Transcripts For CSPAN3 Surgeon General Jerome Adams Testifies On Substance Abuse 20240713

His family and also looks at recommendation of how the treat it, and also looking at Insurance Fraud schemes with witnesses from the government and the Addiction Treatment centers. I usually dont start these meetings until the Ranking Member comes, but because of the service that we have for congressman cummings plus the fact that we had to change this meeting to adjust to that schedule, i wanted to get going, and it is going to be kind of erratic sort of operation, because i have another meeting that i have to attend to make a quorum down the hall here. So, i am going to start out, and then, i know that you want to introduce one person, and are you under a time constraint . Because if you are, i will give you the courtesy of going ahead. Mr. Chairman, i can wait until the regular. Okay. So i welcome our panelists today to our hearing on the oneyear anniversary of the support act. This landmark statute which many of us had a hand in developing responded to the Opioid Epidemic on multiple fronts. That crisis has affected every corner of our nation with approximately 130 americans dying from an overdose every single day. We have devoted a lot of federal resources to tackling the crisis and i look forward to hearing from the Surgeon General on this, of this administrations efforts to implement the support act, and now, it is on the oneyear anniversary. I also commend dr. Adams for launching his own unique initiatives to help raise Public Awareness of the risk of the opioid misuse. Challenges remain however, because roughly 20 million Americans Still struggle with the substance disorder. Addiction to other drugs including meth and heroin pose an even greater challenge to some communities ark and thieco especially true in rural america. Another issue is that few battling addiction actually seek or receive treatment. And another issue is that even those who do seek help lack the expertise to distinguish the good treatment providers from the bad, and solving this issue which is the second focus of a hearing, and easier said than done. The treatment sector includes not just extremely good and extremely bad actors, but those in between. Some for example have updated the methods to incorporate the latest research of what works best for recovering people. Also state requirements for addiction counselors and homes vary, and example, some states require licensing of the recoverying home operators while others might only use voluntary certification, and that is why we have invited two government watchdog agencies in an Addiction Treatment advocate to the committee to share expertise. We welcome back dr. Deegan macauley of jao who testified before this Committee Last year. We have seen the media reports of the socalled sober homes in pennsylvania and massachusetts and other states that exploited recovering addicts with private insurance benefits. We look forward to hearing from her on that subject of the gaos work there, and i extend a look at the Gary Cantwell who heads up the Investigative Team and his investigators worked on a high profile case involving a treatment scam in ohio, and that investigation and partnership with fbi and Law Enforcement generally led to the indictment of six people this year. All six pleaded guilty to medicaid fraud. Some have called for development of more uniform and measurable treatment standards to evaluate the effectiveness of Substance Abuse Treatment Programs. Our last witness, gary mendell has gone a step further in not only identifying eight core standards that are key to any successful program, but also launching a quality rating system. This is unchartered area, and treatment sector. We look forward to hearing from him about the progress that has been made there with the Nonprofit Organization shatter proof. We are here today, because too Many Americans have lost too many loved ones to addiction and americas Opioid Crisis has left a trail of broken hearts and homes across the country, and we are here to help communities to get on a path of health and wellness that Many Americans are desperately seeking a path forward. Working together, we can save tax dollars and save lives. Senator wyden. Thank you very much, mr. Chairman. I wanted to thank you, because this is an exceptionally important issue, and we do need to have the committee tackle it in a bipartisan way, and i also wanted to thank you for moving this mornings start time to 9 00 a. M. , because we both know that there are members who want to attend the Memorial Service for chairman cummings. Todays hearing is going to spotlight the pitfalls that americans face when they try to find quality treatment for a Substance Use disorder. An american battling this disease is often jostled and pushed around from one end of the Health Care System to the other. The last thing you need when you are suffering from this disease is yet more obstacles, ripoff artists and empty promises or just out and out abuse, and the last thing that you need is that when all you need to do is to get better. Too often people travel across the country expecting to arrive at a legitimate Treatment Facility only to find that they have fallen prey to a scheme, and the goal of which is to drain their bank account and just milk their insurance for everything that it is worth. In some instances, unscrupulous operators are working to lure patients by paying for plane tickets and promising free rent. Once the patients arrive, what they end up getting is lousy care or no care at all. And then the fraudsters just go out to bill the Insurance Companies for Health Care Services that may never have even been performed. One of the biggest problems involves facilities that allegedly treat Substance Abuse disorders that are set up to ripoff the taxpayers and the fraudsters illegally recruit patients using bribes and kickbacks and then they bilk the taxpayer by billing the Patients Health plan for medically unnecessary drug tests. Schemes like this and we are very pleased to have this really terrific group of witnesses today, and they are going to outline the schemes in detail, and of course, these schemes as well cost medicare and medicaid and private insurance hundreds of millions of dollars every year. And just this month six people operating a fraudulent Treatment Centers in ohio plead guilty to submitting 130,000 medicaid claims that totaled more than 48 million for medically assisted treatment and other services that were never leg legitimately provided. Part of the reason that this fraud is so common is because there is no way for the patient or the family to learn about the quality of the Treatment Facility before they enroll. So today, we will hear from an organization that is saying, hey, wake up, everybody, this has to change. Shatterproof is currently developing databases in multiple states that are successful to help the public evaluate, and compare substance treatment operations. And this is the type of information that American Families deserve to have, and they deserve to have it now, because it is a key tool to find quality treatment and avoid sham operators trying to make a quick buck. One other point that occurred to me as we were preparing for this hearing is its particularly important now to set in place the kind of concrete policies to rip off, and to make sure that the programs are not ripped off, and the patients are not taken advantage of, because when you are reading the morning newspaper, the fact is that states and communities may now be on the cusp of receiving tense of bitens of billions of dollars from the companies that helped to seed the epidemic. I can look down the row, because i have heard about this from virtually all of my colleagues. So if you are talking about a fund of tens of billions of dollars, a sum of that is going to be a magnet for the fraudsters and the ripoff artists, and so this hearing is going to highlight the need for the making sure that the rules of the road and the vigorous oversight so that the dollars actually go to help patients get proper care, and all of that new money doesnt just find its way into the ripoff artists. I thank the witnesses, and with chairman again, your leadership and we will work on this in a bipartisan way, and i look forward to hearing from the witnesses and the colleagues. The senator from maryland to introduce the Surgeon General. Thank you, mr. Chairman, and i thank you for giving me this courtesy and it is a real pleasure to welcome all of the witnesses today, and particularly with the welcomed the Surgeon General from mechanicsville, maryland, and a proudson of maryland and a glowing career. Mr. Chairman, he is the first winning the prestigious meyerhoff scholarship to where he received both the bachelor of science in biochemistry, and a bachelor of science in biology. Say that because we had a little conversation before dr. Freedman robows skshgs i ca robowski calls him the most successful failure. It is a program that has been extremely successful for africanamericans to get their ph. D. S and going on to extraordinarily successful life. Well, he does not have a ph. D. But he does have a masters and md degree, and has had a very successful career. I want to congratulate him for his leadership and also, a scholar and before serving as the United States Surgeon General, he was in the indiana Surgeon General, and dr. Adams has spent time combatting the Opioid Epidemic. He as been an advocate on behalf of the Public Health in our country, and we are proud of his service, and very proud to have him as hailed from our state of maryland. Three of you, and if i just go to the testimony, i wont feel bad, and i wont introduce you. And i have talked to all of you about in my Opening Statement, because of the time constraints, and i wanted to start with the Surgeon General. Would you start, and then, what we will do is that we will go in the order that you are sitting there at the table, and then well have questions after you all get done. Fantastic. And good morning, chairman grassly, and my wife says to tell my wife barbara hi, and we cant wait to take the kids out to farm, and i hope she told you about that. Everybody knows about my wife, but does anybody know about me . Thank you. Commissioner wiyden and if you will allow me to recognize the flags at halfstaff and lift up the accomplishments of chairman cummings, and he is the very example of public service, and my condolences to his family and those who loved him. And so, i would like to thank you for passing this act which has allowed hhs to make progress in the fight of the Opioid Epidemic. I am so pleased to be here on the oneyear anniversary. Americas overdose and addiction crisis is one of the most daunting and Public Health challenges ever. Recognizing its scale and scope, hhs launched the fivepoint strategy in 2017, and under this strategy, we are achieving better addiction and prevention and Treatment Services, and better data, and better Pain Management, and better targeting of the overdose researching drugs and Better Research. I have been engaged on this problem as an anesthesiologist on chronic and acute Pain Management, and as you heard from representative cardin, i have been on this with a fueled Opioid Epidemic, but my work is very, very personal. My younger brother philip struggles with the addiction no disease. It began with a struggle with depression and leading to opioid Substance Abuse. And my brother has been cycling in and out of incarceration, and he is currently serving a 10year prison sen stetence bec of crimes needed to support his addiction. And so i am an example that this can happen to anybody, including the nations attorney general. So to address this Opioid Epidemic, my Office Released a spotlight on opioids and a postcard at Surgeon General. Gov and also, what you need for five key messages that are e d t detd in the pub collationlycations, intervention is needed to be early. We cant wait for high school or college before we start to talk about the dangers of opioid misuse. Treatment is effective, but it has to be integrated into the Mainstream Health care. Medicationassisted treatment is the Gold Standard, but in the course of the year, 1 in 4 people with opioid use disorder receives the specialty treatment. And three, having the lock zone can save a life and serve as a bridge to treatment and recovery. I hope you know about this, and i carry it with me, and it is that easy to save a life. Since my naloxone advisory was published, too many needlessly die. And four, the Community Support services are essential. I saw this first hand when lady pence and i went to pathways to recovery and employment in which potential employees who fail drug tests are offered counseling and recovery. And this is also provided with a bakery that has employment with no judgment, no history, no background cheblg, abac background check, and their motto is that we dont bake brownies to employ people, we employ people to bake brownies. And we must move from the incarceration approach to one of treatment. And stigma and judgment are keeping the people with the addiction and people like my brother from getting the help they need. This is in my opinion killing more people than overdoses n. Conclusion, this administration and through your support the historic investment has been made in combatting the Opioid Crisis. By the end of 2019, hhs will have awarded over 9 billion to states and tribes to combat addiction and this is nearly 1 billion across 375 projects in 41 states as part of the nihs helping to end addiction long term or heal initiative, and also to samsa funds for the states to strengthen data and surveillance data. Since the start of the administrations, we have seen the amount of opioids in the nation drop 31 in terms of the prescriptions, and we have seen the number of americans recei receiving treatment grow, and now 1. 2 million americans are receiving the medication assisted treatment and we have doubled the number of data providers. And monthly, the naloxone subscriptions have raised 78 , and prevention of Overdose Deaths have dropped by 5 , and the first drop in over 20 years. We are making progress, but the challenges remain and including the resurgence of methamphetamines, and the need for syringe programs, and also to support the medication assisted programs with warm handoffs to care. And we must expand the behavioral workforce, and senator stabenow and i talked about that before the hearing. I promise you, and i promise you that hhs and my office is going to continue our commitment and the focus on the critical Public Health issue. I thank you for the opportunity to testify. I look forward to your questions. Dr. , before you begin, with all of the background in animal science, how did you end up in the gao . Well, as you are probably aware there is a nexus between the animal health, and Public Health, and gao recognizes that. Okay. I needed that explanation. Sure. Proceed, please. Sure. Chairman grassley, and Ranking Member wyde, in, and members of the committee, i am pleads to be here to report on the recovery homes. This drug use is a persistent problem that has ruined families and taken lives. The dea is reporting that since 2011 drug overdoses alone have been the leading cause of death by injury in the United States outnumbering the deaths by guns, car crashes, suicides and homicide. Recovery homes can offer safe and supportive housing, and unfortunately the bad actors have used these homes to take advantage of individuals during their time of need. Today, i would like to highlight two key findings from our report. First, gao found that all five states in our review have received complaints of the potential fraud related to recovery homes, and four of the five, florida, massachusetts, ohio and utah had or were in the process of conducting the investigations. For example, officials told gao that fraud was extensive in southeastern florida, and the Task Force Found that operators were luring individuals to homes using the deceptive marketing techniques and such as promisings of free airfare and rent. And recruiters then brokered the individuals to providers who billed their insurance for hundreds of thousands of dollars in unnecessary drug testing, and home operators were paid 300 to 500 or more per week for every patient that it referred. At the time of the report, some of the arrests had been made. In massachusetts, the medicaid Fraud Control unit found that some laboratories recovered homes and referred residents to their own labs for testing and other labs are paying the kickbacks to homes for patient referral for testing that is not medically necessary and between 2007 and 2015, the state settled with nine labs for more than 40 million in restitution. At the time of the report, ohio was investigating fraud at the breaking Point Recovery center. This month as senator wyden mentioned that the Attorneys Office reported that six people from breaking point plead guilty to Health Care Fraud conspiracy for billing medicaid more than 48 million in drug and Alcohol Recovery Services that were not provided or not medically necessary. To increase oversight, florida, massachusetts and utah established a licensure or the voluntary Certificate Program to have incentives for the recovery homes to participate, and other two states ohio and texas did not have similar programs but they were providing resources such as training to recovery homes. Despite such efforts though, the fraud continues. For example the pennsylvania u. S. Attorneys office recently completed an 18month investigation looking into the Insurance Fraud and Treatment Centers, and the charges includedic canba ikickbacks for unnecessary testing and unnecessary medical procedures. And there were unlicensed recovery homes where the housing was unsafe, and the employees and the patients were engaged in sexual relationships and opportunities to relapse. This is the case of the bad guys getting caught, and that is what leads me to my second point. We do not know the total number of recovery homes, and so therefore we dont know the extent to which it is happening. No federal agency oversees the homes to provide a nationwide perspecti perspective. In closing, when run properly, recovery homes are an important part to sobriety and recovery process. This is part of the gao broader use of drug misuse. These have exploited federal oversight of the opioid prescribing and medicare, and also ongoing work to identifying the medicaid barriers that they may face accessing opioid misuse barriers. And so much of the work is from the mandated support law act, which was mandated a year ago today. We highlight this in the latest report to highlight drug use as an issue requiring close attention. Thank you, chairman grassley and chairman wyden and other members of the committee for this Committee Hearing and this is concluding my remarks. I will be happy to happanswer a questions. Im Gary Cantwell at hhsoig. I am here to talk about the oigs efforts to combat Opioid Crisis. The ongoing work is taking a multi faceted approach and looking at the variety of issues on the prescribing and the treatment dimensions of the crisis. Oig is looking at this crisis through the expanded Law Enforcement, audits and data briefs. The efforts to combat the opioidrelated fraud and abuse while ensuring the opioid treatment and care are a top priority for oig, and we have expanded the enforcement efforts to expand the crisis significantly over the last several years and resulting in the increases over 100 of the investigations in the office from 2015 to 2019. This year, the newly launched appalachian treatment Prescription Strike force, a joint initiative between doj and oig and dea and others took down 73 individuals. 64 of them medical professionals for the alleged participation in the illegal prescribing and distribution of the opioids and the Health Care Related fraud schemes. The opioid fraud encompasses active they is encompassing addiction schemes and also treatment homes and ancillary services such as drug counseling and urine screenings. These homes operating across the nation with increased demand and the availability of federal funds to support the service, we have seen the commensurate increase of the schemes including fraudulent billing and diversion. At the enforcement and the oversight efforts to oversee the Opioid Crisis have expanded. We have come to understand the impact of our work on the patients that we serve. We recognize that when a clinic whose patients are prescribed treatment, the pay not made will be interrupted treatment. And it is vital they have the access to the Pain Management services with minimal disruption in care. This is not something that Law Enforcement can do alone. It requires a collaboration with our federal, state and local Law Enforcement. Our Law Enforcement partners have worked closely with the hhss office of the interior ministry for health and prevention of disease. And this strategy is to provide assistance not provided by Law Enforcement operations. Ooig is going to continue to work hand in hand to help ensure treatment and continuity of care for patients. Oig continues to put forward a robust portfolio of work related to the crisis with more work that is identifying and strengthening activity across the prescribing and the treatment dimensions of the crisis. This is currently several opioidtreatment audits and examining the issues such as access to the medicationassisted treatment, and samsas treatment grants. We look forward to sharing the results of this work with the committee when it is complete. Oigs recent data in prescribing medicare shows significant decline of claims and at the same time it is showing the number of patients receiving butyl norphene and na lloxinome thank you for allowing me the opportunity to discuss this important issue, and i look forward to any questions that you may have. Okay. I realize what little bit i said about you in my Opening Statement, i recognize your success in the private sector and now bringing that to the Nonprofit Organization to help us to accomplish this goal. I should have said that, and it wasnt. So proceed. Chairman grassley and Ranking Member wyden and members of the committee. Thank you for holding this hearing. My name is gary mendell and im the founder and chief executive officer of shatterproof, a nonprofit catering to the Opioid Crisis in america. For nearly a decade, my son struggled with Substance Abuse disorder and despite our family working tirelessly to find our son the best possible care at eight different programs, since 2011, we lost our son to disease of addiction. In the months that followed, i was destroyed all over again when i learned that research existed proving that the interventions that would have significantly improved the outcome for brian and others in treatment for addiction. If only we had known what to look for. That is why i founded shatterproof, a Nonprofit Organization dedicated to helping those addicted to opie d opioids. And our goal is to transform the Treatment Center in the United States. And a core set of values for treatment of addiction. And two, a quality Measurement System. Three, medicaid reform. Four, treatment capacity. Five, and stigma. My remarks are going to focus on the second of the five treatment quality measurement, and addiction is a chronic brain disease and despite the fact that there are clear clinical best practices, the use of the practices varies widely across the addiction field in some facilities that are still employing tactics based on the ineffective methodologies. Unlike other Health Care Services, comprehensive standardized data on the quality of the Addiction Treatment simply does not exist. Even worse, because the consumers, payers, and the state regulators do not have access to the quality measures Market Forces are not aligned for the best practices. In 2006, in the remark of the institute of medicine, it called for the development and dissemination of the common continuously improving set of measures for the treatment disorders to drive Quality Improvement. Seizing shatterproof is seizing upon this longstanding recommendation to develop a public platform known as atlas for three aims. Number one, providing patients and family members the information they need to identify evidencebased treatment for their loved ones. Number two, equipping the providers with the data to provide evidencebased practices. Three, ensuring the policy and Payment Systems are data driven. The tool builds on the eight National Principles of care developed with experts in the field to establish that addiction should be treated like any other chronic illness. We are currently in phase one of atlas and working with the Treatment Facilities and payers and other stakeholders in six states, delaware, louisiana, north carolina, west virginia, massachusetts and new york. Thus far, this phase has included measure identification and refinement through the National Quality Forum Expert Panel sexes. A a panel sessions. And also, a survey across 50 Treatment Facilities in the state of new york. Quality data is going to be accumulated and triangulated from three sources claims data, experience survey and facility survey. And we will provide the data back to the providers the public and the payers and the states. When i say the public, to families. Following the evaluation of the phase one, shatterproof is going to work with other states to bring this resource to serve more than 21 million americans with a Substance Use disorder. Atlas is part of the strategic goal of shatterproof to treat the addiction crisis in america, and the addiction crisis that has had a severe and tragic toll on far too many and for which the impact can absolutely be averted for so many others. Thank you for the opportunity to testify today. I look forward to your questions. Thank you. We will have a fiveminute rounds of questioning. I am going to start with the Surgeon General. First of all, i know and thank you for the top priority that you have given as Surgeon General, and even probably as an individual to making and addressing opioids and addiction as a top priority, and i also thank the administration for the efforts to prioritize the carrying out of the enactment of the legislation. Section 7031 of the new law calls for the Development Best practices. Has the administration appointed a working Group Members to develop such practices or identify the factors that could be used to identify the potentially fraudulent Recovery Housing operators as required by support, and if not, could you give us a timetable when that might happen . Thank you for that question, sir. I wanted to recognize that iowa has led the way in the country of 14. 7 decrease in the overdose rates over the past year. It has been recorded. So we need to share more of what is working in iowa with the rest of the country including connecting the people with treatment and Recovery Services. I will tell you specifically that in the spotlight on addiction which i highlighted, this came out last year, and there wasnt much fanfare. A lot going on in d. C. Nowadays and the folks dont always notice when the Surgeon General puts something out, but i highlighted what to look for in the Substance Use Disorder Treatment program, personalized diagnosis and assessment and treatment and longterm disease management, and as we learned in indiana, it is not just the Substance Abuse disorder, but it is hiv, and hepatitis and other illnesses. Behavioral intervention and other coordinating care for diagnoses and supporting services. So my role is to give the public the information they need to make informed decisions. We have put that out, and we have the samsa treatment finder, and 1800666help. And for that vetting, i would turn it over to mr. Cantwell for treatment. I hate to put you on the spot. From good to bad, sir, we only encounter the bad. What we see is the institutions with no intent to provide the services that they are billing for. Individuals do not receive the type of counselling that they are supposed to receive, and sometimes we have seen the prescriptions paths just left behind for the staff, and nonqualified staff at the facility, and just write the prescriptions as the people walk through the door. And there is zero in most of the cases that we are involved in actual interest in the care of the patients and the treatment, and they are not getting the services that they need and deserve and oftentimes that we are paying for. Dr. Daniga, i wanted to ask you a question about the testimony that you were referring to not knowing how many homes or where the recovery homes are. Do you have any way of telling us what obstacles exist to obtaining this information . Because it seems that we need this information. Yes, it is difficult to obtain the information because as i mentioned, there is no federal oversight of the homes. It is left up to the states, and the states have varying practices. For example, some licensed and some require certification, and n. A. R. Is involved in some of the voluntary, and some of them just fly under the radar. There are many obstacles to identifying the number of homes that we sir, i would highlight and this ties into your question, today medicare or cms is going to be releasing a Substance Use disorder data book and that is a direct request from the support act that you all passed a year ago and this will highlight the people in states getting recovery and Treatment Services through medicaid and that will be a first important step to figuring out who is getting what, where are they getting it and will better allow us to then assess the good from the bad. Mr. Mendel, obviously we didnt i didnt recognize that you lost your son and obviously thats a terrible loss for you and we i hope you know that its not only your son but everybody else that were trying to help in this regard. So id like to you this question and this will have to be my last one. Tell us what lead you to develop the National Standards of care. Sure. Is this on . Yes. What i saw out in the industry was literally three to four, about 45 evidence based practices that they should be following. Clinical trials showing that they worked. If you do x, the patient does better. If you do a, b, c, the patient does better but there were 45 of these proximately and they werent all in one place. They were all in different Peer Reviewed medical journals. Theres not a business in america that bonuses everybody on 45 things. Most businesses are successful and narrow it down to the less than 10 core things that were moved to success. So i knew what we needed was less than 10 Core Principles of care. Our lists are close. Less than 10 Core Principles of care. Number one that could be understood and most importantly to be able to be measured. You cant measure 45 things but you can measure less than 10. We selected working with the leading researchers in the field. In fact, many of the researchers that drafted the 2006 surgeongenerals report which was followed up in the spotlight with working with them to draft 8 principles of care that could be easily measured that were the most impactful to treatment. Whether its inpatient, outpatient, opioids, alcohol, adolescent or adults. Thank you, mr. Chairman. This has been an excellent panel. We thank you all for your commitment and compassion to the patients and let me tell you what is foremost on my mind this morning. Every morning now we wake up to these news reports that there is this effort with the states and the communities to work with the pharmaceutical companies and come up with a settlement that deals with the opioid drug addiction and the overdose epidemic that the Drug Companies contributed mightily to facing in this country. If these Court Settlements go forward it is almost certain that a significant portion of that money is going to go to Substance Use treatment. But based on the fraud and the rip offs that youre already describing to us today, it seems to me that this lack of oversight could mean that with a potential influx of more money were creating a perfect storm for more fraud. So i think with a id like you to do is tell us going forward, what should the federal government working with the states and the private sector do to make sure that if that settlement takes place and there are billions of dollars coming in for Substance Abuse Disorder Treatment, what should the federal government work to do to make sure that the dollars go to reputable operators and not more fraud. However, our work which showed that the certification process, the license process, the certification and the charter houses have oversightment so it would be good if we could insure that the funds could at least go to those homes that have some forms of oversight. What are the gaps in the area . My understanding is that you all already identified some gaps today in the oversight of those key areas. The gaps are numerous. Theres no federal oversight to help us with this program. So who would you make the point person on the federal side . Would this be the center for medicare and Medicaid Services . Who would you make the point person given the fact that you say theres nobody coordinating it. We dont look at that directly however we do know that theyre providing grant money and thats one way to tie it to what the states are doing. That would be the most Cost Effective . Based on your work what would be the most Cost Effective way, starting on the federal side to fill the gaps . Unfortunately we havent looked at it for me to be able to say which is better, however clearly cms is involved. What are the other gaps . The other gaps is just that we just really dont have app understanding and the states are able to do various things. Theres not one program fits all. This is a grass roots level. Some of the states that we interviewed dont want to have actual federal regulations because theyre afraid that you would have less of these recovery homes. What would be the most two serious gaps . I mean, in other words, got to start somewhere. If youre going to have somebody at the federal level coordinating it, then theyre going to say, what are the two most serious gaps . If you dont deal with them, more money is going to get ripped off . I wish i could answer that but i dont know the answer to that. I know that there are many gaps. Who would . Who would be able to tell us with all of this money coming in what the biggest gaps are. And i think that thats an excellent question because when you look at the number of individuals that we had to interview just to get an understanding of the oversight of these homes. I think that you guys have already started us on the way to answering this because you found some problems with the acrediting organizations and the like. Its difficult for the federal government to get down to regulating at the local level but what the federal government can do is condition all the grants its giving to states on states doing evidence based practices. So for example, theyll be giving out billions of dollars to states. They could condition that money on going to states if states did the following five or six things. Go ahead. My point is number one he has been a leader in working on these kind of behavioral issues right now. Were not talking about the federal government taking this over. Were talking about the fact that the federal government if were talking about Substance Abuse, theres significant amounts of dollars that the federal government has been involved with and the federal government being a partner with the acrediting organizations and the states and the private sector and the like will hold the record. The chairman had to go i would be very interested in hearing from each of you what you think the biggest gaps are right now and your ideas for helping to fill them and i also like to throw a bouquet to my seat mate here for doing good work on being part of the Bipartisan Coalition thats coming up with a plan to deal with it. You asked for two things in 20 seconds. 20 seconds. Two big things. One of the hhh pillars is better data. The Substance Use disorder data book is a big, big deal because it will give states better information ability whats going on where so they can make better choices about who to lift up and who needs to be investigated. So better data is one. Number two, again as gary mentioned, as mr. Mendel mentioned we need to let consumers at the local level know what to look for in a good Treatment Center. Please look at what they put out and what we have put out and use it to push that information out to individuals that are making those decisions. Those parents that are going to Treatment Center after Treatment Center after Treatment Center and dont have a checklist to tell good from bad. We need you to help us push those out. Well keep the record open. Chairman wants to move quickly within the neck ten days wed like to have recommendations to make sure that if we see this influx of money, were not going to see it used for more fraud. And well go to him and i just like to recognize that this is exactly why were having this hearing. This is a good very constructive conversation. Thank you mr. Chairman. Drug overdose is now the leading cause of death for those under the age of 50 in the United States. Let me let that sink in for a moment ichlts moment. Its a sobering fact. No doubt our country is in the middle of a major opioid and meth meth crisis and we must do more to combat this epidemic. In my home state of montana its meth destroying families and communities. In fact, from 2011 to 2017, there was a 415 increase in meth cases in montana with meth related deaths rising 375 during those same years. And unfortunately in my state of montana the meth crisis is disproportionally impacting them. Thats i cant we have a debate up here and including a piece of legislation. It helps strengthen the tribes ability to cam bat drug use in the support act signed into law by the president last year. It was a good first step because we know theres a lot more to do. We need to put an end to the stories in the news. No more babies being born addicted to meth. No more stories of meth breaking up families and overwhelming our Foster Care Center in montana. No more stories of people being taken advantage of that are desperately seeking Substance Abuse treatment. I know that i can speak on behalf of montanans, weve had enough. Thank you for being here. Thank you. First id like to invite you and other Administration Officials to come to mop mon to see firsthand how this meth crisis, Mexican Cartel meth is effecting our communities. One of the greatest challenges were facing is meth use. Dr. Adams, can you speak to how meth is the next wave of the Opioid Crisis. In montana your rates have gone up 26 in the last year from them and a 5 decrease in opioid rates nationwide. Weve seen a 23 increase due to meth and stimulants and i would loop back to strategy points number one and better prevention treatment and Better Research on pain and addiction. About a third of my core officers and work for facilities. This Opioid Crisis is not so much of a problem than a symptom. Its a symptom of our failure to build resilience into communities and its a failure of our recognition to see that there is massive untreated pain in our country. It includes all of those things otherwise were going to keep playing wackamole over and over again. Were seeing it happen particularly like you said in montana and on the west coast. We look at the meth crisis in montana. Once upon a time the home grown meth that used to be the source of meth had purity levels of about 25 . Today the Mexican Cartel meth have levels north of 95 . The prices have come down because theres so much more being produced and the distribution is much more sophisticated where it just takes a couple of days from the time it crosses the southern border until it gets to a reservation in montana. We work to bring together Public Safety and Public Health. We need to work on the supply side and you talk a lot about the supply side but i will tell you, if we dont deal with demand, if we dont deal with people selfmedicating away their pain and Mental Health issues theres always going to be a supply. Thats right. Someone is going to find a way. I completely agree with you as well. Lastly, i do believe we need this multifaceted approach. You illueluded to that about th epidemic. Thats why i have been pressing the nih to develop medication assisted treatment or m. A. T. To treat addiction. It exists for opioids and alcohol and other drugs, theres no m. A. T. For meth. Are you familiar with it . I am. I had a ten minute conversation specifically on this topic and ill tell you what she told me action unfortunately, the research out there right now isnt promising in terms of developing m. A. T. For meth and theyll try to develop it but our best solution is prevention. Its trying to get upstream and trying to deal with these problems before they turn into the next wave of a epidemic but well still devote research to try to find solutions for people that need to recover. Would you commit to working with me to advance these efforts to assist montanans in overcoming the meth epidemic . Absolutely. The parts of our country where native american and tribal folks reside are very, very personal to me and its where i try to make a point of getting out to and visiting and i and hhs commit to you that we will not forget about those individuals. They individuals of our country and they should not be forgotten. Thank you, dr. Adams. I ask for consent to enter letters from the federal Law Enforcement Officers Association and others into the record. They see the devastating effects on Substance Abuse of our local communities without objection. Thank you very much and to mr. Chairman for you, thank you so much for holding this hearing. And to each of you on the panel, thank you very much. This is an incredibly important topic that effects all of us in some way. And is im so sorry to hear about your son, brian, and im sure that he is proud of the effort that you have put into moving this forward and making a meaningful difference for so many other families. Ive heard like everyone else so many horrifying stories, individuals and families struggling to get Substance Abuse help as well as Mental Health help. Those are very much together. People are selfmedicating with alcohol and drug use from underneath theres a Mental Illness as well and theyre tied together. People are trying to do the right thing and get the best possible treatment. But ultimately as you have shown people can be taken advantage of and unfortunately i believe this is happening in part because structurally we treat Behavioral Health, addiction and Mental Health differently for reimbursement. Its quality standards, its evidence based but its also we predominantly do this through grants rather than reimbursement like we do for health care. So we have federally qualified Health Centers and we set high standards. You get full reimbursement if youre a physician at the Health Center we dont yet fully have that on Behavioral Health which is what we are working very hard on right now. So we know right now theres a right way to do things and we can spend federal dollars much more wisely with high standards. In fact, a couple of years ago and im so grateful for the senators leadership on this with me as well but around this table, we have people, we have oklahoma, oregon, pennsylvania, nevada, and new jersey where we have two years of data. What happens when you set quality standards on Addiction Treatment and Mental Health and then see how it plays out. Fewer people going to jail. More people getting the treatment they need and i want to thank the chairman and Ranking Member and so many people for giving us the opportunity to take the next step to actually be able to put this in place. And a lead in making sure that we are doing grants to believe to set up these structures. As well as the Certified Community behavioral Health Center grants that are beginning to move this structure forward. We started with unrecognized untreated anxiety and depression. We know that many of these Substance Use disorders are co current with behavioral Health Issues and its our job to make sure that theyre having their behavioral Health Issues being taken into account and that we recognize them before they turn into substance issues and selfmedication. You asked for an update. I know the secretary shares your excitement about whats happening. I will tell you that we have Behavioral Health Work Force Education and training grants. 50 million in 2017. We had Mental Health and Substance Abuse order expansion over 550 million distributed from 1,200 Health Centers across the country and then the pilot grants that you mentioned. So far the results look good. I want to say that we share your concerns. I want to thank you for your support for this in michigan. You have all seen a 10 decrease in your overdose rates band its because you looked at this as a mental and Behavioral Health issue and Substance Abuse issue and not separated out the two. I want to say i often tell folks a long time ago we cutoff the head from the rest of the body. We said anything that happens from here up, oral health, vision health, Mental Health, heres a card and go see somebody. Else from here down well take care of at a primary health visit. Im encouraging them to integrate it back into it. Its a brain disease and so thats a very important part of the body. We should treat it as we treat every other part of the body and i know my time is up so i will just indicate in the areas now where we have Certified Community behavioral Health Centers, we actually have medication assisted treatment. We have specialists. Real trained people with evidence based Treatment Options that are working with people and in each of these centers theres also 24 hour, 7day a week access to services, crisis services. So folks arent going to jail. Theyre not going to the emergency room. Theyre actually able to talk to somebody thats trained to help them. Thank you mr. Chairman. Again i thank all of our panel lists. I certainly agree with the points that have been made by the senator and others that we need more information for consumers. More transparency in order to prevent fraud. I also agree that we have to get the matrix for that. Thats not as easy. And we have to narrow it to where consumers can use that information most effectively in making decisions. I do think it does provide us some ability to look at a group that has looked into these issues. I want to go on to a point that dr. Adams made when you talked about the 5key messages for addressing Opioid Crisis, specifically mentioning Recovery Support services. In maryland, we had found that peer support has worked well in our community. I included a provision and support act that death with studying in the Medicaid Program peer support. Theyre working to increase their capacity for peer support in Emergency Rooms. Theyre looking at nontraditional hours to make sure that we have peer support programs. In Dorchester County theres one called peer support programs that are available. Id like to get your view as to how effective you think peer support programs have been and what we can do to try to encourage more opportunity for peer support, particularly in nontraditional hours and Emergency Rooms and things like that. So quickly, i have been all over the country and the communities that i have seen that have been able to turn around their opioid overdose reversal rates have done four things. They saturated their communities because you cant get someone into treatment and recovery if theyre dead. Number two, they had a warm hand off, usually through some sort of peer recovery type program. They provide medication assistant treatment and they had strong Public Safety and Public Health cooperation so that we can go from criminalizing the problem to medicalizing the problem. Im very proud of the fact that during this administration we have increased the number of medicaid 1115 waivers substantially. 22 have been approved during this administration and thats given states the flexibility to pay for things appropriate to improve success rates and including recovery and child care and transportation. We need to provide those wrap around services but you are right senator, peer recovery is one of the key tenants in making sure that you can stop your overdose reversal rates and get people on the pathway to becoming productive citizens again. Doctor, some states implicated peer supportment do you have any idea of the effectiveness . Its good that you mention the support act. Theyre getting ready to begin a review thats going to look at medicaids use of the peer support in the various states. They very much appreciate it. Id like to get to one other issue if i might. In maryland were looking at Stabilization Centers. Two counties started Stabilization Centers to get them out of the emergency room. I certainly agree we want them alive. The medication is important. The Emergency Services are important but Emergency Rooms are not good places for people needing care. So the current Reimbursement Structure work against the stabilization center. The full cost is usually covered. What can we do to encourage that type of care that a person that is distressed needs. And allow for the funding of programs such as Stabilization Centers and communities. I will highlight giving states the flexibility to find these types of programs such as we had done through the 1115 waivers but this is a good one to kick to mr. Mendel, you can speak from personal experience about the struggle of bringing you son in over and over and not having a place for him to go that will help him. Absolutely. And it comes back to quality measures and measure in and they were the most effective methods to treat people and having a transparent set of quality measures where the information is published on a regular basis. We talked about Consumer Information where they can learn where to send their members and its also for payers. For payers to understand which providers are most appropriate in their networks and which ones are not. Its also for state regulators and its also information that providers can learn from each other. We talk about the providers out there. Theres a lot of good people in the community that dont have the information about what programs are most effective and which tactics are most effective and if we have transparent quality information without even having to regulate, they will learn from each other and have the information they need to improve. So its not just ratings, its quality measurement. Its Quality Improvement and the resources to do so. Thank you. You brought it up so heres what i found out. Your wife sat beside my wife at the International Club. We had lunch at the museum and she was a hostess at the International Club meeting, the childrens inn at nih. Is your wife really that active . My wife is and she shared her story. Many of you know this, my wife actually just finished treatment for melanoma at the National Institutes of health and were cancer free based on the last p. E. T. Scan but she shared her story and your wife was so inkred brii incredibly kind. Shes nervous and you can tell im nervous talking in public too. But she did a great job and appreciated the support from barbara. My wife is a 33 year survivor of breast cancer. Exactly. She shared that. Thank you. Thank you for holding todays hearing. I want to thank all of our witnesses for being here today but dr. Adams and mr. Mendel i want to thank you bth foth for sharing your family stories because in doing that you really do help combat the stigma that is such a part of this disease and undermines our capacity to treat it so, thank you. As many of you mentioned the support for patients and communities act was signed into law. It was a critical step in addressing the Opioid Crisis. But the crisis didnt happen overnight and we know that it will take a continuous and sustained investment at the federal level to curb and ultimately reverse the tide of a truly horrible epidemic. I look forward to continuing to work on a bipartisan basis to adequately fund the support act and expand access to prevention treatment and Recovery Services. I wanted to start with services and access for women in particular. 70 of women entering Substance Abuse treatment have children and many residential Treatment Programs dont allow children to be present when their mother is receiving treatment. This is obviously a real barrier. We have some good examples of what works. Homes offer services for pregnant and post par dom moms. They have proouch to be really effective and when pregnant women and new moms have access to longterm evidence based treatment, outcomes improve for the entire family. Unfortunately recovery homes like hope on haich hiven hill a and far between. As well as the gao report were discussing today have shown that some recovery homes are scanning patients and not using the evidence based treatments we need them to use. One of the best means of recovery is residency in an oxford house which is an evidence based recovery home model that addresses addiction and yet according to the gao report only 29 oxford houses in the United States provide Recovery Housing for womens. So dr. Adams, what is hhs doing to expand access to longterm evidence based treatment to moms that allows them to remain with their children in a safe environment and how can congress support those efforts . Thats the question that i want you to answer and then after dr. Adams how do we ensure that were providing access to the increasing number of women in need of treatment and Recovery Services especially given the relatively limited number of high Quality Homes that serve women. I visited New Hampshire many times. Few places suffered as much but also few places had as much success in overcoming the Opioid Epidemicment you decreased by 10 and that is due to your focus on nas. What are we doing . Well, acl with best practices including keeping mom and baby together. I partnered to write an article calling on more obgyn providers to be trained so we arent playing holt potato with someone with Substance Use disorder. They focus on improving the quality of care for pregnant and post partum patients and a child centered Service Delivery program that emphasizes providing the supports. Couldnt agree with you more and were trying to provide the flexibility. New hampshire also has an 1115 waiver that provides more flexibility. Thank you. Yes, we also have on going work and we have a report thats coming out looking at medicaid and Opioid Use Disorder Services for pregnant and post partum women as a part of the support act and its being released today so there will be more information there. Thank you. I know that im running out of time. Ill follow up with you dr. Adams. We have a bill to help to remove the waiver necessary right now for physicians to be able to do medication assisted treatment. I am concerned that people dont understand that its a Gold Standard and how important it is. Im concerned about the stigma attached to m. A. T. Still and ill have a question for the record for you to follow up on that because we need to get the word out there how important it is. Absolutely. Happy to follow up. Senator menedez i apologize for passing over you. I forgot. Thank you mr. Chairman. Thank you for calling together a important hearing. I recently spoke with a constituent whose son is grappling with a substance based problem and she mentioned there is a disconnect between what she has been told by experts is the appropriate time for her son to be in a Treatment Center and what her insurance will cover so now he cycled through treatment a couple of times and this was not the first time i have heard this which drives me to the question do you think theres a disconnect between what we know are evidence based best practices for Substance Use Disorder Treatment. And Substance Abuse programs. I cant say it any plainer than that. Youre going to put someone in a Treatment Program. In 4 to 6 weeks theyre going to be cured. We know that recovery is a lifetime and its one of the reasons hhs is focussing on treatment and recovery and provide flexibility for states to be able to provide wrap around services at transition at recovery moving forward. Well, again, i can only speak on best practices, not on regulation or legislation but i will say that its important that folks look at the fact that youre not going to solve this problem with a short treatment and that we need to fund that spectrum and again were trying to fund the flexibility that we had through 1115 waivers to give states the ability to do that. Its more consequential the way its more consequential to the life of the individual. And they get paid for different segments and services. A broad array of areas. The whole Service World needs to be looked at very closely and we need to make sure that we are paying people to actually create health and wellness and not paying people to do procedures or to keep someone as an inpatient until their funding runs out. Were committed to providing the flexibility and incentivizing muscles payment models. Were trying to help patients and local entities figure out what works best for them but to show proof of concept that we can scale it up. Mr. Mendel, i have my deepest sympathies for the loss of your son and none of this is easy. You previously stated you did not support heavy federal regulation but an approach into how highway funds are tied to the speed limit changes, for example. The federal government tied funds to the adidiction space. What laws should allstates have in the books and what if any laws should the federal government lead on to provide protection for individuals in recovery. There is one federal law that i think is very important which many members of congress are working on right now which is to require as part of the dea license all doctors and psychiatrists as part of their dea license prescribing controlled substances to tie it to education and if that is done it would be a huge improvement in the system because doctors can prescribe oxycontin, vicodin, percocet, all opioids without having any training. As part of their licensing to to be able to do so to be trained in basic prevention and treatment of addiction would be huge. Number one state medical societies conforming to the cdc prescribing guidelines would be a huge lift. Requiring states to follow a Measurement System. Theyre the only ones out there now but there could be others. Thats specific to us. Tying it to state only going state funding thats coming from the government only going to evidence based to Treatment Programs following evidence based practices. That relates to a quality Measurement System and you can determine which Treatment Programs are following evidence based practices. Requiring medical schools in their state to have basic training on prevention and treatment of addiction. Federal legislation to eliminate data 2000 which requires any doctor in this country to go through a significant process with the dea, licensing, hours of training, oversight by the dea. Doctors can prescribe oxycontin without any additional training. They had to go through a whole process. The result of that is less than 5 of doctors in this country can prescribe it. Less than 50 of the counts in the United States have even one doctor that can prescribe it. Thank you very much. Senator young. Dr. Adams and other witnesses, welcome. Dr. Adams, were really proud of you in the state of indiana and we think that youre doing the country proud in your current capacity. I was really glad to see you high like the important work of belvin industries in richmond, indiana in your testimony. They are really making a difference as well. Dr. Adams, dr. Todd graham, a south bend physician with over three decades of service was sensele sensele senselessly killed on july 26th, 2017 for refusing to prescribe an opioid to a patient. Tragic. And in his memory i worked with the then senator donnelly to pass a provision in the support act that aims to produce the overprescribing of opioid to expand the use of nonopioid alternatives in the program. How are they working on increasing the utilization of the Pain Management approaches. Well, i have to tell you, this is a major point of emphasis for us as part of our fivepoint strategy. Better research on pain and adisc and it cant happen fast enough. Its a fact 25 years ago when i was in medical school. It came from a good place. We did and still do have an epidemic and undertreatment pain in this country. Now were pulling them back. And we have a significant decrease in opioid prescribing and what i say to folks is were also measuring that folks are going to continue to selfmedicate and theyre going to continue to be angry and when they dont get their pain treated were going to continue to chase our tails. They ordered 945 million in the form of grants and contracts across 41 states to increase research and practices in terms of pain and addiction and we have also gone and lifted up the different pain mechanisms and cms has done a lot to make sure that were paying for the right things and i have worked with businesses because we put a lot on cms but the other gorilla in the room are the employer based insurers and make sure that theyre paying for alternatives in not being the first drug dealer. Many will pay for 60 vicodin but wont pay for the alternatives. Thank you. Thats really important. Theres a lot of emphasis so increasing access to treatment. We also need and i know that you agree to this that people are in Treatment Services and working. And during the hearings pertaining to the Opioid Crisis. In your testimony you say we have amassed a mass of evidence on effective prevention. Early intervention treatment and recovery strategies. Can you elaborate on the evidence youre referring to . Especially in terms of treatment . Because as i travel around the great state of indiana and talk to Different Service providers theres often times varying perspectives on what works and doesnt work. You said a few things and ill work backward. We need to make sure that when someone is done with treatment they can be reintegrated back into society. Stigma is killing more people than overdoses and it causes people to relapse when they cant find a job and be reintegrated into society. Work is a very important part of this. Both training and taking a look at the Scarlet Letter we attach to people when they come out of a Treatment Center that prevents them from getting a job. As far as Substance Use disorder Treatment Centers youre right, theres way too much and i would actually turn it over to mr. Mendel and highlight the key aspects of what we should look for in the Treatment Center. Absolutely. In a Treatment Center we have identified we talked 7 principles that every Treatment Program should have. Number one, a full and complete assessment. Not just of addiction issues but also Mental Health issues and any physical issues. It needs to be complete with all three with an evidence based instrument thats proven to be reliable and valid delivered by someone that has the credentials to ask the questions in the right way and understand it. Number two, once you have that assessment, to be continually reassessed and your care adjusted they will not tell me heres what your treatment is going to look like for the next 28 days. Theyll tell me for the next 2 days or 1 day and then test me again and readjust it all along the way. So continue, reassess and care adjusted. Number three, evidence to evidence based medications. Not just for opioid but alcohol. Theres evidence based medications. Number four, access to behavioral therapies thats evidence based. Theres only six excuse me, 7 that were in the surgeongenerals report. Most recently in 2016 and highlighted in the spotlight that have randomly controlled trials and tested and proouchve work. Its all on our website but they exist and theyre easily measured. So thats encouraging and i also noted that it takes 17 years on average for evidence to actually reach the field. Thats going to be unacceptable so i would welcome a future dialogue about things that we might be able to do at the federal level to compress that time frame. Share the surgeongenerals spotlight on opioid that list the steps and criteria to look for in evaluating a Treatment Center that we worked to help develop but we need you to help share that. Senator cassidy will be the last one and will you close the meeting, senator cassidy . Because i have to go to a meeting in my office. So i thank all the panel as chairman of this committee for this very fruitful meeting. Senator, cassidy. Thank you. At the outset the chair will grant himself as much time as is needed. Thank you for being here. First let me highlight something that hhs has done. You had a task force on Pain Management which is really good because your statement earlier said that there is still untreated pain and yet we have people dying from addiction. That is the tension and as you know they differentiated between the patient on chronic pain for many years, never escalating, working in society from the person who is breaking into a car to steel a purse to buy drugs. So lets not turn our backs on the person with the stable dose contributing to society which includes people in this room and differentiate that person from those. Theyre capable of looking at the outcomes. Who is released and goes into a situation requiring more care for addiction and yet we continue to hear that medicaid does a poor job of that. It seems like this could be something that could be done with super computers. If someone has a billing to a Pain Management center and readmission for something that is. [ applause ] bli related to drugs overdose within a period of time and you compare everybody against everybody and you sort out who is doing a good job and who could employ science based methods and improve their work and who should be kicked out. Now what is the what is the obstacle to doing so . Either of you . We do a lot of analysis similar to what you described in the medicare space. But we dont have the same level. So we do have the transform medicaid statistical information system. Is it not ready for primetime . Not quite ready for primetime. Improving but not ready. But its rapidly improving. Some states are ahead of the curve and some states are coming on. Can we take those as proof of concept that are already submitting the data and then creating a system that scales as other states come on board. Thats something that we can explore. Why not something that we can do. Well, i dont want to commit them but ill take it back and we can follow up with you. Okay. Maam. So similarly, the work that we have done that im familiar with would be related to medicare because the data is there and we previously reported. I have spoken to somebody that works for clearing houses and when somebody submits a plan they have to do data and theyre actually better because they got it all. And it has to be with a unique identifyer because its transmitting from plan a to plan b. So these folks have it. Just to point that out as a point of information. So as gao we work for you and we would welcome a conversation to have a discussion about work that we can do in this area. Let me ask you one more time because they always do a wonderful job but in the time it takes you to complete a study, an elephant is born so it takes a little while. We need Something Real time. So dr. Adams, is it possible for hhs to stand up Something Real time as doing this analysis, maybe getting a system from one of these two folk but that which you can employ so that we dont have to wait for a year and a half for an excellent study but by that time situation on the ground has changed. Ill take that back and follow up with you. Let me ask you one more thing. I have done a lot of work in jails. You mentioned your brother and thank you for your openness about that and i think the statistic that i read is that 15 of males entering a jail have a Mental Health issue. 30 of females. If you add addiction to that youre going to be each higher. Current law is that in jail you lose your va and medicare benefits. Okay. So i have been arrests but i am not i have three months, sometimes you spend six months in jail before you go to court and i am mentally ill but i have lost my benefits even though subsequently im declared to be not guilty. This is a fairly common scenario. Im not making things up. Theres a Score Associated with this but as a physician i know that if the form yulary in the jail does not include the psychotropics that my care becomes disruptive and my condition may decline. So im begging the questions but can you give your thoughts, maybe ill kick it over to you, sir as to whatever the score, the wisdom of allowing medicaid and va benefits to continue with someone incarcerated and in jail at least prior to the point of being declared guilty or not guilty. So you bring up two important points. Number one, jails and prisons have become our defacto Mental Health and Substance Use disorder providers in this country and we need to flip that script and number two when i saw this firsthand in scott county we had to work closely with the jails to solve our hiv outbreak that was related to prescription opioid issues because we know that so many folks would cycle on and cycle off. It is a significant problem. So what youre telling me is that they will be admitted for hiv and their regimen would be disrupted so they would develop resistant because theyre getting off the one that controlled it and et cetera, et cetera, right . Its certainly not optimal for care and we need to look at how we can transition that system but ill also say just very plainly and frankly to you that i learned in indiana that we didnt have a lot of flexibility at the state level. Some of that is because of the law as written so we need to take a look at that and take care of the person because it had implications on the individual and society. Im glad senator brown is here from ohio. Im going to need a bipartisan colleague. I think the score is 10 billion over 10 years to allow the medicaid benefits to continue and when someone is as i have described, put in jail but before they are ajudicated. Sir. Thank you. Id like to add something. Throughout the last hour, we have talked about different components of the Opioid Epidemic and solutions. And as we have talked about each, we have talked about how to remedy each of these individually. But i think it would be helpful if we could go back to surgeongeneral adams mentioned three times in the last hour Something Else that i dont think has gotten the air time here which is stigma which is the biggest killer out there. He hasnt talked about any of the specific issues being the biggest killer. Its stigma and why has he said that . He said that because sigma reaches everything we have been talking about for the last hour. If theres policies in jails where people lose their insurance, why is that . Thats because most people in america think that its bad people doing bad things who cant make good decisions. When science shows thats not the case. Its why arent our payment policies different from other physical diseases . We have grown up in a Health Care Industry that believes its their fault. We shouldnt pay for treatment. 20 of doctors in this country in the state of massachusetts in a recent study that we did, which i suspect is relative to the rest of the country dont want them in their waiting rooms. 80 of americans in a recent poll said im uncomfortable associating with someone addicted to prescription opioids as my friend, my coworker and my neighbor. So lets say we get through all the hurdles and someone gets to treatment even though 20 of americans reported is one of the key reasons they dont go to treatment is they dont want anybody to know. Lets say they get past that hurdle and their parents force them in. They get to treatment and then they find a provider even though theres very few providers that treated today for the reasons we have been talking ability. And then they get to a provider that delivers quality care through all the hurlds that we heard about today and theyre successfully treated but they enter a society where 80 of americans dont want you working next to them, dont want you living in their neighborhood. Dont want you to be their friend. Dont want you marrying their daughter or dating their daughter. Im sure my son didnt see those statistics nor the 20 million americans, this is not just opioids or the 20 million americans adikted dicted to dru alcohol see that survey. But they feel it. They feel it every day. I thank you for being so honest with your experience because that helps fight that stigma. Senator brown. Thank you. Thank you for being here and thank you for coming to my office several months ago. Theres a lot of pain on this panel and among a lot of us that have had deaths in our family that we think shouldnt have happened or incarcerations or just difficult times. So thank you for your making it a mission of your lives to step up and help others so they dont have to experience what the pain that some of you and many of us in this room have had. How many instances of Substance Abuse Disorder Treatment recovery, related medicare or medicaid fraud did you investigate across these five states and of that total which percent involved a case where a patient was the perpetrator . Thank you for the question. We dont do the investigation of the case that would be a better question. However we did take we took a sample and fund all five states reported fraud and then we spoke with various actors involved in that including the fraud unit and to our knowledge, as we dont go into the case, but in florida, they were learned there and sent to other places without their knowledge. You can respond to that too. Is it your opinion that individuals with a Substance Abuse disorder seeking treatment are generally the cup pretties of the cases of fraud or more likely the victims . They are the victims. Overwhelmingly . Overwhelm i gueingly. We have some participating patients who are often maybe they are a patient but they are also a patient broker where they are trying to solicit other individuals to come into a fraud scheme. But generally speaking, they are the victims of the crimes. Do the two of you both believe that states are doing a good job of addressing fraud . Would you say they maintain the tools they have at the forefront that they have in their hands to police this fraudulent material, committed much less by the victim than the perpetrator . I think certainly on the Health Care Fraud space where we have medicaid control units, they are active this this space. Our office is very active. But where there have been maybe a need for oversights not in the Law Enforcement space, but the oversight of these Treatment Facilities and quality standards as we have discussed here today, to ensure there are quality Treatment Centers receiving federal funding and delivering the product and the treatment that we all expect. Did you want to add . Sharly, we also found that in our states that florida, massachusetts and utah had all art issed certification or license programs and texas and ohio, while they didnt have those programs, they were providing training and other services to the operators of the homes. They were very concerned and wanting to take oversight steps. Thank you. This question ill start with dr. Adams. But each of you answer, if you would. I preface it. There are every one of us on the parties think we arent doing enough with prevention, education, treatment and all that. I applaud dr. Cassidy for his interest. I know ores to keep them on medica medicaid. Its just upside down thing to think you take away their medicaid when they mostly need it at that point. Were clearly not doing enough to provide the kind of Treatment Options to everyone who needs them, but the overall number of nonelderly adults with a Substance Abuse disorder is low. Those with medicaid are more likely to receive treatment than those with private coverage. Thousands of ohioans are receiving Addiction Treatment right now because of medicaid. I was at a recovery at a Substance Abuse clinic in cincinnati and a man put his hand on his adult daughters arm and said my daughter would not be alive if it werent for medicaid. With know those stories and those statistics. My question for each of you is if youd answer as close as you can to yes or no, putting additional burdens on beneficiaries that make it harder to access and maintain coverage. It could compromise efforts to address the treatment and limit access to disorder. Are those additional burdens helpful or are are they not . Are you talking about medicaid . Yes. I would say that we want the to make medicaid as effective and easy to acts is as we possibly can. You frame it as a burden. It should make it more available. To craft the Medicaid Programs in a way that works if r their constituents. We currently have work looking at beneficiaries of medicaid and their act is sets to medicaid assistant treatment. I am not the expert, so i would have to get back to you. I would agree with the comments earlier. Specifically on any barriers for those who dont have insurance to get medicate. It would create a lot more life. We need to keep as few as possible so more people can be on medicaid. 100 . I appreciate that. Senator cassidy with this, the imposition of work requirements and state medicate programs will have a a Chilling Effect on access to treatment. This hearing underscores the ludicrousness and the hard hardedness of too many people in this body and the Trump Administration who are trying to repeal the Affordable Care act. It will mean more people died. Its young people with the parents plan. We know what it means for the expansion. We had a republican governor who showed more coverage for most of his Party Members around the country and ebs panded medicaid and saved thousands of lives. Its just absolutely cruel and stupid policy to think repeal ing the Affordable Care act could be good for our country. Thank you. Can i make a quick comment . I would just very quickly say that i ran the state department of health in indiana when we expanded coverage to several hundred thousand citizens. As Surgeon General i want everyone to hear that access to Quality Affordable Health Care is kritically important. This administration believed we should give states the flex nlt and opportunity to do it the way it works best for them. Again, the Record Number of waivers shows a commitment to that flexibility and giving states that flexibility. And this my Opening Statement, i talked about industries and in nu and i think its important that when we talk about work, we understand one of the biggest predictors of whether someone is going to be successful in recovery is whether or not they can get back to work. So i will be the first to admit that the idea of work requirements is a hot button topic. But us dont want us to lose that says we need to think about ways that we can help people reintegrate back into society and get a job. Thats what im focused on as Surgeon General. How can we lower the barriers to people getting back to work and how can we bring people together so folks can truly recover. Thank you for the opportunity to testify today. This is a kritically important period. And i also want to give you a shoutout to senator brown to the work youre doing in ohio. You have been able to drive down the overdose rates by 10 . Its because of the partnerships. Its in large part because we expanded medicaid and the president wants to take it away. So i appreciate who apointed you and i dont know your philosophy, i appreciate your comments on work requirements. But the fact is the president of the United States wants to wipe off the books the Affordable Care act with no replacement on medicaid and the fact that we have driven down, not very far yet, but driven down the death rate in ohio is because we have that very, very, very important Public Health tool. That will be the final rule, the chair will thank you all for your testimony. We leave the record open for two weeks for submissions of questions for the record. The hearing is now adjourned. Thank you. The chaur of the House Intelligence Committee is leading the impeachment inquiry into President Trump. He anonsed the fist public hearing will be next wednesday. And george kent. Well have live coverage at 10 00 a. M. Eastern on cspan 3. And former ambassador to ukraine Marie Yovanovitch will testify friday. Today President Trump holds a Campaign Rally in monroe, louisiana. Watch live at 8 00 p. M. Eastern on cspan, online at cspan. Org or listen live with the free radio app. The chair of the House Intelligence Committee adam schiff is leading the impeachment inquiry into President Trump. He ae announced the first public hearing will be held next wednesday, november 13th with testimony from state Department Officials William Taylor and george kent. Good morning, this hear is cool called to order. I want to welcome all the witnesses and thank you for your thoughtful, written testimony and looking forward to your oral tangherlini. Id ask my written Opening Statement be entered into the record. I want to make a couple comments. About really kind of what i want to see the goal of this hearing to be. Its similar to the the goal of every hearing is a base account problem solving process. This committee under my chairmanship developed a a Mission Statement to enhance the National Security of america to promote more effective and accountable government. The reason im pointing it out today is i cant think of a hearing that that Mission Statement is more applicable to. When we Start Talking about 5g were talking about the Economic Opportunity and the National Security risks. In order to take advantage of that and avoid the National Security risks. We need