Part of the Affordable Care act is coverage of Mental Health as well as Substance Abuse which gets to the heart of the issue of this problem. Since the aca Medicaid Expansion is more than 1. 6 million americans have gained access to Substance Abuse treatment. Could you speak to how individuals enrolled in medicaid are using the program and whether or not we are seeing an impact on folks suffering Substance Abuse problems . [inaudible] you would think i would know how to do this by now. National surveys, not having adequate access to Insurance Coverage and, one of the biggest reasons, the Affordable Care act did a number of things as related to increasing access to care. Substance abuse treatment and Mental Health treatment are the essential Health Benefits by Medicaid Expansion. Those are on par with other benefits. And increased access to care, under the Affordable Care act, the Medicaid Expansion population, they had higher problems than Substance Abuse than the general population. There are remarkable results in those states that have been dramatically impacted by this epidemic, like west virginia, kentucky, and we have seen an incredible increase in ability to access care when they do that. And the other intel the point is Substance Abuse disorders have comorbid Mental Health, and other health conditions, access and care for Substance Abuse disorder, they need care for hepatitis, Mental Health coverage, and i worry about people not just losing coverage but the stability of our treatment infrastructure. These programs operate on thin margins and i worry we will have a treatment infrastructure for those remaining people who can access care if they are not able to bill insurance. Anybody else . As i mentioned, in our system, we developed very unique partnerships with community providers. We screen 30,000 admissions to medical hospitals come of the largest in delaware, identify those who they treat that and go into care. That care is predominately medicaid. The Largest Community provider, the largest in the state developing the footprint because they have reliable funding stream. It is not only funding stream that cares for medicaid but all patients so it is a quality provider but the bulk of their revenue, what allows them to exist is they have a reliable revenue stream. Because of that, my records identifying somebody and that coverage is medicaid, medicaid goes away, that collapses and the Substance Abuse infrastructure i will identify individuals but wont have anywhere to send them. They relapse within hours to days and be back in the hospital and return to the good old days of the revolving door and that cost, astronomical cost of caring for these individuals, in places like the Hospital Health system and never find the root cause issue. The big difference these days is the volume used to be at a time is bundled, each bundle 13 bags, 50 bags a day. I think of it as russian roulette, any of those bags has fentanyl in it, it is amazing, because i have access, ready access to Substance Abuse treatment on demand, i am able to make a difference and i am clear that those individuals are not overdosing. You are on the a different perspective. We dont track it specifically, we go out and respond to that scene and one of the most heartbreaking things we see is an individual in the Emergency Department within weeks to sometimes days for a drug overdose, nearly dead of a drug overdose, these are the people doctor horton doesnt see. They dont make it back to treatment. They die and we dont have the capacity in my county to send these people with active attention, they we send them back on the street to try to see if they can work something out. Anything like Medicaid Expansion is eliminated, that limits peoples access to health care. I dont see any good coming from that in this crisis especially with this mortality. I appreciate those comments. Thank you for your service on the front lines. I assume you would concur. Absolutely. I am proud of my colleagues who have taken the lead on this. It is a Public Health issue, and Quick Response teams trying to get Addiction Specialists out there. We have become paramedics. It is not uncommon for users to take treatment. It is well with outside of our round to do this issue but for us we have become Addiction Specialists and for Law Enforcement to talk about that we should not be decreasing medicaid. Told you how important this is to us because in order to reduce that demand which would reduce supply, we have to get people into treatment and one of the programs we are doing is signing people up for medicaid to get them into the treatment so these are individuals walking with that user to get them into treatment and is medicaid is gone that would have a significant impact. It is difficult enough, not uncommon to find a user at numerous Treatment Facilities, driving them up and find their bed is gone so it is difficult enough. Taking away medicaid would make it more difficult and spinning our wheels, we are already like a mouse on a wheel trap standing as it is taking away the tools and we will dig ourselves in a whole. Thank you for your testimony, appreciate it. I will turn the gavel over to my colleague, ranking member, ask him to conduct his final questioning and close us out. I thank you for being here for your work every day come all four of you are in the trenches on the front lines. Thank you for helping to reverse this tied which is moving in the wrong direction so thank you. I will say this to your face thank you for your leadership on this. Maybe we can use the effort you have led along with amy klobu a klobuchar and others. If we can work that well across the aisle on important issues maybe, particularly on the piece of making sure they get treatment that they have access to treatment, how important it is, we need to focus our attention on that as well so thank you so much. I want to come back to as mentioned before. Explain to folks not just here in this room around the country who might be following this is how is it in delaware, when someone shows up at a hospital they had an overdose and they are willing, ready to go, ready to start treatment and within 24 hours or so we have the ability oftentimes to place treatment. Do we do that in delaware, not in other states . Do you have anything to do with Medicaid Expansion . Yes because that was the accident, putting someone into treatment i have to have treatment to put them into and that treatment is primarily the result of Medicaid Expansion, programs like our Largest Program developing outpatient slots they had revenue they could be relied upon. Without that revenue the treatment wouldnt exist. We are able to leverage each moment is there are many more, we are thinking how to partner with our colleagues, an individual so fearful going into that, going into treatment but you have to have partnerships and coordination and in the emergency room they are there but it was more about having the institution accept that this was an issue and moving forward to implement pathways and we are good at that, creating Electronic Health record mechanisms to screen and algorithms to treat so the natural place to do those experiments, they work and they can be replicated and by that i mean identify and vigils quickly, address it aggressively and use that as the liver to move them into care. They are interested and two thirds of my patients are willing to go and most of them show up at the back end. Do we have the same resolve where someone has been arrested for breaking into a garage. Our colleagues in Newcastle County in the police department, trying to struggle with it, they come up with their own programs on their own. Thank you for that. I would think of this as best practice and the ability, folks who of the hospital ready for treatment get them to treatment. Maybe you could give us another quick example of best practice the rest of us could run from and implement. You want to go first . This is an area we focus on at the white house by bringing best practice. The cost to the medical center, we open what i believe is the first opioid Urgent Care Center in the country so that folks who came through the emergency debarment were identified coming into the community could walk in or were brought into Emergency Department and dedicated staff, some peers, recovery coaches are able to work with them and getting a bed and getting access to care is not easy fa work to make sure people have the care they need but i have to say this is really important, i still believe has the lowest uninsured rate in the country so it is not an issue for staff at Boston Medical Center in the Emergency Department or any other facility. We have a generous medicaid benefit. But opioid Urgent Care Center is something worth looking at. I have to go along with that, trying to get hospital to work with us and allow people to go in as patients. Looking from a lawenforcement aspect which isnt going to solve be the answer but the problem we are facing on the front end line is those people who dont want to get treatment which is significant amount of people so there is a hurdle not just going to jail or the hospital but getting them how do we get them there. Those of the challenges we face to overcome. Taking it to a medical system where we go to a hospital, and if we start treating this brain injury or illness like it is defined as a chronic illness, we would have a better solution. Thank you. You know, a lot of ideas come to mind. Give me a really good one. One of the things we have to do is use information gleaned from people who die of overdoses to divine intervention strategies. We saw 40 of people who came to my office during the heroin phase of this epidemic, where they had been in treatment for two years. I send each of the people leaving jail or Treatment Facilities a letter selling Risk Reduction strategies, dont go back to the same does. There is a tremendous amount of Public Health information to be gleaned by medical examiner systems which if we can take the burden off of the epidemic crushing of these systems could be potentially used for intervention strategies. Im going to close, another thought or two, senator peters will close it out. I want to thank you again. For those who represent, we thank them, we have hearings, the hearing is illuminating and terrifying. This is both. It is an all hands on deck a moment as we wrap this up. My deputy Legal Counsel in my last term as governor, things i was asked to do was be the vicechairman of American Legacy Foundation but it was created out of the 50 state tobacco settlement, the Tobacco Industry provided a lot of money to each of the states for period of 25 years. We also provided 2 billion, the American Legacy Foundation which developed a truth campaign, the most Effective Campaign we have seen in this country of history in terms of convincing young people if they were using tobacco to stop and if we hadnt started not to start. I realize it is not entirely comfortable here, talking about messaging, in the back of my mind there has got to be i talked earlier, no silver bullet, that might be something i would not given what we accomplish with the American Legacy Foundation and truth campaign. Finally i mentioned in the first panel, we would be asking questions for the record. A short list, things we ought to be doing. And some of the things you said, that would be fine but you have a sense of urgency on this side and i am sure we feel it on your side as well. Thank you for what you are doing, we are in this together. Senator peters. I concur with your comments, thank you. One last final question going back to the root causes and appreciate your response on how to make sure we have medicaid available for Substance Abuse counseling and treatment but there is compelling evidence prescription opioids are one of the key drivers of what we are seeing here. In your testimony it struck me you mentioned in your county that individuals who were prescribed a controlled substance within two years of their death, half of them had prescription opioids that led to this, are you aware of other sorts of treatment we should be prescribing so we can stop what appears to be perhaps overprescription opioids to patients to become addicted, we have different types of treatment and thinking about how we Practice Medicine and are their impediments to preventing that . What should we be thinking about Going Forward in trying to stop the pipeline that starts with some Prescription Drugs . You hit the genesis of the problem, the nail on the head exactly. The culture in medicine, the scientific support was minimal and that unfortunately became a standard of practice that i think created a large opiate addicted population. If we gave prescription pain medication to everyone in this room they would become addicted to prescription pain medication and opioids. We have created a substantial, large, addicted population through the use and abuse of prescription pain medication. That is in convertible he true. How we get back from that is we have to start the reeducation, put much stricter use and guidelines on people prescribing pain medication. People have chronic pain but if it is an ineffective treatment that creates an unnecessary and detrimental consequence, that is not a good treatment and we should hold accountable people who promoted that idea. It wasnt very well documented and im ashamed to say that the medical community played a part in this crisis is in stopping. I have lots of anecdotal information of people getting them ands worth of vicodin after they get teeth pulled. We have to stop that, turn that flow off. But folks said we have a population of people who are suffering from that overliberal prescription, we cant turn our back, they will be with us for a while, treatment does work and the ways we improve treatment will be more effective for them. We work on comprehensive guidelines and the issues we heard in terms of nonopioid steroids, the challenges of changing the culture, giving out prescriptions, the other issue is insurance reimbursement for things like physical therapy and acupuncture and Mental Health therapy can really help so that is an issue we have to take a look at in terms of those challenges. I will say that we have had some good evidence in states that have really robust drug Monitoring Programs, we have seen good data on Prescription DrugOverdose Deaths where you had to register and check each and every time so many states have moved to mandatory registration and mandatory checks because it seems that worked. You often get pushed back from physicians. I understand sometimes they are busy but my response was we are 15 years into this epidemic and i dont think it is unreasonable for a physician to take a modicum of education to check the Prescription DrugMonitoring Program because we are losing too many people. Appreciate your testimony. Where you going to Say Something . We have been able to implement those measures around the pmp and wretched up regulations for prescribers. There are changes we are starting to see believe a cultural change so there is hope at the levels that are meant. As far as treatments for Prescription Drugs. In many ways we let the genie out of the bottle is most patients i tend to were exposed to Prescription Drugs, then starting to see two epidemics, Prescription Drug epidemic, measures need to continue to reduce exposure and we have a heroin epidemic as well. If i could add one more thing that is important. Because congress supported this. If you talk to the folks at the at institutes of health, we need to do a better job researching nonopioid pain medication and one of the barriers looking at what the Administration Proposed in reductions, youll see that a significant damper on and i ands Research Capabilities to come up with nonopioid, nonaddictive prescriptions for pain medication, it undercuts what Congress Asked as part of 21stcentury care act. That is a good note to end on. A lot of good ideas. Some we heard before. We preaching to the choir. It is safe to tell you a number of good factors, best practice, new ideas and especially the last one makes a lot of sense. My thanks to you for coming, the work your colleagues are doing, the record will remain open for 15 days for any additional comments or questions by subcommittee members. With that, this hearing is adjourned, thank you so much. [inaudible conversations] [inaudible conversations] this morning fcc chair will speak at an event on Telecommunications Policy hosted by the 3 state foundation. It will include discussions about deregulation, Net Neutrality and privacy. Live coverage at 9 30 eastern on Hart Senate Office building and cspan. Org and cspan radio apps. On sunday author and journalist matt type ab taiibi will be our guest on booktv. One faith you feel is honors just for you, that you fall in love in that moment. For me trump was like that except it was the opposite. When i first saw him on the campaign trail i thought this is a person who is unique, horrible, amazing, terrible characteristics, put on earth specifically for me to appreciate or not appreciate or whatever the verb is. I had really been spending a lot of the last 1012 years without knowing it preparing for donald trump to happen. He is a contributor to Rolling Stone magazine it is the author of several books including smells like dead elephant, dispatches from a rotting empire, the great derangement, a terrifying true story of war, politics and religion. Story of bankers, politicians and the most audacious power grab in american history. And his most recent book, insane clown president , dispatches from the 2016 circus. During our live three our conversation we will take your calls, tweets and facebook questions on his literary career. Watch in depth with author and journalist matt taibbi sunday. Gary lynnfoot was paralyzed when serving in iraq in 2008. Hes now the first