Night before. She said, we do not believe in terrorism. She demonstrated this. This extraordinary inner fortitude that she possessed, which was a quality of hers to an extent that very few other peep in World History can demonstrate. She had that. She stood up and she showed it. I think that must have given courage to not just her party but the country. There was fear around. She was going to give in to it. I think thats one of the extraordinary qualities. Thats a tremendous fitting end to the discussion. Thank you very much for our three distinguished guests for a fascinating and extremely insightful discussion. Thank you, everybody for joining us. We have a reception following the event if you would like to join us for that. Thank you. Later today, president obama will be giving a speech in newark, new jersey. We will have coverage on cspan2. The House Veterans Affairs committee will be hearing from subpoenaed Witnesses Today on alleged misuse of the Veterans Affairs program to relocate workers. Live coverage on cspan2. As the new speaker begins his first full week, what will it look like on the house side in terms of his first agenda . Good morning, bill. Well, all eyes will be on ryan. This is his first week as speaker. He hit five talk shows yesterday and made it very clear what his priorities are. He wants to change house rules, the way the house is run. He wants to lay out a bold vision. His first big test in the house will be the highway bill which comes up for consideration. It is facing a november 20th deadline and a little patch was fasted recently to give them extra time to work out a compromise between the senate and the house. The senate has passed its bill. The house is taking up its bill this week. Ryan wants this more open process, is whether he is going to allow a lot of amendments on that bill and there are funding issues as well. Thisi will be his first big tes. Washington post has a picture of president obama signing the veto of the Defense Authorization bill. There is talk that congress may work this week on overriding the president s veto. I am not sure whats going to happen with that. They can try and do that. They dont really have the vote for that. It is not clur what is going to happen with that. How about on the senate side as they return. You are going to see another pushback at the senate on the republican side. Republicans are trying to get a bill through that would have the epa revisit a rule on epa or Environmental ProtectionAgency Oversight of water. Small, small bodies of water. Republicans complain that the epa rule has gone so far that it would regulate puddles and ditches and some democrats from farm states specially agreed with republicans on this, that they would like the epa to go back and relook at this rule, which they see is just incredible overreach. That particular bill faces a procedure hurdle in the senate this week. It is not sure they are going to be able to, republicans, reach the 60 vote threshold to get past that. At the moment, it doesnt look like they will. Francine keifer is congressional reporter for the Christian Science monitor. Thanks for joining us. Thanks, bill. The house is back in for legislative business later, 2 00 eastern today with votes at 6 30 eastern. Live on cspan. The Senate Returns tomorrow at 10 00 a. M. Eastern on cspan2. All persons having business before the honorable, the Supreme Court of the United States are admonished to draw mere and give their attention. This week on cspans landmark cases, we will discuss the historic Supreme Court case of schenck versus the United States. In 1917, the United States entered world war i. Patriotism was high. Some forms of criticism of the government for a federal offense. Charles schank, general secretary of the socialist party handed out and mailed leaflets against the draft. This was the flier that was produced in 1917. 15,000 copies were produced. The point was to encourage member liable for the draft not to register. The language in this flier is particularly fiery. It equates the con description with slavery and calls on every citizen of the United States to resist the conscription laws. He was arrested and he appealed and the case went directly to the Supreme Court. Find out how the court ruled weighing the issues of clear and present danger and freedom of speech. Our guests include attorney, thomas goldstein, cofounder of scotus blog and beverly gauge, professor of his story at yale university, coming up on the next landmark cases live tonight at 9 00 p. M. Eastern on cspan, cspan3 and cspan raid crow. For background on each case while you watch. Order your copy of the landmark cases companion book. It is available for 8. 95 plus shipping at cspan. Org landmark cases. Next, a hearing on Mental Health. The director said they conduct research on guns as it relates to Mental Health. He is joined by other experts testifying before the Senate HealthCommittee Last week. The Senate Committee on health, education, please come to order. Senator murray is on her way. It is suggested we go ahead. She and i will each have an Opening Statement and introduce our panel of witnesses and after our witness testimony, senators will have five minutes of questions. Tom, we are discussing the importance of the issue of Mental Health and Substance Abuse disorders. Mental illness affects a great Many Americans. According to a 2013 report, nearly 1 in 5 adultses over the age of 26 reported suffering from a Mental Illness. Nearly 1 in 10 reported having at least one major depressive episode. In tennessee 1 in 5 adults reported a Mental Illness in 2013. More than 1 million. About 5 had a severe Mental Illness. About 41,000 had a major depressive episode. Already, an enormous response to try to help at the state level, the private sector and the federal government. As a former governor, i know that states have traditionally been on the forefrant with the department of Mental Health, Treatment Facilities and Community Based services. States have had the primary responsibility for behavior, health and Community Based programs that include counseling, case management, social work and provide screening, diagnosis and treatment for children. In the private sector, there are many private hospitals, nonprofits, Mental Health professionals and others working to help those in need. Efforts for the private sector totalled about 67 billion in 2009 or 39 of total dollars spent for behavior health, which includes Mental Health and Substance User advices. Government spending totalled about 105 billion in 2009 or 61 that includes medicare and medicaid. One role is through the agencies. Its role in supporting Mental Health programs is relatively small compared to the responsibility that states have in the role of medicaid. It is critically important. Sam sa supports states, Behavioral Health care providers and others by improving the availability and quality of prevention and treatment services. Collecting Behavioral Health data. Samsa should be looked at as a leader in the field. The biggest Government Role is the amount of money and the amount of money is spend through you medicaid, which is a federal state partnership. In 2009, medicaid spending on Behavioral Health totalled about 44 billion. 26 of total dollars spent. These medicaid dollars can be used to provide care from community Behavioral Health professionals, inpatient or residential treatment for seniors with Mental Illness and help those with severe Mental Illness get the prescription drugs they need. In tennessee, state spending totalled about 555 million. Half was spent on the state. The federal governments medicare spending plays a role financing seven of total expenditures to treat Mental Illness at 21 billion a year. These medicaid dollars could help seniors and a small fraction of inpatient for Mental Health. This federal support already is a significant amount of money. One question for today is, should we be spending these dollars differently or more dollars . If so, in what ways . There are causes for the federal government to help those in need and to do more. Twice, the Senate Health committee has passed different versions of the Mental Health awareness and improvement act senator murray and i have sponsored. This Bipartisan Legislation supports suicide and intervention programs. It helps train teachers and School Personnel to recognize and understand Mental Illness. It works to reduce the stigma against those struggling with Mental Illness and helps children recover from traumatic events. I hope it will be passed by the senate and become law by the congress. Other senators are attacking the issue of how to improve Mental Health treatment. Senators cassidy and murphy have a Mental Health bill. Senator franken and senator cornen has a bill he is working on. So i expect to see the help Committee Report additional legislation in the coming months that better supports states in addressing Mental Health and Substance Use disorder. Today is to better understand the federal governments role in Mental Health treatment and how it can help states like tennessee meet such high need and deliver such critical care. Other things we can do, problematic things. Are we putting up roadblocks . How are our programs working . I am particularly interested in your thoughts onement tall Health Research . Thats one of the most important things our federal government does. That enables individuals to move forward in this big complex society. We are not such good managers. Sometimes we are not even good regulators. Government research that we have funded and encouraged has enabled enormous breakthroughs in our country. I would like your thoughts as well. Senator murray. Thank you to all of our colleagues that are joining us today. I want to welcome you as you prepare to move on and thank you for your tremendous amount of work. We all appreciate what you have been able to do and will continue to do. Over the last three years, we have made Real Progress towards building a Health Care System that works for our families and communities and puts their needs first. As i have often said, there is a lot more we can and must do, specially when addressing Mental Health and Substance Abuse. Today, nearly 1 in 5 people in our country experience Mental Illness in a given year. Far too many do not receive treatment when they need it. There is on average nearly a decade between someone showing signs of Mental Illness and getting treatment. Suicide is the second highest cause of death for those 1534. Nearly a quarter of the state prison population has struggled with Mental Illness. These statistics are deeply disturbing. The stories behind them are even more tragic, of stigma that keeps too many of them from seeking help even though it could make all the difference, of treatable illnesses dealt with by a judge instead of clinicians. All of us have heard these stories far too often and they demand action. Members of this committee on both sides of the aisle have made clear that improving our Mental Health system is a priority. In particular, i do appreciate the bipartisan work that senators murphy and cassidy are doing to push for progress. Im looking forward to hearing from my colleagues and our witnesses about the ideas they have to strengthen our Mental Health system and prevent more of our parents and our friends and our neighbors, students and children from falling through the cracks. Our Mental Health workforce should support the foundation on which a sprong system is built. Far too many communities have inadequate access to Mental Health professions. Half of all u. S. Counties do not have a single psychiatrist, psychologist or social worker. In far too many patients, it is unclear where to turn for help. We have to make sure they can intervene and treatment and support those struggling with Mental Illness. This is critical to show that it is seen as much of a priority as physical health. So is integrating primary care with Mental Health care. Too often, patients mental and physical health are considering separately. Patients with serious Mental Health illness who need primary care may not get it when they need it. On the other hand, any signs of Mental Illness may go undetected. That presents a real threat to patients with Mental Illness, specially those with chronic physical Health Problems or Substance Abuse disorders that can make Mental Health worse. I am interested in a model being practiced where Mental Health professionals can provide telehealth consulting in communities that lack access. That model helps patients receive treatment that is mindful of both mental and physical health. As we work to improve detection and treatment of Mental Illness, with he need to prioritize Crisis Response. I have heard too many stories in my state and across the country of patients with Mental Illness held for days and weeks in Emergency Rooms or even solitary confinement waiting for treatment. That is unacceptable. Communities need the resources to respond quickly and appropriately when someone is clearle in or approaching a crisis. Without those resources, it comes too late or not at all. Suicide takes tens of thousands of lives and shatters countless others. I have been deeply concerned about the high rate of suicide among our veterans. We also need to take a close look at what is driving those tragic decisions among other populations. I was very concerned to learn, for example, recent studies show young adults from tribal communities are at specially high risk. I know the administration is very focused on Suicide Prevention. Our committee recently passed the Mental Health awareness and act. So i look forward to continuing to Work Together to put an end to this crisis in every one of our communities. Finally, it is critical to acknowledge that in order to confront the challenges we have talked about and many others within our Mental Health system, we have to break down the barriers that stigma creates for those sfrufrg Mental Illness. That means prioritizing research that helps enhance our understanding of and ability to effectively treat Mental Illness. It also means raising awareness so those struggling dont feel they have to struggle alone. I saw this stigma early on when i interned in a v. A. Psychiatric ward when i was a college student. There were veterans returning and they were told they were simply shell shocked. Over the course of my career, i have heard time and time again from veterans and constituents from all walks of life that stigma and stereotypes are a crushing burden to bear on top of illness. Those struggling with Mental Illness should be treated with compassion, respect and dignity and they should have the resources they need to live and work in their communities. That is something i will continue to be very focused on. Mr. Chairman, im very pleased that we are having this discussion today. I look forward to working with you on a bipartisan basis to strengthen our Mental Health system and give more patients and family the opportunity to lead healthy, fulfilling lives. Im confident that everybody has a story about a friend or a loved one or a classmate or a coworker that faced Mental Illness. The harsh reality is that these challenges face all of us. Thank you for everyone participating. Mr. Chairman, thank you for holding this hearing. I look forward to this conversation. Thank you, senator murray. This is a subject that has broad interest among members of the committee, as is indicated by a number of senators here today. I would say this is yet another what we call bipartisan hearing, which means that senator murray and i have agreed on the subject. We have agreed on the witnesses. We have had very fusocalled partisan hearings during this kreer. I think that has been good for our committee. I am pleased to welcome three witnesses to our hearing today. Thanks to each of you for taking the time to be here. You have busy jobs overseeing important agencies. First we will hear from kanu inamoto, acting administrator of the Substance Abuse and Mental Health services administration. That means she oversees four centers, one for Mental Health, one for Substance Abuse prevention, Substance Abuse treatment and behavioral statistics and quality. She has been serving at samsa since 1996 in several positions. Our second witness is mr. Jim mccray, acting admin traitor of health administration. He joined hersa in 1992 and has since held several positions. He has received several awards in his leadership. Next, we will hear from dr. Tom insul, director of the National Institute of Mental Health, which is part of the National Institute of health. He has held his position since 2002, focused on genetics and biology of mental disorders. Before that, he was professor of psychology at emmaury university. He will be leaving his position to pursue Research Outside of nih. We appreciate his service and his willingness to come here before his departure to tell us bluntly and safely what we should be doing. It is save to do it now. We will again, mrs. Enumoto. Chairman alexander, Ranking Member murray and members of the committee, thank you for holding this topic. Thank you for inviting me to testify today. Its a great honor to talk to you about the state of americas Mental Health system, a topic veneer and dear to my heart. I would like to discuss with you some of the initiatives that samsa is delivering. Neuropsychiatric disorders are the leading cause of disability burden in the United States. More than 1 in 4 Social SecurityDisability Insurance recipients are enrolled due to a Mental Illness. Individuals with serious Mental Illness or smi, make up over 40 of those dually eligible for medicare and medicaid. Mental Health Spending accounted for only 6 of Health Care Spending and Substance Use spending accounted for only 1 . The burden of untreated or undertreated Behavioral Health conditions on the labor market, criminal Justice System, families, schools and communities and others is tremendous. In this context, the Mental Health budget, approximately 1 billion in 2015, a small but important influencer. To accomplish our mission, samsa cannot work alone. Another key role is to coordinate programs across hhs and with other federal departments. One main example is that sam sa cochairs the council which was established in 2010. The chief goal of that group is to provide a plat foform for Knowledge Exchange and to ensure that behavioral issues are handled col lab borat tifl. Across federal government, samsa works closely with the department of defense, education, hud, just sis, foreign affairs. We work on a wide variety of issues for people with or at risk of Mental Illness. We administer competitive Grant Programs. First, the Community MentalServices Block grant is a flexible spending source. For Mental Health. It is to support planning and educational activities for adults with serious Mental Illness. Starting in fy 2014, congress required states to set aside 5 of those funds for evidencebased programs that addressed the needs of individuals with early Mental Illness including psychotic disorders. An initial evaluation tells us that this is helping states increase access to early programs and reduce untreated psychosis. This news is so excited. The ability to preempt longterm disability for hundreds of thousands of Young Americans is at our finger tips. We also recognize that financing is an essential piece of the pule. We work closely with our colleagues at cms and to align Payment Systems and encourage high quality qucare for adults d children with mentale illness and Substance Abuse disorders. Last week, samsa was pleased to award section 223 planning grants to 24 states to Certified CommunityBehavioral Health clinics and prepare to participate in a twoyear medicaid demonstration program. The ability to transform the Way Community services are reimbursed could help us turn the corner on key provider, quality and capacity disorders. This is also a critical area of focus. An evaluation of the garrettleesmith program demonstrated with counties with Suicide Prevention activity saw lower rates of suicide and suicide attempts. Too many communities and too many communities are unaware of the Major Public Health crisis we are facing around suicide. While we are making progress in the area of youth solid, middle age and older adult suicide continues to climb and samsas Suicide Prevention limits the focus to youth and adolescents. It shows that nine out of ten people that die of suicide are over 24. We must expand the scope of our prevention efforts. As jim mccrae wellknowns, no conversation with be complete without talking about workforce needs. Together, the Affordable Health care act are expected to span to over 60 million americans. We will need additional compass in order to help have space for the people that need treatment and will now begin to seek it. The expanded workforce includes prescribing and nonprescribing professionals, including psychiatrists, social workers, counselors, and peers. We are grateful to sersa and the imh for their outstanding work in Mental Health resource and thankful to the committee. If i make take liberty for a few more seconds, i would like to dedicate a couple of moments to express appreciation to my colleague, dr. Tom insel. You are a powerful leader for our field, steadfast in your vision that Mental Health research, whether at the level of the genome or the globe should be of no less rigor or quality than any other field of researchment your commitment to bringing the best science to bear on any policy or program question has been invaluable to samsa. Thank you for your service. We at samsa stand ready to help you achieve the tenfold impact of your next innovation. Thank you, miss enomoto. Mr. Mccrae. Thank you, all members of the committee. I am pleased to join my colleagues today to share with you what we are doing at the Health Resources and Service Administration to address the Mental Health needs in our nation. As my written testimony conveys, we are the primary Mental HealthAgency Charged with improving access for people medically underserved, including those low income, live in Rural Communities and vulnerable populations. We carry out our work in partnerships with state and local governments and academic institutions among others. The programs and other 3,000 grantees provides millions of dollars to those across the country and we train thousands of health professionals. One key area has been on expanding Behavioral Health within health settings. Hrs can be a critical access point for those suffering from Mental Health issues. As some individuals often feel less stigma and feel more comfortable is discussing and sharing Mental Health concerns with health care providers. For instance, depression and anxiety are ranked third and fifth as the most Important Reasons why people come to the Health Center to a primary care center. Health centers also share with us by having a Mental Health provider on staff and colocated in the primary care setting that their other primary care providers feel more comfortable and are better able to address the Mental Health needs of their patients and better cool nigrdi their care. Hrsa has invested more than 160,000 in the past year to Health Centers nationwide. We have done this through establishing new Mental Health services or expanding existing services. And through the investments we hope to provide care to an additional 1 Million People suffering from Mental Illness. In addition, hrsa supports the National Technical assistance resource that helps Health Centers and other safety net providers on the mechanics of integrating the primary care in Mental Health and Substance Abuse services. How best do you do it . One of the other keys to addressing access to Mental Health services is of course building a strong Mental Health workforce so individuals can see a provider when they need one. The National Service coordina r coordinator, one of our key programs, repays loans for those practicing in underserved services, primary care, dental or Behavioral Health. In return they agree to provide service for two to four years in designated areas of the country that need them most. In particular the National Health workplace has a number of mental and Behavioral Health providers including psychiatrists and Mental Health shortage areas. Since 2008 the number of Mental Health providers has increased from about 800 to well over 3300 in 2015. In addition, our agency also supports a number of Health WorkforceTraining Programs that help increase the Mental Health training of our providers nationwide. For example, since 2014 in collaboration with samsa, we have integrated the educational and grant training program. These grants have enabled more than 1100 social workers, psychologists and family therapists as well as more than 950 Mental Health care professionals to receive Clinical Training in academic years 2014 and 2015. We also recognize that Mental Health is, a particular need in our Rural Communities. And, in particular, despite the need per capita, there are fewer Mental Health providers in Rural Communities compared to urban ones. Through the use of telahealth and telamedicine, they have provided care in rural areas to improve care. These are also common in persons living with hiv and aids and are critical barriers to care as well as adherence to treatment. And through the programs we have supported training for providers to screen, identify and treat those with Substance Abuse or Mental Health needs. In conclusion, hrsa shares the goal of ensuring a primary care Health System that supports Quality Health and mental abuse services. In particular, by integrated the expanded capacity of the primary health care, training more Health Providers and utilizing new methods and technology such as telaMental Health in underserved areas. We look forward to addressing the Nations Health and mental and substancef 4 theres a lot going on thats worth talking about. Senator murray, as you click through the issues around the workforce, we have the opportunity of collaborative care, what we are doing for Crisis Response we also have issues around diabetes and metabolic syndrome and tremendous number of problems with the fact that about twothirds of them are smokers. So they develop chronic pulmonary disease. So one of the reasons why people of Mental Illness die ten years early as you mentioned is not because of suicide so much as all of the chronic and often very expensive medical complications that they develop for a variety of reasons. So these are huge Health Issues that need all of our attention and we need to be thinking about how to address them in the most impactful way. As youve all mentioned and understand, this is part of nih research. We do the science. And the science is changing as well. Partly because of the Brain Initiative and partly because of our understanding that now we can address mental disorders as brain disorders. We have the tools to change the diagnosis and to develop new kinds of treatments. And most of all, the understanding that we have here very much coming out of our experience with Heart Disease and cancer. That if were going to bend the curve, we have to detect early and intervene early. We have to really move upstream. Thats so much of our past focus in this area that has been on people with chronic disability. Thats obviously very important for us to do. But the future has to be much better detection and much earlier intervention. And then developing as i mentioned the comprehensive treatments for early psychosis to ensure that someone who does actually develop psychosis, if we fail to preempt it, gets the best chance for recovery. And the focus on reducing suicide, as you mentioned, senator murray, this is an area that has not budged in the same time when the homicide came down 50 . We are still looking at the same suicide rate we had in 1990. We have got to understand how to address that and put that away. My last comment, as many of you have noted, this is my swan song. And im in some ways whistful about leaving the position and leaving a lot of people i care about so much, and certainly want to continue to focus on the issues now from the private sector. I did want to share with you, but i mentioned in my testimony, which is in leaving as i look back on what i have learned and what are the sort of abiding truths that i would carry with me and want to convey, i think there are really two factors that come back to me over and over again. One is that i think we can do much, much better than were doing currently with the diagnostics and treatments we have. Theres just in this field, more than many areas of medicine, just this unconscionable gap between what we know and what we do. And both of you spoke to that a little bit in your Opening Statements. We are all aware of that from our own communities or personal experience. This is a huge gap that weve got to figure out how to bridge. At the same time, i want to stress that as with Heart Disease and cancer and maybe even more so in this area, we dont know enough. We just dont know enough to ensure that everyone will recover to have a cure for every one of the problems that people with schizophrenia, depression, bipolar disorder, autism develop. These are difficult, complicated problems. And we have got to invest, not only in Better Services but also in more science. Its going to be essential that we understand these disorders at a deeper level if were going to come up with the treatments that are going to be most effective. I think we can do it. In my career ive seen this happen for childhood cancer. Ive seen it happen for Heart Disease with the mortality coming down 60 . I have seen it happen recently with aids with the mortality coming down 50 . We have not seen those numbers bid for mortality in this area. And that is something we have got to tackle in a new way, fresh ideas, better science and closing this gap to take the things we know today and make sure thats what we are actually doing in practice. Thank you very much. I look forward to your questions. Thank you, dr. Insel. Did you say that twothirds of those with Mental Health were smokers . With serious Mental Illness or schizophrenia, the numbers climb higher than twothirds. Is that a lot higher than for people with diseases other than Mental Health . Yeah, absolutely. Its not higher than when you look at males with lung cancer, they have very high rates of smoking as well. But as a group, i dont think theres any medical Demographic Group that has as high of smoking than you see with those of Mental Illness. And i might add, it is not just that they are smokers but the way the people with schizophrenia smoke is quite different than others smoke. They consume more cigarettes, inhale further and are much more likely to develop chronic respiratory diseases as a result. Its a huge medical health problem. We have launched and samsa has worked with us on many of the efforts to get people with schizophrenia who are chronically ill to stop smoking. It is doable but its a tough slot. Its hard for them to slot and always have questions about whether nicotine in some ways is a way of selfaddicting. And we are not really quite the science there isnt quite baked. Dr. Friedman says smoking is still the number one killer in the United States. Lets talk at our research a little bit. Last time you were here you talked about findings from your recovery after initial schizophrenia episode. Youve done some work since then, what have you found out . What have we done to translate those findings in the practice . Right. So the recovery after initial schizophrenia episode was a program in 36 sites across 22 sites, community sites. So try to understand whether we can do better. With what we know today, so taking a whole range of interventions from medication, family psycho education, providing resilience training, looking at the teams and supporting housing and employment, all the things we have known about for years, putting them together in a package and delivering them. The results for the primary outcomes were just published two weeks ago. And they are very positive. It looks great, the most disheartening part of that story is that amongst the nearly 400 subjects that were part of the study, the mean duration of untreated psychosis was 74 weeks. Which is just stunning. Its hard to believe. So what were doing now is moving this forward into communities, working very closely with samsa. I mentioned the importance of putting this what is now called coordinated Specialty Care into this state system thats part of the Mental Health block addon. There are now 32 programs based on this and we are looking to even expand it further through something called the early psychosis intervention network, which will create a learning Health Care System that will actually allow us to have electronic Health System and a coordinated care effort that can incrementally improve as we go. So its a high priority for the institute. High priority for samsa. Its a great story of teamwork across the agencies as well. You refer to your Brain Initiative what are the most significant findings so far there . And is this part of the overall Brain Initiative that dr. Collins has talked to us about at nih that he hopes to be able to do . It is. So dr. Collins has we sometimes joke, hes a bornagain neuroscientist, though he was trained in another area, hes discovered how spectacular neuroscience is today and almost any area in science, this is the place where we have so much traction and so much excitement. The Brain Initiative launched by the president in april of 2013 has moved forward. We have now funded our second year. About 84 million that we have invested for over 100 projects across the country. And what were this was in your agency or the whole entire the 84 million is nih. There are ten institutes within nih engaged in this. Dr. Walter corshetz and the you are inology institute and myself from nih. So its a partnership with darpa and fda and nsef as well. There are a lot of private partners involved. The important thing to understand is 84 million total funding or nih funding . Nih funding in 2014. Thats where we are up to. The president has asked that goes to 150 million. And i hope in the house and senate theres ambition to go way beyond that for next year for 2016. This is not about specific diseases or brain disorders. Its about developing the technologies to be able to understand how the brain works. And were seeing already fantastic tools being developed across the country without wanting to say too much about it at this time, but theres a group in seattle, the brain Allen Institute that has really opened up this whole field for all of us in a way that gives us the excitement that over the next few years well transform the way we study the brain. Thank you, senator murray. I will just followup with that. In my home state we have the brain span atlas at the Brain Institute in downtown seattle. Tell us what you can about that and some of the other applied research projects. We have the Mental HealthResearch Network there as well making amazing strides. We have great hopes for them. Talk a little bit about that. I could spend all morning bragging about my colleagues in seattle. Let me just quickly tell you what those two projects are. Brain span was funded through the recovery act. So that was a great opportunity with some additional funding for us to build something that didnt exist. Essentially it was a way of saying, could we create a map for the human brain where genes are expressed. Theres a reference atlas when we find the gene associated with autism or schizophrenia, the first question you ask, is that gene even found in the brain and if so when . And the most significant piece of information out of this work by the Allen Institute is there are enormous differences in both space and time for how this works in the human brain. And that the developing brain looks almost like a different organ than the adult brain. And to you are a amazement, it wasnt until we had this atlas that we began to realize the genes we are finding, which may not be significant in the adult brain are remarkably important in the development brain. And often though they dont get expressed together in adulthood, they sit in the same cell and same part of the brain at the same time in development. Thats fantastic. We would never know that without this reference atlas. So it has been transformative. The Mental HealthResearch Network developed through group health in seattle, fantastic opportunity. 10 million patients now across it is actually 12 different states with 11 different Health Care Systems to create a single data framework. So all these people getting Mental Healthcare are using the same electronic records. And its giving us a platform to move very quickly to ask questions about what is the best way for a suicide attempt. If someone shows up in an emergency room, we know 2 of these people will be dead in a year from suicide. That represents one in five suicides or people who have been in an e. R. Within 12 months. Can we figure out who those people are . And with gregs help and with the mhrm, which is a vast scale, you can begin to look at how to Deploy Services for those people to make sure that we bring down the suicide rate in that population. So the mhrn has turned out to be for us an ideal platform to ask practical questions about how to provide better care. Instead of the classic, how do we move research and practice . How do we take practice and move that to research and make sure every patient becomes a partner. Thats really interesting and exciting and we will really open up this field. So thank you for that. Senator, you talked about suicide in america with the Public Health crisis. When i was chair of the Veterans Affairs committee i was very focused on improving Mental Health services and Suicide Prevention for our veterans, but its not just veterans that are at risk here. We know suicide is the second cause of death along americanindians and alaska natives between the ages of 10 and 34. The cdc reports that lesbian, gay and transgender are a high number as well. Working with veterans, what lessons have we learned about reducing stigma or encouraging individuals to seek out care and peer counseling, those kinds of things. We have developed Risk Assessment and have learned that it is important to specifically screen for suicide from that work. And we have learned the importance of connecting as tom has mentioned the connecting after a hospital visit as well as the need to connect people that do express further desire for services with suicidespecific services. So it is not enough just to connect them with general Mental Health services but services that are going to address theed is suicide all itself. We have seen them deployed outs the v. A. System into tribal communities. And that is something that samsa is building its initiative around. Is it fair to say in the past we have said, dont talk about suicide because you might make it happen . And rather gone to a lets talk about it so its open and prevent it conversation . Absolutely. I think thats very insightful comment. Thank you, senator murray. We have 11 senators in addition to senator murray and me. Im going to ask the senators, we can try to keep the q a session to five minutes and want everyone to have a chance to join the conversation. Ill call on the senators in seniority of how they arrived before the gavel and first arrival after the gavel. So the next senators will be senator collins, franken, cassidy and then murphy. Senator collins. Thank you, mr. Chairman. Ms. Enomato. One of the Current Issues in the current men tal Health System is that its often for too difficult for parents to get help for their Adult Children who are suffering from serious Mental Illness. Over the past few months i have gotten to know joe gruse from maine who has told me of what happened to his family. I would like to share his story with you and my colleagues in the hope that we can Work Together to come up with some kind of solution. As we look to revise our Mental Health laws. Joes son was 24 years old at the time of this tragedy. He had schizophrenia and yet he was discharged by or from a Psychiatric Hospital and returned home without the benefits of the medication. He had a history of serious and persistent Mental Illness, but he had been advised by federally funded advocates that his parents had no right to participate in his treatment or to have access to his medical records. According to his father and an extensive wall street journal piece, eventually his medical records were released and they showed that the doctors were all opposed to his being discharged. But the advocates has coached him to him thinking he was fine and not involve his parents in his treatment. Well, this ended in a terrible tragedy because will butchered his mother and killed her. He was in a deep psychotic state at the time. And ultimately he was found not responsible for his actions for reason of insanity and recommitted to the same Mental Hospital from which he had been prematurely discharged. Hes now doing well because hes getting the treatment he so desperately needed. Ironically will was only able to get the treatment he needed by killing his mother. Now, i want to make two important points. One, i understand that only a tiny number of americans with serious Mental Illness engage in unspeakable acts of violence, either towards themselves or others. Second, i understand that these federally funded advocates can do some enormously valuable work at preventing the abuse of patients who are institutionalized. But i cannot help but wonder how many tragedies that we have witnessed in recent years might have been prevented if those suffering from Mental Illness had access to treatment, and if the parents of these Adult Children had more role in their treatment, how do we address what admittedly is a very difficult challenge . Thank you for that question, senator collins. I agree that the circumstances of the bruce case are tragic and the loss of anyone in such a horrible act of violence is too much. And our thoughts go out to the bruce family. In the case of the advocacy program, we believe that its important to have a program that protects the rights of people with serious Mental Illness. At the same time, we have worked with the office of civil rights and they have provided guidance to families to understand and to physicians to understand that under hipa patients are allowed to listen to the information and allowed to share that with family members. So i think theres more to be understood about the circumstances of the bruce case, in particular. But i couldnt agree with you more that our country needs to better understand how to get people with the greatest need connected with the care that would most benefit them, keep them safe, keep their families safe and ensure the greatest chance of recovery as we have seen in this particular situation. Thank you, senator collins. Senator franken. Thank you, senator, for raising that. Thats a very important area and i know that Cassidy Murphys bill there is we are addressing that. Thank you, mr. Chairman, for this important hearing. This is obviously of enormous importance. I would like to talk about Mental Health in schools and ms. Enomoto, i read that you started in dealing with Minority Health trauma, which i find very interesting. And treating trauma, i think, early is very important in terms of learning in school, as a matter of fact. Something that we all care about here. Im proud that some of my work got into the new every child achieves act addressing Mental Health in schools. And these provisions will support programs in schools to train staff. Everybody from the bus driver to the principal to the custodians and the lunch ladies to the teachers, the spot when it looks like a kid might have a menial health issue and then get that adult to talk to a professional school counselor, maybe a psychologist, to see the kid and refer them if they have a Mental Health a serious one to get the appropriate services. And we have seen that work. My understanding is that project aware, which is a Grant Program created by president obama in 2013 and administered by your agency supports exactly this type of menital health recipients. Can you talk about how other organizations and Community Organizations help connect young people to the services that they need . Absolutely. Thank you for the question. The program such as the one that you have proposed and the one that we have implemented under proje the project do connect schools and communities with shared information about Mental Health and Mental Illnesses and Substance Abuse orders. What they appear like and what you can do about them. They are not meant to replace treatment or care but they are meant to raise awareness. As senator murray noted, a negative attitude, lack of understanding, these things are what create barriers for people accessing services. So first and foremost, we are educating people, we are helping them understand that these are diseases. These are brain diseases that are treatable, preventable, recoverable. And so people are more willing to talk to people about what they are experiencing, say offer some solutions, and then because people understand it better its less frightening and more accessible and we can move to intervene early or get people connected to care more quickly. The Early Intervention, early diagnosis and early treatment is something we should that we all are witnesses of and know is so important. I just want to ask you a little bit about your background in the Minority Health and trauma. We know that trauma reduces the childs ability to succeed in school. And what can we do in schools to build resill yeps in kids who have have experienced these Adverse Childhood Experiences so they can overcome them. Because i know it changes the brain chemistry to go through this kind of trauma. Trauma could be witnessing violence, see chemical abuse, Mental Illness, child abuse, other all of that stuff, extreme poverty. What can schools do to build resilience in kids to overcome the early diverse extremes . There are many evidencebased interventions that are schoolbased that schools can employ. And through our National Child dramatic stress network and the initiative there, there are many, many Resources Available online and through Technical Assistance for schools to learn about those programs that can be done in classroom, the programs that can be done in partnership with families and communities to help children cope with the experiences they have had. How to learn positive coping and social development skills. And to then for teachers as well how to understand classroom environments and climates so we can create a place where all children can learn well and have healthy and productive lives. Thank you, ms. Enomoto. Thank you, mr. Chairman. Senator, senatfranken, thank. Senator. I am going to ask you a question so please keep your answers briefmebrief. And if i interrupt you, its not to be rude but its because i have limited time. We have two reports released this year critical of how hhs has managed Mental Health issues and talked about samsa for some of these. Hhs is charged with leading the federal governments Public Health efforts related to Mental Health and Substance Abuse. And samsa is told to coordinate programs of Mental Illness through the federal government. With members across the federal government designated to work on the issues, but gao reports you have not met since 2009. Hhs officials have stated that the Behavioral Health coordinating council, the bhcc performs some functions previously carried out by the Steering Committee, yet thats limited to hhs and is not interagency. Well, thats where coordination is important and doesnt take the place or achieve the level of leadership gaos previously found key to successful coordination. And that which is essential to identify whether there are gaps in services. By the way, i will also point out that the Cassidy Murphy bill creates an assistant secretary for Mental Health specifically charged to do this job. The interagency coordination which has not been done since 2009. That being the case, would you agree that hhs should raise what are your thoughts about the Cassidy Murphy bill . Should hhs raise that profile to get that inner agency coordination, despite the mandate has not occurred since 09 . Thoughts . I think any effort to raise the profile of Mental Health issues and to increase collaboration across federal government is a good one. Im happy to engage in further conversation and work with you on creating a positive opportunity for that collaboration. You noted that the federal executive Steering Committee hasnt met since 2009. Many sub components there of the original federal Steering Committee that had 25 components participating do still meet. So the federal executive Steering Committee on trauma, on disaster, there are also groups related to employment that have i really want to hear about menial health. And that what appears to be lacking per gao. Let me move on again, just limited time. The second report talked about the problems of a lack of evaluation for programs for the seriously mental ill at samsa. 30 programs specifically targeting individuals with smi, nine had completed an evaluation, four had an evaluation underway, 17 had no evaluation completed and none planned. I can go through but it is more like that. Dismal statistics regarding those getting evaluated. And again, the Cassidy Murphy bill focuses on the need for evidencebased practices. That said, regularizing there are serious gaps and need for consistency and reviewing monitoring programs. What is samsa doing to create a better culture and evaluation of the agency. I agree that evaluation is an important issue. Samsa takes responsibility for the overnight seriously. The can you give me specifics . Samsa has established an evaluation committee. So we are overlooking our programs to establish the the 17 not evaluated and none planned. Why did that ever occur . I think there was some challenges in terms of how those were measured. So i dont know that thats exactly the same way that we see it. However, we are committed to evaluating our programs and well continue to do so. Dr. Ensil, thank you for your service. You have written before that im going to the nih research fund, we have been told, i am told the reason more money has not been put toward Mental Health is that the scientific promise is not there as it might be elsewhere. You have previously noted in written documents that you have published that the if you look at disability life adjusted, the amount that smi gets is below what normally would be the main. Aids is way up here. But serious Mental Illness is there. I have also seen the statistic that we have spent 987 million for every death from suicide and 420,000 for every death from hiv. 420,987. But it may be too difficult. Is it worthwhile to put more dollars specifically towards the issue of suicide . If we put more Research Dollars there, can we expect to see a benefit from that and is there academic promise . Thats a good point and question. How do you balance scientific traction and the burden of disease. When you look at both of those in making investments, i think it is a place where greater investment will get us greater return. I think we see that already when we got the recovery act dollars in, thats additional money. The results are spectacular with lots of projects that would not have happened that we can point to from recovery act dollars, which i think are some of the best things the institute has done over the decade. No question we could use more funding in great ways. The last issue in a moment, in comparing suicide to aids, i want to stress the fact that that investment in aids could be attributed to the fact that we have reduced mortality 50 . Totally accept that. Do maybe we are not spending too much on aids but not spending enough on other areas. Well talk to the appropriate or thes and try to get you more. Thank you very much. Ive gone over. I yield back. Thank you. Thank you, senator cassidy. Senator murphy. Thank you, senator alexander and murphy for taking this so seriously and convening us here today. I think senator alexanders comments were useful in understanding why Congress Really hasnt taken on this issue of Mental Health reform in the past because it crossed across so many agencies latitudely and longitudely. And i really aappreciate the focus on trying to get to a product that can eventually get to the floor. A few of us were at a really interesting bipartisan briefing this morning from the commonwealth fund, in which they were talking about the need to integrate our Behavioral Health systems. And there are some really interesting facts that they brought out. One of them was that if you study the incidents of diabetes alone as a cost driver and you study the incidents of menial health diagnoses alone as a cost driver in medicare, theyre not exhale that extraordinary by themselves. When you have a physical Health Diagnosis and Mental Health diagnosis together, all of a sudden you are in the small percent annual of patients driving cost. Mr. Mccrae, is this issue of workforce a question of not having enough providers or simply not being as coordinated if as we should be between the Mental Health side and the physical health side . Our bill certainly is focused on this question of coordination. Where should our attack be . More providers or better end grated providers . I think its actually a combination of the two. I would say that in terms of the primary care piece, we have seen an incredible interest from our primary care providers to increase their capacity. By our investments we have made over the last several years we have doubled the number of Mental Health providers that are at our Health Centers. By having those providers on site it has helped our screening in terms of what we do. And it is really affording the primary care system to expand its capacity to do more. So we really see it as we need to build up the primary care passty to do more screening end grated with Behavioral Health. But the second question of enough providers, we see an incredible demand for Mental Health providers for the different programs. Right now we are only able to fund about half the applications through the National Service corps for Mental Health providers. We definitely see the need, both support for coordination but also providers. I want to followup on hipa here, is this a statute not being understood correctly or do the patients need to share this information with family members . This is a problem, the lack of information going to parents and care givers, especially when talking about a young adult, maybe psychotic, of needs and help in that coordination. Is this a matter of needing to clarify the standards . We believe that there are more flexibilities than many physicians and many people understood. And that clarifying the roles and flexibilities that they have to disclose information to family members, when its in the best interest of the patient, would be very helpful to a lot of people. We are happy to work with our colleagues at ocr and across the department to do that. Dr. Insel, the time that you have been at the institute is rough liquor responded in the period of time with the number of reduced patient beds across the country. About 4,000. Most of that occurred during the recession and afterwards with a 15 reduction. I appreciate what youre saying in terms of the focus of trying to identify early, but can we sustain this level of inpatient beds over time . Is this something as you leave that worries you, that the lack of capacity that we have to provide shortterm acute care stays for people who need a period of stabilization . Absolutely its a big issue. Theres no place to send patients. Often thats why we see people being boarded in Emergency Rooms, which is a ridiculous situation we find ourselves in here. So we need to look at how you expand capacity. It is not the answer to all questions but then at least it needs to be developed. And i should just note that the last 13 years theres been a reduction. But the big reduction came long before that. Theres a 90 reduction in public beds for those with Mental Illness since the 1970s. A huge change in what the capacity is to help people when they really need fulltime support. This all changes in the 1960s. We did something great and put them in the institutions and out in the community. But we didnt support the community and set up a community Mental Health system totally separate from the rest of the Health Care System. Hopefully our discussion will be around those two fixes. Making that promise real and bringing those two systems back together. That would be great. I just want to take a moment to say that we do have a system out there called criminal Justice System which has become the de facto of Mental Health care system in this country. When you look at legislation, you cant ignore that and need to really ask a in a bipartisan way, is this the country we want to be . Is this the way we want to treat people with a brain disorder . Hallelujah. Thank you, mr. Chairman. Thank you for the time you and senator cassidy are spending on this issue. We have isakson, warren, scott. Senator isaacson. Thank you. Senator kazcassidy and are Work Together and we know Mental Health is a crisis we are working with. Im not a physician nor am i a technical person, but it appears to me in the emergency room practices theres a golden hour. Its that time the accident takes place from the time the person is treated and you can save a life if someone is in an accident. Its the same golden minute with suicide. They need to have access to a person to talk to. And if there isnt one, we have lack of access to get them to an appointment and to get them to a place to at least talk to a professional. Am i right about that or wrong about that, mr. Macrae . I would defer to my colleague, but i would say absolutely. The other piece is that Early Intervention is important when talking about suicide. We have had much success in terms of doing screening again in the primary care setting where you are actually able to identify children, in particular, adolescents and veterans and other vulnerable patients where if they just had some of the intervention early on it could make a big difference. And we can talk specifically about the golden minute. And because of that, there is that moment that someone is reaching out for help. Thats why samsa has the National Suicide lifeline and partnered with the department of Veterans Affairs for the press one if youre a veteran or Service Member so people can access that military culturally informed type of support and then get connected with services in a local area to them. Out of curiosity, has hrsa reacted with the process of Mental Health . Yes, we have worked with them in terms of workforce and working together to expand the Mental Health workforce for the v. A. And the programs we work with. In addition, we have been working closely with them around the veterans choice act in terms of the connection between the v. A. And some of our community Health Centers, for example. And we are working on model contract language to make that process easier so veterans have greater access. Talking about veterans choice, i realize it is important to improve the veteran Choice Program so the golden minute can take place. Because right now by calling the 800number to get the appointment and prove you are 40 minutes from a center takes a long time. And on Mental Health issues, a long time is not a long time and you dont need to delay that as much as possible. It occurred to me that our veterans administrations problem is that the Community Health communities serve a lot of rural does the v. A. Depend on you or do you work with v. A. In terms of rural environments to give them help. We do. Right now we serve about 3,000 veterans across the country. In addition, we have been partnering with telahealth where we cant get providers out into the Rural Communities but they have access to the v. A. And partnership. Thank you for your testimony, mr. Chairman. Thank you for calling this hearing. Thank you, senator isaacson. Senator warren. Thank you, mr. Chairman. Thank you all for being here. With every mass shooting in this country, the American People call for action and the u. S. Congress does nothing. Instead, the deaths continue to add up with more than 30,000 people lost to gun violence during 2013 alone. Now, theres a lot that we can do. But according to those who object to more thorough background checks or to improve gun safety, the problem of Mass Shootings is a Mental Health problem and should be dealt with that way. But then when it comes time to fundaMental Health research, the same people turn their backs on studying Mental Health problems. Over the past five years the National Institute of health and the Research Budget has been cut by about 12 . And samsas inflation adjusted budget is down 8 and no one knows where the Health Budget will land. But worse yet, even if they had adequate funding, the nih and cdc are effectively banned from conducting research on gunrelated violence. Every appropriations bill since 1996 has included language that bans the cdc from conducting any Meaningful Research related to reducing gun violence. Former republican congressman jay dickey, the author of that rider, called for that ban to be lifted but it remains to be in place year after year. In fact, just months after the shooting in arizona that nearly took the life of congresswoman gabby giffords, Congress Expanded the research ban to include nih research as well. So dr. Insel, let me ask you, what Meaningful Research that might help us better understand the connections between Mental Health and gun deaths, and ultimately that might help us reduce gun violence are we not conducting because of congresss ban on gunrelated science . Thank you, senator warren. Obviously, its a very topical and in some ways difficult issue. The president has talked about this almost from the day after the sandy hook massacre when he announced that now is the time initiative, that included a focus on just this issue. I understand and appreciate your concern about the cdc and of course congressman dickeys language has been talked a lot about in the press and something we have heard quite a bit about as well. At nih we are taking a somewhat different tact. Our interpretation of that language was that, well, it put a prohibition against advocating or promoting any sort of gun control. It didnt actually prohibit us from doing research on firearms and violence as a Public Health issue. And we have continued to do that. Last year we announced a request for applications on research on the Health Determinant and consequence of violence, particularly firearm violence put out by the National Institute of alcohol and abuse addiction. And then it was joined by other institutes including nih. We looked at what the science tells us about how to assess risk for someone when they have made a suicide attempt, particularly for young people who are seen in an e. R. One of the grants is to understand the best way to assess their access and the best way to deal with that. There are projects on developmental pathways of violence and Substance Use in a highrisk sample looking at people who are particularly concerned about having access to weapons and whether theres a way again to put some sort of a Scientific Understanding on the question of who is most likely to get into trouble here and what are the best interventions we can do to prevent that. I guess in a word for us its become its entirely a Public Health issue and something we feel is very much in the sweet spot of what we do at nih in terms of trying to develop how science can save lives. So i appreciate that and just want to make sure i understand. So youre telling me that cdc has been caught by this ban. But in effect nih found ways to work around it so youre still conducting research about the link between Mental Health issues and guns . Well, im not going to speak to cdc because i dont know enough about what their portfolio does. But certainly at nih we are doing the work and trying to get the science that will serve the public thats related to this issue. Well, im grateful for the direction that youre trying to go. I think the idea that congress would witness children, bystanders, spouses, people watching movies, people going to church, die by gun violence and refuse to take any action is irresponsible in the extreme and clearly a sellout to a powerful gun lobby. But to follow that up, with congressional inaction by underfunding Mental Health research and then by refusing to support researchers who could produce factbased nonpartisan Scientific Research that could help us reduce gun violence and improve our Mental Health system moves this congress from irresponsible to culpable. Gun violence is tearing apart our families in our communities and we cannot turn away from that. Thank you. Thank you, senator warren. Senator scott. Thank you, mr. Chairman. Thank you to the panelists for being here this morning and discussing a very important issue certainly without question coming from South Carolina i have an appreciation of the impact of Mental Illness and violence, Mass Violence in South Carolina and in washington and around the country. Certainly we are looking forward to ways to help the reduce the problems. You also highlighted earlier the de facto location of too many suffering from Mental Illness are local and county jails. Frankly, in South Carolina there are 20,000 folks incarcerated and at least 3,000 have been diagnosed with some Mental Illness, not heard that some studies suggest the number could be two or three times even higher. So by default we are finding folks incarcerated not necessarily because they committed a crime but because of Mental Illness as a primary reason for their incarceration. So that is something that we must address and need to address and franklin from a financial perspective is one of the most expensive ways of addressing it. Folks incarcerated lose their freedom at the expense of taxpayers. Dr. Insel, you know that chronic Mental Illness cases begins for so many folks, a first Study Suggests that at least by age 14 half of the Mental Illness cases have begun. And by the age of 24, three quarters of those areas have begun. And theres been a lot of conversation around intervention, Early Intervention. To me it seems like the first folks that might be in the best position as they understand what signs to look for are the family members in the household. Can you comment on how we remove the stigma associated with Mental Illness . And as you have said, we have had Great Success in dealing with physical illnesses, cancer and other issues . Because we have had the ability to put a major spotlight to reduce those challenges. How do we do the same thing in the area of Mental Illness . And i appreciate your service to nih as well. Well, thank you, senator scott, for that question. I wish it was easy to answer. In the other medical areas, we dont have the legacy we have here of a long era, in which we either considered these not illnesses but moral fillings for individuals or worse, blaming families. The explanation for Mental Illness was that your mother or father did this to you. So not surprising families havent been at the forefront of being able to turn the tide here. The future will be largely around better education as well as better science. We need to help people to understand that these are disorders that are like any other disorders. As you say, the one thing that sets them apart is unlike cancer and Heart Disease and most endocrine diseases like diabetes start in young people. So these are the disorders of young people and it makes it therefore even more touching that we dont do enough to help people grapple with them early to get people the supports they need and to help people understand these are real disorders and treatments available. And yet the treatments arent getting to the people who need them. Yes, thank you, sir. Mr. Macrae. A, thank you for your work with the v. A. In helping so many of the veterans in the rural areas of our state. My brother served 32 years in the army and worked with the warrior transition unit. He spent a lot of time focusing on the suicide issue that the military has faced. So it was heartwarming to hear someone talk about the importance and the having a sense of urgency in dealing with the issues. South carolina is a rural state according to your reports. And i believe we have 70 or so areas that are underserved. So we look at telemedicine as the not to fix all the problems, but we know its not going to fix all the problems. Have you seen any other innovations coming our way that might give us reasons to be hopeful for channeling some of the rural areas in states like South Carolina . When i say challenging, i think sometimes we have to challenge the challenges that we face in these rural areas and frankly with 46 counties in South Carolina, 70 underserved areas, that would be helpful to understand and appreciate any new opportunities beyond telemedicine for us to impact those areas. Sure. Thank you, well, definitely, telemedicine is one of the initiatives that we are promoting quite a bit, especially in those Rural Communities, where it can be a challenge to get those providers in, but i think we are looking beyond that to see if we can provide support where there are other types of providers in the community that need some assistance. One of the projects that we have been working on recently is something called project echo, where we bring together academia and basically, we bring together different communities and we have done a lot in Rural Communities to basically be able to bring cases forward and talk to someone who has more expertise in terms of that knowledge or information and they can then use that information to then go back to their practice and provide more care. We are definitely looking at every way we can use any other types of technologies, in terms of improving health care in rural, but a lot of it honestly is meeting the needs through some of our programs, community Health Center program has reached out into Rural Communities, the National Health service corps. 50 is out in rural, almost 40 in the National Service corps. It is a combination of getting physical presence, telehealth where we can and then providing support to those current providers that might need it, just that extra support and we have been doing that through this project echo model. Thank you. I know im out of time, but one quick question, sir. With the number of ptsd cases coming back from the military, have you found that the level of awareness and interest in Mental Health issues has risen substantially in the last few years . Absolutely. In act if a, we have been working very closely with the va in terms of as particular, working on the veterans choice act to increase the capacity in particular, our community Health Centers to first identify and then also treat people with ptsd and particular veterans. We have actually worked with them on a whole curriculum and providing guidelines to our providers to provide them with that support. Thank you, sir. Thank you, senator scott. Senator baldwin. Thank you, mr. Chairman and Ranking Member. We know that in recent years, we have made Great Strides in improving access to Insurance Coverage in this space with the Mental Health parity and the Affordable Care act. However, still too Many Americans face barriers to getting access to highquality Treatment Options for Mental Health issues, but i wanted to specifically hone in on eating disorders. Um, i hear from countless people who share their stories relating to seeking treatment for eating disorders. And they describe insurance that wont cover the care that they need. In some cases, if the plan covers this type of treatment at all, it is usually in another state. And often will only cover a couple of days of residential care. Alternatively, a plan may send them to a general Psychiatric Hospital or facility, where the treating professionals lack the education and background about treating eating disorders. I have teamed up with a number of my colleagues in introducing the anna westin act which aims to improve care for those with eating disorders by clarifying that Mental Health parity includes coverage for residential treatment services. I wonder if you can speak a little bit about the consequences when Insurance Companies fail to treat individuals with eating disorders and certainly other serious Mental Health issues in appropriate care settings by professionals who are fully qualified to address their specific order disorder. And if you could tell me a little bit about what your respective agencies are doing to help improve comprehensive treatment and access for those suffering from eating disorders in their own communities. Obviously, if possible. And then i hope to turn to a little bit more about the state of the science in this arena. Would you mind starting . Thank you very much for this question because so many people dont understand that eating disorders have some of the highest mortality rates of any mental disorders. And also strike very early in life. And from children as young as 8 years old. So, access to services is critical. Denial of coverage can result in tragic outcomes for the affected patient as well as their families. Samsa is working very hard with our federal partners at the department of labor and treasury as well as inside of hhs with assistant secretary for planning and evaluation and the centers for medicare and Medicaid Services to improve insurance compliance with mpia as well as to ensure party of the Insurance Coverage for mental disorders, including eating disorders. We are developing informational materials for the public as well as for insurers and partnering on integrated care models such as the primary Behavioral Health care integration so we can bring the treatment for Mental Illness and health care together as well as ensure that Health Care Organizations are caring for the whole person, as you have noted is so vitally important. Mr. Macray . We have two programs in particular focused on workforce training around the whole issue of eating disorders to really increase the capacity of primary care providers to first identify and then to provide additional treatment and support and we can share that information with you, if that would be helpful. Great. But it definitely is a concern. I appreciate that. Let me just continue in this in this vein. The anna westin act directs samsa to award grants to train primary care physicians, Mental Health providers and other Mental Health professionals on prevention of eating disorders and intervention and how properly to refer patients. Sadly, as noted, individuals suffering from an eating disorder are facing very, very high risks. And they are sort of dual. The risks of people with an eating disorder being more likely to attempt suicide or engage in selfinjury in addition to all the physical impacts of living with and struggling with an eating disord disorder. What more can samsa do to increase awareness about these cooccurring Mental Illnesses and suicidal behavior among individuals suffering from eating disorders and, again, i certainly invite a conversation about the current state of the science on this issue. Yes, people with eating disorders have higher rates of cooccurring Health Conditions as well as Substance Use and suicidality and selfinjury. So, they are very complicated conditions to treat and manage. And samsa does have some specific guidance for clinicians to improve their skills and knowledge in this area for those who are interested, unfortunately, we dont currently have any funding dedicated to improving or raising the clinical floor around eating disorders and it is an area for potential growth. Take just a moment, if i can, the science is going great guns. The good news is that theres a new treatment called family focused therapy which does the opposite of what we have traditionally done. The old treatment was to take parents out of the scene. We called that a parentectomy. Today, we train parents and make them the focus of the treatment and the remission rates are 50 established at two years. So this is with adolescents with anorexia nervosa, save lives. This is a really good story. Very bad news is very few people at this point are trained to provide that therapy with if i had he will i fidelity. And there are features to get a workforce to enable to help the kids who need it i want to thank our three witnesses for your testimony. Senator mullry, do you have any concluding remarks . Mr. Chairman, i just really appreciate this hearing and the participation of so many people. I think we are all learning as we go every day and moving forward to make sure that we are making our Health Care System work for everyone has to include the issue of Mental Health care. So, i really appreciate the focus of this hearing and look forward to working with everyone. Thank you. I appreciate the attendance and involvement of so many members of the committee today. We may very well try to have another hearing on Mental Health before the end of the year. I will talk with senator murray about that and i will talk with other members of the committee about exactly how to do that the hearing record will remain open for ten days. Members may submit Additional Information for the record within that time, if they would like. The next hearing concerning issues of Mental Health and substance disorder will be an opioid abuse hearing will be thursday, november 19th. Thank you for being here today the committee will stand adjourned. [ gavel bangs ]