[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
21ST CENTURY CURES IMPLEMENTATION: EXAMINING MENTAL HEALTH INITIATIVES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
JULY 19, 2018
__________
Serial No. 115-154
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
_________
U.S. GOVERNMENT PUBLISHING OFFICE
35-691 WASHINGTON : 2019
COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee GENE GREEN, Texas
STEVE SCALISE, Louisiana DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California
ADAM KINZINGER, Illinois PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida PAUL TONKO, New York
BILL JOHNSON, Ohio YVETTE D. CLARKE, New York
BILLY LONG, Missouri DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana KURT SCHRADER, Oregon
BILL FLORES, Texas JOSEPH P. KENNEDY, III,
SUSAN W. BROOKS, Indiana Massachusetts
MARKWAYNE MULLIN, Oklahoma TONY CARDENAS, California
RICHARD HUDSON, North Carolina RAUL RUIZ, California
CHRIS COLLINS, New York SCOTT H. PETERS, California
KEVIN CRAMER, North Dakota DEBBIE DINGELL, Michigan
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
Subcommittee on Health
MICHAEL C. BURGESS, Texas
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
JOE BARTON, Texas ELIOT L. ENGEL, New York
FRED UPTON, Michigan JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee DORIS O. MATSUI, California
ROBERT E. LATTA, Ohio KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
C O N T E N T S
----------
Page
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 1
Prepared statement........................................... 3
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Prepared statement........................................... 5
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 6
Prepared statement........................................... 8
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 9
Prepared statement........................................... 10
Witnesses
Elinore McCance-Katz, Ph.D., Assistant Secretary for Mental
Health and Substance Use, Substance Abuse and Mental Health
Services Administration........................................ 11
Prepared statement........................................... 14
Answers to submitted questions \1\........................... 58
Submitted Material
Statement of Texas Tech University Health Sciences Center,
submitted by Mr. Burgess....................................... 43
Statement of the American Academy of Pediatrics, submitted by Mr.
Green.......................................................... 46
Statement of the American Psychiatric Association, submitted by
Mr. Green...................................................... 47
Statement of the American Psychological Association, submitted by
Mr. Green...................................................... 48
Statement of the National Child Traumatic Stress Network,
submitted by Mr. Green......................................... 46
Article entitled, ``Nazis separated me from my parents as a
child. The trauma lasts a lifetime,'' The Guardian, June 18,
2018, submitted by Ms. Schakowsky.............................. 51
Statement of the Anti-Defamation League, submitted by Ms.
Schakowsky..................................................... 54
----------
\1\ The committee did not receive a response to Ms. McCance-
Katz's submitted questions for the record by the time of
printing.
21ST CENTURY CURES IMPLEMENTATION: EXAMINING MENTAL HEALTH INITIATIVES
----------
THURSDAY, JULY 19, 2018
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:03 a.m., in
room 2123, Rayburn House Office Building, Hon. Michael Burgess,
M.D. (chairman of the subcommittee) presiding.
Present: Representatives Burgess, Guthrie, Latta, Lance,
Griffith, Bilirakis, Long, Bucshon, Brooks, Mullin, Hudson,
Carter, Walden (ex officio), Green, Schakowsky, Matsui, Castor,
Kennedy, DeGette, and Pallone (ex officio).
Staff Present: Jennifer Barblan, Chief Counsel, Oversight
and Investigations; Daniel Butler, Legislative Clerk, Health;
Karen Christian, General Counsel; Adam Fromm, Director of
Outreach and Coalitions; Ed Kim, Policy Coordinator, Health;
Ryan Long, Deputy Staff Director; James Paluskiewicz,
Professional Staff Member, Health; Kristen Shatynski,
Professional Staff Member, Health; Jennifer Sherman, Press
Secretary; Austin Stonebreaker, Press Assistant; Josh Trent,
Chief Health Counsel, Health; Hamlin Wade, Special Advisor,
External Affairs; Jacquelyn Bolen, Minority Professional Staff;
Jeff Carrol, Minority Staff Director; Waverly Gordon, Minority
Health Counsel: Tiffany Guarascio, Minority Deputy Staff
Director and Chief Health Advisor; Samantha Satchell, Minority
Senior Policy Analyst; Andrew Souvall, Minority Director of
Communications, Outreach and Member Services; and C.J. Young,
Minority Press Secretary.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. The Subcommittee on Health will now come to
order. The chair recognizes himself 5 minutes for the purpose
of an opening statement.
So today we convene and hold an oversight hearing on the
mental health division of the 21st Century Cures Act which was
signed into law in December 2016. On the anniversary of the
House passage of 21st Century Cures, this subcommittee held a
hearing on the sections of the law that the National Institute
of Health and the Food and Drug Administration are
implementing. Today we have Dr. Elinor McCance-Katz, the
assistant secretary for Mental Health and Substance Use, here
to testify before us about the work that the substance abuse
and Mental Health Services Administration is doing to address
our country's mental health needs.
The mental health title of 21st Century Cures was based
upon the Helping Families and Mental Health Crisis Reform Act
of 2016 which passed the House by a vote of 422 to 2 prior to
its inclusion in the Cures bill. This legislative effort
represents the most significant reforms to the mental health
system in more than a decade.
The first provision within the mental health division
strengthened the leadership and the accountability of SAMHSA
including establishing the position that Dr. McCance-Katz now
holds. One of her duties as the assistant secretary is to
develop a strategic plan by the end of this fiscal year.
Cures also strengthened existing programs, including
SAMHSA's two biggest programs, the Community Mental Health
Services Block Grant and the Substance Abuse Prevention and
Treatment Block Grant. Given that each State and community is
different, this law provides flexibility to States to address
their unique mental health needs. Additionally, the law
authorized the National Mental Health Policy Laboratory to
carry out existing and new activities under the mental health
policy umbrella including awarding grants for promising service
delivery models and expanding evidence-based programs.
Access to mental health and substance use disorder care is
vital to the overall health of our Nation. According to the
National Alliance on Mental Illness, approximately one in five
adults in the United States experience mental illness per year.
Of those adults suffering from mental illness, only a little
more than 40 percent receive mental health services in the past
year. Title 9 of the 21st Century Cures Act focused on
promoting access to mental health and substance use disorder
care.
The programs included in this title authorized and
strengthened several existing programs that previously had not
been in statute. Some of these programs provide grants to
eligible entries that provide mental health and substance use
disorder services to homeless individuals and jail diversion
programs. Additionally, the title authorized the program to
further integrate primary care and behavioral health services
through demonstration projects. Notably, the 21st Century Cures
Act expanded the target population of this integration to
include additional populations such as certain qualifying
children and adolescents.
The Centers for Disease Control and Prevention recently
released a vital signs report that showed a rising suicide rate
across the United States. In 2016, we lost nearly 45,000 lives
to suicide. 21st Century Cures aimed to provide additional
suicide prevention resources by codifying the National Suicide
Prevention Hotline and authorizing the Garrett Lee Smith
Suicide Prevention Resource Center and Youth Suicide Prevention
State Grants.
The existence of all of these programs would be far less
impactful if we did not have an adequate work force to provide
services. Therefore, there was an entire subtitle directed to
strengthening the mental and behavioral healthcare workforce
through training grants, demonstration programs, and other
means.
Cures established several new grant programs to address
mental health needs in populations such as Mothers and
Children. One program provides grants to support Statewide or
regional pediatric mental health care telehealth access
programs. Such programs could be especially helpful in early
identification and treatment of mental health issues in school-
age children. This is especially critical because 50 percent of
all chronic mental illness begins by age 14.
21st Century Cures made meaningful long-sought reforms to
our mental health system and is the result of thoughtful
bipartisan legislation created over the course of several
years. While this law reflects on our diligence and our
commitment to improving America's overall mental health, there
is work that remains to be done.
I will yield back the balance of my time and recognize the
ranking member of the subcommittee, Mr. Green, 5 minutes for an
opening statement, please.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Hon. Michael C. Burgess
Good morning. Today we convene to hold an oversight hearing
on the mental health division of the 21st Century Cures Act,
which was signed into law in December 2016. On the anniversary
of House passage of 21st Century Cures, this Subcommittee held
a hearing on the sections of the law that the National
Institutes of Health and the Food and Drug Administration are
implementing. Today, we have Dr. Elinore McCance-Katz, the
Assistant Secretary for Mental Health and Substance Use, here
to testify before us about the great work that the Substance
Abuse and Mental Health Services Administration (SAMHSA) is
doing to address our country's mental health needs.
The mental health title of 21st Century Cures was based
upon the Helping Families in Mental Health Crisis Reform Act of
2016, whichpassed the House by a vote of 422-2 prior to its
inclusion in Cures. This legislative effort represents the most
significant reforms to the mental health system in more than a
decade.
The first provision within the mental health division
strengthened the leadership and accountability at SAMHSA,
including establishing Dr. McCance-Katz's position. One of her
duties as the Assistant Secretary is to develop a strategic
plan by the end of this fiscal year.
Cures also strengthened existing programs, including
SAMHSA's two biggest programs, the Community Mental Health
Services Block Grant and the Substance Abuse Prevention and
Treatment Block Grant. Given that each state and community is
different, the law provides flexibility to states to address
their unique mental health needs. Additionally, the law
authorized the National Mental Health Policy Laboratory to
carry out existing and new activities under the mental health
policy umbrella, including awarding grants for promising
service delivery models and expanding evidence-based programs.
Access to mental health and substance use disorder care,
especially in the midst of an opioid epidemic, is vital to the
overall health of our nation. According to the National
Alliance on Mental Illness, approximately one in five adults in
the United States experience mental illness per year. Of those
adults suffering from mental illness, only 41 percent received
mental health services in the past year. Title IX of 21st
Century Cures focused on promoting access to mental health and
substance use disorder care.
The programs included in this title authorized and
strengthened several existing programs that had not been in
statute. Some of these programs provide grants to eligible
entities that provide mental health and substance use disorder
services to homeless individuals and jail diversion programs.
Additionally, the title authorized a program to further
integrate primary care and behavioral health care services
through demonstration projects. Notably, 21st Century Cures
expanded the target population of this integration to include
additional populations, such as certain qualifying children and
adolescents.
The Centers for Disease Control and Prevention recently
released a Vital Signs report that showed rising suicide rates
across the United States. In 2016, we lost nearly 45,000 lives
to suicide. 21st Century Cures aimed to provide additional
suicide prevention resources by codifying the National Suicide
Prevention Hotline and authorizing the Garrett Lee Smith
Suicide Prevention Resource Center and Youth Suicide Prevention
State Grants.
The existence of all of these programs would be far less
impactful if we did not have an adequate workforce to provide
services; therefore there was an entire subtitle dedicated to
strengthening the mental and behavioral health care workforce
through training grants, demonstration programs, and other
means.
Cures established several new grant programs to address
mental health needs in populations, such as mothers and
children. One program provides grants to support statewide or
regional pediatric mental health care telehealth access
programs. Such programs could be especially helpful in early
identification and treatment of mental health issues in our
school-aged children. This is especially critical because 50
percent of all chronic mental illness begins by age 14. Another
program awards grants to states for the purpose of screening
and treating depression among women who are pregnant or who
have given birth in the past year.
21st Century Cures made meaningful, long-sought reforms to
our mental health system, and is the result of thoughtful,
bipartisan legislation crafted over the course of several
years. While this law reflects our diligence and our commitment
to improving America's overall mental health, there remains
much work to be done.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman, for holding today's
hearing on the implementation of the 21st Century Cures Act.
Today we will be examining Division C of the law which focuses
on mental health programs and activities administered by the
Substance Abuse and Mental Health Service Administration,
SAMHSA. I want to thank Dr. McCance-Katz, the assistant
secretary for Mental Health and Substance Use of SAMHSA for
joining us this morning.
The enactment of the 21st Century Cures in December of 2016
was a great achievement, particularly in a time of sharp
partisanship and gridlock. But the work started long before
2016 led by colleagues Fred Upton and Congresswoman Diane
DeGette. But all of us on the committee were participants.
In 2014, we set out on a mission to do something positive
to boost medical research and innovation, accelerate the
discovery and development of new cures and treatment, and
improve public health.
After countless hours devoted to roundtables, white papers,
hearings, and drafts, Cures enjoyed bipartisan support and
endorsements from over 700 organizations representing a full
spectrum of the stakeholders. The investment and new
authorities created by Cures are intended to go far in solving
today's complex scientific problems giving new treatments from
the lab table to the bedside and strengthening our nation's
public health infrastructure.
The Cures Act made several changes to mental health
authorities and programs implemented by SAMHSA reauthorizing
several existing mental health grant programs and creating new
programs. For example. The Cures Act Established a chief
medical officer within SAMHSA to assist in evaluating and
organizing programs within the agency and promote best
practices.
The law thoroughly requires SAMHSA to develop a strategic
plan every 4 years to identify priorities and including a
strategy for improving the recruitment, training, and retention
of a mental health workforce. The Cures Act also created a
national mental health policy laboratory and an inter-
department serious mental illness coordinating committee, which
issued a report to Congress last December to address the needs
of Americans suffering from serious mental illness and
suffering emotional disturbance, across Federal agencies. One
of the most important actions that the Federal Government can
take to help Americans suffering from mental illness and
emotional disturbance is ensuring they have the access to care.
Medicaid is the single largest payer for mental health
services in the United States. In 2015, Medicaid covered 21
percent of adults with mental illness and 26 percent of adults
with series mental health. I am concerned that actions taken by
the Trump administration to make it more difficult to receive
Medicaid and increase costs of health coverage more recently by
suspending risk adjustment payments to insurers covering high-
cost patients will make it more difficult for Americans
suffering from mental illness and emotional disturbance to
receive treatment they need to live in a full and healthy life.
Before I close, I must note that on the ongoing mental
health crisis created by the Trump administration regarding the
separation of children from their parents. The American Academy
of Pediatrics has emphasized that highly stressful experiences
like family separation can cause irreparable harm disrupting a
child's brain, architecture, and affecting his or her short-
and long-term health. This type of prolonged exposure is
serious stress known as toxic stress can lead to lifelong
consequences for these children.
Currently there are over 3,000 children who are forcibly
separated from their parents by Federal authorities. We must
hear how these family separations are impacting the mental and
emotional health of these children and what action SAMHSA is
taking to help these children recover from the trauma of family
situation.
Thank you, Mr. Chairman, and I would be glad to yield my
last minute to someone who would like a minute.
Nobody?
Diane? I will yield to my colleague from Colorado.
[The prepared statement of Mr. Green follows:]
Prepared statement of Hon. Gene Green
Mr. Chairman, thank you for holding today's hearing on the
implementation of the 21st Century Cures Act.
Today, we will be examining Division C of the law, which
focuses on mental health programs and activities administered
by the Substance Abuse and Mental Health Services
Administration (SAMHSA).
I would like to thank Dr. McCance-Katz, the Assistant
Secretary for Mental Health and Substance Use at SAMHSA for
joining us this morning.
The enactment of the 21st Century Cures Act in December
2016 was a great achievement, particularly in a time of sharp
partisanship and gridlock.
But the work started long before 2016. In 2014, we set out
on a mission: do something positive to boost medical research
and innovation, accelerate the discovery, development and of
new cures and treatment, and improve public health.
After countless hours devoted to roundtables, whitepapers,
hearings and drafts, Cures enjoyed bipartisan support and
endorsements from over 700 organizations representing the full
spectrum of stakeholders.
The investment and new authorities created by Cures are
intended to go far in solving today's complex scientific
problems, getting new treatments from the lab table to the
bedside and strengthening our nation's public health
infrastructure.
The Cures Act made several changes to mental health
authorities and programs implemented by SAMHSA, reauthorized
several existing mental health grant programs and created new
programs.
For example, the Cures Act established a Chief Medical
Officer within SAMHSA to assist in evaluating and organizing
programs within the agency and promote best practices.
The law further requires SAMHSA to develop a strategic plan
every four years to identify priorities, including a strategy
for improving the recruitment, training, and retention of the
mental health workforce.
The Cures Act also created the National Mental Health
Policy Laboratory and the Inter-Departmental Serious Mental
Illness Coordinating Committee, which issued a report to
Congress last December to address the needs of Americans
suffering from serious mental illness and serious emotional
disturbance across Federal agencies.
One of the most important actions the Federal Government
can take to help Americans suffering from mental illness and
emotional disturbance is ensuring they have access to care.
Medicaid is the single largest payer for mental health
services in the United States. In 2015, Medicaid covered 21
percent of adults with mental illness and 26 percent of adults
with serious mental illness.
I am concerned that actions taken by the Trump
Administration to make it more difficult to receive Medicaid
and the increase the cost of health coverage, most recently by
suspending risk adjustment payments to insurers covering high-
cost patients, will make it more difficult for Americans
suffering from mental illness and emotional disturbance to
receive the treatment they need to live a full and healthy
life.
Before I close, I must note the ongoing mental health
crisis created by the Trump Administration regarding the
separation of children from their parents.
The American Academy of Pediatrics has emphasized that
``highly stressful experiences, like family separation, can
cause irreparable harm, disrupting a child's brain architecture
and effecting his or her short- and long-term health. This type
of prolonged exposure to serious stress--known as toxic
stress--can lead to lifelong consequences for children.''
Currently, there are over 3,000 children who were forcibly
separated from their parents by federal authorities.
We must hear how these family separations are impacting the
mental and emotional health of these children and what action
SAMHSA is taking to help these children recover from the trauma
of family separation.
Thank you, Mr. Chairman, and I yield the remainder of my
time.
Ms. DeGette. Thank you very much.
I just want to thank you, Doctor, for coming today. And I
really look forward to hearing what SAMHSA is doing to
implement the reforms in 21st Century Cures. This really,
particularly the mental health aspects of the bill were issues
that this committee worked on for many years trying to get it
right. And I am not sure we yet have it right, but we are
certainly working in that direction. So thank you.
And I also want to echo what my colleagues are saying about
these kids at the border. I think we are making progress
reuniting them with their families, but we need to double our
efforts down, and we also need to make sure they get adequate
mental health counseling.
I yield back.
Mr. Burgess. The gentleman from Texas yields back.
The chair notes there is a vote on the floor. But with the
Committee's permission, we will finish with our opening
statements before adjourning for the vote.
And I will recognize the gentleman from Oregon, the
chairman of the full committee, Mr. Walden, for his opening
statement.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. Well, thank you very much, Mr. Burgess. We
appreciate that. And we appreciate your convening this hearing.
It is really important that we do oversight on how 21st Century
Cures and the wonderful bipartisan changes incorporated therein
are now being implemented. I want to thank our colleagues on
the committee who are here now, and certainly Dr. Tim Murphy
who was a real leader in the Congress on mental health reform
for his work on this as well. These policies were the result of
multiyear, multimember bipartisan congressional effort, and
they are based largely off the Helping Families in Mental
Health Crisis Act which passed the House in July of 2016 by a
sweeping vote of 422 to 2.
It is also important, as an authorizing committee, that,
once we pass legislation, we come back and review is it
working? Where can we improve? What is not working? And that is
why we are here today.
These provisions were ultimately folded into Cures which
was signed into law on December 13 of 2016. Division B of Cures
authorized these landmark reforms to our nation's mental health
laws, and they were long overdue.
When our committee first took on this, there were 112
Federal programs spread across eight Federal agencies designed
to address mental illness. And they cost taxpayers $130 billion
annually. So 112 programs, eight agencies, $130 billion. And
many of the programs had not been updated or reauthorized in
years.
In Cures, under the leadership of Fred Upton, our chairman
of the committee at the time, and Ms. DeGette and others, we
streamlined these programs and brought them into the 21st
century. We prioritized access to evidence-based programs and
best practices to make them available to providers across the
Nation. We granted States additional flexibility in
administering mental health block grants to address the
specific needs of their patient population. And we increased
oversight, transparency, and accountability for these programs.
Cures also made important progress in boosting resources
for suicide prevention. Too many of us have friends who have
lost loved ones to suicide. My dear friend and colleague,
Senator Gordon Smith from Oregon, tragically lost his son
Garrett Lee Smith to suicide 1 day before his son's 22nd
birthday. I worked hard with Senator Smith to authorize the
original Garrett Lee Smith Memorial Act which provides
information and training for suicide prevention, surveillance,
intervention, strategies for all ages. And I was proud to see
this important program reauthorized in Cures.
In a March funding bill which is now law, Congress provided
critical funding for nearly 30 sections of the provisions
within Cures, and these programs include the National Child
Traumatic Stress Network, the National Child traumatic Stress
Initiative, Mental and Behavioral Health Training Grants,
Assisted Outpatient Treatment, and the National Suicide
Prevention Lifeline. In addition, the bill also appropriated
more than $2.3 billion in new funding for mental health
programs and other training. These are resources that can mean
the difference, literally, between life and death.
It is also worth noting the promotion of integration of
primary and behavioral health care included in Cures. In
Wallowa County out the northeast part of my district and other
areas across rural Oregon, I have heard the success stories of
providers who have been able now to integrate their community
health center and their behavioral health services. We know it
works, but we also know there can be barriers to full
integration. So I would appreciate hearing from our witness
today about what you are seeing at the Federal level in this
space of integration of service.
Finally, I would like to note that the sections in Cures
devoted to substance use disorder. And just last month the
House passed H.R. 6, the Support for Patients in Communities
Act. That is the biggest legislative package to address a drug
crisis in American history. That bill started in this very
subcommittee. And our work on substance use disorder, however,
goes much further back, back to the lead up to the
Comprehensive Addiction Recovery Acts, CARA, and the Cures
legislation.
So this intersection between mental health issues and
substance abuse disorder is clearer now more than ever, and the
grants and programs authorized by Cures have set the table for
our work to combat the opioid crisis.
So I would like to thank our witness for joining us today
and the work that you are doing. Your position was created
under the very law that we are examining today. And I know we
are all eager to learn more about your work to coordinate
critical mental health services and programs across the Federal
Government.
Mr. Chairman, I will yield back the balance of my time.
[The prepared statement of Mr. Walden follows:]
Prepared statement of Hon. Greg Walden
I'd like to thank Dr. Burgess for convening this hearing
today to examine the meaningful mental health reforms enacted
into law with the 21st Century Cures Act, or Cures. These
policies were the result of a multi-year, multi-Congress
effort. They are based largely off the Helping Families in
Mental Health Crisis Act, which passed the House in July 2016
by a sweeping vote of 422-2.
The provisions were ultimately folded into Cures, which was
signed into law on December 13, 2016. Division B of Cures
authorized these landmark reforms to our nation's mental health
system that were long overdue.
When our committee first took this on, there were 112
federal programs spread across eight federal agencies designed
to address mental illness. They cost $130 billion annually, and
many of these programs had not been updated or reauthorized in
years.
In Cures, we streamlined these programs and brought them
into the 21st century. We prioritized access to evidence-based
programs and best practices to make them available to providers
across the country. We granted states additional flexibility in
administering mental health block grants to address the
specific needs of their patient population. And we increased
oversight, transparency, and accountability for these programs.
Cures also made important progress in boosting resources
for suicide prevention. Too many of us have lost loved ones to
suicide--my friend and colleague Senator Gordon Smith from
Oregon tragically lost his son Garrett Lee Smith to suicide,
one day before his 22nd birthday. I worked hard with Senator
Smith to authorize the original Garrett Lee Smith Memorial Act,
which provides information and training for suicide prevention,
surveillance, and intervention strategies for all ages. I was
proud to see this important program reauthorized in Cures.
In a March funding bill which is now law, Congress provided
critical funding for nearly 30 sections of provisions within
Cures. These programs include: The National Child Traumatic
Stress Network, The National Child Traumatic Stress Initiative,
Mental and Behavioral Health Training Grants, Assisted
Outpatient Treatment, and the National Suicide Prevention
Lifeline. In addition, the bill also appropriated more than
$2.3 billion in new funding for mental health programs and
other training. These are resources than can mean the
difference between life and death.
It's also worth noting the promotion of integration of
primary and behavior health care included in Cures. In Wallowa
County and other areas of my district in Oregon, I've heard the
success stories of providers who have integrated their
community health center and behavioral health services. We know
that works, but we also know there can be barriers to full
integration and I'd love to hear from our witness about what
you're seeing at the federal level in this space.
Finally, I'd like to note the sections in Cures devoted to
substance use disorder. Just last month the House passed H.R.
6, the SUPPORT for Patients and Communities Act, the biggest
legislative package to address a drug crisis in history. That
bill started in this very subcommittee. Our work on substance
use disorder, however, goes much further back--back to the
leadup to the Comprehensive Addiction and Recovery Act (CARA)
and Cures.
The intersection between mental health issues and substance
use disorder is clearer now more than ever, and the grants and
programs authorized by Cures have set the table for our work to
combat the opioid crisis.
I'd like to thank our witness for joining us today. Her
position was created under the very law we are examining today,
and I know we are all eager to learn more about her work to
coordinate critical mental health services and programs across
the Federal Government.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
The chair recognizes the gentleman from New Jersey, the
ranking member of the full committee, 5 minutes for an opening
statement, please.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman.
It is a critical function of this committee to conduct
oversight and ensure that the legislation we pass is working as
intended, and that is why I think it is important to hold
hearings like these that allow us to learn directly from the
administration how policies are being implemented.
In December 2016, President Obama signed the landmark 21st
Century Cures Act into law which was truly a product of the
hard work of bipartisan members of this committee. And as we
know, the Cures Act addressed a wide range of issues facing our
healthcare system. However, today we will be focusing on the
provisions related to mental health. And I would like to thank
Dr. McCance-Katz for joining us today to testify on the
important work happening at SAMHSA.
The Helping Families and Mental Health Crisis Act, which
was ultimately passed as part of the Cures Act, was an
important step towards repairing our country's broken mental
health system. And I would specifically like to highlight a
provision that I worked hard with my colleagues to include in
this legislation that expanded an important set of Medicaid
benefits to children receiving inpatient psychiatric treatment.
But despite what was accomplished through this law, I think we
all agree our work on this issue is far from complete, and more
needs to be done to improve access to affordable mental health
treatment.
Unfortunately, in the time since we passed the Cures Act
the, Republican party has been fixated on repealing the
Affordable Care Act and cutting Medicaid, which is the single
largest payer of mental health services in the country. For
many people, Medicaid provides the only chance they have of
getting treatment for a mental health disorder, and I continue
to believe that any progress made by the Helping Families and
Mental Health Crisis Act would be completely reverse if the
Republicans ever succeed in their radical plans to repeal the
Affordable Care Act and drastically cut Medicaid benefits for
low-income individuals. These actions could cause catastrophic
harm to people with mental illness.
And speaking of helping families in crisis, I am reminded
that this committee has still not acted to help the thousands
of families currently in crisis because of the Trump
administration's cruel family separation policy. The
administration recklessly moved ahead with this inhumane policy
with little thought on how to address the long-term health
implications for the children torn away from their parents or
how to reunite them with their family. And this is a man-made
disaster by the Trump administration.
Public health advocates and healthcare providers have
already warned how devastating forceable separation can be to a
child's mental health and overall development. According to the
American Academy of Pediatrics, ``highly stressful experiences
like family separation can cause irreparable harm, disrupting a
child's brain architecture, and affecting his or her short and
long-term health. This type of prolonged exposure to serious
stress--known as toxic stress--can lead to lifelong
consequences for children.''
And as I said at the outset of my remarks, oversight is a
critical function of this committee. And so far Chairman Walden
has not been willing to hold an oversight hearing on the family
separation crisis, which I think we should have before we leave
for the August recess. And that tells me that the Republican
majority are really not as troubled by this crisis as some of
them claim to be.
So we must get to the bottom of how this happened so we can
ensure it never happens again. We must reunite these families
immediately. While we can't undue the trauma that these
children have already endured, the administration must take
every step possible to prevent further harm.
And with that, I yield back, Mr. Chairman.
[The prepared statement of Mr. Pallone follows:]
Prepared statement of Hon. Frank Pallone, Jr.
It's a critical function of this committee to conduct
oversight and ensure that the legislation we pass is working as
intended. That's why I do think it's important to hold hearings
like these that allow us to learn directly from the
Administration how policies are being implemented.
In December 2016, President Obama signed the landmark 21st
Century Cures Act into law--which was truly a product of the
hard work of bipartisan members of this committee. As we know,
the Cures Act addressed a wide range of issues facing our
health care system. However, today we'll be focusing on the
provisions related to mental health-and I'd like to thank Dr.
McCance-Katz for joining us today to testify on the important
work happening at the Substance Abuse and Mental Health
Services Administration (SAMHSA).
The Helping Families in Mental Health Crisis Act, which was
ultimately passed as part of the Cures Act, was an important
step towards repairing our country's broken mental health
system. I'd specifically like to highlight a provision I worked
hard with my colleagues to include in the legislation that
expanded an important set of Medicaid benefits to children
receiving inpatient psychiatric treatment. But despite what was
accomplished through this law, I think we'd all agree our work
on this issue is far from complete and more needs to be done to
improve access to affordable mental health treatment.
Unfortunately, in the time since we've passed the Cures Act
the Republican party has been fixated on repealing the
Affordable Care Act and cutting Medicaid-which is the single
largest payer of mental health services in the country. For
many people, Medicaid provides the only chance they have at
getting treatment for a mental health disorder. I continue to
believe that any progress made by the Helping Families in
Mental Health Crisis Act would be completely reversed if the
Republicans ever succeed in their radical plans to repeal the
Affordable Care Act and drastically cut Medicaid benefits for
low income individuals. These actions would cause catastrophic
harm to people with mental illness.
And speaking of helping families in crisis, I'm reminded
that this committee has still not acted to help the thousands
of families currently in crisis because of the Trump
Administration's cruel family separation policy. The
Administration recklessly moved ahead with this inhumane policy
with little thought on how to address the long-term health
implications for the children torn away from their parents or
how to reunite them with their family. This is a man-made
disaster by the Trump Administration.
Public health advocates and health care providers have
already warned how devastating forcible separation can be to a
child's mental health and overall development. According to the
American Academy of Pediatrics, ``highly stressful experiences,
like family separation, can cause irreparable harm, disrupting
a child's brain architecture and effecting his or her short-
and long-term health. This type of prolonged exposure to
serious stress--known as toxic stress--can lead to lifelong
consequences for children.''
As I said at the outset of my remarks, oversight is a
critical function of this committee and the fact that Chairman
Walden refuses to hold an oversight hearing on the family
separation crisis tells me that Chairman Walden and the
Republican majority are simply not as troubled by this crisis
as some of them claim to be--and I find that incredibly sad.
We must get to the bottom of how this happened so we can
ensure it never happens again. We must reunite these families
immediately--and while we can't undo the trauma that these
children have already endured--the Administration must take
every step possible to prevent further harm.
I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair notes there are under 5 minutes left on this vote
series. My understanding is there are four votes in this
series. That should take us a little less than 1 hour to
complete. And the committee will stand in recess until
immediately after votes.
[Recess.]
Mr. Burgess. I call the committee back to order. As we
recessed we had just concluded with member opening statements.
The chair will remind members that pursuant to committee
rules all member's opening statements will be part of the
record. And we do want to thank our witness for being here
today, and staying with us through votes, and taking time to
testify before the subcommittee.
Our witness will have the opportunity to give an opening
statement followed by questions from members. And today we are
going to hear from Dr. Elinore McCance-Katz, the Assistant
Secretary for Mental Health and Substance Use, United States
Department of Health and Human Services. We appreciate you
being here with us today Dr. McCance-Katz and you are
recognized for 5 minutes for an opening statement, please.
STATEMENT OF ELINORE MCCANCE-KATZ, PHD, ASSISTANT SECRETARY FOR
MENTAL HEALTH AND SUBSTANCE USE, SUBSTANCE ABUSE AND MENTAL
HEALTH SERVICES ADMINISTRATION
Dr. McCance-Katz. Chairman Burgess, Ranking Member Green
and members of the House Energy and Commerce Subcommittee on
Health. Thank you for inviting me to testify at this important
hearing.
In December of 2016, the 21st Century Cures Act was signed
into law. And I want to thank you for your vision and your
leadership on addressing the needs of Americans living with
mental and substance use disorders. We at the Substance Abuse
and mental Health Services Administration, the Department of
Health and Human Services have been actively implementing this
law since its enactment.
As the first Assistant Secretary for Mental Health and
Substance Use, a position created by the Cures Act, I take
seriously my duties outlined in Cures, including leadership and
accountability for behavior health, evidence based program
promotion and coordination across government. Part of
strengthening leadership and accountability includes a strong
clinical perspective at the agency. Cures codifies the role of
the chief medical officer. And we have taken this further by
establishing and expanding the Office of the Chief Medical
Officer to include two additional psychiatrists, a clinical
psychologist and a nurse practitioner.
A new component of SAMHSA created by the Cures Act is the
National Mental Health and Substance Use Policy laboratory. The
policy lab promotes evidence based practices and service
delivery through evaluation of models that would benefit from
further development, expansion, or replication. The policy
laboratory also provides leadership in identifying and
coordinating policies and programs related to mental and
substance use disorders, including needed policy changes.
The Interdepartmental Serious Mental Illness Coordinating
Committee, or ISMIC, was established by the Cures Act to ensure
better coordination across the Federal Government to address
the needs of adults with serious mental illness and children
and youth with serious emotional disturbances and their
families.
The ISMIC has been working within five key areas of focus,
strengthening Federal coordination to improve care, closing the
gap between what works and what is offered, reducing justice
involvement and improving care for those who are just as
involved, making it easier to obtain evidence-based healthcare
for mental and substance use disorders and developing finance
strategies to increase availability and affordability of care.
The Cures Act reauthorized the community mental health
services block grant and codified the first episode psychosis
set aside. If we can intervene early and with needed treatment
in psychosocial services, individuals are better able to manage
their serious mental illnesses similar to other chronic health
conditions.
In 2016, 44,965 Americans died by suicide. And according to
SAMHSA's surveys on drug use and health statistics, over 1.3
million Americans attempted suicide. The Cures Act authorized
SAMHSA's existing national suicide prevention lifeline. Recent
evaluation data showed that the majority of individuals served
and then interview following use of life line purported that
the intervention stopped them from completing suicide and
helped to keep them safe. At the same time, the highest rate of
suicide in America is among adults, aged 45 to 64 years old.
SAMHSA is grateful to the authorization of the adult suicide
prevention program and cures.
The purpose of this program is to implement suicide
prevention intervention programs focused on training of
healthcare professionals, to ask about suicidal ideations, and
to make safety plans and to assist people to treatment should
they endorse thoughts of wanting to end their lives.
One of SAMHSA's roles is it to oversee the implementation
of 42 CFR Part 2, the regulation governing confidentiality of
substance use disorder patient records. SAMHSA made substantive
updates to these regulations in 2017 and 2018. In compliance
with the Cures Act, SAMHSA held a listening session attend by
over 1,200 people in January 2018 to obtain input about Part 2
implementation. Themes included the need to align 42 CFR Part 2
in HIPAA, the need for technical assistance and training, the
importance of integrated care, and the use of electronic health
records.
The Cures Act also demonstrates Congress' commitment to
addressing the opioids crisis. Through implementation of CURE's
SAMHSA awarded $500 million in each of years 2017 and 2018. And
the State targeted response grant funding to States and
communities around the country. These funds support
comprehensive approaches to addressing the opioids crisis
through prevention, treatment and recovery services.
I feel strongly that we need to ensure that the direction
provided by Congress in Cures is followed with fidelity and the
highest quality service delivery possible. In order to achieve
this goal, I have reconfigured SAMHSA's technical assistance
approach from a grantee-based approach to one which supports a
robust national and regional technical assistance strategy
emphasizing training on evidence based and effective practices
to communities across the country.
Much work has been undertaken at SAMHSA and across HHS to
implement the Cures Act, but we know this work is far from
over. I look forward to continuing a strong partnership with
Congress, to help Americans living with mental and substance
use disorders and their families.
I am pleased to answer your questions today. Thank you.
[The prepared statement of Dr. McCance-Katz follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Dr. McCance-Katz, and thank you for
your testimony today. This concludes the witness opening
statement portion of the hearing. We will move to member
questions. I recognize myself 5 minutes for questions.
And I want to begin by asking unanimous consent to place
into the record a statement for the record by Dr. Billy Philips
from Texas Tech University Health Sciences Center, the Hall
Professor of Family Community Medicine, Professor of Public
Health and Executive Vice President for Rural and Community
Health at Texas Tech University describing their program of
Telemedicine, Wellness, Intervention, Triage and Referral.
Without objection so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. And Dr. McCance-Katz, I am submitting the
whole statement for the record. Let me just pull a couple of
pieces out of this. Dr. Philips tell us this program provides
school based screening assessment and referral services to
students that are typically struggling with behavioral and
mental health issues and is currently active in 10 west Texas
independent school districts.
This project uses telemedicine technology to link remote
rural schools that are without sufficient counselors,
psychiatrists, and other mental health service providers. It
also provides mental health recognition and training services
to educators and school resource officers to promote a greater
recognition and prompt referral.
He then goes on to describe in some detail how the program
runs and the coordination that occurs between their staff and
the staff of the school. Interesting he provides some
statistics. He says the impact area has an annual enrollment of
42,000 students in ten mostly rural school districts
surrounding Lubbock, Texas. They have created an environment
where students are empowered to help create a safe learning
environment and better morale.
Of that number, only a small fraction, 414 total, have been
referred by teachers. And we have been trained to recognize
those who will need to be referred to the larger program, the
team has screened out and triaged, by telemedicine, 215
students and 25 of those have been removed from the school
population, most by hospitalizations and a few by arrest. And
they believe they have averted tragic outcomes and started
others on a path towards healing.
So a very interesting program that they have developed for
school safety in their rural school districts in west Texas.
And I would just be interested in your thoughts as to how this
integrates with the work we did in Cures, and you are doing now
with Cures implementation.
Dr. McCance-Katz. Thank you for bringing that forward,
because this is a very important part of not only of Cures Act
but also a focus of the President's Federal school safety
commission. And so we have had the opportunity to speak to a
number of districts across the country, Texas being one of
them. And these kinds of innovative programs are exactly what
we need to better ensure--two things, one a safe environment
for students, a nurturing environment where they can learn.
And the second being one where we identify children early
who may have emotional or mental health issues that need to be
addressed and there are a number of ways to address those kinds
of mental health service needs via either integration directly
within the school system or through a close relationship with
other types of programs.
Some of the things that the Cures Act do that directly
effect those kinds of programs is that Cures reauthorized
several types of mental health programs that are oriented
toward children. And SAMHSA continues to implement those
programs.
So things like Project Aware which provides for
infrastructure of these types of services within schools in the
States, and programs that teach about mental health
psychological, mental health, and mental health first aid type
programs to help to identify youth early so that we can get
them the care and services that they need, Cures reauthorized
those programs and we are in the process right now of making
more awards through our granting system.
In addition, when we start talking about integration of
care, the certified community behavioral health centers that
Congress established for us represent a model that can be used
to provide those needed services to children who would be
referred from the school systems.
Mr. Burgess. Well, certainly I think use of that model will
be important. As I understand this program has been funded
entirely out of funds within Texas Tech University itself, but
they have set up the telemedicine portals, and the secure
connections, and the encrypting and all that is it necessary to
have those secure connections.
But I actually look forward to working with you and your
office on this and perhaps the White House as well, because I
do think they are on to something that is very, very important.
I am going to yield back to you, Mr. Green, and recognize
you for 5 minutes of questions.
Mr. Green. Thank you, Mr. Chairman. And again welcome, Dr.
McCance-Katz.
The 21st Century Cures Act was a landmark law and included
important provisions to strengthen mental and substance use
disorder care for women, children and adolescents. In
particular the Cures has reauthorized the National Child
Traumatic Stress Initiative which supports a national network
of child trauma centers and focuses on increasing access to
affected trauma focused interventions.
Can you explain how the National Child Traumatic Stress
Network operates? And what impact it has on improving the lives
of children impacted by traumatic stress.
Dr. McCance-Katz. Yes, the National Child Traumatic Stress
initiative is a program that is established in a large number
of States, it provides national technical assistance services
around issues of traumatic stress in children. This is a
program that not only trains practitioners and providers of
services, but also will do consultation within communities to
help them to address traumatic issues. So this is a very highly
regarded and valuable program.
Mr. Green. Following the chairman, do you know of any
grantees in the State of Texas off the top of your head?
Dr. McCance-Katz. I don't have the grantees dedicated to
memory. But I will tell you this we can get you that very
quickly.
Mr. Green. OK. Thank you. I appreciate it.
If children that are impacted by traumatic stress receive
early interventions and the trauma informed care they need, can
the long-term health affects of trauma be mitigated in any way?
Dr. McCance-Katz. Yes, they can. There is a fair amount of
literature on this in terms of how trauma affects children and
the ability to address those traumatic events in therapeutic
environments can mitigate the affects later in life.
Mr. Green. I am interested in how the National Child
Traumatic Stress Network is responding to the recent events
related to the family separations at the border as a result of
the Trump administration's zero tolerance. Is the network being
utilized to coordinate or facilitate services for children that
have endured this trauma as a result of family separation
policy?
Dr. McCance-Katz. Well, what I would say, Congressman
Green, is that SAMHSA itself is not involved in those issues.
Those issues are being dealt with by a different part of HHS,
the Administration for Children and Families and the Office for
Refugee Resettlement. Any provider within a jurisdiction can go
to a SAMHSA national program and ask for resources, but SAMHSA
itself is not directly involved in that.
Mr. Green. OK. Well, I was wondering, HHS is responsible
for those children, if you happen to find any information on
what is being done with HHS in the network for these children--
my concern about the National Children Traumatic Stress has a
document on its website that notes, children can recover from
traumatic separation and other traumatic experiences with
development of culturally and linguistically appropriate trauma
services for these children and their families, including
evidence based and trauma folks treatment. I would hope that
would be part of the process and obviously SAMHSA in that
effort.
In the interdepartmental serious mental illness
coordinating committee report that was released by SAMHSA last
December it listed five areas of focus, including increasing
availability and affordability of the care. Could a patient
suffering from a serious mental illness, and SMI or a serious
emotional disturbance, be denied health insurance--insurers as
having a preexisting condition?
Dr. McCance-Katz. So that is not my area of expertise. I
really don't feel comfortable commenting on the details of
health insurance. What I would say is that Medicaid is one of
the largest providers of mental health services through their
insurance program and they serve millions of Americans at this
very moment.
Mr. Green. Thank you, Mr. Chairman. I would also like to
ask unanimous consent to place into the record a statement by
the American Academy of Pediatrics opposing separation of
children at the border, the American Psychiatric Association,
opposing the separation of children from their parents. The
American Psychological Association regarding the traumatic
affects of separating families, and again the National Child
Traumatic Stress Network and key points on the traumatic
separation of refugee children and immigrant children.
I ask unanimous consent to place into the record.
Mr. Burgess. Without objection so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. The gentleman's time has expired.
Mr. Green. I yield.
Mr. Burgess. The gentleman yields back. The chair
recognizes the gentleman from Kentucky, Mr. Guthrie, 5 minutes
for questions.
Mr. Guthrie. Thank you, Mr. Chairman and thanks for being
here Dr. McCance-Katz.
I have a question, the CDC has found that less than half of
substance use disorder patients with multiple mental health
issues have ever received treatment for their mental health
issue. The commission suggests this is due to lack of access,
fear of shame, and discrimination, and a lack of motivation to
seek treatment. Would you discuss how you planned to encourage
and work with States using the State targeted response opioid
money to help patients with untreated mental health disorders?
I am from Kentucky and as you know we have a very large
population in need of these services, and the general public
who just need education and awareness of these services.
Dr. McCance-Katz. Yes, yes. Thank you for that question,
because we are very much engaged on that issue. And so the
State targeted response to opioids part of the Cures Act
provides funding for technical assistance and training within
the States. What we have now done at SAMHSA, what we have put
in place in February was to have a grantee whose requirement
was to establish teams within every State, multiple teams for
States with larger geographic areas, but these teams had to
have addiction experts and other types of mental health
expertise and physical healthcare expertise available so that
they could go into communities. Communities and providers
within those communities let their States know what kinds of
services, and training, and technical assistance, and these
teams go in and provide that on the spot.
And so we believe that that is going to be a way that we
establish evidence-based practice. We know that the co-
occurring rate of mental and substance use disorders is quite
high. And so if somebody has a substance use disorder, they
must be screened for mental health issues. We know that
treating one and not treating the other and the person who has
cooccurring disorders will not solve both problems. And these
teams are professionals. They are licensed within their States
and certified by their various regulatory boards to provide
that kind of technical assistance and training as part of their
own clinical practices and they are doing that in our
communities now.
Mr. Guthrie. OK thanks. And before my next question, I was
watching I guess a new TV show that is out that Amy Adams the
actress stars in. And several of the characters seem to have
addictions so I can't really tell where the show is going yet.
But at the very end of the show they had a public service
announcement for SAMHSA. I don't know if you knew that or saw
that. At the very end it says, if you have any issues or know
people who have, please call. I don't know if you are getting
any response from that, but I was pleased at the end of show
they were trying to show people how to reach out that have
addiction issues.
So my next question is for guidance issued via the 21st
Century Cures Act, SAMHSA has released extensive guidance for
consumers on how they can report parity concerns as well as
tools for health plans. Does SAMHSA have future plans to offer
providers additional pathways for addressing potential--this is
hard to say--offer providers additional pathways for addressing
potential parity violations or concerns?
Dr. McCance-Katz. So we are very pleased that we have a
portal that consumers can use where they can report what they
believe may by parity violations, difficulties they are having
with getting coverage for their mental health or substance use
problems. That portal will get them to the appropriate Federal
agency, be it labor, be it CMS, be it Treasury, so we are
pleased about that.
We also provide guidance--SAMHSA last summer did a 30-State
parity policy academy where we trained on issues related to
parity and MHPAEA and how States can make sure that the
appropriate attention is being paid so the people of their
States can get the services that they need.
Mr. Guthrie. Well thank you. And those are my two questions
and I appreciate you being here.
And I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back. The chair now recognizes the gentleman from New
Jersey, ranking member of the full committee, Mr. Pallone 5
minutes for questioning.
Mr. Pallone. Thank you, Mr. Chairman.
Doctor, the Cures Act included provisions that specifically
addressed child trauma. And as I noted in my opening statement
I continue to have grave concerns about the children forcibly
separated from their parents or guardians as a result of Trump
administration's zero-tolerance policy.
And I have sought information from the administration on
whether children in the office of refugee's care may have
experienced trauma. And my resolution of inquiry that was
debated by the committee last week specifically requested
documents on the long-term health implications of the family
separation policy on the children in ORR's care.
As HHS' leader on mental health issue, SAMHSA is uniquely
qualified to speak to the impacts of trauma and the long-term
health implications. So my questions are going to focus on
this. And it is not just me that has raised concern about the
health impacts of the family separation policy. This has been
echoed by numerous pubic health organizations and child health
advocates, including the American Academy of Pediatrics, the
American Public Health Association, Trust for America's Health
and the National Association of County and City Health
Officials.
So in fact the National Child Traumatic Stress Network,
which is administered by SAMHSA, notes ``that separation from
parents or primary caregivers is one of the most potent,
traumatic stressors a child can experience, especially under
frightening, sudden, chaotic or prolonged circumstances.'' What
is traumatic or toxic stress basically, if you don't mind?
Dr. McCance-Katz. Traumatic or toxic stress can be any of a
number of things that an individual would experience as
emotionally distressing and various individuals will have
different types of responses to that. In fact, as you
mentioned, one of them has been reported to be separation. But
I would suggest to you that there are lots of stressors that
these children have probably experienced in their travels to
the United States.
So not having seen any of these kids, not being able to
attribute what their distress might be about, it is hard to say
exactly what the etiology of any particular individual's
problem might be.
Mr. Pallone. So could you comment on how the circumstances
of separation increase the likelihood of traumatic or toxic
stress, could you comment on that?
Dr. McCance-Katz. Very hard to say. What I will say is that
if you were to look at the literature on traumatic stress, you
would see somewhere depending on the study you look at up to 43
percent of individuals will experience some type of traumatic
stress in their lifetime, most of them do not go on to develop
major mental disorders. And when you mitigate, when you relieve
that stressor, they do recover.
People have an amazing amount of resilience. That's why all
of us who are exposed to some type of stress don't develop
mental disorders, some do, we can't predict with reliability
who will.
Mr. Pallone. Then all the more reason why if you have had
separation to try to get the kids back together with their
parents, because then maybe they can recover.
Dr. McCance-Katz. And our Department is working very hard
on that. Our Secretary has spoken to that issue and they are
addressing it every single day.
Mr. Pallone. Well, I guess the problem that I have is that
you mention that SAMHSA is not involved in the child separation
issue that related from the zero-tolerance policy. But the
problem is that the Cures Bill required SAMHSA to coordinate
mental health services across the Federal Government. Do you
think that SAMHSA as a leader of mental health care for our
country should play a role in responding to this crisis at the
border?
Dr. McCance-Katz. SAMHSA has defined responsibilities. One
of those, as you mentioned in the Cures Act, is the National
Traumatic Child Stress Network and we do implement that and we
work with our grantees to make sure that they are providing the
services that are needed across this nation to serve Americans
who may be experienced with traumatic stress and their
children.
It is also a decision by others as to what agencies are
specifically involved in the day-to-day activities of any
particular event. So SAMHSA does what it is required to do by
the Cures Act and we stand ready to provide additional
assistance if it were requested.
Mr. Pallone. I don't want to put words in your mouth, but
it sounds like you would be willing to help but maybe no one at
the Department is asking you to. But you don't have to respond
to that.
I just think that it is clear that these families must be
reunified immediately and ensure that these kids have access to
the trauma informed prevention and mental health services in
order to recover and mitigate the harm experienced as a result
of this policy.
And I will leave it at that, because my time has run out.
Thank you.
Mr. Burgess. The gentleman's time has expired. The
gentleman yields back. The chair now recognizes the gentleman
from Virginia 5 minutes for questions please.
Mr. Griffith. Thank you very much. Mr. Chairman, thank you
for being here today, very important topics, Cures and CARA and
mental health are all so important. You have touched on a
number of things.
I am going to ask some questions that probably are not
answerable in the 5 minutes that we have. And so I will give
you an opportunity to answer, but recognize that I would like
for you to think about them and come up with answers if you can
and send them to us at a later date.
Dr. McCance-Katz. Certainly.
Mr. Griffith. So the first one is, in your testimony you
discussed concerns brought up about the enforcement of parity
protections, mental health, and other medicine or treatment. I
was in a meeting with Secretary Acosta where he brought up
similar concerns from the Department of Labor about the fact
they have enforcement authority under ERISA plans, et cetera,
but really have difficulty in the enforcement side of that. And
so the question is what tools are necessary? What suggestions
would you have for us about steps that we can take in the
Federal law to ensure compliance with mental health parity and
physical health parity? So the two are being treated the same
in our various plans. And I will give you an opportunity, but I
recognize that is probably an hour lecture as opposed to part
of an answer in a 5-minute segment.
Dr. McCance-Katz. So my quick answer to that would be that
the question is quite an important one. It is one that I would
want to seek legal counsel about.
Mr. Griffith. Yes.
Dr. McCance-Katz. And one that we will be happy to give a
written answer to.
Mr. Griffith. I appreciate that. And I would like an
extended answer because these issues are all complex.
Dr. McCance-Katz. Absolutely.
Mr. Griffith. Switching gears, I am talking to a principal
in one of my rural schools I represent a mostly rural district.
And we are talking about school safety and mental health is
obviously a major component in that. And he says look, we can
identify a child that has some issues and send them off for
evaluation, but because of the current state of privacy laws,
they can't tell us what is going on. And we don't need to know
everything that is going on in the child's life. But if there
are some things that we need to know like are they violent, do
they have a violent tendency, even if you don't expect them to
do something now, is there a violent component in their
emotional or mental issues. We can at least pay more attention,
maybe have them checked by the office so we can look in their
bookbag every day to see if they are bringing in contraband,
guns or other weapons or issues that we maybe ought to be aware
of.
So we have got no ability to do that. And so the question
is is there some way we can expand the knowledge base of folks?
And we have passed some bills here to try to make it more like
HIPAA, but that still wouldn't cover--that would be with drug
abuse, but it still wouldn't cover the school personnel who may
very well need to know what is going on. If you could get my
some answers on that back, if you have something quick, that is
great.
Dr. McCance-Katz. So what I will tell you is this is a
topic that is part of the Federal school safety commission that
is one of the areas that the President has asked us to look at.
And I will just go a little bit further, we will give you
something in writing as well, but part of the big problem here
is that providers, teachers, administrators don't understand
when they can communicate. And if there is a threat already
both HIPAA and FERPA allow communication, but this is not well
understood. And so one of things that we really have to do is
we have to work very hard to get that information out as to
just what these laws allow and what they don't allow.
Mr. Griffith. My time is running out, but I do want to jump
in and say, so here is the dilemma you get, if there is a
direct threat, yes, that is true or if you think they are going
to be harmful to somebody else at that moment, but if you just
detect that there may be a developing problem and that they may
be a threat in the future I don't think it covers.
Now we can certainly sit down and look at this. And so the
school personnel would like to know what signs should we be
looking for if this person might be starting to move further
into their issues with mental illness that might--right now
they are not a threat, but they have got some violent
tendencies that we need to keep an eye on, what should we be
looking for? They don't have a clue and they are with the child
every day during the week, most weeks. And so they are probably
the first people who could pick up on that.
I am going to flip to one more, we don't have time for the
answer, I apologize for that. And that is we did a lot of work
here trying to figure out how we could deal with adult
children, even if they are living in the home, have mental
health issues, also medical issues, and how do the parents get
to be interactive and I would love to help on that, I know Ms.
DeGette of Colorado struggled with this at some time.
Ms. DeGette. Yes.
Mr. Griffith. If we can be of assistance or if there is
something that you all have that we need to do in the code,
this committee on a bipartisan basis wants to help. We want to
fix the problem, but we don't want to give up all the privacy
rights and balancing the two are tough.
I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back. The chair now recognizes the gentlelady from
Illinois Ms. Schakowsky 5 minutes for questions.
Ms. Schakowsky. Thank you, Mr. Chairman.
Dr. McCance-Katz, I was going to--I guess I will ask this
question to start, given SAMHSA's leadership on traumatic
informed care and practice, has the Office of Refugee
Resettlement worked with SAMHSA to ensure the children being
held in their custody are receiving trauma informed care?
Dr. McCance-Katz. So I can say two things about that. One
is that the Office of Refugee Resettlement assures that these
children are getting both physical healthcare and mental
healthcare and they are getting that regularly. That is----
Ms. Schakowsky. OK. And the reason I was going to say I am
not going to ask you that because quite frankly I was pretty
shocked by your attitude that well, we all have trauma in our
life and most of us get over it. And they will probably get
over. You may have heard Congressman Green enter into the
record statements from a number of the professional health
organizations, the American Psychiatric Association, the
American Psychological Association, the American Public Health
Association, the American Academy of Pediatrics. And the
concern about the trauma.
I want to add into the record too a couple of other
articles of people and groups that actually weighed in that
were victims of long ago atrocities about separation of
children.
So I ask unanimous consent to enter into the record two
articles. The first from the Guardian: ``Nazis separated me
from my parents as a child. The trauma lasts a lifetime.'' That
is the one article.
Mr. Burgess. Without objection.
Ms. Schakowsky. On the second from the Anti-Defamation
League, ``Hidden children of the Holocaust open up about border
situation, saying policies separating migrant children from
parents is unconscionable.'' And they have in this article
talking about the lifelong affects which--so maybe it is fine
that they didn't contact you about that.
I wondered if you do have any----
Mr. Bucshon. I object. I have an objection to submitting
articles about the Nazis and comparing what the Nazis did to
what the current U.S. Government's policy is in the United
States. With clarification, I may remove my objection, but to
compare Nazis to the United States of America is something I
will object to and I won't allow those to be submitted to the
record.
Ms. Schakowsky. Well, then let me just comment on that in
defense, particularly of the Anti-Defamation League today
issued a statement on behalf of a group of hidden children of
the Holocaust who felt strongly compelled to oppose the Trump
administration's expanded ``zero tolerance'' policies.
Mr. Bucshon. I Object, Mr. Chairman.
Mr. Burgess. Objection is heard.
Ms. Schakowsky. I am going to ask for the yeas and nays.
Mr. Bucshon. We can resolve this if the gentlelady would
recognize there is no comparison between the current United
States Government and the Nazis.
Ms. Schakowsky. I recognize that there isn't, but this is
about a particular issue of separating children from their
parents and the long-term affect.
Mr. Bucshon. OK, I remove my objection thank you.
[The information appears at the conclusion of the hearing.]
Ms. Schakowsky. Thank you, I appreciate that.
I wanted to ask you about no touching policies. I have had
a hard time pinning down exactly what that is, if there is a
policy, if this is being done by the particular staffs at
particular places, because--it is unclear exactly if it is a
firm policy. But I certainly have heard of places for example,
and there have been articles, that a sister was not able to
embrace her younger brother, that they were told the children
may not touch each other, that staff may not come and hold
children that are in great distress. I wondered what kind of
trauma, if those decisions are trauma informed care?
Dr. McCance-Katz. It is really not possible for me to
comment on that, because I am not familiar with the details of
it.
Ms. Schakowsky. The issue of touching, are you not informed
about the effects of touching or comforting physical touching
when it comes to mental health?
Dr. McCance-Katz. What I am not familiar with is the agency
and its roles and----
Ms. Schakowsky. No, I am asking a more general question.
According to decades of psychological study, positive touch
from adults cannot only lower stress levels in the most, but
can have long-term beneficial affects if administered
regularly. And relatedly, a consistent lack of positive touch
has been shown to have detrimental affects on kids as they
mature. Do you agree with that?
Dr. McCance-Katz. I don't have an opinion on it, it is out
of context.
Ms. Schakowsky. Really? I am asking generally about an
issue that you are supposedly an expert on. Trauma informed
care. And this is not----
Dr. McCance-Katz. Let me just tell you that touching can
have all sorts of implications, good and bad. And so I----
Ms. Schakowsky. Do you agree with the statement----
Mr. Burgess. I think the witness has answered the question
and the gentlelady's time has expired.
I am going to go to Ms. Brooks from Indiana 5 minutes for
questions please. Dr. Bucshon next? Dr. Bucshon 5 minutes for
questions.
Mr. Bucshon. All right. Thank you. Well first of all thanks
for being here. I very much appreciate it.
I just want to say that I am opposed to separating children
from their families so I think all of us on both sides of the
aisle are. But I also have serious concerns and I wasn't going
to bring this subject up, but since it seems like my colleagues
on the other side are staying on message on this and every one
of them is going to talk about this, I feel that I will also. I
am also concerned about the thousands children coming
unaccompanied from and trekking thousands of miles across
Mexico, being brought by coyotes and drug cartels,
approximately 10,000.
I have just been down there so this is information I know,
many of whom have been sexually assaulted and abused. So I am
concerned about them also. Just so everyone knows, we have
about 12,000 children under our custody, 10,000 of which
approximately are unaccompanied that came with no adult, no
family member. It is a tragic circumstance.
As well as the families who are coming in currently, adult
males with children because they know that we don't have any
beds for them in the United States and if they come, we are
releasing with ankle bracelets into the United States, 200 to
300 of these people per day. Again, that is not my opinion,
that is what we are doing, because the cartels and coyotes know
our laws and when we don't follow the law they exploit it--or
when we do follow our law that needs to be changed and it is
Congress' fault, when we need to adjust these things.
But many of these people are coming in my view from the
past failed policies most recently of the Obama administration
on open borders and sanctuary cities and catch and release
being encouraged to send their children thousands of miles by
themselves. In fairness, their countries are in dire
circumstances and I can't say what I would do, but I do know
that the situation is much more complicated than is being
portrayed.
And I am also concerned about the millions of citizen
children every day who are being abused, neglected and
suffering traumatic problems. And we all know that that is a
difficult circumstance, that is all I am going to say on that.
Section 605 of Cures required SAMHSA to develop a strategic
plan every 4 years identifying priorities, including a strategy
for improving the mental health workforce. Additionally, your
testimony mentions engaging subject matter experts from across
the country, from academia hospitals, insurers, community
providers, State governments consumers, and family to inform
SAMHSA on the complex problems and it is a complex problem such
as workforce challenges among other things.
Can you expand a little bit on what SAMHSA is doing it
address the workforce challenges, particularly in rural areas
related to mental health? And let me just say this, I know
because I was a healthcare provider before, one of the big
challenges is financial support for this type of--these type of
services.
But can you expand on that a little bit?
Dr. McCance-Katz. I can. And thank you for the question. So
we have developed a new program that will be in place by
September 30th so the end of this fiscal year that sets up both
specialized programs around issues related to mental and
substance use disorders. So things like the teens that I
mentioned for the opioids crisis, we call it the State targeted
response, we have one for veterans, we have the National Child
Traumatic Stress initiative. We have a number of different
types of topic-related special national programs.
We have the new clinical support system for serious mental
illness that will address issues around serious mental illness.
We also are establishing technical assistance and training
programs within each of the 10 HHS regions. Those again are
focused on localized needs of communities because we know every
community is different.
We also recently have established a relationship with the
Department of Agriculture that does a lot of rural work and so
we are expanding our technical assistance through some of their
initiatives into rural areas. Telehealth is a big issue for the
Department of Health and Human Services. We have the behavioral
health coordinating committee which includes the operating
divisions and telehealth is a specific issue that we are
working on to provide additional guidance to States to try to
expand the reach of the practitioners that we have into rural
areas.
Mr. Bucshon. Thank you very much for that answer. Mr.
Chairman, I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back. The chair recognizes the gentlelady from
California, Ms. Matsui for 5 minutes of questions please.
Ms. Matsui. Thank you, Mr. Chairman.
Dr. McCance-Katz, thank you very much it for joining us
today. I am pleased we are hosting this hearing to discuss the
mental health provisions in 21st Century Cures. I look forward
to having oversight hearing of the final section of 21st
Century Cures, including health IT and interoperability.
Before I ask my questions about mental health and Cures, I
have to make a comment about the mental health of thousands of
children who have been separated their families due to
President Trump's zero-tolerance policy. Public health, mental
health, and pediatric experts, including the American Academy
of Pediatrics, the American Nurses Association have voiced
concerns about the harm caused through the stress and trauma
incurred by children who have been forcibly separated from
their parents. The stress and trauma not only has immediate
harmful impact on these children, but is also damaging a long
term impact, on a child's health and development.
Dr. McCance-Katz, SAMHSA notes that the impact of childhood
traumatic stress can last for far beyond childhood and that
child trauma survivors are more likely to have long term health
problems, including behavior health and substance use
disorders. That is why this committee must act immediately to
ensure that HHS is reuniting children with their parents and to
ensure that HHS has long-term plans to mitigate the impact of
trauma on these children.
Now moving onto my legislative priorities for 21st Century
Cures. I authored Title 11, the compassionate communication on
HIPAA's section of the bill that passed into law, these
provisions seek to clarify confusion about the HIPAA privacy
rule as it applies in mental health scenarios. The confusion
for patients, families, doctors, and even administrators and
lawyers about what information can and cannot be shared
remains.
Cures requires that the HHS Office for Civil Rights to
coordinate with SAMHSA and other relevant agencies to develop,
disseminate, and periodically update model programs to train
healthcare providers, lawyers, patients and the families on the
permitted use and disclosure of protected health information of
individuals seeking and receiving treatment from mental health
or substance use disorders.
Dr. McCance-Katz, as you know, HHS released additional
guidance on this topic back in December. What progress has it
made to develop model training programs?
Dr. McCance-Katz. Well, I have a few things to tell you.
One, is that we are working very hard with the office of civil
rights to coordinate those efforts and one of things that we
did just last week was to train attorneys, healthcare
attorneys, on issues around both HIPAA and 42 CFR. In fact I
brought a copy of the training and I will be happy to leave it
if you would like to see it.
Ms. Matsui. That would be great. Thank you.
Dr. McCance-Katz. We had 1,000 attorneys on that webinar,
that is the most you can have. And the American Bar Association
which has possession of this now and is continuing to
disseminate it, they said that they thought we would have 4,000
could they have accommodated everybody that wanted to learn
about this topic.
We are also using this to develop something that I will
just say is going to be in a little more simpler language for
people like me, who are practitioners, to do special training
for practitioners on the privacy issues. But the thing that I
think is most exciting is that yesterday we were able to
publish a funding announcement, we will have a national center
on privacy. HIPAA and 42 CFR and I think that is going to make
a huge difference.
Ms. Matsui. How about the other stakeholders such as
clinicians, are you going to be bringing them in too as you
develop and disseminate these model training programs?
Dr. McCance-Katz. Absolutely. So we will have a single
grantee whose job it will be to train clinicians, to train
administrators and often these will be lawyers that are
involved in healthcare systems. But the other requirement that
I put in that funding announcement is that we must put out
materials for families and for patients.
Ms. Matsui. That is really very important because many
times this is merely misunderstood, even if we set up these
programs, if we don't have a communication in essence to even
have some patients come in and parents come in to understand
what the process is, because when the family gets into a
certain kind of situation, people don't know what to do.
And I would hope that we would keep these training sessions
going too, because just because we have a certain set trained,
doesn't mean that it is all done.
Dr. McCance-Katz. That is correct. And this will be a
multiyear initiative.
Ms. Matsui. OK well thank you. Yield back.
Mr. Burgess. The chair thanks the gentlelady. The
gentlelady yields back. The chair now recognizes the gentlelady
from Indiana, Mrs. Brooks, for 5 minutes of questions please.
Mrs. Brooks. Thank you, Mr. Chairman and thank you Dr.
McCance-Katz. Thank you so much for being here as the first
Assistant Secretary focused on these issues in this way and
every answer you have given your portfolio is so large about so
many issues that our constituents care about, I am having a
hard time figuring out where to focus.
I have to tell you as an attorney who practiced criminal
defense in the courts. As former U.S. attorney, as someone who
has been very involved in the criminal justice system. We know
that 21st century Cures reauthorized and added some programs
regarding revising the jail diversion grant programs for mental
health in our jails. Our jails are often just overflowing, are
often the largest institutions in many ways in counties that
have those with mental illness.
Can you give us any updates on these successes you have
seen in the programs so far that we can help our local county
jails and State prisons deal with this problem?
Dr. McCance-Katz. Yes. And this is really a great benefit
of the Cures Act that these kinds of resources are being made
available.
What we have done at SAMHSA is to fund mental health courts
both for adults and for youth who are experiencing mental
illness sometimes for the first time but it has involved them
in the justice system. We also are starting programs that
divert people prior to arrest. This is really very important
because people who have serious mental illnesses suffer from a
great deal of stigma. And these things when have you an arrest
it makes it so much more difficult for you to be able to
navigate in communities without problems.
It makes it more difficult to get insurance. Makes it more
difficult to get a job, makes it more difficult to get housing.
So we like the idea of prediversion programs and we are funding
some of those again through the abilities given to us in the
Cures Act.
Mrs. Brooks. And I applaud you from that, and I also think
that what you just mentioned the National Center on Privacy and
the fact that that many lawyers got on a call. I want to
applaud the American Bar Association for encouraging that. And
I believe that many, many lawyers will participate in that kind
of training. And I want to encourage you getting the word out
as well as my colleagues across the aisle.
What is the best way for our constituents to learn about
all of these grant opportunities? There just seems to be so
many new grants, so many new programs and quite frankly we are
having a hard time trying to help direct all of our
constituents. We had a school shooting in my district on May
25th. And when you talked about teachers and educators wanting
to learn more, that is the one thing that I heard is that our
teachers and educators are so concerned about learning more
about whether it is the mental health first aid, whether it is
about identifying as Congressman Griffith brought up.
What can you share with us is the best mechanisms we can
provide our constituents to be educated or to pursue grant
programs, particularly for mental health in our schools, mental
health in our communities, what are the best ways we should be
communicating this, instead of just going to SAMHSA's website?
And how can we have better access to the tools to provide our
constituents?
Dr. McCance-Katz. And so I would say that SAMHSA's website
has that information and it is a resource.
Mrs. Brooks. Extensive.
Dr. McCance-Katz. It is. And we are working on how to
simplify that and make it easier to find things. But we also
are working on developing webinars on specific programs to talk
to the public about what those programs are and about the
funding opportunities that are available.
The other thing that we will be using the system of
regionalized training for is for these kinds of opportunities
as well, to make it easier for those who are taking advantage
of those regional programs to know more about what the
opportunities are.
So if you have an addiction transfer center for example in
region one, the Northeast, that technology transfer center also
can make it easier for the communities and individuals in those
communities to find out what the resources are as it relates to
addiction. We will have one for substance abuse prevention and
we will also have one for mental health issues.
We also are supplementing those mental health technology
transfer centers to specifically work on issues related to
schools and our children's needs. That will be happening in the
next fiscal year and so we hope that by regionalizing the
programs that we can get down to the community level and
communicate better because you are so right it is very
difficult.
Mrs. Brooks. Thank you. I applaud all the work that your
office is doing. It is so critically important. I look forward
to helping you with that. I yield back.
Mr. Burgess. The chair thanks the gentlelady. The
gentlelady yields back.
The chair recognizes the gentlelady from Florida, 5 minutes
for questions, please.
Ms. Castor. Thank you, Mr. Chairman.
Dr. McCance-Katz, thank you for being here today. You have
a very significant responsibility as Assistant Secretary for
Mental Health and Substance Use, and I want to thank you for
taking on this very important assignment. I have reviewed your
bio. You have great experience and a number of degrees from
outstanding institutions, so I think your expertise is needed
here in this area.
I want to ask you about the long-term mental health
implications of child traumatic stress caused by the family
separation policy. You have heard the concern from colleagues
here today. And we are reflecting the concern that we are
hearing back home all across the country.
But I would like to ask you about child traumatic stress
caused by the family separation policy on those children that
have been forcibly separated from their families. I know you
cannot get into specific cases. But based upon your extensive
expertise, I would like you to comment in general.
At this point, many public health organizations have
stressed that ``the practice of separating children from their
loved ones and caregivers for an extensive period of time is a
threat to public health, inflicting serious trauma, and
threatening long-term irreversible health effects.''
Do you agree?
Dr. McCance-Katz. This is a form of trauma.
Ms. Castor. What are some of the serious long-term
irreversible health effects that could result from family
separation?
Dr. McCance-Katz. So I can't speak to family separation per
se. I don't know who might develop a mental disorder that will
have long-term implications for them. None of us do.
Ms. Castor. That kind of runs counter to everything we are
hearing from organizations, the leading mental health
organizations and public health organizations, from across the
country.
Dr. McCance-Katz. The President has directed that families
not be separated further. Secretary Azar has made it very clear
that our job is to reunite these families. We are working very
hard at HHS to do that. These children are in a safe
environment. The practitioners there are all licensed within
the States that these facilities----
Ms. Castor. You would not have recommended this policy at
the outset, would you have?
If they came to you as the Assistant Secretary, would you
have recommended this policy? Were you asked? Were you
consulted?
Dr. McCance-Katz. There are a number of different policy
implications there, and----
Ms. Castor. I am not trying to play gotcha. I am curious. I
know Secretary Azar, I believe he said he was not consulted.
Were you asked as the Assistant Secretary for Substance Use
Mental Health?
Dr. McCance-Katz. Asked what?
Ms. Castor. Before the family separation policy was
implemented?
Dr. McCance-Katz. I was not consulted about that.
Ms. Castor. OK. We know that there is a significant body of
evidence detailing the public health implications of adverse
childhood experiences. Would you consider the forceable
separation of children from their parents to be an adverse
childhood experience?
Dr. McCance-Katz. I would consider separation from parents
to be an adverse experience. And I would also remind you that
these children are getting physical healthcare and mental
healthcare, and they are getting that very regularly.
Ms. Castor. Thank you.
It is likely that this forceable separation already
compounds upon other adverse childhood experiences these
children have faced in their home countries such as witnessing
domestic violence or gun violence.
Do these experiences have a cumulative effect?
Dr. McCance-Katz. Depending on the individual, the reality
is that most people have a great deal of resiliency. And when
they can get their mental health issues addressed, and these
children are getting mental healthcare in these facilities,
then we hope that they will not go on to have any adverse
affects.
Ms. Castor. Well, the CDC and Kaiser Permanente adverse
childhood experiences study found many long-term health impacts
of adverse childhood experience, including the risk of
disrupted neural development, social, emotional, and cognitive
impairment, and heightened risk for disease, disability, and
social problems.
Can you explain some of the specific physical and mental
health problems that can result from adverse childhood
experience?
Dr. McCance-Katz. There are a variety of different types of
mental disorders that can be a result of adverse experiences.
Ms. Castor. And there are risk factors for behavioral
health and substance use disorders specifically, correct?
Dr. McCance-Katz. That is true.
Ms. Castor. There was a recent news report that said----
Mr. Burgess. I believe the gentlelady's time has expired.
Ms. Castor. Well, I would ask the courtesy most members
have gotten an additional 30 seconds. I just want to ask about
funding shifts at HHS, because there is a recent report that
HHS has quietly dipped into tens of millions of dollars to pay
for what has happened through family separation. The Department
has burned through at least $40 million in the past 2 months.
I am just wondering, has that impacted your shop at SAMHSA?
Have you been asked to shift any moneys out that were
previously directed towards SAMHSA?
Dr. McCance-Katz. SAMHSA has not had any direct effect----
Ms. Castor. Thank you very much Mr. Chairman.
Mr. Burgess. That response is negative, and the gentlelady
yields back.
The chair recognizes the gentleman from Florida, 5 minutes,
please.
Mr. Bilirakis. OK. Thank you very much. I appreciate it,
Mr. Chairman.
Dr. McCance-Katz, in accordance with Section 13002 of
Cures, I understand that SAMHSA last year convened a public
listening session on mental health parity involving 15 in-
person groups with an additional 40 comments submitted via
email and in writing.
Can you provide us with a high level summary of those
comments? How were these comments addressed through SAMHSA's
action plan? And do you plan to host another meeting with
industry stakeholders?
Dr. McCance-Katz. Yes, we did hold that listening session.
And the comments that we received were around need for
education around the Parity Act and how individuals who
experience what they believe to be pari violations would get
assistance that they need. And what are the responsibilities of
States and insurers around these issues.
SAMHSA is in the process of developing a guidance on that,
and that should be out before the end of this calendar year is
what I was told prior to this hearing. So I am giving you the
information that I have available to me.
Mr. Bilirakis. OK. Thank you very much.
In your testimony, you mentioned that over 7.4 million
children and youth in our nation have a serious mental health
disorder while only 41 percent actually receive treatment
leaving the vast majority untreated. The 41 percent are the
ones that were identified, so it could be even more than that.
So, as you know, it is a serious issue. And I am glad that
the chairman is holding this hearing and we are taking this
issue very seriously. It really is an epidemic.
And In addition to supporting systems of care, how is
SAMHSA working with industry to address workforce shortage
issues?
Dr. McCance-Katz. So when you think about what type of
problem we have, we have an urgent problem, we have an urgent
need to get more services to Americans who are living with
these kinds of conditions. What is the fastest way to do that?
By the way, it is not going to be by opening more medical
schools. That is going to take too long.
And so when I think about this, I have to think about how
can I get services to Americans. I can do it by training and
providing technical assistance that will prepare practitioners
to intervene and to provide care and treatment for mental and
substance use disorders. And that is why so much attention,
since I have come to SAMHSA----
Mr. Bilirakis. So when you talk about practitioners, are
you talking about psychologists, psychiatrists, or primary care
physicians who would get additional training?
Dr. McCance-Katz. All of the above.
Mr. Bilirakis. All of the above.
Dr. McCance-Katz. All of the above. And so we are setting
up programs of regional training and technical assistance. We
also have speciality programs. We are working very hard to
disseminate that information so that clinicians and
practitioners, psychiatrists, psychologists, nurse
practitioners, physician assistants, counselors, social
workers, and primary care doctors would be able to take
advantage of these kinds of trainings. That allows them to get
specialized kinds of skills and provide that service to their
clients.
Now, the other thing that I would say is that we are
working to set up programs through our grant-funded
organizations that will provide ways that practical assistance
can be provided. So, for example, in the State targeted
response funds that Cures provided, the States can contract
with providers that provide specialized opioid treatment
services. We also have a grant program at SAMHSA. It is called
MAT-PDOA, which just means medication assisted--it is a way to
implement medication assisted treatment.
Those programs provide practical experience. So we have the
ability to provide didactic classroom style webinar, web-based
training, but then the ability within regions of the country
where people can go and see this in practice. And we think that
that is a way to better assure that practitioners will feel
confident enough and able to use a new skill set to provide
care when Americans need it.
We also continue to support programs called SBIRT,
Screening, Brief Intervention, Referral to Treatment. We also
encourage primary care to continue to----
Mr. Bilirakis. How does that work now in the schools? How
are we going to identify the kids that have these issues? And
is the burden going to be always on the teacher? Where do you
go next once they are diagnosed?
I know it is very expensive. The treatment centers and a
lot of the insurance companies do not cover.
Mr. Burgess. And the gentlemen----
Mr. Bilirakis. And even if they do, the co-pays are so very
high and the deductibles.
I am sorry, Doctor.
Mr. Burgess. The gentleman's time has expired.
Mr. Bilirakis. OK. All right.
Mr. Burgess. The gentleman from Georgia has been waiting
very, very patiently here all day. Perhaps that question could
be responded to in writing.
The gentleman from Georgia is recognized for 5 minutes.
Mr. Carter. Thank you, Mr. Chairman.
Dr. McCance-Katz, thank you for being here. And thank you
for what you do for the children, particularly of our citizens.
We appreciate that very much. I know a lot of this hearing has
gotten a little bit off base, but I want you to know that we
appreciate what you are doing for our citizens here.
I am sorry to have to report to you that Georgia is not
doing so good with mental health services. In fact, we rate
about 47th out of 50. And that is one of the things that
bothers me. And, in fact, it is estimated that we have less
than 20 percent of the beds that we need for mental health
services in the State of Georgia as well. Particularly when it
comes to childhood mental health, we have got 159 counties in
the State of Georgia, and only 76 of them have a licensed--or
76 do not have a licensed psychologist. We have got, again, 159
counties, 52 of them have no licensed social worker.
All of these figures are alarming to us, and alarming to me
in particular because of the fact that in the State of Georgia,
for those children between the ages of 15 and 19, the second
leading cause of death is suicide. And for those between 10 and
14, the third leading cause of death is suicide.
So all of that leads me to ask you, Cures reauthorized the
children's mental health initiative, and that provided a lot of
grants and a lot of assistance that we are very appreciative
for. But I just wanted to ask you, particularly in the State of
Georgia, we have a lot of rural areas, particularly in south
Georgia, in my district, a lot of rural areas. And I am just
wondering how do we get services to those areas? Any
suggestions on how we can improve services there?
Dr. McCance-Katz. So SAMHSA has supported two types of
integrated care programs. One is where behavioral health
providers would be able to be part of a team in a primary care
program such as a federally qualified health center.
The second way is through programs such as our certified
community behavioral health clinics that bring primary care
directly into a behavioral health setting. So that a person can
easily access all the care and services that they need in one
setting.
SAMHSA, as you know, has limited funds. We do
demonstrations. We work closely in terms of establishing those
demonstrations and then doing more technical assistance in
training and try to establish those programs on a national
level. We talk with our colleagues at the Centers for Medicare
and Medicaid Services.
Mr. Carter. OK. What about telemedicine? Telehealth,
telemedicine. Is that something that we should be focusing more
on?
Dr. McCance-Katz. Yes. And I was just about to get there.
Mr. Carter. I am sorry.
Dr. McCance-Katz. So, yes, telehealth is a very important
piece of it, particularly for areas that have a lot of large
rural communities.
Mr. Carter. Right.
Dr. McCance-Katz. Telehealth can really extend the reach of
a practitioner who may be in a more urban area but can--and so
the Department of Health and Human Services has a committee
that is working on telehealth guidance for the States and, in
addition to that, is working with, for example, the Drug
Enforcement Administration around issues of prescribing so that
we can utilize those telehealth providers to the very best
extent.
Mr. Carter. Great.
Are there grants specifically for that, or are they just
included in the regular grants that you can use it for that
purpose?
Dr. McCance-Katz. We have, at SAMHSA, part of a larger
grant program that our telehealth services come from and I
believe that other parts of HHS, such as HRSA, have specific
funding for telehealth services.
Mr. Carter. Great.
Another thing I want to talk about real quickly is the
opioid addiction and the funds that have been going there, the
grants that have been going there. We have been very fortunate.
The Georgia Department of Behavioral Health and Developmental
Disabilities has gotten over almost $12 million. And I want to
report back to you, because I have been a part of some of these
programs. And it is working well, and it is been utilized well.
In fact, one of the cities, and I want to give them a shout-
out, the city of Pembroke, Georgia, in my district, in Bryan
County, has been very active in this and has implemented a
number of programs that have media campaigns, school
partnerships. A number of programs that have been very
successful.
Can you elaborate just very quickly on what else we might
be doing with that?
Dr. McCance-Katz. So the opioids crisis is one of Secretary
Azar's priorities.
Mr. Carter. And this committee's priority.
Dr. McCance-Katz. Yes. And we are very grateful to Congress
for the increase in funding to address these issues.
So what we have to do is to work very hard to integrate
substance abuse treatment, opioid addiction treatment, into
primary care settings in addition to having speciality care
available. We know that people find it very difficult to access
care, and so we want to broaden the number of providers that
are willing to engage in the care and to use innovative
practices, such as telehealth, this is why we are working with
the Drug Enforcement Administration, to make it possible for a
clinician to have a greater reach and to reach Americans in
those rural areas that have such difficulty accessing.
Mr. Carter. Great.
And thank you again for your work.
And I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
Seeing that all members have had the opportunity to ask
questions, I want to again thank our witness for taking time to
be here with us today.
Pursuant to committee rules, I remind members they have 10
business days to submit additional questions for the record.
And I ask our witness to submit responses within 10 business
days upon receipt of those questions.
Without objection, the subcommittee is adjourned.
[Whereupon, at 12:30 p.m., the subcommittee was adjourned.]
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