[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
HIGH ANXIETY AND STRESS: LEGISLATION TO
IMPROVE MENTAL HEALTH DURING CRISIS
=======================================================================
VIRTUAL HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
JUNE 30, 2020
__________
Serial No. 116-117
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
54-859 PDF WASHINGTON : 2024
COMMITTEE ON ENERGY AND COMMERCE
FRANK PALLONE, Jr., New Jersey
Chairman
BOBBY L. RUSH, Illinois GREG WALDEN, Oregon
ANNA G. ESHOO, California Ranking Member
ELIOT L. ENGEL, New York FRED UPTON, Michigan
DIANA DeGETTE, Colorado JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland PETE OLSON, Texas
JERRY McNERNEY, California DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice BILL JOHNSON, Ohio
Chair 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 TIM WALBERG, Michigan
SCOTT H. PETERS, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
------
Professional Staff
JEFFREY C. CARROLL, Staff Director
TIFFANY GUARASCIO, Deputy Staff Director
MIKE BLOOMQUIST, Minority Staff Director
Subcommittee on Health
ANNA G. ESHOO, California
Chairwoman
ELIOT L. ENGEL, New York MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina, Ranking Member
Vice Chair FRED UPTON, Michigan
DORIS O. MATSUI, California JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon BILLY LONG, Missouri
JOSEPH P. KENNEDY III, LARRY BUCSHON, Indiana
Massachusetts SUSAN W. BROOKS, Indiana
TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont RICHARD HUDSON, North Carolina
RAUL RUIZ, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex
officio)
C O N T E N T S
----------
Page
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 2
Prepared statement \1\
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 3
Prepared statement........................................... 5
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 6
Prepared statement \1\
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 8
Prepared statement........................................... 9
Witnesses
Patrick J. Kennedy, Founder, the Kennedy Forum................... 11
Prepared statement........................................... 13
Answers to submitted questions............................... 253
Arthur C. Evans, Jr., Ph.D., Chief Executive Officer, American
Psychological Association...................................... 19
Prepared statement........................................... 21
Answers to submitted questions............................... 259
Jeffrey L. Geller, M.D., M.P.H., President, American Psychiatric
Association, Professor of Psychiatry, Director of Public Sector
Psychiatry at the University of Massachusetts Medical School,
Worcester Recovery Center and Hospital......................... 31
Prepared statement........................................... 33
Answers to submitted questions............................... 271
Arriana Gross, National Youth Advisory Board Member, Sandy Hook
Promise Students Against Violence Everywhere (Save) Promise
Club........................................................... 47
Prepared statement........................................... 49
Answers to submitted questions............................... 279
----------
\1\ Ms. Eshoo and Mr. Pallone did not submit prepared documents
for the record by the time of publication.
Submitted Material
H.R. 884, the Medicare Mental Health Access Act, submitted by Ms.
Chu \2\
H.R. 945, the Mental Health Access Improvement Act of 2019,
submitted by Mr. Thompson \3\
H.R. 1109, the Mental Health Services for Students Act of 2019,
submitted by Ms. Napolitano \4\
H.R. 1646, the Helping Emergency Responders Overcome Act of 2019,
submitted by Ms. Bera \5\
H.R. 2519, the Improving Mental Health Access from the Emergency
Department Act of 2019, submitted by Mr. Ruiz \6\
H.R. 2874, the Behavioral Health Coverage Transparency Act,
submitted by Mr. Kennedy \7\
H.R. 3165, the Mental Health Parity Compliance Act, submitted by
Ms. Katie Porter \8\
H.R. 3539, the Behavioral Health Intervention Guidelines Act of
2019, submitted by Mr. Drew \9\
H.R. 4428, the Greater Mental Health Access Act, submitted by Ms.
Wild \10\
H.R. 4564, the Suicide Prevention Lifeline Improvement Act of
2019, submitted by Mr. Katko, Mr. Beyer, and Ms. Napolitano
\11\
H.R. 4585, the Campaign to Prevent Suicide Act, submitted by Mr.
Beyer and Mr. Gianforte \12\
----------
\2\ The information has been retained in committee files and also
is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-116884ih.pdf.
\3\ The information has been retained in committee files and also
is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-116945ih.pdf.
\4\ The information has been retained in committee files and also
is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1161109ih.pdf.
\5\ The information has been retained in committee files and also
is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1161646ih.pdf.
\6\ The information has been retained in committee files and also
is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1162519ih.pdf.
\7\ The information has been retained in committee files and also
is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1162874ih.pdf.
\8\ The information has been retained in committee files and also
is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1163165ih.pdf.
\9\ The information has been retained in committee files and also
is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1163539ih.pdf.
\10\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1164428ih.pdf.
\11\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1164565ih.pdf.
\12\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1164585ih.pdf.
H.R. 4861, the Effective Suicide Screening and Assessment in the
Emergency Department Act of 2019, submitted by Mr. Bilirakis
and Mr. Engel \13\
H.R. 5201, the Telemental Health Expansion Act of 2019, submitted
by Ms. Matsui and Mr. Johnson \14\
H.R. 5469, the Pursuing Equity in Mental Health Act of 2019,
submitted by Ms. Watson Coleman \15\
H.R. 5619, the Suicide Prevention Act, submitted by Mr. Stewart
and Ms. Matsui \16\
H.R 5855, the Bipartisan Solution to Cyclical Violence Act of
2020, submitted by Mr. Dutch Ruppersberger and Mr. Kinzinger
\17\
H.R. 6645, To direct the Secretary of Health and Human Services,
acting through the Director of the National Institute of Mental
Health, to conduct or support research on the mental health
consequences of SARS-CoV-2 or COVID-19, and for other purposes,
submitted by Mr. Tonko \18\
H.R 7080, the Stopping the Mental Health Pandemic Act, submitted
by Ms. Porter \19\
H.R. 7147, the Creating Resources to Improve Situations of
Inherent Severity Act, submitted by Mr. Latta \20\
H.R. 7159, the Crisis Care Improvement and Suicide Prevention Act
of 2020, submitted by Ms. Bustos \21\
H.R. 7293, the Suicide Training and Awareness Nationally
Delivered for Universal Prevention Act of 2020, submitted by
Mr. Peters \22\
H.R. 7316, the Emergency Mental Health and SubStance Use Training
and Technical as Sistance Center, submitted by Ms. Eshoo \23\
----------
\13\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1164861ih.pdf.
\14\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1165201ih.pdf.
\15\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1165469ih.pdf.
\16\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1165619ih.pdf.
\17\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1165855ih.pdf.
\18\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1166645ih.pdf.
\19\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1167080ih-U1.pdf.
\20\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1167147ih.pdf.
\21\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1167159ih.pdf.
\22\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1167293ih.pdf.
\23\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/BILLS-1167316ih-PublicHealthServiceActamd.pdf.
Letter of June 29, 2020, to Mr. Pallone and Mr. Walden, by Mike
Thompson and John Katko, Member of Congress, submitted by Ms.
Eshoo.......................................................... 113
Letter of June 30, 2020, to Ms. Eshoo and Mr. Burgess, by Grace
Napolitano, submitted by Ms. Eshoo............................. 115
Letter of June 25, 2020, to Ms. Wild, by John H. Madigan, Senior
Vice President and Chief Public Policy Officer, American
Foundation for Suicide Prevention, submitted by Ms. Eshoo...... 117
Letter of February 28, 2019, to Ms. Napolitano, from Arthur C.
Evans, Jr., Ph.D, Chief Executive Officer, American
Psychological Association, submitted by Ms. Eshoo.............. 118
Statement of March 21, 2019, by Grace F. Napoliano, Azusa Pacific
University, submitted by Ms. Eshoo............................. 119
Letter of June 30, 2020 to Mr. Pallone and Mr. Walden, by Michael
Pollock, Chief Executive Officer, Depression and Bipolar
Support Alliance, submitted by Ms. Eshoo....................... 120
Statement of June 26, 2020, by Brian Hepburn, M.D., Executive
Director, National Association of State and Mental Health
Program Directors, submitted by Ms. Eshoo...................... 123
Letter of March 7, 2018, to Mr. Katko and Mr. Thompson, by Joyce
A. Rodgers, Senior Vice President, Government Affairs, AARP,
submitted by Ms. Eshoo......................................... 124
Letter of June 30, 2020 to Ms. Eshoo and Mr. Burgess, by Richard
Yep, CAE, FASAE, Chief Executive Officer, American Counseling
Association, submitted by Ms. Eshoo............................ 126
Letter of October 10, 2019, to Mr. Baldwin, et al., by Carole
Kretschman, Chair, Area Agency on Aging of Dane County,
submitted by Ms. Eshoo......................................... 128
Letter of May 8, 2020, to Mr. Neal, et al., from Medicare
Coalition Groups, submitted by Ms. Eshoo....................... 130
Letter of June 5, 2020, to Mr. Neal, et al., from the Mental
Health Liaison Group, submitted by Ms. Eshoo................... 132
Letter of April 30, 2020, to Mr. McConnell, et al., from the
Unified Parkinson's Advocacy Council, submitted by Ms. Eshoo... 135
Letter of May 11, 2020, to Ms. Pelosi, et al., from Mental Health
Liaison Group, submitted by Ms. Eshoo.......................... 137
Letter of June 6, 2019 to Ms. Porter, et al., by Saul Levin, MD,
MPA, FRCP-E, CEO and Medical Director, American Psychiatric
Association, submitted by Ms. Eshoo............................ 141
Letter of June 6, 2019, to Ms. Porter and Mr. Bilirakis, from
Mental Health Liaison Group, submitted by Ms. Eshoo............ 143
Letter of June 29, 2020, to Mr. Palalone and Mr. Walden, by Dr.
Chris Markwood, President, Georgia Columbus State University,
submitted by Ms. Eshoo......................................... 146
Letter of June 29, 2020, to Mr. Pallone and Mr. Walden, by John
Katko, Don Beyer, and Grace Napolitano, Members of Congress
submitted by Ms. Eshoo......................................... 147
Letter of June 26, 2020, to Mr. Katko, by John H. Madigan, Senior
Vice President and Chief Public Policy Officer, American
Foundation for Suicide Prevention, submitted by Ms. Eshoo...... 149
Letter of May 5, 2020, to Mr. Katko, et al., by Kim Williams,
President and CEO, Vibrant Emotional Health, submitted by Ms.
Eshoo.......................................................... 150
Letter of June 26, 2020, to Mr. Beyer, by John H. Madigan, Senior
Vice President and Chief Public Policy Officer, American
Foundation for Suicide Prevention, submitted by Ms. Eshoo...... 151
Letter of June 25, 2020, to Mr. Bilirakis, by John H. Madigan,
Senior Vice President and Chief Public Policy Officer, American
Foundation for Suicide Prevention, submitted by Ms. Eshoo...... 152
Letter of November 4, 2019, to Mr. Bilirakis, by Patricia Kunz
Howard, Ph.D, RN, President, Emergency Nurses Association,
submitted by Ms. Eshoo......................................... 153
Letter to Mr. Bilirakis and Mr. Engel, from the Mental Health
Liaison Group, submitted by Ms. Eshoo.......................... 155
Letter of June 29, 2020 to Ms. Eshoo and Mr. Burgess, by Pastor
James R. Domen, M. Div., Founder, Church United, submitted by
Ms. Eshoo...................................................... 157
Statement from Dr. Andre Van Mol, American College of
Pediatricians, submitted by Ms. Eshoo.......................... 159
Letter of June 28, 2020, to Ms. Eshoo, et al., from Family Watch
International, submitted by Ms. Eshoo.......................... 163
Letter of June 29, 2020, to Ms. Eshoo and Mr. Burgess, by Travis
Weber, Vice President, Policy and Government Affairs, Advancing
Faith, Family and Freedom, submitted by Ms. Eshoo.............. 164
Letter of June 29, 2020, to Ms. Eshoo and Mr. Burgess, from
KathyGrace Duncan, submitted by Ms. Eshoo...................... 167
Letter to Mr. Stewart and Ms. Matsui, from the Mental Health
Liaison Group, submitted by Ms. Eshoo.......................... 168
Letter February 12, 2020, to Mr. Ruppersberger and Mr. Kinziger,
by David B. Hoyt, MD, FACS, Executive Director, American
College of Surgeons, submitted by Ms. Eshoo.................... 170
Letter to Mr. Ruppersberger and Mr. Kinziger, by Fatimah Loren
Muhammad, Executive Director, Health Alliance Violence
Intervention, submitted by Ms. Eshoo........................... 171
Statement of June 26, 2020, by Brian Hepburn, M.D., Executive
Director, National Association of State Mental Health Program
Directors, submitted by Ms. Eshoo.............................. 172
Letter of June 26, 2020, to Mr. Latta, by Shawn Coughlin,
President and CEO, National Association for Behavioral
Healthcare, submitted by Ms. Eshoo............................. 173
Letter of September 19, 2019, to MS. Napolitano, by James J.
Balla, MBA, President and CEO, Pacific Clinics, submitted by
Ms. Eshoo...................................................... 175
Letter of March 18, 2019, by Elizabeth Planet, Executive
Director, Child Mind Institute, submitted by Ms. Eshoo......... 176
Letter of June 30, 2020, to Mr. Pallone and Mr. Walden, by Harold
A. Schaitberger, General President, International Association
of Firefighters, submitted by Ms. Eshoo........................ 177
Issue Brief ``Mental Health Parity and Addiction Equity'' from
Association for Behavioral Health and Wellness, submitted by
Ms. Eshoo...................................................... 179
Letter of June 14, 2019, to Ms. Napolitano, by Janice Hahn, et
al., County of Los Angeles Board of Supervisors, submitted by
Ms. Eshoo...................................................... 181
Statement of May 17, 2017, by Michelle Cretella, M.D., President,
et al., American College of Pediatricians, submitted by Ms.
Eshoo.......................................................... 183
Letter of June 28, 2020, by Jennifer Feist, Fonder, Dr. Lorna
Breen Heroes' Foundation Charlottesville, Virginia, submitted
by Ms. Eshoo................................................... 188
Letter of June 29, 2020, to Ms. Eshoo and Mr. Burgess, by Diana
Felner, Vice President, Public Policy, Tourette Association of
America, submitted by Ms. Eshoo................................ 192
Letter of August 14, 2019, to Ms. Napolitano, by Andre Quintero,
Mayor, El Monte City Council, submitted by Ms. Eshoo........... 195
Letter of May 21, 2019, to Ms. Napolitano and Mr. Katko, Marc
Egan, Director of Government Relations, National Education
Association, submitted by Ms. Eshoo............................ 196
Letter of January 3, 2020, to Mr. Bilirakis and Mr. Engel, from
the Mental Health Liaison Group, submitted by Ms. Eshoo........ 197
Letter of March 20, 2019, to Ms. Napolitano and Mr. Katko, from
the Mental Health Liaison Group, submitted by Ms. Eshoo........ 200
Letter of June 26, 2020, to Mr. Latta, by Shawn Coughlin,
President and CEO, National Association Behavioral Healthcare,
submitted by Ms. Eshoo......................................... 202
Letter of July 17, 2019, to Ms. Napolitano, by Debra Manners,
LCSW, President and Chief Executie Officer, Hathaway-Sycamores,
submitted by Ms. Eshoo......................................... 203
Letter of June 29, 2020, to Ms. Napolitano, by Elena Rios, M.D.,
MSPH, FACP President and CEO, National Hispanic Medical
Association, submitted by Ms. Eshoo............................ 204
Statement of June 30, 2020, from Rep. Katie Porter, submitted by
Ms. Eshoo...................................................... 205
Letter of June 29, 2020, to Ms. Eshoo and Mr. Burgess, by Susan
Wild, Member of Congress, submitted by Ms. Eshoo............... 207
Report ``Ring the Alarm: The Crisis of Black Youth Suicide in
America,'' submitted by Ms. Eshoo \24\
Letter of May 29, 2019, to Ms. Napolitano, by Randi Weingarten,
President, Union of Professionals, submitted by Ms. Eshoo...... 209
Letter of June 29, 2020, to Mr. Pallone and Mr. Walden, by Philip
W. Eaton CEO and David Gomel, President, Rosecrance Health
Network, submitted by Ms. Eshoo................................ 210
Letter of January 13, 2019, to Ms. Napolitano, by Rebecca Oliver,
Executive Director, School Social Work Association America,
submitted by Ms. Eshoo......................................... 214
Statement of Ami Beau, submitted by Ms. Eshoo.................... 216
Statement of June 30, 2020, from Rep. C. A. Dutch Ruppersberger,
submitted by Ms. Eshoo......................................... 218
Statement of June 29, 2020, to Mr. Latta, by David W. Covington,
CEO and President, International Innovations, submitted by Ms.
Eshoo.......................................................... 219
Letter of June 29, 2020, to Mr. Latta, by Rick Kellar, President,
Peg's Foundation, submitted by Ms. Eshoo....................... 220
Letter of June 29, 2020, to Mr. Pallone, et al., by Mary
Giliberti, Executive Vice President, and Caren Howard, Advocacy
Manage, Mental Health America, submitted by Ms. Eshoo.......... 221
Letter of June 30, 2020, to Mr. Latta, by Tony Coder, Executive
Director, Ohio Suicide Prevention Foundation, submitted by Ms.
Eshoo.......................................................... 225
Letter of June 30, 2020, to Ms. Eshoo and Mr. Burgess, by Don
Beyer, submitted by Ms. Eshoo.................................. 226
Letter of September 16, 2019, to Mr. Ferguson, by John Vinson,
Ph.D., President, International Association of Campus Law
Enforcement Administrators, submitted by Ms. Eshoo............. 227
Letter of June 30, 2020, to Ms. Eshoo and Mr. Burgess, by Adam
Kinzinger, submitted by Ms. Eshoo.............................. 229
Letter of June 29, 2020, to Mr. Ruppersberger and Mr. Kinzinger,
by David B. Hoyt, M.D., FACS, Executive Director and Eileen M.
Bulger, M.D., FACS, Chair, Committee on Trauma, American
College of Surgeons, submitted by Ms. Eshoo.................... 231
Letter of June 29, 2020, to Mr. Pallone and Mr. Walden, by
Kathleen Minke, Ph.D, Executive Director, National Association
of School Psychologists, submitted by Ms. Eshoo................ 233
Letter or June 30, 2020, to Mr. Pallone and Mr. Walden, by Pamela
Greenberg, MPP, President and CEO, Association for Behavioral
Health and Wellness, submitted by Ms. Eshoo.................... 234
Statement of June 30, 2020, from National Safety Council,
submitted by Ms. Eshoo......................................... 240
Letter of June 30, 2020, to Mr. Latta, by Angela Kimball,
National Alliance on Mental Health Illness, submitted by Ms.
Eshoo.......................................................... 245
Letter of June 6, 2019, to Ms. Porter and Mr. Bilirakis, by
Katherine B. McGuire, Chief Advocacy Officer, American
Psychological Association, submitted by Ms. Eshoo.............. 247
Letter of June 29, 2020, to Mr. Pallone, et al., from the
National Mental Health and Education Nonprofits Group,
submitted by Ms. Eshoo......................................... 249
----------
\24\ The information has been retained in committee files and
also is available at https://docs.house.gov/meetings/IF/IF14/
20200630/110845/HHRG-116-IF14-20200630-SD055.pdf.
HIGH ANXIETY AND STRESS: LEGISLATION TO
IMPROVE MENTAL HEALTH DURING CRISIS
----------
TUESDAY, JUNE 30, 2020
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 11:00 a.m., via
Cisco Webex online video conferencing, Hon. Anna G. Eshoo
(chairwoman of the subcommittee) presiding.
Members present: Representatives Eshoo, Engel, Butterfield,
Matsui, Sarbanes, Schrader, Kennedy, Cardenas, Welch, Ruiz,
Dingell, Kuster, Kelly, Barragan, Blunt Rochester, Rush,
Pallone (ex officio), Burgess, Upton, Shimkus, Guthrie,
Griffith, Bilirakis, Long, Bucshon, Brooks, Mullin, Carter,
Gianforte, and Walden (ex officio).
Also present: Representatives Schakowsky, Tonko, Peters,
O'Halleran, Latta, and Johnson.
Staff present: Jeffrey C. Carroll, Staff Director; Tiffany
Guarascio, Deputy Staff Director; Timothy Robinson, Chief
Counsel; Waverly Gordon, Deputy Chief Counsel; Kaitlyn Peel,
Digital Director; Joe Orlando, Executive Assistant; Kimberlee
Trzeciak, Chief Health Advisor; Joe Banez, Professional Staff
Member; Meghan Mullon, Policy Analyst; Nolan Ahern, Minority
Professional Staff, Health; Jennifer Barblan, Minority Chief
Counsel, Oversight and Investigations; Mike Bloomquist,
Minority Staff Director; S. K. Bowen, Minority Press Secretary;
William Clutterbuck, Minority Staff Assistant; Molly Jenkins,
Minority Press Secretary; Theresa Gambo, Minority Human
Resources/Office Administrator; Caleb Graff, Minority
Professional Staff, Health; Tyler Greenberg, Minority Staff
Assistant; Tiffany Haverly, Minority Communications Director;
Brittany Havens, Minority Professional Staff, Oversight and
Investigations; Peter Kielty, Minority General Counsel; Ryan
Long, Minority Deputy Staff Director; James Paluskiewicz,
Minority Chief Counsel, Health; Brannon Rains, Minority Policy
Analyst; Kristin Seum, Minority Counsel, Health; Kristen
Shatynski, Minority Professional Staff Member, Health; Alan
Slobodin, Minority Chief Investigative Counsel, Oversight and
Investigations; and Everett Winnick, Minority Director of
Information Technology.
Ms. Eshoo. The Subcommittee on Health will now come to
order.
Due to COVID-19, today's hearing, obviously, is being held
remotely. All members and witnesses will participate via video
conferencing. As part of our hearing, microphones will be set
on mute to eliminate background noise.
Members and witnesses, you are going to have to unmute your
microphone each time you wish to speak. So I just say that as a
reminder, and it is a little housekeeping issue, but please
remember to do that.
Documents for the record can be sent to Meghan Mullon at
the email address we have provided to your staff. All documents
will be entered into the record at the conclusion of the
hearing.
The Chair now recognizes yourself for 5 minutes for an
opening statement. Let's see, where is the clock on the screen?
There it is. OK.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
In any given year, one in five adults experience a mental
health illness, such as depression, anxiety, or bipolar
disorder. But 2020 has been a year like no other. In a recent
poll, half of adults report that their mental health has been
negatively impacted due to the coronavirus. One can only
imagine the mental impacts on the American families who are
grieving the loss of their loved ones due to the virus.
The economic downturn is also taking a mental health toll
on our fellow Americans. Studies have found that for every one
percent increase in the unemployment rate, the suicide rate
increases 1 to 1.6 percent.
Despite the frequency of mental illness, too many suffer in
silence. Mental health is a neglected part of our healthcare
system, with less than 40 percent of people with mental health
illness receiving any treatment whatsoever. This is because of
the high cost of care, insufficient insurance coverage, limited
options due to poor provider reimbursement, and an antiquated
system that too often relies on prisons, jails, and shelters.
We are so fortunate to have our colleague, former
Congressman Patrick Kennedy, as a witness today. He has led the
way in attacking the stigma of mental health by being open
about his own journey and advocating for transformational
changes to our mental health system.
He authored the 2008 Mental Health Parity and Addiction
Equity Act, which required health insurers to treat mental
healthcare the same as physical healthcare. But, unfortunately,
years after its passage, health insurers still deny too many
Americans coverage because they don't follow the letter and the
spirit of that law.
The good news is there are many strong bills to address
these issues. Today, we are considering 22 bills. So there is
clearly bipartisan demand to address this crisis.
The legislation we are considering cover the recent
increase in suicide; racial disparities in mental health
outcomes; telehealth; coverage parity; and access to mental
health services in schools, a very, very important one.
Several bills also address the mental health issues caused
by COVID-19. The pandemic is fueling mental health problems
while also hurting the ability of caregivers to deal with the
crisis. Mental health programs are struggling to treat an
influx of patients while awaiting funding that Congress did
appropriate, very importantly and in very large sums, but HHS
has been slow to release them.
Our health as a Nation, both physical and mental, will be
tested in the days and months ahead. Aristotle said: Even
calamities have a soul and can teach us a wise life. I view
this calamity as an opportunity to correct the wrongs in our
society and create hope for recovery for all.
Now I yield the remainder of my time to Representative Joe
Kennedy, who has been a leader on this issue.
[The prepared statement of Ms. Eshoo follows:]
Mr. Kennedy of Massachusetts. Madam Chair, thank you. I am
grateful for your leadership and you yielding this moment. And,
obviously, great to see my cousin Patrick here before the
committee and grateful for all of his work.
Our mental healthcare system is broken. Our addiction
treatment system is broken. All of us here today bring stories
of constituents and loved ones who fell through the gaps that
were wide and have only been widened.
This pandemic did not create these gaps. It only
highlighted them, and it has shown what many of us already
knew: that our mental health system is underfunded,
underprioritized, and overstigmatized.
We are beyond the point of cosmetic fixes and incremental
change. We need substantive systemic reform. We need legal
mental health parity, like what my cousin Patrick has
envisioned. We need to put teeth behind it that holds insurers
accountable for the violations that they commit on a daily
basis.
This hearing is yet another critical step forward. But this
hearing alone won't protect those who need our protection most.
Only action and true reform will do that. I look forward to
working with all of my colleagues to accomplish that in the
weeks ahead.
Thank you so much, Madam Chair. Thank you to all of our
colleagues for addressing this critical issue. I yield back.
Ms. Eshoo. Thank you, Congressman Kennedy. He yields back.
The Chair now recognizes Dr. Burgess, the ranking member of
our subcommittee, for 5 minutes for his opening statement.
Please remember to unmute.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. Maybe I have.
I thank the Chair, and I thank your willingness to work on
a productive bipartisan agenda for this subcommittee. And I am
grateful for your respecting my request that we have a hearing
on mental health and the coronavirus.
It was a topic that we were slated to talk about prior to
the outbreak, but now that the outbreak has occurred it has
become even more serious. The human loss, the job loss, the
isolation that Americans have faced due to this pandemic make
it an even more critical topic.
At the very beginning of this crisis the American
Psychiatric Association found that one-third of Americans felt
it seriously affected their mental health. That reality,
compounded with the existing prevalence of mental health
substance and use disorders, make this issue urgent.
According to the National Institute of Mental Health,
nearly one in five adults lives with a mental illness. Ensuring
proper supports are in place for families to manage and treat
these illnesses should be a priority.
So there are 22 bills before us today, and many of these
bills have a bipartisan consensus. I appreciate that you have
included the bills that I mentioned in my letter, specifically,
H.R. 3539, the Behavior Interventions Guidelines Act, which I
worked on with Dr. Drew Ferguson of Georgia. We had successful
behavioral intervention programs in schools in our States, and
that inspired us to work together.
For me, it was hearing from the leadership at Texas Tech
University Health Sciences Center and their program to provide
training for behavioral health intervention and telebehavioral
health services at schools in rural west Texas. School-aged
children are a prime age to identify and treat behavioral
health issues before they worsen.
I believe this bill is even more important now. Students
have been away from school and friends during a difficult time,
and some may be dealing with the loss of loved ones or being
home with family, a difficult family situation. I hope that we
will advance this bill toward markup.
Other bills cover a wide range of important issues, from
improving the National Suicide Prevention Hotline to extending
the authorization for Community Services Block Grants. These
bills will ensure stable, high-quality resources for those in
need.
One issue not addressed today is the mental health of the
frontline healthcare worker. And this is especially important
now, and I believe this has long been a serious issue in our
healthcare system but has taken on added importance with the
additional stress that caring for the seriously ill coronavirus
patient entails.
I do have concerns about the Medicare bills. I do oppose
opening Medicare's definition of what is a physician.
I do support telemedicine. It has been critical during the
coronavirus for many services. But we must make sure that
appropriate guardrails are in place because we don't want it to
be used inappropriately, as has been noted by MedPAC and the
Government Accountability Office and the inspector general.
We must also seriously evaluate if resources are better
focused on getting psychologists and psychiatrists into
underserved areas.
I, unfortunately, need to devote some time to process.
There is a strong bipartisan commitment to improve our Nation's
mental health. So I am frustrated by the majority's willingness
to make even small changes to some of the bills to accommodate
some concerns prior to this hearing.
And, you know, when compromise was clearly possible, we
did--majority staff acknowledged that changes would make some
of these bills easier to enact. Still, what were introduced
were very partisan bills instead of what we have been working
on to secure Republican support.
Unfortunately, this has become all too predictable in the
public health space in this Congress, which is sad, because
historically it is the public health space where this
subcommittee comes together to legislate the most.
It also concerns me that we are considering bills as
introduced rather than the language negotiated as part of the
bipartisan efforts. And this is not the first time that the
majority and minority have had an agreement only to have the
majority move the goalpost. It makes it difficult for members
on this side of the dais to trust you and the agreements that
are made. Ignoring our requests--our reasonable requests--
actively harms the legacy of this committee.
And it did not need to happen. I am puzzled why it did. You
should fully expect members to file amendments should bills be
brought up to markup that you were unwilling to engage with us
or our staff and then refused to acknowledge our proactive
outreach and ignored our flagged concerns. My expectation for a
supposedly noncontroversial markup is that you will not notice
these bills, but the ones where the general agreement had
occurred.
Many issues, but especially mental health, should rise
above partisan politics. We should come together to change the
landscape and provide the much-needed resources to individuals
who are struggling with mental health issues.
And I will yield back.
[The prepared statement of Mr. Burgess follows:]
Prepared Statement of Hon. Michael C. Burgess
Thank you, Madam Chair. I appreciate your willingness to
work on a productive, bipartisan agenda for this subcommittee
and respect of my request for a hearing on mental health and
coronavirus. This was a topic that we were slated to address
prior to the outbreak but has become even more serious. The
human loss, job loss, and isolation that Americans have faced
due to this pandemic makes this an even more critical topic.
Even at the beginning of this crisis, the American
Psychiatric Association found that one-third of Americans felt
it seriously affected their mental health. That reality
compounded with the existing prevalence of mental health and
substance use disorders makes this issue urgent.
According to the National Institute of Mental Health,
nearly one in five American adults lives with mental illness.
Ensuring proper supports are in place for people to manage and
treat these illnesses should be a priority.
There are 22 bills before us today, many of which have
bipartisan consensus. I appreciate that you included all the
bills I mentioned in my letter, especially H.R. 3539, the
Behavioral Interventions Guidelines Act, which I worked on with
Dr. Drew Ferguson. We had successfulbehavioral intervention
programs in schools in our states that inspired us to work
together.
For me, it was hearing from leadership at the Texas Tech
University Health Sciences Center and their program to provide
training forbehavioral health intervention and telebehavioral
health services at schools in rural West Texas. School-aged
children are at a prime age to identify and treat behavioral
health issues before they might worsen.
I believe this bill is even more important now. Students
have been away from school and friends during a difficult time,
and some may be dealing with the loss of loved ones or being
home with a difficult family situation. I hope that we will
advance this bill to markup.
Other bills cover a wide range of important issues from
improving the national suicide prevention hotline to extending
the authorization for the Community Services Block Grant two
years. These bills will ensure stable, high quality resources
for those who need them.
One issue not addressed today is the mental health of
healthcare workers. This may be especially prevalent now, but I
believe this has long been a serious issue in our healthcare
system that deserves attention.
I have concerns about the Medicare bills. I oppose opening
Medicare's definition of physician. I do support telemedicine,
and it has been critical during COVID for many services, but we
must make sure appropriate guardrails are in place to
discourage waste, fraud or abuse, as noted by MedPAC, the
Government Accountability Office, and the Inspector General. We
also must seriously evaluate if resources are better focused
getting psychologists and psychiatrists into underserved areas
than expanding Medicare reimbursement to lesser trained health
workers.
I unfortunately also need to devote some time to process.
There is a strong bipartisan commitment to improve our nation's
mental health. I am frustrated by the Majority's unwillingness
to make small changes to some bills to accommodate our concerns
prior to this hearing, when compromise was clearly in sight.
Majority staff acknowledged those changes would make progress
much easier. Still, you introduced partisan bills when you knew
you could secure Republican support. Unfortunately, this has
become all too predictable in public health, which is sad since
historically it is where this Subcommittee comes together to
legislate the most.
It also concerns me that we are considering bills as
introduced rather than language negotiated as part of
bipartisan, bicameral efforts. I assume that you and Chairman
Pallone still intend to adhere to our agreement on negotiated
language. We are not interested in resetting the clock on our
hard work.
This is not the first time the Majority has reneged on a
deal. That makes it difficult for Members on this side of the
dais to trust you and the deals we make. Ignoring our
reasonable requests actively harms the legacy of this Committee
and did not need to happen. I am puzzled why it did.
You should fully expect Members to file amendments should
bills be brought to markup if you were unwilling to engage with
our staff on them, refused to acknowledge our proactive
outreach to you, or outright ignored our flagged concerns. My
expectation for a supposedly noncontroversial virtual markup is
that you will not notice these bills.
Many issues, but especially mental health, should rise
above partisan politics. We should come together to change the
landscape and provide much needed resources to individuals
struggling with mental health issues.
Ms. Eshoo. The gentleman yields back.
Everyone was not on when I said this earlier, but we expect
votes between 11:15 and 11:30. We are not going to recess since
we will be voting in shifts. So the full committee chairman,
Mr. Pallone, has agreed to chair the hearing when I go over to
the Capitol to vote. So thank you for that.
The Chair now recognizes the chairman of the full
committee, Mr. Pallone, for 5 minutes for his opening
statement.
And remember to unmute, please.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Chairwoman Eshoo, for convening the
hearing today, the legislative hearing on 22 bills to improve
both quality and access to mental healthcare in our country.
And, of course, I want to welcome back our former colleague
Patrick Kennedy, who I have to--everyone knows now--if you
don't, I will tell you--is a New Jersey resident, actually a
resident at the Jersey Shore, which I am particularly fond of.
I understand, you know, coming from the Ocean State to the
Jersey Shore.
So you have been there a few years now, so I really
shouldn't be welcoming you. But thank you. Good to see you,
Patrick.
This hearing is particularly timely as our Nation is
simultaneously confronting a global health crisis, a severe
economic downturn, and centuries of systemic racism. All three
of these crises are understandably triggering distress for
millions of people, and it is compounded by the fact that many
people are isolated from family and friends. It is no wonder
that nearly half of Americans are reporting that their mental
health has been negatively impacted through the worry and
stress in recent months.
And mental health is an essential part of our overall
health and well-being. Thanks to this committee's work, we have
made progress to better incorporate comprehensive mental
healthcare into our healthcare system. We have improved
insurance coverage for mental health services through the
Mental Health Parity Act of 1996--which I think Patrick was
involved with--and the Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act of 2008.
And thanks to the Affordable Care Act, which we voted to
enhance yesterday, millions of Americans now have access to
comprehensive health insurance plans that include mental health
services. The ACA dramatically improved access to mental health
and substance use disorder benefits by requiring individual and
small group insurance plans to cover these benefits. As a
result, millions of Americans can now access mental health
services and substance use disorder treatment without fear of
exorbitant out-of-pocket costs that all too often deter people
from seeking treatment. And the ACA also applied mental health
parity requirements to individual market plans.
Now, we continued to build on this progress in 2016 when
President Obama signed the 21st Century Cures Act into law. It
expanded access to mental health services for children through
Medicaid, improved coordination between primary care and
behavioral health services, and reauthorized important
programs, including those focused on suicide prevention.
Again, thank you, Congresswoman DeGette and Congressman
Upton, for their role in that.
Taken together, all these legislative changes have made a
true difference in Americans' lives, but there is a lot that
has to be done to help people in need.
In 2018, more than 47 million Americans said they suffered
from a mental illness over the past year, including more than
11 million who had a serious mental illness. Research estimates
that more than 7 million American children have a mental health
disorder. And, tragically, far too many conditions in children
go unidentified and untreated, and research has found large
disparities in access to mental health services amongst Black
and Latino children.
We also know that people experiencing mental illness are at
a higher risk of developing substance use disorder. According
to surveys, roughly half of individuals experiencing mental
illness will also experience a co-occurring substance use
disorder, and this underscores the importance of expanding
access toboth mental health and substance use disorder
treatment. This is particularly important as we continue to
respond to the opioid epidemic that claims 130 lives every day,
as well as emerging epidemics involving cocaine and
methamphetamine use.
Unfortunately, suicide has also been on the rise. In 2018,
more than 10 million Americans seriously contemplated suicide,
and 1.4 million people made nonfatal attempts. Suicide is now
one of the top ten leading causes of death in the U.S. and is
the second leading cause of death among young people ages 10 to
34.
Today less than half of those with mental health conditions
get treatment, with many citing the inability to pay for
services as their primary reason for not seeking treatment. And
individuals in need of care also often cite stigma and fear of
discrimination as reasons for not seeking treatment, and many
others report difficulty getting access to providers due to
workforce shortages.
All of this speaks to the urgent need for additional action
to help those in need. That is why we are considering a variety
of policies, including proposals to improve telemental health,
mental health parity, mental health services for students and
in the emergency room, and suicide prevention programs. And
taken together, these proposals are focused on improving our
Nation's well-being.
So I want to thank our witnesses, thank everyone.
You know, this has always been, as has been mentioned, a
bipartisan issue for our committee. Many people have spoken
out. Many people have told their individual stories, which is
often difficult, but I admire those who do that.
And again, thank you, Chairwoman Eshoo. This is a really
important legislative hearing. And as you mentioned, we do
intend to move bills. Thank you again.
[The prepared statement of Mr. Pallone follows:]
Ms. Eshoo. We thank the chairman of the committee, and he
yields back.
It is now a pleasure to recognize the ranking member of the
full committee, Mr. Walden of Oregon, for his 5 minutes for an
opening statement.
OPENING STATEMENT OF HON. GREG WALDEN A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. Good morning, Madam Chair. Thank you very much.
Good morning, Madam Chair, and I thank you for holding this
hearing. I think it is a really important hearing and one that
we have a lot of work do on.
I would share some frustration at the outset about the
bills and the lineup. I am hopeful that we can work through, as
Dr. Burgess said, some of the legislative initiatives where we
had already found some agreement, but we are hearing the
underlying bill not what has been agreed to.
As Chairman Pallone said, this has always been bipartisan
work on mental health issues, not by our voter registration,
and there is a lot of bipartisan work to be done here.
I also must express a little frustration. I had trouble
getting on, so maybe that is where my frustration starts this
morning. But that we are going to roll through with the votes,
because the way we are voting, and the elongated voting and
all, I know some of our Members are a little concerned about
missing out on some of the presentation and the Q&A with the
hearing going on. And I think for a future hearing, we should
have a discussion about how we do that.
Too many of us have lost loved ones because of suicide,
like my friend former Oregon U.S. Senator Gordon Smith, who
tragically lost his son Garrett Lee Smith one day before his
22nd birthday. I worked with Senator Smith on 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 and expanded in Cures. Many of the bills
before us today will further improve crisis intervention and
suicide prevention.
I am looking forward to working with our colleagues in the
majority to move these bills through the legislative process.
Consideration of these bills could not come at a more pressing
time. As we all know, COVID-19 and the resulting economic
downturn have impacted the mental health and well-being of all
Americans.
A recently released report by the Well Being Trust and the
American Academy of Family Physicians predicted that an
additional 150,000 Americans could die because of suicide or
drug and alcohol misuse as a result of the pandemic. These
deaths from despair, as they are called, will likely increase
as continued lockdowns further isolation that deepens the
economic downturn. States will need resources to help prevent
them.
However, I am concerned that one of the bills would make
States ineligible for mental health and substance use disorder
grants if they cannot meet the bill's mandate. Under this bill,
certain States would be stripped of all sense of funding,
including substance abuse prevention and treatment and
community mental health services block grants.
My friends in the majority may not have considered that
these mandates are logistically impossible to meet as many
States do not have year-round legislatures. Furthermore,
cutting States' critical funding at a time when they are
needing it the most is simply not acceptable.
So I wish the majority would take the time to the work with
us on consensus language on some of the bills today, but we
have covered that, and we will look forward to working with you
as we go forward.
So with that, Madam Chair, I will yield back, knowing that
we have votes coming up.
[The prepared statement of Mr. Walden follows:]
Prepared Statement of Hon. Greg Walden
I'd like to thank Chairwoman Eshoo and Ranking Member
Burgess for convening this hearing today to examine several
measures to make meaningful improvements to mental health
services in this country. The Committee on Energy and Commerce
has led the way in addressing mental health and substance use
disorders for years, and I'm pleased that we are continuing to
work to address these issues that are so critical for many
Americans.
Too many of us have lost loved ones to suicide--like my
friend former Oregon Senator Gordon Smith, who tragically lost
his son Garrett Lee Smith to suicide one day before his 22nd
birthday. I worked with Senator Smith on the original Garrett
Lee Smith Memorial Act, which provides information and training
for suicide prevention, surveillance, and intervention
strategies for all ages, and was proud to see this important
program reauthorized and expanded in Cures. Many of the bills
before us today will further improve crisis intervention and
suicide prevention, including:
H.R. 3539, the Behavioral Health Intervention Guidelines
Act;
H.R. 4564, the Suicide Prevention Lifeline Improvement Act;
H.R.4585, the Campaign to Prevent Suicide Act;
H.R. 4861, Effective Suicide Screening in the
EmergencyDepartment Act;
H.R. 5619, the Suicide Prevention Act;
H.R. 5855, Bipartisan Solution to Cyclical Violence Act;
H.R. 7147, the CRISIS Act;
H.R. 7293, the STANDUP Act; and
H.R. 7316, the Emergency Mental Health and Substance Use
Technical Assistance Act.
I am looking forward to working with our colleagues in the
majority to move these bills through the legislative process.
Consideration of these bills could not come at a more pressing
time. The COVID-19 pandemic and resulting economic downturn
have impacted the mentalhealth and wellbeing of all Americans.
A recently released report by the Well Being Trust and the
American Academy of Family Physicians predicted that an
additional 150,000Americans could die because of suicide, or
drug/alcohol misuse as a result of the pandemic.\1\ These
``deaths from despair'' will likely increase. As continued
lockdowns further isolation and deepen the economic downturn;
states will need resources to help prevent them.
---------------------------------------------------------------------------
\1\Jayne O'Donnell, 'Deaths of despair': Coronavirus pandemic
could push suicide, drug deaths as high as 150k, study says, USA TODAY
(May 8, 2020), available at https://www.usatoday.com/story/news/health/
2020/05/08/coronavirus-pandemic-boostssuicide-alcohol-drug-death-
predictions/3081706001/.
---------------------------------------------------------------------------
However, I am concerned that one of the bills would make
states ineligible for mental health and substance use disorder
grants if they cannot meet the bill's mandates. Under this
bill, certain states would be stripped of all SAMHSA funding,
including Substance Abuse Prevention and Treatment and
Community Mental Health Services Block Grants. My friends in
the majority may not have considered that these mandates are
logistically impossible to meet as many states do not have
year-round legislatures. Furthermore, cutting states' critical
funding at a time when they are needed most is wrong.
I wish the Majority had taken the time to work with us on
consensus language on some of the bills before us today. Our
staff proactively reached out to try to find agreement on
modifications that could have led us to support the bills
instead of moving these bills in a partisan fashion.
Unfortunately, these efforts were not successful and our
friends on the other side of the aisle ignored our concerns. I
have serious concerns about moving forward with any virtual
markup of partisan bills. And if the Majority chooses to do so,
I'd like to beon-record here today saying our members will be
prepared to offer any and all amendments necessary to get these
bills to an acceptable place.
Moving public health bills should not be a partisan
exercise. When Dr. Burgess and I chaired this committee, RARELY
did we notice public health bills that the minority could not
support. I urge the majority to go back to the bipartisan
tradition of this committee and work together with us on a
package of bills that can make it across the finish line. We
remain open to compromise; we want to find consensus; and we
want to legislate--so I hope the majority can course-correct
going forward.
There are many bills that I think could make meaningful
improvements to mental health services in this country, and I
hope we can work together over the next few weeks to get the
needed Agency technical assistance. Should this occur, I look
forward to advancing these measures together.
We have a lot of ground to cover today. I thank you for the
opportunity to discuss these critical issues and I yield back.
Ms. Eshoo. We thank the gentleman, and he yields back.
I now would like to introduce our witnesses for today.
First, the Honorable Patrick Kennedy. He is the founder of
the Kennedy Forum and, as we all know, is a beloved former
colleague of the House of Representatives, where he represented
Rhode Island's First Congressional District.
Welcome to you, dear Patrick. Thank you for being with us.
It means everything to us to have you here with us.
Dr. Arthur Evans, Jr., is the chief executive officer of
the American Psychological Association.
Welcome to you, and thank you for being with us.
Dr. Jeffrey Geller is the president of the American
Psychiatric Association and the director of public sector
psychiatry of the University of Massachusetts Medical School.
Thank you, Dr. Geller.
Ms. Arriana Gross is the National Youth Advisory Board
Member of the Sandy Hook Promise Students Against Violence
Everywhere--it is called SAVE--Promise Club.
Welcome to you and thank you for being with us. We are so
pleased. We really are. It is an honor.
So, former Congressman Patrick Kennedy, you are recognized
for 5 minutes, and please remember to unmute. We don't want to
lose one word offered to us. Thank you.
STATEMENTS OF FORMER REPRESENTATIVE PATRICK J. KENNEDY,
FOUNDER, THE KENNEDY FORUM; ARTHUR C. EVANS, JR., PH.D., CHIEF
EXECUTIVE OFFICER, AMERICAN PSYCHOLOGICAL ASSOCIATION; JEFFREY
L. GELLER, M.D., M.P.H., PRESIDENT, AMERICAN PSYCHIATRIC
ASSOCIATION, PROFESSOR OF PSYCHIATRY AND DIRECTOR OF PUBLIC
SECTOR PSYCHIATRY AT THE UNIVERSITY OF MASSACHUSETTS MEDICAL
SCHOOL, WORCESTER RECOVERY CENTER AND HOSPITAL; AND ARRIANA
GROSS, NATIONAL YOUTH ADVISORY BOARD MEMBER, SANDY HOOK PROMISE
STUDENTS AGAINST VIOLENCE EVERYWHERE (SAVE) PROMISE CLUB
STATEMENT OF PATRICK J. KENNEDY
Mr. Kennedy. Thank you, Madam Chairwoman, and it is so
great to see you always, you are family. And I just want to
say, in addition to your being family, it was nice that you
shared your opening remarks with family, my cousin Joe, who
does everything I tell him to do on mental health. And I am so
honored that he is a member of this committee which has such
important jurisdiction over this critical issue to our Nation's
health.
And I want to thank Chairman Pallone for his leadership,
Chairman Burgess, and Chairman Walden, for the opportunity to
address all of you. And, of course, as I look on the screen I
see so many of my former colleagues, and I am so grateful for
the opportunity to see your faces, some of whom are covered by
face masks. Kudos to you for setting a standard and a model.
So I get acknowledged for having some great courage on
this, and it often was the case with my great colleague and
coauthor of the Mental Health Parity and Addiction Equity Act,
Republican Jim Ramstad. I appreciate this is a bipartisan
process, especially on mental health, which affects every
family. We can go around saying it is one in four, or it is 50
percent, but we all know in our own lives it is every family.
And Jim always used to say Patrickhas got the same kind of
profile in courage as his uncle President Kennedy. And I always
would stop him and I would say, I didn't have any courage about
coming forward because what happened to me was the guy that I
was in drug rehab with at 17 wrote about being in drug rehab
with me in The National Enquirer, and he sold his story to The
National Enquirer.
So, basically, I had no out. I wanted to keep the fact that
I had suffered from addiction from an early age private. I
didn't want anyone to know. And what ended up happening was I
had no choice in the matter. I came from a public family and,
unfortunately, like everything else, it was always made public.
I would say that was probably the best thing that ever
happened to me in my life in the sense that, for one thing, as
a Congressman I didn't have any fear for being an outspoken
proponent for mental health. And it was because I didn't have
to worry about the press reporting about why I was a supporter
of mental health, because they somehow had the goods on me,
that they could hold it against me that I would disclose this
private factor in my life.
And it also helped address the main point, and that is that
we keep these illnesses secret. And these illnesses being
secret are the reason why they are exacerbated.
So let me just say, in recovery we say we are only as sick
as our secrets. And I would say, even though we have made great
progress on mental health, we are still very sick as a Nation
because we keep these things secret.
I also think in recovery we have these phrases, like you
have got to walk the walk, not talk the talk. And in our
country, we have really just talked the talk, we have never
walked the walk on including mental health and addiction
treatment in our country on par as we would cancer,
cardiovascular disease, or any form of treatment that we would
expect from our medical system.
And then, finally, I would say that denial is the big issue
here. And we all know growing up in families where there is
alcoholism and addiction or mental illness that we don't like
to talk about these things. And I, frankly, think the reason we
as a Nation have not addressed this issue is because we are
still in deep denial about these illnesses and their
pervasiveness.
And the evidence and Exhibit A of that is the fact that
Congress and the country have really never appropriated the
necessary resources for this crisis, to Chairwoman Eshoo's
point earlier. And they never enforced the Parity Act, which,
as I said, was a bipartisan bill that simply says treat these
illnesses like other chronic illnesses.
And until there is that same urgency towards enforcing, and
until there is that same money backing up our words that these
are really equal illnesses, we are really still in denial as a
Nation.
And I look forward to hearing my other counterparts testify
and to answering any of your questions. And my time is up.
Thank you for letting me share.
[The prepared statement of Mr. Kennedy follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you. And we need to heed your words,
Patrick. Thank you very much.
Now I would like to recognize Dr. Evans.
You are recognized for 5 minutes. And please remember to
unmute, Doctor. And thank you, again, for being with us. We so
appreciate it.
STATEMENT OF ARTHUR C. EVANS, Jr., Ph.D.
Dr. Evans. Chairman Eshoo,Ranking Member Burgess, and
Members of the Subcommittee on Health, thank you for this
opportunity to testify today.
The American Psychological Association is the leading
scientific and professional organization representing
psychology in the United States, with more than 121,000
researchers, educators, clinicians, consultants, and students
as its members.
Even before COVID our mental health system was facing
severe challenges. Less than half of the individuals with a
mental health disorder receive treatment, and only about one in
nine individuals with a substance use disorder receive
treatment.
The tragic result is that we have multiple crises happening
simultaneously. We have a pandemic that is creating a number of
psychological challenges for individuals. We have, on top of
that, an economic crisis that is also contributing to the
psychological distress of Americans. And then on top of that,
more recently we have been dealing with systemic racism and the
impact that that has on many of our fellow Americans.
All of this results in data that show consistently across a
number of different sources that we are seeing increases in
anxiety, depression, post-traumatic stress disorder, and eating
disorders. This is having a disproportionate impact on
marginalized communities. The public health term for this is
syndemic, a disease that is spreading more rapidly as a result
of social inequality and injustice impacting those already at
higher risk for poorer health.
To address this syndemic, we need a population-based
approach that targets appropriate interventions across a
population, including addressing social determinants of health.
An example of the power of addressing social determinants
like housing is when I worked as commissioner for behavioral
health in the city of Philadelphia. My agency, working with the
housing agency, leveraged Section 8 housing funding with
Medicaid funding for mental health services to address
homelessness.
As a result of this, we were able to improve mental health
outcomes, we were able to get over 800 people off of the
streets of Philadelphia, and we saved literally hundreds of
thousands of dollars. A win, win, win.
We need improvements on a number of fronts, as would be
addressed by the array of bills before you today. This includes
stronger parity enforcement. Enactment of the Mental Health
Parity and Addiction Equality Act of 2008 was a major step
forward, and my fellow panelist and good friend, Congressman
Kennedy, will forever deserve our thanks and our gratitude for
leading this fight, which APA was proud to be a part of, along
with our colleagues at the American Psychiatric Association and
many other groups.
Unfortunately, parity has not reached its full potential
and we need support for the parity bills before the committee
to strengthen existing law.
We also need to give patients better access to mental
health and substance use providers. One of the bills before
you, H.R. 884, the Medicare Mental Health Access Act, would
incentivize mental health service delivery in rural and
underserved areas by making psychologists eligible for mental
health shortage area bonus payments.
I want to thank the bill's longtime champions,
Congresswoman Schakowsky, co-lead Congressman Mullin, and
cosponsors Congressman Gianforte, Congressman Lujan, and
Congressman Long, for their support.
I would also like to highlight Congresswoman Matsui's
Telemental Health Expansion Act, or Telehealth Expansion Act.
CMS has taken some great strides in expanding telehealth across
mental health treatment, which has been critically important in
helping patients get the help that they need during COVID.
Ultimately, CMS and Congress should make most of these
telehealth provisions permanent.
In addition to the bills I have already mentioned, we
support many others before you today, including the Behavioral
Health Coverage Transparency Act and the Mental Health Parity
Compliance Act, the Mental Health Services for Students Act,
the Pursuing Equity in Mental Health Act, and H.R. 6645, to
provide additional funds for the National Institute of Mental
Health for research related to the mental health effects of
COVID.
Finally, I commend the leadership on the range of suicide
prevention bills before you today, notably by the co-chairs of
the Suicide Prevention Task Force, Congressman Katko and
Congressman Beyer, as well as Congresswoman Bustos.
Members of the committee, I am grateful for this
opportunity to testify today, and I look forward to working
with you to advance these important pieces of mental health
legislation. And I am happy to address any of the questions
that you might have for us today.
[The prepared statement of Dr. Evans follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you very much, Dr. Evans, for your
important testimony.
The Chair is now pleased to recognize Dr. Geller.
You are recognized for 5 minutes for your statement, and
please unmute. Welcome to you.
STATEMENT OF JEFFREY L. GELLER, M.D.
Dr. Geller. Thank you very much, Chairwoman Eshoo, Ranking
Member Burgess, and distinguished members of the Energy and
Commerce Health Subcommittee. Thank you for allowing me the
opportunity to testify before you today.
My name is Dr. Jeffrey Geller. I am professor of psychiatry
at the University of Massachusetts Medical School and staff
psychiatrist at Worcester Recovery Center and Hospital. I
testify today as president of the American Psychiatric
Association.
Throughout the COVID pandemic, I work onsite daily to treat
severely mentally ill patients, and I see outpatients through
telepsychiatry.
I am also a parent. One of my sons, who has intellectual
disabilities, goes to work daily at Brigham and Women's
Hospital where he delivers medical supplies throughout the
hospital. I have been much more concerned about his well-being
than I have about my own.
The COVID-19 crisis is exacerbating anxiety, depression,
and other mental health and substance use conditions. It has
unmasked clear racial disparities and inequities, and we are
pleased to see these are part of today's focus. I am going to
highlight a few areas from my written testimony.
First, the COVID crisis has made the value of your actions
to facilitate telehealth clear. Access to video- and audio-only
telehealth has enabled large numbers of patients, including
vulnerable urban and rural residents, to receive care while
also minimizing their risks of contracting or spreading COVID-
19. Telehealth is popular with patients and our members, has
reduced no-show rates dramatically, and it has been quite
effective.
It is essential that current telehealth authorization not
end prematurely. The APA has actively been working with
psychology and others to ensure continued access to telehealth
for our patients beyond the current emergency. We strongly
encourage H.R. 5201, introduced by Representatives Matsui and
Johnson, which would permanently exempt mental health services
from Medicare's geographic and site-of-service restrictions.
Second, the only bill before the committee that APA opposes
is H.R. 884, which would define psychologists as physicians
under Medicare. Psychiatrists, psychologists, and other team
members, like nurses, physician assistants, social workers, and
care managers, help patients by each contributing in their own
area of expertise.
The goal of H.R. 884 is unclear, since Medicare already
recognizes and allows psychologists to provide services they
are trained to perform and to practice independently in
Medicare and appropriate settings.
But psychologists are not physicians. Psychologists do not
have medical training. A psychiatrist treats patients with
mental illness and comorbid medical illnesses in inpatient and
partial hospital settings. A psychiatrist has to recognize
medical disorders masquerading as psychiatric disorders. You
cannot be equipped to do this without a medical school
background.
CMS emphasizes that Medicare patients and partial
hospitalization programs require comprehensive, structured,
multi-model treatment requiring medical supervision and
coordination.
We know high quality care is best provided by a team
working together to provide coordinated services. But this
legislation would do the opposite, further fragment and create
unnecessary and dangerous silos.
Existing guardrails are there for a reason. Administrative
hurdles can be addressed without going to the extreme, like
inappropriately defining psychologists as physicians under
Medicare.
We suggest the subcommittee focus its attention on the
impressive array of proposals before you on which there is
broad agreement and little controversy.
Finally, there is mental health parity. Both APAs, my
fellow panelist Patrick Kennedy, and the unified mental health
and substance use disorder community championed the parity law
in 2008, but it has failed to end discriminatory health
insurance practices. Numerous investigations by State
regulators and the Department of Labor have revealed systematic
parity violations again and again.
The parity proposal introduced by Representative Kennedy
and the bill proposed by Representatives Porter and Bilirakis
can each improve reporting of health plans on medical
management practices and thereby enhance compliance. We support
both bills and recommend the reporting language in the Porter-
Bilirakis bill because it mirrors the language many States have
applied to State-regulated plans.
I appreciate the opportunity to testify today on behalf of
the American Psychiatric Association. We look forward to
working with you to improve the availability, accessibility,
and affordability of quality mental healthcare across our
Nation. Thank you.
[The prepared statement of Dr. Geller follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you very much, Dr. Geller. We have learned
a lot from your testimony and look forward to asking you
questions and so appreciate the role that you play in today's
hearing.
I now have the pleasure of recognizing Ms. Arriana Gross.
You are recognized for 5 minutes, and please unmute.
Welcome to you.
STATEMENT OF ARRIANA GROSS
Ms. Gross. Thank you. Good morning and thank you to the
subcommittee chairwoman, ranking member, and all the members of
the Subcommittee on Health for having me here today.
My name is Arriana Gross, and I am a 15-year-old rising
junior at Newton High School in Covington, Georgia. I am in my
second year serving as one of the only ten youth advisory board
members on Sandy Hook Promise's Students Against Violence
Everywhere, also known as SAVE, Promise Clubs.
SAVE Promise Clubs were formed in 1989 after the death of a
17-year-old named Alex Orange who died from gun violence. Today
there are over 3,500 clubs across the Nation in all 50 States.
The SAVE Promise Club in my community is called Jared's
Heart of Success, and they mentor youth and empower us to
protect our friends, schools, and communities from all forms of
violence, including suicide. We do this by promoting student
mental health and wellness, including training students to
recognize warning signs of violence and how to seek help.
For example, in response to fighting at our school, we
created an anti-bullying project where we had students write
positive messages about themselves and each other and put them
on the walls around the school. It provided an opportunity to
reframe students' thinking about themselves and their peers.
Because of COVID, our SAVE Club is now holding weekly calls
with the primary focus of supporting the mental health of our
students. We have opened this up to the community at large
because everyone needs help.
As a student, I know that mental health and well-being are
more important now than ever. Suicide is the second leading
cause of death for students, and for Black boys the rates are
on the rise.
However, unlike other tragedies that are accidents, this
one is preventable. Seventy percent of students who died by
suicide will show a warning sign or tell a friend.
COVID is only making this worse. For some students, home
isn't the safest place. And with no place to go and no one to
go to from our schools, it has become very stressful, lonely,
and even dangerous for some students.
I have seen firsthand the need for support for student
mental health. In our school, a year doesn't go by without a
student dying by suicide. I have even known of elementary kids
who died by suicide.
I am concerned that youth suicide has become so common that
my school community and our Nation is stuck in a pattern of
mourning and accepting these deaths as something that is normal
instead of seeing them as preventable and tragic.
As students, we see everything--in class, in the
neighborhood, and on social media. We are on social media sites
that you probably haven't even heard of. We see way more than
our parents, teachers, and other adults.
But we aren't given the tools to help our friends
struggling with mental health or thinking about suicide. We
just need those tools to know how to help in order to save
lives. Trust me, we have seen and been through way more than
you realize, and we can and want to help.
Our SAVE Promise Club teaches us how to spot a friend who
might be struggling, reach out and help, and talk to a trusted
adult. I recently had a friend who was struggling and didn't
feel comfortable talking to her parents or a teacher. However,
she was only comfortable talking to me. Through my experience
with SAVE, I knew how to have the conversation with her and
make sure she was supported.
The pandemic has shown that mental health challenges go
beyond school walls. As part of the Black community in the
South, there is a lot of stigma to saying you have mental
health issues.
Once you do say it, finding and affording that care can be
challenging. When I needed to see a therapist, I had to travel
2 hours from my home to talk to someone. This shouldn't be the
case, and all youth should be able to get help at school.
Unfortunately, where I go to school, the counselors are
only there to support someone with academics and are not
qualified mental health professionals. Because of that, many
students don't have someone they can talk to about how they are
feeling or what they are struggling with emotionally. We need
counselors for both our minds and our academics.
We need your help in creating a system of support in our
schools. Allow us to be the eyes and ears of our peers. Give us
the tools and trainings we need to know when our friends or
ourselves may be struggling so that we can speak up and prevent
suicides. And once we do speak up, give us mental health
professionals in our schools to go to when we are struggling.
I ask the committee to vote in favor of the bipartisan
STANDUP Act of 2020 and the Mental Health Services for Students
Act. These bills will help support mental health and wellness
by encouraging more schools to adopt policies to train students
on suicide prevention and provide more mental health
professionals in schools.
The effects of COVID on our mental health are happening in
our homes now, whether we talk about it or not. You have the
power to help, and I ask that you act now to prevent another
one of my friends from dying by suicide.
Thank you.
[The prepared statement of Ms. Gross follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you very much for your excellent
testimony.
We have completed the testimony of our witnesses, and we
will move to member questions. And I recognize myself for 5
minutes for questions.
First, to Patrick.
Patrick, you wrote the Mental Health Parity and Addiction
Equality Act. You have referenced it, others have. It is not
working. That is what you essentially have said.
So as we move forward, I mean, we have 22 bills. What I am
interested in mostly, as we weave different bills together,
what are the major pillars of reform to our entire mental
health system in the country?
As your cousin Joe said, we have a lot of broken pieces. So
what are the major pillars that you would advise us that need
to be reformed, including getting your legislation to finally
have teeth in it? Is it because it is missing money, or did we
miss something in the legislation? So that is my question to
you.
Mr. Kennedy. Thank you, Anna.
I would say it all revolves around the money. And as we
know, you see what is important based upon what you spend your
money on. And, clearly, when mental health gets 0.04 percent of
the CARES Act funding, it says a lot about where mental health
is in this country. And when you see how many routine
violations by insurance companies there are of, I should say,
discriminatory practices against people who live in your
districts and their family members and friends just because
their illnesses happen to originate in their brain as opposed
to another organ in their body. And that is just widely
accepted.
And, unfortunately, as we are learning with Black Lives
Matter, so many things that we have come to take for granted
are just routinely accepted. And I think we are in denial as a
Nation about mental health. I mean, we have been at it for a
long time, accepting it as a moral failing and not a medical
failing.
And so that kind of grows on you, gets to make you think
that someone is to blame. As if they get up in a given day and
think that trying to lose their job, if they have one, or
sacrifice their housing because they jeopardize the rules of
their housing, or that they piss off or alienate all their
friends or family members is all part of what someone
voluntarily chooses to do in any given day, which of course, as
we know, is not the case.
So why can't our country get over the fact that these are
biologically based disorders and behavior is but a symptom of
them? That is what the neuroscientists at NIH tell us.
So I would say if we can understand that as the premise,
then why wouldn't the payment models--which, by the way,
reimburse for all kinds of health benefits rather than sick
benefits for cardiovascular disease.
I mean, I have been on Lipitor for 20 years, right?
Apparently, our healthcare system thinks that it is best if I
don't die from a stroke or a heart attack in ten more years and
they have invested that much in me. But when it comes to mental
health they are just missing in action.
And yet we allow that as a society. We don't enforce parity
laws both at the State or Federal level. There are now some
States that are doing a terrific job at stepping towards that.
But as far as you are concerned, our Department of Labor, I
know, which is regulated by one of your colleagues' committees,
needs to step up and pass an enforcement action so that we hold
these insurers accountable.
But that is what I would say in a longwinded way to your
question. Sorry for taking up too much time.
Ms. Eshoo. No, I hang on every word that you say.
Just very quickly, Dr. Evans and Dr. Geller, I only have a
minute left, but would either one of you like to weigh in about
major pillars and how you would reform the system?
Dr. Geller. So I can respond to that.
I think that Patrick Kennedy is exactly right. In the
entire history of our country we have always tied together any
reform in mental healthcare with saving money.
Dorothea Dix, who traveled around this country and
testified before the House and Senate, said two things in every
one of her messages: We can save money and we can do what is
right. If we can actually address this problem, we have to say
we need to do what is right, and it is going to cost us some
money.
You go in for a surgery for cancer, no one asks: How much
money is that going to save?
Ms. Eshoo. Thank you very much, Doctor.
I think my time has expired. And so I now will call on,
recognize Dr. Burgess, the ranking member of our subcommittee,
for his 5 minutes to ask questions.
Mr. Burgess. Thank you. I thank the Chair.
Dr. Geller, I want to thank you for raising the concerns
you did about H.R. 884. It seems like too often in this
subcommittee we dismiss or ignore or devalue the benefit that a
medical curriculum can actually bring to a person's background,
and I appreciate you for highlighting that.
One of the other things that I mentioned in my opening
statement is my concern about--and I don't think we have a bill
in front of us today that is specifically looking at helping
our frontline healthcare providers.
We knew that suicide was a problem amongst our colleagues
prior to the onset of this coronavirus epidemic, and I know it
is more pronounced now.
So do you have any recommendations for us on this
subcommittee--we are going to be working through these things,
we will have a full committee markup at some point, perhaps the
Katko, perhaps some other legislation--where you would see it
where we could modify it to more properly account for and
perhaps impact positively our frontline healthcare personnel?
Dr. Geller. I can tell you that besides prejudice and
discrimination in relationship to presenting with a mental
illness, a major problem for physicians and nurses and other
licensed personnel is the fear that they will lose their
license to practice if they report that they have had treatment
for a mental illness.
When I applied for a license and renewal every three years,
generally, I am asked the question in almost every State, have
I sought psychiatric treatment and am I mentally impaired or do
I believe I am mentally impaired? If Congress could address
that problem, I think that it would make frontline healthcare
workers more willing to seek treatment.
The second is we need to do a massive campaign to educate
the population about what mental illness is. We are familiar
with a very ineffective massive campaign currently in terms of
how to protect oneself from COVID. But we have also experienced
a very successful campaign to remove the prejudice and
discrimination against homosexuals in the time of the AIDS
crisis. We dramatically turned that around. In the 1940s and
1950s, we actually did the same thing with breast cancer.
Nobody would even say the word "cancer."
So we know how to do it, and that is what we need to do.
Mr. Burgess. Right. I thank you for those observations.
I do, Mr. Kennedy, I wanted to ask you, Representative
Ferguson and I have introduced a bill, 3539, and I think I see
in your written testimony you talk about schools who embed
social and emotional learning. And as our last witness
testified, oftentimes amongst the student population they can
quickly identify for you who perhaps is having trouble.
So do you have any thoughts, have you had an opportunity to
look at 3539? Is there any advice you would give us for
perfecting that?
Well, Patrick, you need to unmute. I have the trouble all
the time.
Mr. Kennedy. I am sorry.
Thank you, Dr. Burgess, for prioritizing that. You know, it
is shocking. Literally as shocking as it is that we don't
address mental health in our healthcare system is that we don't
address mental health in our education system. Because how are
children supposed to learn when their amygdalas are on fire,
when they can't have their prefrontal cortex operate because
there is no adequate coping mechanism skills developed, so
there is no problem-solving skills developed, there is no
social-emotional learning skills developed?
So I think that you are absolutely on point that this needs
to be a priority. And it will be an enormous protective factor
for kids, especially since we are seeing suicide rates
skyrocket. This will help kids learn how to mediate their
impulses, which of course this is the key factor in helping to
do that.
So thank you very much. I am happy to follow up with your
office.
Mr. Burgess. Our time is always limited here [inaudible]. I
do want to ask you, though, because you reference in your
testimony that probably the largest mental health treatment
facility in all of our districts is our county jail. And we are
looking now at people who are asking for reduction in funding
for law enforcement. Do you see a problem developing here?
Mr. Kennedy. No, you know, I am familiar--you should also
ask Judge Leifman, who has successfully turned around a major
bond for an additional jail down in Florida. And he took that
money and he put it into supportive housing for those with
severe mental illness, predominantly schizophrenia diagnoses,
Bipolar I. And what he ended up doing is reducing the total
docket in his jurisdiction dramatically such that they didn't
have to build a new jail to house all of the people because a
good 30 percent of them were people who were being arrested for
routine charges, loitering, all kinds of what they call
nonviolent offenses that could be better picked up by a mental
health system that, frankly, that we are all talking about
today, is nonexistent.
So our criminal justice system has become the default
mode--in fact, we don't have a mental health system.
So all I would say to you is that it is not necessarily the
case that less is less. If it can be redirected towards what we
know is more, which is reducing the total number of people in
our criminal justice system by providing those services which
Arthur Evans and others have spent their lives providing, that
supportive housing that he talked about in his opening
statement, that is the solution we need.
Mr. Burgess. Well, I thank you for that. Redirecting is, of
course, a part of that process, not just eliminating, but I
thank you for your input. I am going to follow up with you
offline, because you have raised some interesting points that I
want to discuss with you.
Mr. Kennedy. Look forward to that. Thank you.
Mr. Burgess. I yield back, Madam Chair.
Ms. Eshoo. The gentleman's time is expired.
I can't help, Patrick, but think of our good friend and his
wife, Norm and Judy Ornstein, who have done extraordinary work
in this area, and the example that you use from Florida
relative to the criminal justice system and bringing justice to
those that have the mental health issues and using the dollars
in a very, very smart and effective way.
Now, Mr. Pallone is voting. Mr. Butterfield is not there. I
believe Ms. Matsui is to be recognized now for her 5 minutes of
questions.
Ms. Matsui. Thank you very much, Madam Chair, and I really
do appreciate your calling this hearing today. It is such an
important subject, because it is a subject that has impacted so
many of our own lives.
Before I get to my questions, I do want to acknowledge the
tremendous pressure our community behavior health centers are
facing in the demands of this crisis. Given the vital role of
these providers, it is completely unacceptable that they are
largely excluded from COVID-19 relief funds made available by
HHS. I urge the committee today to commit to working on finding
a solution that will guarantee adequate aid for those providers
to avoid permanent losses to our behavior health
infrastructure.
Prior to this pandemic, my E&C colleague, Representative
Johnson, and I introduced the Telemental Health Expansion Act,
legislation that expands access by removing Medicare site
restrictions for telemental health services delivered in urban
areas and the patient's home.
In Sacramento, our community health centers have been using
telehealth to help their patients get regular mental health
treatment. WellSpace Health, a local FQHC, has seen overall
encounters in patient visits increase by almost 50 percent.
WellSpace is now conducting 80 percent of behavior health
visits via telehealth.
Remarkably, these telehealth visits have a no-show rate of
just 10 percent compared to 40 percent for face-to-face visits.
With that in mind, I want to ask about this new reality of
widespread virtual care.
Dr. Geller, can you expand on how lifting certain
restrictions on mental health services via telehealth has
changed patient access during the pandemic?
Dr. Geller. It has had a remarkable effect. First of all,
we have shifted providers. Previously, psychiatrists in a poll
responded that approximately 65 percent had not previously used
telehealth, and now about 85 percent are using telehealth for
about three-quarters of their patients.
Ms. Matsui. OK.
Dr. Geller. Many patients have difficulties getting to
appointments. Particularly in the period of social distancing,
they actually have no way to get to appointments. There is
either no public transportation or no public transportation
that anybody with intelligence would use, because of infection
rates.
Ms. Matsui. Sure.
Dr. Geller. So they can't physically get to an appointment.
There are people across the country that are in rural areas
that had difficulty before COVID, and now it is close to
impossible.
Telehealth actually makes psychiatric services available to
a huge percentage of the population that didn't previously have
available services.
Ms. Matsui. Right.
Dr. Geller. So the combination of allowing for visual as
well as telephone-only services is very important, as you have
many patients who have no idea how to use any electronic
equipment whatsoever.
Ms. Matsui. Exactly.
Dr. Geller. So the addition of that is very important.
Ms. Matsui. Mr. Kennedy, my former colleague, at the outset
of this pandemic CMS made certain that all connected health
services would be reimbursed at the same rate as in-person
service. Why is payment parity critical to sustaining the use
of telehealth?
Mr. Kennedy. Well, it is obviously the key driver in terms
of ability to provide the services necessary, because while
there is a suspension now and people are using it, that is not
going to continue unless the biggest payer of all, CMS, steps
up and starts paying for it. And by parity, meaning it is
deemed equally effective, especially in addiction medicine--
Ms. Matsui. Exactly.
Mr. Kennedy [continue]. To in person. Why we wouldn't pay
the same is beyond me. And you guys need to really sit on CMS
to do that.
And you also, to your point, Congresswoman Matsui, you have
to do, like you said, make sure the money you already
appropriated for healthcare relief goes to mental health
providers. They are the ones who are getting the shortest of
the short end of the stick in terms of the money, because it
went through Medicare as a mechanism, not through Medicaid as a
mechanism for payment, just as a highlight for your colleagues
who don't know why their behavioral health providers are barely
hanging on, if at all, right now in their districts.
Ms. Matsui. Well, thank you very much. I really want to
thank you, Patrick, for your advocacy. It has been
unbelievable. Medicare beneficiaries now more than ever need
access to telehealth treatment for mental health services,
regardless of where they are located.
I encourage my colleagues to support access and parity for
telemental health as we look ahead to support similar proposals
for even a broader set of telehealth services.
And I see that my time has already gone, so I yield back.
Thank you.
Ms. Eshoo. The gentlewoman yields back. And we are all very
grateful to you, Congresswoman Matsui, for your special
leadership. This is not only a public health issue for
Congresswoman Matsui, it is highly personal.
As Patrick said in his opening statement, we have family
members. We have family members, and so we carry those
experiences and those wounds with us, and you certainly have,
and is that is why your advocacy and your work is so important.
Ms. Matsui. Thank you.
Ms. Eshoo. The Chair would now like to recognize with
pleasure the ranking member of the full committee, Mr. Walden,
for his 5 minutes of questions.
Is Mr. Walden with us? Then we will go to Mr. Upton.
Mr. Upton. Well, thank you, Madam Chair. I really
appreciate this hearing.
It is really terrific to see my I will say old friend.
Patrick and I go back a long way. I was one of the team with
Rammer and him that looked at mental health parity a long time
ago, but obviously, we still need to step up. We need to do
more. And his friendship, his advocacy with other key players
and certainly in our committee really makes a difference.
And I think the point that he made early on where one in
four families directly, but let's face it, every family, mine
too, directly impacted by suicide and things that we know we
can do to really make a difference to begin to turn that
around, the startling statistics and everything else.
I have got a couple of questions and want to follow up with
I guess what Doris was talking a little bit about earlier, and
that is the impact of telehealth. You know, we hear so many
cases of folks, patients not showing up at doctors' offices.
Telehealth is a real key. And, of course, we know that there
are so many areas around the country that are underserved, that
don't have access to broadband.
I know that Mr. Clyburn and I have been very active in
introducing some legislation. I think you will see some
additional legislation that we are going to introduce literally
in the next couple of days. It would require the [inaudible]
Actually to auction off some of that spectrum.
And for States like mine, underserved, Michigan is going to
get about a billion dollars in the next ten years, $108 million
each year for the next ten years. And I have got areas in my
district without a four-lane road and without broadband. You
know, as kids go back to school this fall, their access with e-
Learning is obviously extremely limited without that access.
But as we look at the benefits of what we can do, not only
working with CMS, but also working to make sure that patients
have access to that, I look at what we might be doing with 21st
Century Cures 2.0. Diana DeGette and I have had good
conversations on how we might be able to expand telehealth and
also look at CMS to make sure that they, in fact, are
[inaudible] Those services.
But I might ask both Dr. Geller and Evans, what additional
things can we do as it relates to telehealth for mental health
services?
Dr. Evans. Well, Congressman, I would say a couple of
things. One is that in addition to supporting the principle of
telehealth and, as you noted, it helps with access for a
variety of people, not only in rural areas but in urban areas.
When I was a commissioner for mental health, we had
immigrant communities in our city that had fairly large
immigrant populations that didn't have mental health
professionals who spoke their language in the city. And so
telehealth was a mechanism that we could use to reach those
communities that even in urban areas can be a challenge in
serving.
There are a couple of things. One of them is to understand
that for many people who don't have broadband, having
telephonic access for telehealth is extremely important. We
fought very hard for that provision with CMS and, fortunately,
we were able to get that.
But it is not just having videoconferencing ability, which
many communities don't have, but it is also being able to do
telephonic care as well, which is very important. So I think
making a long-term commitment to this is going to be very
important for continued access.
Mr. Upton. I might just add this. You know, a 2019 NIH-
funded study found that patients who were admitted to emergency
departments due to deliberate self-harm had a high suicide rate
in the year following their discharge. How important is it to
screen for suicide risk in emergency departments and followup
care?
Dr. Evans. It is extremely important. One of the things we
know is that for people who die by suicide, most of them, the
majority have visited a healthcare practitioner within the last
year. And there is a high percentage of people who die by
suicide who have had an emergency department visit within a
relatively short time in relation to their suicide. So doing
universal screenings in emergency departments is very
important, having surveillance mechanisms.
But I can tell you, as someone who has overseen mental
health systems, one of the most important aspects of this is to
have connections between emergency departments and the local
mental health system. Too often people are evaluated. If they
are not meeting criteria for involuntary commitment, they are
discharged without a good connection. And that is where you see
a lot of the problems with people who die by suicide who have
had recent visits to emergency departments.
Mr. Upton. Thank you. My time has expired. The clock goes
way too fast.
Ms. Eshoo. It really does. I have 27 questions I have got
to ask, but I can't.
The gentleman yields back and thank him for his questions.
The Chair would now like to recognize the gentleman from
North Carolina, and a gentleman he is, Mr. Butterfield.
And, Mr. Butterfield, I want to ask you to--I have to
vacate the Chair to go over to vote, so I ask you to fill the
Chair and be recognized for your 5 minutes of questions, and
thank you.
Mr. Butterfield. [presiding.] Thank you to the Chair. I
just left the floor a few moments ago and they are, indeed,
waiting for you. So thank you for allowing me to sit in your
chair for just a few minutes.
The Chair will now recognize himself for 5 minutes. Let me
just start with our dear friend Patrick Kennedy. Patrick, all
the Members on both sides of the aisle have said such nice
things about you, and I just want you to know that they are all
deserving. We appreciate you. We miss your service here in the
Congress. But thank you for the incredible work you are doing
all across the country.
Patrick, while we have made progress in normalizing
conversations and reducing stigma about mental illness, it is
clear, it is so clear--and you have made that abundantly clear
in your opening statement--we have such a long way to go.
You note in your testimony that the promise of the Mental
Health Parity and Addiction Equity Act has not been realized
and that many Americans are encountering barriers when seeking
professional help.
I am sure that many individuals give up, they just
absolutely give up after receiving denials or limited benefits.
Barriers to care can close a window of opportunity for the
individual to get the help that they need, resulting in harm,
serious harm to the individual. And, as you point out in your
testimony, societal and economic losses to our communities.
Our country, as we all know, is experiencing crises on so
many different fronts, from COVID to the epidemic of police
violence against African Americans. Now more than ever, the
process to seek help should not be a barrier to receiving help.
Question: What should we do? What should we do to enforce
behavioral health standards and regulations to ensure that
beneficiaries are not encountering needless roadblocks to
receiving the care that they need when they need it?
Mr. Kennedy. Thank you so much, G.K. Obviously, you have
got before your committee a couple of different bills, both of
which are very, very important to help bring greater
transparency to really what insurance companies deliberately
obfuscate, which is, basically, they hide behind this seeming
confusion as to how they determine someone's medical necessity.
Well, we have in the Federal law very clear guidelines that
are now being adopted by all of your respective States to bring
absolute clarity, based upon the administrative rule to enforce
the Federal Parity Act.
And so I would basically encourage you to pass those parity
bills that you have before you, because, as you said, G.K.,
what it is really about is insurance companies know that it is
going to take forever for you to appeal their denial. They are
counting on it as a cost of doing business.
So, so many people who are in a mental health crisis,
family is in a mental health crisis, they have nowhere near the
wherewithal to challenge a major payer, a major insurance
company, so they give up. That is what the insurance industry
counts on. And as a result, this insurance industry reduces its
total liability to provide care, because they basically deny
care.
And yet, if you looked at the comparable between the
percentage of care they denied that is mental health and
addiction-related versus the amount of care that they deny that
is medical and surgical-related, you would see a huge
disparity. And what your bills before your committee do is they
will require that to be opened up for the light of day so that
there is transparency.
And I think if there is transparency, the insurance
industry will be loathe to put together any plan that, when
evaluated, will clearly illustrate that they are
discriminating, because, as you know, G.K., through your long
work on behalf of civil rights, you know, the more you bring
transparency and open it up, the less people have the
opportunity to discriminate, because ultimately people don't
want to be caught discriminating or they shouldn't want to be
caught discriminating, I should say.
So thank you for that question. Thanks for your service and
your friendship.
Mr. Butterfield. Well, thank you. Thank you as well.
I have one other question for Dr. Evans, but it looks like
the gentleman is running out of time and so I am going to yield
back the balance of my time and recognize the next Republican.
I am being told who that is right now. It looks like it is our
friend John Shimkus.
Mr. Shimkus, you are recognized, sir, for 5 minutes.
Mr. Shimkus. Yes. Thank you, Congressman Butterfield. And,
Patrick, it is great to see you. I was interested in the
exchange between Fred Upton and Dr. Evans, and it was kind of
on my line.
There are 102 counties in Illinois. I represent 33 of them.
And so what COVID has caused to happen, which is, I mean, kind
of a side benefit, is it really has forced us to ease some of
the regulatory burdens on the telehealth stuff. And so I know,
Dr. Geller, in your testimony, you talk about telepsychiatry.
And then we go into this--I think a lot of our concern is
if somethingis working, when this COVID crisis fails--I mean,
when it ends, we don't want some of these reforms that were
kind of created for emergency purposes--we would like to see
them continue, because I just think that is helpful.
Everybody understands there are unserved, underserved
areas. Moneyis going in, whether it is--for us, it is USDA
rural development, the FCC, even some individual States are now
starting to put more money to broadband deployment and laying
fiber.
So, first of all, let me go to Dr. Geller. I have heard
requests from a 22-month extension or more, and I guess we will
be asked as to why, not just because my perception that there
is a huge benefit, but do we need time to extend this program
now to gather data and how long should that be and what kind of
data are we looking at?
Dr. Geller.
Dr. Geller. So yes, we do. An extension should allow for a
study, and we can look at various outcomes in terms of access.
And we can also look at something I mentioned before, but
it is, unfortunately, of incredible importance, and that is
cost. Because while it is going to cost more up front if people
have more services available and they actually access more
services, there is a high likelihood that there is going to be
a significant downstream savings, not having people go to
emergency rooms, not having people need inpatient admissions.
So we need to look at clinical variables and economic
variables to see how this is working. We also need to include
the capacity for physicians to work with each other through
telehealth, so that we have coordinated care across the board,
and that should address lots of the problems in rural counties
like you are talking about.
Mr. Shimkus. Yes. What would you think would be a timeframe
that we would need to gather this data?
Dr. Geller. Well, that is an excellent question, because we
expect even after the infectious aspect of this pandemic is
over that we are going to have a mental health pandemic that
could go on for quite some time. And we don't really know how
long that is going to be.
The APA doesn't have any official position on how long that
should be. If you were asking me, I don't think we could know
the answer in less than five years.
Mr. Shimkus. Yes. I think that is important for us to hear,
because, again, this has been such a great opportunity to
exercise and show the benefit of telehealth in your world and
also just in the, you know, the medical practice field for
underserved/unserved communities in rural areas.
Dr. Evans, do you want to add anything to this debate on
the period of time and our push to keep this? When they ease
the regulatory burdens, we want to make sure that we don't
reinplace them once someone thinks this thing is over.
Dr. Evans. Sure. Well, I think that it is important to keep
it and to recognize that telehealth is only a means to an end.
It is a mechanism to provide services that we know work for
people. And, as Dr. Geller referenced in his point, one of the
things we know is that there are significant cost offsets on
the physical health side when people have access to mental
healthcare.
So I would expect that not only will people be able to
address their mental health challenges, but we are going to see
savings on the physical healthcare side.
I think this is really critical. Our organization has been
working on getting access to members of the rural communities.
We have relationships with Farm Aid and the Farm Bureau, and we
are currently working with SAMHSA on a program to train
individuals to work with people in rural communities.
And one of the things that is really clear, we can do our
part as an association to train people and to encourage people,
but we need to have the infrastructure available so that people
can get those services delivered. So I appreciate your
question.
Mr. Shimkus. My time has expired. Thank you, G.K., and I
will yield back.
Mr. Butterfield. Thank you. Thank you, Mr. Shimkus.
The Chairman now recognizes the chairman of the full
committee, Mr. Pallone, for 5 minutes. Please remember to
unmute, Frank.
Mr. Pallone. Thank you, G.K.
Patrick, I wanted to go back. I know everyone keeps asking
you about the promise of the Federal parity law which you
sponsored and, you know, what more needs to be done, and you
talked a little--you certainly talked a lot about it, but I
want to kind of drill down again.
We have these two important bills introduced by your
cousin, Representative Joe Kennedy, and Representative Porter
that would strengthen the enforcement of mental health parity
laws and increase transparency regarding how the health
insurance plans are complying with the law. So I wanted to ask
you about both of those things.
Looking back at the implementation of the Federal parity
law over the past decade, can you discuss the challenges
associated with the enforcement and oversight, you know,
basically transparency. I know you don't think it has been
fully realized, but, you know, what remains to be done to
achieve parity, looking at the enforcement and the
transparency, if you would, a little more detail?
Mr. Kennedy. Well, for one thing, having one inspector for
over 1,500 plants obviously lets, you know, the whole process
go to pieces, because how are we going to have any
accountability if there is no oversight?
Two, what we need to do is really strengthen the
requirements, that there is kind of a forensic audit of the way
insurers make these medical necessity determinations. And they
need to now, under the bills that are proposed before the
committee, really demonstrate how that all works.
And, you know, that is a process of evaluating what is
known as these nonquantitative treatment limits, a medical
necessity criteria, all of which are very crucial to people's
ability to get the care that they need in a timely manner.
And I know that Dr. Evans as well as Dr. Geller, their
professions know full well how they get micromanaged well
beyond what they ever would expect if they were any other area
of healthcare delivery.
Mr. Pallone. And I mean from an enforcement perspective,
obviously, you just need more staff. That is what you are--
Mr. Kennedy. A call by the whole community for $20 million
would dramatically improve Department of Labor's--I mean,
nearly 80 percent of all people in our country are covered
under ERISA plans, so that their oversight is by, obviously,
Department of Labor. Most people don't know that.
So I would encourage all of you in your jobs as Federal
members, this is exactly your purview. You need to have your
Department of Labor step up its game. It is absolutely
unbelievable. In the time where we are losing more people to
suicide and overdose and alcoholic death than we are COVID,
more than COVID, and what do we spend?
We can't even get $20 million to even--and by the way, for
my Republican friends, enforcing parity means making sure that
insurance companies don't give the Heisman to mental health and
addiction such that our taxpayers have to pay the difference
here.
Because that is ultimately what happens is, because payers
never really fully adhere to this Federal parity law, what they
end up doing is pushing the cases down, down, out, out, out the
door while they don't assume any accountability. And then who
pays? The taxpayer pays, through our corrections system,
through our policing system, through our firefighters and all
of their disproportionate time gobbled up by trying to pick up
people who are homeless, who are on the streets, all because
early on, you know, payers tried to save money and they pushed
it onto the taxpayers.
And really, in essence, this is corporate welfare of the
first order. We are allowing the richest companies in our
country, the healthcare insurance companies, who, by the way,
are sitting on a boatload of cash because they have never had
to pay any bills for the last 5 months, and they are denying
mental health still. You can't even make this up. And who is
paying for this? The hard-strapped taxpayer is paying for it in
innumerable ways, including through Medicaid and also through
their local property tax base.
So if I were both a liberal or a conservative, parity would
be a big issue for me.
Mr. Pallone. Thank you, Patrick, and thanks for all your
work over the years.
I yield back, G.K.
Mr. Kennedy. Thank you.
Mr. Pallone. Or Anna. I see Anna is back as well.
Mr. Butterfield. Anna is back.
Ms. Eshoo [presiding]. I went as fast I could. And I want
to thank Mr. Butterfield for stepping into the Chair.
I believe that Mr. Walden is the next to question. Is he
there? Going, going, gone. So we will return to him.
It is a pleasure to recognize the gentleman from Virginia,
Mr. Griffith, for your 5 minutes of questions.
Mr. Griffith. Thank you, Madam Chair. Can you hear me?
Ms. Eshoo. Yes.
Mr. Griffith. All right. I have submitted for the record a
letter from Jennifer Feist.
Many of you have likely heard about Jennifer's sister, Dr.
Lorna Breen, head of the emergency department at Columbia
Presbyterian's Allen Hospital in New York City.
Dr. Breen endured weeks of extreme stress as she worked
around the clock to help COVID-19 patients and also battled the
virus herself. Eventually, the responsibility for human life,
lack of sleep, and unknowns of this virus became so burdensome
that Dr. Breen became physically unable to continue and sought
help for a weakened mental state. She told her family as a
result she believed her license to practice medicine was at
risk and her career could be over. Approximately two weeks
later, she took her own life.
The bills before us today address many important issues,
but none would have alleviated Dr. Breen's concerns. We must
consider the mental health of the providers on the front lines
of a pandemic. I dare say very few individuals could have
endured the struggles Dr. Breen faced without help.
Now, I know somebody talked about it earlier but I was on
my way over to vote. I was listening even though I was going
over to vote.
But for Dr. Evans' and or Dr. Gellar, do you believe
doctors should be able to seek help from mental health
professionals without fear of losing licensure?
Dr. Geller. So I spoke about that earlier, and I am quite
familiar with the Dr. Breen case. And the answer to that
question is absolutely. One of the questions is, should States
even be able to ask the question on your license application.
And most States, in fact, ask the question.
We have got to start a major campaign to address prejudice
and discrimination. You know, we use the word "stigma," but I
think it is actually an unfortunate word. If we used the words
"prejudice and discrimination," we would understand that it is
the same prejudice and discrimination against minorities.
It is prejudice and discrimination to think that if a
person has a mental illness, they are not capable of
functioning. You have a panel member right here, Patrick
Kennedy, who addresses that throughout his life, and he is
actually one of millions of examples.
We have clubhouses that help people go back to work. We
have all sorts of interventions, and I mentioned in my
introductory remarks I have a son with pretty significant
intellectual disabilities who keeps people alive every day on
his job by delivering medical supplies that are necessary to
the functioning of that hospital.
So yes, emphatically, we need help from Congress to remove
prejudice and discrimination and treat it just like all other
forms of prejudice and discrimination.
Dr. Evans. Congressman, if I could add something?
Mr. Griffith. Absolutely, yes, sir
Dr. Evans. Your point is a really good one. And one of the
big challenges of the way we deal with mental health in this
country--and Patrick referenced this--is almost entirely
reactive, and we wait for people to have a diagnosis before we
intervene.
One of the things that we have to start doing is start
working upstream, start providing services to people before
they need--before they are in crisis, before they have a
diagnosis.
One of the things that the American Psychological
Association is doing is developing information--and, in fact,
for healthcare workers is one of the groups--that is based on
psychological science that tells people how they can help to
manage and mitigate their stress and to do self-care that will
reduce the likelihood that their psychological distress is
going to lead to self-harm.
Mr. Griffith. One more quick question before I run out of
time. I represent a large rural district where access to every
kind of care is often limited. And as much as we might like to
have psychiatrists everywhere, we just don't have them. Do you
believe H.R. 945 would help rural communities?
Dr. Geller. Absolutely. I can tell you that I spent a good
amount of time last year in a southern State, and the major
reason that people missed their followup appointments is they
didn't have money to put gas in the car. And the other is, one
of the reasons that we have affected attendance at a followup
visit is that it is the doctor who initiates the contact.
So I can tell you in my own experience, I have had lots of
telepsychiatry contacts where the person says, oh, I forgot
about my appointment. Well, lo and behold, we had the
appointment anyway, because I contacted them. So yes, it can
make a huge difference in rural areas.
Mr. Griffith. Well, the telemedicine certainly can, but I
am also talking about expanding the ability of a number of
people to be able to provide some help who aren't currently
licensed to do so.
Dr. Evans. One of the things that is happening in global
mental health is the notion of task shifting. Not all of the
functions that mental health professionals do necessarily need
to be done by a highly trained mental health professional, and
many of those things other people can be trained to do.
In addition to that, peer support is extremely important,
both in terms of engaging people who would otherwise not be
engaged, keeping people retained in treatment, and otherwise
supporting people in long-term recovery. So it absolutely is
something that is important, another important element to a
well-rounded mental health system.
Mr. Griffith. Thank you very much. I yield back.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize our colleague from Maryland,
Mr. Sarbanes, for his 5 minutes of questions.
Mr. Sarbanes. Thank you very much, Madam Chair. Can you
hear me OK?
Ms. Eshoo. Yes, very well. Thank you.
Mr. Sarbanes. Thanks for this hearing.
To Patrick, it is great to see you. And to all of the other
panelists, thanks for your testimony today.
The New York Times recently ran a piece written by an
emergency physician in Arizona titled "I am a healthcare
worker, you need to know how close I am to breaking." Arizona
is among the States experiencing some spikes in the COVID-19
cases right now. This physician makes clear the impacts of
responding and treating high numbers of COVID patients are,
obviously, more than physical.
This was true in New York City, other hard-hit medical
communities that lacked the adequate personal protective
equipment and testing and respirators and so forth. So we know
the stress of this is like nothing we have seen before. It is
taking a huge toll on our healthcare workforce.
There are bills under consideration. Katie Porter, our
colleague, has a bill that would provide support to States and
communities for frontline healthcare workers for workforce
training.
Paul Tonko has a bill to study the impact of COVID-19 on
the mental health of Americans, including healthcare workers.
And I think both of these have been included in a modified
fashion in the HEROES Act.
I want to speak a little bit--it has been touched on I
think in response to some questions from Congressman Burgess,
but maybe, Dr. Geller and Dr. Evans, you could share your
perspective on the best way to deploy the support, the mental
health support and counselling for healthcare workers.
Because, obviously, one avenue for this is through the
institutions, the hospitals, the community health clinics where
they work, but is there also a role to play for sort of a
separate resource to be brought to bear that comes from outside
the four walls of a hospital, for example.
So if you could speak to if you could design the best
program through an employee assistance program and other
measures to help those healthcare workers that are on the front
line, what would that look like? And I will start with Dr.
Geller and then, Dr. Evans, if you have any thoughts as well.
Dr. Geller. Three components: The first is that you have to
have the services on site and immediately available. Those of
us in healthcare are terrible at saying no. They are not going
to leave at the end of their shift because it is the end of
their shift when they have people that are dying. So you have
to have services immediately available.
Second is the advantages, again, of telehealth. You are
much more likely to have a healthcare worker who has gotten
home and can call in to somebody than somebody after working 16
hours, asking them to go to somebody's office.
And the third, which Dr. Evans alluded to previously, is
proactive wellness programs that are available right on site.
So if I am in the emergency room, I can take a half an hour and
go to a yoga class.
Mr. Sarbanes. Great. Dr. Evans.
Dr. Evans. Sure. What I would add to that is peer support
is extremely important. As Dr. Geller mentioned earlier in his
testimony, that often people in the medical and nursing
professions don't want to reach out for help. And so what we
have found in working with over 65 nursing associations, how
important it was to have peer support groups on floors that
people can access, have access to immediately.
In addition to that, the kind of self-care information that
we have provided for healthcare workers is really important,
because what we do is we talk about here is an exercise that
you can do when you are extremely stressed, and then we give
people the science behind why that works and why that is an
effective strategy.
So I think it really is a combination of making sure that
people have access to care, that there is peer support, that
there are options to help people understand things that they
can do themselves, and ultimately ensuring that people can have
access to care when they need it.
Mr. Sarbanes. Thank you.
Mr. Kennedy. [Inaudible] Bills of this are already in
place. As you know, for oncologists, particularly pediatric
oncologists and others, they have these support systems.
At Mayo Clinic, where I went to drug rehab, I learned all
about this, because they incorporate, frankly, a lot of the
same recovery they had for people with addiction were for
people with doctors who were experiencing enormous stress in
their jobs and needed ways to learn how to manage their own
stress and feelings.
Mr. Sarbanes. Thanks very much, Patrick.
And as I close, thank you for your leadership and advocacy
in this area.
Two things that I am coming away with from this call that
you have emphasized: We have got to address the stigma, and we
have got to put the resources behind these efforts.
Thank you, Madam Chair. I yield back.
Ms. Eshoo. I thank the gentleman for his excellent
questions, and he yields back.
Has Mr. Walden come back? I can recognize him. If not, then
the Chair will recognize Mr. Bilirakis for his 5 minutes of
questions. Is he on board? Not now.
Then the Chair will recognize Mr. Long for his 5 minutes of
questions.
Mr. Long. Thank you, Madam Chairwoman.
Ms. Eshoo. Yes. Nice to see you.
Mr. Long. I am here.
Dr. Geller, could you describe to me the benefits you have
seen from patients receiving care for mental health services
via telehealth during COVID-19? And, in your opinion, has the
flexibility provided by Congress and the Trump administration
facilitated access to needed mental health and substance use
disorder services during this pandemic?
Dr. Geller. The greater flexibility and access to
telehealth I think has made a tremendous difference. The
inclusion of the ability to havetelephone appointments has made
a tremendous difference. People have referred several times to
people who actually don't have broadband access, but the
population is much greater.
I have a gentleman who hasn't ordered a new electronic
piece of equipment since the Johnson administration. His
favorite activity is to sit at home listening to his records on
his record player. He and I before COVID met every month for 25
years. He only talks to his brother and to me, the only two
people he talks to in his adult lifetime. And he and I have a
telephone contact every week--every month. And if we didn't
have that ability, he would be without services and probably be
hospitalized.
So it has made huge differences, andalso, as I indicated
previously, particularly for people who have trouble keeping
track of appointments or have some disorganization. I initiate
the contact, often by phone, so that I can actually track them
down and they actually have an appointment. I think it is
making a world of difference, and Congress should be taking
movements to extend this far beyond the infectious pandemic.
Mr. Long. OK. I will stay with you, Dr. Geller. Bureau of
Mental Health in Springfield, Missouri, I toured it, oh, about
a year, year and a half ago. I have also toured it more
recently during the pandemic. But I know that they take
advantage of the mental health telehealth thing a lot, and it
is very, very vital, very, very important. They also were just
issued a large grant, which we were happy to see. But I know
how important telehealth is, and I appreciate your comments.
The U.S. is facing a serious shortfall of mental health/
behavioral health professionals, as you know, and what will it
take to attract more students into this field?
Dr. Geller. There are several things. One is we need a
program, a much expanded program on loan forgiveness. People
can get out at the end of their training with half a million
dollars in debt. That is going to direct them to high-paying
specialties, not to low-paying specialties. So we need people
in primary care. We need people in psychiatry. Those are low
paying--and pediatrics, low-paying specialties. So loan
forgiveness would make a big difference.
An increase in GME slots, that is Medicare-funded residency
slots, directing those slots to underserved areas, the same as
minority fellowships, and those should all be directed to
specialties that are underrepresented, like psychiatry. Those
are all efforts that are within the purview of some of the
bills that you face that will make a big difference to the
workforce.
Mr. Long. OK, thank you.
And I am going to Ms. Gross next, if I can. Thank you for
being here, Ms. Gross, and speaking to us about what you are
doing in your community to promote student health and wellness.
You say that as students, you see way more parents,
teachers, and other adults, but you aren't given the tools to
help your friends struggling with mental health. Can you talk
about your experiences in the SAVE Promise Club and what tools
would be beneficial for you to help a friend struggling with
mental health and for creating a system of supports for
students in your school?
Ms. Gross. Yes. Thank you for that question. So one thing
that SAVE has taught me is definitely being able--first, you
have to learn how to communicate with people. That is one thing
that we focus on is reaching out and getting into the
community.
And so one thing that my club does is we go out and we talk
to different schools and we build communities where people feel
comfortable discussing themselves with each other, where
somebody feels safe enough to speak about those kinds of
things.
We have trusted adult training. So we train people to bring
their communities together by being there for our students,
because students, we go through a lot. And I think that, at
least in my perspective, that is why we need our peers as well
as mental health professionals to be able to help us within our
schools, because we don't have a lot of that around us.
And so SAVE has allowed me to learn how to do that so that
I can help my peers, that I know how to explain how I can help
them, because that is one reason why I am here today. I am here
today to get this message out and let people know that there is
help beyond just being in a state where you don't feel
comfortable. So just offering that. It taught me how to
communicate and how to build communities so that people feel
comfortable.
Mr. Long. Very good. Well, thank you again very much for
being here today. And thank you for all our witnesses here
today for participating.
And, Madam Chairwoman, I yield back. Thank you.
Ms. Eshoo. The gentleman yields back. And I thank him,
especially for the question that he asked of the witness,
because the student population is just so important and we
really need to address that and make sure that they get exactly
what they need.
The Chair would like to recognize the gentleman from
Oregon, Mr. Schrader. Is he available? Not seeing or hearing
him.
The Chair recognizes Mr. Kennedy. Is Mr. Kennedy available?
Not in his chair.
Then the Chair will recognize the gentlewoman from New
Hampshire, Ms. Kuster, for her 5 minutes of questions. You need
to unmute.
Ms. Kuster. Thank you. Thank you very much. Thank you,
Madam Chair. I appreciate this hearing, and I appreciate the
opportunity to address you on this important issue. Here in New
Hampshire, we have had a dramatic increase of depression,
anxiety, trauma and grief as a result of COVID, and we are
struggling as well with changes to the economic impact on our
healthcare providers, particularly mental health providers.
Eighty-three percent of small and large group substance use
disorder providers have experienced what they would describe as
a significant financial hardship as a result of COVID, and 48
percent of those providers surveyed have had to cancel income-
generating events while 74 percent have incurred unanticipated
expenses, including PPE. Across the board, we have seen an
experience of lost billing revenue of $23,000 per organization
in just the first three months.
So I wanted to focus my questions on some of the
conversations that we have been having today, including the
impact on substance use disorder--the opioid epidemic has taken
a big toll here in New Hampshire, we have a dramatic increase
in deaths from opioid overdose--as well as focusing in on
trauma.
We had some conversation--I think it was Mr. Burgess--
talking about mental health and substance use disorder
treatment in prisons and jails.
And I wanted to direct my questions to Dr. Geller. You had
mentioned this in your written testimony. I have legislation,
the Humane Correctional Health Care Act, which would repeal the
Medicaid inmate exclusion and allow healthcare to follow an
individual through the justice system so that they could access
mental health and substance use disorder treatment while
incarcerated.
Could you comment on that, Dr. Geller, and how that could
make a difference in terms of the outcomes? And I think there
was also comment about how people are being incarcerated for
their mental health challenges. I think Representative Kennedy
talked about that.
Dr. Geller. So I think that your State motto, live free or
die, now has another meaning. It means that I am going to live
free of services and I am going to die. So it is extremely
important.
I am personally delighted by that notion about removing the
Medicaid exemption. I have thought for a very long time that we
will never solve this problem if people can't get the funded
services because they happen to get incarcerated when many
times they get incarcerated because they have a psychiatric
problem. So I think that that can make a huge difference.
In terms of--you also mentioned small providers, and that
is something that Congress needs to attend to, because they are
really the bedrock. The public sector substance abuse programs,
community mental health centers are really taking care of the
disenfranchised population, and they are having tremendous
problems currently, because they are not beneficiaries of most
of the COVID funding that has been coming from the Federal
Government.
Ms. Kuster. I wanted to also ask, I recently was visiting
with our--oh, excuse me, my time is getting short.
I also was visiting with our State prison recently, and I
was told that 100 percent of the women in the State prison are
survivors of trauma--sexual assault, domestic violence, abuse
and neglect--as children.
I am very concerned during COVID--I chair a task force to
end sexual violence. It is a bipartisan task force. We recently
had a roundtable about the increased incidence of sexual
assault, and during the stay-at-home order children that are at
home with their perpetrator/predator.
Do you have any concerns or how could we go about this as
we reopen? And, again, my time is short.
Dr. Geller. Well, just really quickly, one of the problems
we have is circular. I have had patients who when get released
from jail--and they fall into that serious trauma category--
commit crimes to go back to jail, because it is the only place
they have where they can feel any safety or comfort. That is a
huge problem in our society.
The new problem with domestic abuse is the significant
problem we have with people staying at home together. People
are afraid to report. People are afraid to leave home to
report. We have to be cognizant of that phenomenon and
specifically address it. It has not been talked about a great
deal.
Ms. Kuster. Well, I thank you.
Madam chair, I yield back.
But I very much appreciate this hearing and I think these
are critically important issues for us to address, especially
now during COVID.
Thank you. I yield back.
Ms. Eshoo. The gentlewoman yields back, and we thank her
for her excellent questions.
I see the ranking member of the full committee has
returned, just took his mask off. The Chair recognizes my good
friend from Oregon, Mr. Walden, for his 5 minutes of questions.
Mr. Walden. Well, thank you, Madam Chair. I appreciate it.
And I appreciate this hearing and the courage of our witnesses
and the work they do in the communities or in their schools.
Thank you for what you do.
And it is good to see our former colleague here on the
screen as well, and I sure appreciate your continued speaking
out on these so important issues. We are getting there, but not
fast enough and there is more to be done.
And that is part of the question I want to direct to you,
Patrick: What is it when you look at these bills? And there are
obviously some we are all in agreement on, some we are going to
work some things out on and all. But what are the gaps? What
are we missing here, especially as it relates to data that
could better inform us in terms of what else we need to do?
I know money is always an issue. Mental health resource is
always an issue. We have tried to increase funding into our
communities like we did through the opioid legislation. But as
you look at these and you know the realities in Washington,
what are we missing?
Mr. Kennedy. Thank you. I would say that if I had a magic
wand, I would fully fund the Nurse-Family Partnership in this
country, which would ensure that every at-risk mom would be
able to get the wraparound services.
The payoff of that, Greg, is so well-established, but the
problem in our health insurance system, as in our society, is
that we don't often measure the long-term payoff. If it is not
a quarterly payoff or an annual payoff, we really don't see the
real value of investing in mental health early, to the previous
question about trauma, and really doing the kind of systemic
things in society that could mitigate the impact of trauma.
So in terms of, you know, obviously, the parity laws that
you have asked us to enhance, I could answer more to there, but
let me go to you.
What particularly it could be helpful with in addition to
that. I mean, I would do first instance of schizophrenia. If I
had a magic wand, I would do not only Nurse-Family Partnership,
I would say that every first instance of schizophrenia in this
country, we provide coordinated rapid response. If you did
that, you would permanently change the trajectory of long-term
comorbidities and illnesses due to mental illness in a dramatic
way.
And I see this every day, and for the life of me I don't
know why, as a Nation, we do not make that a done deal on a
bipartisan basis.
You would automatically reduce the number of people in
jail, in prison in our country overnight. I don't know why our
general accounting office--if I were you, Chairman, I would
find a way to have GAO or OMB come up with some kind of
accounting, because you all know you don't spend anything that
you can't find offsets for.
And that is part of the big problem here. We all know this
stuff works, but you have to find a way of justifying to spend
money on those things, because, invariably, it will come out of
other programs that you think are equally worthwhile but,
frankly, may not have the pounds per square inch of a solution
that these do.
Mr. Walden. Yes, it is really good counsel. I did a town
meeting several years ago in one part of my district. I
remember we were doing some of the opioid issues and some of
the mental health issues, and I remember one of the law
enforcement people kind of made that case. He said, look, we
get somebody in, we pick them up because they are off their
meds, we get them into in this case a county jail setting, we
get them back on their meds, they are stable, and we know once
they are released we are going to pick them up again.
And this seems to be a huge gap still in the country trying
to get that help to people. We are part of a pilot, and it may
be going on in New Hampshire as well, where we have mental
health people that intercede before the arrest occurs. They are
there 24/7 on site, and they have been able to do diversions
and keep people out of jail, get them the help that, really,
they need. And I think that is a focus that seems to work.
Ms. Gross, thank you for speaking up. Thank you for the
leadership that you have provided. When it comes to kids, what
are we, quote/unquote, old people missing here? What can we do
more? I mean, we know we are missing a lot, so I will just
stipulate that. But from your perspective?
Ms. Gross. I think a lot of what we need is just people to
listen. I think a lot of times what we think and feel are
downplayed because, you know, they are just kids, they don't
know what they are feeling.
But I think that is why, at least in my perspective, coming
around and allowing our peers to be able to be there for us
through the STANDUP Act or having mental health professionals,
who I do know, know exactly what we are going through. And, you
know, know that kids can go through these kinds of things is
really important.
And getting to have that voice and be listened to because,
you know, like we all said, we have concerns and we go through
a lot. And so just being able to have people who listen, and
care is really important.
Mr. Walden. I appreciate that, and thanks for your work.
And, Madam Chair, thanks again for this hearing and I yield
back.
Ms. Eshoo. The gentleman yields back, and I thank him for
his excellent questions.
It is a pleasure to recognize the gentleman from
Massachusetts, Mr. Joseph Kennedy, for 5 minutes.
Mr. Kennedy of Massachusetts. Madam Chair, thank you, and
thank you for calling this incredibly important hearing.
So, Patrick, I will start with you, my friend.
So you mentioned in your opening statement in the written
part, but I want to have you have the opportunity to remind us
how long ago that you were able to get the Mental Health Parity
and Addiction Treatment Act enacted.
Mr. Kennedy. Ten years. Over ten years.
Mr. Kennedy of Massachusetts. Yes, 11 and change, I think.
Time flies.
Mr. Kennedy. That is why you are in Congress, I am not.
Mr. Kennedy of Massachusetts. Twelve years later, time
flies. There you go.
Mr. Kennedy of Massachusetts. So almost 12 years later,
though, there are still insurers that are not compliant with
the Federal law, right?
Mr. Kennedy. Exactly.
Mr. Kennedy of Massachusetts. And so to highlight that, the
Department of Labor conducted 187 investigations in fiscal year
2017 and found that 92, almost 50 percent of those surveyed,
were not compliant.
In December, the GAO came out with a report saying that the
Departments of Labor and Health and Human Services commonly
found violations of the parity requirement and recommended
evaluating whether or not targeted auditing is an effective
method for mental and behavioral healthcare parity.
So you are familiar with those reports?
Mr. Kennedy. Yes.
Mr. Kennedy of Massachusetts. So one of the things that the
Mental Health Parity and Addiction Treatment Act, along with
subsequent parity laws, did was to ensure that plans provide
information on how they are making mental and behavioral health
parity decisions. I mean, that for almost 12 years all plans,
all plans, should be doing this and have that information
already readily available.
For this one I want to turn to Dr. Geller.
Doctor, because insurers should be collecting and reporting
this information already, should it be difficult for them to
make that information available immediately?
Dr. Geller. It should not. They should be required to do
so.
Mr. Kennedy of Massachusetts. So knowing that you are not
an insurer but are a provider, would it surprise you if an
insurance company were to make alterations to give a false
impression of compliance with those parity laws?
Dr. Geller. I am sorry to say it would not surprise me.
Mr. Kennedy of Massachusetts. And so, Doctor, if a health
plan is not compliant in providing parity coverage for mental
and behavioral health services, do you think that should be
public knowledge?
Dr. Geller. Absolutely.
Mr. Kennedy of Massachusetts. Do you think that it should
be proactively publicized in some capacity to protect current
and future enrollees?
Dr. Geller. Absolutely, because the enrollees have no
capacity to do this on their own.
Mr. Kennedy of Massachusetts. Do you know how many health
plans are in the Department of Labor alone, Dr. Geller?
Dr. Geller. I am sorry, I do not.
Mr. Kennedy of Massachusetts. 2.2 million, roughly. So 2.2
million different plans covered by DOL alone.
So I believe that because of the wide number of plans and
the fact that these plans have not yet come close to earning
our trust or their patients' trust, we not only need to have
random, robust, and immediate audits, but also public
disclosures of parity compliance to hold them responsible for
parity violations.
And the point on this is to force, as Patrick has
articulated before the committee before, to actually have teeth
behind those requirements to allow for that investment to be
made up front, because he was just talking about the
partnership with nurses.
One of the challenges that we have is we don't actually
have those incentives put in place to require or incentivize
that investment up front to provide access to patients and care
for patients, which is why the largest providers of mental and
behavioral health in this country are the jails in L.A. And
Chicago.
When you talk to the sheriffs in my home State of
Massachusetts, 98 percent of people that have access to
healthcare--well, I should say, 98 percent of people that have
healthcare coverage--you talk to the sheriffs, those folks in
Massachusetts that run our jails, they will tell that between
80 and 90 percent of the incarcerated individuals on any given
night are suffering from a substance abuse disorder, mental
illness, or both. In a State with 98 percent coverage, we are
so failing people with mental and behavioral illness.
And so I just want to come back to the fact that--Patrick
has obviously worked on this for a long time, and many of us
have on this committee--but the Behavioral Health Coverage
Transparency Act, that would improve enforcement authority,
increase transparency of parity disclosure, and to have it made
available to the public.
And that public piece, I think, is so critical because, as
you said, Doctor, there is no way that patients would possibly
be able to get access to this, particularly if plans aren't
making that information available.
And so how do you possibly hold people accountable if there
is no remedy?
Mr. Kennedy. Joe, I think you are, if I can say so, right
on, and I think if Congress responds by actually saying you are
not allowed to sell your health insurance product anywhere else
in our market if you don't adhere to our laws.
I mean, imagine a health insurer coming and saying, "Oh, I
want to sell into your market." It is a very lucrative thing
for an insurer to be able to sell their insurance product in a
given State. Why doesn't the State put up a big barrier and
say, "You are not allowed to sell in our State if you
discriminate against the most important set of illnesses
affecting our people."
What your bill is calling for is the ability for that to be
transparent, to get out, so that State legislatures can start
to enact similar laws like that to help provide some
accountability.
And to your point on the numbers, it is hard to believe but
in your colleagues' committee overseeing DOL appropriations,
there is only one inspector, I should correct myself from
earlier, 2,500 plans that one inspector has to oversee, 2,500
plans from one inspection.
So you need to pass your bill, you need to have greater
money to support enforcement overall, and you need to give
these States more authority to invoke their own accountability
measures by making this more public like your legislation calls
for.
Mr. Kennedy of Massachusetts. Thank you, cousin.
Grateful, Madam Chair. Thank you for your flexibility.
Dr. Evans, good to see you again.
Ms. Gross, thank you for joining us.
I yield back.
Ms. Eshoo. The gentleman yields back, and we look forward
to your legislation becoming law, Mr. Kennedy.
And thank you, Patrick, for all of your responses. We are
just learning so much from you about what we actually need to
do.
The Chair would now like to recognize the gentleman from
Florida, Mr. Bilirakis, for his 5 minutes of questions.
Mr. Bilirakis. Thank you, Madam Chair. I appreciate it very
much.
Again, let's see, I am especially appreciative of today's
consideration of a few of my priorities, H.R. 4861, H.R. 7293,
H.R. 3165.
I also want to flag a bill I introduced with Congressman
Soto, H.R. 5473, the Enhance Access to Support Essential
Behavioral Health Services Act, which builds upon the SUPPORT
for Patients and Communities Act to allow Medicare and Medicaid
to reimburse for behavioral health services delivered through
telehealth.
I hope we can consider this great bill in the future, Madam
Chair.
And I also want to say hello to my former colleague,
Patrick Kennedy, who always did a great job on these issues.
Thanks for being here, Patrick, and giving us all your
great advice.
Dr. Geller, this question is for you. Our Nation is in the
midst of [inaudible].
Ms. Eshoo. We have an audio problem?
Mr. Walden. Yes. I am going to give him my computer to work
off of, Madam Chair.
Mr. Bilirakis. Thank you.
Ms. Eshoo. OK. We will make a little adjustment for that
time, Mr. Bilirakis.
Mr. Bilirakis. Madam Chair?
Ms. Eshoo. Yes. All right. We won't penalize you for the
time out.
Mr. Bilirakis. OK. Very good. Thank you.
Ms. Eshoo. Proceed.
Mr. Bilirakis. OK. Thank you. I appreciate it very much.
I will go ahead and start with Dr. Geller again.
Our Nation is in the midst of a suicide crisis, as you
know. Over the past several decades, the suicide rate has risen
sharply, increasing to 31 percent since 2001. At the same time,
emergency departments, which are often the place within our
healthcare system to provide care for people who are at risk
for suicide, have inconsistent protocols for screening and
treating high-risk patients.
For this reason, I introduced H.R. 4861, the Effective
Suicide Screening and Assessment in the Emergency Department
Act. This bill will assist hospital emergency departments in
improving their ability to identify and treat those who may be
suicidal.
What is the potential impact of COVID-19 on the risk for
suicides? And what role can hospitals, especially emergency
departments, play in identifying and treating individuals who
are at risk for suicide?
Dr. Geller, please. Thank you.
Dr. Geller. The effect of COVID on suicide is substantial
and actually multifactorial. One is the response to an
individual in the stress of the potential for infection.
Another is grief, loss, and significant depression from people
who are losing family members to COVID-19. And the third, which
is probably the newest information, is that we are seeing in
some recent data from the United Kingdom that there is a direct
neurocognitive effect on some patients from the COVID, that is,
it affects their brain, there is an increased risk of strokes.
And there are all sorts of other psychiatric presentations.
So we have three rather distinct ways that the COVID is
significantly affecting suicide. We are not doing something
right in this country. Of all developed countries in the world,
we are the only one, the United States, who is seeing an
increased rate of suicide. All the other countries are seeing a
decreased rate of suicide.
I think your bill is extremely important. Not only should
we be doing suicide screening for people who show up for
psychiatric problems, we should have a high index of suspicion
of people who show up for other reasons. Just like we have a
high suspicion when a kid shows up with a bunch of broken bones
that maybe there is parental abuse, we need people who when
they are doing the evaluation, for whatever reason, are paying
attention to a suicide risk.
We also need then continuous follow-up, as is covered in
some of the other bills, so that people don't get lost the day
or minute they walk out of the emergency room.
Mr. Bilirakis. Thank you very much.
Ms. Gross, thank you for your testimony again today. I have
seen firsthand the power of Sandy Hook Promise's work and seen
Promise Clubs at Palm Harbor University High School, where my
kids go, in my district last fall, and I agree with you that
the students are equipped and able to prevent all forms of
violence.
Congressman Peters and I would led the recent introduction
of H.R. 7293, the Suicide Training and Awareness Nationally
Developed for Universal Prevention, the STANDUP Act, which
encourages States, Tribes, and schools to create policies for
student suicide prevention training utilizing the SAMHSA,
providing best practices, training, and technical assistance.
You mentioned that the SAVE Promise Club trained you on how
to notice the signs and talk to your classmates who may be
struggling, and you have done that, and we appreciate it so
much.
If students like you weren't trained in your school and
there weren't SAVE Promise Clubs, what do you think you and
your classmates would do if they were struggling with mental
health? If you could answer that question, I would appreciate
it.
Ms. Gross. Yes. First of all, I would like thank you for
that question. Thank you for supporting the STANDUP Act. I
think it is so important.
And in my mind, or in my perspective, kids would begin to
start showing signs--kids would show signs that they are going
through something, but they wouldn't be able to express it,
because a lot of kids don't feel comfortable doing that.
So you might see a lot of kids getting into fights, because
that might be the only way that they can get out this
aggravation, or self-harm, because they wouldn't have anyone
who was like them, like another peer or student, that is going
through the same thing to talk to. They wouldn't have someone
to relay that on.
So you would see kids, maybe their grades would be
dropping, which could like ruin their future really, because
colleges, and all that stress really put on you, it just would
lead them closer to losing their lives.
So that is why I think, in my perspective, the STANDUP Act
is so important, because it allows us to save lives by being
there for people who are like us and allow students to step in
and help and give another hand to something that is so
important.
Mr. Bilirakis. Thank you so very much.
Madam Chair, I guess I don't have much time left.
Ms. Eshoo. We always have more time. But the gentleman
yields back. And I thank him for his excellent questions.
Mr. Bilirakis. Thank you so much.
Ms. Eshoo. The Chair is pleased to recognize the gentleman
from New York, Mr. Engel, for his 5 minutes of questions.
Mr. Engel. Thank you, Madam Chair. And thank you, Chairman
Pallone, Chairwoman Eshoo, for holding today's important
hearing on legislation to address ongoing mental health crises
in the United States.
My district in New York, which includes the Bronx and
Westchester, has been at the epicenter of the Nation's
coronavirus outbreak. This pandemic has taken an untold
physical and emotional toll on my constituents. Health
officials have reported a surge in COVID-19-related mental and
behavioral health problems.
As Dr. Evans noted in his written testimony, text messages
to the Federal Government's Disaster Distress Hotline are up a
thousand percent for the month of April. There is also a
growing concern about a rise in suicide, as we have heard
before, which before the pandemic had increased by nearly 30
percent in New York State since 2000 and nationally was the
tenth-leading cause of death.
Dr. Geller, I would like to ask you, can you please explain
why the coronavirus pandemic has exacerbated the suicide
epidemic?
Dr. Geller. There are several reasons, Congressman.
First is a reaction to a pandemic where people are required
to quarantine. People are spending much more time without
social supports. And for people with depression, that increases
depressive symptoms.
Second, we have a generalized feeling of helplessness and a
feeling of helplessness that is already a key component of
depression. So we increased depressive symptoms. People don't
have contact with family that they have used for supports.
People are losing family members, and they can't even attend a
ceremony like a funeral, and that is exacerbating depression.
So we have people who have depression whose symptoms are
much worse, and we have people who are developing symptoms who
didn't previously have it.
And as I mentioned in my testimony before, the newest
information is we are actually getting direct effects of the
COVID-19 on the brain itself, which is affecting people's
functioning and also increasing rates of suicide.
Mr. Engel. Well, to help reduce rates of suicide in the
United States, I offered the Effective Suicide Screening and
Assessment in the Emergency Department Act with Congressman Gus
Bilirakis. So it is bipartisan. Studies show that as many as 11
percent of all patients visiting the hospital emergency
departments are at risk of suicide, but only a fraction of
these at-risk patients are ever identified.
This bipartisan legislation would provide $100 million over
5 years to help emergency departments improve the
identification, assessment, and treatment of patients at risk
of suicide.
Madam Chairwoman, I ask for unanimous consent to submit
into the record a letter of support from 48 advocacy groups in
support of our legislation.
Ms. Eshoo. I thank the gentleman for his request. We will
take up all of these unanimous consent requests en banc at the
end of today's hearing.
Mr. Engel. Thank you.
Dr. Evans, in your written testimony you called the
Nation's rising rate of suicide the fourth pandemic. Since the
Nation's emergency departments account for close to 50 percent
of all patients' healthcare visits each year, do you support a
more focused approach on identifying and treating patients at
risk for suicide while they are still in the emergency
department, such as the approach provided in H.R. 4861?
Dr. Evans. I do. I think it is very important. We know that
a high percentage of people who die by suicide have had an
emergency room visit within the last year. And when we don't
screen people for suicide, we are missing an opportunity to
intervene.
I do think, though, it is really important to look at this
issue as a systemic issue. When we design our interventions for
suicide, we have to do the kind of clinical interventions that
you are talking about with our one-on-one, but we also have to
think about the network of resources that are available to
people.
I mentioned earlier the importance of having a connection
between the mental health system and emergency departments. But
it is also important to have crisis intervention services that
don't require people to actually need to be hospitalized, need
to be admitted to a service before they can intervene.
Those are the things that help people have the level of
support when they leave an emergency department, they don't
meet criteria for being admitted, but they can be followed in
the community, reducing the likelihood that they are going to
get into crisis without having a connection to a mental health
professional.
Mr. Engel. Thank you.
Thank you, Madam Chairwoman. Thank you.
Ms. Eshoo. The gentleman yields back.
The Chair would now like to recognize Dr. Bucshon from
Indiana. Is he available?
If he is not, then we will go to Mr. Carter of Georgia. You
are recognized for 5 minutes for your questions.
Are you there? Are you unmuted?
Mr. Carter. I am unmuted now thanks to the ranking member,
who is here holding my hand, making sure I do everything
correctly, and I appreciate him very much.
Thank you, Madam Chair. And thank all of the panelists
here. This is certainly a very, extremely important subject.
And I certainly support the legislation that we are discussing
today. But I do feel like we need more time to work on some
outstanding issues and to come to a mutually agreeable place.
You know, I have been a practicing pharmacist for many
years, and I know firsthand through personal experience as
well, but also through professional experience, that mental
health is not a partisan issue. Mental health is a very
personal issue and a very serious issue that we need to--and
not only mental health but addiction, and extremely important.
And we have to address this in a partisan fashion--in a
bipartisan fashion, excuse me--and make sure we are getting
everything right.
You know, I really do, I am one who feels like the
administration has done a fantastic job during the pandemic
especially of expanding telehealth. It has been said that
telehealth has had 10 years of expansion in one week, and I
think that is true. You know, before this started, there were
almost 11,000 telehealth visits a week. Now it is over a
million per week. And telehealth is here to stay, and it is
something we have got to work on.
I wanted to ask Dr. Evans and Dr. Geller, if I could, both
of you wrote in your testimony that Congress and the
administration can do more to build upon the rapid success of
telehealth. What can specifically we do to expand telehealth
and the patient usage of this service as well?
And I will start with Dr. Geller.
Dr. Geller. One is that we can ensure that telehealth
includes telephonic services, that is the use of the telephone,
as I have described before.
The second is that we can ensure, as I believe has been
mentioned previously, parity in reimbursement, that there
should be no difference if a person comes to an appointment or
if a person is seen through a telehealth center.
Third, we should be putting in components to allow for
collaborative care through telephonic and other electronic
needs. The idea is that, for example, the psychiatrist is
coordinating care with the primary physician and that is a
billable service.
All of those things would make quite significant
differences as compared to what we had before COVID-19.
Mr. Carter. Dr. Evans, if I could ask you, one of the
things that we have come to notice during this and come to
realize is the lack of health services in our rural and
minority communities. How can telehealth help us in that
respect?
Dr. Evans. Well, it can provide services to people who
would otherwise not receive them.
I think one of the other issues when you talk about
telehealth, one of the things that we have to fix or to work
on, is the issue of providing those services across State
lines. Right now, telehealth is limited and regulated by the
license laws within the State. There were a few exceptions to
that.
And when you think about areas of the country where there
are not enough practitioners and other areas of the country
where you have an abundance of practitioners, one of the ways
to solving the problem in rural and frontier parts of the
country is to allow providers who are licensed to work across
those State likes, something that we are working on at the
American Psychological Association, and it is really essential
for this to address some of the disparities that we see.
Mr. Carter. Thank you, Dr. Evans.
Congressman Kennedy, I wanted to ask you, as I said
earlier, as a practicing pharmacist, and also as a pharmacist
legislator, in the Georgia State Senate in 2009, I sponsored
legislation that created a prescription drug monitoring
program.
So I am very concerned about opioid use and I think that we
have done a good job of managing our opioid prescriptions for
patients, but the lasting effects are still there. And what we
have seen is that just recently, in the last year, we have had
overdose deaths have gone up 11 percent. Still they have gone
up 11 percent with everything that we have done in the way of
addiction, and that is something that is very concerning to me.
And I wanted to you ask, how do you think we can utilize
telehealth to help us with--to treat this and to treat
addiction? And how can it be--how can it encourage providers
and patients to seek out treatment through telehealth?
Mr. Kennedy. Thank you so much for your question,
Congressman.
As you know as a pharmacist, addiction is addiction is
addiction. It could be opioids today, but it could be
benzodiazepines tomorrow. And as you know, one of the real
impacts we have never talked about in this hearing so far is
benzodiazepine scripts have gone up over 30 percent since COVID
hit--30 percent.
So not only has alcohol consumption far surpassed even very
high rates, but now we have this. So as a pharmacist, you are
seeing the full scope of what people are prescribed. That is
crucial data.
And so we narrowed it to opioid because it was the, quote,
"opioid crisis." But as we know, it is really an addiction
crisis where opioids are one thing, but it could also include
any number of other drugs that could also get people in
trouble.
So thank you so much, Congressman. It is great you are
serving as someone with the experience that you are bringing to
this effort and keep asking these important questions.
Telehealth can definitely help in a number of ways, and thank
you.
Mr. Carter. OK. Thank you.
And thank all the panelists.
And thank you, Madam Chair, and I yield back.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize our colleague from
California, Mr. Cardenas, for his 5 minutes of questions.
Mr. Cardenas. Thank you very much, Chair Eshoo, and also
Ranking Member Burgess.
And to all the witnesses, thank you for your testimony,
your expertise, and your practical knowledge that you are
sharing with us.
We are going through a pandemic, and let's pray for all of
those families who have been affected and for all the loved
ones who have lost family members.
I am glad to see us discussing legislative solutions to
improve mental health today. I have expressed concerns in
previous hearings about our disjointed mental health system and
the historic wave of mental health problems that experts warn
are approaching. As Mr. Kennedy mentioned, there is no health
without mental health.
Support for schools is very important. All of our witnesses
identified schools as an important piece of the puzzle.
I was especially glad to hear a student perspective from
Ms. Gross. Thank you so much for being with us today, and thank
you for sharing your experiences with us.
Mr. Kennedy, in your testimony you mentioned goals around
social and emotional learning and addressing the student
trauma. How could the Federal Government best support schools
with these goals and prevention overall?
Mr. Kennedy. Thank you, Congressman.
Well, first, I would overhaul the way we think of education
so that we understand that there is no education without mental
health, just like we say there is no health without mental
health, because how can the body learn numeracy, literacy when
the mind can't absorb information because of what we understand
neurobiologically, that their prefrontal cortex is inhibited by
their amygdala. And that may be getting into the domain of Dr.
Geller, but I will let him talk about that.
The bottom line is we need to give our kids the ability to
modulate their emotions. And just like they work out and learn
other skills, they have to practice these skills. And those are
problem-solving skills, coping mechanism skills. And if they
learn these, they build resilience.
And, frankly, unfortunately for too many of us, we learn
all these skills after the fact. It would be so much better for
all of us if our kids had these skills as early in life as
possible and that would be able to stick with them throughout
their education careers.
Mr. Cardenas. Thank you.
Dr. Evans, in your written testimony you mentioned some
challenges schools are facing. Some of my colleagues and I are
working on a bill to strengthen technical assistance and
training support from the Substance Abuse and Mental Health
Administration, SAMHSA.
What type of support from SAMHSA would be most beneficial
for schools and school systems right now?
Dr. Evans. Well, I think it is important to look at schools
in a comprehensive way. In my role as the commissioner, I
worked very closely with the school superintendent in the
system that I was commissioner for. And one of the things is to
help teachers have the skill set to recognize when children and
youth are having mental health problems and challenges. It is a
big issue.
I also think that implementing evidence-based approaches
like school climate programs, which have been shown to reduce
not only violence but to improve school climate, is really
important.
The kind of services that you heard Ms. Gross talk about--
and by the way, as a former Connecticut person, I am really
proud of her being able to articulate some of the needs of
students.
But not every child needs to see a mental health counselor
to get into a mental health program. And having people, whether
they are youth and peers, or even counselors who are simply
giving an opportunity for children to talk to them, is also
very important.
And then, finally, having connections to mental health
services. In my system, we actually embedded those services
within schools so that children got high-level mental health
services there.
So really it is a range of things, ranging from educating
teachers all the way to having services that meet the needs of
children who have more high-end needs.
Mr. Cardenas. Thank you.
And we don't have time on this discussion to discuss the
lack of diversity when it comes to service providers in the
field in general, whether it is mental health or physical
health. And, hopefully, we can figure out ways in which, in
this country, we can actually encourage and get young people to
get into the mental and physical health space so that they can
be more of the doctors that look like the people and the
patients that they are serving.
Ms. Gross, when it comes to education, don't you think it
is just as important that students identify within each other,
not just the parent--excuse me, not just the teachers that
identify when a student is having a crisis, so that students
would probably---if we gave them the knowledge and experience
to identify peer to peer, don't you think that would be a good
way for us reduce the incidents on school campuses?
Ms. Gross. Yes. Thanks for the question. That is
definitively important because, think about it, teachers spend
about 45 minutes to an hour with a student every day in class.
We get that time out of school working on projects and being
with our friends just spending that kind of time. And we follow
them on social media. These are people that we have constant
contact with. So what we see actually is really important to
fighting this cause.
Mr. Cardenas. Thank you very much. My time has expired. I
yield back. Thank you, Madam Chair.
Ms. Eshoo. The gentleman has completed his questions.
Is Dr. Bucshon available? I don't see him.
Mr. Bucshon. Yes, I am coming.
Ms. Eshoo. OK.
Mr. Bucshon. I am starting my video, Madam Chairwoman, as
we speak. Thank you.
Ms. Eshoo. OK. The gentleman is recognized for his 5
minutes of questions. I am glad you are there.
Mr. Bucshon. Thank you. I had just another brief thing that
I had to deal with.
First of all, I want to thank you for holding this
important hearing. This is the work we need to be focused on, I
think, during challenging times in this pandemic, and I think
mental health sometimes gets overlooked.
During the midst of COVID-19, I have spoken directly to
mental health facilities across my district, and the increase
in challenges, I mean, honestly, the increase in calls to their
help lines has been dramatic during the pandemic. You would be
surprised.
One center I talked to went from receiving 2 to 3 calls a
week on their suicide hotline to upwards of 20 and more calls
every week. And one part of my district, talking to first
responders that normally go out on a suicide call once or twice
every 2 to 3 months, it is once or twice every 2 to 3 weeks
during the pandemic. I mean, it has created a pretty
substantial toll on the mental health of our society.
I have also spoken to universities who are now left trying
to figure out how to provide continuing therapy for their out-
of-state students. I wasn't aware of this until I talked to one
of my presidents of one of my universities, and there are a lot
more college students that are getting therapy on campus, I
think, than people understand. They shared with me the
difference this therapy has on their students, and it is
troubling they can't continue to provide that continued care to
their students in many cases just because now the students are
all over the country.
This particular university, as many do, has people in 50
States and foreign countries. I mean, the issues, of course,
are reimbursement, liability, and sometimes technology.
As was pointed out in the testimony today, continued care
past the first visit is really important. Therefore, as we
continue to look to improving mental health and mental health
through telehealth, this is an issue I hope that we can work to
address.
Dr. Evans, do you have any comments maybe on what is
happening at universities and the counseling services that
universities provide to their students and the challenges that
we might be facing during this pandemic?
Dr. Evans. Sure. We have been seeing a growing trend on
college campuses around the country of increased mental health
needs and an increase of students in crisis on campuses.
And I think the good news is that I think a lot of college
campuses around the country are starting to pay more attention
to this, they are building in services, they are building in
peer services, which actually is a really effective way to
reach students.
I think it is also important for us to not only make sure
that there are services on campuses, but there are active
efforts to reduce stigma so that people will reach out for
help.
One of the things, we do a survey each year looking at some
of these issues, and one of the things that we notice is that
the younger generation is much more likely to reach out for and
be open to receiving mental health services. So that is a good
thing, but we know that we still have more work to do there in
terms of continuing to reduce that stigma so people will reach
out for help.
Mr. Bucshon. What can we do in Congress to help facilitate
this type of activity?
Dr. Evans. Well, I think it is continuing to support
efforts to embed mental health services on college campuses.
It is also encouraging innovative strategies. For example,
in Philadelphia where I was at, we started to do mental health
screenings and make them available in the community, but then
took those same screening tools and put them in a kiosk in
which students could walk up in the student center, take a 10-
minute screening, which would not do a diagnosis but it would
tell the student whether or not they were exhibiting symptoms
that were consistent with depression or anxiety, and then it
gave them information on how to connect to those mental health
services.
So for a millennial population that is really accustomed to
using technology, using these kinds of innovative strategies is
an effective way of reaching students who would otherwise not
get that help.
Mr. Bucshon. Excellent. Thank you.
And, Dr. Geller, can you talk briefly, because my time is
running out, about the complexity of managing both mental and
physical health of patients and what the challenges are there?
Because it is usually more complex than we think.
Dr. Geller. It is generally much more complex than we
think. As I mentioned briefly before, lots of medical illnesses
present with a psychiatric presentation, and we have to have
the ability to do a workup to differentiate.
We have a clear example of that now, as I indicated, with
central nervous system presentations. So somebody shows up with
psychosis and they are COVID positive, the mistake is to send
them home for 14 days and tell them to come back because the
psychosis may be a direct effect of the COVID infection. And
there are literally hundreds of examples of medical
presentations that look like psychiatric disorders.
Mr. Bucshon. Well, thank you.
Just briefly, Madam Chairwoman.
I was a physician before I was in Congress, for the
witnesses, and the complexity of dealing with both physical and
mental health problems at one time is becoming more and more, I
think, prominent in the medical community, realizing that you
have to deal with the medical issues and with these patients
that have mental illness or you are not going to really get
them through their mental illness and support them.
So thank you. With that, I yield back.
Ms. Eshoo. The gentleman yields back. And I would just say
that you are a doctor for life. And we are blessed to have you
as part of this committee.
Mr. Bucshon. Thank you.
Ms. Eshoo. The Chair now will recognize the gentleman from
Vermont, Mr. Welch, for his 5 minutes of questions.
Mr. Welch. Thank you very much.
I want to start with the telehealth service. It has been
terrific in Vermont, and I do think that Congress and the
President have done a good job in taking advantage of it.
But, Dr. Geller, you talked about a lot about it. I have
had a lot of feedback from practitioners that, contrary to what
I expected, the interactions are oftentimes not only easier but
more intimate.
One practitioner told me about being able to go on a
virtual walk with a client who was in a very rural part of
Vermont, and also how at times it would be relevant for other
members of the family to be able to participate in the call.
Can you comment on that, the effectiveness from
establishing that intimate relationship and trusting
relationship so essential for the person seeking help and the
provider giving help?
Dr. Geller. Sure. It works in both directions. There is
something to be said for being in the same room. But I have had
lot of experiences with patients in telepsychiatry where not
only are they more willing to speak, but you have opportunities
for in-the-moment experiences that you can then bring into
therapy.
So I have a woman who is a single mom with four kids, and
sometimes the kids run in and interactions take place, and then
we can actually talk about what just took place.
So you are in the moment with patients, and that can make a
huge difference.
Mr. Welch. Thank you.
Another question I have about mental health is this. There
are--I will probably get this wrong--but there are some
conditions like bipolar, schizophrenia that are chronic with
acute episodes that require medication and constant treatment.
But so much of mental health seems to be an outgrowth of
loneliness, depression, erosion of community stability, lack of
jobs, communities getting hollowed out.
And one of the challenges we face in Congress seeking to do
with our bipartisan commitment to addressing opioids is that it
really doesn't--it is after the fact, it is really not
providing that underpinning of some security that folks need in
a community, stability in relationships, stability in their
social networks.
How much of the explosion in mental health situations that
we have here do you see as having a connection to the erosion
of those communities, jobs, support structures, and so on,
because so much--you indicated that the suicide level in Europe
was significantly below us here.
Maybe I will start with you, Dr. Evans.
Dr. Evans. Sure. Well, what you are referring to, what we
call in the field social determinants of health. And we know
that there are certain things that we experience that can lead
to challenges for us both physically and mentally. And as you
noted, things like losing your job, being under a lot of
stress, being homeless, all of those things are stresses that
can lead to mental health challenges.
Our field has not done a good job of understanding or at
least incorporating into our clinical approaches and
understanding those social determinants and using that
information to actually help people.
I mentioned in my testimony, my oral testimony, the
importance of addressing issues like homelessness as a way of
actually improving people's mental health--
Mr. Welch. If I may interrupt there, because I only have a
minute, but with respect to that, with all of the activity we
are seeing with the activism around Black Lives Matter, are we
in many cases focusing too much on police as the responders of
first resort rather than a kind of rapid response team that
Patrick Kennedy said we need when there is a mental issue?
Patrick, maybe you could address that.
Mr. Kennedy. Well, thank you so much, Peter.
I think, obviously, when you look at the fact that so many
of our jails are filled with people with mental illnesses and
addictions, that clearly a better response than occupying
police time would be to make sure that proper first responder
teams are in place who are mental health first aid responders
and of the like.
So, obviously, I hope that is in your number of things that
you can consider today, and it would certainly be a terrific
allocation of resources, or, if you will, reallocation.
Because I think any firefighter will tell you, these days
especially, they spend more of their time trying to do first
response to overdoses and mental health crisis than they do
putting out fires. And the same with police officers. Most of
the cases they get called to may present as a criminal justice
issue but clearly have a mental health at the root cause.
Mr. Welch. Thank you very much. I yield back.
But I do want to say thank you to Arriana Gross for her
excellent testimony and the work she does.
Thank you, Madam Chair.
Ms. Eshoo. The gentleman yields back. And I thank him for
his excellent questions.
The Chair is pleased to now recognize the gentleman from
Oklahoma, Mr. Mullin, for his 5 minutes of questions.
Mr. Mullin. Thank you, Madam Chair, and I appreciate you
holding this hearing because it is an important issue. It is
something that, obviously, I have been working on for quite
sometime, starting with the 42 CFR part II, which I was glad to
see was aligned and put in with the CARES Act.
And so, Mr. Kennedy, this is a question for you. I know our
offices had spoke multiple times about this. I appreciate your
insight and your feedback while we were taking this fight on
for 42 CFR part II. Your feedback was instrumental, and you
provided some influence in there that I think really helped
with the colleagues on the other side of the aisle, which this
is a bipartisan approach in this committee.
How does this important measure with aligning part II with
HIPAA help in the times that we find ourselves in, especially
when we see an increasing mental health crisis going on because
of the pandemic?
Mr. Kennedy. Thank you, Mr. Mullin, and thank you for your
leadership on this. I appreciate it very much.
I think, as we just heard Dr. Geller talk about, the co-
occurring of psychiatric symptoms with physical symptoms and
conditions. And the bottom line is, when I go into the ER, if I
am going in with COVID or something else and they don't
understand about my underlying psychiatric issues, or in the
case of addiction they do not know that I am someone who
suffered from the chronic disease of addiction, which has a
better chance of killing me than any other illness that I face,
there is a couple of them, but nothing as critical as the life
or death issue of having to fight addiction as a disease.
Which by the way, when I go to my doctor, my doctor doesn't
ask me about my addiction, because it is not in my electronic
medical record. And my doctor has a pen, an electronic pen
these days to prescribe anything that they want. And if they do
not know that I have the disease of addiction, they are
practicing medicine without a license.
And that is why I thank you for that 42 CFR, because there
are hundreds of thousands of my fellows in America who are
dying because their medical system does not know they have an
underlying addiction because it doesn't show in the EMR that
they have been treated for addiction.
So I just assume if you are protecting my privacy with
respect to anything else that is super sensitive, and if, you
know, sexually transmitted diseases are protected by HIPAA,
then I should think mental health could be protected by and
addiction could be protected by HIPAA as well. So I think that
this about protecting patients' health. That is why it is
important to have a 42 CFR fix.
Thanks.
Mr. Mullin. Well,Patrick, you have been very passionate
about this. It was something that affects all of us. I think in
your opening statement you said this. Every family is affected
by this. Mine is no different.
In Oklahoma, we have been devastated by mental illness and
the opioid and meth issue, which a lot of times mental illness
runs hand in hand with that too, because they are trying to
self-medicate. And all of our families, you are right, have
been devastated by this.
And so I just want to tell you again I really appreciate
it. Thanks for your insight and your input on that too.
Dr. Evans, real quick, there has been an increase of almost
900 percent of mental health crisis hotline, calls to the
hotline this year. Now more than ever do you think it is
appropriate, it is more appropriate to remove some of the
barriers that are prohibiting some of the treatments that could
take place for people that are suffering from mental illness?
Dr. Evans. Well, absolutely, and I appreciate that
question, Congressman, because, as you know, you are a
supporter of 884, which removes barriers in the Medicare
program for psychologists. It is a real travesty that in 2020
we have administrative barriers that prevent people from
getting the care that they need.
That legislation would allow two things. One is to ensure
that seniors, who right now are experiencing the worst mental
health crises of our lifetime, have access to psychological
care. And then the second thing is to make sure that
psychologists are eligible for reimbursement for the incentive
payment to work in some of the rural areas and underserved
areas that we have talked a lot about in this hearing.
Our seniors have significant mental health needs normally.
They have exorbitant mental health needs under this current
crisis. And it is just not right. It is not right to deny them
that care when there are ways to remove these administrative
barriers.
And let me just say that the barriers that we are talking
about have been removed for podiatrists, they have been removed
for optometrists, for chiropractors, for a lot of other
doctorally trained professionals.
And the administrative barriers that we are talking about
are only in the Medicare program. They are not in the VA, they
are not in TRICARE, they are not in any private insurance. It
is only the Medicare program where we have the most vulnerable
people in our society.
And I really appreciate your support, and other Members of
Congress, so that we can remove that barrier and really focus
on making sure that everyone gets the care that they need.
Mr. Mullin. Thank you, Dr. Evans.
And, Madam Chair, sorry about going over there. I
appreciate the indulgence there and will yield back. Thank you.
Ms. Eshoo. Well, thank you for your good work, Mr. Mullin.
The gentleman yields back.
A pleasure to recognize Dr. Ruiz from California for his 5
minutes of questions.
Mr. Ruiz. Thank you. Thank you very much. We are very happy
to have this hearing today on such a critical issue.
This is especially important at this very time as we are
seeing anxiety stress levels go up during this pandemic. This
March, for example, the Disaster Distress Helpline supported by
the Substance Abuse and Mental Health Services Administration
saw an 891 percent increase in calls compared to March of last
year.
The mental health system in our country was already
strained prior to the public health crisis, which is why it is
more important now than ever to look at ways to expand access
to mental health for all Americans.
It is worth noting that if the ACA were to be overturned,
health insurance plans would no longer have to cover mental
health and substance use disorder services, including
behavioral health treatment, as an essential health benefit.
Having spent my career prior to coming to Congress as an
emergency department physician, I can tell you from firsthand
experience some of the access issues that individuals face.
Oftentimes, individuals with an acute mental health episode end
up in the emergency department, sometimes because there is
literally nowhere else to go.
Then the emergency physician needs to make a decision,
either they hold them for a psychiatric evaluation for suicidal
ideation or they hold them because they cannot find any
transfer beds, any mental health hospital beds, or they
discharge them and are unable to start treatments or get them
the care that they need because there are not enough primary
care practicing psychiatrists on the community or other mental
health professionals.
The biggest concern is "lost to follow-up." That is a term
that we use when you discharge somebody knowing that they need
follow-on care but, unfortunately, because of the systematic
problems, they are lost to follow-up.
The emergency physicians or providers want to find the
appropriate care for their patients before releasing them. They
want to hand them off directly to the next provider knowing
full well that once that patient walks out the door the chances
of them taking the next step drops dramatically.
So emergency departments across the country have
implemented innovative approaches to securing follow-on care
for their patients, like putting in place transportation
systems to get their patients from the hospital to the rehab
facility or tracking regional inpatient bed capacities or
coordinating with area mental health providers in a team
community-like approach. But they don't always have the
resources or capacity to do as much as they want to do.
That is why I introduced H.R. 2519, the Improving Mental
Health Access From the Emergency Department Act of 2019, which
would create a grant program for emergency departments to
transition their patients into more appropriate care for
longer-term treatment.
Dr. Geller, can you talk a little bit about the specific
barriers that emergency departments have to be able to give
their patients a warm hand-off to their follow-on care?
Dr. Geller. Sure. As you have indicated, most emergency
departments operate like silos. They have no relationship
whatsoever to the services that follow unless those services
happen to be within the same hospital as the emergency
department. So your bill is making huge steps forward in that
regard.
The second piece of this is we don't have enough beds in
that. So people sit in emergency rooms where they don't belong
for lengths of time. We have had people sit in emergency rooms
for up to 30 days looking for a bed.
Why can't we find a bed from the emergency room? Because we
have people in general hospitals where we don't have enough
beds. Why do we have some people in general hospitals? People
in general hospitals can wait 6 months to get transferred in
some States to the public sector hospital. We also have jails
and prisons filled with individuals because we don't have
enough beds.
So we need coordinated services, and we need funding for
that, and your bill does an excellent job with that, but it
needs to be coordinated with an adequate number of psychiatric
beds.
Mr. Ruiz. And what are some of the barriers that the
patients face when they are discharged for follow-on care that
go beyond the lack of beds or locations? And how could a grant
help?
Dr. Geller. So the grant can help because we are asking
people who are in distress and may have, but depending upon
their diagnoses, problems with social skills, problems with
organization, and we are saying here, here is a phone number,
you follow up. They call that phone number, they get a
recording.
So that this bill would actually create steps that are
going to be facilitated by people in the emergency room to make
sure there is a warm hand-off. And as you well know as a
physician, there is nothing more important than a warm hand-
off.
Mr. Ruiz. Thank you very much.
Ms. Eshoo. Your time has expired.
It is a pleasure to recognize the gentleman from Montana,
Mr. Gianforte, for his 5 minutes of questions.
Mr. Gianforte. Thank you, Chairwoman. I appreciate the
committee hearing today to discuss legislation to improve our
mental healthcare system.
I appreciate that legislation I introduced with my friend
from Virginia, Mr. Beyer, was included in this hearing, our
bill, H.R. 4585, the Campaign to Prevent Suicide Act. Our
legislation would direct the CDC and SAMHSA to conduct a
national suicide prevention education program. This includes
advertising for the new 988 number for the National Suicide
Prevention Lifeline. It would also encourage individuals to
engage with people showing signs of suicidal behavior instead
of ignoring them.
We introduced this legislation to complement the efforts of
Mr. Stewart's legislation to designate 988 as the suicide
hotline and Mr. Katko's legislation to ensure funding to
implement the designation.
To better respond to those in crisis, we need to have a
shorter number. People need to know about it. And it needs to
be resourced so that those in crisis don't call and get put on
hold or get a busy signal.
Mr. Stewart's legislation has already been voted out of the
Communications Subcommittee. I hope H.R. 4585 and H.R. 4564 can
join it in a bipartisan markup at full committee soon.
These bills were needed before the Nation entered this
unprecedented health and economic crisis. With hundreds of
millions of Americans worried about their health and millions
out of work and restricted from social interactions, it is more
important now than ever.
I supported legislation that was included in the farm bill
to prevent farm suicides, and the need to address this in all
walks of life has only grown. People are hurting in Montana and
across our Nation. We should be able to work together to help
make the suicide hotline work in this crisis.
Madam Chair, I ask you for unanimous consent to enter into
the record letters in support for H.R. 4585 from the American
Foundation for Suicide Prevention, the Mental Health Liaison
Group, and Vibrant.
Ms. Eshoo. I want the gentleman to know that I am going to
take up the request for unanimous consent en banc at the end of
today's hearing. So thank you.
Mr. Gianforte. Thank you, Madam Chair.
I also appreciate that we are considering legislation to
expand the use of telehealth for mental health services.
So, Dr. Geller, I want to go back to the topic of
telehealth. We have talked about it a lot today. My home State
of Montana frequently ranks among one of the worst States for
suicides in our country. We have a population that is mostly
rural, and it is extremely hard to find mental health providers
for these communities.
Can you talk specifically about how telehealth for mental
services helps fill this gap in rural America?
Dr. Geller. Absolutely. It can make all the difference. I
have been to Montana. I know how long it took me to get from
one farm to the next farm.
It makes services accessible to anybody no matter where
they are. And if we include, as I have said before, the
telephone component, it doesn't matter whether you have access
or not electronically. You can use your telephone.
It also means, in terms of both of the issues that you have
talked about, with the crisis number, we know that a
significant number of successful suicides are impulsive acts.
If a person has the ability to dial three digits and get
immediate attention, that can absolutely interrupt that
impulsive act.
So between that and the ability to access a professional,
no matter where they are in the State of Montana or anyplace
else in the United States, I think we can make a significant
inroad.
As a footnote, every State should have places across the
State where there are billboards that say what number that is
and what its purpose is.
Mr. Gianforte. OK. Thank you, Dr. Geller.
What additional steps--Dr. Evans mentioned earlier
practicing across State lines, but for both of you gentlemen,
what additional steps do we need to make sure that we can get
quality mental health services into a rural America?
Dr. Evans. Well, I think the legislation--and I mentioned
earlier 884, which allows psychologists to practice to the full
extent of their license--is one example of that. It is clear
that we need technological solutions, and telehealth does that.
We need policy solutions, like interstate compacts that
allow people to work. But we also need to make sure that the
providers are there to provide those services, and the
legislation that you are supporting, 884, does that, and we
appreciate that.
Mr. Gianforte. Madam Chair, could Dr. Geller comment
briefly on that point as well?
Ms. Eshoo. Yes. I am sorry. Go ahead, Dr. Geller.
Dr. Geller. I think we have to have more opportunities for
graduate medical education, more attention to deploying people
to underserved areas. Like if I go to an underserved area in
Montana, I can get loan forgiveness.
And if I can respectfully disagree, I do not believe that
turning psychologists into physicians is going to increase
access and there are some ways in which it is potentially
dangerous. For example, psychologists running a partial
hospital program is, I think, dangerous.
Mr. Gianforte. OK. Thank you, Madam Chair. I yield back.
Ms. Eshoo. The gentleman yields back, and thank him for his
excellent questions.
The gentlewoman from Michigan, Mrs. Dingell, is recognized
for her 5 minutes of questions.
And I want to thank all the Members for their patience. We
are living in a new era. Everything takes more time. I can't
help but think that today's hearing is some of the best time
spent, but it still takes patience on the part of Members. So I
thank all of you.
And the gentlewoman is recognized for her 5 minutes of
questions.
Mrs. Dingell. Thank you, Madam Chair. And patience is also
exhibited by the witnesses for staying so long and answering
our questions. So we thank you. And I thank the Ranking Member
Burgess too.
This is a subject that is very important to me, like many
others here. I think the fact that the committee has chosen to
highlight this issue is really important, because, quite
frankly, during normal times, mental health access remains a
significant challenge.
And I guess I even sit here--I listened to Patrick, and it
is wonderful to see him at the beginning of this talking
about--he and I have been friends and we have talked and
partnered about this. One of the things we haven't talked about
as much as I thought we might is just, quite frankly,
eliminating the stigma.
It is still a reality that too many people are afraid to
acknowledge that there is a problem. Like him, my father was a
drug addict at a time that no one ever talked about it and had
a number of pretty horrific incidences. And my sister
ultimately died when I tried to save her, and I tried for years
in and out of the system. So I have learned a lot and had other
people. But too many people are still afraid to even
acknowledge that they have a problem, and it is in every
family.
Yes, the jails have people in them that should be getting
help and they need mental health treatment, they don't need to
be in a prison. But there are a lot of people that are sitting
in their homes and their jobs that need help that won't
acknowledge that they have a problem, because they are afraid
what someone will say.
And COVID has only made it worse. Seniors have told me that
we have already made a decision that if they get COVID, they
are going to die, because nobody cares, we have decided they
are disposable. I deal with a lot of domestic violence cases,
et cetera. And my law enforcement have been doing wellness
checks this entire period.
So we need to be talking about this. And our mental health
system is broken. I am going to--I hate talking about money
because--and when you were talking earlier, we don't have
enough psychiatrists going into the psychiatric field.
We had an incident, an unfortunate one with a college
student at Central Michigan University who knew he needed help.
He went to the hospital. There was no doctor available to take
care of him. They called his parents to come get him. And when
his parents came, his father was a sheriff in Illinois. He took
his father's gun and shot and killed his two parents, because
there was nobody to help him and there was no bed available.
And then I learned that only one person had gone into
psychiatric residency in Michigan that year. And we have got
to--we have to incentivize. It is something else that I want to
talk about down the road.
But, Mr. Kennedy, Patrick, thank you for your longstanding
advocacy and all that you have done and your standing up. But
will you talk specifically about what sort of cuts will non-
Medicaid State and local mental health and addiction services
face if we don't provide fiscal relief in these next few weeks?
Mr. Kennedy. Yes, thank you, Debbie. And, by the way, my
book ``The Dean of the House'' is right next to my bed. I am so
grateful for that book and the nice words that your husband
mentioned. And I loved him and loved being scolded by him when
I wasn't following the proper rules of the House. And I know
how proud he still is up in heaven of your carrying on that
tremendous legacy of public service. So sorry for wasting all
that time, but say that you are a great person. I am so glad
you are there.
And, you know, we don't--the mental health budget I think
we can all agree is about the first thing to go. And the reason
it is is because there aren't a lot of people raising your hand
saying that you are a consumer, unlike if you had cancer or
heart disease. You don't have the big Cancer Societies,
American Heart Foundations. God bless NAMI and MHA, but they
will be the first to remind everyone that they are very
woefully underfunded as an advocacy group.
So, basically, if you have a mental illness or addiction,
you are either in jail, in an institution, or you are in a 12-
step meeting and you are supposed to remain anonymous, OK,
which means that there is no public advocacy going on there,
unfortunately.
So I am just trying to paint for all of your colleagues--
very well put, Debbie--that this is the first area of
government that they are going to see as able to be disposed
of, because you are not going to hear the hue and cry that you
will get if you try to cut many other areas of State and county
funding.
Mrs. Dingell. Thank you. Madam Chair, I am already out of
time. Thank you.
Ms. Eshoo. The gentlewoman yields back.
It is a pleasure to recognize my good friend from Illinois,
Congresswoman Susan Brooks, for her 5 minutes of questions.
Indiana, I am sorry.
Mrs. Brooks. Thank you, Madam Chairwoman. And I apologize.
I am having some technical difficulties with my WiFi here in my
office.
But I just want to thank the Chair for having this really
important hearing. I know that you and the ranking member, he
had requested as well and it is very important that we focus on
mental health, especially during this time with COVID.
I really appreciated all of the panelists who are here and
providing us their expertise. Last year or in the last
Congress, I led the additional Law Enforcement Mental Health
and Wellness Act, and we got that signed into law, providing
more resources for those frontline workers.
I want to talk a little bit more and go back to providing
more and more resources for those frontline workers,
particularly the healthcare workers and what they are
experiencing, firefighters, first responders still who are our
first responders who are often going to the homes and helping
people who may be very ill with COVID, but particularly those
healthcare workers.
And I think Dr. Evans or maybe--I am sorry, it was Dr.
Geller who talked about the stigma of those providers seeking
help, because of their licensure and because--and I would like
to talk about that a little bit further.
And, Dr. Geller, what is it that you believe we should do?
Because I am an attorney. Often with licenses, you have to
indicate whether or not you have sought psychiatric help. Is it
your position that we should no longer be having that on
applications, whether you are going to be a police officer, a
lawyer, a doctor, a teacher?
How is it that we address that, Dr. Geller? Because I do
agree that I do think it keeps people from accessing and it
does build on the stigma of accessing services.
Dr. Geller. So two parts to that answer, I think: We have
had an explosion of attention to health inequities for Black
people, but we have had health inequities for Black people in
this country for 300 years. We need an explosion of attention
to the discrimination and prejudice against people with mental
illness. That is the first part.
The second part specifically is, well, what is the purpose
of that question? What is the relevance on my licensure
application or your licensure application as an attorney as to
whether or not I have ever sought psychiatric treatment? They
don't ask me if I went to a dermatologist.
If there is some concern about impairment, then a question
ought to be a broad question about impairment, because I could
be impaired because I have a medical disorder just as easily as
I could because I have a psychiatric disorder.
So I think that the question should be changed if we are
concerned about impairment, and that should be the same across
the spectrum. The fact that I saw a psychiatrist should not
preclude me from being a doctor, from being an attorney, you
know, or from being a school janitor or from anything else.
Mrs. Brooks. Thank you. Thank you very much.
I would like to ask Ms. Gross--and thank you so much for
sharing. One of my high schools in the Fifth District of
Indiana actually created a stigma-free club created by a young
man whose mother very much suffered from mental illness, and it
was all about peer education.
How might we educate young people around the country about
the warning signs of suicide or about increasing the number of
peer educators and peer counselors we get involved at that high
school level and then maybe into college? What do you think we
ought to do?
Ms. Gross. I think that there is--you know how at the
beginning of the school year there is often time put aside for
orientation or just getting used to the school, and you might
even do some career training. Like, I feel like we could use
that time to put in place just a little bit of learning that
people can understand how to help their peers, because, from my
perspective, it is so important.
And in order to be a good student, you have to have a great
mental health. And I feel like if we don't use things such as
the STANDUP Act, we could easily be failing our students in
that regard, because the mental health and well-being of our
students is so important to how well they end up doing.
So, as you said before, just getting that little bit of
time. It doesn't even have to be a lot as long as we can make
sure that they have the information they need. The same amount
of time as it takes to teach them about what their classes are
going to be or a little bit of career training about what they
might want to do in the future. It is just that bit of time
that really will impact the future.
Mrs. Brooks. Thank you for your leadership.
Thank you. I yield back, Madam Chairwoman.
Ms. Eshoo. The gentlewoman yields back.
It is now a pleasure to recognize the gentlewoman from
Illinois, Ms. Kelly, for her 5 minutes of questions.
Ms. Kelly. Thank you, Madam Chair. I thank you and the
ranking for bringing us together to discuss mental health
issues. And I thank all of our witnesses for being willing to
testify today.
A 2003 national academic study found that even when
controlling for barriers to care, minority patients have worse
health outcomes than White patients. The report found that both
explicit and implicit racial bias contributed to these worsened
health outcomes.
As we all have heard by now, minority communities show a
disproportionate number of COVID-19 cases and deaths. This is
compounded by pandemic-related shutdowns and layoffs hitting
minority communities especially hard, because we are the
essential workers. These parallel economic and medical crises
are a recipe for stress, anxiety, and grief within the
community of color. Yet too often, these same communities lack,
as you know, access to care and mental health services.
Dr. Evans, how can we address disparities in access to
mental healthcare and treatment for communities of color?
Dr. Evans. Well, we have to do a number of things. The
first and one of the things, you know, in my role as
commissioner in two different States, it is really clear that
while we need to make sure that services are funded, we also
need to make sure that we work on the community's understanding
of the importance of mental health.
The biggest shift that we have to make in the mental health
system or how we deal with mental health is to move from
thinking about mental health as about them to thinking about
mental health as about us, and that means all of us. And when
we understand that our mental health is as important as our
physical health and that all of us have some mental health
issues going on at some point in our lives, it reduces the
stigma and it makes it much easier for people to reach out for
help.
We also have to make sure that we have policies that are
directed at communities that are affected. When I was a
commissioner, I made sure that the immigrant communities,
particularly the small communities that didn't have a loud
voice, got funding, or areas of the community that had deserts
in terms of healthcare providers had services in those
communities. There is no way around making sure that the
resources are in the places and directed to the people that
need them. OK. Thank you.
Ms. Kelly. I wanted to ask Dr.--well, the Pursuing Equity
in Mental Health Act would fund culturally and linguistically
appropriate mental health services for underserved communities.
The bill would also provide support for more students of color
to enter the mental health workforce.
Dr. Geller, regarding the creation of a culturally
competent workforce, your organization has a task force to
address racism within psychiatry. What are some of the barriers
the task force has found, and what are you doing to address the
issue?
Dr. Geller. Well, the task force has really just begun its
work, so I can't answer it specifically from the task force's
stance, but I can answer in terms of the APA.
We have very long worked on healthcare inequities,
disparities, and we have all sorts of educational material that
is directly related to that subject matter. Also, we have been
working on deploying personnel outside of traditional offices.
You know, besides having financial resources, you have to
send services where people are going to get them. If you want
to meet the needs of a Black man in the community, you got to
have somebody sitting in the barber shop.
Ms. Kelly. Definitely.
Despite the pandemic, gun violence continues to plague
communities in my district. The Bipartisan Solution to Cyclical
Violence Act of 2020 would create grants to violence prevention
programs, including intimate partner violence, to try and stop
this crisis.
Dr. Evans, can you discuss how cycles of violence influence
the mental health of trauma victims, and can violence
prevention programs assist in reducing the burden of violence
and mental illness?
And I am a big gun violence prevention person. I am not
against guns, but we have such easy access to guns, that has to
contribute to the suicide levels also.
Dr. Evans.
Dr. Evans. Sure. Sure. And let me just commend you for your
leadership around CDC and the data, because that is a really
critical piece in reducing these disparities.
It is really important to have community interrupters to
interrupt violence in communities, but it is also important to
connect those efforts with addressing trauma.
One of the things that happens in--we would talk about in
my work is that hurt people hurt people. So when people are
traumatized, they are much more likely to continue that pattern
of traumatizing others.
And so a big part of addressing community trauma and
violence helps to reduce both of those when you combine those
in your efforts to reduce violence and trauma.
Ms. Kelly. Thank you so much. I am out of time. Take care.
I yield back.
Ms. Eshoo. The gentlewoman yields back.
A pleasure to recognize the gentleman from Ohio, Mr. Latta,
for his 5 minutes of questions.
Nice to see you. You need to unmute. You need to unmute.
Are you unmuted? The gentleman needs to unmute. We can't hear
you. We can't hear you, Mr. Latta. Mr. Latta, we can't hear
you. There he is.
Mr. Latta. Madam Chair.
Ms. Eshoo. There you are.
Mr. Latta. Madam Chair, can you hear me now?
Ms. Eshoo. We can hear you now. Thank you.
Mr. Latta. I am having a little technical difficulty here.
I am sorry about that.
Ms. Eshoo. That is all right. The gentleman is recognized
for 5 minutes.
Mr. Latta. Well, thank you. And, Madam Chair, before I
begin, if I could ask unanimous consent to submit some letters
for the record.
Ms. Eshoo. Yes. The Chair announced earlier that all
unanimous consent requests would be considered en bloc at the
end of the hearing.
Mr. Latta. Well, thank you very much, Madam Chair.
Ms. Eshoo. Certainly.
Mr. Latta. And today we are shining a light on the
importance of improving mental health in our country. And I
would first like to thank you for allowing me to waive onto the
subcommittee for this hearing.
Before I ask my questions, I would like to highlight how
COVID-19 has taken a toll on virtually every aspect of our
life. Rates of mental health conditions, substance abuse
disorders, and suicides have risen drastically over the past
few months. The White House Drug Policy Office has released a
troubling statistic. They shared that drug overdose deaths have
increased 11.4 percent in just the first four months of 2020
compared to the same period last year.
The social repercussions of COVID-19 have caused stress and
anxiety in our communities. Providing care and assistance to
those who are suffering is a must, especially during this
global pandemic. That is why I authored the Creating Resources
to Improve Situations of Inherent Severity Act, or the CRISIS
Act.
The CRISIS Act would direct States to utilize funds from
the Mental Health Block Grant for crisis care services and
improved care to individuals experiencing a psychiatric
episode.
Again, I want to thank our witnesses for their attendance
today, and if I may begin with Dr. Geller.
Dr. Geller, your testimony indicates that mental health
crisis services can help those with mental illness by limiting
their contact with the criminal justice system and reducing
visits to the ER. As you know, I have introduced legislation to
provide resources to States through the Mental Health Block
Grant to enhance their crisis services.
What is special about the crisis services and how do
communities stand to benefit from having more of them?
Dr. Geller. Crisis services take many forms. They can be
freestanding mobile crisis intervention. They can ride with
police officers. They can be involved with diversions from the
courts.
Crisis services we have known will divert people from
higher levels of care, and diverting people from higher level
of care will allow those levels of care to be available for
people who actually really need them.
So not only is the individual a beneficiary from getting
the crisis services, the system is a beneficiary because it can
then target people who need higher levels of care. That piece
of legislation is extremely important and will highly benefit
the psychiatric population.
Mr. Latta. Wouldn't it also decrease costs since we are not
having those folks at the ER and also incarceration? I know
when I visit with my sheriffs in northwest Ohio, I have had a
lot of the sheriffs say, unfortunately, that they are the first
place that they bring folks that need care on the psychiatric
side, but they can't provide those services.
Dr. Geller. Well, that is a double-edged sword, because it
may absolutely decrease costs, because it is going to have
people not go to places that they don't need. But it is also
going to do case finding. That is, it is going to find people
who need services that otherwise never would have gotten
services.
But let's just say it is cost-neutral. It is cost-neutral,
and we have given a whole lot more people the services that
they need. That is the bottom line. We will actually serve more
people more effectively without spending more money.
Mr. Latta. Well, thank you very much.
And to our former colleague, Mr. Kennedy, suicide, drug
overdose, and alcohol use killed more than 180,000 Americans in
2018. How has COVID-19 increased the anxiety and depression for
these Americans?
Mr. Kennedy. Thank you. Again, the number is startling,
because, you know, we are counting all the time the number of
Americans who are dying as a result of COVID.
To think that we are losing just as much, if not more, to
these illnesses and we are not hearing about it at all. We are
not hearing a word about it. Just the silence on this is
deafening.
COVID forces people to stay isolated, removed, you know,
disconnected. And, you know, people who have addiction, mental
illness, they like to isolate. So this, unfortunately, adds
gasoline to the fire, because isolation is not good for your
mental health. It is a coping mechanism for people who do have
addiction and mental illness, and it is reinforced by the
messages that we are getting in society now which says that we
shouldn't talk or connect with each other. So I think it could,
obviously, as we have seen from the science thus far, really
add enormously to the current number of tragedies.
Mr. Latta. Well, thank you very much. And thank you to our
witnesses, again.
And, Madam Chair, again, thank you for letting me waive on.
And I yield back.
Ms. Eshoo. You are always welcome, Mr. Latta. Thank you.
A pleasure to recognize a fellow Californian, the
gentlewoman from California, Ms. Barragan, for her 5 minutes of
questions.
Ms. Barragan. Thank you, Madam Chairwoman, for having this
really important hearing today.
I am sorry, I am going to ask our colleague to mute.
Ms. Eshoo. Just a moment, please. I am going to suspend.
Mr. Latta. Mr. Latta, you need to unmute, please. I think he is
unmuted now.
The gentlewoman can proceed, and we will add another ten
seconds on and not have you lose any time.
Ms. Barragan. Thank you, Madam Chairwoman, for holding this
very important hearing today to address the mental health
crisis facing the country.
Dr. Evans, you have mentioned many things that I have been
talking about and can relate with. Oftentimes, I am somebody
who says, we all have mental health issues, the question is to
what degree do we have them. And so to hear you say that today
just reaffirms what I have seen, what I have experienced just
throughout my life, and just across the board.
You have also talked about the importance of looking at the
social determinants of health, which I think is so critical.
That I represent a community in a district that includes
Compton and Watts. We have children who worry about getting
shot as opposed to worried about the next school report that is
due, and what impact that has on their mental health and what
those factors have on a child.
And the importance of us looking at that is so important
that I have introduced a bill to address the social
determinants of health that will create a program specifically
at the CDC to address these social determinants of health and
create partnerships with local public health agencies so they
could also address this issue. So thank you for bringing that
up.
I think this hearing is great. I think we need to have more
of them on mental health. Mental health touches every single
part of our lives, whether it is gun violence, whether it is
homelessness, certainly now under COVID-19. Addiction, we all
have family members who have experienced addiction, and I think
it goes across the board that we hear it day in and day out.
Mr. Kennedy, I want to follow up with you on a topic that
my colleague Rep Brooks brought up on the applications. I want
to share quickly a very personal story. When I was in college,
I was applying to be an intern in the White House, and I
remember seeing the application asking if I had ever seen a
mental health professional. And my father had been terminally
ill for all of my last ten years of my--well, I think it was
the ten years of his life which was me being in college. And I
remember thinking to myself, geez, as I leave--I ended up
getting the job at the White House, but if I end up leaving and
seeing a mental health expert, maybe one day I can't work in
government if I go. And having that thought I think had me even
second-guessing whether I should ever seek any mental health
services.
We heard Dr. Geller talk about his belief that we should
change the question. Do you think we should eliminate the
question, or if we are going to change it, in what aspect do
you think it should be on an application?
Mr. Kennedy. Thank you. Well, I will just add that the
Green Berets, which no one would think have any mental health
problems, they are the best of the best in our military, they
are afforded and take advantage of more mental health than any
other branch of the service.
Now, why would the Green Berets, who are the best of the
best, have so much mental health provided? Because our Nation's
military has figured out that in order to have the best of the
best, all of those that they have invested so much in in terms
of training, they need to be on their game and they need to be
able to minimize intrusive thoughts, anything that might
compromise their ultimate ability to meet the task of the
mission.
Now, why, as a Nation, don't we take that same attitude
that the United States military has taken, that Chairmen of the
Joint Chiefs of Staff have taken, and that is seeking mental
health makes you mentally healthier. We ought to be encouraging
people in this country to seek mental health. That should not
be a disqualifying factor. If anything, it ought to be a
rewarding factor to folks.
So for the same reason, I am for eliminating checking the
box for those who have been in our criminal justice system for
whom saying that after they have already paid their dues to
society totally hinders their ability to move on in their life.
The same thing with this, we need to eliminate this check the
box as well.
And I think that the job that you are going for, there
ought to be criteria, and whether you are able to meet that
criteria ought to be the criteria, not some, you know, question
about whether you have ever sought mental health. That should
not be a disqualifying criteria. But thank you so much for
letting me eat up all your time for that answer.
Ms. Barragan. Well, thank you, Mr. Kennedy, and I will
certainly follow up with some of our other witnesses, given
that my time has expired.
Thank you, Madam Chairwoman, for having this hearing.
Again, I think we need to have more on this really critical
issue.
Ms. Eshoo. I think we do too as well. Thank you to you, Ms.
Barragan.
The Chair now recognizes a wonderful addition to our
committee, the gentlewoman from Delaware, Ms. Blunt Rochester,
for 5 minutes of her questions.
Ms. Blunt Rochester. Thank you, Madam Chairwoman. And thank
you to the ranking member, and a special thank you to the
witnesses today. As has been said, this is a crucial hearing.
Not only are mental health issues a crisis in our country,
we couple that with an economic crisis. I come from a State
that has a farming community, and we have seen suicides rise in
the farming community. You add onto that COVID-19 and think
about our essential workers and our frontline workers and just
the stresses and pressures there.
But then more recent, the racial injustice issues that we
have been facing as a country, and you know that this is an
important time for us to be having this conversation and to be
really dealing with it.
For communities of color, there are persistent disparities
in mental health. And in 2018, 16 percent of African American
adults reported having a mental illness; and in 2017, suicide
was the second leading cause of death for African Americans
ages 15 to 24. In fact, the suicide death rate among Black
youth has been increasing faster than any other racial or
ethnic group.
I actually have legislation that I am working on right now
that is really taking a look also at the issues of trauma and
policing in the African American community and access to mental
health.
I want to address a question to Ms. Gross. And thank you so
much. And also congratulations on your leadership, but also on
your focus on the arts as well, because I do think that there
is a connection between mental health and the arts as well.
And in your testimony, you said, quote, "Trust me, we have
seen and been through more than you realize and we can and want
to help." And that is what you said of your generation.
And I was wondering if you could talk a little bit about
two things: One, if you feel that there--we talk a lot about
the stigma associated with mental health and the shame. Do you
feel that your generation is more focused on getting the help
than they are on the stigma or the shame, or do you feel that
that is still a problem? And also, how does social media and
the internet contribute to that?
Ms. Gross. Yes. Thank you for that awesome question. So, I
definitely do believe that students today--I am sorry. Can you
please say the beginning again? I am so sorry.
Ms. Blunt Rochester. Just do you think that there is still
that stigma attached to it, and how does social media feed that
or not? Do students want help or is that stigma still there?
Ms. Gross. I tend to see both. Because students today, I
feel like we kind of have set away, we try to set away the
stigma. But the thing is I feel like sometimes the older
generation, sometimes it is like, you know, you are young, you
don't really know how you feel.
And I feel like sometimes we feel like we won't be
understood, our problems won't be understood, because I think
we have grown up in a unique set of times and the way that we
understand things is a lot different.
So, in my perspective, I think that the STANDUP Act and
having our peers be able to help us through these times is very
important, especially with social media.
Social media is both a good and bad thing. I see that it is
a place where a lot of kids feel comfortable just expressing
themselves to other kids who go to their school and are their
friends that understand their issues, because I think that is
one thing so great about our generation is that a lot of times
we can be a very strong community which we can rely on in those
times. There are so many people that I have been able to call
on who have just supported me when I needed it.
So, in my perspective, that is why it is so important to,
yes, use social media and to kind of see that we are trying to
eliminate the stigma so that working together to kind of create
that bond so that we can help achieve what we are all here for.
Ms. Blunt Rochester. Thank you for your answer.
And for Dr. Geller and Evans, I will put this question out
here and we will follow up with you as well, but how could
expanding access to culturally competent care, like H.R. 5469
would do, help reduce those systematic barriers, systemic
barriers, and what else do you recommend that Congress do to
address these barriers?
Dr. Evans. Well, I think that any attempt to create more
culturally competent services is going to help people feel like
the person on the other side of the door is going to be
responsive.
One of the things that I think Congress should really
consider is increasing the Mental Health Block Grant, and that
is because you have much more flexibility within the block
grant than you do in the Medicaid program, which is the other
major funder of mental health services in our public system.
And so I think that the block grant really gives each State
the ability to have flexible services that are geared towards
the unique cultural groups within their States.
Ms. Blunt Rochester. Thank you. Thank you, Dr. Evans.
Dr. Geller, I have run out of time, and so I will yield
back to the chairwoman.
Ms. Eshoo. I thank the gentlewoman. She yields back.
A pleasure to recognize the gentleman from Ohio, Mr.
Johnson, for his 5 minutes of questions.
Mr. Johnson. Well, thank you, Madam Chairwoman, especially
for giving me the opportunity to waive on today and to speak in
favor of legislation that our Health Subcommittee is
considering and to----
Ms. Eshoo. You are always welcome to waive on.
Mr. Johnson. Well, thank you very much. I appreciate it. I
know my friend Doris Matsui and I worked very, very closely
together on issues that are important to the Health
Subcommittee, and I am proud that today we are going to be
talking about one of those.
You know, even in normal times without a global pandemic
raging around us, many of our fellow Americans suffer from
severe anxiety, depression, and substance use disorders.
Unfortunately, as we have heard in the testimony today, all of
the evidence is pointing to the fact that COVID-19 is severely
exacerbating these problems.
I think the experts here today would all agree that to
fight this problem effectively, it is imperative that patients
keep their regular mental health treatment schedule.
Fortunately, Congress gave the Trump administration temporary
authority to waive burdensome restrictions on accessing
telemental health from the safety of their home.
Telehealth has proven to be a convenient, effective, and
popular technology with the American people. The COVID-19
pandemic will end at some point and when it does what we will
do with telehealth services, that is still a big question. Will
patients and providers now taking advantage of this convenient
new service be left in the lurch?
You all might remember last Congress the passage of the
SUPPORT Act, wide-ranging legislation to combat America's
opioid crisis. This bipartisan legislation, which many of us
worked closely on, was overwhelmingly passed on the floor and
included provisions to waive restrictions for Medicare
beneficiaries seeking to use telehealth treatment for substance
use disorders and co-occurring mental health needs.
If we all can support telemental health for those with a
substance abuse problem and psychological issues along with the
substance abuse, there is no logical reason why we can't finish
what we started and make this care available to those with
standalone mental health needs as well.
This is why it is time to pass the Telemental Health
Expansion Act which I introduced, as I mentioned, with
Congresswoman Doris Matsui. This bipartisan legislation will
ensure that Medicare beneficiaries can access mental
healthcare, regardless of where they live or where they are
able to travel.
So, Dr. Geller, just a couple of quick questions. Let me
start with you and thank you for your support of this
legislation. And, Dr. Evans, feel free to chime in here as
well.
In your experience and in the experience of your members,
can you quickly walk us through the consequences if someone who
is suffering from mental health issues or a substance use
disorder undergoing regular therapy visits suddenly stops
showing up? Can these individuals regress from the progress
that they have made?
Dr. Geller. Absolutely, that is a high risk. Other risks
that go along with that regression are for people with
medications. If they abruptly stop those medications, there can
be dire consequences, life-threatening consequences, and that
contributes to an increased rate of suicide. So I, as I said
before, strongly support your bill.
Another thing that actually nobody has mentioned today is
many of you come from States where in the winter you can't get
there from here. This then doesn't mean that people miss their
appointments because it doesn't depend upon their using
transportation to get to those appointments.
The difference I think is spoken by our members, who, as I
said before, 64 percent had never used telehealth before COVID-
19, 85 percent are seeing three-quarters of their patients that
way now, and there has been very little negative feedback.
Mr. Johnson. OK. Well, you know, as I mentioned, we have
made some progress, but it is well-known that mental health
problems and drug addiction can be related, especially during
the stress of a global pandemic like we are in now.
If an individual in need of psychiatric care can get access
to effective treatment, perhaps through telehealth, could this
help to prevent them from developing problems with substance
abuse disorder in the future?
Dr. Geller. Absolutely. It can prevent them from, as
somebody alluded to before, self-medication. That is one of the
hypotheses for increase in substance use. That is, I can't get
the services I need, so I resort to drugs and alcohol.
It also can affect people who are being treated for
substances in terms of increasing their use of substances
despite the treatment. So for both those populations it is
extremely important.
Mr. Johnson. Well, thank you.
Madam Chairwoman, I have exceeded my time and I thank you
for your indulgence. I yield back.
Ms. Eshoo. Thank you, Mr. Johnson. And the gentleman yields
back.
It is a pleasure to recognize the gentleman from Illinois,
Mr. Rush, for your 5 minutes of questions.
Mr. Rush. Thank you, Madam Chair. This has been a very,
very important and powerful hearing that you are having.
And, Madam Chair, this is something that is personal with
me in a number of different ways. I have my oldest grandson
right now reported to a hospital in Atlanta, Georgia, for a
psychiatric evaluation, and I am praying that he can get the
help that he desperately needs even as we speak.
Ms. Eshoo. Well, he resides in all of our prayers.
Certainly, mine are with him.
Mr. Rush. And, Madam Chair, I am looking at it from the
legislative approach, and I have some broader questions that I
want to ask.
Dr. Evans, let me ask you, how would you regard
macroaggression and microaggression that is associated with
racism for accounting for the undiagnosed and untreated mental
health status of African American communities in this Nation?
And if you would also include your views on how does the White
superiority complex contribute to the PTSD of racial and gender
minorities in the U.S.?
And I just want you to address these issues because our
Nation right now is tiptoeing through the subject of racism and
how it has completely made life almost unbearable for a
significant segment of our society.
And I think that these are issues that we just can't ignore
and these are issues that are front and center.
So can you address some answers, your views on my
questions?
Dr. Evans. Sure. And I think your framing of it is exactly
right, that we can no longer ignore that racism has an impact
on the mental health of African Americans. I think one of the
things that has been hopeful about the recent dialogue is that
we don't have to continue to make the case that racism has a
psychological impact.
There are a number of scholars in psychology who have
documented what is called race-based traumatic stress. That is
the daily stressors that happen to African Americans and other
people of color, based on their race.
And I want to give you a quick anecdote. Recently, after
some of the protests, I casually mentioned that I had been
stopped by police. I have been patted down. My car has been
searched. I have been followed. And my colleagues were
surprised by that. They had no idea that any African American
man of my age has had that experience.
Almost it is a universal experience. And those daily kinds
of experiences that people face have a cost, and that cost is
in terms of stress.
We do an annual survey, and our survey indicated just in
one month alone that we saw a 15 percent increase in the stress
that African Americans were experiencing after the--and,
actually, this was right before the George Floyd death.
So it is really important that as we are looking at the
broader social issues around racism that we understand that
there is a psychological and a physical impact that we also
have to address.
Dr. Geller. Could I address that just quickly?
Mr. Rush. Absolutely.
Dr. Geller. Racism is a mental health problem for
everybody, not just Black folks. And if we are going to change
that, White folks have to understand that it has negative
consequences to their mental health and they need to do
something about that.
Mr. Rush. Right. I mean, I absolutely agree. Stress is
pandemic. It is felt in the African American community. The
White citizen, White folks have to understand that their
privilege and the maintenance of their privilege, their power,
and their status also carries with it an enormous amount of
stress.
And also the fact that they can look and see other American
citizens who are denied the opportunity for freedom and justice
and equality, and that also creates stress in the White
communities.
Madam Chairwoman, I think my time might be up, but if I
have time for one final question, I would like to ask this
final question: I am familiar with the writings and the
thoughts of the French psychiatrist Dr. Frantz Fanon. And I
don't know whether or not his conclusions or his methodology or
his views are pertinent to our current congressional condition
here and psychosis here in America.
Are either of you familiar with the writings of Dr. Frantz
Fanon, and do you think that any of his work is appropriate for
discussion, at least here today in contemporary America?
Ms. Eshoo. Excuse me. The Chair would just ask that you be
very succinct, because it is a minute and a half past the
gentleman's time. Please answer.
Dr. Geller. Frantz Fanon had a significant effect on
Chester Pierce. Chester Pierce is the psychiatrist who actually
came up with the concept of microaggression. So he lives today.
Mr. Rush. Thank you. Thank you very much.
Thank you, Madam Chair. I yield back.
Ms. Eshoo. The gentleman yields back.
The Chair is pleased to welcome back to our subcommittee,
waiving on, Ms. Schakowsky from Illinois. You are recognized
for 5 minutes.
Ms. Schakowsky. Well, thank you so much, Madam Chair, for
allowing me to participate today.
I wanted to first give a big shout-out to my dear, dear
friend Patrick Kennedy. You know, I think that--are you still
here, Patrick?
Mr. Kennedy. Yes, I am here. Great to see you too, Jan.
Ms. Schakowsky. Great to see you.
I just want to acknowledge the fact that I think you have
had such an important role not only in conveying proper
information, but eliminating stigma, which is still the curse
of mental health in many ways. And because of that, thank you
for saving lives. I know that there are thousands of people who
are willing to accept and feel good about getting the help they
need. So let me move on.
By 2030, the number of psychiatrists in the United States
is projected to decline by 20 percent from 2017 levels. And
that is why I first introduced the Medicare Mental Health
Access Act in the 111th Congress, which would allow
psychologists to utilize their full scope of practice. And now
Judy Chu, Congresswoman Chu and I are cosponsoring H.R. 884,
which would do just that.
And though older Americans have a higher rate of
psychotropic drug use, they are also less likely to receive any
care from a psychiatrist. In my district, I want to give a
shout-out to Dr. Kenneth Finns, a psychologist from my hometown
of Chicago who runs a group practice that provides
psychological services to residents of nursing homes throughout
the Chicago area. So much needed now.
But, Dr. Evans, I want to ask you this: Do you believe that
expanding Medicare's statutory definition of physician to
include psychologist would enhance the availability of help for
the patients that need it?
Dr. Evans. Yes, I do. And I am so appreciative and we are
so appreciative of your support of this legislation.
I want to address some misinformation that we have heard
here today. The legislation does not try to redefine
psychologist as physicians. Psychologists are not interested in
that. What psychologists are interested in is being able to
practice to the full extent of their training and their
licensure without administrative barriers.
I find it ironic that at this hearing, where we have talked
about needless administrative burdens, requiring people to jump
through hoops to get services, that we would have this as an
issue. The reality is that the Medicare program is the only
payer, the only payer that does this, not Medicaid, not
TRICARE, not the VA, not any private payer.
Requiring psychologists to have to go through a
psychiatrist to get to provide services is just unconscionable
at a time when our seniors are isolated. They are experiencing
anxiety. They need direct services.
And I will just leave you with this: I got correspondence
from psychologists who have experienced those barriers, where a
physician told a psychologist who was waiting to be able to
provide services, waiting for an order from a physician, he was
told to his face, the psychiatrist said to his face, I don't
believe in psychotherapy, I am not going to provide that order.
That is unconscionable, and we cannot allow those kind of
barriers in 2020 to continue to exist. It doesn't exist in any
other programs. And we should not discriminate against seniors
in the Medicare program, who should get these services just
like they would if they were in private insurance, the VA, or
any other place.
Ms. Schakowsky. I am going to tell you I couldn't agree
with you more, especially at a time when we need more, not
fewer providers for these services, and particularly our
seniors but really everyone. And all psychologists should be
able to practice to the full scope of their licensing.
And finally, let me just ask, Madam Chair, I ask unanimous
consent to enter a letter into the record from Rosecrance, a
large and well-respected behavioral health provider serving my
district that is, unfortunately, looking at laying off staff
and closing programs.
We need to help organizations like this, and we need to
allow psychologists finally to be able to do the qualified work
that they do.
So, with that, I yield back. Thank you.
Ms. Eshoo. I thank the gentlewoman. And on your unanimous
consent request, the Chair announced earlier that all of the
requests will be taken up en bloc at the end of the hearing. We
have I think at least 70, so yours will be included in that.
Now it is a pleasure to recognize another wonderfully
important member from the full committee who is waiving on
today. The gentleman from New York and a good friend, an
important legislator, Mr. Tonko, you are recognized for 5
minutes. You need to unmute.
Mr. Tonko. Can you hear me?
Ms. Eshoo. Yes.
Mr. Tonko. Thank you, Madam Chair, and thank you for
allowing me to waive on and for your hosting this very
important discussion.
I thank you to all of our witnesses that have joined us
today. It is always good to have our friends from the mental
health community joining us. And to my former colleague and
friend, Representative Patrick Kennedy, welcome home.
With the COVID-19 crisis and the associated economic
downturn, we are really facing enormous challenges when it
comes to our Nation's mental health. The threat of coronavirus
has instilled in so many of us an unprecedented feeling of fear
and anxiety. For those living with a mental illness or mental
health condition, this stress must be magnified, I have got to
believe.
So we also know that dislocation and social isolation are
key risk factors for substance use. Despite the heroic efforts
of those in the treatment and recovery communities during this
time, we know that many will become disconnected from support
systems that help them stay on the path of recovery.
And as we work to tackle these multiple public health
crises, we must ensure that we have the knowledge base needed
to understand the scope of the challenge before us, which is
why I authored H.R. 6645, the COVID-19 Mental Health Research
Act.
This legislation would authorize $100 million annually over
the next five years for the National Institute of Mental Health
to study the impact of COVID-19 pandemic and the impact that it
has had on the mental health of Americans and in particular
frontline healthcare providers.
So, Dr. Geller, can you speak to why the COVID-19 pandemic
presents unique mental health challenges and why such a
research program would be useful in helping to calibrate our
response?
Dr. Geller. Well, it is unique because we have not only an
infectious pandemic, we have a mental health pandemic.
You can't fix a problem if you don't know what the problem
is. So the research that you are proposing being funded, which
APA highly supports, would answer such questions as: Well, we
know that there is a disproportionate rate of COVID in African
Americans. We know there is a disproportionate rate of COVID in
Hispanics. But we also know there is a disproportionate rate of
COVID in poor people. So we need research to figure out: Well,
what degree is poverty accounting for this? And what degree is
the fact that African Americans have sickle cell anemia
accounting for this?
So if we are going to fix the problem, we have to
understand the problem, and your bill will help us understand
the problem.
Mr. Tonko. Thank you.
Dr. Evans, H.R. 6645 specifically requires the National
Institute of Mental Health to examine the mental health impact
that COVID has had on populations that have traditionally been
underserved by mental health services.
Can you speak specifically as to why this is an important
topic to study and generally how the needs of underserved
populations might be different from the populations at large?
Dr. Evans. Sure. So I have been doing research for 30
years, and I am trained in experimental psychology. And I will
tell you that one of the big challenges with a lot of research
and one of the hallmarks of good research is that you don't
generalize the populations on which you have not done the
research.
And the problem that we have in our country is that we
don't always have robust samples that include all of the
populations that we are talking about that are at greater risk
for some of these conditions. So that is number one, that we do
that.
It is also important to have researchers who are from the
communities that are being researched, understand those
communities, one, so that they can design studies that are
going to be more accurate, but also so that they can do the
proper interpretation of that data.
And, finally, I just want to give props to NIMH because
they are doing this kind of disparities research. It is
something that we need.
And one thing that I would add to the kind of research that
they are doing is to do much more clinical services research,
implementation research that is closer to where services are
being delivered. Establishing something in the lab is one
thing, or in a study, but what we really need are studies set
in real world settings, understanding some of the
implementation issues, and making sure that we can take the
science that we have spent money on and accurately translate it
into real world settings.
Mr. Tonko. Thank you.
And, Congressman Kennedy, in May the Census Bureau reported
that more than one-third of Americans are now self-reporting
signs of anxiety or depression, representing a huge jump from
pre-pandemic numbers.
What do these figures mean to you? And what consequences do
you think we will see in American society in the years to come
as a result?
Mr. Kennedy. Thank you, Paul, and thank you for your
leadership both in the State legislature in New York before you
came to Congress and then carrying that on in Congress.
I can't help but think a huge uptick in the prescribing of
benzodiazepines, coupled with huge increases in alcohol
consumption, and then, of course, coupled with the new
commercialization of marijuana, that we don't have a kind of
major tsunami of addiction that we are creating right now that
is not going to be fully realized for another few years.
We are still reeling from the opioid crisis, which we never
quite got our arms around. And I am just thinking that we are
adding fuel to the fire here and that we should be very mindful
of the fact that this is going to get, as we are discussing
today, a much bigger public health crisis going down the road.
Mr. Tonko. Thank you.
Thank you very much, Madam Chair. Thank you for your
leadership. And I yield back.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize the gentleman from
California, Mr. Peters. And welcome. You are part of the
committee. It is wonderful to have you with us today. So 5
minutes for your questions.
Mr. Peters. Thanks very much, Madam Chairman, and thanks
very much for having this important hearing today considering
critical bills to improve Americans' mental health. The hearing
is so important, I think, as other members have mentioned,
especially now when the coronavirus is taking a mental and
emotional toll on every single American.
So I am thankful and grateful that my bipartisan bill, the
Suicide Training and Awareness Nationally Delivered for
Universal Prevention Act, or the STANDUP Act, is included in
today's hearing. And I want to thank Mr. Bilirakis for co-
introducing this bill with me, which will help combat youth
suicide.
Since 2010, suicide has been the second-leading cause of
death among youth, young people between the ages of 10 and 24.
A study published in October 2019 found that adolescent suicide
rates for young people age 12 to 19 increased by 87 percent
from 2007 to 2017--87 percent just in one decade.
This concerning rise in youth suicide, coupled with other
senseless deaths due to shootings and acts of violence in
schools, points to a serious public health crisis that existed
long before the COVID-19 pandemic.
Now, there is no question that COVID-19 will influence the
mental health of our Nation's children. Students have been
separated from their friends, classes are moving online, and
many young people see that the future is uncertain. These
turbulent circumstances exacerbate stressors linked to mental
health challenges and heighten risk of suicide.
Adolescent suicide and violence against others is
preventable. Seventy percent of people who die by suicide tell
someone their plans or demonstrate warning signs. And 80
percent of school shooters tell someone their plans prior to
acting. However, youth and adults need to recognize the warning
signs and know how they can intervene.
Trainings help educate and empower students to know the
signs of suicidal ideation in themselves and their peers and
connect them to the care that they need. The STANDUP Act would
do just that. It is supported by Sandy Hook Promise. And this
bill would require States, public schools, and Tribes to
implement commonsense, evidence-based policies to prevent
suicides in order to receive Project AWARE grants, which
promote youth mental health awareness among schools and
communities. We have to prioritize early prevention, heed
warning signs, and give educators and administrators the tools
to stop violence before it happens.
I visited Bernardo Heights Middle School last November in
my district for a Sandy Hook Promise student and administrator
training which displayed how the STANDUP Act would be
implemented and why it is so important we give students the
tools they need to help peers that may be struggling.
In addition to Sandy Hook Promise, the STANDUP Act is
backed by over 50 organizations, including all of the witnesses
here today--thank you very much--the American Foundation for
Suicide Prevention, and the National Association of School
Psychologists.
Ms. Chairman, I would add a letter of record in support
from these organizations to your list of things for the record
to be considered later.
Ms. Eshoo. Yes, and it will be en banc with the other
unanimous consent requests for the gentleman.
Mr. Peters. I want to thank my fellow committee members
Tonko, Schrader, Soto, Upton, DeGette, Matsui, Doyle, and
Kuster for supporting this bill.
Just some brief questions for Ms. Gross, who I want to
thank for speaking on behalf of students today.
You mentioned that you are trained as a Save Promise Club
Member to help identify those warning signs, talking to your
peers, talk to a trusted adult. My question is, does your
school provide any type of suicide prevention or mental health
prevention training for all students in your school outside of
the SAVE Promise Club? And if not, how do you think your school
could train all students?
Ms. Gross. Thank you. And I do want to thank you for
leading this act. I think it is so important for youth today.
So my school actually does not lead or have any programs
that focus on our well-being or offer students any help outside
of school. So that leaves a lot of students who have to go out
on their own and go to seek help. And that can be hard for a
lot of people, especially when you have to travel two hours to
go seek help.
So one way I think they could do this is simply by taking
just a little bit of time, like at the beginning of the school
year, how a lot of times we do career training or something
similar to that, introductions to your classes and things like
that, just take a little bit of that time and just teach people
how to help others. I think that would be most effective.
Mr. Peters. And you mentioned that students are struggling
during COVID. Can you just talk a little bit more what it is
like to be a high school student with classes going virtual and
the challenges you have seen your classmates struggle with? And
I don't have very much time, so maybe you could be a little bit
brief.
Ms. Gross. Right. For me, I have trouble focusing outside
of the classroom. I know it is particularly hard for seniors
because they don't get a prom, they don't get to graduate and
throw their caps in the air and be excited with the people that
they have spent all four years with. So that is something they
are really missing out on.
So I think that the STANDUP Act and getting mental health
professionals in schools that students can rely on and get them
access to what they need will most definitely allow kids to
cope with these hard times.
Mr. Peters. Great. Thank you very much.
Thanks for being here, everyone.
And, Ms. Eshoo, thank you very much for your leadership,
and I yield back.
Ms. Eshoo. The gentleman's time has expired. And I think we
are nearing the end of our hearing.
Last but not least, the very gentle man from Arizona, Mr.
O'Halleran.
Thank you for joining us today, waiving on. And you have 5
minutes to question.
Mr. O'Halleran. Thank you, Madam Chair.
Ms. Eshoo. There you are.
Mr. O'Halleran. Thank you. I appreciate the opportunity to
waive on to the committee and on this critical issue. I worked
on parity when I was in the legislature for year after year
after year. I am still sad to see that it is not being
addressed in the appropriate way.
I also--
Ms. Eshoo. We changed that.
Mr. O'Halleran. Yes.
COVID-19 has exposed something that those of us living in
rural America have known for a long time. We have a shortage of
psychiatrists, psychologists, therapists, and other important
mental professionals and support groups.
Telehealth can help, but broadband speeds are still too
slow in many parts of my district, and in many cases telehealth
cannot fully replace the ability for patients to see each other
with their provider.
According to the Rural Health Information Hub, supported by
HHS and HRSA, 14 of the 15 counties in Arizona are designated a
shortage area for mental health professionals. This is not a
new issue.
This shortage is despite rural America having a higher
prevalence of mental health issues, including substance abuse
disorders, in urban areas. There are high levels of poverty,
food insecurity. And over time, people suffer in silence and
lack of providers makes the early intervention in people's
mental health more challenging. And this pandemic is going to
leave a footprint into the future.
The issues on Tribal lands are even more stark. In fact,
for young Americans, Indian and Alaska Native people, ages 15
to 34, the youth suicide rate is 1.5 times higher than the
national average. There are Tribal communities where that rate
is ten times the national average.
For this reason, I helped lead H.R. 1191, the Native
American Suicide Prevention Act. This bill ensures that States
work with Tribes and Native American organizations to ensure
that statewide suicide prevention programs are actually as
culturally sensitive and effective as possible. This
legislation I hope this committee considers in the future.
As I mentioned earlier, rural areas have higher rates of
suicide, higher rates of mental health issues, and higher rates
of substance use disorder.
Dr. Evans and Dr. Geller, we have talked about these
problems throughout the hearing, throughout decades, but in
your opinion, how do we best ensure providers practice in these
rural and Tribal areas? What can Congress, the administration,
and even the medical community itself do to help solve these
problems?
Dr. Evans. Well, I think a few things. One is we are
partnering with SAMHSA to train providers on the unique issues
of people in rural communities. Just like different ethnic
groups have a culture, there is a culture, a different cultural
perspective for people who live in rural areas, and mental
health professionals need to know how to work with those
communities.
I spent some time last year with Farm Aid, and one of the
things that many people don't actually recognize is that
farmers are experiencing a significant crisis, unlike any
crisis that we have seen, and they have much higher suicide
rates.
So I think we have to pay attention, and your legislation
does that. But I also think we have to remove administrative
barriers that make it hard for practitioners to practice in
those areas, and we have to make sure that people have the
incentives, the financial incentives.
That is one of the reasons that we are very supportive of
884, which provides financial incentives for psychologists to
work in these underserved areas, not only in rural America but
in underserved communities in urban areas and suburban areas as
well.
Mr. O'Halleran. Doctor, thank you very much.
And, Dr. Geller, I am going to send you questions.
And, Madam Chair, I yield.
Ms. Eshoo. The gentleman yields back, and we thank him for
joining us.
Are there any other members that have joined us that were
not recognized earlier? Not seeing or hearing anyone.
For the benefit of the members, I want to remind them that
pursuant to committee rules, each member has 10 business days
to submit additional questions for the record to be answered by
the witnesses.
To the witnesses, I ask that you respond as promptly as
possible to any questions that are submitted to you.
I want to thank each one of the witnesses. Let me start
with the youngest.
And, Arriana, you have just hit the ball out of the park.
You have really explained to us exactly the way it is on the
ground in your time, in your life, and that of your peers. We
have learned a great deal from you, and we are going to build
on it and use your testimony to improve the system for young
people across our country.
Dear Patrick, dear Patrick, I don't know if you can see
behind me, but dad's portrait is right here with me, and he is
with me every day. And I think that he--he has always been
proud of you, but today exceedingly proud of you. You have
given us testimony both from the outside, understanding how the
inside works. And so what you have said, what you have shared
with us is invaluable.
Thank you for raising the point about the Green Berets.
Very few people think that the Green Berets would ever need
any--have any issues relative to mental health. So this expands
across humanity, across humanity.
A friend of mine just alerted me to something last evening,
and that is that there is going to be a powerful and revealing
documentary on HBO entitled "The Weight of Gold." And that
documentary is going to explore the mental health challenges
with deeply personal details about Olympic sports figures.
Now, who would have thought of that? But when you mentioned
the Green Berets, I thought of this that I just learned about
last evening. I want to acknowledge one of the executive
directors, Michael O'Hara Lynch, for advising me of that.
And we are going to take what you have given to us,
Patrick. And really bless you for spending well over--each one
of you--over 4 hours with us. This is one of the longest
hearings the subcommittee, I think, has ever had, at least
since I have been chair. But every second, every second has
been really 18-carat gold because we have learned from you, and
we are going to build on it.
So, Patrick, you are always welcome to be with us, and we
are especially grateful to you today.
To both of the doctors, you have given us magnificent
testimony, not only your years of experience, which is on full
display, but also your depth and breadth of knowledge, because
you practice medicine. And so you see it and you feel it and
you treat it firsthand.
To Dr. Evans, thank you for going even layers deeper to
demonstrate the curse of racism and the toll it takes on the
entire human being. And we will certainly be taking all of that
into consideration with the bills that have been written by
members.
So to the four witnesses, you have broadened and enhanced
our thinking, I think you have been highly instructive to the
American people today that have listened and have watched. And
I would ask that--I know that you will keep yourselves
available so that in the interim period, as we are looking to
mark these bills up, that any additional advice that members
may have, that they be able to access that from you because you
have just been so outstanding.
I will just end on this note, and it was one of the things
that I said in my opening statement, that with the enormous
challenges, I mean, just extraordinary, breathtaking challenges
our country has today, I think that we need to view them as
opportunities. That we can right the wrongs in our society,
that we can address the full health of all Americans, and that
when we do that, that we are saying that there really is
justice for all.
And that, finally, I think that when we are called and
judged that we will be judged on how we cared for each other.
And I think more than anything else, that is what the hearing
was about today.
So I thank each one of you.
I would like to ask the ranking member if he will join in a
unanimous consent request, because we have 69 documents, Mr.
Griffith, and I don't think you want to hear me go through
every single one of them. They are all important. Every member,
what they have put in, they obviously feel very strongly about,
we want that to be part of the record.
So will you join me in a unanimous consent request to
approve what has been entered for all the documents and entered
into the record.
Mr. Griffith. Yes, ma'am.
[The information appears at the conclusion of the hearing.]
Ms. Eshoo. Oh, that is wonderful. I have got to buy you a
nice ice cream sundae or something for that.
Well, thank you to all of the witnesses. Bless you.
Thank you to the members, your excellent questions, all the
time that you gave us today.
And with that, the Health Subcommittee of the House of
Representatives--oh, G.K.? Do you want to add something G.K.?
Mr. Butterfield. No, I was just saying goodbye to Patrick.
I was going with a wave.
Ms. Eshoo. Oh, I see that Congresswoman Blount Rochester is
still with us, G.K. They are waving, saying thank you.
Thank you. Thank you. It is wonderful to be together. God
bless all of you. God bless our country. May we do the right
thing for it. Bye-bye, everyone. Thank you.
The meeting is now adjourned.
[Whereupon, at 3:18 p.m., the subcommittee was adjourned.]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[all]