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89–830 2014

WHERE HAVE ALL THE PATIENTS GONE? 

EXAMINING THE PSYCHIATRIC BED SHORTAGE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

MARCH 26, 2014 

Serial No. 113–130 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

RALPH M. HALL, Texas 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BILL CASSIDY, Louisiana 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

CORY GARDNER, Colorado 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Missouri 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

HENRY A. WAXMAN, California 

Ranking Member 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

FRANK PALLONE, JR., New Jersey 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

JOHN BARROW, Georgia 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

BEN RAY LUJAN, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

(III) 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

TIM MURPHY, Pennsylvania 

Chairman 

MICHAEL C. BURGESS, Texas 

Vice Chairman 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

GREGG HARPER, Mississippi 

PETE OLSON, Texas 

CORY GARDNER, Colorado 

H. MORGAN GRIFFITH, Virginia 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

DIANA DEGETTE, Colorado 

Ranking Member 

BRUCE L. BRALEY, Iowa 

BEN RAY LUJAN, New Mexico 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

KATHY CASTOR, Florida 

PETER WELCH, Vermont 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

GENE GREEN, Texas 

HENRY A. WAXMAN, California (ex officio) 

(V) 

C O N T E N T S 

Page 

Hon. Tim Murphy, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Diana DeGette, a Representative in Congress from the state of Colorado, 

opening statement ................................................................................................ 5 

Hon. Henry A. Waxman, a Representative in Congress from the state of 

California, opening statement ............................................................................. 7 

WITNESSES

Lisa Ashley, parent of a son with serious mental illness, Sacramento, California ..................................................................................................................... 9 

Prepared statement .......................................................................................... 12 

Jeffrey L. Geller, M.D., M.P.H., Professor of Psychiatry and Director of Public 

Sector Psychiatry, University of Massachusetts Medical School, Worcester, 

Massachusetts ...................................................................................................... 17 

Prepared statement .......................................................................................... 19 

Answers to submitted questions ...................................................................... 120 

Jon M. Hirshon, M.D., M.P.H., Ph.D., FACEP, Task Force Chair, 2014 American College of Emergency Physicians National Report Card on Emergency 

Care, and Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland ............................. 37 

Prepared statement .......................................................................................... 39 

Answers to submitted questions ...................................................................... 176 

Michael C. Biasotti, Chief of Police and Immediate Past President of New 

York State Association of Chiefs of Police, and parent of a daughter with 

serious mental illness, New Windsor, New York .............................................. 51 

Prepared statement .......................................................................................... 53 

Answers to submitted questions ...................................................................... 178 

Thomas J. Dart, Sheriff, Cook County Sheriff’s Office, Chicago, Illinois ............ 65 

Prepared statement .......................................................................................... 68 

Steve Leifman, Associate Administrative Judge, Miami-Dade County Court, 

Eleventh Judicial Circuit of Florida, Miami, Florida ........................................ 74 

Prepared statement .......................................................................................... 77 

Gunther Stern, Executive Director, Georgetown Ministry Center, Washington, 

D.C. ........................................................................................................................ 97

Prepared statement .......................................................................................... 99 

Hakeem Rahim, Ed.M., M.A., Speaker and Mental Health Educator and 

Advocate, Hempstead, New York ........................................................................ 103 

Prepared statement .......................................................................................... 105 

Lamarr D. Edgerson, Psy.D., LMFT, NBCCH, Clinical Mental Health Counselor, Director at Large, American Mental Health Counselors Association, 

Family Harmony, Albuquerque, New Mexico .................................................... 107 

Prepared statement .......................................................................................... 109 

Arthur C. Evans, Jr., Ph.D., Commissioner, Department of Behavioral Health 

and Intellectual Disability Services, University of Pennsylvania, Philadelphia, Pennsylvania ............................................................................................... 129 

Prepared statement .......................................................................................... 131 

Answers to submitted questions ...................................................................... 181 

Page

VI 

SUBMITTED MATERIAL

Article entitled, ‘‘Dashed Hopes; Broken Promises; More Despair: How the 

Lack of State Participation in the Medicaid Expansion Will Punish Americans with Mental Illness,’’ by the American Mental Health Counselors 

Association, submitted by Mr. Waxman 1

Letter of March 26, 2014 from the National Association of Psychiatric Health 

Systems to the subcommittee, submitted by Mr. Murphy ................................ 163 

Articles submitted by Mr. Burgess ......................................................................... 165 

1 The article is available at http://docs.house.gov/meetings/if/if02/20140326/ 

101980/hhrg-113-if02-20140326-sd004.pdf. 

(1) 

WHERE HAVE ALL THE PATIENTS GONE? EXAMINING THE PSYCHIATRIC BED SHORTAGE 

WEDNESDAY, MARCH 26, 2014 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:02 a.m., in room 

2123 of the Rayburn House Office Building, Hon. Tim Murphy 

(chairman of the subcommittee) presiding. 

Present: Representatives Murphy, Burgess, Blackburn, Harper, 

Griffith, Johnson, Ellmers, DeGette, Braley, Schakowsky, 

Butterfield, Castor, Tonko, Green, and Waxman (ex officio). 

Staff present: Leighton Brown, Deputy Press Secretary; Karen 

Christian, Chief Counsel, Oversight and Investigations; Noelle 

Clemente, Press Secretary; Brad Grantz, Policy Coordinator, Oversight and Investigations; Brittany Havens, Legislative Clerk; Sean 

Hayes, Counsel, Oversight and Investigations; Alan Slobodin, Deputy Chief Counsel, Oversight; Sam Spector, Counsel, Oversight and 

Investigations; Tom Wilbur, Digital Media Advisor; Jessica 

Wilkerson, Legislative Clerk; Brian Cohen, Democratic Staff Director, Oversight and Investigations, and Senior Policy Advisor; Hannah Green, Democratic Staff Assistant; Elizabeth Letter, Democratic Press Secretary; Karen Lightfoot, Democratic Communications Director and Senior Policy Advisor; Anne Morris Reid, Democratic Senior Professional Staff Member; and Stephen Salsbury, 

Democratic Investigator. 

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA 

Mr. MURPHY. Good morning. I now convene this morning’s hearing entitled ‘‘Where Have All the Patients Gone? Examining the 

Psychiatric Bed Shortage.’’ 

Right after the December 14, 2012, elementary school shootings 

in Newtown, Connecticut, the Subcommittee on Oversight and Investigations began a review of federal programs and resources devoted to mental health and serious mental illness. Recent events 

have shown the continuing importance of this inquiry, including 

the September 2013 Navy Yard shooting just a couple of miles from 

where we sit this morning, in Washington, D.C. Other tragic cases, 

like Seung-Hui Cho, James Holmes, Jared Loughner, and Adam 

2 

Lanza, all exhibited a record of untreated severe mental illness 

prior to their crimes. It is a reflection of the total dysfunction of 

our current mental health system that despite clear warning signs, 

these individuals failed to receive inpatient or outpatient treatment 

for their illnesses that might have averted these tragedies. And 

they all leave us wondering, what would have happened if—— 

What would have happened if Aaron Alexis was not just given 

sleeping pills at the VA hospitals, or if there was hospital bed or 

outpatient treatment available for others who later became violent, 

involved in a crime, unable to pay their bills, or tossed out on the 

street? 

Part of the problem is that our laws on involuntary commitment 

are in dire need of modernization. It is simply unreasonable, if not 

a danger to public safety, that our current system often waits until 

an individual is on the brink of harming himself or others, or has 

already done so, before any action can be taken. The scarcity of effective inpatient or outpatient treatment options in the community, 

as illustrated by the premature release of Gus Deeds, son of Virginia Senator Creigh Deeds, from emergency custody because of the 

lack of psychiatric hospital beds, is also to blame, and it is a sad, 

sad ending. In our heart we cannot begin to imagine a parent’s 

grief when told there is no place for your son or daughter to get 

help. 

Nationwide, we face an alarming shortage in inpatient psychiatric beds that, if not addressed, will result in more tragic outcomes. This is part of the long-term legacy of deinstitutionalization, 

the emptying out of State psychiatric hospitals resulting from the 

financial burden for community-based care being shifted from the 

State to the Federal Government. With the deinstitutionalization, 

the number of available inpatient psychiatric beds has fallen considerably. The number of beds has decreased in the 1950s from 

559,000 to just 43,000 today. Back in the 1950s, half of every hospital bed was a psychiatric bed. We needed to close those old hospitals that had become asylums, lockups and, quite frankly, they 

were dumping grounds. 

But where did all the patients go? They were supposed to be in 

community treatment. They were supposed to be on the road to recovery. But for many, that simply did not happen. 

The result is that individuals with serious mental illness who are 

unable to obtain treatment through ordinary means are in too 

many cases homeless or entangled in the criminal justice system, 

including being locked up in jails or prisons. 

Right now, the country’s three largest jail systems in Cook County, Illinois, Los Angeles County; and New York City have more 

than 11,000 prisoners receiving treatment on any given day and 

are, in fact, the largest mental health treatment facilities in the 

country. These jails are many times larger than the largest State 

psychiatric hospitals. 

Not surprisingly, neither living on the streets nor being confined 

to a high-security cellblock are known to improve the chances that 

an individual’s serious mental illness will stabilize, let alone prepare them, where possible, for eventual reentry into the community, to find housing, to find jobs, and to find confidence in their 

future. 

3 

It is an unplanned, albeit entirely unacceptable consequence of 

deinstitutionalization that the State psychiatric asylums, dismantled out of concern for the humane treatment and care of individuals with serious mental illness, have now effectively been replaced 

by confinement in prisons and homeless shelters and tied to hospital beds. 

What can we do earlier in people’s lives to get them evidencebased treatment, community support, and on the road to recovery, 

not the road to recidivism? Where is the humanity in saying there 

are no beds to treat a person suffering from acute schizophrenia, 

delusions, agitation, and aggression and what they are offered is 

sedation and being restrained in ER hospital bed for days? 

This morning, to provide some perspective on the far-reaching 

implications of the current psychiatric bed shortage and to hear 

some creative approaches to address it, we will be receiving testimony from individuals with a wealth of experience across the full 

range of public services consumed by the seriously mentally ill 

across our Nation. These include Lisa Ashley, the mother of a son 

with serious mental illness who has been boarded multiple times 

at the emergency department; Dr. Jeffrey Geller, a psychiatrist and 

co-author of a report on the trends and consequences of closing 

public psychiatric hospitals; Dr. Jon Mark Hirshon, an ER physician and Task Force Chair on a recent study of emergency care 

compiled by the American College of Emergency Physicians; Chief 

Mike Biasotti, immediate past President of the New York State Association of Chiefs of Police and parent of a daughter with serious 

mental illness; Sheriff Tom Dart, of the Cook County, Illinois, 

Sheriff’s Office, who oversees one of the largest single site county 

pre-detention facilities in the United States; the Hon. Steve 

Leifman, Associate Administrative Judge, Miami-Dade County 

Court, 11th Judicial Circuit of Florida; Gunther Stern, Executive 

Director of Georgetown Ministry Center, a shelter and clubhouse 

caring for Washington D.C.’s homeless; Hakeem Rahim, a Mental 

Health Educator and Advocate; LaMarr Edgerson, a Clinical Mental Health Counselor and Director at Large of the American Mental 

Health Counselors Association; and Dr. Arthur Evans, Jr., Commissioner of Philadelphia’s Department of Behavioral Health and 

Intellectual DisAbility Services. I thank you all for being with us 

this morning and giving us so much of your time. 

[The prepared statement of Mr. Murphy follows:] 

PREPARED STATEMENT OF HON. TIM MURPHY

Right after the December 14, 2012 elementary school shootings in Newtown, Connecticut, the Subcommittee on Oversight and Investigations began a review of federal programs and resources devoted to mental health and serious mental illness. 

Recent events have shown the continuing importance of this inquiry, including the 

September 2013 Navy Yard shooting just a couple of miles from where we sit this 

morning, in Washington, D.C. 

Other tragic cases, like Seung-Hui Cho, James Holmes, Jared Loughner, and 

Adam Lanza, all exhibited a record of untreated severe mental illness prior to their 

crimes. It is a reflection of the total dysfunction of our current mental health system 

that despite clear warning signs, these individuals failed to receive inpatient or outpatient treatment for their illnesses that might have averted these tragedies. 

They all leave us wondering what would have happened if. 

What would have happened if Aaron Alexis was not just given sleeping pills at 

the VA? Or if there was an available hospital bed or outpatient treatment available 

4 

for others who later became violent, involved in a crime, unable to pay bills, or 

tossed out on the street? 

Part of the problem is that our laws on involuntary commitment are in dire need 

of modernization—it is simply unreasonable, if not a danger to public safety, that 

our current system often waits until an individual is on the brink of harming himself or others, or has already done so, before any action can be taken. The scarcity 

of effective inpatient or outpatient treatment options in the community, as illustrated by the premature release of Gus Deeds, son of Virginia senator Creigh Deeds, 

from emergency custody because of the lack of psychiatric beds, is also to blame. 

A sad ending that in our heart we cannot begin to imagine a parent’s grief when 

told there is no place for your son to get help. 

Nationwide, we face an alarming shortage in inpatient psychiatric beds that, if 

not addressed, will result in more tragic outcomes. This is part of the long-term legacy of deinstitutionalization, the emptying out of state psychiatric hospitals resulting from the financial burden for communitybased care being shifted from the state 

to the federal government. With deinstitutionalization, the number of available inpatient psychiatric beds has fallen considerably. On the whole, the number of beds 

has decreased from 559,000 in the 1950s to just 43,000 today. We needed to close 

those old hospitals that had become asylums, lock-ups, and dumping grounds. 

But where did all the patients go? They were supposed to be in community treatment—on the road to recovery—but for many that did not happen. 

The result is that individuals with serious mental illness who are unable to obtain 

treatment through ordinary means are now homeless or entangled in the criminal 

justice system, including being locked up in jails and prisons. 

Right now, the country’s three largest jail systems—in Cook County, Illinois; Los 

Angeles County; and New York City—have more than 11,000 prisoners receiving 

treatment on any given day and are, in fact, the largest mental health treatment 

facilities in the country. These jails are many times larger than the largest state 

psychiatric hospitals. 

Not surprisingly, neither living on the streets nor being confined to a high-security cellblock are known to improve the chances that an individual’s serious mental 

illness will stabilize, let alone prepare them, where possible, for eventual reentry 

into the community, to find housing, jobs, and confidence for their future. 

It is an unplanned, albeit entirely unacceptable consequence of deinstitutionalization that the state psychiatric asylums, dismantled out of concern for the humane 

treatment and care of individuals with serious mental illness, have now effectively 

been replaced by confinement in prisons and homeless shelters. 

What can we do earlier in people’s lives to get them evidence-based treatment, 

community support, and on the road to recovery not recidivism? 

Where is the humanity in saying there are no beds to treat a person suffering 

from schizophrenia, delusions, and aggression so we will sedate you and restrain 

you to an ER bed for days? 

This morning, to provide some perspective on the far-reaching implications of the 

current psychiatric bed shortage and to hear some creative approaches to address 

it, we’ll be receiving testimony from individuals with a wealth of experience across 

the full range of public services consumed by the seriously mentally ill. These include: 

•Lisa Ashley, the mother of a son with serious mental illness who has been 

boarded multiple times at the emergency department; 

• Dr. Jeffrey Geller, a psychiatrist and co-author of a report on the trends and consequences of closing public psychiatric hospitals; 

• Dr. Jon Mark Hirshon, an ER physician and Task Force Chair on a recent study 

of emergency care compiled by the American College of Emergency Physicians; 

• Chief Mike Biasotti, Immediate Past President of the New York State Association of Chiefs of Police and parent of a daughter with serious mental illness; 

• Sheriff Tom Dart, of the Cook County, IL Sheriff’s Office, who oversees one of 

the largest single site county pre-detention facilities in the U.S.; 

•The Honorable Steve Leifman, Associate Administrative Judge, Miami-Dade 

County Court, 11th Judicial Circuit of Florida; 

• Gunther Stern, Executive Director of Georgetown Ministry Center, a shelter and 

clubhouse caring for Washington D.C.’s homeless; 

• Hakeem Rahim, a mental health educator and advocate; 

•LaMarr Edgerson, a clinical mental health counselor and Director at Large of 

the American Mental Health Counselors Association; and 

• Dr. Arthur Evans, Jr., Commissioner of Philadelphia’s Department of Behavioral 

Health and Intellectual DisAbility Services. 

I thank them all for joining us this morning. 

5 

# # # 

Mr. MURPHY. I would now like to give the ranking member an 

opportunity to deliver brief remarks of her own. Ms. DeGette. 

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO 

Ms. DEGETTE. Thank you very much, Mr. Chairman. I want to 

thank you for having this hearing and also for your continued leadership on the important topic of mental health. I want to thank all 

of the witnesses for appearing before us today. I think this sets a 

record as the biggest panel we have ever had in this subcommittee, 

and I am looking forward to hearing each one of your perspectives. 

It is rare we ever get so much knowledge and such a breadth gathered in one place. 

Mr. Rahim, I am especially glad that you are here with us this 

morning. This is our fourth hearing in this subcommittee on mental health during this Congress, but this is the first time we have 

ever heard directly from somebody who can share his own personal 

history with mental illness and sit before us as a testament to the 

possibility of recovery. I know it takes a lot of courage to tell these 

personal stories in public, and I want to commend you for being 

here. 

I also want to commend Ms. Ashley and Mr. Biasotti for being 

here today as parents because I have been approached by so many 

parents in my district who know that I am working on these issues, 

talking to me about the heartbreak of having young adults or teenagers who are dealing with these issues and what it is like as a 

family member. All of you can add really good perspective to this, 

and I want to thank you. 

The question for this hearing, where have all the patients gone, 

is a very important one. Individuals with serious mental illnesses 

like bipolar disorder or schizophrenia are showing up in emergency 

rooms, encountering the criminal justice system and becoming 

homeless far too often. One reason why this problem is getting 

worse is because of budget cuts for mental health and addiction 

services at the State and local level. The American Mental Health 

Counselors Association reported that between 2009 and 2012, 

States have cut nearly $5 billion in mental health services. 

Mr. Chairman, I am concerned about the impact of these cuts, 

and I hope that we can address them today, and also as we continue our joint efforts to work towards comprehensive mental 

health legislation, how we can address these cuts because, to be 

honest, if there are no beds for folks to go to, then anything we can 

do is going to be useless, and so we are going to have to work with 

State and local governments to figure out how to fund the appropriate amount of beds that we need. 

It is also important to address the issue of patients with mental 

illnesses showing up in the ER, which we all know is less effective 

and more expensive to receive treatment than other alternatives, 

but I do think if these folks do show up in the ER, there are ways 

to improve the way they are treated there. 

6 

But I also want to focus our attention on an even more important 

question: how can we keep people with serious mental illness out 

of the emergency room in the first place? When people show up in 

the ER, it means that they have reached a crisis point and that 

represents a broader failure of our mental health system in this 

country. Our goal should be preventing crises from arising in the 

first place by investing in approaches to identify the early signs 

and symptoms of mental illness and to make sure that patients 

have quality health insurance and can get timely and effective 

mental health treatment and support services, and I will bet you 

every single provider, parent and patient in this room would agree 

with what I just said. 

I don’t want to downplay the concerns about the lack of inpatient 

beds for patients who need them. Despite our best efforts, there 

still will be instances where more intensive interventions are needed. But I hope that we can agree that these should be exceedingly 

rare occurrences and that having more inpatient beds is only a partial solution. The benefits provided by the Mental Health Parity 

and Addiction Equity Act and the Affordable Care Act will help 

prevent these ER crises if implemented correctly. They will provide 

millions of Americans with access to quality, affordable health insurance that includes coverage for mental health services. We need 

to build from these laws to support the continuum of mental health 

services at all levels of government, and I must say, I was very 

proud that we were able to include mental health parity in the Affordable Care Act. This will be very important for patients. 

We also need to remember that recovery, even for individuals living with serious mental illness, is possible, or certainly at least 

management. Mr. Rahim is proof that individuals with access to 

the right range of services not only can we greatly reduce the number of individuals in crisis winding up in prisons or emergency 

rooms but we can produce hardworking, contributing members of 

society as well. As well as your bill that you have introduced, Mr. 

Chairman, there is a lot of other legislation out there, and I know 

we intend to continue working together to try to have some kind 

of comprehensive legislation that will begin to address all of these 

issues. 

Thank you so much, Mr. Chairman. 

Mr. MURPHY. I thank the gentlelady for her comments, and yes, 

we will continue to work together. 

I now recognize the gentlelady from North Carolina, Mrs. 

Ellmers, if you want to make an opening statement. 

Mrs. ELLMERS. Thank you, Mr. Chairman. I just want to make 

a brief statement, especially due to the size of our panel, and I am 

very anxious to hear from all of you on these issues. 

You know, I served as a nurse for 21 years before coming to Congress, and there is nothing that is more heartbreaking than when 

you see a situation of mental illness and a family who is struggling 

to deal with that. I just want to say thank you to all of you. I want 

to take that opportunity because you coming forward will help us 

to finally deal with the situation, and it is a multifaceted situation 

and we all have to come together. This is not a political one, this 

is not one that we can’t reach across the aisle and work together 

on. 

7 

So thank you to all of you, and God bless all of you. 

Mr. MURPHY. The gentlelady yields back. Anybody on this side 

want any more of the remaining time? If not, we will now recognize 

the ranking member of the full committee, Mr. Waxman, for an 

opening statement, 5 minutes. 

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. Thank you very much, Mr. Chairman. 

Today’s hearing addresses an important issue affecting treatment 

and outcomes for patients with mental illnesses. We will hear 

today that budget cuts and other factors have resulted in a lack of 

inpatient beds for intensive psychiatric treatment, meaning that 

patients with serious mental illness who show up to the emergency 

room at a crisis point are forced to wait far too long, for days at 

a time, for an inpatient psychiatric bed. 

This is a growing problem, but it is not a new one. A decade ago, 

as ranking member of the Oversight Committee, I released a report 

finding that all too often, jails and juvenile detention facilities have 

had to provide care for individuals with mental illnesses. This report found that due to lack of available treatment, youth with serious mental disorders were placed in detention without any criminal 

charges pending against them. In other cases, youth who had been 

charged with crimes but who had served their time or were otherwise able to be released remained incarcerated for extended periods 

of time because no inpatient bed, residential placement or outpatient appointment was available. That investigation found that 

two-thirds of juvenile detention facilities were holding youth waiting for mental health treatment, and that in one 6-month period, 

nearly 15,000 incarcerated youth were waiting for mental health 

services. 

Mr. Chairman, I share your desire to end these practices. That 

is why I supported the Affordable Care Act, which provides health 

insurance coverage, including coverage for mental illness, to millions of Americans, and that is why I have opposed Republican efforts to repeal this law and take this coverage away. It is also why 

I hope that this hearing does not ignore the elephant in the room: 

the impact on millions of Americans with mental illnesses of the 

failure by 24 States to expand their Medicaid programs under the 

Affordable Care Act. 

Last month the American Mental Health Counselors Association 

released a new study titled ‘‘Dashed Hopes, Broken Promises, More 

Despair,’’ and I would like to ask that this report be made part of 

the hearing record. 

Mr. MURPHY. Without objection, yes, it will be included. 

[The information appears at http://docs.house.gov/meetings/if/ 

if02/20140326/101980/hhrg-113-if02-20140326-sd004.pdf.] 

Mr. WAXMAN. Dr. Edgerson is here today to testify on behalf of 

the organization, and I appreciate him joining us. 

The report found that the failure by states to expand their Medicaid programs is causing nearly four million people who are in serious psychological distress or have a serious mental illness or substance disorder to go without health insurance. That is four million 

8 

Americans in need who are left without coverage, largely because 

of Republican governors’ ideological obsession with rejecting everything associated with the Affordable Care Act. 

Mr. Chairman, this includes over 200,000 people with mental illnesses in your home State of Pennsylvania. 

The report described the impact of this lack of coverage, finding 

that ‘‘The lack of health insurance coverage keeps people with mental illness from obtaining needed services and treatments and follow-up care with the goal of achieving long-term recovery and quality of life.’’ 

This is a tragedy and a shame. If these four million Americans 

obtained coverage, they would receive better ongoing treatment and 

care, and they would be less likely to end up in a hospital emergency room, or worse, a prison, with a mental health crisis. 

Mr. Chairman, I know you want to help individuals with mental 

illnesses. We have both introduced mental health legislation, and 

I hope that as we move forward, we can find common ground with 

these bills. 

But the biggest and easiest step we can take to improve care for 

those with serious mental illnesses is to make sure they have 

health insurance. The Medicaid expansion is a good deal for the 

states, and it is desperately needed by millions of Americans. This 

committee should be working together to make sure that regardless 

of where they live, Americans in all 50 states can obtain this coverage. 

I yield back the balance of my time. 

Mr. MURPHY. The gentleman yields back. Thank you. 

I also have a letter from the National Association of Psychiatric 

Health Systems, also commenting on this topic today of psychiatric 

beds, and so I ask without objection to include that in the record 

as well. 

[The information appears at the conclusion of the hearing.] 

Mr. MURPHY. I have already introduced all of our witnesses 

today, so I am now going to swear you in. So you are aware, the 

committee is holding an investigative hearing, and we have the 

practice of taking testimony under oath. Do any of you object to 

taking an oath? All right. The Chair then advises you that under 

the rules of the House and the rules of the committee, you are entitled to be advised by counsel. Do any of you desire to be advised 

by counsel during your testimony today? It shouldn’t be an issue. 

Thank you. In that case, if you would please rise and raise your 

right hand, and I will swear you in. 

[Witnesses sworn.] 

Mr. MURPHY. You may now sit down, and you are under oath 

and subject to the penalties set forth in Title XVIII, section 1001 

of the United States Code. We will now recognize each of you to 

give a 5-minute opening statement. 

I recognize first Ms. Ashley. Make sure your microphone is on 

and it is pulled close to you. Thank you. 

9 

TESTIMONY OF LISA ASHLEY, PARENT OF A SON WITH SERIOUS MENTAL ILLNESS, SACRAMENTO, CALIFORNIA; JEFFREY L. GELLER, M.D., M.P.H., PROFESSOR OF PSYCHIATRY 

AND DIRECTOR OF PUBLIC SECTOR PSYCHIATRY, UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL, WORCESTER, 

MASSACHUSETTS; JON M. HIRSHON, M.D., M.P.H., PH.D., 

FACEP, TASK FORCE CHAIR, 2014 AMERICAN COLLEGE OF 

EMERGENCY PHYSICIANS NATIONAL REPORT CARD ON 

EMERGENCY CARE, AND ASSOCIATE PROFESSOR, DEPARTMENT OF EMERGENCY MEDICINE, UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE, BALTIMORE, MARYLAND; MICHAEL C. BIASOTTI, CHIEF OF POLICE AND IMMEDIATE 

PAST PRESIDENT OF NEW YORK STATE ASSOCIATION OF 

CHIEFS OF POLICE, AND PARENT OF A DAUGHTER WITH SERIOUS MENTAL ILLNESS, NEW WINDSOR, NEW YORK; THOMAS J. DART, SHERIFF, COOK COUNTY SHERIFF’S OFFICE, 

CHICAGO, ILLINOIS; STEVE LEIFMAN, ASSOCIATE ADMINISTRATIVE JUDGE, MIAMI-DADE COUNTY COURT, ELEVENTH 

JUDICIAL CIRCUIT OF FLORIDA, MIAMI, FLORIDA; GUNTHER 

STERN, EXECUTIVE DIRECTOR, GEORGETOWN MINISTRY 

CENTER, WASHINGTON, D.C.; HAKEEM RAHIM, ED.M., M.A., 

SPEAKER AND MENTAL HEALTH EDUCATOR AND ADVOCATE, HEMPSTEAD, NEW YORK; LAMARR D. EDGERSON, 

PSY.D., LMFT, NBCCH, CLINICAL MENTAL HEALTH COUNSELOR, DIRECTOR AT LARGE, AMERICAN MENTAL HEALTH 

COUNSELORS ASSOCIATION, FAMILY HARMONY, ALBUQUERQUE, NEW MEXICO; AND ARTHUR C. EVANS, JR., PH.D., 

COMMISSIONER, DEPARTMENT OF BEHAVIORAL HEALTH 

AND INTELLECTUAL DISABILITY SERVICES, UNIVERSITY OF 

PENNSYLVANIA, PHILADELPHIA, PENNSYLVANIA 

TESTIMONY OF LISA ASHLEY 

Ms. ASHLEY. Hello, and good morning, Mr. Chairman and members of the subcommittee. Thank you for inviting me here to tell 

my son’s story with the emergency room department in my vicinity. 

I am a Nurse Practitioner with a master’s degree. I have been 

in pediatric practice for 38 years, but that is not why I am here 

today. I am here as a mother of a son who is now 27 and diagnosed 

with paranoid schizophrenia 2 years ago. It has been a long and 

difficult story which I share with many parents. 

My son was about 20 or 21 years old when I knew something 

was wrong but it wasn’t until he went homeless when he was in 

L.A. and went missing for 3 weeks that I knew for sure. Of course 

he saw nothing wrong. When I was finally able to locate him, I 

brought him back to Sacramento. He was delusional, thinking the 

FBI was watching him, there were satellites in the sky monitoring 

his thoughts, having auditory hallucinations, could not have a conversation, laughing to himself, and not caring for his hygiene. Prior 

to this, my son was extremely bright, received 740 out of 800 on 

his math SATs, and was accepted to seven universities for mechanical engineering. His bizarre behavior went on for months but he 

refused to see a psychiatrist. He was bonded to his primary medical provider, who saw him several times trying to get him on a 

hold. I felt helpless and extremely frustrated. Even calling the poVerDate Nov 24 2008 12:19 Oct 10, 2014 Jkt 037690 PO 00000 Frm 00015 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-130 CHRIS
10 

lice did not help because they did not feel that he was a harm to 

himself or others. 

I am specifically going to tell a story regarding his hospital emergency department stays three times over a 2-year period. Each 

time, I struggled with pain and anguish to see my beautiful son 

taken into custody, especially for the first time, because he didn’t 

know how sick he was and how very confused as to why he could 

not go home with me, and I cried my heart out. 

The first time was in May 2012. He had been sick over a year 

before I was able to get him some help. His first time in the emergency room was approximately 12 hours. I couldn’t believe they 

had to hold him there that long, not knowing there was a shortage 

of psych beds in the county. He was then transferred to a psych 

facility locally and remained 2 weeks, just as long as my insurance 

would allow him. Although it was very difficult to have my son hospitalized, I know he was in good hands and it relieved some of my 

anxiety, but still, it was nothing like I had ever been through and 

having to trust a system that was so foreign to you and difficult, 

I worried every minute. 

The second time was not quite as smooth. In January of 2013, 

my son asked voluntarily to be taken to the hospital because his 

head felt like it was on fire. He was anxious and very distressed. 

I dropped everything, knowing that he was asking to go, he must 

have felt pretty bad. I brought him to the same emergency room 

that morning, we reached the triage nurse. I identified myself as 

an employee and a nurse practitioner. I explained my son was a 

paranoid schizophrenic and he was in psychosis. I tried to remain 

calm as the triage nurses took his blood pressure and temperature 

and then assigned him to a gurney in the hallway with at least 

eight other patients, which included children, all waiting to be seen 

by a doctor. It was not long before my son started to get agitated 

and wanting to leave. The R.N. called the social worker to help intervene. She could not quiet him down. As he tried to approach the 

exit, the emergency room policeman tried to stop him by holding 

him back. His behavior escalated. My son was screaming at him 

not to touch him. When schizophrenics are in psychosis, they do 

not want to be touched. In front of all the children and adults waiting in the hallway, the police officer wrestled him to the ground 

and handcuffed him. 

I tell you this because I brought him to the hospital for medical 

treatment, not for police handcuffing him, and their intervention 

escalating his psychosis made it worse. If he had been able to go 

to some kind of psych facility, he would have gotten medical attention rather than police detention. Doctors would have known how 

to deal with him, calm him down, isolate him from others. The 

emergency room is not a quiet place and they are not trained to 

deal with psychiatric illnesses and certainly not serious mental illness. 

They then placed him on a gurney and put him in four-point restraints and then medicated him. He was there on a Friday morning the whole day, all day Saturday, all day Sunday and all day 

Monday afternoon because they could not find a psych bed anywhere. He stayed in a room tied to his bed for four days, heavily 

medicated. Seeing him helpless tied to a bed for days was like a 

11 

nightmare. This was my son, and I was helpless except to keep him 

company and try to reassure him things would be all right. I was 

angry they couldn’t find him a place. Does it really take that long 

to find a psych bed? 

Finally, on Monday, I was told there was an opening at a hospital in San Francisco, which is 100 miles east of Sacramento. They 

finally took him there later that day. I was unable to be involved 

in his care because he was so far away except for weekends. It was 

very frustrating. I didn’t understand why he needed to go so far 

away from his family member, who cared for him and loved him. 

By the way, if I hadn’t had private insurance, he never would 

have gone to that hospital because they don’t accept public monies, 

so because I had private insurance, they took him. Otherwise, who 

knows? He might still be there. 

The third time was in November. Again, his head was burning 

and voices were screaming at him. I took him back to the hospital. 

They put him on a gurney in the hallway again. I was able to be 

proactive and talk with other providers prior to this, and set up a 

plan so that the second intervention would never, ever happen to 

him again. I was able to make some phone calls, and after two days 

get him into a local psych facility, where he stayed another 3 days. 

My son is fairly stable since that time in November. He has not 

required any additional hospitalization but he attends regular psychiatric visits and takes his medications regularly, and I pray every 

day that he continues to stay out of the emergency room because 

there are no other alternatives for him. 

Thank you. 

[The prepared statement of Ms. Ashley follows:] 

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Mr. MURPHY. Thank you, Ms. Ashley. I appreciate your moving 

testimony. 

I forgot to mention at the time to keep your comments to 5 minutes, so if you hear my gavel tapping, that is why. 

Doctor, you are next. 

TESTIMONY OF JEFFREY L. GELLER 

Dr. GELLER. Mr. Chairman, Representatives, ladies and gentlemen, good morning. I am Dr. Jeffrey Geller, a board-certified psychiatrist, currently Professor of Psychiatry at the University of 

Massachusetts Medical School, Medical Director of the Worcester 

Recovery Center and Hospital, and Staff Psychiatrist at the Carson 

Community Mental Health Center. 

I have consulted public mental health systems and State hospitals in one-half of the States in the United States, the District 

of Columbia and Puerto Rico. I am the author of 250 publications 

in the professional literature, and the book, ‘‘Women of the Asylum.’’ I serve on many professional boards but I come here today 

representing only my own experience taking care of patients with 

serious mental illness for 40 years. 

Just yesterday, there were 22 psychiatric patients in a general 

hospital emergency room in a city of 150,000 not far from here 

waiting for disposition. Why? What is to be done? 

On May 3, 1854, President Franklin Pierce vetoed a bill that 

would have made the Federal Government responsible for America’s population with serious mental illness. His veto message includes the following beliefs of his: State hospitals or public psychiatric hospitals are meritorious institutions doing good. They fulfill a historic role belonging to the States, meeting the needs of a 

population outside the purview of the Federal Government and susceptible to becoming the responsibility of the Federal Government 

if the Federal Government provided any opportunity to the States 

to shift the burden. 

The Federal Government left the care of the serious mentally ill 

to the states until Congress passed and President Kennedy signed 

the Mental Retardation Facilities and Community Mental Health 

Centers Construction Act of 1963. From then until now, federal actions such as Medicaid, Medicare, the IMD exclusion and many 

others have resulted in the unintended consequences of massive 

proportions, not the least of which is deinstitutionalization. We created the perfect formula for the current debacle: an expanding 

array of fiscal incentives for States to move people out of state hospitals, inadequate resources to meet the needs of State residents 

with serious mental illness in the community, no beds in State hospitals to meet the needs of former State hospital patients, who did 

not find the community the panacea promised by the Supreme 

Court and were dangerous outside of hospitals, no beds to meet the 

needs of new cases of serious mental illness requiring a hospital 

level of care, and a public more willing to build jails and prisons 

than hospitals because they found no solace in a state system they 

saw as pushing ill-prepared folks with mental illness into their 

neighborhoods. 

How did this lead to individuals waiting in hospital emergency 

departments, or EDs, for weeks, sometimes a month? Pick any 

18 

State. There are no available beds in the State’s public psychiatric 

hospitals because there are too few beds. A patient on the psychiatric unit in a general hospital has been approved for transfer 

to the State hospital but cannot be transferred because there is no 

available bed. Thus, the general hospital psychiatric unit is populated by some patients who are stuck there awaiting state hospital 

transfer. An individual is brought to the general hospital’s emergency department by police, family, ambulance, or comes on her 

own. The individual was assessed and determined to need hospitalization. The individual cannot be admitted to the psychiatric 

unit in the same hospital as the emergency department because 

there are no beds there. 

What happens next is, a hospital emergency department staff or 

a member of a contracted crisis team starts a bed search. A bed 

search means calling every hospital in the State seeking a bed. 

Frequently, the bed search is fruitless. There are no beds available 

anywhere because all the hospitals are in the same situation as the 

psychiatric unit in the hospital the worker is calling from. So the 

individual remains in the emergency department waiting for an 

available bed. The days waiting benefit no one. The ED becomes 

overcrowded. The patient is a patient in name only. He is not getting treatment except that he is receiving food, a bed or gurney, 

and maybe some medication. He might as well be waiting on a 

bench in a train station. Or the individual is simply released from 

the emergency department because there is no place else for her to 

go. The threshold for holding somebody in the emergency department awaiting admission keeps creeping up. Many released folks 

are picked up by the police, processed through the courts, sent to 

the State hospital for a forensic evaluation, further decreasing 

available beds to the person awaiting a bed in the emergency department. 

Congress can enact measures to ameliorate the problems of 

boarders in emergency departments. These include: provide States 

with opportunities to obtain IMD exclusion waivers with maintenance of effort; make SSI and SSDI payments to eligible individuals independent of where they reside and require their contribution for room and board to be the same in all locations including 

jails and prisons; individuals keep their Medicaid and Medicare in 

all settings. Improve the federal grant process for research into 

prevention and early intervention; provide grants to States to create or expand crisis intervention teams so that such a program is 

available in every city and town; set fair and reasonable Medicaid 

payment rates for psychiatric services at community mental health 

centers and Federally Qualified Health Centers; incentivize States 

to actually use the assisted outpatient treatment statutes they 

have; define Medicaid and Medicare payments to clubhouses in 

ways that do not destroy the mission of clubhouses; incentivize 

States to establish mental health courts. 

Mr. Chairman, Representatives, it is time the Federal Government took explicit action through bipartisan, bicameral efforts to 

remedy the calamitous state of the public care and treatment of 

persons with serious mental illness in the United States today. 

Thank you. 

[The prepared statement of Dr. Geller follows:] 

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Mr. MURPHY. Thank you, Doctor. 

Dr. Hirshon, you are recognized for 5 minutes. 

TESTIMONY OF JON M. HIRSHON 

Dr. HIRSHON. In emergency departments throughout the country, 

we emergency physicians expect the unexpected. This is what we 

are trained to do. Even so, there is one thing that we all know is 

happening: increasing demand by patients in need of acute psychiatric care. 

Mr. Chairman and members of the subcommittee, thank you for 

this opportunity to testify today on behalf of the American College 

of Emergency Physicians. ACEP is the largest specialty organization in emergency medicine with more than 32,000 members in all 

50 States and the District of Columbia. 

My purpose today is to help you understand that we are in the 

midst of a national crisis, facing a dramatic increase in vulnerable 

mental health patients seeking emergent and urgent care. America’s mental health services are experiencing increasing demand 

while concurrently receiving decreased funding, which drives psychiatric patients to the ED, or emergency department. 

In 2000, psychiatric patients to the ED accounted for only 5.4 

percent of all ED visits, but by 2007, that number had risen to 12.5 

percent, well over a doubling of the number of psychiatric patients. 

Until more services and funding are made available to address this 

crisis, EDs will be the safety net for these patients. This is due in 

large part to the federal Emergency Medicine Treatment and Labor 

Act, EMTALA, which mandates medical screening evaluation and 

stabilization for anyone seeking care in an ED. Additionally, unlike 

many other health care settings, EDs are open 24 hours a day, 7 

days a week every day of the year. 

Emergency physicians do their best to provide care to patients 

with psychiatric conditions but the ED is not the ideal location for 

these services. ED crowding leads to delays in care and have been 

associated with poor clinical outcomes. For patients with mental 

health and/or substance abuse problems, prolonged ED stays are 

associated with increased risk of worsening symptoms. Without 

available appropriate inpatient resources for admitted patients, 

these patients wait or are boarded in the ED until an inpatient bed 

becomes available or an accepting facility can be found. 

When the normal capacity of the ED is overwhelmed with 

boarded patients, there remains absolutely no room for surge capacity, which would be critical in the event of a manmade or natural disaster. 

In a recent ACEP survey, 99 percent of emergency physicians reported admitting psychiatric patients daily while 80 percent said 

that they were boarding psychiatric patients in their EDs. Acutely 

ill psychiatric patients require more physician, more nurse and 

more hospital resources. ED staff spends more than three times as 

long looking for a psychiatric bed as they would for a non-psychiatric patient. 

Other factors contribute to the extended ED boarding times for 

psychiatric patients including defensive medicine or threat of legal 

action, required preauthorization for inpatient services, medical 

clearance prior to psychiatric evaluation, substance abuse-related 

38 

issues, and inadequate outpatient services. As communities have 

seen, many of these issues are systems issues and beyond the control of the clinician. It is imperative that access to high-quality inpatient and community mental health care be a priority. 

I go into further detail on suggested solutions in my written testimony but some important ones include full capacity protocols to 

improve the movement of admitted patients to inpatient floors, separate psychiatric ED and behavioral health annexes to help address urgent and emergent psychiatric needs, regionalized care and 

telemedicine to help efficiently and effectively address increasing 

demand, as well as the elimination of out-of-network insurance 

issues and community and State mental health buy-in. 

Let me leave you with this: the increasing burden of mental illness in this country combined with a lack of resources to care for 

these individuals is a national crisis. Mass deinstitutionalization of 

mental health patients over the past few decades did not result in 

successful community integration of individuals needing psychiatric 

services, in part because the necessary services and funding were 

not put in place for adequate community support. 

Systematic changes are needed in the way we care for these individuals with mental illness in this country. How we deal with these 

vulnerable individuals is an important measure of who we are as 

a society. Necessary resources must be made available for additional inpatient and outpatient treatment beds with the corresponding professional staff as well as for critically needed research. Otherwise mental health services will continue to deteriorate and these individuals, often our family members, will continue 

to be at risk for abuse and neglect, seeking care in EDs for lack 

of any other support. 

I thank you for your attention to this alarming problem. 

[The prepared statement of Dr. Hirshon follows:] 

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Mr. MURPHY. Thank you, Doctor. 

Chief Biasotti, you can pull that microphone right up next to you, 

please. Thank you. 

TESTIMONY OF MICHAEL C. BIASOTTI 

Chief BIASOTTI. Good morning, Chairman Murphy and Ms. 

DeGette. I am the immediate past President of the New York State 

Association of Chiefs of Police and Chief of Police in New Windsor, 

New York. I am in my 38th year of service. 

My wife, Barbara, who is a psychologist, is here today with me. 

We have a daughter with schizophrenia who has been involuntarily 

hospitalized in excess of 20 times. Barbara and I met when she, 

like many moms, turned to the police for help when her, now our 

daughter became psychotic, disruptive and threatening. She was 

self-medicating, unemployed and deteriorating, despite my wife’s 

heroic efforts to help her. Then she went into assisted outpatient 

treatment. It saved her life. 

In 2011, while at the United States Naval Postgraduate School’s 

s Center for Homeland Defense and Security, I published a survey 

of over 2,400 senior law enforcement officers titled ‘‘Management of 

the Severely Mentally Ill and its Effects on Homeland Security.’’ It 

found that the mentally ill consume a disproportionate percentage 

of law enforcement resources. Many commit low-level crimes. One 

hundred and sixty thousand attempt suicide, 3 million become 

crime victims, and 164,000 are homeless each year. 

The survey essentially found that we have two mental health 

systems today, serving two mutually exclusive populations. Community programs serve those who seek and accept treatment. 

Those who refuse, or are too sick to seek voluntary treatment, become law enforcement responsibilities. Officers in the survey were 

frustrated that mental health officials seemed unwilling to recognize or take responsibility for this second more symptomatic group. 

Ignoring them puts patients, the public and police at risk and costs 

more than keeping care within the mental health system. 

As an example, there are fewer than 100,000 mentally ill in psychiatric hospitals but over 300,000 in jails and prisons. The officers 

I surveyed pointed out the drain on resources it takes to investigate, arrest, fill out paperwork and participate in the trials of all 

of them. Add to that the sheriffs, district attorneys, judges, prisons, 

jails and corrections officers it takes to manage each of them and 

you see the scope of the problem. 

Many more related incidents, like suicides, fights and nuisance 

calls take police time, but don’t result in arrest or incarceration. 

Overly restrictive commitment standards and the shortage of hospital beds are major sources of frustration for officers. Hospitals 

are so overcrowded they often can’t admit new patients and discharge many before they are completely stable. They become what 

we call round trippers or frequent flyers. One officer referred to it 

as a human catch and release program. Anyone who asks for help 

is generally not sick enough to be admitted, so involuntary admission, that is, being a danger to self or others, becomes the main 

pathway for treatment. Officers are called to defuse situations and 

then have to drive in some cases hours to transport individuals to 

hospitals and then wait hours in the emergency rooms, only to find 

52 

the hospital refuses admission because there are no beds or that 

the commitment standard is so restrictive. The only remaining solution for our officers is to arrest these people with serious mental 

illness for whatever minor violation exists, something that they are 

loathe to do to sick people who need medical help, not incarceration. 

Finally, while everyone knows that everyday mental illness is 

not associated with violence, untreated serious mental illness clearly is. The officers in the survey deal with that reality every day. 

You in Congress dealt with it when Ronald Reagan and Gabrielle 

Giffords were shot; two guards in the Capitol building were killed, 

and the Navy Yard shooting happened. Representatives DeGette, 

Gardner and Griffith have experienced the worst of the worst in 

their States. 

We have to stop pretending that violence is not associated with 

untreated serious mental illness. We have to stop pretending that 

everyone is well enough to volunteer for treatment and then selfdirect their own care; some clearly are not. 

As I wrote in the intro to the survey, police and sheriffs are being 

overwhelmed dealing with the unintended consequences of a policy 

change that in effect removed the daily care of our Nation’s severely mentally ill population from the medical community and 

placed it with the criminal justice system. This policy change has 

caused a spike in the frequency of arrests of severely mentally ill 

persons, prisons, and jail populations as well as the homeless population and has become a major consumer of law enforcement resources nationwide. 

If I could make one recommendation, it would be to prevent individuals from deteriorating to the point where law enforcement becomes involved. Return care and treatment of the most seriously ill 

back to the mental health system. Make the seriously mentally ill 

first in line for services rather than last. As a law enforcement officer and a father, I know that treatment before tragedy is a far better policy than treatment after tragedy. 

Thank you so much. 

[The prepared statement of Chief Biasotti follows:] 

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Mr. MURPHY. Thank you, Chief. 

Mr. Dart, you are recognized for 5 minutes. 

TESTIMONY OF THOMAS J. DART 

Sheriff DART. Thank you, Mr. Chairman and the committee, for 

having me here today. 

I am the Sheriff of Cook County, and as the Sheriff, I run the 

Cook County Jail, which is the largest single site jail in the country. My office is in the jail. Our average daily population is between 

10,000 to 12,000 inmates and it costs about $143 a day to house 

someone there. 

Since becoming Sheriff in 2006, I have seen an explosion in the 

percentage of seriously mentally ill individuals housed in the jail. 

I have seen firsthand the devastating impact cuts to mental health 

programs and services have had on the mentally ill in Illinois. This 

is a crisis we must all care about because it affects all of us. I find 

it ironic that in the 1950s we thought it was inhumane to house 

people in state hospitals but now in the 21st century we are OK 

with them being in jails and prisons. 

On any given day, an average of 30 to 35 percent of my population suffers from a serious mental illness. The diagnoses fall into 

two main categories: mood disorders such as major depressive disorder or bipolar disorder, or a psychotic disorder such as schizophrenia. While some mentally ill individuals are charged with violent offenses, the majority are charged with crimes seemingly committed to survive, including retail theft, trespassing, prostitution 

and drug possession. 

A cursory review of our statistics tells the story. Last year in one 

of my living units, 1,265 men were in that dorm on low-level drugrelated offenses. The average length of stay was 87 days. At $143 

a day, it costs over $12,000 just to house these individuals pretrial 

because they cannot afford to post a minimal bail or have nowhere 

to live. Many of these inmates ultimately are sentenced to probation, more often than not, or sentenced to time while they were sitting with me. 

The unfortunate and undeniable conclusion is that because of 

dramatic and sustained cuts in mental health funding, we have 

criminalized mental illness in this country and county jails and 

State prison facilities are where the majority of mental health care 

and treatment is administered. 

Three recent case studies illustrate this. J.J. was arrested by the 

Chicago Police Department last May after a failed attempt to steal 

sheets or towels from a local Walgreens drug store. When we spoke 

to him shortly after his arrest, he explained that he took the items 

off the shelf and as he walked past the cashier and he asked her 

to charge him. He was arrested and charged with retail theft. The 

value of the items he stole were $29.99. He spent 110 days in my 

jail before being sentenced to probation. During his custody, he was 

stabilized on medication and received drug and mental health 

treatment. The taxpayers of Cook County spent close to $16,000 

after his failed attempt to steal $29 worth of sheets. 

J.D. suffers from a psychotic disorder and has visions that terrify 

him. He was arrested in California on a warrant from my county. 

While in custody in California, he removed one of his eyeballs in 

66 

an attempt to stop seeing his visions. He lost sight in that eye. So 

we were alerted to this issue. He was transferred to our custody 

2 weeks ago and recently attempted to remove his other eye. While 

staff acted quickly, we were able to stop that from occurring. We 

presently have him where he wears a helmet and face mask and 

has gloves on his hands. 

T.A. was arrested over 100 times. Her most recent arrest came 

after she attempted to steal $20 from a person’s purse during a 

church service. She is a chronic self-mutilator. She attacks her 

arms with her own fingernails or any objects she can find. To keep 

her safe while in our custody, we make special mittens for her that 

go up to her armpits. Incredibly, she was sentenced to a prison 

term and recently was transferred to a state hospital. We are 

awaiting right now her imminent return to Chicago. She has cost 

us, the taxpayers, conservatively, over a million dollars for all of 

her custody. 

What we have done in our county now is my staff interviews 

every detainee before they appear in bond court regarding their 

mental health history. Those who admit to a history are identified 

for the public defender’s office and then we make efforts to try to 

appeal to the judges for alternative programs. Unlike State prisoners who have fixed release dates, pretrial detainees may be released at any time, which significantly complicates our ability to 

provide discharge planning. The inmates are offered written information on available community resources and enrollment in County Care and allowed access to a telephone to contact someone to arrange for transportation home or to identified housing. If the inmate requires discharge to a facility in the next day, we will shelter them overnight before we will try to get them to a hospital. If 

the inmate requires assistance with transportation to his or her 

home or a shelter, we will drive them there. If the inmate is stable, 

coordinated releases are typically initiated by our health care provider and the steps are followed. Additionally, we communicate 

with the party the inmate is being released to. Once it is confirmed 

the party is outside the jail, someone from our records unit will go 

out there to make sure that person is there. The past practice always had been, we released them out to the street where they 

would wander around aimlessly for hours, if not days. 

If the inmate is unstable and in need of psychiatric hospitalization in the community, he or she is petitioned by a licensed mental 

health professional. A certificate for involuntary hospitalization is 

completed by psychiatrists and accompanies the individual to the 

receiving hospital. 

Finally, in August, I launched the Mental Health Help Line. It 

is a 24-hour help line dedicated to assisting former mentally ill detainees or families of mentally ill detainees. The phone line is 

manned by members of my policy team and supported by our mental health staff. It has been an invaluable resource to the families 

who communicate with us through this help line. We receive calls 

on this help line 24 hours a day, 7 days a week. 

In conclusion, we are in an unsustainable position. I often refer 

to the jail as the last car on a long train. Every single day and at 

every step before a person comes in to the jail, there is discretion: 

discretion to arrest, to charge and to set bond. But as custodian, 

67 

I am obligated to care for those individuals. Every day I am faced 

with the mental health crisis in this county and in the country. I 

see the pain of those suffering from mental illness and the pain of 

their families who have struggled to care for them and provide 

them with resources. The question that plagues me, that keeps me 

up at night, is where do we go from here? 

As that question is debated, I will continue to do all I can to care 

for, protect and advocate for increased funding to address mental 

illness in our country and I will continue to provide the best care 

I can for the mentally ill. This is truly a crisis that we can no 

longer ignore. 

Thank you. 

[The prepared statement of Sheriff Dart follows:] 

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Mr. MURPHY. Thank you, Sheriff. 

I now recognize Judge Leifman for 5 minutes. 

TESTIMONY OF STEVE LEIFMAN 

Mr. LEIFMAN. Thank you very much, Mr. Chairman, members of 

the subcommittee. My name is Steve Leifman. I am a Judge for 

Miami-Dade County and I chair the Florida Supreme Court Task 

Force on Substance Abuse, Mental Illness and Issues in the Court. 

You asked where have the patients gone. Sadly, the answer is 

jail and prisons, and this is an American travesty. As you already 

stated, in 1955 there were some 550,000 people in State psychiatric 

hospitals around this country. If nothing had changed and we use 

today’s population, there would have been about 1.5 million people 

in State psychiatric hospitals today. 

Last year, 1.5 million people with serious mental illnesses were 

arrested in this country. On any given day in the United States, 

we have approximately 500,000 people with serious mental illnesses in jails and prisons and another 850,000 in the community 

on some type of community control or probation. Since 1955, we 

have closed 90 percent of the hospital beds in this country and we 

have seen a corresponding increase of 400 percent of the number 

of people going to jail with mental illnesses, and because jails are 

not conducive to treatment and courts do not know what to do with 

this population, people with mental illnesses generally stay four to 

eight times longer in jail than anyone else with the exact same 

charge who does not have a mental illness and costs seven times 

more. 

I had no idea that when I become a judge I was actually becoming the gatekeeper to the largest psychiatric facility in the State of 

Florida, and tragically, that is the Miami-Dade County Jail. I see 

more people on any given day with mental illness than most psychiatrists see in a month. 

People with mental illnesses in this country are three times more 

likely to be arrested than to be hospitalized, and in my State, it 

is nine times more likely. The closing of the hospitals is not the 

only and primary reason all these individuals had ended up in hospitals. It is a combination that created the perfect storm. It includes the IMD exclusion. It includes what Medicaid pays for its 

services. It includes the war on drugs. It includes the reduction of 

hospital beds. It includes the antiquated involuntary hospital laws. 

They have all conspired to create this perfect, perfect storm. And 

if this wasn’t bad enough, just listen to the costs this is having to 

our communities. 

We worked with the Florida Mental Health Institute at the University of South Florida and Tampa. We wanted to know who the 

highest utilizers of criminal justice and mental health services 

were in my county so that we could wrap our arms around this 

population to see if we could get them services so they didn’t keep 

reoffending. I thought I would get a list of thousands of individuals 

back. They send me a list of 97 people, and I guarantee every one 

of you have these same 97 in your communities. These 97 individuals, primarily men, primarily diagnosed with schizophrenia, over 

5 years were arrested 2,200 times. They spent 27,000 days in the 

Dade County Jail, 13,000 days at a psychiatric hospital or an emerVerDate Nov 24 2008 12:19 Oct 10, 2014 Jkt 037690 PO 00000 Frm 00080 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-130 CHRIS
75 

gency room, and cost taxpayers $13 million, and we got absolutely 

nothing for it. We would have been better off sending them to Harvard and maybe giving them an opportunity for an education. It is 

an outrage. 

The other part of the problem is that where we spend our money 

is killing us. In Florida, we spend one-third of all of our adult public mental health dollars—that is almost a quarter of a billion dollars—to try to restore competency for 2,700 people. We have between 170,000 and 180,000 people in any given year in Florida who 

at the time of their arrest need acute mental health care treatment 

but we spend a third of our money trying to restore competency so 

we can try these 2,700 people. Well, 70 percent of these individuals 

have three things happen to them. Either the charges are dropped 

because the witnesses disappear, they get credit for time served because they have been in the system so long and they walk out of 

the front door of the courthouse without any access to treatment, 

or they get probation and they walk out of the courthouse with any 

access to treatment and we just spent a quarter of a billion dollars, 

and that money is coming out of the community mental health system, making it harder for people to get access. It actually meets 

the definition of insanity. We keep doing the same thing again and 

again and we expect a different outcome. 

It is even worse at the prison level, and on competency restora- tion, in the United States we are spending almost $3.5 billion and 

we are getting very little return for that money. 

The fastest growing population in Florida’s prisons are people 

with mental illnesses. While our prison population has begun to 

stabilize over the last 2 years, the mental health population continues to grow at exceedingly alarming rates. Over the last 15 

years, the percentage of people with mental illnesses has grown by 

178 percent. We went from about 6,500 people with serious mental 

illnesses 15 years ago to 18,000 today. It is growing so fast that it 

is projected to double again in the next 10 years. Florida needs to 

start building 10 new prisons for the next 10 years just to get to 

this population. It will cost my State $3.5 billion to deal with this 

population if we don’t do something soon to correct the problem. 

We are looking at a huge cost and we are getting very little for 

our outcome. We have a three-legged stool that is wobbling and 

about to break, and there are three parts that I really hope that 

you are able to address. The first part is how and what we finance 

through federal Medicaid dollars for mental health services. It 

doesn’t work. The second somebody is no longer a danger to self or 

others, Medicaid will cut them off and the hospital will discharge 

them back to the community, often to homelessness, often into the 

criminal justice system. 

The second part that needs to be addressed is the antiquated involuntary hospitalization laws. Most of these laws were written before we had TV, microwave ovens, computers, brain imaging and 

antipsychotic medication. It is an absurdity. The first laws come 

from 1788 out of New York. It doesn’t work. People cannot get into 

the system to get treatment, and then when they are ready to be 

discharged, there is nothing for them. 

The third part is that we need to have a coordinated system in 

the criminal justice system to make sure we can take care of this 

76 

population, and let me just make two quick points. We are doing 

some significant things in Miami-Dade County that are having 

huge impacts. We have trained over 4,000 police officers in order 

to identify people with mental illnesses in the community. Last 

year, the city of Miami and Miami-Dade County did 10,000 mental 

health calls. These 4,000 officers only made 27 arrests out of these 

10,000 calls. Our jail audit plummeted from 7,800 to 5,000, allowing the county to close a jail and saving $12 million. We also have 

post-arrest diversion programs where if someone comes in, we get 

them treated and make sure that they are not just discharged to 

the community without any assistance. 

We are saving lives, we are saving dollars, and we are starting 

to make the system work, but we need to fix those other three 

pieces. We also need to begin to use advanced technology, which we 

are beginning to do. We are part of a unique private and public 

partnership in Dade County where we are working to see if predictive analytics can actually be used in the behavioral health 

space so that we can have an unfragmented system of care, more 

accountability, and make sure that people with mental illnesses are 

treated fairly and properly. 

Thank you very much. 

[The prepared statement of Judge Leifman follows:] 

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Mr. MURPHY. Thank you, Judge. I was afraid to gavel a judge. 

Judge LEIFMAN. And I appreciate that, and I won’t hold anyone 

in contempt today, so appreciate the reciprocation. 

Mr. MURPHY. I don’t think this is your jurisdiction, so we are 

good. 

Judge LEIFMAN. Thank you. 

Mr. MURPHY. But thank you for your testimony. 

Mr. Stern, you are recognized for 5 minutes. 

TESTIMONY OF GUNTHER STERN 

Mr. STERN. Thank you for hearing me today. I am here to talk 

about people who are homeless with severe, untreated mental illness. I have been working with homeless people for nearly 30 

years, for the last 24 at Georgetown Ministry Center. Our goal 

back in 1990 was to put ourselves out of business by ending homelessness. Instead, homelessness has become a career for me and so 

many others. It has now been 10 years since cities around the 

country including Washington, D.C., issued their 10-year-plan to 

end homelessness. Not much has changed. 

Why is homelessness so hard to solve? From my perspective, it 

is because we lack the tools to intervene when a person’s life has 

devolved to the point where he or she has moved out onto the 

street because of an untreated mental illness. When I began to 

work with the homeless population nearly 30 years ago, deinstitutionalization was in full swing. At the time many people I was 

working with were cycling in and out of hospitals. The community 

mental health centers were trying to figure out what their role 

was. 

As deinstitutionalization has continued, I have noticed that it is 

increasingly harder to access beds for people in acute psychiatric 

crisis. In the past 2 years, I have only seen two people admitted 

to the hospital. More typically now, people referred for psychiatric 

crisis get poor or no intervention and are returned to the street, almost always because they refuse treatment. 

Georgetown Ministry Center brings free psychiatric and medical 

care to the streets but very few people with untreated mental illness are willing to engage in conversations with our psychiatrists 

about their mental health. It is the nature of the illness. 

However, when we talk about a shortage of beds for treatment, 

we are not talking about the people I work with because these people with limited or no insight into their illness don’t think they 

need treatment and vehemently refuse treatment when it is offered. 

Homeless people are real people with families like yours and 

mine, families that care. Greg is someone I met sitting on a park 

bench near our center. He was shabbily dressed and smelled bad. 

He would drink, I assume to tame the voices that I knew he heard 

because of the frequent spontaneous smiles and grimaces. All this 

belied the fact that Greg was once a gifted constitutional lawyer 

who delighted his children with his dry wit. They were in their late 

teens when he began to show the signs of what would become a 

profoundly disabling bipolar disorder. Not long after, he disappeared. He would call occasionally on birthdays or out of the blue 

for no reason. The kids tried so hard to keep up with him. They 

98 

wanted desperately to make him whole again but it was futile. 

Greg drifted from city to city around the country, ending up in our 

center, ultimately in our small shelter one winter 8 years ago. Greg 

was a delight some of the time. His thick southern drawl and witty 

conversation would enchant volunteers, but other times he was 

withdrawn and surly. In January of 2006, Greg became sick. We 

encouraged him to go to the hospital and he said that he would. 

Instead, he disappeared. A week later I received a call from the 

medical examiner’s office. They needed a body identified. It was 

Greg. The bodies never look the way you remember a person. Only 

Greg’s face and hair showed from the white shroud covering his 

body. It took a few moments to work out that these were the features of the person that I once knew. 

A few years later, I met Greg’s two adult children. They had 

learned he had died in Washington 3 years after the fact. Each of 

them traveled, one from New York, the other from Phoenix, to meet 

here and see the place where their dad spent his final days. They 

needed to know what his last days were like. I shared coffee with 

them, and they told stories about him and they asked questions 

about his final days. They laughed and they cried. You could tell 

that they loved and missed their father. 

There are so many stories I could tell if I had time about mothers, brothers, sons, daughters who have wept for their relatives lost 

to mental illness. If the families had the tools to intervene, they 

would intervene. 

Most of all, what I want to impart here is that people who live 

on the street are real people with families and hopes and dreams 

abandoned because of an illness that has robbed them of their competency. The other important takeaway is that almost all the people I see on the street are there because they have refused treatment, not for rational reasons but because illness has insidiously 

robbed them of their insight to understand that they have an illness and that treatment can help them. 

So finally, what I have concluded after nearly 30 years of working with people who are homeless is that all I can do is provide 

some comfort and harm reduction. Until we are given tools for 

more assertive interventions, we will not resolve homelessness. 

Thank you. 

[The prepared statement of Mr. Stern follows:] 

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Mr. MURPHY. Thank you, Mr. Stern. 

Mr. Rahim, you are recognized for 5 minutes. 

TESTIMONY OF HAKEEM RAHIM 

Mr. RAHIM. Chairman Murphy, Ranking Member DeGette and 

members of the subcommittee, my journey with mental illness 

began in 1998 during my freshman year at Harvard University. 

That fall I experienced a terrifying panic attack. In that episode I 

had heart palpitations, sweaty palms and dizziness yet I did not 

know it was an anxiety-induced state. What I did know, however, 

was the deep terror I felt. 

My journey continued when I had my first manic episode. During 

the spring of 1999, I roamed the streets of Hempstead, New York, 

possessed with a prophetic delusion that I had to share with any 

and every one I met. Concerned, my parents sent me to my father’s 

homeland of Grenada to relax and be with family. However, while 

there, I plunged into a deep depression. I returned to Harvard that 

fall and struggled through the year battling anxiety and depression. 

In the spring of 2000, I was consumed by my second manic episode. My next 2 weeks were filled with sleepless nights and endless 

writing sessions. I showered less frequently and ate sporadically. 

During this manic episode, I experienced psychosis. I had visions 

of Jesus, heard cars talking and spoke foreign languages. Upon 

hearing my condition, my parents rushed to pick me up from Harvard’s campus. That same evening, my parents decided to take me 

to a psychiatric hospital in Queens. When we arrived at the emergency room, I was taken to the triage area. Over the next few 

hours, I was held in a curtained room in the ER. I tossed and 

turned and remained restless, as now I had not slept in 24 hours. 

My parents sat in the curtained room with me until I was admitted 

to the hospital later that night. 

Accompanied by two hospital aides, I was transported to the psychiatric ward in a hospital van. I walked through the dimly lit 

ward door and was met by approximately six staff members. They 

gave me a hospital gown, requested I change into it, and encouraged me to relax when they noted my agitated state. When I continued to toss, the staff stated they were going to put straps around 

my arms and legs. After placing the straps, they then said they 

were going to give me a sedative to help me sleep. I felt a prick 

on my upper arm. 

The next morning I awoke, drowsy and unable to speak. I walked 

to the common room on the ward, sat down and began to hold my 

breath. I received another sedative. I was hospitalized for 2 weeks. 

The first week is a blur due to my mental confusion and the psychiatric medication administered to me. 

However, I do remember some of my experiences. I interacted 

frequently with staff and the other patients. One staff member I 

felt an affinity toward and spoke with him frequently. He advised 

me to focus on getting better and to not come back to the hospital 

as so many other patients had. My psychiatrist on the ward diagnosed me with bipolar disorder and briefly explained that I would 

be on several medications. Upon my release from the hospital I 

found and met with a psychiatrist in Brooklyn. 

104 

During my hospitalization, I accepted my illness and began my 

arduous road to recovery. I cannot pinpoint what triggered my immediate acceptance, but I am grateful it did not take years for me 

to obtain insight. Over the course of my 16-year journey with mental illness, I have simultaneously embraced my diagnosis and realized that I am more than a label. I have embraced that I am more 

than medication, therapist appointments and support groups. I 

have learned that I am not bipolar, I am Hakeem Rahim, and not 

just any one piece of my treatment regimen. 

At the same time, I have learned that a good treatment regimen 

has to be accompanied by positive coping skills, diet, exercise for 

brain health, along with spirituality and spiritual perspective. 

The biggest challenge I faced getting to where I am now was 

openly acknowledging my mental illness. For so long, I felt a deep 

and personal shame for having bipolar disorder. This shame was 

so entrenched that I even felt uncomfortable sharing my diagnosis 

with close friends and even family members. 

In 2012, I decided to speak openly and joined NAMI’s In Our 

Own Voice program. Through the In Our Own Voice program, I 

have shared my story with over 600 people including individuals 

living with mental illness and their family members. Currently, I 

am the NAMI Queens/Nassau’s Let’s Talk Mental Illness presenter. 

Through the Let’s Talk Mental Illness program, I have shared my 

story and provided much needed awareness to over 5,000 high 

school students and middle school students at 37 schools. I see the 

importance in and will continue to speak up for mental health and 

mental illness education in schools and beyond. 

Millions of people in America desire to give voice to their struggles, but cannot because of stigma. I am fueled by the desire to 

break the silence. I am inspired by students who want to learn 

about mental illness to help a friend or a struggling parent who is 

hurting. I am strengthened by people who have decided to out 

themselves in an effort to normalize mental illness. Mental illness 

education and awareness is essential to combat stigma, end suffering and to normalize seeking help. 

I am grateful to my parents, family and loved ones who have 

supported me. I am also grateful for this committee for picking up 

this topic as well as this panel because it is my hope that the ideas 

put forth today will transform the already shifting conversation 

around mental illness, and I thank you very much. 

[The prepared statement of Mr. Rahim follows:] 

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Mr. MURPHY. Thank you, Mr. Rahim. We appreciate that. 

Dr. Edgerson. 

TESTIMONY OF LAMARR D. EDGERSON 

Mr. EDGERSON. My name is Dr. LaMarr Demetri Edgerson, and 

I wish to thank the chairman and ranking member for the opportunity to testify today at this very important hearing on the psychiatric bed shortage. My doctorate is in psychology. I am a clinical 

mental health counselor and licensed marriage and family therapist. 

The population we are focusing on today is the population that 

I primarily serve in my private practice. Over the past year, I have 

served as the Director at Large for the American Mental Health 

Counselors Association, also known as AMHCA. I am here representing AMHCA’s 7,100 members. I am also a board member and 

two-time past President of the New Mexico Mental Health Counselors Association. 

Clinical mental health counselors are primary mental health care 

providers who offer high-quality, comprehensive, integrative, costeffective services across the life span of the individual. We are 

uniquely qualified licensed clinicians trying to provide mental 

health assessment, prevention, diagnosis and treatment. 

I grew up in the welfare system with inadequate health insurance. Since the age of 18 years I have provided health care for patients. My career began as an enlisted member of the United States 

Air Force where I served for 20 years as a medic. As a clinical mental health counselor, I now see children, adults and families in a 

private practice in Albuquerque, New Mexico. My specialty is trauma. 

Evidence all around demonstrates the Nation’s mental health 

care system is in crisis. It is generating increasing demand for inpatient psychiatric beds while simultaneously decreasing its supply. Because patients have trouble accessing services in a community, they use the emergency department for basic and intermediate care. Our current mental health system still suffers from 

poor transition from inpatient institutions to community-based 

treatment. 

In a recent scholarly article, Ms. Nalini Pande estimated that 

psychiatric boarding lost nearly $4 million a year in revenue from 

service that could have been provided in lieu of boarding at just 

one 450-bed teaching hospital here. Ms. Pande also found that as 

patients waited, sometimes for hours, some for days, their psychiatric health deteriorated. Patients who often came in with manageable psychiatric illness subsequently turned into patients with 

acute needs. 

But still, there is more than meets the eye. We at AMHCA believe some policymakers are going down the wrong path in addressing the problem of hospital boarding. The barrier to treatment is 

accessing timely, effective, quality mental health service in the 

community. Surmounting these barriers requires continuous comprehensive health insurance coverage that enables access to essential inpatient and outpatient care, prescription drugs, early intervention, and prevention programs. All of those essential benefits 

are provided in health plans governed by the Affordable Care Act 

108 

and new State Medicaid expansion programs, and some are available to Medicare beneficiaries as well. 

We can work smarter to have a better health care system that 

systematically reduces crisis situations from developing. In addition to the importance of State Medicaid expansion, Medicare mental health services too have never been fully modernized to include 

newer providers like clinical mental health counselors and marriage and family therapists such as proposed by Representatives 

Chris Gibson and Mike Thompson in H.R. 3662. Comprehensive 

and stable health insurance coverage is the key to cost-effective, efficient, timely mental health services in the United States. 

The new State Medicaid expansion effort has the potential for 

millions of currently uninsured Americans with mental health diagnoses to obtain greatly expanded access to mental health and 

substance use treatment in an integrated community-based setting 

with a person-centered treatment focus, the exact objectives, I believe, all policymakers are trying to achieve today. 

Unfortunately, 25 States are refusing to participate in the new 

Medicaid expansion program, which will continue to leave millions 

of uninsured people with serious mental health conditions out in 

the coverage cold. AMHCA believes it is a huge and costly mistake 

that Congress under Medicare and State policymakers under Medicaid have decided to deny their most vulnerable citizens State 

health insurance coverage with comprehensive health care and 

mental health services. 

In summary, Medicare and mental health provider coverage modernization and State Medicaid expansion will provide health insurance coverage to millions of people with serious mental health conditions who have had difficulty accessing needed and timely service. These changes are necessary to dramatically reduce the 

chances of future crisis situations and increasing emergency department visits. 

Thank you again for the opportunity to present this testimony 

today before the committee. 

[The prepared statement of Mr. Edgerson follows:] 

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Mr. MURPHY. Thank you, Doctor. We appreciate that. 

Dr. Evans, you are recognized for 5 minutes. 

TESTIMONY OF ARTHUR C. EVANS, JR. 

Mr. EVANS. Thank you. Mr. Chairman Dr. Murphy, Ranking 

Member Representative DeGette and members of the committee, 

thank you for inviting me to participate in this hearing. I am Dr. 

Arthur C. Evans, Jr., Commissioner of the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, and 

I also have a faculty appointment at the University of Pennsylvania School of Medicine. 

I appear here today on behalf of the American Psychological Association, which is the largest scientific and professional organization representing psychology. 

As the Commissioner of the Department of Behavioral Health, 

my job is to ensure that the resources are deployed to address the 

needs of 1.5 million people in the city of Philadelphia. 

So today what I wanted to do is to talk as an administrator, as 

someone who is trained as both a scientist and a practitioner, and 

also a family member myself, and I want to start by saying I think 

all of the issues that we have heard today are solvable problems. 

I absolutely believe that. I think we have evidence both in Philadelphia and around the country that all of the issues that we have 

heard today are solvable I think with political will, with resources 

and with leadership. 

I really appreciate the family members who have testified today 

and especially Mr. Rahim, who gave his personal story, because I 

think that we have to hear that people can and do recover, and I 

want to start my comments by just giving a few examples of things 

that I think that we can do to improve the Nation’s mental health 

systems. 

First of all, people can and do recover, and we know from the research, we know from clinical practice that given the right resources, given the right types of services, people can do really well 

who have even the most serious forms of mental illness. Unfortunately, our systems are set up in a way that they don’t acknowledge that. We have systems that are geared towards maintaining 

people, addressing people when they are in crisis, and you heard 

some of the stories of people who have family members who have 

a very difficult time getting help, and the reason that is, is because 

of the way we finance our mental health system. It is diagnostically 

driven. People either have to have a diagnosis or to be in crisis. So 

one of the first issues I think we have to take on is, how are we 

financing our services and are we doing things and are we financing our service system in such a way that we have the resources 

to do outreach and to do early intervention. 

Secondly, I think that any discussion around psychiatric bed capacity has to deal with the efficiency of the current system. There 

are a number of things that we can do to improve the current efficiency, and I will give you a couple of examples from Philadelphia. 

We have in Philadelphia a unit that has people who historically 

would have been in the State hospital, very long lengths of stay, 

numbering sometimes in the months. We have employed evidencebased practices, both on the unit and in deploying ACT teams, or 

130 

Assertive Community Treatment teams, who have also been 

trained up in evidence-based practices, and we are starting to see 

a reduction in lengths of stay. I use that as an example because 

when we talk about increasing bed capacity and not addressing the 

inefficiencies in the current system, it is not a good use of our resources, and I think we have to take on those issues. 

Similarly, we use a pay-for-performance system because we believe as a payer that it is really important to have accountability 

around the services that are provided. We have saved over $4 million over a 2-year period simply by working with our inpatient 

treatment providers, focusing on things like continuity of care, 

making sure that when people are admitted that if they have a 

case manager that those people are coming onto the units, working 

with people so that there is a smooth transition. Those kinds of efficiencies can go a long way in increasing capacity. 

I also believe that we have to have a public health strategy. We 

cannot simply have a treatment strategy around this. When people 

have difficulty getting into services, sometimes that is because people don’t know how to navigate the system but often it is because 

there is stigma associated with mental illness that prevents people 

from reaching out for help and so part of our strategies have to be 

to reduce stigma and make it more likely for people to reach out 

for help. That is one of the reasons that we support things like 

mental health first-aid that help people to understand how to intervene. 

Fourthly, I think that we have to think about cross-systems financing. Many of the issues—if you talk to mental health commissioners around the country and you ask them what are the top 

three issues, I would almost guarantee you that every single one 

of them would have housing as one of their top issues related to 

the administration of their system and so as we are talking about 

this, we have to think not only about services within the mental 

health system but we have to think about other services that people need to be successful. 

So with that, I will stop and hopefully we will have questions 

that we can talk more about those. 

[The prepared statement of Mr. Evans follows:] 

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Mr. MURPHY. Thank you, Dr. Evans. As we go into comments 

here, or questions from Members of Congress, I just want to have 

a special thank you for this panel. We have had a number of hearings and panels on this issue of mental health, and I recognize 

members have very busy lives and some are at other hearings and 

other areas, but for those members who missed your testimony, I 

think their lives are the poorer for it, and to watch how someone 

would walk through the system is pretty difficult. So let me recognize myself for 5 minutes. 

Ms. Ashley, your experience you related to us in your testimony 

concerning your son’s admission and boarding in a local ER from 

hours to days, I mean, it is alarming to us. So were there any other 

places in the area, were you informed of any other place in the area 

where you could have taken your son instead of having those long 

delays in the hospital? 

Ms. ASHLEY. You mean another emergency room? 

Mr. MURPHY. Yes. 

Ms. ASHLEY. Well, my insurance only pays for the hospital that 

we went to. 

Mr. MURPHY. OK. And Dr. Hirshon, in this case, and we had 

heard this also, for example, on 60 Minutes when State Senator 

Creigh Deeds was talking about his own son, he couldn’t find a 

place. Is that part of the problem that occurs too with emergency 

rooms in terms of getting someone to—— 

Mr. HIRSHON. Yes, the issue of finding an inpatient facility can 

be very problematic. You have to find a place that is going to accept that patient, and historically, there may have been insurance 

issues as well. And so, in Maryland we have tried to devise mechanisms to improve this. One of the things we have now is kind of 

a central listing of the hospitals that have inpatient facilities, that 

have beds available, but even that is problematic getting the hospitals to buy into it. So this is a traditional problem, especially if 

you have someone who has got a dual diagnosis. Perhaps they are 

an adolescent with bipolar and maybe substance abuse. They can 

wait—I have had friends had patients wait for 13 days in their 

emergency department looking for a place to stay. 

Mr. MURPHY. Thank you. 

Sheriff Dart, any idea what your total costs per year in dealing 

with folks with mental illness in your jail are? 

Sheriff DART. You know, Mr. Chairman, that has always been a 

difficult number for us to ascertain, but just as a rule of thumb, 

it is in the ballpark clearly double, closer to triple the cost of an 

average detainee, so we are talking just tripling every expense that 

we have there, but the difficulty where it gets to be sort of quantifying this is that they come back to us so quickly. So it isn’t even 

as if you took the one detainee and said OK, he cost more than the 

other ones and—— 

Mr. MURPHY. You are talking about some of those costs, $12,000 

for pretrial costs and other things with that. Now, is any of this 

federal money that is used to help these patients, these inmates 

while they are there? 

Sheriff DART. No, no, virtually none. It is all county-related 

money. 

142 

Mr. MURPHY. OK. Let me ask also, in this past winter, I heard 

about a homeless man who had mental illness in Washington, D.C., 

couldn’t take him in because it was only 32 degrees. But once the 

temperature hit zero, it would be OK. Is that true, this story that 

I heard, Mr. Stern? 

Mr. STERN. Actually, I think Washington did sort of a heroic job 

over past years. They had buses, metro buses out when it got, I 

think below 15 degrees, and there was hypothermia in effect under 

32 degrees. 

Mr. MURPHY. When I look upon this, and we talk about somebody being—we are not going to provide help until there is a crisis, 

they threaten to kill someone, themselves, or you had talked about 

people who are not even aware of their symptoms. In this case, now 

they are an imminent threat because they are not even aware of 

their illness. It is sad that we have to go to that extent. 

Mr. STERN. Yes. I mean, the one thing that I would say is, on 

the day it got really cold, I went out to the bus, and there were 

three people on the bus. I then went under a bridge nearby and 

there were five or six people there who refused to go on the bus, 

so there is that. 

Mr. MURPHY. Thank you. 

Dr. Evans, as you heard these stories about how much is spent— 

Judge Leifman talked about this, Sheriff Dart talked about this, 

Chief Biasotti, all these other folks. If you had that kind of money, 

could you make a difference? I mean, we are spending it in hospital 

beds and emergency rooms where they are not getting treatment. 

We are spending it in jails. We are spending it in courts. Could you 

keep people out of those systems if Medicaid and other things paid 

for that kind of thing? 

Mr. EVANS. There is no question that we can and we do. For example, in Philadelphia, take the issue of homelessness. Because we 

have a mayor that has been pretty interested in this issue, he has 

been able to convince the Philadelphia Housing Authority to make 

available Section 8 vouchers to my department, which does homeless outreach. Over the last several years, we have had approximately 200 vouchers a year, and with that, we have been able to 

get over 500 people off of the streets of Philadelphia who were formerly homeless, many of whom have serious mental illness and/or 

substance use problems, and the way we were able to do that is 

to use those housing resources matched with Medicaid-funded behavioral health care services, and to date we have about 93 percent 

of those people are still in stable housing. So I think that these are 

solvable issues. I think it takes creative financing and I think it 

takes innovations in how we deliver services. 

Mr. MURPHY. We look forward to hearing some specific comments 

from you and others too on what needs to change in some of the 

definitions of care so that money can be spent in helping people, 

preventing problems and treating them. 

I have to ask you, Mr. Rahim, because you have Ms. Ashley at 

the table here, who has a son who is a good man but dealing with 

schizophrenia, do you have advice for parents and for other people 

dealing with this? 

Mr. RAHIM. I believe that Dr. Evans said it best, that mental illness is treatable and I think a lot of the panel said mental illness 

143 

is treatable but I think we have to have the education to know that 

it is treatable and that it is something that you can overcome, and 

I think having faced this as well as evidence-based practices will 

do so much. 

Mr. MURPHY. Thank you. That is a good message of hope. 

Ms. DeGette. 

Ms. DEGETTE. Thank you. Let me follow up on that statement, 

Mr. Rahim, by you and Dr. Evans. 

Dr. Evans, you talked about how evidence-based practices and 

lengths of stay can really be used for treatment, and part of the 

problem, part of some of these illnesses is people don’t realize that 

they are ill, and part of it is stigma. So my question to you is, from 

what I understand from what you are saying and others, is that 

if we can identify someone with severe mental illness early on and 

get them into that treatment, we actually can stabilize their situation. Is that correct? 

Mr. EVANS. That is absolutely correct, and the research is pretty 

clear on this. If you can intervene with people early, particularly 

after their first episode, and there are evidence-based treatments 

for people who are experiencing their first episode, you can dramatically change the trajectory of their illness and significantly improve clinical outcomes. 

Ms. DEGETTE. And I would assume you would agree with me 

that probably the way to do that early identification is not when 

they present in an emergency room or a jail, correct? 

Mr. EVANS. That would be correct. 

Ms. DEGETTE. And I would assume, Dr. Hirshon, you would 

agree with that from an emergency room perspective as well. That 

is not the ideal way to identify a severe mental illness and treat 

it, correct? 

Dr. HIRSHON. We take care of emergent and urgent, you know, 

acute psychiatric problems but my preference would be not to have 

to deal with that, I mean, to find support systems, both inpatient 

and outpatient, that they don’t come at 3 o’clock in the morning 

homeless and cold because they have no other place to go, and so 

yes, I would—— 

Ms. DEGETTE. And have to find a bed. 

And Mr. Dart, you would agree with that from a penal perspective as well, correct? 

Sheriff DART. Oh, absolutely, on two fronts. One, frankly, during 

the cold weather, we have people affirmatively commit offenses so 

they can come into our housing. I talk with the detainees on a regular basis. They will tell me frequently they don’t want to leave the 

jail because it is the best place they can go for treatment, they feel 

safe, they don’t get harmed out in the community, and we have had 

some where when we release them, they will try to break back into 

the jail as a result of that, and Congresswoman, the one thing that 

always has troubled me, when you think about it, each and every 

one of these people, we have a full file on them, not only on their 

criminal background but their mental health needs. Why we can’t 

follow them out in simple case management type of fashion, and 

even if we just break the cycle for a short period of time, we would 

save tremendous amounts of money. 

144 

Ms. DEGETTE. You don’t know this, Sheriff, but I started my career as a public defender, and so I know this very, very well. I had 

so many clients in those days who you could just see they were severely mentally ill, and there was nothing we could do with them. 

Now, I want to ask you again, Dr. Hirshon, I mean, if we had 

a better system like one Dr. Evans is talking about to identify and 

to treat folks at an early stage, then when somebody really did 

have an acute problem, the emergency system would be better 

equipped to deal with those folks because theoretically, there would 

be fewer of them, correct? 

Dr. HIRSHON. Well, there would be fewer but there would also be 

more structure to support them. So a lot of this is the lack of a 

kind of systematic structure to support these people who are either 

coming in because they have acute needs or because of their social 

circumstances. So the idea to have that improved structure both 

from a mental as well as social perspective I think is very critical. 

Ms. DEGETTE. Yes, and I want to ask you, Ms. Ashley, as a fellow mom here, you would much rather—you, as a nurse, identified 

that your son had severe psychiatric problems from an early stage 

but you didn’t have any recourse to get him the kind of treatment 

he needed except for continually taking him to the emergency 

room. Is that what I heard you saying? 

Ms. ASHLEY. Yes, that is right. I worked very closely with his primary medical provider, who obviously knew there was something 

wrong with him, but my son would continuously deny going to the 

emergency room to get psychiatric evaluation. The psychiatric people were even willing to come to his medical appointment to evaluate him. That is how tight our community was. And still my son 

would say no, he would not go. So I actually had to set up a situation where he went to the emergency room to get lab work done 

and then have him received by the psychiatrist and his primary 

medical provider to put him on a hold. 

Ms. DEGETTE. Thank you. 

Now, Dr. Evans, just if you can briefly tell me, you have got several projects going on. Where do you get the funding for those 

projects? 

Mr. EVANS. So Philadelphia is unique in that the city manages 

all of the public sector behavioral health services that come in. The 

city is capitated for the entire Medicaid population so we manage 

the Medicaid benefit for everyone who has—— 

Ms. DEGETTE. So you are getting Medicaid benefits? 

Mr. EVANS. They are getting Medicaid, but we also receive State, 

federal, local grant dollars as well. 

Ms. DEGETTE. And I just want to finish up with you, Mr. Rahim. 

You heard what Ms. Ashley was talking about. Her son was denying what was happening and she had to sort of trick him. What do 

you think about people who get diagnosed with these diseases? Is 

it the stigma? Is it the nature of the disease? And what is your 

opinion what we can do to get folks into treatment like you were 

able to do and to accept the disease, very briefly? 

Mr. RAHIM. So, I have to very much recognize that mental illness 

is individual to each person. There are so many different diagnoses, 

and each person, even with the same diagnosis, responds differently to the medication, responds differently to the knowledge 

145 

that they may even have it, or even responds differently to their 

parents’ care and concern. So I mean, with that—and I do want to 

acknowledge that. I am a voice but I am not the only voice, and 

there are so many people out there, so I just want to acknowledge 

that to your point, that is, it is so different, and it is hard. This 

is hard, you know, this is not easy. So even if you have the care 

provided, it is still a journey, one, and two, you still have to recognize that everybody is different. 

Ms. DEGETTE. Thank you. Thank you very much, Mr. Chairman. 

Mr. MURPHY. Thank you. I now recognize the vice chair of the 

full committee from Tennessee, Mrs. Blackburn, for 5 minutes. 

Mrs. BLACKBURN. Thank you, Mr. Chairman. 

I want to thank each of you for taking the time to be here and 

for your willingness to tell your stories, and I think it is such an 

important component, and it is important for us to have your insights as we look at the issue. The chairman has been on this since 

day one, and looking for a way to reach parity and to provide some 

certainty for those that suffer from mental illness. So we appreciate 

that you are helping us work through this process. 

Dr. Hirshon, I want to come to you first. Going back to the American College of Emergency Physicians 2014 State by State report 

card that is out there, and looking at the data relative to 5 years 

earlier, and you look at the declines in the psychiatric beds across 

the country. Has that been consistent in your rural, suburban and 

urban issues? Where are we seeing the greatest attrition in the 

number of beds? Because one of the things we hear from people, 

especially in our rural areas, is, they have no access and they don’t 

know where to turn. 

Dr. HIRSHON. So I would say that each jurisdiction, each region, 

each State is different. It is a little hard to say. But as a general 

rule, access to care in rural settings is much more difficult. And the 

other thing to recognize is that even if you have insurance, insurance doesn’t mean access because you have to find someone who 

can take that insurance and who will be there to give you the services. So as a general rule, the rural settings and the areas in which 

there are fewer services are disproportionately impacted. So I 

would agree with that. 

Mrs. BLACKBURN. OK. How do we fix that? How do we fix that 

disparity? What do you think? Because the access is so critical, and 

as you said, you may have access to the queue but that does not 

mean you have access to the physician, and what we are seeing 

with the implementation of Obamacare, the President’s health care 

law. So many people say well, I have got an insurance card now, 

and of course, in Tennessee, we saw this with the advent of 

TennCare back in the 1990s but there was nowhere that they could 

go for the care or it may be 180 miles away, which is debilitating 

when you are trying to access this. So what do you think? 

Dr. HIRSHON. I think again that, you know, not just psychiatric 

care but many types of care, you have to look for creative solutions, 

and one of the solutions for that is regionalization of care. So for 

example, if you have got a regional center of excellence for psychiatric care, to be able to utilize that either through telemedicine 

so they can do evaluations long distance or in a setting in which 

they don’t have a psychiatric provider there or there is a way that 

146 

you can use that regionalization to help improve the care I think 

is one potential model. I think we need to do research to look for 

better ways to be able to provide care, recognizing that our technology—there is an increased demand but our ability to perhaps 

meet that demand can be adjusted. 

Mrs. BLACKBURN. OK. 

Ms. Ashley, I see you shaking your head. You like the idea of 

using the telemedicine concepts? 

Ms. ASHLEY. Yes. At UC Davis, we already use telemedicine for 

medical diagnoses and so forth, and so I definitely can see telemedicine with good case management follow-up definitely would be 

very helpful to the family and the consumer. 

Mrs. BLACKBURN. So would you classify that primarily as using 

the telemedicine concept as an assistance in early intervention or 

where would that have the greatest impact? 

Ms. ASHLEY. At the very beginning. 

Mrs. BLACKBURN. The very beginning, being able to utilize that. 

I have just a couple of seconds left. Dr. Geller, deinstitutionalization, and you talked about that in your testimony and you said it 

was not initiated as a considered policy but as an accident of history. I want you to expand on that for just a moment. 

Dr. GELLER. Sure. If you look at the literature throughout the 

era, you don’t find any literature that talks about deinstitutionalization before it happened. It was labeled retrospectively. 

Some of the downsizing occurred because of the introduction of psychotropic medications, and some because of advocacy. But the 

major incentive for deinstitutionalization is the IMD rule. The IMD 

exclusion means that if I am in a State hospital, my State pays dollar for dollar for my care. If I am in a community, my State pays 

no more than 50 cents on the dollar and may pay as little as 13 

cents on the dollar. So that any State has a vested interest in moving people from State hospitals to the community, the cost shift 

from State tax dollars to federal tax dollars, and I believe that has 

been the major incentive. It was never designed policy. 

Mrs. BLACKBURN. So it was done for the money. 

I yield back. 

Mr. MURPHY. Thank you. I now recognize Mr. Butterfield for 5 

minutes. 

Mr. BUTTERFIELD. Thank you very much, Mr. Chairman, for convening this hearing, and thank all of the witnesses for your testimony today, but more importantly, thank you for your passion. I 

understand what mental health is all about, and I thank you so 

very much. 

I missed some of your testimony but I have been reading as 

quickly as I could. Dr. Edgerson’s testimony, I have it in my hand, 

and it is very interesting and it is very correct. You dwell on the 

Medicaid expansion aspect of health care, and I thank you for raising that because that is critically important. As most of us know, 

this committee wrote the Affordable Care Act. It was written several years ago, and the Energy and Commerce Committee is the 

proud author of that legislation, and as part of that legislation, it 

was our intent to expand the Medicaid provision so that low-income, childless adults could receive the benefit of health care. We 

mandated that the States expand their program, and that part of 

147 

the law was tested in the U.S. Supreme Court, and unfortunately, 

the Court said that we overstepped our authority, and even though 

it was a proper exercise of legislation that we could not compel the 

States to expand their Medicaid program, and that was very disappointing to me. And now 25 States have refused to participate 

in that expansion, and my State of North Carolina happens to one 

of those States. My State turns down nearly $5 million per day 

which could help provide care to those with mental health issues, 

and so I am appalled, not only appalled at my State but the other 

States that have chosen not to expand their Medicaid program because we need it. 

The Medicaid expansion would not have been a cost to the 

States, at least for the first 3 years. All of the costs would be borne 

by the Federal Government. Following that, the Federal Government would pay 90 percent of the cost of care, and so we have lowincome individuals all across the country who are suffering from 

mental health issues, from substance abuse who are not getting the 

care that they rightfully deserve. 

I live in a low-income community. It is an African American community in North Carolina, and I can tell you that mental health 

and substance abuse issues are pervasive all across my community. 

Before coming to Congress 10 years ago, I was a trial judge, not 

only in my community but in 32 counties throughout my region. I 

was one of 10 judges who presided over the most serious cases in 

32 counties, and I can tell you that we need to extend a hand of 

friendship and a safety net for those who are in need. And so I applaud you for lifting up the whole idea of Medicaid expansion. 

Now I get to the question, Dr. Edgerson. I had to get that off my 

chest because I understand mental health, not as much as the 10 

of you, but I clearly understand it. I understand the cost of not 

treating and detecting mental health issues, and I know that we 

would be a better nation if we just slowed down long enough to recognize the importance of this issue, and while I am on that, Mr. 

Chairman, I want to thank you. I think Ms. Blackburn was correct, 

that you have lifted this issue up as a priority of yours from day 

one, and I thank you for it. 

Dr. Edgerson, it is estimated that 189,000 people in my State 

with mental illness would be eligible for Medicaid if my State 

would expand Medicaid. How many of the individuals presenting in 

the emergency rooms with psychiatric and psychological issues 

would have avoided an emergency room visit if Medicaid had been 

expanded and they were able to seek treatment before their disease 

became a crisis? 

Mr. EDGERSON. I cannot give you an exact number. However, 

what generally happens is, if there is not one thing that we know, 

we know we can go to the emergency department if we are having 

any kind of crisis. A lot of people do not necessarily have to go to 

an emergency department because the crisis can be averted in the 

beginning, and this is where I believe that clinical mental health 

counselors and marriage and family therapists can come in. So 

while I may not know that I have a mental health issue, my friend 

or my family member may know, and they may be able to convince 

me or persuade me, hey, why don’t you go and talk to this person 

here and maybe we can help you out, and for me, that is where 

148 

the beginning steps are because once I create the relationship with 

that patient or client, then they are less likely to go into a crisis 

scenario and end up in an emergency department. 

Mr. BUTTERFIELD. Thank you. 

My next question is to you, Mr. Dart, and I heard some of your 

testimony earlier, and you talked about some people believe that 

jail is the best place for treatment, and you are absolutely correct. 

Some in the audience or some watching on television may find that 

incomprehensible but that is a fact in real life. 

When I was a trial judge, people would inappropriately—they 

didn’t know they were being inappropriate—they would call me at 

home the night before their loved one was to be sentenced and they 

knew that the next day the loved one would probably be getting out 

of jail and returning to the community, and families would literally 

call me and beg me—many of them knew me personally. We had 

grown up together years ago. They would call and plead with me 

as a judge not to release their loved one because they could get better care and treatment in the facility as opposed to the community, 

and they felt that releasing their loved one would be a danger to 

the inmate and to the community. So thank you for bringing that 

up and reminding me of those days when I was on the bench. 

You have been very kind, Mr. Chairman. Thank you very much. 

I yield back. 

Mr. MURPHY. I now recognized the vice chair of the subcommittee, Dr. Burgess, for 5 minutes. 

Mr. BURGESS. Thank you, Mr. Chairman. 

Mr. Rahim, I just have to say, I don’t think it was part of your 

prepared remarks but your comments about the individualization 

of care and the personalization of care, those words are golden and 

I hope that everyone on this dais heard those and will consider 

them. 

Dr. Geller, thank you for your thoughtful chronicling of the problem. I cannot go back as far as Franklin Pierce but I did practice 

medicine in the 1980s and 1990s, not psychiatry but more in the 

general medicine realm, but I remember during that time the vast 

expansion of psychiatric facilities that occurred. I am not sure if I 

know why that expansion occurred but then as a result of probably 

actions by perhaps this subcommittee in April of 1992, a lot of that 

was curtailed, and in fact, just researching for this hearing, there 

is an article from 1993 that talked about in one 4-year period the 

number of psychiatric institutions doubled, and the graphic they 

have is 1984 to 1988. This was a major scandal in the country. A 

company known then as National Medical Enterprises eventually 

entered into some sort of consent decree with the Department of 

Justice and many of the private insurers sued the hospital company for overutilization or overhospitalization of patients. 

So it seems like we went from there where there was too much 

activity going on to now where there is not enough. I can’t help but 

feel the emphasis on administrative pricing and not paying attention to the individual care that Mr. Rahim talked about is perhaps 

responsible, but I think this subcommittee would do well to remember that it was 20 years ago where we were talking about a very 

different problem. You were probably—I don’t want to presuppose, 

but you were probably in practice at that time. Is that correct? 

149 

Dr. GELLER. Yes, sir. 

Mr. BURGESS. Do you recall the events that I am talking about? 

Dr. GELLER. Yes, sir. 

Mr. BURGESS. And what is your observation? I mean, help us 

here. You were there, a psychiatrist on the ground, when this was 

going on. In your opinion, what is it that happened that caused 

that rapid expansion of psychiatric meds and their overutilization 

and then the contraction that followed? 

Dr. GELLER. The expansion that you are talking about was largely accounted for by private psychiatric hospitals, generally chain 

hospitals, that saw an opportunity to make money quickly. When 

managed care began to require pre authorization and the possibilities for admission became more stringent, those hospitals quickly 

disappeared. While all that is happening, the public psychiatric 

hospitals were still shrinking, and if I could take a moment? 

Mr. BURGESS. Sure. 

Dr. GELLER. What we seem to not be spending time on is that 

we are talking about psychiatric disorders, and while resources are 

necessary, ‘‘build it and they will come’’ does not apply to all the 

people who have psychiatric disorders. We had a demonstration of 

that in western Massachusetts. We had a federal court-ordered consent decree in 1978. Western Massachusetts, the catchment area, 

is larger than five of the States in the United States. At that time 

western Massachusetts had more per capita expenditure for mental 

health services than any State in the United States and there 

wasn’t another State that came close. And we still had some of the 

same problems. 

Mr. BURGESS. Yes, sir. 

Dr. GELLER. We have a population, some of whom have something called anosognosia. They don’t recognize they have an illness. 

You need more than just resources. 

Mr. BURGESS. Let me ask you, Dr. Hirshon, in the few seconds 

I have left. I mean, you bought up EMTALA, and as a practicing 

physician, I am familiar with that. One of the great venerable institutions in my neck of the woods, Parkland Hospital, got into a 

great deal of difficulty with their psychiatric emergency room not 

too terribly long ago, in fact, put the whole institution at risk because of some federal regulations that they ran afoul of, but eventually they went to outsourcing their psychiatric emergency room 

to a private hospital facility. In your experience, does it seem like 

more hospitals are going to be doing this? 

Dr. HIRSHON. My sense is that it is more complicated than simply a single answer. You have to look at it from both the patient’s 

perspective as well as the provider’s perspective, and coming up 

with solutions that allow you to meet the patient’s needs. If it is 

outsourced in one jurisdiction, that might work, but again, I think 

recognizing that there is a limited number of resources, looking for 

ways to more efficiently and effectively utilize those resources will 

be key. 

Mr. BURGESS. Thank you, Mr. Chairman. I will yield back. 

Mr. MURPHY. Thank you. The doctor yields back. 

Mr. Tonko, you are recognized for 5 minutes. 

Mr. TONKO. Thank you, Mr. Chair, and I appreciate your continued use of this subcommittee to shed light on the issues related to 

150 

mental health. For far too long now, mental health issues have 

been swept away in the shadows, so anything we can do to raise 

the profile and reduce the stigma associated with mental illnesses 

is a very worthy endeavor indeed. 

As amply demonstrated today, the lack of available psychiatric 

beds, particularly in times of crises, can be a pressing issue. For 

example, we all witnessed the tragedy that occurred in neighboring 

Virginia when State Senator Creigh Deeds was unable to locate an 

available bed for his son in time. However, we also all share a goal 

of deescalating in treating these types of situations before they do 

reach the stage where a patient requires hospital-based care. 

So with that in mind, Dr. Evans, from your experience, how can 

we improve our mental health delivery system in a way that reduces the demand factor for inpatient psychiatric care? 

Mr. EVANS. Thank you for that question. I think that, you know, 

any discussion about psychiatric bed capacity focuses on expanding 

bed capacity, and I think that is a trap. Prior to being in Philadelphia, I was also the Deputy Commissioner in the State of Connecticut, so the past 15 years I have been in administrative positions that have to make decisions about how resources are deployed 

in a mental health system, and I can tell you that the fundamental 

issue is that we have to build a very strong community-based system. That is the fundamental problem. Psychiatric bed capacity is 

only a symptom of a deeper problem, and I think you hear the testimony of all the people here, they talk about the difficulty when 

it is clear that a family member or even a person is having a problem. Well, there are not the resources to do the kind of outreach 

to individuals when they are at that point, and the way we finance 

our service system, we have to wait until people are at a crisis 

point, and you know, that is not only the problem of the mental 

health systems but it really has to do with the fact that unless we 

create the kind of flexibility where mental health systems can do 

the kind of assertive outreach, we are going to continue to have 

this problem. 

I remember, maybe it was Dr. Geller that said, you know, one 

of the problems with mental illness is that often people don’t recognize that they have a problem, and if people don’t recognize that 

they have a problem, you can build as many beds as you want, people are not going to get there unless they are forced into those 

beds. The solution is to have resources in the community where 

people can—for example, in Philadelphia, we have mobile crisis 

teams that can go out and reach out to people before they are hospitalized. Those kinds of services I think are critical. 

Mr. TONKO. Thank you. And so as you build that infrastructure 

and that holistic response, Dr. Evans, what is the appropriate way 

to measure the amount of inpatient beds that would be required in 

a given community? 

Mr. EVANS. I think that that is a very difficult question to answer, and people have used things like population and so forth. The 

reality is that it depends on how your service system is structured. 

If you have a service system that has resources on the front end, 

for example, in Philadelphia, we have a network of five crisis response centers, so we don’t have the problem of people going to 

emergency departments who are in psychiatric crisis, not to the exVerDate Nov 24 2008 12:19 Oct 10, 2014 Jkt 037690 PO 00000 Frm 00156 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-130 CHRIS
151 

tent that you have in other cities. We have a mobile crisis team 

that can do outreach, and so in Philadelphia that might look different than another system that might be similarly resourced in 

terms of the amount of money but doesn’t have those kinds of services. 

I think the issue is, we have to build a very strong communitybased system that prevents people from going into crisis and we 

have to have the services so that when people come out of those 

beds, that we are able to help them in their process of recovery, 

we are able to help them to stabilize and we are able to do things 

like helping people get supported employment or to use supported 

employment, for example, which dramatically decreases hospitalization. So those kinds of community-based services are really 

important in terms of the capacity that you need. 

Mr. TONKO. Thank you. And Dr. Geller, in your testimony you 

rely heavily on the fact that State investments in mental health 

have been predicated upon where they can shift most of the cost 

to the Federal Government. In your opinion, how could we address 

the Medicaid IMD exclusion without leading to a disinvestment by 

our States’ mental health services? 

Dr. GELLER. That is an excellent question. In my testimony, I 

mentioned that the Federal Government should offer the IMD exclusion waivers to States, requiring a maintenance of effort. The 

American Psychiatric Association has a position statement that is 

rather specific on this—I could certainly provide it to you—that indicates that a State who took such a waiver would be required to 

continue its expenditure as averaged over the past 5 years from all 

sources that they spent previously. That is not just the department 

of mental health but the department of children’s services, department of corrections and so on and so forth. If there was a requirement for maintenance of effort, there couldn’t be a reverse shift. 

Mr. TONKO. Thank you. I agree with that maintenance of effort, 

so thank you very much, and again, to the entire panel, your testimony is very much appreciated. 

Mr. MURPHY. I now recognize the gentleman from Virginia, Mr. 

Griffith, for 5 minutes. 

Mr. GRIFFITH. Thank you, Mr. Chairman. 

First, Dr. Geller, if you could provide that information to me as 

well that you were just talking about? 

Dr. GELLER. Yes, sir. 

Mr. GRIFFITH. It is very interesting. I found your testimony and 

everybody’s testimony very informative. 

Mr. Chairman, I appreciate you having these hearings. I have to 

say that I don’t understand mental illness. It worries me because 

I don’t, and it is one of those areas where I least like these hearings that the chairman has called because normally I have a pretty 

good idea of where I think we ought to go when it comes to these 

mental health issues. I have to confess that I am learning something every time we even have a hearing, but I am also concerned 

that I don’t think that we have all the answers or that we even 

have any idea what all the answers are, so I appreciate you all 

helping us try to figure that out. As representatives of the people, 

it is interesting because we are all trying, I think, Democrats and 

152 

Republicans on this subcommittee, to figure out what we can do to 

make the situation better. 

I don’t, however, believe that in the short term we are going to 

be able to make huge differences because we are going to have to 

do some trial and error. We are going to have to try to do some 

new things and some different things, and I appreciate that. 

In that regard, I guess I will look to Mr. Dart and to Judge 

Leifman. How can we make the court system better? We are not 

going to overnight say OK, none of the folks with mental illnesses 

are going to come into the court systems, but what can we do to 

make the court system better? You have heard from Ms. DeGette, 

who has a public defender background, and Judge, now Congressman Butterfield. I was a criminal defense attorney for 27 years, 

and I have to commend one of my judges back home. He hasn’t set 

up a mental health court but has a mental health docket where she 

deals with folks who have those issues and tries to identify those 

in advance so that they can have the experts present to help on 

that. 

But what types of things can we do to encourage the States and 

the federal system to do a better job? Until we fix it, what can we 

do to help out in the court systems? 

Sheriff DART. Thank you, Congressman. I will be quick, because 

Judge Leifman and I have talked before about these things. 

Getting the courts more engaged is imperative. In our court system, they have been completely disengaged. Whenever you ask 

them about solutions, they say well, we have a mental health court 

so it is done. Their mental health court usually handles about 150 

cases total a year. I usually have about 3,500 mentally ill in my 

jail in a day. So we can’t be diverted when people have programs 

that are inherently good but aren’t getting at the heart of the problem. 

What we have been doing internally is trying to identify people 

literally as they are dropped off from being arrested the night before, downloading quickly their information on their mental illness, 

and then we put a file together for the public defender. I am a 

former State’s attorney. We put a file together for the public defender to plead with the judge that this person is not necessarily 

a criminal, put them in an alternative setting such as a nursing 

home setting. We have been doing that at my jail where I put electronic bracelets on their legs, I monitor them at this setting. The 

results are fantastic, as you can imagine, compared to what the 

other treatment would be, which is, I put them in a four by eight 

cell with a complete stranger with their own issues as well. 

So we have been doing that, and then on the back end, we have 

been pretty much winging it, and that is why, Congressman, when 

you talk about trial and error, that really is the route that we have 

been going. It can’t get any worse than it is now so let us try some 

new things. So on the back end what we have been doing is, we 

ourselves are putting together case plans for them. We drive them 

to locations where we potentially can get housing for them so they 

can be there and be stabilized, and then we run a 24-hour hotline 

when they are in crisis to get out to them to help them. But it is 

just what you said, Congressman. We are at a trial-and-error stage 

153 

right now but there are things such as that that certain judicial 

circuits could be doing. Others are better. Ours is a real struggle. 

Mr. GRIFFITH. Judge? 

Judge LEIFMAN. Thank you for your question. We have created 

an organization called the Judges Leadership Initiative with a parallel organization called the Psychiatric Leadership Group, and we 

are working with the American Psychiatric Foundation, and what 

we are doing now is, we have about 400 judges involved in this operation and we are going around the country. We have developed 

a curriculum to teach judges how to identify people in court who 

may have a serious mental illness, how to deescalate a situation in 

court so they don’t make it worse, but more importantly, how to 

work in the community to set up the kind of supports you need to 

be able to divert this population, and so what we recommend are 

a couple things. A pre-arrest-type diversion where you work with 

law enforcement to teach them a program called crisis intervention 

team policing where the police are actually taught how to deescalate, where to transport and how to avoid an arrest. Our statistics 

are phenomenal. As I mentioned, we have closed a jail as a result 

of our CIT officers in Dade County. We have also taught them to 

set up post-arrest diversion programs so that you take low-level offenses that don’t need to be in jail or felonies that are nonviolent 

and you make sure that they get access to treatment. 

Sheriff Dart is correct. The mental health court only handles a 

fraction of the cases, and the data is such that unless they are taking the right people, they actually can do more harm than good, so 

you have to be very careful and you have to be educated. 

Mr. GRIFFITH. And Mr. Chairman, I know I am out of time but 

could we give Chief Biasotti—I know I mispronounced that. I apologize. But could we give the chief a moment to comment on that as 

well? 

Mr. MURPHY. Yes. 

Chief BIASOTTI. I would say our main concern law enforcementwise is the seriously mentally ill group that is unaware of their illness. I mean, that is wherein the problem lies for us. The police 

departments, your county directors know who these certain groups 

of people are because we deal with them every day, and there are 

answers that we can deal with that. 

In a case that we had not long ago, we had a woman severely 

mentally ill, went into a house, no one was home, took the pit bull 

and put it in a closet, went upstairs, took all the clothing out of 

the woman’s closet, put her dishes from upstairs downstairs, moved 

all the pictures, spent the day. The woman came home—the homeowner—and walked in on her and of course, you know, had a cow 

right then and there, called the police. The police come, and she 

was totally out of her mind, psychotic, carrying on. So when I arrived at the police station on a different matter, I heard this 

screaming coming from our booking area. She was in the booking 

area, you know, voices were talking to her and she was complaining she was being raped by whatever at the time while she 

is sitting there. So I made a decision at that point, which a lot of 

people don’t do, but being familiar with this topic I said listen, we 

are not arresting her for burglary. I said she is going to go to the 

psych unit but I am going to send a letter with her saying that she 

154 

is obviously dangerous. She could have been killed. Whoever came 

home could have shot and killed her is most likely to happen. I 

said if we arrest her, she is going to go to the county jail, she is 

going to be a major problem for them. From there our officers are 

going to go out to grand jury where they are going to move to indict 

her for whatever. She will be in jail for a year before they decide 

that she is so mentally ill that she can’t stand trial, and then she 

will be back here again. I said so let us get her into the system 

now and put her through that service. But I accompanied that with 

a letter to our county mental health director saying I strongly suggest that, you know, she is proven to be dangerous, she has a long 

history, to herself, mostly; I suggest that you enter her into the assisted outpatient treatment program. This program, they provide 

the services to her through this program. She has not been a problem since. They monitor her, make sure that she is in some kind 

of treatment, and as long as she is in treatment, she is not a problem. However, if we went the legal system as we normally would 

do, we would be dealing with her every few weeks because she has 

anosognosia, she does not believe she is ill. 

And I know, you know, stigmatism is a big concern, and my wife 

and I both pray for the day that our daughter has the insight that 

Mr. Rahim has into her illness because I believe if she had that 

insight, she could seek what everybody is talking about, care in the 

community. It has been 20 years almost and she does not have that 

insight. She has voices, and they are, as she is concerned, a supreme being. 

Mr. GRIFFITH. I hate to cut you off but my time is way over. 

Chief BIASOTTI. I am sorry. 

Mr. GRIFFITH. That is all right. No, I appreciate the testimony. 

Thank you, Mr. Chairman, and I yield back. 

Mr. MURPHY. That was valuable because New York, as I understand, has actually reduced their incarceration rates and homeless 

rates, I think by 70 percent. It has been a massive savings. 

Chief BIASOTTI. That is correct, through AOT. 

Mr. MURPHY. Thank you. Ms. Schakowsky, you are recognized 

for 5 minutes. 

Ms. SCHAKOWSKY. Well, I am so glad I got here because I wanted 

to say a special welcome to my great friend, Sheriff Tom Dart. We 

were seatmates for a while in the Illinois General Assembly. And 

I wanted to really talk to you about a problem I know you are 

struggling with so much. 

The New York Times article ‘‘Inside a Mental Hospital Called 

Jail’’ really focused on the largest mental health center in America. 

It is a huge compound here in Chicago with thousands of people 

suffering from mania, psychosis, other disorders, all surrounded by 

high fences and barbwire. That is the county jail. 

So I wish you would just briefly discuss how cuts to mental 

health programs and services have affected individuals with mental illness that are now in your custody. 

Sheriff DART. Thank you so much, Congresswoman, and it is 

great seeing you again. 

You know, you almost don’t know where to start because up until 

about 5 years ago, the normal process in our jail 5, 6 years ago 

and, frankly, from my understanding, in most jails around the 

155 

country now, when you get that court order to release somebody, 

you release them. The court is ordering their release and you have 

got to let them go, so you let them go. What we were seeing is out 

in front of our jail, there were people that just wandered around, 

stayed there, and as I had mentioned earlier, we have people trying 

to break back in. One threw a planter through a window to crawl 

back into the jail, and then we had to arrest him. 

The reality of it is, is that when we were releasing people, they 

had nowhere to go, and in the face of that, in our State we have 

made tremendous cuts, I mean, just over the last 10 years. We are 

one of the leading States in cutting mental health funding, period, 

and in the city of Chicago, we just cut in half our clinics in the 

community. So when the people leave, not only do they have nowhere to go, there was no plan whatsoever, and as I had referenced 

earlier, I do think this is doable with not great expenditures because we literally have everything about this person in our possession. So if you are trying to think of case plans and diagnosing 

them and what would be the best strategies, there is a myriad of 

things we can do, but when you have no place for them to go—I 

used to hand out a resource book in my first couple of years as 

sheriff to give people a place to go. I had to stop doing that because 

everything in it was wrong because most of the things that we 

were trying to steer people toward were all closing, and so we were 

then setting them up to fail because there was nothing really out 

there. 

And so the cuts are so tremendous, it has left all the locals including ourselves trying to devise unique, creative strategies on 

what to do including, as I say, I will drive people now. If I can find 

homes for them, we will drive them there. I mean, I will contact 

their family members ahead of time to get them to come pick people up, and mind you, we are happy to do this, but I don’t think 

in anyone’s estimation sheriffs should be doing this. We are supposed to lock people up, and that is really sort of supposed to be 

the end of it, but there is nothing else out there, and in our county 

in particular, it has really been bad, and it is desperate, and it is 

really heartbreaking. I talk with the detainees frequently, and do 

we have bad people in the jail who have committed offenses who 

have mental illness? Yes, we have those. The vast majority of 

them, though, are good people who are suffering from mental illness and the reason they are there is because of the mental illness. 

It is not because they are a criminal, and yet we treat them like 

criminals, they are housed with criminals, and then when we leave 

them, we basically pat them on the back and say good luck and we 

will see you soon, and then we are all puzzled that they are back 

with me. 

Ms. SCHAKOWSKY. So it is not just a matter then of driving them 

to a place. It is that at the end of the day there is no place for 

many of them, right? 

Sheriff DART. There is no place for them, and there is no one to 

work with them because they need a certain level of case managing 

to make sure they stay on their meds, that when they do go into 

crisis they are not left to doing what is going on right now, which 

they call myself and my staff and we try to figure out what we can 

help them with. There are things that we can do that will not be 

156 

expensive that can help and it be a continuum of care. It could 

work with people. It won’t be 100 percent successful but it can’t 

conceivably be any worse than what we do now. 

Ms. SCHAKOWSKY. And what are those simple things? 

Sheriff DART. Oh, upon leaving the jail, if I had someone from 

a county agency, State agency that would literally be their case 

manager who would just literally work with them through housing 

issues, staying on their meds so that they don’t start self-medicating which is, you know, no surprise that we are having this heroin epidemic in our county because it is the next best thing to their 

meds is the heroin and so cheap these days. They stay on their 

meds. Housing—there is some housing available. It is not the best 

but it is not that expensive. I was paying for housing out of my 

own budget but I have run out of money now. So as Judge Leifman 

said, if we had a continuum working with the medical side but also 

with the judiciary, we could have something that could be somewhat of a model for a lot of people and not that expensive. 

Ms. SCHAKOWSKY. Thank you very much, and thanks for what 

you are doing. 

Sheriff DART. Thank you so much. It is great seeing you. 

Mr. MURPHY. I just want to follow, Sheriff Dart. You heard Chief 

Biasotti talk about New York has assisted outpatient treatment 

where they make sure, as long as that person has been shown to 

be a safety risk or they have had an episode of violence or jail time 

before, they can work with a judge and they work on an agreement 

to stay on their medication and get in treatment. Now, I understand you don’t have that in Cook County. Am I correct? 

Sheriff DART. No. We had some intervention just literally days 

ago from our State Supreme Court to try to rearrange and help our 

local judiciary in doing their job, but we have not had engagement 

from our judiciary. I will be honest with you: you need an enlightened judiciary who clearly understands the distinction between 

criminal law and mental illness and know that there are other 

paths to go. Because otherwise you are left with, frankly, Mr. 

Chairman, isolated judges who get it, who will run certain courts 

and frankly take risks. We for years now, as I say, have been putting all these files together to hand to the public defender to just 

show the mental health background here, the lack of criminality, 

and yet they go up and they might as well be talking in a foreign 

language to the judge. The judge does the same thing. They throw 

them in the jail and we continue to do the same work. 

So an enlightened judiciary that is engaged with it, and it does 

happen in other jurisdictions. It would be absolutely remarkable. It 

would save money. 

Mr. MURPHY. Thank you. Mrs. Ellmers, you are recognized for 5 

minutes. 

Mrs. ELLMERS. Thank you, Mr. Chairman, and again, thank you 

to the panel. This is one of those situations where I have questions 

for every one of you, but unfortunately, we don’t have enough time 

for that, so I will try to stay focused to the point of how we can 

as legislators help this issue and try to focus on those areas where 

we think there is the greatest need, at least to get it started, because Mr. Dart, as you have pointed out, we are in a pretty bad 

place right now so anything we do is going to improve the situaVerDate Nov 24 2008 12:19 Oct 10, 2014 Jkt 037690 PO 00000 Frm 00162 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 113\113-130 CHRIS
157 

tion, and I am very concerned about those who are being released 

from jail and, you know, not able to continue their treatment, because as you have pointed out, it is just cyclic, and Mr. Biasotti as 

well. 

Ms. Ashley, I do want to go back to one of the issues that has 

been raised, and I know we are discussing medical coverage. I 

know some of my colleagues are saying if we just had a bigger 

Medicaid system, that that might actually help the situation. You 

know, obviously you know we are dealing with that every day here, 

trying to make our health care coverage system work better. If I 

remember correctly from your testimony and previous questions, 

you said you have private insurance that your son was able to receive treatment under. Is that correct? 

Ms. ASHLEY. Yes, it is. I have him as a disabled adult under my 

insurance. 

Mrs. ELLMERS. OK. So you actually have insurance coverage but 

still had the difficulties. It wasn’t just an issue of here is my insurance card, therefore I am going to get mental health services for 

my son? 

Ms. ASHLEY. Right. In fact, he is denied some services in the 

community because he does have private insurance. 

Mrs. ELLMERS. I see. OK. 

Ms. ASHLEY. Even though he has SSI and Medi-Cal, they have 

no way to bill the insurance to get it denied and then go on MediCal, so I don’t even have access to a lot of the support services that 

are available in my community because he is on private insurance, 

and people have even told me to take him off private insurance, 

and really, having private insurance is what gets him hospitalized 

quickly because the lights go off when they see that I have private 

insurance versus Medi-Cal or Medicaid. 

Mrs. ELLMERS. I see. Now, to that point, one of the things that 

I was wondering, when you were describing your situation in the 

emergency room, and I have seen this in so many hospitals where 

they literally brought me to the designated area in the emergency 

room that they have literally put together because of this situation 

so that they can give the best treatment possible but they are still 

hampered because they are obviously not a psychiatric unit, and 

they are dealing with the situation. Was he able to at least start 

receiving mental health treatment while he was there in the emergency room? I mean, was that pretty much at a standstill until he 

received the psychiatric bed? 

Ms. ASHLEY. Right. He was put in four-point restraints and heavily sedated until they transferred him to the hospital. 

Mrs. ELLMERS. OK. And you did mention that, so I thank you for 

that. And again, that is an area we are trying to fix. You know, 

there are so many pieces and parts to this issue. 

Mr. Biasotti, one of the things that I would like to clarify even 

just for committee is the difference between civil commitment and 

forensic commitment, if you can answer that question, because I 

think that will help us as well because I think sometimes we do 

find ourselves again struggling with the situation of those who do 

not acknowledge that they have a problem and yet they are having 

a psychotic episode. 

158 

Chief BIASOTTI. And that is where the problem lies. The police 

will bring the person from their home or from wherever the instance occurs to the emergency room, usually against their will, 

under a State code for imminent dangerousness and then they are 

relying on the interview at the hospital for the psychiatrist to make 

a determination that they meet the standards to hold for a 72-hour 

period for evaluation for commitment under that standard. So I 

think Dr. Geller could probably help me with the difference between the civil—I am more familiar with how we would do it. 

Mrs. ELLMERS. Dr. Geller, would you like to expand on that 

then? 

Dr. GELLER. Sure. Every State has its mental health act, and 

that allows people to be civilly committed, usually on a standard 

of dangerous to self, dangerous to others or gravely in need of care, 

and there is no crime involved. Forensic commitment would mean 

that a person has been charged and booked and then they are 

going to be committed usually initially for a determination of competency to stand trial, criminal responsibility, or both, that you 

heard about earlier. If they cannot stand trial or are found not 

guilty by reason of insanity, then they can be further committed 

under a criminal statute of that State. 

Mrs. ELLMERS. And yes, Dr. Hirshon? 

Dr. HIRSHON. I think it may vary state by state but in my state, 

what happens is, there is a fixed number of inpatient beds, and 

these individuals who are on forensic, not the ones who have been 

convicted but they are often the pretrial folks will be taking up the 

beds that I will be looking for from the emergency department. So 

it doubly impacts it because it then backs up my system because 

the forensic folks are being housed in that situation. 

Chief BIASOTTI. And if I could add, from a law enforcement aspect, most of the people that we are talking about we are bringing 

in not because of crimes, we are bringing them in just because of 

bizarre activity or dangerousness. The criminal aspect, we would 

have to make an arrest and it would go through the jail system 

and they would arrange for psychiatric evaluation. 

Mrs. ELLMERS. And Judge Leifman, I think you look like you 

wanted to indicate, and I realize I have gone over my time but I 

would love to hear from you. 

Judge LEIFMAN. What is happening is, the forensic beds are actually taking over the civil beds, because it is constitutional, because 

if you are arrested on a felony generally and you are incompetent 

to stand trial, you have to go—— 

Mrs. ELLMERS. To a—— 

Judge LEIFMAN. —for competency restoration. So as the States 

don’t want to expand those budgets, they just start to use the civil 

beds for forensic beds. So it is really creating this horrible pressure. 

Mrs. ELLMERS. I see. Well, thank you all, and Mr. Rahim too and 

Ms. Ashley for your personal stories. It is so important for us to 

hear because we need to understand how we can deal with this situation better, and again, thank you to all of you. This has been a 

very, very good subcommittee hearing, and I am hoping that we 

will really be able to fix this problem. Thank you. 

Mr. MURPHY. Thank you, Mrs. Ellmers. I now recognize Mr. 

Harper for 5 minutes. 

159 

Mr. HARPER. Thank you, Mr. Chairman, and I thank each of you 

for being here and helping us, and we hope in the process we will 

be able to look at some suggestions and directions and things that 

may help you. 

Chief Biasotti, if I could ask you, you know, you have described 

obviously law enforcement being the front line on counteracting the 

impacts of serious mental illness in the community. What kind of 

burden is this on your resources and your department? 

Chief BIASOTTI. Well, that is the problem. That is what my paper 

focused on, and it was that most police agencies are very small in 

this country. The big cities are the anomalies. So for instance, in 

my department, which is considered midsized with an authorized 

staff of 50 officers, we will have three or four cars per shift, a minimum of three on the road per shift. So normally when we deal 

with a severely mentally ill person who is acting violent, it requires 

at least two of our officers. So that is two out of three people available. Now we have one officer for a municipality, a good-sized municipality, until those officers are free. A lot of times the ambulance 

can’t take them because they are too combative and the hospital 

wants you to stay with them while they are in the emergency room 

until they make a determination as they are staying, which is because if they decide they are not staying, they don’t want this psychotic person in their lobby and you need to take them back to 

where you came from. So it is a great depletion of resources for law 

enforcement nationwide, especially those in the rural areas. 

Mr. HARPER. You know, I actually was a city prosecutor for about 

6 years before I came here, and that was always the thing, and I 

appreciate what you said you do because sometimes you know they 

don’t need to be incarcerated; they need to get help. Because not 

every department does it that way. So I want to commend you for 

that. 

Chief BIASOTTI. Well, it is difficult because you also have a crime 

victim that doesn’t understand why the person that broke into 

their house is not going to jail, so you have to have cooperation on 

a lot of levels. But also to that end, what I wanted to bring up 

quickly is, I got to work with Governor Cuomo’s office on the SAFE 

Act, the back end, Kendra’s Law, and one thing that I think we are 

hopeful is going to make a change is, one of the changes in 

Kendra’s Law mandates that in prison settings, those who are receiving psychiatric care in the prison will be evaluated upon release for inclusion into an assisted outpatient treatment program, 

which hadn’t happened before. Before that, your time is up and 

you’re out the door and there goes your treatment. So we are hoping that that is going to make changes and lessen recidivism. 

Mr. HARPER. Thank you very much. 

Dr. Evans, I was looking at your title as we were going here, and 

I am also seeing what Ms. Ashley has gone through on a personal 

level, and what you have too, Chief. I have a 24-year-old son with 

fragile X syndrome, so he has intellectual disabilities. So how do 

you distinguish between, you know, classic mental illnesses or 

someone with an intellectual disability that someone who is not 

trained may not recognize? Give us some wisdom or advice. What 

do you—how do you handle that? 

160 

Mr. EVANS. Sure. So the easy way to make the distinction is that 

if a person has an intellectual disability, that is pretty much permanent. So those kinds of disabilities are lifelong, and our goal 

there is not necessarily recovery but it is really to help people have 

a high quality of life, to have self-determination. Mental illnesses 

are treatable, and one can have a very severe mental illness, schizophrenia, for example, bipolar illness, and can recover and can do 

well. It doesn’t happen all the time but the majority of the time 

and so that is really the distinction. We work with people differently based on that. 

Mr. HARPER. You know, with my son, if he were out by himself, 

if he was maybe in a sensory overload moment, it might be misinterpreted as to what he has, so training and understanding and 

realizing that every case, every person is different I know is an important thing for you. 

Mr. EVANS. It is, and I think that educating the community 

about mental illnesses and intellectual disabilities is a real important part of this because you have heard the impact that stigma 

has on people reaching out for help, on the shame that comes with 

that, and I think that our strategies have to not only include how 

do we change the service system but like we have done with other 

illnesses like cancer. You know, 30, 40 years ago, people used to 

whisper that and now people have marches about that and walks 

about that, and I think it has changed how people reach out for 

help when they need it. It has changed how we funded research 

and treatment. And I think the same thing applies to mental illness and behavioral health conditions. 

Mr. HARPER. Thank you, Dr. Evans, and thanks to each of you. 

Mr. Chairman, I yield back. 

Mr. MURPHY. Thank you. Dr. Burgess asked, we have two items 

here from the New York Times and from Freedom magazine regarding some cases from 1992 and 1993 that he would like to have 

submitted into the record, so without objection. 

[The information appears at the conclusion of the hearing.] 

Mr. MURPHY. And Ms. DeGette, you have a clarifying question? 

Ms. DEGETTE. I just have a clarifying comment, Mr. Chairman, 

and I just want to say again, I have been on this subcommittee for 

18 years, and this is, I think, maybe the best panel we have ever 

had, so thank you all for coming. You have practical solutions. You 

had different takes on the mental health system, and I hope that 

each of you will be willing to make yourselves a resource to the 

chairman and myself as we move forward in our efforts. 

Chief, you referred to Kendra’s Law, and I just wanted to put in 

the record what that is, so you can correct me if I am wrong. I understand what this is. It is a law that was passed in New York that 

establishes more structured treatment combined with resources 

across the mental health system, and it is designed to get treatment to folks earlier on without having them participate in the 

penal system like Sheriff Dart was talking about or in the emergency room system. It is designed to get them treatment. But of 

course, you have to have an investment to do that of resources. 

The chairman and I were up here talking about this, and if you 

did have this investment of resources and you were really able to 

implement things like this, it would actually probably save money 

161 

because you wouldn’t be putting these people in incarceration or in 

very expensive ER situations. Every single person here is nodding 

their head. I would like to just say that for the record. 

Thank you very much. 

Chief BIASOTTI. If I can say, the shame of it is, we have 45 States 

that have a very similar law but very few use it. 

Ms. DEGETTE. Because they are probably not putting the resources into it, right? 

Chief BIASOTTI. That is correct. 

Ms. DEGETTE. Thank you. And we are going to try to work to see 

what the federal partnership that we can have with all 50 States 

to help this along. 

Thank you, Mr. Chairman. 

Mr. MURPHY. Thank you. And Chief, along those lines, I understand, for example, California has a law on the books but only Nevada County, only one county, uses it. 

Chief BIASOTTI. In California, it is optional by county, and only 

one county, correct. 

Mr. MURPHY. Let me say this. Deep thanks—oh, Dr. Burgess 

wants a brief comment. 

Mr. BURGESS. Just as a brief follow-up. Dr. Evans, in your testimony you talk about the introduction of peer specialists. This has 

come up before in briefings that we have had. This strikes me as 

likely one of the most cost-effective ways to get rational treatment 

decisions and to keep people in their treatment. So I do hope you 

will share with the committee your experience with that. We are 

constrained under budgetary rules. We can never score a savings 

from something that will actually save money. It always scores as 

a cost. But perhaps this is one of those areas where spending the 

money wisely would in fact be a good investment. I thank you for 

bringing that to our committee today. 

Mr. EVANS. Could I just—— 

Mr. BURGESS. Sure. 

Mr. MURPHY. Real quick. 

Mr. EVANS. I think that there are data that support that peer 

services are cost-effective. I think it is probably the most important 

thing that we have done in our service that not only gives people 

hope but one of the real challenges is keeping people engaged in 

treatment, and we have found nothing that is more effective than 

a person who has gone through the experience, connecting with another individual, and keeping that person connected, giving that 

person hope, frankly. It makes a huge difference, and we have one 

program where we have instituted peers. We have reduced our crisis visits by a third, and half of those visits would have resulted 

in an inpatient stay. So we have saved millions of dollars, we believe, by implementing peer services. 

Mr. BURGESS. Thank you. I yield back. 

Mr. MURPHY. Mr. Rahim, you wanted to comment on that? 

Mr. RAHIM. Again, thank you so much for giving patients voice, 

and I think a couple of words. I know Mr. Dart talked about enlightenment, but I think enlightenment means compassion, dignity 

and education. So I think each of us has an ability to be compassionate and we have ability to treat each patient as an individual 

and with dignity, and I think through contact with people who are 

162 

doing well and then that follow-up education as a foundation and 

groundwork, we can do so much good. So I do thank you again. 

Mr. MURPHY. And again, my thanks to the whole panel. Just a 

couple of suggestions. While you are in town, I hope you stop in 

at your Member of Congress and say it is important to do some 

mental health reforms. 

I am committed to do this and I know Representative DeGette 

is too. It has been since 1963, as you referenced, Dr. Geller, the 

last time this country really did some major mental health reforms. 

It is long overdue. I know you are all passionate about this but I 

hope you energize your own Members of Congress as well to help 

them understand the importance of moving forward on this. 

Even though you spoke for 5 minutes and you added a few minutes to other things, oftentimes people go through life and wonder 

if their voice makes a difference, it does. Yours does, and it will 

continue to echo throughout the House of Representatives and this 

Nation. So I thank you a great deal for all that. And Mr. Rahim, 

you used the word ‘‘hope.’’ Where there is no help, there is no hope, 

and we will make sure we continue to work on that help. 

So in conclusion, again, thank you to all the witnesses and members that participated in today’s hearing. I remind members they 

have 10 business days to submit questions for the record, and I ask 

that all witnesses agree to respond promptly to the questions. 

Thanks so much. God bless. 

[Whereupon, at 12:25 p.m., the subcommittee was adjourned.] 

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