Transcripts For CSPAN2 House Hearing On COVID-19 Impact On Mental Health 20240712

And make sure that they get exactly what they need. The chair would like to recognize the gentleman from oregon, mister schrader. Is he available . Not seeing or hearing him. The chair recognizes Mister Kennedy. Mister kennedy available . Not in his chair. Then the chair will recognize thegentleman from New Hampshire , miss custer or five minutes of questions. You need to unmute. 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 weve had a dramatic increase. 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. 83 percent of small and large groups Substance Abuse providers have described what is a Financial Hardship as a result of covid and 48 percent of those providers have had to cancel income generating events while 74 percent have incurred unanticipated expenses including ppe. Across the board we seem an experience of lost billing revenue of 23,000 per organization in just the first threemonths. Though i wanted to focus my questions on some of the conversations that weve been having today including the impact on Substance Use disorders, the Opioid Epidemic has taken a big toll 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 mister burgess talking about Mental Health and Substance Use Disorder Treatment in prisons and jails and i wanted to direct my questions to doctor geller. You had mentioned this in your written testimony. I have legislation but 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 whileincarcerated. Could you comment on that, doctor geller and how that could make a difference in terms of the outcomes and i think the there was also comment about how people are being incarcerated for their Mental Health challenges. I think representative kennedy talkedabout that. So i think thats your state motto, live free or die now has anothermeaning. It means im going to live free of services and im going todie. So it is extremely important. Im personally delighted by the notion that of moving medicaid exemption. I bought a long time we would never solve this problem people cant get funded services because they incarcerated and many times they get incarcerated because they had a psychiatric problem so i think i can makea huge difference. In terms of you also mentioned School Providers and that is something that Congress Needs to attend to because they are really the bedrock of Public Sector Substance Abuse programs, an Entity Health centers are taking care of the disenfranchised population, now having tremendous problems currently because they are not beneficiaries of most of the covid funding thats been coming from the federal government. I wanted to also ask i recently was visited with our , 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. We are very concerned during covid, i chair the task force and Sexual Violence and we recently had a roundtable about the increased incidence of Sexual Assault and during the stayathome order children are at home with a perpetrator or creditor. You have any concerns or how would you go about this as we reopen and again time is short. Just quickly one of the problems we have is circular. I have patience when they get released from jail and they fall into that serious trauma category crimes, go back to jail because its the only place they feel any safety or comfort and thats a huge problem in our society. The new problem that Domestic Abuse is asignificant problem, we have people staying at home together and people afraid to report. People are afraid to be home to report. We have to address that phenomenon and it has not been talked about a great deal. I think you madam chair and i yelled back and i appreciate this hearing and think these are critically important issues for us to address especially now during covid and ideals back. The gentleman yields back and we thank her for her excellent question. I see the Ranking Member has returned, just took his mask off and the chair recognizes my good friend from oregon, mister walden or his five minutes of questions. I appreciate it and i appreciate this urine and encourage our witnesses for the work they do in the schools. Thank you for what you do and its good to see our former colleague here on the screen as well and i appreciate your continued speaking out on these so important issues. Were getting there but not fast enough and theres more to be done and thats part of the question i wanted to direct to you patrick is what is it when you look at these bills and there are obviously some who are on agreement and some are going to work some things out on what are we missing here especially as it relates to data that can better inform us in terms of what else we need to do. I know money is always an issue. We tried to increase funding into our communities like we did the opioid legislation but as you look at these and you know the realities in washington, what are we missing . Thank you. I would say if i had a magic wand i would fully fund the Nurse Family Partnership in this country which would ensure every atrisk mom would be able to get the wraparound services. The payoff of that is so well established that the problem in our Health Insurance system and our society is that we dont often measure the longterm payoff. If its not a quarterly pay off or an annual payoff we really dont see the real value of that in Mental Health early. To the previous question about trauma and really doing the kind of systemic things in societies that could mitigate the impact of trauma so in terms of you know, obviously the parity laws that youve enhanced, i could answer more there but let me go to you. What particularly that could be helpful with. I would do instance of its a front. If i had a magic wand i would say every first instance of schizophrenia we provide coordinated Rapid Response. If you did that you would permanently change that your directory of longterm comorbidities and illnesses due to Mental Illness. In a dramatic way and i see this every day and for the life of me i dont know why as a nation wedo 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 dont know why our general accounting office. If i were you mister chairman i would find a way to have gao or omb come up with some kind of accounting because as you know you dont spend anythingyou cant find offsets for and thats part of the big problem. 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 power per square inch of a solution that these do. I did a town meeting several years ago as part of my district and we were doing this on the opioid issue and some of the Mental Health issues and i know some of the Law Enforcement people made that case. They said we get somebody in, we picked them up because theyre off their meds. We get them into in this case a county jail setting and get them back on theirmeds. They are stable and we know once theyre released 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. Where 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. There there 24 seven onsite and theyve been able to do divergence to keep people out of jail and get them the help that they need. I think thats a focus that seems towork. Thank you for speaking up, thank you for the leadership that you provided. When it comes to kids, what are we quote unquote old people missinghere . I know we miss a lot so ill stipulate that but from your perspective. I think of a lot of what we need is for people to listen. A lot of times what we think and feel are downplayed because they dont know what kids are feeling but i think thats why at least from my perspective coming around and allowing us kids to be able to be the same and Health Professionals who know exactly what were going through and know that kids can go through these types of things to is important and getting to have that and be listened to because like we said we have concerns and we go through a lot so just to have people and listen. I appreciate that and thank you, thanks again for this hearing and i yelled back. The gentleman yields back and we thank him for his excellent questions. Its a pleasure torecognize the gentleman from massachusetts, Mister Joseph kennedy. Thanks for calling this incredibly important hearing. So patrick, ill start with you my friend. You mentioned in your Opening Statement in written form, but i want to have you have the opportunity to remind us how long ago you were able to get the Mental Health parity and Addiction Treatment act and acted . 10 years, over 10 years. 11 and a change i think area. Thats why youre in congress and im not. Time flies, there we go. So 12 years later, there are still insurers not compliant with federallaw. Exactly. So the highlight that the department of labor conducted 187 investigations in fiscal year 2017 and found92 , almost 50 percent of those surveyed were not compliant and in december gao came out with a report saying the department of labor commonly found relations of the parity requirement and recommended evaluating whether or not targeted auditing is an effective treatment for Mental Health parity youre familiar with those . Yes. One of the things that you dont parity treatment act did was contribute plans to provide information on how theyre making Mental Health parity decisions and you have almost 12 years, all should be doing this andhave that information already renovated readily available. I want to turn to doctor geller. Because insurers should be protecting information already should beable to make that Information Available immediately . It should not and they should be required to do so. I know youre not an insurer but if an Insurance Company were to make alterations and togive a false impression of compliance with those parities . Im sorry to say it would not surprise me. So doctor if the health plan is not compliant in providing coverage, you think that should bepublic knowledge . Absolutely. You think it should be proactively publicized to protect current and future enrollees . Absolutely because the enrollee has no capacity to do this on their own. The know how manyhealth plans are in the department of labor alone . I do not. 2. 2 million. So 2. 2 million different plans covered alone. I believe that because of the plans and the fact that these plans have not yet come close to earning our trust, we not only need to have random, robust and immediate but all the Public Disclosures of parity compliance to hold them responsible for parity violations and appoint on this is that as particular patrick articulated before to actually have teeth behind those requirements to allow for that investment to be made up front as we talk about nurses, one of the challenges we have is we dont have the 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 Health in this country are the jails in la and chicago. Talk to the sheriffs in my home state in massachusetts and 98 percent of people that have access to healthcare, 98 percent of people that have Health Care Coverage , you talk to those parents and the people that run our jails and ill tell you 80 to 90 percent of incarcerated individuals on any given night are suffering from Substance Abuse, Mental Health disorders or both and interstate with 98 percent coverage we are so failing people with mental behavior illness so i want to come back to the fact that patrick has worked on this a long time and many of us have on the committee but the Mental Health Transparency Act that would improve Enforcement Authority and increased transparency and have it made available to the public and that public peace is so critical as you said doctor, theres no way patients would possibly be able to get access to this particularly if plans are making that Information Available how can we hold people accountable if theres no remedies . Right on and i think if Congress Responds by actually saying youre not allowed to sell your Health Insurance product anywhere else in our market if you dont adhere to our laws. I mean, imagine a Health Insurer coming in and saying i want to sell into your market, its a lucrative thing for an insurer to sell their product in a given state. Why doesnt the state of a big barrier and say youre 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 and to get out so state legislators and start to end similar laws like that to help provide some accountability and to your point on the numbers, its hard to believe but in your colleagues committee overseeing dll appropriations that only one in inspector, i should correct myself from earlier read 2500 plants and one inspector has to oversee 2500 plants from one inspector so you need to pass your bill you need to have greater money to support enforcement overall and you need to give these days more authority to invoke their own Accountability Measures im making this more public like your legislation calls for. Thank you, madam chair for your flexibility. Its good to see you again and thank you for joining us. The gentleman yields back and we look forward to your legislation becoming law Mister Kennedy and thank you patrick for your, for all of your responses. Were just learning so much from you about what we actually need to do. The chair would now like to recognize the gentleman from florida, mister bill rockett for his five minutes of questions. Thank you madam chair,i appreciate it very much. Im especially appreciative of the police consideration of my few priorities. Hr 41, hr 7293, hr 3165. I also wanted to fly a bill introduced for congressman soto, hr 5473 the enhanced access to support Behavioral Health services act which builds on the support for patients and communities act so to allow medicare and medicaid to reimburse for Behavioral Health services delivered through telehealth. I hope you can consider this great bill in the future madam chair and i also want to say hello to my colleague Patrick Kennedy who always did a great job on these issues. Thanks for being here patrick and including us all in your great advice. Doctor geller this question is for you. Our nation is in the midst of. Do we have an audio problem . Im going to give my computing work off of that, thank you. Okay. We will make a little adjustment for that time. Madam chair. We wont penalize you for the timeout. Thank you. I appreciate it. Ill go ahead and start with doctor geller again. Our nation is in the midst of a suicide crisis as you know and over the past several decades suicide rate is risen sharply increasing 31 percent since 2001. At the same time Emergency Departments which are within our Healthcare System to provide care for people are at risk for suicide have inconsistent protocols for screening and treating highrisk patients and for this reason i introduced hr 4861, the effective suicide screening and assessment an emergency deferment act and this bill will assess hospital Emergency Departments in improving their ability to identify and treat those who may be suicidal. What is the potential impact of covid19 on the risk for suicide and what role can hospitals, especially Emergency Department play in treating individuals who are at risk for suicide. Doctor geller please. The effect of covid on suicide is its substantial and actually multifactorial. One is the response to the individual under stress of potential for infection, another is a grief, loss and depression from people who are losing family members to covid19 and the third which is probably the newest information that we are seeing this recent data from the United Kingdom that theres a direct neuro pathogen effect on some patients from the covid19 that affects their brain that theres an increased risk of stroke and also other presentations so we have three rather distinct ways that covid is affecting suicide. Were not doing something right in this country, of all the countries in the world we are the only one who is seeing an increased rate of suicide, all the other countries are seeing a decreased rate insuicide. I think its 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 a kid shows up with a bunch of broken bones. We need people who when theyre doing the evaluations for whatever reason are paying attention to a suicide risk. We also need to continue a followup and discovery of some of the other bills so people dont get lost and walk out of the emergency room. Thank you very much and mistress, thank you for your money again. Ive seen firsthand the power of diplomacy in our work and Palm Harbor University high school my kids go in my district, last fall and i agree with you that students are equipped and able to prevent all forms of violence. Congressman peters and i affected the recent introduction of hr 2293, developed for universal prevention, the standup act which encourages states, tribes and schools to create policies for student suicide revenge and training utilizing the best practices training and technical assistance. You mentioned that the save furnace club train you on how to notice the signs and talk to your classmates who may be struggling and youve done that. We appreciate it so much. If students like you were trained in your schools and their words clubs, the what do you think you and your classmates would do if they were struggling withMental Health . If youd answer that question id appreciate it. First of all thank you for that question and thankyou for supporting the standup act. I think its so important and in my mind, we could begin to start showing signs that they are going through something but they wouldnt be able to expected because the other kids dont feel comfortable doing that. Might see kids getting in a fight because that is the only way they can get out this aggravation of spore selfharm because they wouldnt have anyone or another student thats going through the same things. They wouldnt have someone to relay that on so you would see like colleges and all that stuff that is put on you just move them closer to this in their lives so i think in my perspective the state act is so important because it allows us to save lives for being there for people and allows students to step in and help and give another hand to something that is so important. Thank you very much and madam chair. We always say we have more time but the gentleman yields back and thank you for those questions. The chair recognizes the gentleman from new york mister engle for his five minutes of questions. Thank you madam chair and thank you chairman alone, chairwoman eschoo for holding todays important hearing on legislation to address ongoing Mental Health crises in the United States. My district which includes westchester has been at the epicenter of the nations rotavirus outreach. This pandemic has taken an untold physical and emotional toll on my constituents. Health officials have reported a surge in covid19 Mental Health problems and doctor edward noted in his written testimony , Text Messages for disaster distress are up 1000 percent in the month of april. It was also a growing concern about rising suicides which before the pandemic had increased by 30 percent in new york state 2000 and nationally where the tent leading cause of death. Doctor geller id like to ask you and you can please explain why the coronavirus pandemic has exacerbated the suicide epidemic. There are several reasons congressman. Is a reaction to a pandemic where people are required to quarantine. People are spending much more time without social support and for people with depression, that increases depressive symptoms. And, you have a generalized feeling of helplessness and a feeling of helplessness is already a key component of depression so we increase depressive symptoms. People dont have contact with family that they have used for support. People are losing family members and they cant 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 didnt previously had it and as i mentioned in my testimony before the newest information is actually getting direct effects of the covid19 on the brain itself which is affecting peoples functioning and also increasing rates of suicide. To help reduce rates of suicide in the United States i offered be effective suicide screening and assessment and Emergency Department act with congressman larocco so its bipartisan. Studies show that as many as 11 percent of all Patients Living in the Emergency Department are at risk of suicide. Her only a fraction of these at risk patients are ever identified. This Bipartisan Legislation to provide 100 million over five years to help Emergency Departments improve the identification, assessment and treatment of patients at risk of suicide. Madam chairwoman i asked for unanimous consent to submit into the record and letter of support from 48 advocacy groups in support of our legislation. I think the gentleman for his request and we will take up all of this in the consent request at the end of todays hearing. Thank you, doctor edmonds in your written testimony you called the nations rising rate of suicide a pandemic area since the nations Emergency Department accounts for close to 50 percent of all Patients Health care visits each year do you support a more focused third on identifying and treating patients at risk for suicide while they are still in the Emergency Department such as the approach regarding an hr 46 one . I do and i think its very important. A High Percentage of people who die by suicide and had an emergency room visit within the last year. And when we dont screen people for suicide, we are missing an opportunity to intervene. Ido think though its 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 youre talking about that are one on one we also have to think about a network of resources that are available to people and i mentioned earlier persons having a connection between the Mental Health system and Emergency Departments but its also important to have Crisis Intervention Services that dont require people to actually need to be hospitalized or 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 dont need crutches for being admitted but they can be followed in the community reducing the likelihood theyre going to get into crisis without having a connection to a mentalhealth professional. You madam chairwoman. The gentleman yields back. The chair would now like to recognize doctor bouchon from indiana if hes available. If he is not, we will go to Mister Carter of georgia. You are recognized for five minutes for your questions. Are you there . Okay. Are you on muted . I am on muted now next to the Ranking Member is here holding my hand sure i do everythingcorrectly 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 but and i certainly support the legislation 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 agreeableplace. Ive been a practicing pharmacist for many years and i know firsthand and from personal experience as well but also from professional experience Mental Health is not apartisan issue. Mental health is a very personal issue and a very serious issue that we need to , and not only Mental Health but connection and extremely important and we have to address this in a partisan fashion, in a bipartisan fashion and make sure that we are getting everything right. Im one who feels like the administrations done a fantastic job during the pandemic, especially expanding telehealth. Its been said telehealth has had 10 years expansion in one week and i think thats true. Before this started there were almost 11,000 telehealth visits a week and now its over 1 million per week and telehealth is here to stay and its something weve got to work on. I want to ask doctor evans and doctor geller if i could, both of you wrote in your testimony on this and the administration can do more to build upon the rapid success of telehealth. What specifically can we do to expand telehealth and the patient usage of this service as well and ill start with doctor geller. One is that we can ensure that telehealth includes telephonic services, that is the use of the telephone as ive described before and the second is that we can ensure as i believe has been mentioned previously parity and reimbursement, that there should be no difference if a person comes to an appointment or if a person comes through telehealth and third we should be putting in components to allow for collaborative care through telephonic and other electronic means and as an example the coronary care with a primary physician and thats a vital service, all those things would make quite significant differences as compared to what we had before. If i could ask you, one of the things about 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 . It can provide services to people who otherwise would not receive them and i think one of those 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 laws within the state and there are a few exceptions to that but 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 way to solve the problem in rural and run to your parts of the country is to allow providers who are licensed to work across those statelines. One of the things we working on at the american Ecological Association and its essential for this to address him of the disparities that we see. Thank you doctor evans and congressman kennedy i want to ask you as i said earlier as a practicingpharmacist and also as a pharmacist legislator , and the Georgia State senate in 2009 i sponsored legislation created are Prescription Drug Monitoring Program im concerned about opioid abuse and i think weve done a good job of managing our prescriptions but the lasting effects are still there and what weve seen is that just recently in the last year weve had Overdose Deaths have gone up 11 percent. They gone up 11 percent with everything weve done in the way of addiction and thats something thats concerning to me and i wanted to ask you how do you think we can utilize telehealth to help us with, to treat this and to treat addiction and how can it, how can we encourage dividers and patients to seek out treatment through telehealth . Thank you for your question punishment as a pharmacist addiction is addiction is addiction. It could be opioids today but it could be benzodiazepine tomorrow and one of the impacts of, weve never talked about in this hearing so far as benzodiazepine bricks have gone up over 30 percent since covid hit so not only has Alcohol Consumption far surpassed even high rates but now we have this so as a pharmacist youre seeing the full scope of what people are prescribed. Thats crucial data and so we narrowed it to opioids because it was the quote, Opioid Crisis but as we know its really an addiction crisis where opioids are one thing but it can also include any number of other drugs that can also get people in trouble. So thank you so much congressman. Its great youre serving as someone with the experience that youre bringing to this effort and keep asking these importantquestions. Telehealth and definitely help in a number of ways. Thank you and thank all the panelists and bank madam chair and i yelled back. The gentleman yields back and its a pleasure to recognize our colleague in california Mister Cardin or his five minutes of questions. Thank you very much chair eschoo and Ranking Member burgess, thank you for your expertise and your practical knowledge. We are going through a pandemic and its great for all those families whove been affected and those loved ones who have lost family members and im glad to see legislative solutions to improve dentalhealth today. Ive expressed in sermons in previous hearings about our disjointed Mental Health problems that experts warned are approaching and as Mister Kennedy mentioned there no health not Mental Health. Support for schools is important. All are witnesses identified schools and their an important piece of the puzzle and i was especially glad to hear a student perspective, thank you for being with us today and thank you for sharing your experiences with us. Mister kennedy you mentioned goals around so Emotional Learning and student trauma. How can the federal government for schools with these goals and prevention overall . Iq congressman. At first i would overhaul the way we think of education so that we understand the that there is no education not Mental Health and like we said theres no Mental Health help without Mental Health because how can the body learn literacy when the mind and absorb information of what we understand neural biologically that they are, their prefrontal cortex is inhibited by their makeup and its the domain of doctor geller but ill let him talk about that. The bottom line is we need to get 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 problemsolving 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 the skills as early in life as possible and then we be able to stick with them throughout their education careers. Doctor evans in your written testimony you mentioned challenges and some of my colleagues and i am working on a bill for training support from a Substance Abuse and Mental Health administration standpoint. What type of support from samsung would be beneficial for students right now . Its important to look at schools in a comprehensiveway. Ive worked closely with School Superintendents and the system i was commissioner for and one of the things is to help teachers have the skill sets to recognize when children and youth are having Mental Health problems and challenges. Its a big issue. I also think lamenting evidencebased approaches like School Climate programs that have been shown to reduce not only violence and improve School Climate is important. The kind of services that you heard this grossman talk about and im glad that as a former connecticut person youre proud of her being able to articulate some of the needs of students but you know, not every child needs to see a Mental Health counselor or to get into a Mental Health program. And having people whether they are used and appears or even counselors who are simply giving an opportunity for children to talk to them is important and finally having connections to Mental Healthservices. In my system we actually invented those Services Within schools so that children highlevel Mental Health services there really a range of things ranging from educating teachers all the way to having services that meet the needs of children without more highend needs. Thank you and we dont have time on this discussion about the lack of diversity when it comes to Service Providers whether its Mental Health or physical health and hopefully we can figure out ways in which in this country can encourage you to get young people to get into the mental and physical health space that they can be more of the doctors and the patients there serving. When it comes to education, dont you think its just as important that students identify within each other not just the teachers that identify when a student is detected . If we gave them the knowledge and experience to identify peertopeer, dont you think that would be a good way for us to reduce the incidence of School Counseling . Yes, thanks for the counseling. Thats important because think about it, teachers and 45 minutes to an hour with a student every day. We get that time out of School Working on projects and being with our sons just spending that time so these are people that we have Constant Contact with so what we see out there is important to providing those calls. My time has expired andi yelled back. The gentleman has completed his questions. His doctor bouchon available . I dont see him. Im coming. Im starting my videomadam chairman. Thank you. The gentleman is recognized for his five minutes. I had just another great thing i had to deal with and i thank you for holding this hearing. This is a work we need to be focused on and i think Mental Health sometimes get overlooked. During the midst, ive spoken directly to Mental Health facilities across my district and the increase in challenges and the increase in calls to their helpline, youd be surprised read i talked to 2 to 3 calls aweek on the hotline , there are 20 or 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 two or three months, is once or twice every two or three weeks during the pandemic and i mean, its created a pretty substantial toll. On the Mental Health of our society. Weve also spoken to universities who are left trying to figure out how to provide continuing therapy or outofstatestudents. I wasnt aware of this until i talked to one of my president s of one of my universities and theres a lot more College Students are getting therapy on campus and i think people understand. They should share with me the difference is therapy as on their students and its troubling they cant continue to provide continued care to the students in many cases just because now the students are all over the country area this particular university as people in 50states in foreign countries. These are issues of reimbursement and liability and sometimes technology. As was pointed out in the testimony continued care past the first visit is important. Therefore as we continue to look to improving Mental Health through telehealth its an issue we can work to address. Doctor evans you have any comments maybe on what is happening in universities and the Counseling Services that universities provide to their students and the challenges we might be facing during this pandemic . Weve been seeing a growing trend on College Campuses around the country of increase until health needs and increased students in crisis on campuses and i think the good news is that i think a lot of College Campuses around the country are going to pay more attention to this. Theyre building in services. Theyre building in here services which is an effective way to reach students. I think its also important for us to not only make sure that there are services on campuses but there are active efforts to reduce stigmas so that people will reach outfor help. One of the things that we do a survey each year looking at some of these issues and one of the things that we notice is the Younger Generation is much more likely to reach out for and be open to receiving Mental Health services so thats a good thing but we notice we still have more work to do there in terms of continuing to reduce that stigma so people will reach out for help. What can we do in congress to help facilitate this type of activity . I think its continuing to support efforts to embed Mental Health services on College Campuses. Its also encouraging Innovative Strategies, for example in philadelphia we started to do Mental Health screenings and make them available in the community 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 would not do a diagnosis but it would tell the students 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. Excellent, thank you and doctor geller can you talk briefly because my time is running out about the complexity of managing mental and physical health of patients and what the challenges are there because its usually more complex than we think. Its generally much more complex than we think and as i mentioned briefly before lots of Mental Illnesses present with psychiatric presentation and we have to have the ability to work up to differentiate. We have a clear example of that now as i indicated with Central Nervous systems presentations so somebody shows up with psychosis and their covid19 positive, 14 weeks for them to come back and the psychosis maybe a direct effect of the covid19 infection and there are hundreds of examples of medical presentations that look like psychiatric disorders. I 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 youre not going to get them through their Mental Illness support so thank you with that and i yelled back. The gentleman yields back and i would just saythat you are a doctor for life. We are blessed to have you. The chair now will recognize the gentleman from vermont. For his five minutes of questions. Thank you very much and i want to start with the teleHealth Services. My friend mister partin would say telehealth, its been terrific and i do think the congress and thepresident have done a good job in taking advantage of it. Doctor geller, youve thought a lot about we have, ive had feedback from practitioners that contrary to what i expected, the interactions are often times not only easier but your intimate. One practitioner told me about being able to go on a virtual walk with our client who was in a very rural part of vermont and also happy to be relevant for other members of the family to be able to participate in the call. Can you comment on that effectiveness from establishing that intimate relationship and trusting relationship so essential for a person seeking help and the provider getting help . It works in both directions, theres nothing to be said for being in the same room that ive had lots 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 as a single mom with four kids and sometimes when kids run in and interactions take place we can actually talk about what just took place so you are in the moment with patients and that can make a huge difference. Thank you. Another question i have about Mental Health is ill probably get this wrong but theres some conditions like bipolar, schizophrenia that are chronic acute episodes that require medication that constitute treatment. Theres so much of Mental Health seems to be related to loneliness, depression, erosion of Community Stability like a job, communities getting hollowed out and in one of the challenges we face in congress as we do with our bipartisan commitment to addressing opioids is that it really doesnt, its afterthefact. Its not providing the underpinning of security that folks need in a community of stability and relationships, stability to 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 of you indicated that the suicide levels in europe were significantly below us here. Maybe ill start withyou doctor evans. What youre referring to, what we call our social determinants themselves and we know 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 a job, being under a lot of stress area being homeless. All those things are stresses that can lead to Mental Health challenges. Our field is not done a good job of understanding or at least incorporating into our clinical approaches an understanding of those social determinants and using information to actually help people. I mentioned in my testimony oral testimony the importance of addressing issues like homelessness as a way of actually improving peoples Mental Health. Let me interrupt you there , with respect to that in policy as we are seeing in black lives matter, are we in many cases focusing too much on police as the responders of first resort rather than the kind of Rapid Response team that doctor kennedy said we need when theres a Mental Health issue. After, maybe you could address that. You so much peter and i think obviously when you look at the fact that so many of our jails are filled with people with Mental Illnesses and addictions but clearly a better response and occupying least time would be to make sure that proper First Responder teens are in place who are Mental Health, first aid responders and the like so obviously i hope that 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 a spend more of their time trying to do First Response to overdoses and Mental Health crisis than they do putting out fires the same with police officers. Though most of the cases they get called to may present as a criminal justice issue clearly have a Mental Health act as the root cause. Ill yield back but i want to say thank you to carry on a gross for her excellent testimony. Thank you madam chair. The gentleman yields back and thank you for his excellent questions read the chair is pleased to now recognize the gentleman from oklahoma. Mister mullen for his five minutes of questions. I appreciate you holding this during. Because it is an important issue and its something obviously i have been working on for quite some time darting with the 42 cfr part two which i was glad to see was aligned and put in with the care and so Mister Kennedy, this is a question for you. I know our offices have spoken multiple times about this. I appreciate your insight and feedback taking this on. Your feedback was instrumental and you provided some input in there that i think really helped with your colleagues on the other side of the aisle which this was a bipartisan approach inthe committee. How does this important measurement of aligning part two with the help in the time we find ourselves in especially when we see a Mental Health crisison because of the pandemic . Thank you Mister Mullen and thank you for your leadership on this. I think as we just heard doctor geller talk about the cooccurring of psychiatric symptoms with physical symptoms and conditions and the bottom line is when i go into the er, im going in with covid or Something Else and they dont understand about my underlying psychiatric issues or in the case of addiction, they do not know that i have and someone was suffered from a chronic disease of addiction which has a better chance of killing me and any other illness that i face and thats 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 doesnt ask me about my addiction. Cause its not in my Electronic Medical record. The doctor has a pen, electronic pen these days to prescribe anything that they want and if they do not know that i have a disease of addiction, they are practicing medicine without a license. And thats why i thank you for that 42 cfr because there are hundreds of thousands of my fellow americans who are dying from it because their medical system does not know they have an underlying addiction because it doesnt show in the emr a beentreated for addiction. I just assume you are protecting my legacy with respect to anything else thats supersensitive and sexually transmitted diseases are protected by hippa, id say Mental Health should be protected by an addiction could be affected by hippa as well. This is about protecting Patients Health and thats why its important to have 42 cfr. You have been very passionate about this and it was something that affects all of us area i think in your Opening Statement you said this. Every family is affected by this and in oklahoma weve been devastated by Mental Illness and the opioid and mask issue which a lot of times Mental Illness runs handinhand with that do the cause theyre trying to sell medicaid and in all our families have been devastated by this so i just want to tell you again, i really appreciate it thanks for your insight and your input on that red doctor evans, real quick been an increase of almost 900 percent of Mental Health crisis call the hotlines this year and now more than ever, do you think its appropriate, more appropriate to remove some of the barriers to hitting some of the treatments that could take place or people that are sufferingfrom Mental Illness . Absolutely and i appreciate that question congressman because as you know , youre a supporter of 884 which removes barriers in the Medicaid Program for psychologists. It is a real travesty that in 2020 administrative barriers that prevent people from getting the care that they need. Legislation would allow two things. One is to ensure that seniors who right now are experiencing what personal Health Crisis of our lifetime , have access to psychological care and the second thing is to make sure that psychologists are eligible for reimbursement for the incentive payments to work in some of the rural areas and underserved areas that we thought a lot about in this hearing. Our seniors have a significant Mental Health needs normally. An exorbitant Mental Health needs under this Current Crisis and it is just not right. It is not right to deny them care. When there are ways to remove these uncertain barriers and let me just say that the barriers that we talked about have been removed for podiatrists, they beenremoved for optometrists , or a lot of other doctoral he trained professionals. And the administrative barriers that were talking about our only in the Medicare Program. Theyre not in the ba. Theyre not in child care, theyre not in any private insurance, its 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 where we can remove that barrier and focus on making sure everyone gets the care lady. Thank you doctor evans and appreciate the indulgence and we will yield back. Thank you for your good work Mister Mullen. The gentleman yields that. Pleasure to recognize doctor release from california for his five minutes of questions. 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 and stress levels go up during this pandemic. This march for example the disaster distress helpline supported by the Mental Health Service Administration saw an 891 percent increase in calls impaired 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 Abuse 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 active issues that individuals face. Often times individuals with an acute Mental Health episode sometimes because theres literally nowhere else to go. Then the emergency physician needs to make a decision on either a hold them work 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 treatment or get them the tear care that they need because theres not enough primary care practicing psychiatrist on the community or other Mental Health professionals. The biggest concern is lost to followup. Thats a term that we use when you discharge somebody knowing that they need followon care rather unfortunately because of a systematic problem they are lost to followup. The Emergency Physicians that providers want to findthe appropriate care for their patients before releasing them. They want to have them hand them off directly to the next provider knowing full well that one 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 followup care for their patients like putting in place Transportation Systems to get their patients from the hospital to the Rehab Facility for tracking regional inpatient bed capacities or coordinating with area Mental Health providers in a team entity like approach but they dont always have the resources or capacity to do as much as they want to do. That is why i introduced hr 2519, improving Mental Health access from the Emergency Department act of 2019 create a Grant Program for Emergency Departments to transition their patients into more appropriate care for longerterm. Doctor geller, can you talk about the specific barriers Emergency Departments have to be able to give their patients a warm hand off to their followon care mark. Sure. And as you indicated most Emergency Departments operate likesilos. They have no relationship whatsoever to the service that follows unless those services happen to be within the same hospital as the Emergency Department. So your bill making huge steps forward in that regard. The second piece of this is we dont have enough beds. And that so people sit in emergency rooms. Where they dont belong. For length of time. We had people in emergency room for up to 30 days looking for abed. Why cant we find a bed for the emergency room and mark because we have people in hospitals but we dont have enough beds. Have some people in general hospitals, people can wait six months to get transferred in some states to the Public Sector. We also have jails and prisons built withindividuals because they dont have enough beds. So we need coordinated services and we need funding for that and your bill does an excellent job with that. There needs to be coordinated and adequate number of psychiatric beds. What are some of the barriers the patients face in their discharge for a followon care. Go beyond the lack of beds or locations. And how could a grant help . The grant can help because we are asking people are in distress and may have dependent upon their diagnosis problems with social skills, problems with organization and working your phone number. You followup you a call that phone numberand they get a recording. This will would actually create steps that are going to facilitate the emergency room to make sure theres a warm hand and as you well know, theres nothing more important than a warm hand. You very much. Gentlemens time is expired. Its a pleasure to recognize the gentleman from montana mister jan forte for his five minutes of questions. Chairwoman i appreciate the Committee Hearing today to discuss the decision to improve our Mental Health care system. I appreciate that legislation i introduced withmy friend from virginia mister buyer. Whos included in this hearing. Our bill hr 4585, the campaign to prevent suicide. Our legislation would direct the cdc samsara to conduct a National Suicide prevention education program. This includes advertising for the new 988 number or the National Suicide engine line. 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 mister stewarts legislation to designate 988 as a suicide hotline and mister goes legislation to ensure funding to implement that information and we need to have a shorter number. People need to knowabout it. And in the city resource to those in crisis call and get put on hold or get a busy signal. Mister stewarts legislation is already been voted out of the Communications Subcommittee and i hope hr 4585 and hr 4564 can join in and 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, its more important now than ever. I supported the legislation included in the farm bill to prevent farm suicides and the need to address this in all walks of life is has only grown. People are hurting in montana andacross our nation. We should be able to Work Together to help make the suicide hotline work in this crisis. Madam chair i asked for unanimous consent to enter into the record enters of support or hr 4585 from the American Foundation for Suicide Prevention and Mental Health Liaison Group and vibrant. I want the gentleman to know im going to take up the request for unanimous consent. So thank you. Thank you madam chair. I appreciate we are considering legislation to expand the use of telehealth for Mental Health services so doctor geller, i want to go back to the topic of telehealth. We talked about it a lot today and my home state of montana , frequently ranks among one of the worst states for suicide in our country. We have a population thats mostly rural and its extremely hard to find Mental Health providers for these communities. And you talk specifically about how mental telehealth for mental services, Mental Health versus help fill this gap in Rural America . Absolutely. It can make all the difference. Ive been to montana and i know how long it took me to get from one farm to thenext farm. It makes Services Accessible to anybody no matter where they are and it includes as i said before a telephone component, doesnt matter whether youhave access were not electronically. You can use your telephone. And it also means in terms of both of the issues that you talk 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 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 states, i think we can make a significant inroad and as a footnote, every major, every state should have places across the state that are billboards that say what number that is and what its purpose is. Thank you doctor geller. What additional steps, doctor evans mentioned earlier missing across state lines but for both of gentleman additional steps we need to make sure that we can get quality Mental Health services into a Rural America. I think the legislation that 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 an interstate compact to allow people to abort but we also need to make sure that providers are there to provide those services and the legislation that youre supporting 84 does that and we appreciate that. Doctor geller comment briefly on that point as well and mark. Im sorry, go ahead doctor geller. I think we have to have more opportunities or medical education, more attention to deploying people, to underserved areas area i think if i go to an underserved area in montana i can get loan forgiveness and if i can respectively disagree, i do not believe that returning psychologists position is going to increase access theres some ways in which its potentially dangerous, for example ecologists wanting a partial Hospital Program is i think insurers. Thank you madam chair and i go back. The gentleman yields back and thank him for his excellent question. The gentleman from michigan. Miss nagel is recognized for her five minutes of questions. I want to thank all the members for their patients. Were living in a new era, everything takes more time. I cant help but think that todays hearing is some of the best time spent but it still takes patience on the part of numbers so i all of you. The gentleman is recognized or for five minutes of questions you. Thank you maam chair thank you both for staying so long andanswering us. So we thank you and i think the Ranking Member. This is a subject thats very important to me. And my committee and others here, with respect that the committee 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 wasnt too its wonderful to see him at the beginning theyre talking about, he and i have taught at the department about this and one of the things we havent talked about as much as i thought we might is just quite frankly eliminating the stigma. Its a reality. Too many people are afraid to acknowledge that theres a problem. Like my father was a drug addict at the time that no one ever talk about it. And had a number of 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 ive learned a lot. And at other people, because too many people are still afraid to acknowledge that they have a problem it is in every family. Yes, the tales have people in them that should be getting help and they need Mental Health. They dont need to be referred but there are a lot of people that are sitting in our homes and our jobs that need help that wont acknowledge that they have a problem is theyre afraid someone will say and covid19 has only made it worse. Seniors have told me with already made a decision that if they get covid19, theyre going to die because nobody cares you there just disposable and i deal with a lot of Domestic Violence cases etc. And my Law Enforcement has been doing well this entire period. So we need to be talking about this. And our Mental Health systems are focus. I hate talking about money because when you were talking earlier, i have, we dont have enough psychiatrists going into the psychiatric field. We had an unfortunate one with a College Students at Central Michigan university who needed help and went to the hospital. And there was no doctor available to take care of him. They call his parents to get him. And when his parents came his father was the sheriff and in illinois and he took his fathers gun and shot and killed his own parents there was nobody to help him. There was no bed available. And he and i learned that if only one person had gone into psychiatric residence in michigan. And weve got to, we have to incentivize. Its Something Else i want to talk about down the road but Mister Kennedy, for your longstanding advocacy and all that youve done when youre standing up. Can we talk quickly about what sort of cuts will nonmedicaid state and local Mental Health and Addiction Services face if we dont provide this all needs in these next few weeks . Thank you debbie and by the way, my book is right next to my bed, im so grateful for that book and nice words that your husband mentioned and i loved him and love being scolded by him when i wasnt following the proper rules ofthe house. I know how proud he still is carrying on the tremendous legacy of Public Service sorry for wasting all that time. But thats to say that youre a great person and im so glad youre there and you know, we, the Mental Health but i think we can agree is aboutthe first thing to go. And the reason is because there are a lot of people raising their hands saying that youre a consumer. Unlike if youre a cancer or disease, you dont have the big Cancer Society american heart foundations, god bless the nha but theyll be the first to remind everyone that theyre very well underfunded as an advocacy group. So basically if you have a Mental Illness or addiction are either in jail, in an institution, or youre in a 12 step meetingand youre supposed to remain anonymous. Which means that theres no Public Advocates going on there unfortunately. Im just trying to pay for all your colleagues, very well put debbie that this is the area, the first area thats able to be disposed of because youre not going to see the outcry you will get if you try to get many other areas of state and county funding. Thank you madam chairwoman and im already out of time. You. The gentleman yields back. Its a pleasure to recognize my good friend from illinois, congresswoman susan brooks for her five minutes of questions. Indiana, im sorry. Thank you madam chairwoman and i apologize. Im having some technical difficulties with my wifi youre in my office but i just want to thank the chair for having this really important hearing. I know you and the Ranking Member, youve requested it as well and its important to focus on Mental Health during this time with covid. I appreciate all the panelists who are here and providing us their expertise. In the last congress i lead the additional Law Enforcement Mental Health and wellness act and i think he got that signed into law. Providing more resources for those frontline workers area i want to talk a little bit more time to go back to providing those resources for those frontline workers, particularly the healthcare workers what theyre experiencing. Firefighters, First Responders still who are First Responders who are going to homes and helping people who may be very ill with covid but also particularly those healthcare workers and i think doctor evans or the committee, im sorry doctor geller talk about the stigma of those providers seeking help because of their licensure and because and id like to talk about that a little bit further and doctor geller, what is it that you believe we should do. Because im an attorney. Im often with licenses you have to indicate whether or not you have sought psychiatric help, is it your position we should no longer be having that on applications whether youre going to be a police officer, a lawyer, a doctor, a teacher. How is it that we address that doctor geller. Because i do agree that i do think it keeps people from accessing and it does provide , build on the stigma of accessing services area. So two parts to the answer i think we have had an explosion of the 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. Thats the first part and second part is typically is whats the purpose of that question. Whats the relevance on my Life Insurance application or your licensure application as an attorney to whether or not its ever sought psychiatric treatment. They dont ask me that requisite on the colleges. Theres some concern that impairment and that . To be a broadquestion about impairment. With respect of being impaired because we have a mental disorder its just as easily as we could if it was a psychiatric disorder so i think the question should be changed if we are concerned about impairment that should be the sameacross the spectrum. Psychiatrists, that should not be preclude me from being a doctor or being an attorney but for being a School Janitor or anything else area. Thank you very much. Id like to ask mister gross and thank you so much for sharing one of my high schools in the district of indiana actually created a stigma free club, created by another man with mother very much suffered from the illness and it was all about their education. How might we educate young people around the country about the warnings about increasing the number of tear educators and counselors to get involved at the High School Level and maybe into college. What you think we ought to do . I think that in the beginning of the school year theres often times the size for orientation or getting used to the school and you might even get someCareer Training. Like i feel we could use that time to put in place just a little bit of learning as people can understand how to help their peers because and from my perspective it so important and in order to be a good student you have to have a great Mental Health and i feel like if we dont do things like the standup act we can be failing our students in that regard because the Mental Health of our students is so important to how well they end up doing so as you said before, just a little bit of time, it doesnt even have to be a lot. As long as we can actually have the information they need. To teach them about what their classes are going to be for a little bit of Career Training what theyre doing in the future. Its just that timethat will impact the future. Thank you for your leadership and ideals back madam chairwoman. The gentleman yields back. Its not a pleasure to recognize the gentleman from illinois, missed kelly for her fiveminutes of questions. You madam chair and the ranking for bringing us together to discuss Mental Health issues and i thank all four witnesses for being willing to testify today. A 2003 National Academic study found that even when controlled barriers to care, minority patients have worse Health Outcomes and white patients. The report found that both explicit and implicit racial bias contributed to the Health Outcomes and as we all have heard by now minority communities show a disproportionate number of covid19 cases aand this is compounded by pandemic related shutdowns and layoffs hitting minority communities especially hard because we are the essential workers area the parallel economic and medical crises are recipes for stress, anxiety and grief within the community of color yet too often the same committees lack access tocare and Mental Health services. Evans, how can we address disparities in access to Mental Health care and treatment for committees of color area. We have todo are a number of things. But first one of the things in my role as a commissioner in twodifferent states , its really clear that while we need to make sure that services are funded, we also need to make sure that we were on the committees understanding of the importance of Mental Health. The big mistake we make in the Mental Health system or how we deal with Mental Health is to move from thinking about Mental Health as about themtoo thinking about Mental Health as about us. And that means all of us read and we need to 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 that reduces the stigma that makes it 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 immigrants communities particularly in a Small Community that didnt have to allow 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. And thank you. I would add doctor, the equity in Mental Health act would fund culturally and worsen the upper Mental Health services for undeserved community. We have educational material that correctly on the subject matter. So far, we have deploying personal outside of traditional offices. Besides financial resources, you have to send resources where people who get them. The black man in the community, youve got to have somebody in the box shop. Despite the pandemic, violence continues in my district. The solution in the violence act 2020 includes intimate Partner Violence to stop this crisis. Can you discuss the cycle of violence and Mental Health from trauma victims and reducing the burden of violence and Mental Illness . I am a big gun violence advocate, we have easy access has to contribute to this was lead levels also. Let me commend you for your leadership around cdc, that is a big piece in reducing these disparities. Its really important to have community interruptions to interrupt violence in communities but its also important to connect those efforts with addressing trauma. One of the things that happened and we talk about in my work is that hurt people hurt people. When people are traumatized, they are much more likely to continue the pattern of traumatizing others so a big part of addressing Community Trauma and violence helps reduce both of those when you combine those in your efforts to reduce violence and trauma. Thank you, i am out of time. Take care. A pleasure to recognize the gentleman from ohio. Five minutes of questions. You need to unmute. You need to unmute. Are you unmute it . The gentleman needs to unmute. We cant hear you. Want to use mine . We cant hear you. How do we reach him . We cant hear you. What . There he is. There you are. Can you hear me now . We can hear you now. Having a little technical difficulty here. Sorry about that. Thats right. Youre recognized for five minutes. Before i begin, if i could have unanimous consent to dismiss letters for the record. The chair announced earlier, unanimous consent request at the end of the hearing. Thank you. And today, we are shining a light on the importance of improving Mental Health in our country. Id like to thank you for this hearing. Before i asked my questions, id like to highlight how covid19 has taken a toll on every aspect of our life. Substance abuse disorders and suicide is gone up drastically over the last few months. The Office Released a troubling statistic, drug Overdose Deaths increased 11. 4 in the first four months in 2020. The same period last year. The social repercussions of covid19 have caused stress and anxiety in our communities providing care and assistance to those suffering the most especially during this Global Pandemic. Reading resources improves situations of severity act or the crisis act. It diverts states to utilize them from the Mental Health Crisis Care Services care to individuals experiencing psychiatric episode. I want to thank our witnesses for their attendance today and fa i may begin with doctor, your testimony indicates Mental Health Crisis Services and help those with Mental Illness by eliminating contact with the criminal Justice System by reducing visits to the er. Have introduced legislation to provide resources and states for the Mental Health branch to enhance Crisis Services. How do communities stand to benefit of having more of them . Crisis services take many forms. It can be standing will crisis intervention, they can ride with police officers, they can be involved with diversions from the court. Crisis services, we have known will divert people from higher levels of care and adverting people from higher level of care or allow those levels of care to be available for people who need them. Not only if the individual from getting the crisis service, they can then target people who need higher levels of care. It is extremely important and will highly benefit that population. Wouldnt it also decrease costs for folks in the er they say unfortunately there the first place they bring folks who need care, hijackers died but they cant refer them. Its a double edge sword. It may decrease costs to have people not go to places they dont need but they will do case findings, they would have gotten services but lets say it is neutral and was getting a lot of people to services they need. They will serve more people more effectively without spending more. Thank you. Mr. Kennedy. Suicide Drug Overdose and alcohol use killed more than 180,000 americans in 2018 covid19 increased anxiety or depression for these americans . The number is startling because we are seeing all of the time the number of americans dying as a result of covid. Things are losing as much, if not more to these illnesses and we are not hearing about it at all. The silence is deafening. Covid forces people to stay isolated, removed, disconnected and people who have addiction, they like to isolate so this adds to the prior. Isolation is not good for your Mental Health. Its company coping mechanism for them and its reinforced by the messages getting into society now that says we shouldnt connect with each other so as we seen from the science, it adds enormously to the current number of tragedies. Thank you. Adam chair, thank you for letting me waive on and i yield back. Thank you. Pleasure to recognize fellow californians. Five minutes of questions. [inaudible] just a moment, please. You need to unmute. I think he is unmute it now. The gentlewoman can proceed. I dont want you to lose any time. Thank you for holding this important hearing today. Doctor evans, youve mentioned many things ive been talking about and can relate with. Oftentimes, im somebody says we all have Mental Health issues. The question is to what degree do we have them . To hear you say that today reaffirms what ive seen and experienced throughout my life and across the board. You also talked about the importance of looking at the social determinants of health which is so critical. Represent the community and district we have children who worry about getting shot as opposed to worried about the next School Report thats due and what impact that has on their Mental Health and what those factors have on a child in the importance of loss looking at that. Ive introduce a bill to address social determinants to create a program at the cdc to address the social determinants and create partnerships with local Public Health agencies so they can also address this issue so thank you for bringing that up. We need to have more on Mental Health and every single parts of our life whether its homelessness, certainly not under covid19. We all have family members who have experienced addiction and its here day in and day out. I want to follow up on you with the topic, my colleague who brought this upon the application. I want to share a personal story. When i was in college, i was applying to be an intern in the white house. Remember seeing the application, asking if i had ever seen a Mental Health professional and my father had been terminally ill all of my last ten years, ten years of his life which was me being in college. I remember thinking to myself, as i leave the white house but if i leave and see a Mental Health expert, maybe i cant work in government if i go. Having that thought had me secondguessing whether i should have a seat on any Mental Health services. We heard about his belief we should change the question, you think we should eliminate the question or what you think should be on an application . Ill 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. Why would the green berets, the best of the best have so much to help provided . Our nations military has figured out in order to have the best of the best, all of those theyve 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. Why as a nation, dont we take that same attitude the u. S. Military has taken . Chairman of the joint chief of staff has taken and that is 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. 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, after theyve already paid their dues to society, totally hinders their ability to move on in their life. Same thing with this, we need to eliminate this check the box as well. I think the job youre going for there ought to be criteria and whether you are able to meet that criteria ought to be the criteria, not some question about whether he sought Mental Health. That should not be disqualifying criteria. Thank you. I will followup on other witnesses. Thank you to you. It is now the chair now recognizes a wonderful addition to our committee. Five minutes for your questions. Thank you to the Ranking Member and a special thank you to the witnesses today, this is a crucial hearing, not only our Mental Health issues, a crisis in our country, we couple that with an economic crisis, i come from a state as a Farming Community and we seen suicide rise in the Farming Community to add on to that, covid19 and think about essential workers and frontline workers and stresses and pressures there. But then more recent, the Racial Injustice issues weve been facing as a country and you know this is an important time to have this conversation and to be dealing with it. Their persistent is Mental Health. In 2018, 16 of them africanamerican adults reported having a Mental Illness and in 2017, suicide was the second leading cause of death for African Americans ages 15 24. This was like death rate among black use has been increasing faster than any other racial or ethnic group. I have legislation im working on right now taking a look at the issues of trauma and policing in the Africanamerican Community access to Mental Health. I want to address a question and thank you so much and congratulations on your leadership but also your focus on the arts as well because i think theres a connection between health and arts as well. Your testimony, you said trust me, weve seen and been through more than you realize and we can and want to help. I was wondering if you could talk a bit about two things, if you feel, we talk about the stigma associated with Mental Health and the shame, do you feel your generation is more focused on getting the help they are on the stigma or shame . You feel still a problem . How does social media and the internet contribute to that . Thank you for that question. I definitely do believe im sorry, can you asking again . Do you think theres still the stigma attached to it . If students want help or is there a stigma still there . I can see both. I feel like we need to get away, but the thing is, i feel like sometimes older generations, youre young, you dont know how you feel and sometimes we are like we wont be understood. Our problems will be understood because youve grown up in a unique set of time and the way we understand things is different. From myer peers helping us to this time is important, social media is both good and bad thing. Its where a lot of kids feel comfortable, kids go to their schools and understand their issues because one thing great about our generations, a lot of times there are Strong Communities which we can rely on. So many people ive been able to call on who have supported me when i needed it. Thats why its so important to yes, use social media to kind of see that we are trying to eliminate the stigma so working together to create that bond we can use and achieve what we are here for. Ill put this question and we will followup but how could expanding access to competent care like a chair reduce systematic barriers and what do you recommend congress do to address these . Any attempt for these services will help people feel like the person on the other side of the door is going to be responsive. One of the things i think congress should consider his increasing Mental Health because you have much more flexibility then the Medicaid Program which is the other part of Mental Health. It gives each state the ability to have Flexible Services geared toward the unique cultural then there states. I will yield back to the chairwoman. Pleasure to recognize gentleman from ohio, mr. Johnson for his five minutes of questions. Thank you, madam chairwoman, especially for giving me the opportunity to waive on today and speak in favor of legislation that our subcommittee is considering. Your always welcome to waive on. Thank you very much. I appreciate it. My friend and i work closely together on issues that are important to the subcommittee and im proud today we will talk about one of those, 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. As reported in the testimony today, all of the evidence is pointing to the fact that covid19 is severely exacerbating these problems. Experts here today would all agree to fight this problem effectively, its imperative to keep their regular Mental Health treatment schedules. Fortunately, Congress Gave the Trump Administration temporary authority to waive burdens and restrictions on accessing tele Mental Health from the safety of their home. Telehealth has proven to be a convenient and Popular Technology with the American People. The covid19 pandemic will end and when it does, what we will do with teleHealth Services, thats still a big questions. Theyre not taking advantage of the community services, will it be left in the lurch what you all might remember last congress, the passage of the support act, wide ranging efforts on the Opioid Crisis, this Bipartisan Legislation, which many of us work closely on, was overwhelming passed on the floor and include provisions to waive restrictions for Medicare Beneficiaries seeking to use telehealth treatment for Substance Abuse disorders and co occurring Mental Health needs. If we all can support tele Mental Health for those with a Substance Abuse problem and psychological issues along with the Substance Abuse, theres no logical reason why we cant finish what we started and make this care available to those with standalone Mental Health needs as well. This is why its time to pass the tele Mental Health expansion act, which i introduced this Bipartisan Legislation will ensure Medicare Beneficiaries and access Mental Health care regardless of where they live or where they are able to travel. So a couple of quick questions, me start with you and thank you for your support of this legislation and feel free to chime in. In your experience and the experience of your members, can you walk us through the consequences of someone suffering from Mental Health issues or Substance Use disorder undergoing regular therapy visits suddenly stop showing up . Can these individuals regress from the progress theyve made . Absolutely that is a high risk. Other wrists with that are people with medications, they abruptly this stop the medications, there can be dire lifethreatening consequences which contributes to increased race rates of suicide. Another thing nobody has mentioned is many of you come from states were you cant get there from here. They dont miss their appointments because it doesnt depend on transportation. The difference i think is spoken by our members have never used telehealth before covid. Weve made some progress but Mental Health problems and drug addiction can be related especially nearing the stress level pandemic like we are in now. Its an individual in need of Psychiatric Care can get access to treatment through telehealth, can it help prevent them from develop Substance Abuse disorders . Absolute. It can prevent them from what they alluded to before, selfmedication. Thats one of the hypotheses for increased Substance Abuse, getting the services they need so i resort to drugs and alcohol. It also can affect people being treated for substances in terms of increasing their use of substances despite the treatment. Thank you. Ive exceeded my time and i thank you for your indulgence and i yield back. Thank you. Pleasure to recognize the gentleman from illinois. You have five minutes of questions. Thank you. This is been an important and powerful hearing my own grandson right now reported to the hospital in Atlanta Georgia for a psychiatric appointment, i hope he can get the help he desperately needs. And certainly going. I learned from the legislature approach, doctor evans, let me ask you, how will you record macro aggression . And micro aggressions associated with a diagnosed Mental Health part in this nation . Will you include your views on how it contributes to tds see in the u. S. Our nation right now is almost minimal for a significant segment of our society and i think we just cant ignore this front and center. Can you address your views on my questions . Sure. I think that is exactly right, we can no longer ignore racism having an impact on Mental Health. One of the things thats been hopeful about the recent dialogue is that you dont have to continue to say racism has a psychological impact. There are number of scholars and psychology who has documented racebased traumatic stress. That is the daily stress based on their race. Recently, after the protests, i casually mentioned i had been stopped by police, ive been patted down, my car has been surged and my colleagues were surprised by that. Almost a universal experience. Those daily times of experiences that people face have a cost. The cost is in terms of stress, we do an annual survey and it indicated in one month alone but we saw 815 increase africanamericans were experiencing after and this was right before the George Floyd Death so its important that we, as we are looking at the social issues around racism, that we understand his impact we also have to address. Could i address that quickly . Sure. Racism in the Mental Health problem, everybody. If we are going to change that, white folks have to understand there are negative consequences and they need to do something about the. I absolutely agree. Stress is felt. The maintenance on their power and status is an enormous amount of stress. Also, they can look and see other american citizens who have denied equality. Its also in the white communities. Chairman, i think my time is up. I am familiar with these and other low whether or not this methodology is pertinent to what we are doing here in america. If youre familiar with this and renewing this, work here today in contemporary america. You have an minute and a half past. Please answer. A significant effect on chester peers, a psychiatrist who came up with the concept of micro aggression so he lists today. Thank you. I yield back. The judgment fields back. The chair is pleased to welcome back to our subcommittee. From illinois. Your recognized for five minut minutes. Thank you for allowing me to participate today. I want to give a shout out to pastor kennedy, i think are you still here, pastor . I am here. Great to see you, too. Great to see you. I just want to acknowledge the fact that i think you have such an important role, not only in conveying proper information but eliminating stigma, which is still the course of Mental Health in many ways and because of that, thank you for saving lives. I know there are thousands of people willing to accept and feel good about getting the help they need. Let me move on. By 2030, the number of psychiatrists in the u. S. Is projected to decline by 20 from 2017 levels. Thats why i first introduced the medicare Mental Health access act in the one 11th congress at which would allow psychologists to utilize their full scope of practice and now we are cosponsoring hr 88 884 which would do just that. Older americans have a higher rate of drug use, they are also less likely to receive care from a psychiatrist. In my district, i want to give a shout out to doctor kenneth, the psychologist from my hometown, chicago who runs a Group Practice that provides Psychological Services to residents of Nursing Homes throughout the chicago area. So much needed now. Doctor evans, i want to ask you, do you believe expanding medicare statutory positions to include psychologists would enhance the availability of help for the patients who need it . I do. I appreciate your support of this legislation. I want to address misinformation weve heard here today, legislation does not try to read to find psychologists theyre not interested in that. Psychologists are interested in being able to practice to the full extent of their training. Without administrative barriers. I find it on my neck that this hearing, where weve talked about need this administrative burdens, requiring people to get services that we would have this as an issue. The reality is the Medicare Program is the only one that does this. Medicaid, not try care for the va, not any private one requiring colleges to go through psychiatrist to provide servic services. A time where our seniors are isolated, experiencing anxiety, they need direct services and ill leave you with this, i got psychologists who have experienced where they have a physician who told psychologists waiting to be able to provide services from a physician, he is told that he, the psychiatrist said i dont believe in psychotherapy, im not going to provide that. That is unconscionable and we cannot allow those in 2022 continue. It doesnt exist in any other program and we should not discredit against seniors and Medicare Program, we should get these Services Just like they would in private insurance, ba or any other insurance. I couldnt agree with you more especially in a time where we need more, not fewer providers for these services all psychologists should be able to practice to the full scope of their licensing. Finally, let me ask madam chair, i asked unanimous consent to submit a letter into the record for the 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 psychiatrists to do the qualified work they do so i yield back. Thank you, the chair announced earlier all of the requests will be taken up at the end of the hearing. At least 70 so that will be included in that. It is a pleasure to recognize another wonderful, important, wonderfully important member from the full committee who is waving today. The gentleman from new york and a good friend, love recognized for five minutes. You need to unmute. Thank you for allowing me to waive on thank you to our witnesses joining us today. With the covid19 crisis and economic downturn, we are facing enormous challenges when it comes to our nations Mental Health. The threat is instilled in us fear and anxiety for those living with a Mental Health condition, this must be magnified. We know social isolation are key risk factors to Substance Abuse despite heroic efforts of those in the recovery communities during this time. As we work to tackle these crises, we must ensure we have the Knowledge Base needed to understand the scope of the challenge before us which is why i altered the covid19 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 covid19 pandemic and the effect it had on the Mental Health of americans, any frontline Healthcare Providers. Can you speak to wife the covid19 pandemic present Mental Health challenges and why Research Program would be useful in helping calibrate our response . Its unique because we have not only infectious pandemic, we have a Mental Health pandemic. You cant fix a problem if you dont know what the problem is. The research funded, but answer such questions as we know theres a disproportionate covid and africanamericans. We also know theres covid in four people. We need research to figure out what degree is in poverty and what degree is the fact that africanamericans have sickle cell anemia accounting for this. We have to understand the problem in your field will help us understand the problem. Requires National Institute of Mental Health to examine the Mental Health impact covid has had on populations that have been underserved by Mental Health services. Can you speak specifically as to why this is an important topic to study and how the needs of underserved populations might be different from the population at large . Sure. research for 30 years and one of the challenges is that you dont get the information in which you have not done the research. We dont always have robust inclusions of the calculations we are talking about. Its also important to have researchers who are from the communities being researched and understand them so they can design studies that are more accurate but also so they can do the proper interpretations of the data and finally, on to give props to them because they are doing the research, its something they need and one thing i would add to the research they are doing, to do more research, Implementation Research closer to where they are being delivered. But we need our studies understanding implementation issues and making sure we can take the signs we spent money on and translate it into those settings. More than one third of americans are selfreported signs of anxiety or depression representing a huge jump from prepandemic numbers. What do these figures mean to you and what consequences do you think we will see in american societies in the years to come as a result . Thank you for your leadership both in the state legislature and new york before you came to congress and caring that are into congress. I cant help but a huge uptick in prescribing of benzodiazepine coupled with huge increases in Alcohol Consumption and coupled with a new commercialization of marijuana we dont have a major tsunami of addiction we are creating right now is not going to be fully realized for another few years. Your reeling from the your crisis so which we never quite got our arms around him im thinking they are adding fuel to the fire here we should be mindful this will get out much for your public Health Crisis. Thank you. I yield back. Its a pleasure to recognize the gentleman from california. Wonderful to have you with us here today. Thanks for having this important hearing. Today considering critical bills during this Critical Health presses. Its taking a mental toll on every single american. Im thankful my bipartisan bill bring awareness nationally delivered to this in todays hearing and i want to thank you for introducing this bill. It will help combat suicide. Since 2010, suicide has been the second leading cause of death among between ten to 24. A study published in two october 2019 found adolescent suicide rate in young people aged 12 to 19 increased by 87 from 2007 in 2017. 87 in one decade. This is concerning coupled with other senseless deaths in shootings and acts of violence in school. The serious public Health Crisis that existed long before the covid pandemic. Theres no question covid19 will influence the health of our nation. It been separated from their friends, classes are moving online in many young people see the future is uncertain. Circumstances exacerbate its links to Mental Health. 70 of people who died by suicide tell someone their plan would demonstrate warning signs and 80 of School Shooters have some with their plans prior to acting. Adults need to recognize warning signs and know how they can intervene. Note the signs of Suicidal Ideation. Connect them to the care they need. The standup act would do just that this bill would require states in Public Schools and tribes to implement commonsense evidencebased policies to prevent suicide from to receive grants. Promotes Mental Health Awareness Among schools and communities. Cap to prioritized the prevention and warning signs and give education will stop violence before it happens. In november in my district, was a promise to the administrative training and displayed how the act would be implemented and why its important to give students the tools they need to help those who may be struggling. They promise the act is backed by over 50 organizations including the witnesses here today and thank you very much, the American Foundation for Suicide Prevention, the National Association of school psychologists, id add a letter of record to support these administrations, to your list of things on the record to be considered later. The other unanimous consent request for the judgment. On to thank my readers for supporting this bill. Brief questions you mentioned you will help identify warning signs, if your school provide any Suicide Prevention Mental Health training to all students . How do you think it has affected them. Thank you for reading this, it is important today. They dont have programs that focus on these outside of school. Students have to go out on their own to seek help. I can be hard for a lot of people, especially if they have to go through hours of that. A lot of times we do training or something similar we need to teach others to do that. During covid talk more about what its like going for children challenges youve seen your classmates struggle with. I know it is particularly hard for seniors because they dont into graduate be excited with the people theyve done this with. I think students can rely on this and give them access to what they think it will most definitely allow kids to cope with these hard times. Thank you very much. Thank you for being here, everyone. Thank you for your leadership and i yield back. The time is expired. I think we are nearing the end of our hearing. Last, but not least, the gentleman from arizona. Thank you for joining us today. You have five minutes for questions. I appreciate the opportunity to be on this committee. I worked on parity when i was in the legislature year after year end im still sad to see still not being addressed in the appropriate way. We need to change that. Yes. Covid19 is exposed to something in Rural America has known for a long time. A shortage of psychologists, therapists and other Mental Health professionals. Telehealth can help but broadband speeds are still too slow in many parts of my district 20 cases cannot replace seeing their provider. Supported by hhs, 14 of the 15 counties in arizona are designated shortage for Mental Health professionals. This is not a new issue. The shortages, despite Rural America having a higher prevalence of Mental Health issues including Substance Abuse disorders, and urban areas, there are high levels of poverty, Food Insecurity and over time, people suffer in silence and lack of providers, Early Intervention peoples Mental Health more challenging. This pandemic will leave a footprint into the future. The issues on tribal lands are even more stark. In fact, for Young Americans in alaska native people, 15 to 34 age is the use suicide rates 1. 5 times higher than the national average. There are problem communities where the rate is ten times the national average. For this reason, i helped lead hr 1191, native american Suicide Prevention act. This bill ensures states work with tribes, native americans organizations to ensure statewide suicide pension programs are culturally sensitive and effective as possible. I hope this Committee Considers this in the future. As i mentioned earlier, rural areas have higher rates of suicide and Mental Health issues and higher rates of Substance Abuse. We talked about these problems throughout the hearing for decades. In your opinion, ensuring providers is rural and tribal areas, what can the administration and medical community do to help solve these problems . A few things, one is we are partnering to train providers on these issues of people in rural communities. Just like different ethnic groups have a culture there, the different cultural perspectives for people in rural areas and Mental Health professionals need to know how to work with those communities. Of time last year with farming and one of the things many people dont recognize is that farmers are exchanging a significant crisis. Unlike any types weve seen they have much higher suicide rate so i think we have to Pay Attention in your legislation i also think we have to remove administrative barriers that make it hard for practitioners to practice in those areas. We have to make sure people have the incentives, financial incentives. Thats one of the reasons we are supportive for financial incentives for psychologists to work in underserved areas. Not only in Rural America underserved committees and suburban areas as well. Thank you. Ill send you questions and i yelled now. The gentleman yields back and we thank him for joining us. Are there any other members who have joined us who were not recognized earlier . For the benefit of the members, i want to remind them committees rule, each member has ten Business Days to submit additional questions for the record to be answered by the witnesses. I ask that you respond as quickly as possible to questions submitted through you. I want to thank the witnesses, let me start with the youngest arianna, you hit it out of the park. You have really explained to us exactly the way it is on the ground your time, in your life and that of your peers. Weve 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. Patrick, i dont know if you can see behind me but that portrait is there with me and hes with me every day. He has always been proud of you but today exceedingly proud of you. Youve given us testimony both from the outside, understanding how the inside works. What you have shared with us is invaluable. Thank you for raising the points about the green beret. Very few people think the green beret have any issues relative to Mental Health. This expands across humanity. A friend of mine alerted me to something last evening, theres going to be a powerful and revealing documentary on hbo entitled the weight of gold and the documentary will explore the Mental Health challenges with deeply personal details about olympic sports figures. Who would have thought of that . When you mentioned the green beret, i thought of this, that i just learned about last evening so i want to acknowledge one of the executive directors for reminding me of that. We are going to take what youve given to us and bless you for spending over four hours with us. This is one of the longest hearings the subcommittee has ever had but every second has been 18 caret gold because weve learned from you and we will build on it. Patrick, youre always welcome to be with us and we are grateful to you today. Too both of the doctors, youve given us magnificent testimony only years of experience which is on full display but also your depth and breadth of knowledge because you Practice Medicine so you see it and feel it and treated. Thank you for going even deeper to demonstrate the curse of racism and the toll it takes on the entire human being. We will certainly take all of that into consideration with the bills by members. The four witnesses, he broadened and enhance our thinking, youve been highly instructed to the American People today have listened and watched and i would ask, i know you will keep yourself available so in this. As we are looking to mark these bills up, any additional advice that members may have, that they would be able to access that from you because youve been so outstanding. This was one of the things i said in my Opening Statement, the enormous challenges, extraordinary breathtaking challenges our country has today, i think we need to view them as opportunities, that we can right the wrongs in our society, address the help of all americans and when we do that, we are saying there is justice for all and finally, when we are called and judged, that we will be judged on how we care for each other. More than anything else, thats what the hearing was about today so i think each one of you, id like to ask the Ranking Member if hell join in unanimous consent request because we have 69 documents and i dont think you want to hear me go through these. They are all important, every member they feel very strongly about, join me in a unanimous consent request to approve whats been entered and all documents not entered into the records. I need to buy you a nice ice cream sundae or something. Thank you to all of the witnesses, bless you. Thank you to the members for your excellent questions. The Health Subcommittee and house of representatives [laughter] i was saying goodbye to patrick. Thank you to everyone. They are saying thank you, thank you. Wonderful to be together, god bless all of you in our country. May we do the right thing for us. Thank you. Meeting is now adjourned. During the summer months, reach out to your elected officials with cspans congressional directory. It contains all the Contact Information you need to stay in touch with members of congress, federal agencies state governors. Order your copy online today at cspan tort. Org. The contenders about the men who ran for the presidency and lost. 8 00 p. M. Eastern on cspan. Tonight, president ial candidate chief justice of the supreme court, hughes. Weeknights this month, we are featuring tv programs as a preview of whats available every weekend on cspan2. Tonight 8 00 p. M. 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