. It
includes the antiquated involuntary hospital laws. They have
all conspired to create this perfect, perfect storm. And if
this wasn't bad enough, just listen to the costs this is having
to our communities.
We worked with the Florida Mental Health Institute at the
University of South Florida and Tampa. We wanted to know who
the highest utilizers of criminal justice and mental health
services were in my county so that we could wrap our arms
around this population to see if we could get them services so
they didn't keep reoffending. I thought I would get a list of
thousands of individuals back. They send me a list of 97
people, and I guarantee every one of you have these same 97 in
your communities. These 97 individuals, primarily men,
primarily diagnosed with schizophrenia, over 5 years were
arrested 2,200 times. They spent 27,000 days in the Dade County
Jail, 13,000 days at a psychiatric hospital or an emergency
room, and cost taxpayers $13 million, and we got absolutely
nothing for it. We would have been better off sending them to
Harvard and maybe giving them an opportunity for an education.
It is an outrage.
The other part of the problem is that where we spend our
money is killing us. In Florida, we spend one-third of all of
our adult public mental health dollars--that is almost a
quarter of a billion dollars--to try to restore competency for
2,700 people. We have between 170,000 and 180,000 people in any
given year in Florida who at the time of their arrest need
acute mental health care treatment but we spend a third of our
money trying to restore competency so we can try these 2,700
people. Well, 70 percent of these individuals have three things
happen to them. Either the charges are dropped because the
witnesses disappear, they get credit for time served because
they have been in the system so long and they walk out of the
front door of the courthouse without any access to treatment,
or they get probation and they walk out of the courthouse with
any access to treatment and we just spent a quarter of a
billion dollars, and that money is coming out of the community
mental health system, making it harder for people to get
access. It actually meets the definition of insanity. We keep
doing the same thing again and again and we expect a different
outcome.
It is even worse at the prison level, and on competency
restoration, in the United States we are spending almost $3.5
billion and we are getting very little return for that money.
The fastest growing population in Florida's prisons are
people with mental illnesses. While our prison population has
begun to stabilize over the last 2 years, the mental health
population continues to grow at exceedingly alarming rates.
Over the last 15 years, the percentage of people with mental
illnesses has grown by 178 percent. We went from about 6,500
people with serious mental illnesses 15 years ago to 18,000
today. It is growing so fast that it is projected to double
again in the next 10 years. Florida needs to start building 10
new prisons for the next 10 years just to get to this
population. It will cost my State $3.5 billion to deal with
this population if we don't do something soon to correct the
problem.
We are looking at a huge cost and we are getting very
little for our outcome. We have a three-legged stool that is
wobbling and about to break, and there are three parts that I
really hope that you are able to address. The first part is how
and what we finance through federal Medicaid dollars for mental
health services. It doesn't work. The second somebody is no
longer a danger to self or others, Medicaid will cut them off
and the hospital will discharge them back to the community,
often to homelessness, often into the criminal justice system.
The second part that needs to be addressed is the
antiquated involuntary hospitalization laws. Most of these laws
were written before we had TV, microwave ovens, computers,
brain imaging and antipsychotic medication. It is an absurdity.
The first laws come from 1788 out of New York. It doesn't work.
People cannot get into the system to get treatment, and then
when they are ready to be discharged, there is nothing for
them.
The third part is that we need to have a coordinated system
in the criminal justice system to make sure we can take care of
this population, and let me just make two quick points. We are
doing some significant things in Miami-Dade County that are
having huge impacts. We have trained over 4,000 police officers
in order to identify people with mental illnesses in the
community. Last year, the city of Miami and Miami-Dade County
did 10,000 mental health calls. These 4,000 officers only made
27 arrests out of these 10,000 calls. Our jail audit plummeted
from 7,800 to 5,000, allowing the county to close a jail and
saving $12 million. We also have post-arrest diversion programs
where if someone comes in, we get them treated and make sure
that they are not just discharged to the community without any
assistance.
We are saving lives, we are saving dollars, and we are
starting to make the system work, but we need to fix those
other three pieces. We also need to begin to use advanced
technology, which we are beginning to do. We are part of a
unique private and public partnership in Dade County where we
are working to see if predictive analytics can actually be used
in the behavioral health space so that we can have an
unfragmented system of care, more accountability, and make sure
that people with mental illnesses are treated fairly and
properly.
Thank you very much.
[The prepared statement of Judge Leifman follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Judge. I was afraid to gavel a
judge.
Judge Leifman. And I appreciate that, and I won't hold
anyone in contempt today, so appreciate the reciprocation.
Mr. Murphy. I don't think this is your jurisdiction, so we
are good.
Judge Leifman. Thank you.
Mr. Murphy. But thank you for your testimony.
Mr. Stern, you are recognized for 5 minutes.
TESTIMONY OF GUNTHER STERN
Mr. Stern. Thank you for hearing me today. I am here to
talk about people who are homeless with severe, untreated
mental illness. I have been working with homeless people for
nearly 30 years, for the last 24 at Georgetown Ministry Center.
Our goal back in 1990 was to put ourselves out of business by
ending homelessness. Instead, homelessness has become a career
for me and so many others. It has now been 10 years since
cities around the country including Washington, D.C., issued
their 10-year-plan to end homelessness. Not much has changed.
Why is homelessness so hard to solve? From my perspective,
it is because we lack the tools to intervene when a person's
life has devolved to the point where he or she has moved out
onto the street because of an untreated mental illness. When I
began to work with the homeless population nearly 30 years ago,
deinstitutionalization was in full swing. At the time many
people I was working with were cycling in and out of hospitals.
The community mental health centers were trying to figure out
what their role was.
As deinstitutionalization has continued, I have noticed
that it is increasingly harder to access beds for people in
acute psychiatric crisis. In the past 2 years, I have only seen
two people admitted to the hospital. More typically now, people
referred for psychiatric crisis get poor or no intervention and
are returned to the street, almost always because they refuse
treatment.
Georgetown Ministry Center brings free psychiatric and
medical care to the streets but very few people with untreated
mental illness are willing to engage in conversations with our
psychiatrists about their mental health. It is the nature of
the illness.
However, when we talk about a shortage of beds for
treatment, we are not talking about the people I work with
because these people with limited or no insight into their
illness don't think they need treatment and vehemently refuse
treatment when it is offered.
Homeless people are real people with families like yours
and mine, families that care. Greg is someone I met sitting on
a park bench near our center. He was shabbily dressed and
smelled bad. He would drink, I assume to tame the voices that I
knew he heard because of the frequent spontaneous smiles and
grimaces. All this belied the fact that Greg was once a gifted
constitutional lawyer who delighted his children with his dry
wit. They were in their late teens when he began to show the
signs of what would become a profoundly disabling bipolar
disorder. Not long after, he disappeared. He would call
occasionally on birthdays or out of the blue for no reason. The
kids tried so hard to keep up with him. They wanted desperately
to make him whole again but it was futile. Greg drifted from
city to city around the country, ending up in our center,
ultimately in our small shelter one winter 8 years ago. Greg
was a delight some of the time. His thick southern drawl and
witty conversation would enchant volunteers, but other times he
was withdrawn and surly. In January of 2006, Greg became sick.
We encouraged him to go to the hospital and he said that he
would. Instead, he disappeared. A week later I received a call
from the medical examiner's office. They needed a body
identified. It was Greg. The bodies never look the way you
remember a person. Only Greg's face and hair showed from the
white shroud covering his body. It took a few moments to work
out that these were the features of the person that I once
knew.
A few years later, I met Greg's two adult children. They
had learned he had died in Washington 3 years after the fact.
Each of them traveled, one from New York, the other from
Phoenix, to meet here and see the place where their dad spent
his final days. They needed to know what his last days were
like. I shared coffee with them, and they told stories about
him and they asked questions about his final days. They laughed
and they cried. You could tell that they loved and missed their
father.
There are so many stories I could tell if I had time about
mothers, brothers, sons, daughters who have wept for their
relatives lost to mental illness. If the families had the tools
to intervene, they would intervene.
Most of all, what I want to impart here is that people who
live on the street are real people with families and hopes and
dreams abandoned because of an illness that has robbed them of
their competency. The other important takeaway is that almost
all the people I see on the street are there because they have
refused treatment, not for rational reasons but because illness
has insidiously robbed them of their insight to understand that
they have an illness and that treatment can help them.
So finally, what I have concluded after nearly 30 years of
working with people who are homeless is that all I can do is
provide some comfort and harm reduction. Until we are given
tools for more assertive interventions, we will not resolve
homelessness.
Thank you.
[The prepared statement of Mr. Stern follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Mr. Stern.
Mr. Rahim, you are recognized for 5 minutes.
TESTIMONY OF HAKEEM RAHIM
Mr. Rahim. Chairman Murphy, Ranking Member DeGette and
members of the subcommittee, my journey with mental illness
began in 1998 during my freshman year at Harvard University.
That fall I experienced a terrifying panic attack. In that
episode I had heart palpitations, sweaty palms and dizziness
yet I did not know it was an anxiety-induced state. What I did
know, however, was the deep terror I felt.
My journey continued when I had my first manic episode.
During the spring of 1999, I roamed the streets of Hempstead,
New York, possessed with a prophetic delusion that I had to
share with any and every one I met. Concerned, my parents sent
me to my father's homeland of Grenada to relax and be with
family. However, while there, I plunged into a deep depression.
I returned to Harvard that fall and struggled through the year
battling anxiety and depression.
In the spring of 2000, I was consumed by my second manic
episode. My next 2 weeks were filled with sleepless nights and
endless writing sessions. I showered less frequently and ate
sporadically. During this manic episode, I experienced
psychosis. I had visions of Jesus, heard cars talking and spoke
foreign languages. Upon hearing my condition, my parents rushed
to pick me up from Harvard's campus. That same evening, my
parents decided to take me to a psychiatric hospital in Queens.
When we arrived at the emergency room, I was taken to the
triage area. Over the next few hours, I was held in a curtained
room in the ER. I tossed and turned and remained restless, as
now I had not slept in 24 hours. My parents sat in the
curtained room with me until I was admitted to the hospital
later that night.
Accompanied by two hospital aides, I was transported to the
psychiatric ward in a hospital van. I walked through the dimly
lit ward door and was met by approximately six staff members.
They gave me a hospital gown, requested I change into it, and
encouraged me to relax when they noted my agitated state. When
I continued to toss, the staff stated they were going to put
straps around my arms and legs. After placing the straps, they
then said they were going to give me a sedative to help me
sleep. I felt a prick on my upper arm.
The next morning I awoke, drowsy and unable to speak. I
walked to the common room on the ward, sat down and began to
hold my breath. I received another sedative. I was hospitalized
for 2 weeks. The first week is a blur due to my mental
confusion and the psychiatric medication administered to me.
However, I do remember some of my experiences. I interacted
frequently with staff and the other patients. One staff member
I felt an affinity toward and spoke with him frequently. He
advised me to focus on getting better and to not come back to
the hospital as so many other patients had. My psychiatrist on
the ward diagnosed me with bipolar disorder and briefly
explained that I would be on several medications. Upon my
release from the hospital I found and met with a psychiatrist
in Brooklyn.
During my hospitalization, I accepted my illness and began
my arduous road to recovery. I cannot pinpoint what triggered
my immediate acceptance, but I am grateful it did not take
years for me to obtain insight. Over the course of my 16-year
journey with mental illness, I have simultaneously embraced my
diagnosis and realized that I am more than a label. I have
embraced that I am more than medication, therapist appointments
and support groups. I have learned that I am not bipolar, I am
Hakeem Rahim, and not just any one piece of my treatment
regimen.
At the same time, I have learned that a good treatment
regimen has to be accompanied by positive coping skills, diet,
exercise for brain health, along with spirituality and
spiritual perspective.
The biggest challenge I faced getting to where I am now was
openly acknowledging my mental illness. For so long, I felt a
deep and personal shame for having bipolar disorder. This shame
was so entrenched that I even felt uncomfortable sharing my
diagnosis with close friends and even family members.
In 2012, I decided to speak openly and joined NAMI's In Our
Own Voice program. Through the In Our Own Voice program, I have
shared my story with over 600 people including individuals
living with mental illness and their family members. Currently,
I am the NAMI Queens/Nassau's Let's Talk Mental Illness
presenter. Through the Let's Talk Mental Illness program, I
have shared my story and provided much needed awareness to over
5,000 high school students and middle school students at 37
schools. I see the importance in and will continue to speak up
for mental health and mental illness education in schools and
beyond.
Millions of people in America desire to give voice to their
struggles, but cannot because of stigma. I am fueled by the
desire to break the silence. I am inspired by students who want
to learn about mental illness to help a friend or a struggling
parent who is hurting. I am strengthened by people who have
decided to out themselves in an effort to normalize mental
illness. Mental illness education and awareness is essential to
combat stigma, end suffering and to normalize seeking help.
I am grateful to my parents, family and loved ones who have
supported me. I am also grateful for this committee for picking
up this topic as well as this panel because it is my hope that
the ideas put forth today will transform the already shifting
conversation around mental illness, and I thank you very much.
[The prepared statement of Mr. Rahim follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Mr. Rahim. We appreciate that.
Dr. Edgerson.
TESTIMONY OF LAMARR D. EDGERSON
Mr. Edgerson. My name is Dr. LaMarr Demetri Edgerson, and I
wish to thank the chairman and ranking member for the
opportunity to testify today at this very important hearing on
the psychiatric bed shortage. My doctorate is in psychology. I
am a clinical mental health counselor and licensed marriage and
family therapist.
The population we are focusing on today is the population
that I primarily serve in my private practice. Over the past
year, I have served as the Director at Large for the American
Mental Health Counselors Association, also known as AMHCA. I am
here representing AMHCA's 7,100 members. I am also a board
member and two-time past President of the New Mexico Mental
Health Counselors Association.
Clinical mental health counselors are primary mental health
care providers who offer high-quality, comprehensive,
integrative, cost-effective services across the life span of
the individual. We are uniquely qualified licensed clinicians
trying to provide mental health assessment, prevention,
diagnosis and treatment.
I grew up in the welfare system with inadequate health
insurance. Since the age of 18 years I have provided health
care for patients. My career began as an enlisted member of the
United States Air Force where I served for 20 years as a medic.
As a clinical mental health counselor, I now see children,
adults and families in a private practice in Albuquerque, New
Mexico. My specialty is trauma.
Evidence all around demonstrates the Nation's mental health
care system is in crisis. It is generating increasing demand
for inpatient psychiatric beds while simultaneously decreasing
its supply. Because patients have trouble accessing services in
a community, they use the emergency department for basic and
intermediate care. Our current mental health system still
suffers from poor transition from inpatient institutions to
community-based treatment.
In a recent scholarly article, Ms. Nalini Pande estimated
that psychiatric boarding lost nearly $4 million a year in
revenue from service that could have been provided in lieu of
boarding at just one 450-bed teaching hospital here. Ms. Pande
also found that as patients waited, sometimes for hours, some
for days, their psychiatric health deteriorated. Patients who
often came in with manageable psychiatric illness subsequently
turned into patients with acute needs.
But still, there is more than meets the eye. We at AMHCA
believe some policymakers are going down the wrong path in
addressing the problem of hospital boarding. The barrier to
treatment is accessing timely, effective, quality mental health
service in the community. Surmounting these barriers requires
continuous comprehensive health insurance coverage that enables
access to essential inpatient and outpatient care, prescription
drugs, early intervention, and prevention programs. All of
those essential benefits are provided in health plans governed
by the Affordable Care Act and new State Medicaid expansion
programs, and some are available to Medicare beneficiaries as
well.
We can work smarter to have a better health care system
that systematically reduces crisis situations from developing.
In addition to the importance of State Medicaid expansion,
Medicare mental health services too have never been fully
modernized to include newer providers like clinical mental
health counselors and marriage and family therapists such as
proposed by Representatives Chris Gibson and Mike Thompson in
H.R. 3662. Comprehensive and stable health insurance coverage
is the key to cost-effective, efficient, timely mental health
services in the United States.
The new State Medicaid expansion effort has the potential
for millions of currently uninsured Americans with mental
health diagnoses to obtain greatly expanded access to mental
health and substance use treatment in an integrated community-
based setting with a person-centered treatment focus, the exact
objectives, I believe, all policymakers are trying to achieve
today.
Unfortunately, 25 States are refusing to participate in the
new Medicaid expansion program, which will continue to leave
millions of uninsured people with serious mental health
conditions out in the coverage cold. AMHCA believes it is a
huge and costly mistake that Congress under Medicare and State
policymakers under Medicaid have decided to deny their most
vulnerable citizens State health insurance coverage with
comprehensive health care and mental health services.
In summary, Medicare and mental health provider coverage
modernization and State Medicaid expansion will provide health
insurance coverage to millions of people with serious mental
health conditions who have had difficulty accessing needed and
timely service. These changes are necessary to dramatically
reduce the chances of future crisis situations and increasing
emergency department visits.
Thank you again for the opportunity to present this
testimony today before the committee.
[The prepared statement of Mr. Edgerson follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Doctor. We appreciate that.
Dr. Evans, you are recognized for 5 minutes.
TESTIMONY OF ARTHUR C. EVANS, JR.
Mr. Evans. Thank you. Mr. Chairman Dr. Murphy, Ranking
Member Representative DeGette and members of the committee,
thank you for inviting me to participate in this hearing. I am
Dr. Arthur C. Evans, Jr., Commissioner of the Philadelphia
Department of Behavioral Health and Intellectual disAbility
Services, and I also have a faculty appointment at the
University of Pennsylvania School of Medicine.
I appear here today on behalf of the American Psychological
Association, which is the largest scientific and professional
organization representing psychology.
As the Commissioner of the Department of Behavioral Health,
my job is to ensure that the resources are deployed to address
the needs of 1.5 million people in the city of Philadelphia.
So today what I wanted to do is to talk as an
administrator, as someone who is trained as both a scientist
and a practitioner, and also a family member myself, and I want
to start by saying I think all of the issues that we have heard
today are solvable problems. I absolutely believe that. I think
we have evidence both in Philadelphia and around the country
that all of the issues that we have heard today are solvable I
think with political will, with resources and with leadership.
I really appreciate the family members who have testified
today and especially Mr. Rahim, who gave his personal story,
because I think that we have to hear that people can and do
recover, and I want to start my comments by just giving a few
examples of things that I think that we can do to improve the
Nation's mental health systems.
First of all, people can and do recover, and we know from
the research, we know from clinical practice that given the
right resources, given the right types of services, people can
do really well who have even the most serious forms of mental
illness. Unfortunately, our systems are set up in a way that
they don't acknowledge that. We have systems that are geared
towards maintaining people, addressing people when they are in
crisis, and you heard some of the stories of people who have
family members who have a very difficult time getting help, and
the reason that is, is because of the way we finance our mental
health system. It is diagnostically driven. People either have
to have a diagnosis or to be in crisis. So one of the first
issues I think we have to take on is, how are we financing our
services and are we doing things and are we financing our
service system in such a way that we have the resources to do
outreach and to do early intervention.
Secondly, I think that any discussion around psychiatric
bed capacity has to deal with the efficiency of the current
system. There are a number of things that we can do to improve
the current efficiency, and I will give you a couple of
examples from Philadelphia. We have in Philadelphia a unit that
has people who historically would have been in the State
hospital, very long lengths of stay, numbering sometimes in the
months. We have employed evidence-based practices, both on the
unit and in deploying ACT teams, or Assertive Community
Treatment teams, who have also been trained up in evidence-
based practices, and we are starting to see a reduction in
lengths of stay. I use that as an example because when we talk
about increasing bed capacity and not addressing the
inefficiencies in the current system, it is not a good use of
our resources, and I think we have to take on those issues.
Similarly, we use a pay-for-performance system because we
believe as a payer that it is really important to have
accountability around the services that are provided. We have
saved over $4 million over a 2-year period simply by working
with our inpatient treatment providers, focusing on things like
continuity of care, making sure that when people are admitted
that if they have a case manager that those people are coming
onto the units, working with people so that there is a smooth
transition. Those kinds of efficiencies can go a long way in
increasing capacity.
I also believe that we have to have a public health
strategy. We cannot simply have a treatment strategy around
this. When people have difficulty getting into services,
sometimes that is because people don't know how to navigate the
system but often it is because there is stigma associated with
mental illness that prevents people from reaching out for help
and so part of our strategies have to be to reduce stigma and
make it more likely for people to reach out for help. That is
one of the reasons that we support things like mental health
first-aid that help people to understand how to intervene.
Fourthly, I think that we have to think about cross-systems
financing. Many of the issues--if you talk to mental health
commissioners around the country and you ask them what are the
top three issues, I would almost guarantee you that every
single one of them would have housing as one of their top
issues related to the administration of their system and so as
we are talking about this, we have to think not only about
services within the mental health system but we have to think
about other services that people need to be successful.
So with that, I will stop and hopefully we will have
questions that we can talk more about those.
[The prepared statement of Mr. Evans follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Dr. Evans. As we go into comments
here, or questions from Members of Congress, I just want to
have a special thank you for this panel. We have had a number
of hearings and panels on this issue of mental health, and I
recognize members have very busy lives and some are at other
hearings and other areas, but for those members who missed your
testimony, I think their lives are the poorer for it, and to
watch how someone would walk through the system is pretty
difficult. So let me recognize myself for 5 minutes.
Ms. Ashley, your experience you related to us in your
testimony concerning your son's admission and boarding in a
local ER from hours to days, I mean, it is alarming to us. So
were there any other places in the area, were you informed of
any other place in the area where you could have taken your son
instead of having those long delays in the hospital?
Ms. Ashley. You mean another emergency room?
Mr. Murphy. Yes.
Ms. Ashley. Well, my insurance only pays for the hospital
that we went to.
Mr. Murphy. OK. And Dr. Hirshon, in this case, and we had
heard this also, for example, on 60 Minutes when State Senator
Creigh Deeds was talking about his own son, he couldn't find a
place. Is that part of the problem that occurs too with
emergency rooms in terms of getting someone to----
Mr. Hirshon. Yes, the issue of finding an inpatient
facility can be very problematic. You have to find a place that
is going to accept that patient, and historically, there may
have been insurance issues as well. And so, in Maryland we have
tried to devise mechanisms to improve this. One of the things
we have now is kind of a central listing of the hospitals that
have inpatient facilities, that have beds available, but even
that is problematic getting the hospitals to buy into it. So
this is a traditional problem, especially if you have someone
who has got a dual diagnosis. Perhaps they are an adolescent
with bipolar and maybe substance abuse. They can wait--I have
had friends had patients wait for 13 days in their emergency
department looking for a place to stay.
Mr. Murphy. Thank you.
Sheriff Dart, any idea what your total costs per year in
dealing with folks with mental illness in your jail are?
Sheriff Dart. You know, Mr. Chairman, that has always been
a difficult number for us to ascertain, but just as a rule of
thumb, it is in the ballpark clearly double, closer to triple
the cost of an average detainee, so we are talking just
tripling every expense that we have there, but the difficulty
where it gets to be sort of quantifying this is that they come
back to us so quickly. So it isn't even as if you took the one
detainee and said OK, he cost more than the other ones and----
Mr. Murphy. You are talking about some of those costs,
$12,000 for pretrial costs and other things with that. Now, is
any of this federal money that is used to help these patients,
these inmates while they are there?
Sheriff Dart. No, no, virtually none. It is all county-
related money.
Mr. Murphy. OK. Let me ask also, in this past winter, I
heard about a homeless man who had mental illness in
Washington, D.C., couldn't take him in because it was only 32
degrees. But once the temperature hit zero, it would be OK. Is
that true, this story that I heard, Mr. Stern?
Mr. Stern. Actually, I think Washington did sort of a
heroic job over past years. They had buses, metro buses out
when it got, I think below 15 degrees, and there was
hypothermia in effect under 32 degrees.
Mr. Murphy. When I look upon this, and we talk about
somebody being--we are not going to provide help until there is
a crisis, they threaten to kill someone, themselves, or you had
talked about people who are not even aware of their symptoms.
In this case, now they are an imminent threat because they are
not even aware of their illness. It is sad that we have to go
to that extent.
Mr. Stern. Yes. I mean, the one thing that I would say is,
on the day it got really cold, I went out to the bus, and there
were three people on the bus. I then went under a bridge nearby
and there were five or six people there who refused to go on
the bus, so there is that.
Mr. Murphy. Thank you.
Dr. Evans, as you heard these stories about how much is
spent--Judge Leifman talked about this, Sheriff Dart talked
about this, Chief Biasotti, all these other folks. If you had
that kind of money, could you make a difference? I mean, we are
spending it in hospital beds and emergency rooms where they are
not getting treatment. We are spending it in jails. We are
spending it in courts. Could you keep people out of those
systems if Medicaid and other things paid for that kind of
thing?
Mr. Evans. There is no question that we can and we do. For
example, in Philadelphia, take the issue of homelessness.
Because we have a mayor that has been pretty interested in this
issue, he has been able to convince the Philadelphia Housing
Authority to make available Section 8 vouchers to my
department, which does homeless outreach. Over the last several
years, we have had approximately 200 vouchers a year, and with
that, we have been able to get over 500 people off of the
streets of Philadelphia who were formerly homeless, many of
whom have serious mental illness and/or substance use problems,
and the way we were able to do that is to use those housing
resources matched with Medicaid-funded behavioral health care
services, and to date we have about 93 percent of those people
are still in stable housing. So I think that these are solvable
issues. I think it takes creative financing and I think it
takes innovations in how we deliver services.
Mr. Murphy. We look forward to hearing some specific
comments from you and others too on what needs to change in
some of the definitions of care so that money can be spent in
helping people, preventing problems and treating them.
I have to ask you, Mr. Rahim, because you have Ms. Ashley
at the table here, who has a son who is a good man but dealing
with schizophrenia, do you have advice for parents and for
other people dealing with this?
Mr. Rahim. I believe that Dr. Evans said it best, that
mental illness is treatable and I think a lot of the panel said
mental illness is treatable but I think we have to have the
education to know that it is treatable and that it is something
that you can overcome, and I think having faced this as well as
evidence-based practices will do so much.
Mr. Murphy. Thank you. That is a good message of hope.
Ms. DeGette.
Ms. DeGette. Thank you. Let me follow up on that statement,
Mr. Rahim, by you and Dr. Evans.
Dr. Evans, you talked about how evidence-based practices
and lengths of stay can really be used for treatment, and part
of the problem, part of some of these illnesses is people don't
realize that they are ill, and part of it is stigma. So my
question to you is, from what I understand from what you are
saying and others, is that if we can identify someone with
severe mental illness early on and get them into that
treatment, we actually can stabilize their situation. Is that
correct?
Mr. Evans. That is absolutely correct, and the research is
pretty clear on this. If you can intervene with people early,
particularly after their first episode, and there are evidence-
based treatments for people who are experiencing their first
episode, you can dramatically change the trajectory of their
illness and significantly improve clinical outcomes.
Ms. DeGette. And I would assume you would agree with me
that probably the way to do that early identification is not
when they present in an emergency room or a jail, correct?
Mr. Evans. That would be correct.
Ms. DeGette. And I would assume, Dr. Hirshon, you would
agree with that from an emergency room perspective as well.
That is not the ideal way to identify a severe mental illness
and treat it, correct?
Dr. Hirshon. We take care of emergent and urgent, you know,
acute psychiatric problems but my preference would be not to
have to deal with that, I mean, to find support systems, both
inpatient and outpatient, that they don't come at 3 o'clock in
the morning homeless and cold because they have no other place
to go, and so yes, I would----
Ms. DeGette. And have to find a bed.
And Mr. Dart, you would agree with that from a penal
perspective as well, correct?
Sheriff Dart. Oh, absolutely, on two fronts. One, frankly,
during the cold weather, we have people affirmatively commit
offenses so they can come into our housing. I talk with the
detainees on a regular basis. They will tell me frequently they
don't want to leave the jail because it is the best place they
can go for treatment, they feel safe, they don't get harmed out
in the community, and we have had some where when we release
them, they will try to break back into the jail as a result of
that, and Congresswoman, the one thing that always has troubled
me, when you think about it, each and every one of these
people, we have a full file on them, not only on their criminal
background but their mental health needs. Why we can't follow
them out in simple case management type of fashion, and even if
we just break the cycle for a short period of time, we would
save tremendous amounts of money.
Ms. DeGette. You don't know this, Sheriff, but I started my
career as a public defender, and so I know this very, very
well. I had so many clients in those days who you could just
see they were severely mentally ill, and there was nothing we
could do with them.
Now, I want to ask you again, Dr. Hirshon, I mean, if we
had a better system like one Dr. Evans is talking about to
identify and to treat folks at an early stage, then when
somebody really did have an acute problem, the emergency system
would be better equipped to deal with those folks because
theoretically, there would be fewer of them, correct?
Dr. Hirshon. Well, there would be fewer but there would
also be more structure to support them. So a lot of this is the
lack of a kind of systematic structure to support these people
who are either coming in because they have acute needs or
because of their social circumstances. So the idea to have that
improved structure both from a mental as well as social
perspective I think is very critical.
Ms. DeGette. Yes, and I want to ask you, Ms. Ashley, as a
fellow mom here, you would much rather--you, as a nurse,
identified that your son had severe psychiatric problems from
an early stage but you didn't have any recourse to get him the
kind of treatment he needed except for continually taking him
to the emergency room. Is that what I heard you saying?
Ms. Ashley. Yes, that is right. I worked very closely with
his primary medical provider, who obviously knew there was
something wrong with him, but my son would continuously deny
going to the emergency room to get psychiatric evaluation. The
psychiatric people were even willing to come to his medical
appointment to evaluate him. That is how tight our community
was. And still my son would say no, he would not go. So I
actually had to set up a situation where he went to the
emergency room to get lab work done and then have him received
by the psychiatrist and his primary medical provider to put him
on a hold.
Ms. DeGette. Thank you.
Now, Dr. Evans, just if you can briefly tell me, you have
got several projects going on. Where do you get the funding for
those projects?
Mr. Evans. So Philadelphia is unique in that the city
manages all of the public sector behavioral health services
that come in. The city is capitated for the entire Medicaid
population so we manage the Medicaid benefit for everyone who
has----
Ms. DeGette. So you are getting Medicaid benefits?
Mr. Evans. They are getting Medicaid, but we also receive
State, federal, local grant dollars as well.
Ms. DeGette. And I just want to finish up with you, Mr.
Rahim. You heard what Ms. Ashley was talking about. Her son was
denying what was happening and she had to sort of trick him.
What do you think about people who get diagnosed with these
diseases? Is it the stigma? Is it the nature of the disease?
And what is your opinion what we can do to get folks into
treatment like you were able to do and to accept the disease,
very briefly?
Mr. Rahim. So, I have to very much recognize that mental
illness is individual to each person. There are so many
different diagnoses, and each person, even with the same
diagnosis, responds differently to the medication, responds
differently to the knowledge that they may even have it, or
even responds differently to their parents' care and concern.
So I mean, with that--and I do want to acknowledge that. I am a
voice but I am not the only voice, and there are so many people
out there, so I just want to acknowledge that to your point,
that is, it is so different, and it is hard. This is hard, you
know, this is not easy. So even if you have the care provided,
it is still a journey, one, and two, you still have to
recognize that everybody is different.
Ms. DeGette. Thank you. Thank you very much, Mr. Chairman.
Mr. Murphy. Thank you. I now recognize the vice chair of
the full committee from Tennessee, Mrs. Blackburn, for 5
minutes.
Mrs. Blackburn. Thank you, Mr. Chairman.
I want to thank each of you for taking the time to be here
and for your willingness to tell your stories, and I think it
is such an important component, and it is important for us to
have your insights as we look at the issue. The chairman has
been on this since day one, and looking for a way to reach
parity and to provide some certainty for those that suffer from
mental illness. So we appreciate that you are helping us work
through this process.
Dr. Hirshon, I want to come to you first. Going back to the
American College of Emergency Physicians 2014 State by State
report card that is out there, and looking at the data relative
to 5 years earlier, and you look at the declines in the
psychiatric beds across the country. Has that been consistent
in your rural, suburban and urban issues? Where are we seeing
the greatest attrition in the number of beds? Because one of
the things we hear from people, especially in our rural areas,
is, they have no access and they don't know where to turn.
Dr. Hirshon. So I would say that each jurisdiction, each
region, each State is different. It is a little hard to say.
But as a general rule, access to care in rural settings is much
more difficult. And the other thing to recognize is that even
if you have insurance, insurance doesn't mean access because
you have to find someone who can take that insurance and who
will be there to give you the services. So as a general rule,
the rural settings and the areas in which there are fewer
services are disproportionately impacted. So I would agree with
that.
Mrs. Blackburn. OK. How do we fix that? How do we fix that
disparity? What do you think? Because the access is so
critical, and as you said, you may have access to the queue but
that does not mean you have access to the physician, and what
we are seeing with the implementation of Obamacare, the
President's health care law. So many people say well, I have
got an insurance card now, and of course, in Tennessee, we saw
this with the advent of TennCare back in the 1990s but there
was nowhere that they could go for the care or it may be 180
miles away, which is debilitating when you are trying to access
this. So what do you think?
Dr. Hirshon. I think again that, you know, not just
psychiatric care but many types of care, you have to look for
creative solutions, and one of the solutions for that is
regionalization of care. So for example, if you have got a
regional center of excellence for psychiatric care, to be able
to utilize that either through telemedicine so they can do
evaluations long distance or in a setting in which they don't
have a psychiatric provider there or there is a way that you
can use that regionalization to help improve the care I think
is one potential model. I think we need to do research to look
for better ways to be able to provide care, recognizing that
our technology--there is an increased demand but our ability to
perhaps meet that demand can be adjusted.
Mrs. Blackburn. OK.
Ms. Ashley, I see you shaking your head. You like the idea
of using the telemedicine concepts?
Ms. Ashley. Yes. At UC Davis, we already use telemedicine
for medical diagnoses and so forth, and so I definitely can see
telemedicine with good case management follow-up definitely
would be very helpful to the family and the consumer.
Mrs. Blackburn. So would you classify that primarily as
using the telemedicine concept as an assistance in early
intervention or where would that have the greatest impact?
Ms. Ashley. At the very beginning.
Mrs. Blackburn. The very beginning, being able to utilize
that.
I have just a couple of seconds left. Dr. Geller,
deinstitutionalization, and you talked about that in your
testimony and you said it was not initiated as a considered
policy but as an accident of history. I want you to expand on
that for just a moment.
Dr. Geller. Sure. If you look at the literature throughout
the era, you don't find any literature that talks about
deinstitutionalization before it happened. It was labeled
retrospectively. Some of the downsizing occurred because of the
introduction of psychotropic medications, and some because of
advocacy. But the major incentive for deinstitutionalization is
the IMD rule. The IMD exclusion means that if I am in a State
hospital, my State pays dollar for dollar for my care. If I am
in a community, my State pays no more than 50 cents on the
dollar and may pay as little as 13 cents on the dollar. So that
any State has a vested interest in moving people from State
hospitals to the community, the cost shift from State tax
dollars to federal tax dollars, and I believe that has been the
major incentive. It was never designed policy.
Mrs. Blackburn. So it was done for the money.
I yield back.
Mr. Murphy. Thank you. I now recognize Mr. Butterfield for
5 minutes.
Mr. Butterfield. Thank you very much, Mr. Chairman, for
convening this hearing, and thank all of the witnesses for your
testimony today, but more importantly, thank you for your
passion. I understand what mental health is all about, and I
thank you so very much.
I missed some of your testimony but I have been reading as
quickly as I could. Dr. Edgerson's testimony, I have it in my
hand, and it is very interesting and it is very correct. You
dwell on the Medicaid expansion aspect of health care, and I
thank you for raising that because that is critically
important. As most of us know, this committee wrote the
Affordable Care Act. It was written several years ago, and the
Energy and Commerce Committee is the proud author of that
legislation, and as part of that legislation, it was our intent
to expand the Medicaid provision so that low-income, childless
adults could receive the benefit of health care. We mandated
that the States expand their program, and that part of the law
was tested in the U.S. Supreme Court, and unfortunately, the
Court said that we overstepped our authority, and even though
it was a proper exercise of legislation that we could not
compel the States to expand their Medicaid program, and that
was very disappointing to me. And now 25 States have refused to
participate in that expansion, and my State of North Carolina
happens to one of those States. My State turns down nearly $5
million per day which could help provide care to those with
mental health issues, and so I am appalled, not only appalled
at my State but the other States that have chosen not to expand
their Medicaid program because we need it.
The Medicaid expansion would not have been a cost to the
States, at least for the first 3 years. All of the costs would
be borne by the Federal Government. Following that, the Federal
Government would pay 90 percent of the cost of care, and so we
have low-income individuals all across the country who are
suffering from mental health issues, from substance abuse who
are not getting the care that they rightfully deserve.
I live in a low-income community. It is an African American
community in North Carolina, and I can tell you that mental
health and substance abuse issues are pervasive all across my
community. Before coming to Congress 10 years ago, I was a
trial judge, not only in my community but in 32 counties
throughout my region. I was one of 10 judges who presided over
the most serious cases in 32 counties, and I can tell you that
we need to extend a hand of friendship and a safety net for
those who are in need. And so I applaud you for lifting up the
whole idea of Medicaid expansion.
Now I get to the question, Dr. Edgerson. I had to get that
off my chest because I understand mental health, not as much as
the 10 of you, but I clearly understand it. I understand the
cost of not treating and detecting mental health issues, and I
know that we would be a better nation if we just slowed down
long enough to recognize the importance of this issue, and
while I am on that, Mr. Chairman, I want to thank you. I think
Ms. Blackburn was correct, that you have lifted this issue up
as a priority of yours from day one, and I thank you for it.
Dr. Edgerson, it is estimated that 189,000 people in my
State with mental illness would be eligible for Medicaid if my
State would expand Medicaid. How many of the individuals
presenting in the emergency rooms with psychiatric and
psychological issues would have avoided an emergency room visit
if Medicaid had been expanded and they were able to seek
treatment before their disease became a crisis?
Mr. Edgerson. I cannot give you an exact number. However,
what generally happens is, if there is not one thing that we
know, we know we can go to the emergency department if we are
having any kind of crisis. A lot of people do not necessarily
have to go to an emergency department because the crisis can be
averted in the beginning, and this is where I believe that
clinical mental health counselors and marriage and family
therapists can come in. So while I may not know that I have a
mental health issue, my friend or my family member may know,
and they may be able to convince me or persuade me, hey, why
don't you go and talk to this person here and maybe we can help
you out, and for me, that is where the beginning steps are
because once I create the relationship with that patient or
client, then they are less likely to go into a crisis scenario
and end up in an emergency department.
Mr. Butterfield. Thank you.
My next question is to you, Mr. Dart, and I heard some of
your testimony earlier, and you talked about some people
believe that jail is the best place for treatment, and you are
absolutely correct. Some in the audience or some watching on
television may find that incomprehensible but that is a fact in
real life.
When I was a trial judge, people would inappropriately--
they didn't know they were being inappropriate--they would call
me at home the night before their loved one was to be sentenced
and they knew that the next day the loved one would probably be
getting out of jail and returning to the community, and
families would literally call me and beg me--many of them knew
me personally. We had grown up together years ago. They would
call and plead with me as a judge not to release their loved
one because they could get better care and treatment in the
facility as opposed to the community, and they felt that
releasing their loved one would be a danger to the inmate and
to the community. So thank you for bringing that up and
reminding me of those days when I was on the bench.
You have been very kind, Mr. Chairman. Thank you very much.
I yield back.
Mr. Murphy. I now recognized the vice chair of the
subcommittee, Dr. Burgess, for 5 minutes.
Mr. Burgess. Thank you, Mr. Chairman.
Mr. Rahim, I just have to say, I don't think it was part of
your prepared remarks but your comments about the
individualization of care and the personalization of care,
those words are golden and I hope that everyone on this dais
heard those and will consider them.
Dr. Geller, thank you for your thoughtful chronicling of
the problem. I cannot go back as far as Franklin Pierce but I
did practice medicine in the 1980s and 1990s, not psychiatry
but more in the general medicine realm, but I remember during
that time the vast expansion of psychiatric facilities that
occurred. I am not sure if I know why that expansion occurred
but then as a result of probably actions by perhaps this
subcommittee in April of 1992, a lot of that was curtailed, and
in fact, just researching for this hearing, there is an article
from 1993 that talked about in one 4-year period the number of
psychiatric institutions doubled, and the graphic they have is
1984 to 1988. This was a major scandal in the country. A
company known then as National Medical Enterprises eventually
entered into some sort of consent decree with the Department of
Justice and many of the private insurers sued the hospital
company for overutilization or overhospitalization of patients.
So it seems like we went from there where there was too
much activity going on to now where there is not enough. I
can't help but feel the emphasis on administrative pricing and
not paying attention to the individual care that Mr. Rahim
talked about is perhaps responsible, but I think this
subcommittee would do well to remember that it was 20 years ago
where we were talking about a very different problem. You were
probably--I don't want to presuppose, but you were probably in
practice at that time. Is that correct?
Dr. Geller. Yes, sir.
Mr. Burgess. Do you recall the events that I am talking
about?
Dr. Geller. Yes, sir.
Mr. Burgess. And what is your observation? I mean, help us
here. You were there, a psychiatrist on the ground, when this
was going on. In your opinion, what is it that happened that
caused that rapid expansion of psychiatric meds and their
overutilization and then the contraction that followed?
Dr. Geller. The expansion that you are talking about was
largely accounted for by private psychiatric hospitals,
generally chain hospitals, that saw an opportunity to make
money quickly. When managed care began to require pre
authorization and the possibilities for admission became more
stringent, those hospitals quickly disappeared. While all that
is happening, the public psychiatric hospitals were still
shrinking, and if I could take a moment?
Mr. Burgess. Sure.
Dr. Geller. What we seem to not be spending time on is that
we are talking about psychiatric disorders, and while resources
are necessary, ``build it and they will come'' does not apply
to all the people who have psychiatric disorders. We had a
demonstration of that in western Massachusetts. We had a
federal court-ordered consent decree in 1978. Western
Massachusetts, the catchment area, is larger than five of the
States in the United States. At that time western Massachusetts
had more per capita expenditure for mental health services than
any State in the United States and there wasn't another State
that came close. And we still had some of the same problems.
Mr. Burgess. Yes, sir.
Dr. Geller. We have a population, some of whom have
something called anosognosia. They don't recognize they have an
illness. You need more than just resources.
Mr. Burgess. Let me ask you, Dr. Hirshon, in the few
seconds I have left. I mean, you bought up EMTALA, and as a
practicing physician, I am familiar with that. One of the great
venerable institutions in my neck of the woods, Parkland
Hospital, got into a great deal of difficulty with their
psychiatric emergency room not too terribly long ago, in fact,
put the whole institution at risk because of some federal
regulations that they ran afoul of, but eventually they went to
outsourcing their psychiatric emergency room to a private
hospital facility. In your experience, does it seem like more
hospitals are going to be doing this?
Dr. Hirshon. My sense is that it is more complicated than
simply a single answer. You have to look at it from both the
patient's perspective as well as the provider's perspective,
and coming up with solutions that allow you to meet the
patient's needs. If it is outsourced in one jurisdiction, that
might work, but again, I think recognizing that there is a
limited number of resources, looking for ways to more
efficiently and effectively utilize those resources will be
key.
Mr. Burgess. Thank you, Mr. Chairman. I will yield back.
Mr. Murphy. Thank you. The doctor yields back.
Mr. Tonko, you are recognized for 5 minutes.
Mr. Tonko. Thank you, Mr. Chair, and I appreciate your
continued use of this subcommittee to shed light on the issues
related to mental health. For far too long now, mental health
issues have been swept away in the shadows, so anything we can
do to raise the profile and reduce the stigma associated with
mental illnesses is a very worthy endeavor indeed.
As amply demonstrated today, the lack of available
psychiatric beds, particularly in times of crises, can be a
pressing issue. For example, we all witnessed the tragedy that
occurred in neighboring Virginia when State Senator Creigh
Deeds was unable to locate an available bed for his son in
time. However, we also all share a goal of deescalating in
treating these types of situations before they do reach the
stage where a patient requires hospital-based care.
So with that in mind, Dr. Evans, from your experience, how
can we improve our mental health delivery system in a way that
reduces the demand factor for inpatient psychiatric care?
Mr. Evans. Thank you for that question. I think that, you
know, any discussion about psychiatric bed capacity focuses on
expanding bed capacity, and I think that is a trap. Prior to
being in Philadelphia, I was also the Deputy Commissioner in
the State of Connecticut, so the past 15 years I have been in
administrative positions that have to make decisions about how
resources are deployed in a mental health system, and I can
tell you that the fundamental issue is that we have to build a
very strong community-based system. That is the fundamental
problem. Psychiatric bed capacity is only a symptom of a deeper
problem, and I think you hear the testimony of all the people
here, they talk about the difficulty when it is clear that a
family member or even a person is having a problem. Well, there
are not the resources to do the kind of outreach to individuals
when they are at that point, and the way we finance our service
system, we have to wait until people are at a crisis point, and
you know, that is not only the problem of the mental health
systems but it really has to do with the fact that unless we
create the kind of flexibility where mental health systems can
do the kind of assertive outreach, we are going to continue to
have this problem.
I remember, maybe it was Dr. Geller that said, you know,
one of the problems with mental illness is that often people
don't recognize that they have a problem, and if people don't
recognize that they have a problem, you can build as many beds
as you want, people are not going to get there unless they are
forced into those beds. The solution is to have resources in
the community where people can--for example, in Philadelphia,
we have mobile crisis teams that can go out and reach out to
people before they are hospitalized. Those kinds of services I
think are critical.
Mr. Tonko. Thank you. And so as you build that
infrastructure and that holistic response, Dr. Evans, what is
the appropriate way to measure the amount of inpatient beds
that would be required in a given community?
Mr. Evans. I think that that is a very difficult question
to answer, and people have used things like population and so
forth. The reality is that it depends on how your service
system is structured. If you have a service system that has
resources on the front end, for example, in Philadelphia, we
have a network of five crisis response centers, so we don't
have the problem of people going to emergency departments who
are in psychiatric crisis, not to the extent that you have in
other cities. We have a mobile crisis team that can do
outreach, and so in Philadelphia that might look different than
another system that might be similarly resourced in terms of
the amount of money but doesn't have those kinds of services.
I think the issue is, we have to build a very strong
community-based system that prevents people from going into
crisis and we have to have the services so that when people
come out of those beds, that we are able to help them in their
process of recovery, we are able to help them to stabilize and
we are able to do things like helping people get supported
employment or to use supported employment, for example, which
dramatically decreases hospitalization. So those kinds of
community-based services are really important in terms of the
capacity that you need.
Mr. Tonko. Thank you. And Dr. Geller, in your testimony you
rely heavily on the fact that State investments in mental
health have been predicated upon where they can shift most of
the cost to the Federal Government. In your opinion, how could
we address the Medicaid IMD exclusion without leading to a
disinvestment by our States' mental health services?
Dr. Geller. That is an excellent question. In my testimony,
I mentioned that the Federal Government should offer the IMD
exclusion waivers to States, requiring a maintenance of effort.
The American Psychiatric Association has a position statement
that is rather specific on this--I could certainly provide it
to you--that indicates that a State who took such a waiver
would be required to continue its expenditure as averaged over
the past 5 years from all sources that they spent previously.
That is not just the department of mental health but the
department of children's services, department of corrections
and so on and so forth. If there was a requirement for
maintenance of effort, there couldn't be a reverse shift.
Mr. Tonko. Thank you. I agree with that maintenance of
effort, so thank you very much, and again, to the entire panel,
your testimony is very much appreciated.
Mr. Murphy. I now recognize the gentleman from Virginia,
Mr. Griffith, for 5 minutes.
Mr. Griffith. Thank you, Mr. Chairman.
First, Dr. Geller, if you could provide that information to
me as well that you were just talking about?
Dr. Geller. Yes, sir.
Mr. Griffith. It is very interesting. I found your
testimony and everybody's testimony very informative.
Mr. Chairman, I appreciate you having these hearings. I
have to say that I don't understand mental illness. It worries
me because I don't, and it is one of those areas where I least
like these hearings that the chairman has called because
normally I have a pretty good idea of where I think we ought to
go when it comes to these mental health issues. I have to
confess that I am learning something every time we even have a
hearing, but I am also concerned that I don't think that we
have all the answers or that we even have any idea what all the
answers are, so I appreciate you all helping us try to figure
that out. As representatives of the people, it is interesting
because we are all trying, I think, Democrats and Republicans
on this subcommittee, to figure out what we can do to make the
situation better.
I don't, however, believe that in the short term we are
going to be able to make huge differences because we are going
to have to do some trial and error. We are going to have to try
to do some new things and some different things, and I
appreciate that.
In that regard, I guess I will look to Mr. Dart and to
Judge Leifman. How can we make the court system better? We are
not going to overnight say OK, none of the folks with mental
illnesses are going to come into the court systems, but what
can we do to make the court system better? You have heard from
Ms. DeGette, who has a public defender background, and Judge,
now Congressman Butterfield. I was a criminal defense attorney
for 27 years, and I have to commend one of my judges back home.
He hasn't set up a mental health court but has a mental health
docket where she deals with folks who have those issues and
tries to identify those in advance so that they can have the
experts present to help on that.
But what types of things can we do to encourage the States
and the federal system to do a better job? Until we fix it,
what can we do to help out in the court systems?
Sheriff Dart. Thank you, Congressman. I will be quick,
because Judge Leifman and I have talked before about these
things.
Getting the courts more engaged is imperative. In our court
system, they have been completely disengaged. Whenever you ask
them about solutions, they say well, we have a mental health
court so it is done. Their mental health court usually handles
about 150 cases total a year. I usually have about 3,500
mentally ill in my jail in a day. So we can't be diverted when
people have programs that are inherently good but aren't
getting at the heart of the problem.
What we have been doing internally is trying to identify
people literally as they are dropped off from being arrested
the night before, downloading quickly their information on
their mental illness, and then we put a file together for the
public defender. I am a former State's attorney. We put a file
together for the public defender to plead with the judge that
this person is not necessarily a criminal, put them in an
alternative setting such as a nursing home setting. We have
been doing that at my jail where I put electronic bracelets on
their legs, I monitor them at this setting. The results are
fantastic, as you can imagine, compared to what the other
treatment would be, which is, I put them in a four by eight
cell with a complete stranger with their own issues as well.
So we have been doing that, and then on the back end, we
have been pretty much winging it, and that is why, Congressman,
when you talk about trial and error, that really is the route
that we have been going. It can't get any worse than it is now
so let us try some new things. So on the back end what we have
been doing is, we ourselves are putting together case plans for
them. We drive them to locations where we potentially can get
housing for them so they can be there and be stabilized, and
then we run a 24-hour hotline when they are in crisis to get
out to them to help them. But it is just what you said,
Congressman. We are at a trial-and-error stage right now but
there are things such as that that certain judicial circuits
could be doing. Others are better. Ours is a real struggle.
Mr. Griffith. Judge?
Judge Leifman. Thank you for your question. We have created
an organization called the Judges Leadership Initiative with a
parallel organization called the Psychiatric Leadership Group,
and we are working with the American Psychiatric Foundation,
and what we are doing now is, we have about 400 judges involved
in this operation and we are going around the country. We have
developed a curriculum to teach judges how to identify people
in court who may have a serious mental illness, how to
deescalate a situation in court so they don't make it worse,
but more importantly, how to work in the community to set up
the kind of supports you need to be able to divert this
population, and so what we recommend are a couple things. A
pre-arrest-type diversion where you work with law enforcement
to teach them a program called crisis intervention team
policing where the police are actually taught how to
deescalate, where to transport and how to avoid an arrest. Our
statistics are phenomenal. As I mentioned, we have closed a
jail as a result of our CIT officers in Dade County. We have
also taught them to set up post-arrest diversion programs so
that you take low-level offenses that don't need to be in jail
or felonies that are nonviolent and you make sure that they get
access to treatment.
Sheriff Dart is correct. The mental health court only
handles a fraction of the cases, and the data is such that
unless they are taking the right people, they actually can do
more harm than good, so you have to be very careful and you
have to be educated.
Mr. Griffith. And Mr. Chairman, I know I am out of time but
could we give Chief Biasotti--I know I mispronounced that. I
apologize. But could we give the chief a moment to comment on
that as well?
Mr. Murphy. Yes.
Chief Biasotti. I would say our main concern law
enforcement-wise is the seriously mentally ill group that is
unaware of their illness. I mean, that is wherein the problem
lies for us. The police departments, your county directors know
who these certain groups of people are because we deal with
them every day, and there are answers that we can deal with
that.
In a case that we had not long ago, we had a woman severely
mentally ill, went into a house, no one was home, took the pit
bull and put it in a closet, went upstairs, took all the
clothing out of the woman's closet, put her dishes from
upstairs downstairs, moved all the pictures, spent the day. The
woman came home--the homeowner--and walked in on her and of
course, you know, had a cow right then and there, called the
police. The police come, and she was totally out of her mind,
psychotic, carrying on. So when I arrived at the police station
on a different matter, I heard this screaming coming from our
booking area. She was in the booking area, you know, voices
were talking to her and she was complaining she was being raped
by whatever at the time while she is sitting there. So I made a
decision at that point, which a lot of people don't do, but
being familiar with this topic I said listen, we are not
arresting her for burglary. I said she is going to go to the
psych unit but I am going to send a letter with her saying that
she is obviously dangerous. She could have been killed. Whoever
came home could have shot and killed her is most likely to
happen. I said if we arrest her, she is going to go to the
county jail, she is going to be a major problem for them. From
there our officers are going to go out to grand jury where they
are going to move to indict her for whatever. She will be in
jail for a year before they decide that she is so mentally ill
that she can't stand trial, and then she will be back here
again. I said so let us get her into the system now and put her
through that service. But I accompanied that with a letter to
our county mental health director saying I strongly suggest
that, you know, she is proven to be dangerous, she has a long
history, to herself, mostly; I suggest that you enter her into
the assisted outpatient treatment program. This program, they
provide the services to her through this program. She has not
been a problem since. They monitor her, make sure that she is
in some kind of treatment, and as long as she is in treatment,
she is not a problem. However, if we went the legal system as
we normally would do, we would be dealing with her every few
weeks because she has anosognosia, she does not believe she is
ill.
And I know, you know, stigmatism is a big concern, and my
wife and I both pray for the day that our daughter has the
insight that Mr. Rahim has into her illness because I believe
if she had that insight, she could seek what everybody is
talking about, care in the community. It has been 20 years
almost and she does not have that insight. She has voices, and
they are, as she is concerned, a supreme being.
Mr. Griffith. I hate to cut you off but my time is way
over.
Chief Biasotti. I am sorry.
Mr. Griffith. That is all right. No, I appreciate the
testimony.
Thank you, Mr. Chairman, and I yield back.
Mr. Murphy. That was valuable because New York, as I
understand, has actually reduced their incarceration rates and
homeless rates, I think by 70 percent. It has been a massive
savings.
Chief Biasotti. That is correct, through AOT.
Mr. Murphy. Thank you. Ms. Schakowsky, you are recognized
for 5 minutes.
Ms. Schakowsky. Well, I am so glad I got here because I
wanted to say a special welcome to my great friend, Sheriff Tom
Dart. We were seatmates for a while in the Illinois General
Assembly. And I wanted to really talk to you about a problem I
know you are struggling with so much.
The New York Times article ``Inside a Mental Hospital
Called Jail'' really focused on the largest mental health
center in America. It is a huge compound here in Chicago with
thousands of people suffering from mania, psychosis, other
disorders, all surrounded by high fences and barbwire. That is
the county jail.
So I wish you would just briefly discuss how cuts to mental
health programs and services have affected individuals with
mental illness that are now in your custody.
Sheriff Dart. Thank you so much, Congresswoman, and it is
great seeing you again.
You know, you almost don't know where to start because up
until about 5 years ago, the normal process in our jail 5, 6
years ago and, frankly, from my understanding, in most jails
around the country now, when you get that court order to
release somebody, you release them. The court is ordering their
release and you have got to let them go, so you let them go.
What we were seeing is out in front of our jail, there were
people that just wandered around, stayed there, and as I had
mentioned earlier, we have people trying to break back in. One
threw a planter through a window to crawl back into the jail,
and then we had to arrest him.
The reality of it is, is that when we were releasing
people, they had nowhere to go, and in the face of that, in our
State we have made tremendous cuts, I mean, just over the last
10 years. We are one of the leading States in cutting mental
health funding, period, and in the city of Chicago, we just cut
in half our clinics in the community. So when the people leave,
not only do they have nowhere to go, there was no plan
whatsoever, and as I had referenced earlier, I do think this is
doable with not great expenditures because we literally have
everything about this person in our possession. So if you are
trying to think of case plans and diagnosing them and what
would be the best strategies, there is a myriad of things we
can do, but when you have no place for them to go--I used to
hand out a resource book in my first couple of years as sheriff
to give people a place to go. I had to stop doing that because
everything in it was wrong because most of the things that we
were trying to steer people toward were all closing, and so we
were then setting them up to fail because there was nothing
really out there.
And so the cuts are so tremendous, it has left all the
locals including ourselves trying to devise unique, creative
strategies on what to do including, as I say, I will drive
people now. If I can find homes for them, we will drive them
there. I mean, I will contact their family members ahead of
time to get them to come pick people up, and mind you, we are
happy to do this, but I don't think in anyone's estimation
sheriffs should be doing this. We are supposed to lock people
up, and that is really sort of supposed to be the end of it,
but there is nothing else out there, and in our county in
particular, it has really been bad, and it is desperate, and it
is really heartbreaking. I talk with the detainees frequently,
and do we have bad people in the jail who have committed
offenses who have mental illness? Yes, we have those. The vast
majority of them, though, are good people who are suffering
from mental illness and the reason they are there is because of
the mental illness. It is not because they are a criminal, and
yet we treat them like criminals, they are housed with
criminals, and then when we leave them, we basically pat them
on the back and say good luck and we will see you soon, and
then we are all puzzled that they are back with me.
Ms. Schakowsky. So it is not just a matter then of driving
them to a place. It is that at the end of the day there is no
place for many of them, right?
Sheriff Dart. There is no place for them, and there is no
one to work with them because they need a certain level of case
managing to make sure they stay on their meds, that when they
do go into crisis they are not left to doing what is going on
right now, which they call myself and my staff and we try to
figure out what we can help them with. There are things that we
can do that will not be expensive that can help and it be a
continuum of care. It could work with people. It won't be 100
percent successful but it can't conceivably be any worse than
what we do now.
Ms. Schakowsky. And what are those simple things?
Sheriff Dart. Oh, upon leaving the jail, if I had someone
from a county agency, State agency that would literally be
their case manager who would just literally work with them
through housing issues, staying on their meds so that they
don't start self-medicating which is, you know, no surprise
that we are having this heroin epidemic in our county because
it is the next best thing to their meds is the heroin and so
cheap these days. They stay on their meds. Housing--there is
some housing available. It is not the best but it is not that
expensive. I was paying for housing out of my own budget but I
have run out of money now. So as Judge Leifman said, if we had
a continuum working with the medical side but also with the
judiciary, we could have something that could be somewhat of a
model for a lot of people and not that expensive.
Ms. Schakowsky. Thank you very much, and thanks for what
you are doing.
Sheriff Dart. Thank you so much. It is great seeing you.
Mr. Murphy. I just want to follow, Sheriff Dart. You heard
Chief Biasotti talk about New York has assisted outpatient
treatment where they make sure, as long as that person has been
shown to be a safety risk or they have had an episode of
violence or jail time before, they can work with a judge and
they work on an agreement to stay on their medication and get
in treatment. Now, I understand you don't have that in Cook
County. Am I correct?
Sheriff Dart. No. We had some intervention just literally
days ago from our State Supreme Court to try to rearrange and
help our local judiciary in doing their job, but we have not
had engagement from our judiciary. I will be honest with you:
you need an enlightened judiciary who clearly understands the
distinction between criminal law and mental illness and know
that there are other paths to go. Because otherwise you are
left with, frankly, Mr. Chairman, isolated judges who get it,
who will run certain courts and frankly take risks. We for
years now, as I say, have been putting all these files together
to hand to the public defender to just show the mental health
background here, the lack of criminality, and yet they go up
and they might as well be talking in a foreign language to the
judge. The judge does the same thing. They throw them in the
jail and we continue to do the same work.
So an enlightened judiciary that is engaged with it, and it
does happen in other jurisdictions. It would be absolutely
remarkable. It would save money.
Mr. Murphy. Thank you. Mrs. Ellmers, you are recognized for
5 minutes.
Mrs. Ellmers. Thank you, Mr. Chairman, and again, thank you
to the panel. This is one of those situations where I have
questions for every one of you, but unfortunately, we don't
have enough time for that, so I will try to stay focused to the
point of how we can as legislators help this issue and try to
focus on those areas where we think there is the greatest need,
at least to get it started, because Mr. Dart, as you have
pointed out, we are in a pretty bad place right now so anything
we do is going to improve the situation, and I am very
concerned about those who are being released from jail and, you
know, not able to continue their treatment, because as you have
pointed out, it is just cyclic, and Mr. Biasotti as well.
Ms. Ashley, I do want to go back to one of the issues that
has been raised, and I know we are discussing medical coverage.
I know some of my colleagues are saying if we just had a bigger
Medicaid system, that that might actually help the situation.
You know, obviously you know we are dealing with that every day
here, trying to make our health care coverage system work
better. If I remember correctly from your testimony and
previous questions, you said you have private insurance that
your son was able to receive treatment under. Is that correct?
Ms. Ashley. Yes, it is. I have him as a disabled adult
under my insurance.
Mrs. Ellmers. OK. So you actually have insurance coverage
but still had the difficulties. It wasn't just an issue of here
is my insurance card, therefore I am going to get mental health
services for my son?
Ms. Ashley. Right. In fact, he is denied some services in
the community because he does have private insurance.
Mrs. Ellmers. I see. OK.
Ms. Ashley. Even though he has SSI and Medi-Cal, they have
no way to bill the insurance to get it denied and then go on
Medi-Cal, so I don't even have access to a lot of the support
services that are available in my community because he is on
private insurance, and people have even told me to take him off
private insurance, and really, having private insurance is what
gets him hospitalized quickly because the lights go off when
they see that I have private insurance versus Medi-Cal or
Medicaid.
Mrs. Ellmers. I see. Now, to that point, one of the things
that I was wondering, when you were describing your situation
in the emergency room, and I have seen this in so many
hospitals where they literally brought me to the designated
area in the emergency room that they have literally put
together because of this situation so that they can give the
best treatment possible but they are still hampered because
they are obviously not a psychiatric unit, and they are dealing
with the situation. Was he able to at least start receiving
mental health treatment while he was there in the emergency
room? I mean, was that pretty much at a standstill until he
received the psychiatric bed?
Ms. Ashley. Right. He was put in four-point restraints and
heavily sedated until they transferred him to the hospital.
Mrs. Ellmers. OK. And you did mention that, so I thank you
for that. And again, that is an area we are trying to fix. You
know, there are so many pieces and parts to this issue.
Mr. Biasotti, one of the things that I would like to
clarify even just for committee is the difference between civil
commitment and forensic commitment, if you can answer that
question, because I think that will help us as well because I
think sometimes we do find ourselves again struggling with the
situation of those who do not acknowledge that they have a
problem and yet they are having a psychotic episode.
Chief Biasotti. And that is where the problem lies. The
police will bring the person from their home or from wherever
the instance occurs to the emergency room, usually against
their will, under a State code for imminent dangerousness and
then they are relying on the interview at the hospital for the
psychiatrist to make a determination that they meet the
standards to hold for a 72-hour period for evaluation for
commitment under that standard. So I think Dr. Geller could
probably help me with the difference between the civil--I am
more familiar with how we would do it.
Mrs. Ellmers. Dr. Geller, would you like to expand on that
then?
Dr. Geller. Sure. Every State has its mental health act,
and that allows people to be civilly committed, usually on a
standard of dangerous to self, dangerous to others or gravely
in need of care, and there is no crime involved. Forensic
commitment would mean that a person has been charged and booked
and then they are going to be committed usually initially for a
determination of competency to stand trial, criminal
responsibility, or both, that you heard about earlier. If they
cannot stand trial or are found not guilty by reason of
insanity, then they can be further committed under a criminal
statute of that State.
Mrs. Ellmers. And yes, Dr. Hirshon?
Dr. Hirshon. I think it may vary state by state but in my
state, what happens is, there is a fixed number of inpatient
beds, and these individuals who are on forensic, not the ones
who have been convicted but they are often the pretrial folks
will be taking up the beds that I will be looking for from the
emergency department. So it doubly impacts it because it then
backs up my system because the forensic folks are being housed
in that situation.
Chief Biasotti. And if I could add, from a law enforcement
aspect, most of the people that we are talking about we are
bringing in not because of crimes, we are bringing them in just
because of bizarre activity or dangerousness. The criminal
aspect, we would have to make an arrest and it would go through
the jail system and they would arrange for psychiatric
evaluation.
Mrs. Ellmers. And Judge Leifman, I think you look like you
wanted to indicate, and I realize I have gone over my time but
I would love to hear from you.
Judge Leifman. What is happening is, the forensic beds are
actually taking over the civil beds, because it is
constitutional, because if you are arrested on a felony
generally and you are incompetent to stand trial, you have to
go----
Mrs. Ellmers. To a----
Judge Leifman. --for competency restoration. So as the
States don't want to expand those budgets, they just start to
use the civil beds for forensic beds. So it is really creating
this horrible pressure.
Mrs. Ellmers. I see. Well, thank you all, and Mr. Rahim too
and Ms. Ashley for your personal stories. It is so important
for us to hear because we need to understand how we can deal
with this situation better, and again, thank you to all of you.
This has been a very, very good subcommittee hearing, and I am
hoping that we will really be able to fix this problem. Thank
you.
Mr. Murphy. Thank you, Mrs. Ellmers. I now recognize Mr.
Harper for 5 minutes.
Mr. Harper. Thank you, Mr. Chairman, and I thank each of
you for being here and helping us, and we hope in the process
we will be able to look at some suggestions and directions and
things that may help you.
Chief Biasotti, if I could ask you, you know, you have
described obviously law enforcement being the front line on
counteracting the impacts of serious mental illness in the
community. What kind of burden is this on your resources and
your department?
Chief Biasotti. Well, that is the problem. That is what my
paper focused on, and it was that most police agencies are very
small in this country. The big cities are the anomalies. So for
instance, in my department, which is considered midsized with
an authorized staff of 50 officers, we will have three or four
cars per shift, a minimum of three on the road per shift. So
normally when we deal with a severely mentally ill person who
is acting violent, it requires at least two of our officers. So
that is two out of three people available. Now we have one
officer for a municipality, a good-sized municipality, until
those officers are free. A lot of times the ambulance can't
take them because they are too combative and the hospital wants
you to stay with them while they are in the emergency room
until they make a determination as they are staying, which is
because if they decide they are not staying, they don't want
this psychotic person in their lobby and you need to take them
back to where you came from. So it is a great depletion of
resources for law enforcement nationwide, especially those in
the rural areas.
Mr. Harper. You know, I actually was a city prosecutor for
about 6 years before I came here, and that was always the
thing, and I appreciate what you said you do because sometimes
you know they don't need to be incarcerated; they need to get
help. Because not every department does it that way. So I want
to commend you for that.
Chief Biasotti. Well, it is difficult because you also have
a crime victim that doesn't understand why the person that
broke into their house is not going to jail, so you have to
have cooperation on a lot of levels. But also to that end, what
I wanted to bring up quickly is, I got to work with Governor
Cuomo's office on the SAFE Act, the back end, Kendra's Law, and
one thing that I think we are hopeful is going to make a change
is, one of the changes in Kendra's Law mandates that in prison
settings, those who are receiving psychiatric care in the
prison will be evaluated upon release for inclusion into an
assisted outpatient treatment program, which hadn't happened
before. Before that, your time is up and you're out the door
and there goes your treatment. So we are hoping that that is
going to make changes and lessen recidivism.
Mr. Harper. Thank you very much.
Dr. Evans, I was looking at your title as we were going
here, and I am also seeing what Ms. Ashley has gone through on
a personal level, and what you have too, Chief. I have a 24-
year-old son with fragile X syndrome, so he has intellectual
disabilities. So how do you distinguish between, you know,
classic mental illnesses or someone with an intellectual
disability that someone who is not trained may not recognize?
Give us some wisdom or advice. What do you--how do you handle
that?
Mr. Evans. Sure. So the easy way to make the distinction is
that if a person has an intellectual disability, that is pretty
much permanent. So those kinds of disabilities are lifelong,
and our goal there is not necessarily recovery but it is really
to help people have a high quality of life, to have self-
determination. Mental illnesses are treatable, and one can have
a very severe mental illness, schizophrenia, for example,
bipolar illness, and can recover and can do well. It doesn't
happen all the time but the majority of the time and so that is
really the distinction. We work with people differently based
on that.
Mr. Harper. You know, with my son, if he were out by
himself, if he was maybe in a sensory overload moment, it might
be misinterpreted as to what he has, so training and
understanding and realizing that every case, every person is
different I know is an important thing for you.
Mr. Evans. It is, and I think that educating the community
about mental illnesses and intellectual disabilities is a real
important part of this because you have heard the impact that
stigma has on people reaching out for help, on the shame that
comes with that, and I think that our strategies have to not
only include how do we change the service system but like we
have done with other illnesses like cancer. You know, 30, 40
years ago, people used to whisper that and now people have
marches about that and walks about that, and I think it has
changed how people reach out for help when they need it. It has
changed how we funded research and treatment. And I think the
same thing applies to mental illness and behavioral health
conditions.
Mr. Harper. Thank you, Dr. Evans, and thanks to each of
you. Mr. Chairman, I yield back.
Mr. Murphy. Thank you. Dr. Burgess asked, we have two items
here from the New York Times and from Freedom magazine
regarding some cases from 1992 and 1993 that he would like to
have submitted into the record, so without objection.
[The information appears at the conclusion of the hearing.]
Mr. Murphy. And Ms. DeGette, you have a clarifying
question?
Ms. DeGette. I just have a clarifying comment, Mr.
Chairman, and I just want to say again, I have been on this
subcommittee for 18 years, and this is, I think, maybe the best
panel we have ever had, so thank you all for coming. You have
practical solutions. You had different takes on the mental
health system, and I hope that each of you will be willing to
make yourselves a resource to the chairman and myself as we
move forward in our efforts.
Chief, you referred to Kendra's Law, and I just wanted to
put in the record what that is, so you can correct me if I am
wrong. I understand what this is. It is a law that was passed
in New York that establishes more structured treatment combined
with resources across the mental health system, and it is
designed to get treatment to folks earlier on without having
them participate in the penal system like Sheriff Dart was
talking about or in the emergency room system. It is designed
to get them treatment. But of course, you have to have an
investment to do that of resources.
The chairman and I were up here talking about this, and if
you did have this investment of resources and you were really
able to implement things like this, it would actually probably
save money because you wouldn't be putting these people in
incarceration or in very expensive ER situations. Every single
person here is nodding their head. I would like to just say
that for the record.
Thank you very much.
Chief Biasotti. If I can say, the shame of it is, we have
45 States that have a very similar law but very few use it.
Ms. DeGette. Because they are probably not putting the
resources into it, right?
Chief Biasotti. That is correct.
Ms. DeGette. Thank you. And we are going to try to work to
see what the federal partnership that we can have with all 50
States to help this along.
Thank you, Mr. Chairman.
Mr. Murphy. Thank you. And Chief, along those lines, I
understand, for example, California has a law on the books but
only Nevada County, only one county, uses it.
Chief Biasotti. In California, it is optional by county,
and only one county, correct.
Mr. Murphy. Let me say this. Deep thanks--oh, Dr. Burgess
wants a brief comment.
Mr. Burgess. Just as a brief follow-up. Dr. Evans, in your
testimony you talk about the introduction of peer specialists.
This has come up before in briefings that we have had. This
strikes me as likely one of the most cost-effective ways to get
rational treatment decisions and to keep people in their
treatment. So I do hope you will share with the committee your
experience with that. We are constrained under budgetary rules.
We can never score a savings from something that will actually
save money. It always scores as a cost. But perhaps this is one
of those areas where spending the money wisely would in fact be
a good investment. I thank you for bringing that to our
committee today.
Mr. Evans. Could I just----
Mr. Burgess. Sure.
Mr. Murphy. Real quick.
Mr. Evans. I think that there are data that support that
peer services are cost-effective. I think it is probably the
most important thing that we have done in our service that not
only gives people hope but one of the real challenges is
keeping people engaged in treatment, and we have found nothing
that is more effective than a person who has gone through the
experience, connecting with another individual, and keeping
that person connected, giving that person hope, frankly. It
makes a huge difference, and we have one program where we have
instituted peers. We have reduced our crisis visits by a third,
and half of those visits would have resulted in an inpatient
stay. So we have saved millions of dollars, we believe, by
implementing peer services.
Mr. Burgess. Thank you. I yield back.
Mr. Murphy. Mr. Rahim, you wanted to comment on that?
Mr. Rahim. Again, thank you so much for giving patients
voice, and I think a couple of words. I know Mr. Dart talked
about enlightenment, but I think enlightenment means
compassion, dignity and education. So I think each of us has an
ability to be compassionate and we have ability to treat each
patient as an individual and with dignity, and I think through
contact with people who are doing well and then that follow-up
education as a foundation and groundwork, we can do so much
good. So I do thank you again.
Mr. Murphy. And again, my thanks to the whole panel. Just a
couple of suggestions. While you are in town, I hope you stop
in at your Member of Congress and say it is important to do
some mental health reforms.
I am committed to do this and I know Representative DeGette
is too. It has been since 1963, as you referenced, Dr. Geller,
the last time this country really did some major mental health
reforms. It is long overdue. I know you are all passionate
about this but I hope you energize your own Members of Congress
as well to help them understand the importance of moving
forward on this.
Even though you spoke for 5 minutes and you added a few
minutes to other things, oftentimes people go through life and
wonder if their voice makes a difference, it does. Yours does,
and it will continue to echo throughout the House of
Representatives and this Nation. So I thank you a great deal
for all that. And Mr. Rahim, you used the word ``hope.'' Where
there is no help, there is no hope, and we will make sure we
continue to work on that help.
So in conclusion, again, thank you to all the witnesses and
members that participated in today's hearing. I remind members
they have 10 business days to submit questions for the record,
and I ask that all witnesses agree to respond promptly to the
questions. Thanks so much. God bless.
[Whereupon, at 12:25 p.m., the subcommittee was adjourned.]
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