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95–097 2015

FEDERAL EFFORTS ON MENTAL HEALTH: WHY 

GREATER HHS LEADERSHIP IS NEEDED 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

FEBRUARY 11, 2015 

Serial No. 114–8 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

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 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJAN, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CARDENAS, California 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

TIM MURPHY, Pennsylvania 

Chairman 

DAVID B. MCKINLEY, West Virginia 

Vice Chairman 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

H. MORGAN GRIFFITH, Virginia 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

DIANA DEGETTE, Colorado 

Ranking Member 

JANICE D. SCHAKOWSKY, Illinois 

KATHY CASTOR, Florida 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

JOSEPH P. KENNEDY, III, Massachusetts 

GENE GREEN, Texas 

PETER WELCH, Vermont 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(III) 

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 .......................................................................................... 4 

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

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

Hon. Marsha Blackburn, a Representative in Congress from the State of 

Tennessee, opening statement ............................................................................ 7 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 8 

Hon. Fred Upton, a Representative in Congress from the state of Michigan, 

prepared statement .............................................................................................. 76 

WITNESSES

Linda T. Kohn, Ph.D., Director, Health Care, U.S. Government Accountability 

Office ..................................................................................................................... 10 

Prepared statement .......................................................................................... 13 

Richard G. Frank, Ph.D., Assistant Secretary for Planning and Evaluation, 

U.S. Department of Health and Human Services ............................................. 23 

Prepared statement .......................................................................................... 27 

Answers to submitted questions ...................................................................... 80 

Pamela S. Hyde, J.D., Administrator, Substance Abuse and Mental Health 

Services Administration ...................................................................................... 24 

Prepared statement .......................................................................................... 27 

Answers to submitted questions ...................................................................... 87 

SUBMITTED MATERIAL

Subcommittee memorandum .................................................................................. 77 

(1) 

FEDERAL EFFORTS ON MENTAL HEALTH: 

WHY GREATER HHS LEADERSHIP IS NEEDED 

WEDNESDAY, FEBRUARY 11, 2015 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 10:05 a.m., in room 

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

(chairman of the subcommittee) presiding. 

Members present: Representatives Murphy, McKinley, Burgess, 

Blackburn, Griffith, Bucshon, Flores, Brooks, Mullin, Hudson, Collins, Cramer, DeGette, Schakowsky, Tonko, Yarmuth, Clarke, Kennedy, and Pallone (ex officio). 

Staff present: Gary Andres, Staff Director; Sean Bonyun, Communications Director; Karen Christian, General Counsel; Noelle 

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

Charles Ingebretson, Chief Counsel, Oversight and Investigations; 

Peter Kielty, Deputy General Counsel; Alan Slobodin, Deputy Chief 

Counsel, Oversight; Sam Spector, Counsel, Oversight; Peter 

Bodner, Democratic Counsel; Hannah Green, Democratic Policy Analyst; Tiffany Guarascio, Democratic Deputy Staff Director and 

Chief Health Advisor; Elizabeth Letter, Democratic Professional 

Staff Member; and Nick Richter, Democratic Staff Assistant. 

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, ‘‘Federal Efforts on Mental Health: Why Greater HHS 

Leadership is Needed.’’ 

In December 2013, Laura Pogliano of Maryland sent to me a 

poem she wrote about what it is like to raise a child with schizophrenia, as opposed to other life-threatening conditions. Here is an 

excerpt: ‘‘Your child’s illness is afforded the cooperation of caregivers and parents to attend to it. My child’s illness is left to the 

right to refuse care laws, leaving him to get as sick as he can possibly be, and choose suicide, death, starvation, and continued illness with severe brain damage. Your child is never arrested or 

jailed because he is sick. My child is almost always arrested at 

some point. Your child can have any bed in any hospital in the 

country across the board. My child can only have a psychiatric bed. 

And there is an estimated deficit of 100,000 beds in this country, 

2 

and the wait for one can take 6 months or longer in some places. 

Your child can tell people if he is sick. My child cannot, or he won’t 

get a job or a date or an apartment. Your child can get a fun trip 

sponsored by an organization that assists sick children. My child 

can’t go on any trips usually, and neither can his family.’’ 

Despite her struggles getting Zac into care, Laura considered 

herself lucky, telling USA Today in November that, even though 

her son’s mental illness has driven her to bankruptcy, sidetracked 

her career, and left her clinically depressed, she called herself 

lucky, though Zac was in and out of a hospital 13 times in 6 years. 

She said, even though he has fantasies that he is rich, hallucinations that he is being followed, and delusions that his mother is 

a robot, even though he has slept with a butcher knife under his 

pillow, Laura considered herself lucky that Zac wasn’t in jail or 

homeless. 

Last month, Zac was found dead in his apartment. He was 23 

years old. 

Laura had dreams for her son, Zac, just like every parent does. 

For countless parents, those dreams are tragically cut short. She 

searched for help and faced barriers to care. Federal laws, HIPAA 

laws, state laws. We have criminalized mental illness so you can’t 

get help unless you are homicidal, suicidal, or you are well enough 

to understand you have problems and ask for help. 

This has been a growing problem since states closed down their 

old asylums, as they should have, but what did the Federal Government do here to take care of this problem, to meet the needs 

of millions of Americans with serious mental illness and their families? 

Today, we will hear how our mental health system is an abject 

failure for those families. Its failure is not a Democrat or Republican issue; it knows no party label, and to be honest, this spans 

multiple administrations, but the cost is enormous for the 10 million Americans with serious mental illness. Those with schizophrenia die 25 years earlier than the rest of the population. Forty 

thousand people in this country died last year from suicide, while 

another million attempted it in the last year. And that is a trend 

that is getting worse. Rates of homelessness, incarceration, unemployment, substance abuse, violence, victimization, and suicide 

among those with serious mental illness continue to soar. These 

are the very human, very tragic, and very deadly results of a very, 

very bad report card. 

Today, thanks to a diligent year-long review of Federal efforts related to severe mental illness conducted at the bipartisan request 

of this committee, the Government Accountability Office has produced unassailable evidence that our mental health system is dysfunctional, disjointed, and a disaster. 

No Federal agency has had a more central role in the disaster 

than the Department of Health and Human Services. HHS is 

charged with leading the Federal Government’s public health efforts related to mental health, and the Substance Abuse and Mental Health Services Administration, otherwise known as SAMHSA, 

is required to promote coordination of programs related to mental 

illness throughout the Federal Government. At the onset of our investigation 2 years ago, we found it troubling that no one in the 

3 

Federal Government kept track of all the Federal programs serving 

individuals with severe mental illness. My colleague and I, Representative Diana DeGette, asked GAO to take on this task. Following a detailed survey of eight Federal departments, including 

the Department of Defense, Veterans Affairs, and HHS, the GAO 

identified at least 112 separate Federal programs supporting individuals with severe mental illness. But most damning in this GAO 

report were these two principal findings. One, interagency coordination for programs supporting individuals with serious mental illness, a key function of SAMHSA, is lacking. And number two, to 

see whether programs specifically targeted at individuals with serious mental illness are working, agencies evaluated fewer than 1⁄3

of them. 

Now, you can’t manage what you don’t measure. For families 

who want and need treatment, HHS has given families bureaucracy, burdens and barriers instead. 

We spend a lot of money in this country on mental illness, and 

the term evidence is thrown around like candy to prevent people 

from asking where is the real proof that this works. GAO offered 

two recommendations to correct these failings. HHS rejected them 

both. In each instance, HHS dismissed GAO’s concerns rather than 

presenting evidence to dispute GAO’s conclusions or volunteering 

improvements, or having the humility to say maybe we ought to do 

something about this. 

When you have a mental health system that is as broken as the 

one we face today, with a report card so tragic, you would think 

that the Federal agency charged with coordinating a myriad of activities supporting individuals with severe mental illness would be 

open to recommendations from an experienced, nonpartisan authority, steeped in the practices of good government. HHS, in rejecting 

both of GAO’s recommendations, and failing to identify any aspect 

of either recommendation worth working with or leaning from, is 

essentially saying there is no room for improvement, and that the 

agency is doing everything right at present. This is unbelievable. 

The hubris shown by HHS is downright insulting and callous to 

the millions of families and individuals suffering under this broken 

system. This is a clear example of unaccountable government; one 

that refuses to recognize its failings even when it is presented with 

constructive recommendations for improvement. 

We want to help in this committee, this Congress wants to help, 

but we can’t help you if you are not even willing to admit there is 

a problem. We are not talking simply about wasted dollars or lost 

program efficiencies. We are talking about lives ruined, about 

dreams that are shattered, we are talking about preventable tragedies and lives lost. 

I have spoken before about individuals with schizophrenia and 

bipolar disorders who aren’t just in denial, but have the very real 

medical pathology that they cannot recognize they have an illness. 

It is called anosognosia, and it is a symptom found in stroke victims, Alzheimer patients, and persons with schizophrenia. HHS 

and SAMHSA are similarly in denial. You are so out of touch with 

understanding their own failures that it causes greater pain to millions of American families. Meanwhile, the lives of individuals with 

severe mental illness and their families remain in the balance. 

4 

This morning, we will hear from the author of the GAO report, 

as well as representatives from HHS. These include Dr. Linda 

Kohn, Director of Health Care at GAO; Dr. Richard Frank, Assistant Secretary for Planning and Evaluation at HHS; and Pamela 

Hyde, Esquire, the Administrator of SAMHSA. I thank them all for 

joining us this morning, and I would like to give the ranking member an opportunity to deliver remarks of her own. 

[The prepared statement of Mr. Murphy follows:] 

PREPARED STATEMENT OF HON. TIM MURPHY

In December 2013, Laura Pogliano of Maryland sent to me a poem she wrote 

about the what it’s like to raise a child with schizophrenia as opposed to other lifethreatening conditions. Here’s an excerpt: 

Your child’s illness is afforded the cooperation of caregivers and parents to attend 

to it. 

My child’s illness is left to the Right to Refuse Care Laws, leaving him to get as 

sick as he can possibly be, and choose suicide, death, starvation, continued illness 

with severe brain damage. 

Your child is never arrested or jailed because he’s sick. 

My child is almost always arrested at some point. 

Your child can have any bed in any hospital in the country, across the board. 

My child can ONLY have a psychiatric bed, and there’s an estimated deficit of 

100,000 beds in this country, and the wait for one can take 6 months or longer in 

some places. 

Your child can tell people he’s sick. My child cannot, or he won’t get a job, or a 

date, or an apartment. 

Your child can get a fun trip sponsored by an organization that assists sick children. 

My child can’t go on any trips, usually, and neither can his family... 

Despite her struggles getting Zac into care, Laura considered herself lucky, telling 

USA Today in November that ‘‘even though her son’s mental illness has driven her 

to bankruptcy, sidetracked her career and left her clinically depressed.’’ 

She called herself ‘‘lucky’’ even though Zac was in and out of the hospital 13 times 

in 6 years. 

‘‘Even though he has fantasies (he’s rich), hallucinations (he’s being followed) and 

delusions (Mom is a robot). Even though he’s slept with a butcher knife under his 

pillow.’’ 

Laura considered herself lucky that Zac wasn’t in jail or homeless. 

Last month, Zac was found dead in his apartment. He was 23. 

Laura had dreams for her son Zac just like every parent does. 

For countless parents, those dreams are tragically cut short. 

She searched for help and to face barriers to care—federal laws, HIPAA laws, 

state laws. We’ve criminalized mental illness so you get help unless you are homicidal, suicidal, or well enough to understand you have a problem. 

This has been a growing problem since states closed down their old asylums—as 

they should have. But what did the federal government do here? 

Today, we’ll hear how our mental health system is an abject failure for those families. Its failure is not a Republican or Democrat issue. It knows no party label and 

spans multiple Administrations. 

The cost is enormous for the ten million Americans with serious mental illness. 

Those with schizophrenia die 25 years earlier than the rest of the population. 

40,000 die from suicide while another million will have attempted it in the last 

year alone, a trend that’s getting worse 

Rates of homelessness, incarceration, unemployment, substance abuse, violence, 

victimization, and suicide amongst those with serious mental illness continue to 

soar. These are the very human, very tragic, and very deadly results of a very, very 

bad report card. 

Today, thanks to a diligent year-long review of federal efforts related to severe 

mental illness conducted at the bipartisan request of this Subcommittee, the Government Accountability Office (GAO) has produced unassailable evidence that our 

mental health system is dysfunctional, disjointed, and a disaster. 

No federal agency has had a more central role in the disaster than the Department of Health and Human Services (HHS). HHS is charged with leading the federal government’s public health efforts related to mental health, and the Substance 

5 

Abuse and Mental Health Services Administration (SAMHSA) is required to promote coordination of programs relating to mental illness throughout the federal government. 

At the onset of our investigation two years ago, we found it troubling that no one 

in the federal government kept track of all of the federal programs serving individuals with severe mental illness. My colleague Diana DeGette and I asked GAO to 

take on this task. Following a survey of eight federal agencies, including the Departments of Defense, Veterans Affairs, and HHS, GAO identified at least 112 separate 

federal programs supporting individuals with severe mental illness. 

Most damning in the GAO report were these two principle findings: 

(1) interagency coordination for programs supporting individuals with serious 

mental illness, a key function of SAMHSA, is lacking 

(2) to see whether programs specifically targeting individuals with serious mental 

illness are working, agencies evaluated fewer than one-third of them. 

You can’t manage what you don’t measure, which is why HHS has given families 

and individuals who want and need treatment bureaucracy, burdens, and barriers 

instead. 

We spend a lot of money and the term ‘‘evidence’’ is thrown around like candy— 

to prevent people from asking where the true proof that it really works. 

GAO offered two recommendations to correct these failings; HHS rejected them 

both, in each instance dismissing GAO’s concerns rather than presenting evidence 

to dispute GAO’s conclusions orvolunteering improvements. 

When you have a mental health system as broken as the one we face today with 

a report card so tragic, you would think that the federal agency charged with coordinating the myriad of activities supporting individuals with severe mental illness 

would be open to recommendations from an experienced, nonpartisan authority 

steeped in the practices of good government. HHS, in rejecting both of GAO’s recommendations—and failing to identify any aspect of either recommendation worth 

working with or learning from—is essentially saying there is no room for improvement, and that the agency is doing everything right at present. It’s unbelievable. 

The hubris shown by HHS is downright insulting to the millions of families and 

individuals suffering under this broken system. 

This is a clear example of unaccountable government—one that refuses to recognize its failings, even when it is presented with constructive recommendations for 

improvement. We are not talking simply about wasted dollars or lost program efficiencies. We are talking about lives ruined, dreams shattered, and preventable tragedies. 

I’ve spoken before about individuals with schizophrenia and bipolar disorder who 

aren’t just in denial but who have the very real medical pathology that they cannot 

recognize they have an illness. It’s called anosognosia, and it’s a symptom found in 

stroke victims and persons with schizophrenia. 

HHS and SAMHSA are similarly in denial. They are so out of touch with understanding their own failures that is tgreater pain to millions of American families. 

Meanwhile, the lives of individuals with severe mental illness, and their families, 

remain in the balance. 

This morning, we will hear from the author of the GAO report, as well as representatives of HHS. These include: 

•Linda T. Kohn, PhD, Director, Health Care at GAO; 

• Richard G. Frank, PhD. Assistant Secretary for Planning and Evaluation at 

HHS; and 

•Pamela S. Hyde, Esquire, Administrator of SAMHSA. 

I thank them all for joining us this morning. 

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

Ms. DEGETTE. Thank you, Mr. Chairman. 

This is an issue that is important to both of us, and so I am really glad that you have convened this hearing as part of our continuing oversight of the Federal Government’s mental health programs. 

This hearing, as the chairman mentioned, follows a report by the 

GAO released last week, which raises questions about the more 

than 100 programs that generally support individuals with serious 

6 

mental illness, and 30 programs that specifically target those individuals. 

In particular, the GAO report raises questions about the coordination and evaluation of mental health programs, and offers recommendations to help us improve the mental health system. 

I look forward to hearing our witnesses’ testimony today because 

they are very familiar with the report and the issues that it raises, 

and I know that we will all be able to see further insights and context for our understanding of the Federal role in mental health 

care. 

The report provides us with an importance chance to assess current Federal efforts to address mental health, and to see where 

there is room for improvement in our system. And I know we can 

all agree there is ample room for improvement. I want to hear 

about how we can ensure that Federal programs actually assist 

people who need them, and I also think we need to talk about how 

to assess the efficacy and cost of those programs. 

While it is important to talk about providing services and support to those with serious mental illnesses, I think we also need to 

have a broader conversation about mental health in this country. 

According to the National Institute of Mental Health, we have 

nearly 44 million individuals, almost 19 percent of all U.S. adults, 

living with mental illness every year. And, Mr. Chairman, as we 

have discussed, sometimes if we can help folks in the early stages 

of mental illness, then that helps us begin to prevent the disintegration into very, very serious mental illness and worse. 

So we have spent a lot of time on this subcommittee looking at 

mental health issues. We have learned about the need to appropriately target mental health funding, and the need to adequately 

fund mental health research. We have learned about the importance of health insurance that provides coverage for those with 

mental illnesses. I know, Mr. Chairman, that you want to pass 

mental health legislation that will make a real difference. I do too. 

I hope there are ways that we can work through these issues and 

concerns on a bipartisan basis, with the focus group that we have 

put together over the last year. I think we should work together 

to put the lessons learned in these Oversight hearings into practice. 

I want to thank all of the witnesses for being here today. It is 

important to hear from all of you. I know we can agree there is always room for improvement, and we look forward to hearing from 

you about how we can do that. 

With that, I will yield the balance of my time to Representative 

Kennedy. 

Mr. KENNEDY. I want to thank the ranking member, and I thank 

the chairman for calling this important hearing. I thank the witnesses for their testimony today, and for your work on an extraordinarily important issue. 

This report outlines alarming lapses in coordination at the Federal level. It raises questions about how Federal funds are being 

spent, and points a finger at our Nation’s patchwork mental health 

system for failing to meet the needs of millions of Americans. 

Back home, I see communities on the frontlines of a growing crisis, looking for the Federal Government for support. From subVerDate Nov 24 2008 11:04 Jun 19, 2015 Jkt 037690 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 114\114-8 CHRIS
7 

stance abuse to at-risk youth, our failure to delivery dependable, 

affordable, and accessible mental health care is costing lives back 

at home. 

So instead of throwing in the towel, we should see this report as 

a rallying cry. We must do better, devote more resources to mental 

illness, invest in our efforts at improving coordination, evaluation, 

and delivery of care. But for that to work, we need to know the 

scope of the problem and the range of our response. We must have 

the commitment of our Federal partners to take on a growing problem. Lasting mental health reforms are long overdue, and I look 

forward to working with all of you. And I want to thank again the 

chairman and ranking member for calling this important hearing. 

I yield back. 

Mr. MURPHY. Yields back. Thank you. 

I now recognize the vice chair of the full committee, Mrs. 

Blackburn of Tennessee, for 5 minutes. 

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE 

Mrs. BLACKBURN. Thank you, Mr. Chairman. And I want to welcome our witnesses, and highlight a couple of things that have already been said that I think are important to all of us on the panel. 

As the chairman mentioned, 10 million adults in the U.S. had a 

serious mental illness during 2013. That should not be lost on us. 

And we also were very concerned about coordination of care, and 

we are going to have some questions about that. I have discussed 

this with some of the mental health professionals in my district 

who are involved in this coordination of care. And Ms. DeGette’s 

comments are so on point with so much of what we are going to 

look at, the money that is spent. Your budget is a hefty budget for 

substance abuse and mental illness, but the lack of coordination of 

care, the lack of the resources meeting the needs at the local and 

state agencies, how this feeds through, this is something that does 

cause us concern. We are pleased to hear from the GAO today, and 

we want to look at where the recommendations the GAO has, how 

they have fallen on deaf ears at HHS and SAMHSA, and we are 

concerned about the delivery of parity, if you will, in mental illness 

and addressing those needs, and we are concerned with what appears to be a great deal of indifference when it comes to just spending money but not getting results. 

So I will yield back my time, Mr. Chairman, or yield to whomever would like to have the time. And we look forward to hearing 

from our witnesses. 

Mr. MURPHY. Thank you. 

Does anybody on this side wish to make any comments? If not, 

then we will proceed. Thank you. 

Mr. Pallone. I am sorry, Mr. Pallone is here now. Mr. Pallone is 

recognized for 5 minutes. 

8 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. Thank you for convening the hearing today. And I am glad we are taking this opportunity to examine how the Federal Government supports individuals with serious mental illness, but also looking into how we can 

strengthen our mental health system for the future. We all agree 

that there are ways we can do better. 

The GAO report we are talking about today calls for improved 

coordination and evaluation of Federal programs that help those 

with serious mental illness. And these are valuable goals, but I 

want to make sure we don’t discount the work HHS, SAMHSA, and 

other Federal agencies are already doing in these areas. 

The GAO report identified 112 programs across the Federal Government that support those with serious mental illness. Now, within that group, there are 30 programs that specifically focus on individuals with serious mental illness. GAO, however, did not review 

the merits or quality of these programs, so we should hear from 

HHS and SAMHSA about the work they are doing, how these programs help individuals with a variety of needs, and how these 

agencies plan to build upon these programs moving forward. 

It is also important to emphasize that HHS, SAMHSA, and their 

partners across the Federal Government do coordinate on mental 

health programming. The GAO report notes that, and I quote, 

‘‘Staff from 90 percent of the programs targeted serious mental illness reported coordinating with their counterparts and other programs.’’ 

HHS coordinates with a number of departments and agencies, including the Department of Defense, the Department of Veterans 

Affairs, the Department of Education, to carry out critical programs for individuals with serious mental illness. SAMHSA also 

co-chairs the HHS Behavioral Health Coordinating Council, which 

includes a Subcommittee on Serious Mental Illness. 

The GAO report also noted that SAMHSA had completed, or was 

in the process of completing, nine program evaluations in the past 

several years, and I look forward to hearing from SAMHSA about 

the results of these evaluations, and how they have improved program efficiency and effectiveness, as well as how SAMHSA utilizes 

other monitoring and evaluation tools. Notably, the GAO report did 

not review the programs that provide reimbursement of insured 

services for individuals with serious mental illness, including Medicare and Medicaid. These programs are a huge part of the work 

HHS does to support early diagnosis and treatment of mental illness. 

And lastly, Mr. Chairman, I want to highlight the role of the Affordable Care Act in guaranteeing coverage of mental health services. Continuing implementation of the ACA will go a long way in 

ensuring that people with serious mental illness have access to the 

treatments they need. In fact, we should support programs that 

focus on prevention and early diagnosis of mental illness. We can 

more effectively support individuals with serious mental illness by 

treating them early in the course of their illnesses, and altering the 

trajectory of their condition. 

9 

So again, I want to thank our witnesses. And I would like to 

yield my remaining time to the gentleman from New York, Mr. 

Tonko. 

Mr. TONKO. I thank the ranking member of our Energy and Commerce Committee for yielding. And I thank you, Mr. Chair, and, 

Ranking Member DeGette, for holding this hearing on such a critically important topic. 

As I travel around my congressional district in the capital region 

of New York, I hear stories daily from individuals and families as 

they struggle with the ravages of mental illness. Their pain is indeed real, and we must commit this Congress to doing everything 

within its power to ease their burdens. 

In that vein, I welcome today’s hearing, and the underlying GAO 

report that we are here to discuss as it advances the conversation 

on some basic good governance questions on how the Federal Government should approach programs aimed at helping individuals 

with serious mental illness. And while I concur with the report’s 

conclusion that high-level coordination can be essential to identifying gaps in services and evaluating overall efforts, it is important 

to keep in mind that coordination is not an end unto itself. Where 

additional interagency coordination, whether at the programmatic 

or department level, can be an effective use of the Federal Government’s time and money, and more importantly, is beneficial to individuals with serious mental illness, we should welcome it. Where 

it does not meet that test, we should not be adding additional layers of bureaucracy that divert time and resources from the people 

that need it the most. 

As such, I look forward to hearing from our witnesses today on 

where coordination efforts can be built upon so that we can have 

an improved outcome for those living with mental illness. 

And I thank you and yield back the balance of my time. 

Mr. MURPHY. The gentleman yields back. 

So at this point, we will proceed with testimony of our witnesses. 

I would now like to introduce the panel. 

First, we have Dr. Linda Kohn, who is Director with the Health 

Care Team at the U.S. Government Accountability Office, where 

she works on issues related to public health, health information 

technology, and medical research programs. Welcome. Dr. Richard 

Frank is the Assistant Secretary for Planning and Evaluation at 

the U.S. Department of Health and Human Services. In this role, 

he advises the Secretary on development of health and disability, 

human services data, and science policy, and provides advice and 

analysis on economic policy. Welcome here. And the Honorable 

Pamela Hyde is accompanying Dr. Frank. Ms. Hyde is the Administrator of the Substance Abuse and Mental Health Services Administration, otherwise known as SAMHSA. Ms. Hyde has more 

than 35 years of experience in management and consulting for public health care and human service agencies. 

I will now swear in our witnesses. 

You are all aware that the committee is holding an investigative 

hearing, and when doing so, has the practice of taking testimony 

under oath. Do any of you have any objections to testifying under 

oath? Seeing that no one has an objection, the chair then advises 

you that under the rules of the House and the rules of the comVerDate Nov 24 2008 11:04 Jun 19, 2015 Jkt 037690 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 114\114-8 CHRIS
10 

mittee, you are entitled to be advised by counsel. Do any of you desire to be advised by counsel during testimony today? And all the 

witnesses decline. In that case, would you all please rise and raise 

your right hand, and I will swear you in? 

[Witnesses sworn.] 

Mr. MURPHY. You are now under oath and subject to the penalties set forth in Title XVIII, section 1001 of the United States 

Code. 

You may now each give a 5-minute summary of your written 

statement. Please make sure the microphone is turned on and close 

to your face. 

Dr. Kohn, you may begin. Make sure the microphone is on and 

pulled close. 

Ms. KOHN. Is it on? Got it. OK. 

Mr. MURPHY. Thank you. 

STATEMENTS OF LINDA T. KOHN, PH.D., DIRECTOR, HEALTH 

CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; RICHARD G. FRANK, PH.D., ASSISTANT SECRETARY FOR PLANNING AND EVALUATION, U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES; ACCOMPANIED BY PAMELA S. HYDE, J.D., 

ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH 

SERVICES ADMINISTRATION 

STATEMENT OF LINDA T. KOHN, PH.D. 

Ms. KOHN. Thank you, Chairman Murphy, Ranking Member 

DeGette, and members of the subcommittee. I am pleased to be 

here today to talk about GAO’s recent report on Federal programs 

related to serious mental illness. Our report calls for leadership 

from HHS to coordinate Federal efforts in addressing the needs of 

this very vulnerable population. 

Our report has three major findings, and I will touch briefly on 

each. First, we found 112 programs across eight different agencies 

that serve the needs of people with serious mental illness, and 30 

of these programs target or specifically focus on people with serious 

mental illness. We believe it is unlikely that all the programs were 

identified because agencies had difficulty identifying them, not because they weren’t willing to, that was not an issue, but the agencies didn’t always have information on the extent to which a program was serving the seriously mentally ill, although they knew 

that their programs were serving that population; for example, a 

program related to homelessness. 

The list we think is also incomplete because agencies varied in 

how they decided which programs to include in their responses to 

us. So, for example, DoD identified all of their suicide prevention 

programs in their list of programs for the seriously mentally ill, but 

SAMHSA initially did not because they saw the program as serving 

a broader population. Subsequently, SAMHSA added these programs to the list. 

There was another example, HUD and VA jointly administer a 

housing program for disabled veterans. VA put it on the list of programs, HUD didn’t put it on the list of programs. So there are a 

number of examples like that, and it is that kind of variation that 

11 

can limit comparability among similar programs. So this list is a 

starting point, not an ending point. 

Our second objective related to coordination, and we found that 

while the staff involved in implementing these programs reported 

taking steps to coordinate activities with staff in other agencies, we 

were unable to identify any formal mechanism to support interagency coordination at a higher level. And such coordination, GAO 

believes, could help comprehensively identify the programs, resources, and potential gaps or duplication in Federal efforts that 

support the seriously mentally ill. 

In the past, HHS has led the Federal Executive Steering Committee for Mental Health with members from across the Federal 

Government, but that group hasn’t met since 2009. HHS told us 

that another group, the Behavioral Health Coordinating Council, 

performed some of the activities previously done by the Steering 

Committee, but that council is limited to HHS and doesn’t have 

members from across the Federal Government. 

We identified examples of other interagency committees, but they 

tended to be broader in scope, such as the focus on homelessness 

or focused on a specific population such as veterans. It is important 

to emphasize, and has been noted, that the staff that carry out the 

programs reported to us that they were working with colleagues in 

different agencies, and trying to coordinate their efforts. That is a 

very positive thing in place, however, staff at the program level are 

not necessarily in the right position to identify possible gaps, potential duplication, whether Federal resources are being spent wisely. 

Getting that kind of an overarching perspective requires some 

higher level, interagency coordination, and we called on HHS to establish a mechanism for that. HHS did not agree because they said 

that coordination is already occurring at the programmatic level, 

but for the reasons I noted, we continue to believe that action is 

necessary. 

Our third recommendation related to evaluation, and we found 

that as of September 2014, across the 30 programs that specifically 

target the seriously mentally ill, fewer than 1⁄2 had evaluations 

that were done in the last 5 years or were underway. Of the completed evaluations, SAMHSA had evaluated the greatest proportion 

of their programs, seven of the 13 programs they listed, and had 

two evaluations underway. And there were a couple of other evaluations that were done at DoD. 

We recognize program evaluations can be costly and very timeconsuming, and that the agencies need to prioritize those efforts. 

Our report also notes that the agencies reported to us that they do 

other program monitoring activities. They look at data performance 

measures, they stay on top of the literature to understand how to 

improve programs and identify improvements, and again, that is a 

very important component, but we don’t believe that performance 

monitoring takes the place of formal program evaluations that can 

examine the overall effectiveness of a program. 

We called on four agencies that sponsor programs that target the 

seriously mentally ill; specifically, DoD, Justice, HHS, and VA, to 

document which of their programs should be evaluated and how 

often. DoD, Justice, and VA agreed with our recommendation; HHS 

12 

did not agree, and suggested our report overemphasized the role of 

evaluations, but again, we continue to believe that action is needed. 

That concludes my prepared remarks. Thank you very much. 

[The prepared statement of Ms. Kohn follows:] 

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Mr. MURPHY. Thank you, Dr. Kohn. 

Dr. Frank, you are recognized for 5 minutes. 

STATEMENT OF RICHARD G. FRANK, PH.D. 

Mr. FRANK. Good morning, Chairman Murphy, Ranking Member 

DeGette, and members of the subcommittee. My name is Richard 

Frank, and I am the Assistant Secretary for Planning and Evaluation. I am pleased to be here to discuss coordination of care for people with serious mental illness. I have dedicated much of my career 

to studying mental health care and mental health policies, so it is 

gratifying to participate in a serious conversation on this issue. 

The occasion that brings us here is the release of GAO’s report 

on efforts to coordinate care for people with serious mental illness. 

Past GAO reports on serious mental illness have had profound effects on this Nation’s mental health policy. I think of the 1977 report, Returning the Mentally Disabled to the Community, Government Needs to Do More, as having set the standard. The GAO 

showed how government could best support people with serious 

mental illness by improving the care they receive from community 

providers. 

Today’s report falls short of that earlier effort. It doesn’t adequately make the connection between government activities and 

meeting the complex needs of people with serious mental illness. 

In the time I have with you, I aim to make some of those connections; one, by offering a more complete view of HHS programs that 

serve people with serious mental illnesses; two, by describing the 

investments that we are making to coordinate services for this population; and three, to explain our evaluation efforts. 

Serious mental illnesses are not a diagnosis. Serious mental illness is how we talk about a collection of conditions and impairments that disrupt peoples’ lives, much as the chairman mentioned. Therefore, serious mental illness does not fall easily into 

quantified categories of programs, peoples, and dollars. 

Let me begin first by outlining the role of the Federal Government in serving people with serious mental illnesses, and putting 

that into context. 

Medicare and Medicaid Supplemental Security Income and Social 

Security Disability Insurance are the largest sources of public support for people with serious mental illnesses. With regard to HHS 

programs that pay for and deliver mental health services, Medicare 

and Medicaid account for 40 percent of national spending on mental health care, and an even larger share of care for people with 

serious mental illnesses. All other Federal programs, including 

SAMHSA’s programs, account for 5 percent of spending. The remaining 55 percent is made up of spending by private insurance, 

state and local government expenditures, and out-of-pocket payments by households. By focusing on the 5 percent, the GAO report 

overlooks much of HHS activities regarding caregiving and support 

for people with serious mental illnesses. HHS leadership recognizes 

the need to coordinate services for this population. Coordination 

can be thought of in a number of ways. It can occur at the level 

of formal coordination across large Federal agencies, at the program level, at the provider level, or at the level of the individual 

beneficiaries where providers, programs, and people interact. 

24 

People do not live their lives according to program boundaries, 

and we have learned not to run our programs as if they do. As a 

result, we have been making substantial investments in new organizations and institutions that coordinate public services at the 

level of the individual beneficiary. A few important examples include SAMHSA’s Primary Behavioral Health Care Integration, or 

PBHCI, Program, Medicaid Health Homes, and the Integrated 

Care demonstration for beneficiaries that are dually eligible for 

Medicare and Medicaid. 

The GAO report also raised the issue of evaluation to develop 

evidence to guide program design and funding decisions. We have, 

and are conducting a variety of important and rigorous evaluations 

of programs that coordinate care for people with serious mental illnesses. They include evaluations of programs run by SAMHSA, 

CMS, Social Security, HUD, and by states using Federal program 

funds. The results of evaluations have shaped legislation, program 

design and regulations. 

I will highlight two to give you a flavor of our efforts. First, 

ASPE has worked with SAMHSA to evaluate primary behavioral 

health care integration programs, showing how coordination across 

providers affects health and mental health of people with serious 

mental illnesses. Second, we will be evaluating early intervention 

programs for serious mental illnesses, in conjunction with the Social Security Administration and in relation to SAMHSA’s block 

grant set aside. In addition, SAMHSA, ASPE, and CMS are jointly 

developing new performance and quality measures that are essential to conducting evaluations and monitoring progress. 

This Administration has shown a deep commitment to addressing mental health care, and support for serious mental illnesses, 

specifically. It is that commitment that was an important factor in 

my returning to work here at HHS. I am proud of the record to 

date, but I know we can do more. More needs to be done, and I 

hope to join you in doing just that. 

Thank you. 

Mr. MURPHY. Thank you. 

Ms. Hyde, you are recognized for 5 minutes. 

STATEMENT OF PAMELA S. HYDE, J.D. 

Ms. HYDE. Good morning, Chairman Murphy, Ranking Member 

DeGette, and members of the subcommittee. My name is Pamela 

Hyde and I am the Administrator of the Substance Abuse and 

Mental Health Services Administration. 

In 2014, over 3⁄4 of SAMHSA’s mental health funding was targeted toward improving the lives of persons with serious mental illness, or SMI. Individuals with SMI in their families, like those I 

have met, served, and advocated for over 4 decades, are the reason 

we are, at SAMHSA, working so hard to coordinate critical Federal 

programs to maximize the impact on the ground for those who need 

it the most. For example, SAMHSA and other HHS agencies work 

with the U.S. Interagency Council on Homelessness, the Departments of Veterans Affairs and Housing and Urban Development, to 

prioritize the needs of veterans and individuals experiencing chronic homelessness; many of whom have serious mental illnesses. Because of these joint efforts, 25,000 fewer people experienced chronic 

25 

homelessness in 2014 than in 2013, and the number of homeless 

veterans has declined 33 percent. 

I also represent Secretary Burwell as co-chair of the President’s 

Interagency Task Force on Military and Veterans Mental Health. 

Through this effort, SAMHSA is working with the Department of 

Defense, VA, and the White House to address the mental health 

needs of military families. SAMHSA also leads the Interdepartmental Federal Working Group on suicide prevention, and helps 

fund and support the Federal and private sector collaboration that 

developed, and is beginning to implement the Surgeon General’s 

national strategy on suicide prevention. 

In 2014, the National Suicide Prevention Lifeline, funded by 

SAMHSA, and coordinated with the VA, served over 1.3 million 

Americans. 

SAMHSA’s Children’s Mental Health Initiative coordinates mental health, education, juvenile justice, and human services structures that serve young people with serious emotional disturbances. 

Evaluations of this program have demonstrated impressive results 

in improving functioning, reducing arrests, suicidal thoughts, and 

days spent in inpatient care, and increasing family satisfaction 

with services. 

Along with the Assistant Secretary for Health, I co-chair the Secretary’s Behavioral Health Coordinating Council, which includes a 

new subcommittee focused on the needs of persons with SMI, and 

other subcommittees that address issues affecting SMI individuals 

and their families across multiple programs. 

SAMHSA also coordinates Federal efforts informally. For example, SAMHSA worked with the Departments of Labor and Education to develop and disseminate a toolkit about supported employment for persons with SMI. In 2014, SAMHSA implemented a 

new grant program to test how to help states take this evidencebased practice to scale. 

In 2014, SAMHSA also implemented new congressional language 

requiring that at least 5 percent of each state’s mental health block 

grant funds be used to provide treatment and services for individuals with first-episode serious mental illness. SAMHSA is coordinating with the National Institute of Mental Health to provide 

guidance and technical assistance to help states implement evidence-based interventions to prevent the disability often associated 

with early onset SMI. 

Also new in 2014 is the President’s Now is The Time plan, which 

grew out of the tragedy in Newtown, Connecticut, and received 

broad bipartisan support by Congress. This series of programs allows us to increase the behavioral health workforce, train and support school personnel, and assist youth and young adults, especially 

those with serious emotional disturbances, to be identified and receive the treatment they need for emerging mental health and substance use problems as they transition to adulthood. These new 

programs necessitate robust interdepartmental coordination with 

other HHS agencies. The Departments of Education and Justice, 

and state education and behavioral health entities, as well as students, families, and community responders. 

And in collaboration with the Departments of Treasury and 

Labor, SAMHSA and other HHS agencies have coordinated efforts 

26 

to help individuals with significant behavioral health needs enroll 

in newly available affordable care coverage, and to help plans and 

consumers know about their obligations and rights under National 

parity legislation. 

Even though much has been accomplished, we recognize the need 

to do more. The President’s 2016 budget proposes a new SAMHSA 

Crisis Services Program to bring together multiple state, Federal, 

and community funding streams, and service deliver infrastructures so that emergency rooms, inpatient residential and treatment 

facilities, and jail cells will not be the only options for SMI individuals in crisis and their families. 

SAMHSA works every day to coordinate and collaborate within 

the Federal Government and across the country to assure evidencebased treatment is available and delivered so individuals with SMI 

and their families can live satisfying and productive lives. We appreciate Congress’ continuing partnership in these efforts. 

Thank you. 

[The prepared statement of Mr. Frank and Ms. Hyde follows:] 

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Mr. MURPHY. Thank you. I thank the witnesses for their testimony. 

I am now going to recognize myself for 5 minutes. Just for the 

record, I just want to make it clear, Dr. Kohn, you have never 

treated a patient with mental illness, correct? 

Ms. KOHN. No, I have not. 

Mr. MURPHY. Dr. Frank, you never have? You have never treated 

anybody with mental illness, right? That is not your field, correct? 

And, Ms. Hyde, you have never treated anybody in the service for 

mental illness, correct? 

Ms. HYDE. Right. 

Mr. MURPHY. I just want to be on the record. That way—yes. 

So, Dr. Kohn, despite HHS’s disagreement with your recommendations, does GAO stand by its report and its recommendations? 

Ms. KOHN. We do. We continue to believe that action is needed 

in both areas. We think there can be greater coordination to provide that overarching perspective. It is not that we didn’t acknowledge a number of—— 

Mr. MURPHY. OK, I just need to have that yes or no. I—— 

Ms. KOHN. Yes. 

Mr. MURPHY. Thank you. Dr. Frank, in this 2006 book that you 

wrote, Better But Not Well, you wrote that individuals with a mental illness have flexible entitlements to an array of largely uncoordinated programs and resources. The resources flow from a dizzying range of Federal, state, and private organizations. Do you 

still believe that? 

Mr. FRANK. I believe that continues to be the case. 

Mr. MURPHY. I want to post these two posters. One is a list of 

all the Federal programs on the right there, and then I have put 

together, based upon the GAO report, the organizational flowchart 

of the programs on the left, using your term dizzying array. 

So you still believe that? Yes? 

Mr. FRANK. I believe that there is a complex set of needs provided by a complex set of organizations for people with serious 

mental illness. 

Mr. MURPHY. The law states that SAMHSA must promote the coordination of service programs conducted by other departments, 

agencies and organizations, and individuals that are or may be related to the problems of individuals suffering from mental illness. 

So yes or no, do you believe SAMHSA is responsible for the interagency coordination of mental health programs? 

Mr. FRANK. I am focused with—— 

Mr. MURPHY. Well, it is a yes or no. I have just read you what 

is the regulations of law. Is that true or not? 

Mr. FRANK. Well, SAMHSA has some responsibilities. What I 

want to do is point out that it is very important in our view how 

services actually get coordinated on the ground for people, and part 

of that is—— 

Mr. MURPHY. That is a good point. 

Mr. FRANK [continuing]. On a Federal level, but part of it is also 

done in other places that involve Federal activities. 

41 

Mr. MURPHY. Well, that is a good point. So let me look at the 

bottom line here because I don’t want to just talk about bureaucracy and the beltway—people don’t understand that. 

So first I have a slide up, heart disease mortality rate. As you 

can see, it is going down over the last 10 years. Let us look at the 

next slide. Stroke mortality rate. That is going down. Next slide, 

HIV/AIDS mortality rate, that is going down. Next slide, auto accident mortality rate, that is going down. The next slide, cancer mortality rate, that is going down. Now, none of these are within your 

wheelhouse, but let us look at the next slide. Wow. Suicide mortality rate, it is getting worse. 

Ms. Hyde, you just talked about these programs you have; one 

of them being the suicide plans, and I think you even said you 

thought it was having some success, but I look at this—do you intend to take any action to respond to either or both of the recommendations by GAO about the need to better evaluate and coordinate these programs? 

Ms. HYDE. We have taken significant action in this arena and 

brought together a public-private partnership that has developed 

with the Surgeon General a national strategy for suicide prevention. 

Mr. MURPHY. Well, they said some of these—— 

Ms. HYDE. It is only a—— 

Mr. MURPHY [continuing]. Organizations haven’t met for 5 years. 

Ms. HYDE. It is only a couple of years old. We are just beginning 

to implement—— 

Mr. MURPHY These organizations have been in place for a long 

time. The mandate of SAMHSA to meet has been in place for a 

long time. The GAO report says that some of these groups haven’t 

met since 2009. Now, you said that there is a new group which has 

met once in January. So when you talk about coordination of these 

programs, I just want to deal with—we are trying to help here, but 

I oftentimes tell people when they come to this committee, if you 

want to meet a friendly Congress, come in and say, you know what, 

we messed up big time and we have to change this. But when you 

give me this litany of all these successes, and I look at that, that 

is 40,000 people died in this country last year. Forty thousand. One 

point two million suicide attempts requiring some help. 

Now, if we were to also look at the employment rate among the 

mentally ill, it also is getting worse. You also have states saying 

a huge number of people in jails, increase in homelessness. I don’t 

know where these numbers come from, but when I go around to 

different states, I am sure where you are from colleagues, it is a 

problem. So you are obligated under the law to coordinate these 

programs. You have the Congressional Committee that has jurisdiction over your agency. It is concerned over this lack of coordination in this area. And here the nonpartisan Government Accountability Office is concerned about this. The Assistant Secretary for 

Planning and Evaluation of HHS sitting next to you is concerned 

about this lack of coordination in this area. So are you going to 

take action to change this coordination, not to say we have done 

it in the past, everything is fine, but are you going to make further 

changes on coordination? 

42 

Ms. HYDE. You asked about one thing, and you made a comment 

about a separate thing. So we have taken significant action on suicide. We are concerned about those numbers and working on it. We 

have plans in place and a public-private partnership that is working to develop approaches to deal with zero suicide and health care, 

and other clinical guidelines and other approaches to measuring 

and dealing with getting people to pay attention—— 

Mr. MURPHY. Well, I—— 

Ms. HYDE [continuing]. To suicide. So we have a lot of work 

going on in—— 

Mr. MURPHY. I appreciate that, and I think—— 

Ms. HYDE [continuing]. Coordinating suicide efforts. You asked a 

different question about a different entity. 

Mr. MURPHY. Well, it is all related here, and the issue too is, as 

Dr. Kohn also said, that at first, SAMHSA couldn’t even acknowledge that suicide was related to serious mental illness is a problem. 

I am out of time. I will now recognize Ms. DeGette for 5 minutes. 

Ms. DEGETTE. Administrator Hyde, I will give you the opportunity to respond to the second question that the chairman asked, 

if you would like to, very briefly. 

Ms. HYDE. Yes, we initially didn’t—obviously, not everyone who 

has suicidal ideation, or decides that they may want to make a 

plan to hurt themselves, has a serious mental illness, but about 90 

percent of them do have mental health issues. So when first asked 

was that an SMI program, we were concerned with calling it an 

SMI program. As we went through the work with GAO, the distinction between a program that supports people with serious mental 

illness versus a program that is specifically and only designated for 

those individuals was made, and in that case, we brought our program into the SMI tent. 

Ms. DEGETTE. And actually, that is a perfect segue, Dr. Kohn, to 

the question I wanted to ask you, which is, you testified and your 

report really talked about how agencies had difficulty identifying 

which programs served the seriously mentally ill. Is that because 

of definitional problems? In other words, you might have a program 

that has a lot of mentally ill people it is serving, some of them serious, some of them not, by definition. Is it a definitional issue sometimes? 

Ms. KOHN. It may be sometimes. We provided a definition of 

what we meant by program, what we meant by serious mental illness, what we meant by serious emotional disturbance, SED. We 

provided those definitions. So sometimes it could be that there 

were definitional issues and they counted the programs differently. 

Sometimes an agency might have rolled up their programs into 1, 

another one disaggregated the programs. 

Ms. DEGETTE. OK, so it is. Dr. Frank, I want to ask you, 

throughout all of your agency’s programs, is there one clear definition of seriously mentally ill that all of the different programs are 

broken into? 

Mr. FRANK. As I mentioned in my testimony, it is very difficult 

to draw a line around a program and say that that is—— 

Ms. DEGETTE. So your answer is no, it is not specifically polled 

out? 

Mr. FRANK. We have a definition of serious mental illness—— 

43 

Ms. DEGETTE. Right. 

Mr. FRANK [continuing]. So we can identify the people and we 

can identify the services they need, but there are many programs—— 

Ms. DEGETTE. But the programs aren’t just separated out for 

that. 

Mr. FRANK. The programs don’t cut that—— 

Ms. DEGETTE. Administrator Hyde, is this true in SAMHSA as 

well? 

Ms. HYDE. That is correct. There are multiple definitions of serious mental illness both in the law and in peoples’ parlance and 

how they use that term. 

Ms. DEGETTE. Do you think in evaluating the programs at your 

agencies, it would be important to make this distinction or not? Yes 

or no will work here if you can do that. 

Ms. HYDE. For any particular program, yes. We are in the process of actually redefining SMI for purposes of the block grants because the definitions and the DSM and the standards for determining who has what diagnoses have changed. 

Ms. DEGETTE. And, Dr. Frank? 

Mr. FRANK. Could you repeat the question? 

Ms. DEGETTE. Yes, the question is do you think it would be important to be able to more clearly identify illnesses—or treatments 

affecting seriously mentally ill patients, or is that impossible? 

Mr. FRANK. I think the most important thing is to identify the 

people and then we can sort of work up to the programs—— 

Ms. DEGETTE. What the programs they need, OK. 

One of the things Dr. Kohn talked about in her report that really 

struck me was that a lot of the programs throughout the Federal 

Government have really not been evaluated for efficacy. And I am 

wondering, Administrator Hyde, if you can talk about what she 

says, in particular, about SAMHSA, because I am a very evidencebased person. If you have a program targeted at the mentally ill 

in general, the seriously mentally ill in particular, one might think 

that you would want to have evidence that it works. 

Ms. HYDE. If you look at the report, actually, SAMHSA is doing 

a good job at evaluating our programs. And I am very proud, actually, of the work we have done to create a Center for Behavioral 

Health Statistics and Quality to actually develop our capacity to do 

quality measurement, and to do evaluations. 

Ms. DEGETTE. And so you think that kind of evaluation is important? 

Ms. HYDE. Absolutely, and we—— 

Ms. DEGETTE. And—— 

Ms. HYDE [continuing]. Are doing a lot of it. 

Ms. DEGETTE. And, Dr. Frank, what about through the other 

agencies? 

Mr. FRANK. Yes, we do a tremendous amount of evaluation. 

Ms. DEGETTE. OK, but a lot of your programs have not been 

evaluated—— 

Mr. FRANK. Well, actually—— 

Ms. DEGETTE [continuing]. Like that. 

Mr. FRANK [continuing]. I think that one of the problems in the 

report is when you overlook 89 percent of the money that we spend, 

44 

and pretend we don’t evaluate there, you miss all the evaluations 

we are doing. So we have lots of Medicaid—— 

Ms. DEGETTE. But of the ones you looked at—— 

Mr. FRANK. Well—— 

Ms. DEGETTE [continuing]. Some of them were not being evaluated. 

Mr. FRANK. Some of them were not, for example—— 

Ms. DEGETTE. Do you intend to evaluate them? 

Mr. FRANK. Well, let us take a particular example. One of the 

four programs that they pointed out was a technical assistance program. OK? We don’t usually evaluate small technical assistance 

programs, whereas we do evaluate treatment programs. And so 

there is a distinction, and those were not brought out very clearly 

in the report. 

Ms. DEGETTE. If you could supplement your answers with more 

specific—— 

Mr. FRANK. Yes. 

Ms. DEGETTE [continuing]. That would be helpful. 

Thank you, Mr. Chairman. 

Mr. MURPHY. Sure thing. Can I just ask, as a clarification, because as this hearing goes on we are going to need this distinction, 

when Congresswoman DeGette asked about defining things for serious mental illness, and you said we should identify the people, 

what does that mean? 

Mr. FRANK. What I think is very important to do is, as you said 

earlier, work from the bottom line up. So let us find the people we 

are worried about here, people with serious mental illness, let us 

look at what they need, let us look at what they are getting, and 

then when they are not getting what they need, let us figure out 

how to fix that. 

Mr. MURPHY. So you are acknowledging that is not taking place 

right now. 

Mr. FRANK. Excuse me? 

Mr. MURPHY. So you are acknowledging that is not taking place 

right now. 

Mr. FRANK. I am acknowledging that it—well, as you held out, 

my view of this is better but not well, which means—— 

Mr. MURPHY. All right. 

Mr. FRANK [continuing]. We are getting better. 

Mr. MURPHY. Mrs. Blackburn, recognized for 5 minutes. 

Mrs. BLACKBURN. Thank you, Mr. Chairman. 

Let us stay with this issue of efficacy because I think it is so important. And, Ms. Hyde, I want to come to you on this. Your strategic plan, the 2011–2014 strategic plan, does acknowledge the 

need for coordination to solve the problems of homelessness, joblessness, educational challenges of the serious mental ill. The GAO 

report says this is not taking place, so we are wanting to see where 

the outcomes are. So does SAMHSA believe that the present state 

of program staff level, as opposed to agency level coordination, 

within and across different agencies, and Mr. Frank talked a little 

bit about this, that it is adequate to achieve the GAO-approved 

standards of interagency coordination, despite the concerns expressed by the GAO report? 

45 

Ms. HYDE. I think we can always do better, but we do a significant amount of work with Justice, with VA, with DoD, with a number of other agencies that touch and work with our population—— 

Mrs. BLACKBURN. Ms. Hyde, let me interrupt you right there. 

Yes, you are doing work, but we are not seeing that you are achieving outcomes. Now, you get $3.6 billion a year. How much of that 

money, and I want a detail on this, how much of that money is 

going to make it down to the local and state agency level to help 

with these problems, and how much of that are you all keeping 

here in D.C. over at the agency? I want to know where this money 

is going and where it is meeting the need, because we are not seeing the outcomes. And you can submit that to me. 

Dr. Frank, let me come to you. You say serious mental illness is 

a collection of problems. And yes, you have substance abuse and 

mental health, we understand that. Should Congress help you out 

on this? Should we help you and legislate a definition of serious 

mental illness? Do you need us to do that to help you get to the 

point of saying here is a problem, we can define it, here is an action item, here is what the expected outcome. Yes or no? 

Mr. FRANK. I don’t think there is a lot of disagreement. I think 

there are ambiguities around the edges, but I would say that if you 

and I and the chairman and the ranking member sat down, we 

would come to a 99 percent agreement on what we are talking 

about here. 

Mrs. BLACKBURN. OK. Well, then let us pull Congress into this, 

and as we are trying to get to a point of coordination, how about 

working with the Energy and Commerce Committee, or perhaps 

keeping an open mind to GAO’s recommendations rather than rejecting them outright, so that we can say here is the definition of 

serious mental illness, and here is what the expected outcomes are 

going to be to help individuals. See, I don’t think we are ever going 

to get to mental health parity unless we can do this. We can admit 

there is a problem in how we address it, how we expend these 

funds. 

So are you all willing to keep an open mind to the GAO’s report 

say maybe we are not meeting the need, and maybe we are missing 

the mark on this one? Are you open-minded about that? 

Mr. FRANK. Ms. Kohn? 

Mrs. BLACKBURN. Each of you. Go ahead. 

Mr. FRANK. Yes, OK. I am certainly open-minded to—I think the 

problem that we started the hearing off with that the chairman 

raised, which is what do we do for people on the ground, how do 

we coordinate their care, is absolutely something that we have an 

open mind about how to deal with. 

Mrs. BLACKBURN. Are you open-minded to working with us—— 

Mr. FRANK. Absolutely. 

Mrs. BLACKBURN [continuing]. To get to the bottom of this? OK, 

Ms.—— 

Mr. FRANK. Absolutely. 

Mrs. BLACKBURN. Ms. Hyde? 

Mr. FRANK. Can I add one other point? 

Mrs. BLACKBURN. Sure. 

Mr. FRANK. I think the very important thing though is we need 

to talk about all of HHS programs, and all the tools we have in the 

46 

toolkit in order to fix the problem, and not just focus on 11 percent 

of the action. 

Mrs. BLACKBURN. Yes. 

Mr. FRANK. We need to focus on 100 percent. 

Mrs. BLACKBURN. On the total thing. I appreciate that. 

Let me ask you this, Dr. Frank, I only have 24 seconds left. If 

we were to move to zero-base budgeting, where you start from dollar one ever year and build out your programs based on what is 

working, would that be helpful to you? So would you have more 

flexibility there? 

Mr. FRANK. I was reading Robert McNamara’s biography the 

other day. I am not sure where I stand on zero-base budgeting 

there. 

Mrs. BLACKBURN. OK. I yield back. 

Mr. MURPHY. Thank you. 

Now recognize the ranking member of the full committee, Mr. 

Pallone, for 5 minutes. 

Mr. PALLONE. Thank you, Mr. Chairman. 

There are always going to be opportunities to strengthen and expand the Federal programs that serve individuals living with serious mental illness, and I know that the officials here from HHS 

would agree with that statement. 

So I would like to learn more about the new programs and other 

improvements that the department has made since fiscal year 2013 

when GAO conducted its evaluation, and how the department plans 

to expand its work in the future. 

So in fiscal year 2014, SAMHSA implemented a new set-aside in 

the mental health services block grant requiring the states to use 

5 percent of their block grant funds to support treatment for individuals in the early stages of serious mental illness. 

Administrator Hyde, can you describe how states will be using 

that funding, and how will SAMHSA be monitoring and evaluating 

this initiative? 

Ms. HYDE. Thank you for the question. First of all, we are very 

pleased with this set-aside approach. We are working with all 50 

states and working with NIMH to provide guidance and technical 

assistance to them based on evidence-based approaches that NIMH 

has developed. 

Some of the states get very little money out of this 5 percent setaside because the block grant is, frankly, not enough money for the 

country. So to the extent that it is a very small amount, it is going 

to be hard to do a consistent evaluation. We are working with each 

state to try to make sure within their system they can identify 

what they are doing, and in some states, for example, they are actually putting their own money and multiplying these dollars by as 

much as seven times. So different states are going to have different 

capacity to give us, feed us back what they have been able to do 

with it. Some states, they will be able to train people on what the 

new evidence-based approaches are. And other cases, they will be 

able to actually put services on the ground. And in many states, 

Medicaid is going to pay for the actual service for some people, 

whereas the state will be using our dollars to evaluate, to oversee, 

to train, and to direct the traffic. 

47 

Mr. PALLONE. OK, thanks. In your testimony, you mentioned 

that many people living with serious mental illness are unemployed. And in fiscal year 2014, SAMHSA launched the Transforming Lives Through Supported Employment program to help address this problem. Can you elaborate on how this program specifically supports individuals with serious mental illness, and what 

other partners does SAMHSA work with on this program? 

Ms. HYDE. Yes. This is a program that we work with the Department of Labor, and now within HHS because the program has 

moved over to the Administration on Community Living to implement an evidence-based practice that we developed through evaluation and through research and approaches a few years ago to develop a toolkit that is actually specifically for people with serious 

mental illness, and specifically supports them in gaining and maintaining employment. 

We have seen increases in employment using that approach. And 

so what we are trying to do with this very small amount of transformative money is help a state figure out how to take that to scale 

using their multiple systems and approaches within their state. So 

their labor departments, their job departments, whatever departments they have that make those things and those supports available in their state. 

Mr. PALLONE. OK. Last week, SAMHSA outlined additional 

plans to support individuals with serious mental illness in its fiscal 

year 2016 budget request. So I wanted to ask you if you could tell 

us about the demonstration program that SAMHSA has proposed 

to improve state and local responses to behavioral health crisis. 

Ms. HYDE. Yes, thank you for that question. The crisis program 

which I mentioned is, again, one we are really excited about because there has been a lot of conversation about emergency rooms 

and appropriate use of emergency rooms, and that is the only option that people have, or people ending up in jails and prisons 

when they really should be getting treatment, or lack of inpatient 

beds, and all of that, when you look at it, surrounds the issue of 

how you deal with a crisis. How do you prevent it, how do you deescalate it, and how do you follow up so that it doesn’t happen 

again, and how do you engage the family as well as the individual 

in managing that process. 

So we are proposing a crisis services system program to try to 

see if we can bring those multiple funding streams and multiple 

systems together in a few communities to test and demonstrate 

how best to do that. These are multifaceted systems that have to 

work with that. We do have some evidence that if we do it right, 

we can prevent the need for so many inpatient beds, and certainly 

prevent the boarding and other kinds of inappropriate emergency 

room use. 

Mr. PALLONE. Did you want to mention any other initiatives that 

HHS hopes to launch or expand in the next fiscal year to support 

individuals with serious mental illness? 

Ms. HYDE. Well, we are expanding other areas for veterans’ mental health, we are expanding mental health workforce issues, because that is a huge and growing issue for our ability to meet 

goals. And we are actually also expanding tribal mental health 

issues to try to make sure that we can address mental health 

48 

issues in Indian country, which have been sorely unaddressed, especially for young people who are dealing with suicide issues, bullying issues, job issues, and other things. 

So we are trying very hard to focus on this transition-aged youth. 

We also have a healthy transitions program that we are going to 

continue in the next fiscal year through the President’s budget. So 

trying to put all of that together to deal with that group or that 

set of young people, first episode issues and trying to prevent, as 

the chairman said and Ms. DeGette said, to try to prevent it from 

getting to be a more serious problem later. 

Mr. PALLONE. Thank you. 

Mr. MURPHY. Thank you. Just as a follow up to something that 

Mr. Pallone had mentioned, and you talked about the block grant 

program, I want to clarify, in your draft block grant application 

here, when it comes to the block grants, you actually say that these 

block grants—you don’t talk about being for serious mental illness. 

In fact, you say the opposite, ‘‘it is about everyone, not just those 

with illness or disease, but families, communities, and the whole 

population, with an emphasis on prevention and wellness.’’ That is 

not serious mental illness. So I want to make it clear that when 

you are responding to Members on this, if it is partly related to 

mental illness, let us know that, but don’t tell us the whole thing 

is related to that because it is not. 

Ms. HYDE. Mr. Chairman, the people with serious mental illness 

have been documented to have significant health problems. They 

die sooner—— 

Mr. MURPHY. Yes. 

Ms. HYDE [continuing]. Than other people, and some cases with 

serious mental illness, years and years earlier, mostly from preventable health issues. 

Mr. MURPHY. Right. 

Ms. HYDE. So our wellness efforts are definitely directed toward 

people with serious mental illness who, we don’t want them to 

die—— 

Mr. MURPHY. I—— 

Ms. HYDE [continuing]. And we don’t want them to have diabetes. 

Mr. MURPHY. I will challenge that later, but I need to get on to 

the next Member. 

Mr. McKinley is recognized for 5 minutes. 

Mr. MCKINLEY. Thank you, Mr. Chairman. And thank you for 

holding this hearing. I think that this is something that you have 

been championing for the 4 years I have been in Congress, and I 

really applaud you for the efforts of trying to get better attention 

on serious mental illness. So congratulations on continuing to move 

this. 

But, Ms. Kohn, I have a question of you, if you could. You heard 

a lot of the testimony. I saw you studying those charts that showed 

the mortality rate dropping, and we have heard some folks here explain how they really are making progress. That is the spin of 

Washington. 

So my question is, based on what you have heard, what you have 

studied, do you believe that HHS and SAMHSA have done everything they can to reduce the chance of duplication, and in parVerDate Nov 24 2008 11:04 Jun 19, 2015 Jkt 037690 PO 00000 Frm 00052 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 114\114-8 CHRIS
49 

ticular, really supporting mental illness in this country? Do you 

think they are doing everything they can? 

Ms. KOHN. Our report acknowledges the variety of activities they 

are undertaking right now, but we do believe there is room for improvement, particularly in areas related to greater interagency coordination, and greater evaluation as part of helping uncover, develop, advance the data—the evidence base for treatment of mental 

illness—— 

Mr. MCKINLEY. OK, thank you. 

Ms. KOHN [continuing]. And serious mental illness. 

Mr. MCKINLEY. Ms. Hyde, you appeared at this committee back 

in 2013, and you acknowledged apparently during that, I wasn’t on 

the committee at the time, that some of the organizations that 

SAMHSA is funding may be running programs or expressing opinions that are at odds with SAMHSA. Is that still accurate? 

Ms. HYDE. When we fund a program, we fund them for a specific 

activity. They may have positions that they take before Congress 

or in the press, or any place else, that they have a right to take, 

that is not associated with our program. 

Mr. MCKINLEY. But are you funding agencies that—for example, 

one was apparently cited during that meeting that you were funding a group that encouraged individuals with serious mental illness 

to experiment going off their doctor-prescribed medicines. 

Ms. HYDE. We do not fund going off medications. We do fund assistance and helping—— 

Mr. MCKINLEY. But—— 

Ms. HYDE [continuing]. People understand medications and how 

best to work with their doctors. 

Mr. MCKINLEY. But you are funding the National Coalition of 

Mental Health Recovery. Dr. Fischer has put out articles about 

how it is designed to help people—in their literature, their newsletter, how to come off their psychiatric medicine on their own. 

So—— 

Ms. HYDE. We do not fund that organization for—— 

Mr. MCKINLEY. I am sorry, but—— 

Ms. HYDE [continuing]. Any of those positions. 

Mr. MCKINLEY [continuing]. You funded it to $330,000. 

Ms. HYDE. If you listen to my whole sentence, we don’t fund that 

organization for that position—— 

Mr. MCKINLEY. Well, I saw you make fun of the other—so I 

guess I need to get—because I saw your look, and I may be deaf 

but I can read body language and I saw your disgust with the question asked earlier. So I am concerned that you are funding some 

of these programs, and I hope that you will be more cognizant, 

more careful about the agencies that you are funding. 

I am curious about one other that I haven’t seen. Is SAMHSA 

taking a position on the—I guess it is the medical use or maybe 

just the use of marijuana for relieving anxiety? Has SAMHSA 

taken a position on whether or not marijuana is a drug that might 

help people with mental illness? 

Ms. HYDE. Our position on marijuana is that for young people, 

it is unacceptable and inappropriate in any case, in any state, anywhere. And our efforts around marijuana are primarily around prevention and dealing with underage use where the evidence shows 

50 

that it has negative educational and social and other implications 

for young people. Same is true of alcohol. 

Mr. MCKINLEY. OK, but I am just staying with marijuana—— 

Ms. HYDE. That is in our effort—— 

Mr. MCKINLEY [continuing]. That the epidemiological studies 

have indicated that there is beyond a doubt that the marijuana use 

increases the risk of schizophrenia. Do you agree with that report 

that I have a copy of here? 

Ms. HYDE. We are concerned about the issues with marijuana, 

and we are working with NIDA and with other entities within 

HHS to look at—— 

Mr. MCKINLEY. So do you fund—— 

Ms. HYDE [continuing]. The research issues. 

Mr. MCKINLEY. Do you fund—we have such short time. You 

know the game here. Do you fund any organization that supports 

the use of marijuana as a treatment? 

Ms. HYDE. I don’t know the answer to that. 

Mr. MCKINLEY. Could you get back to me on that—— 

Ms. HYDE. I don’t know whether or not the—— 

Mr. MCKINLEY [continuing]. Please? 

Ms. HYDE [continuing]. American Psychological Association supports it, and we do fund them. 

Mr. MCKINLEY. OK, in the time frame that I have—— 

Ms. HYDE. I don’t know whether or not other organizations—— 

Mr. MCKINLEY [continuing]. Dr. Frank—— 

Ms. HYDE [continuing]. Support that. 

Mr. MCKINLEY. Dr. Frank, if you could, please, last week we had 

on a meeting here about the influenza and the vaccines, do you 

know of any group that the HHS is funding along the same line 

of reasoning, any group that we are funding that is advocating not 

using vaccines? 

Mr. FRANK. I don’t know the answer to that question. I would be 

happy to find out and get back to you on it. 

Mr. MCKINLEY. You understand the question? 

Mr. FRANK. No, I understand the question, I just don’t know the 

answer. 

Mr. MCKINLEY. Yes, OK. If you could please. 

Mr. FRANK. Yes. 

Mr. MCKINLEY. It would make a lot of—— 

Mr. FRANK. I think it is a perfectly reasonable question, I just 

don’t know the answer. 

Mr. MCKINLEY. OK, if you could get back to us and—— 

Mr. FRANK. Sure. 

Mr. MCKINLEY. Thank you very much. I—— 

Mr. MURPHY. Thank you. Mr. Kennedy, you are recognized for 5 

minutes. 

Mr. KENNEDY. Thank you, Mr. Chairman. And I thank the witnesses again for their testimony. 

I just want to put the discussion today in context, which I think 

is an extraordinarily important discussion, and hopefully we can 

try to find some ways to work together on making sure that these 

programs are getting to a population that needs some extra assistance. 

51 

But, Dr. Frank, I think in the HHS response letter, they put into 

context that—of Federal Government expenditures on mental 

health, Medicaid pays for about 27 percent, Medicare is about 13 

percent, private insurance is about 26 percent, and all of the other 

programs that are subject to today’s discussion are roughly 5 percent. Is that right? 

Mr. FRANK. Correct. 

Mr. KENNEDY. So the discussion that we are having here, as integral as it is to making sure the system works better, we are also 

talking about 5 percent of the overall mental health spending in 

this country. So if we are looking at a much more systemic approach, one would say we should also focus on the 95 percent of 

the rest of that funding, and how to reform that delivery system 

and make sure that care is much enhanced. Is that fair to say? 

Mr. FRANK. Yes. I think that is exactly the point I was making, 

not to in any way diminish our need to pay attention to the 5 percent, but the other part, the other 40 percent really needs attention, and that is why our integration efforts on Health Homes, on 

duals, on expanding SNPs, on expanding case management, are so 

important because they happen in that other part. 

Mr. KENNEDY. When I am back home, Doctor, I hear all the time 

about lack of beds, lack of availability at doctors, lack of wraparound services. It strikes me that a lot of that has to do with incentives and the way the Federal Government reimburses doctors, 

hospitals, clinicians that are working in this field. You align those 

incentives properly, you are going to get the beds, the treatment facilities, the incentives for doctors to treat. Is that fair to say? 

Mr. FRANK. I am an economist and I believe that. 

Mr. KENNEDY. OK, thank you. 

So with that as context, I do want to go back to the basis of the 

report for a quick minute. The report indicates, ‘‘that coordination 

specific to serious mental illness was lacking among interagencies, 

committees,’’ but it goes on to say that, I believe again, ‘‘staff from 

90 percent of the programs targeted serious mental illness reported 

coordinating with the counterparts in other programs.’’ 

The coordination we are talking about doesn’t happen because it 

is legislated, it will only be enhanced if there is a cultural change 

at some senior staff level, and a willingness to implement both the 

letter and the spirit of the law. 

Dr. Frank, how can we engage senior staff, and does that interaction at the staff level suffice, or is more senior staff interaction 

necessary? We will start with you and go from there. 

Mr. FRANK. I think your point about culture is very important, 

and I think this Administration has been extraordinarily attentive 

to building that culture. Administrator Hyde has had a central role 

in that, taking steps to reach out far beyond their 5 percent there 

into Medicaid and into other areas. Our Secretary is extraordinarily supportive of these matters. And so the result is we have 

tremendous amount of joint activities with HUD, with SSA, with 

Labor, with Treasury, et cetera, and it is really those types of focused working groups across the government that have really, I 

think, improved our ability to coordinate with in a variety of problem-specific areas. 

52 

Mr. KENNEDY. Thank you, doctor. I will just stop you there because I have about a minute left. And, Ms. Hyde, if you have a response to that. 

Ms. HYDE. I think I would just echo Dr. Frank. The recommendation that was made was about a specific type of infrastructure that 

we think isn’t going to be the best way to address the issue on the 

ground. So that is the distinction we are trying to make here, that 

we have a lot of coordination going on, we believe in coordination, 

but the particular recommendation and the approach seems just 

like more bureaucracy. 

Mr. KENNEDY. So if creating that or strengthening that interagency working group from the senior level isn’t the right way, and 

understanding that you are pushing coordination now, I realize I 

only have about 30 seconds, but what would you suggest, in 30 seconds, to really push that out to the lowest levels on the ground and 

try to enhance that coordination even more so? I think it is hard 

to debate the fact that that is needed. 

Ms. HYDE. I think it is multifaceted. We have to have person-toperson interactions, we have to have working groups on specific 

issues as what we described, we have to have staff-to-staff level 

programmatic interactions, and we have to push our grant programs to require coordination at the state and grantee level. So we 

are doing all of those things, and trying to bring that together 

where it works on the ground for individuals. 

Mr. KENNEDY. Thank you. I yield back my extra 7 seconds. 

Mr. MURPHY. Do you want Dr. Kohn to also answer your question too because she didn’t get a chance to answer—— 

Mr. KENNEDY. Yes, if you don’t mind. 

Mr. MURPHY [continuing]. That question? 

Mr. KENNEDY. Thank you. 

Mr. MURPHY. Dr. Kohn? 

Mr. KENNEDY. Please. 

Ms. KOHN. OK, sure. Thank you. I don’t think what we are putting out here is an either/or, that if there is coordination at a local 

level that, therefore, coordination at the Federal level is unneeded, 

or vice-versa, that coordination at the Federal level will supplant 

the coordination that happens at the local level. I don’t think there 

is that kind of a trade-off. And the concerns we were raising about 

lack of coordination at the Federal level inhibits our understanding 

of the Federal footprint in this area. What are the programs in 

place, recognizing that there is a lot there in Medicare and Medicaid and Social Security, as the OMB letter in response to this 

committee had shown, but we didn’t start from that spending side. 

We started from the programs, the population served. As Dr. Frank 

noted, people don’t fall into neat program categories, and that is 

why that coordination becomes so important because that coordination helps identify if there is any potential overlap or duplication, 

are there gaps, are there programs that are complementary that 

aren’t being linked together, need some stronger linkages so we 

maximize our existing resources in our existing programs. If it is 

a gap and nobody is looking at it right now, then how does the coordination happen? It is by definition not visible. 

So the coordination we talk about is not instead of the coordination at the local level, it is in addition to. 

53 

Mr. KENNEDY. Thank you. Thanks for the extra time. 

Mr. MURPHY. Thank you. Mr. Griffith, you are recognized for 5 

minutes. 

Mr. GRIFFITH. Thank you, Mr. Chairman. And I appreciate having 5 minutes, but I wish I had a lot more. I would like to get the 

information that Mrs. Blackburn asked for earlier in regard to the 

money as it flows to the state and local levels as well. So when you 

report to her, if you could make sure I get a copy of that, I would 

greatly appreciate it. 

I am going to need some yes-or-no answers because I have to fly 

through this because of the time limitations that we do have. But 

GAO noted that SAMHSA officials did not initially include any of 

their suicide prevention programs among those that can support individuals with serious mental illness. Isn’t that true, Ms. Hyde, yes 

or no? 

Ms. HYDE. I explained why. Yes. 

Mr. GRIFFITH. And SAMHSA explained to GAO that the suicide 

prevention services it administered were not limited only to individuals with serious mental illness, and served a broader population. That is also true, isn’t it? Yes. 

Ms. HYDE. It does serve a broader population. 

Mr. GRIFFITH. And at the subcommittee’s hearing on suicide prevention held last September, the Chief Medical Officer of the American Foundation for Suicide Prevention noted that in more than 

120 studies of completed suicides, at least 90 percent of the individuals involved were suffering from a mental illness at the time of 

their deaths. And I thought I heard you say earlier that you agreed 

with that number, is that correct? 

Ms. HYDE. That is correct. 

Mr. GRIFFITH. And my one concern there is that, of course, we 

had the 10 percent. Would you also consider that 90 percent to be 

serious mentally ill, yes or no? 

Ms. HYDE. I don’t think researchers think that that is all serious 

mental illness as it might be defined in a functional level. 

Mr. GRIFFITH. But it is pretty serious when somebody ends up 

dead, isn’t it? 

Ms. HYDE. Absolutely. That is why we had the—— 

Mr. GRIFFITH. All right. 

Ms. HYDE [continuing]. Conversation about—— 

Mr. GRIFFITH. And—— 

Ms. HYDE [continuing]. What to include in—— 

Mr. GRIFFITH [continuing]. After further discussion with GAO, 

SAMHSA included its suicide prevention programs, among those 

that can support individuals with serious mental illness. Isn’t that 

also true? 

Ms. HYDE. I am sorry, can you repeat that question? 

Mr. GRIFFITH. I can. After further discussion, you then submitted 

the suicide prevention programs, among those that can support individuals with serious mental illness, even though earlier you had 

not included them because you thought it was a broader audience. 

Isn’t that true? 

Ms. HYDE. We were trying to understand—— 

Mr. GRIFFITH. Yes or no. 

Ms. HYDE [continuing]. What GAO wanted, yes. 

54 

Mr. GRIFFITH. OK. And DoD officials initially identified all of 

their suicide prevention programs as supporting individuals with 

serious mental illness. Do you think that there might be some institutional bias on the part of SAMHSA in favor of dealing with 

mild as opposed to more severe behavior or health conditions that 

make it more difficult for SAMHSA to recognize and act upon the 

unique nature and impacts of serious mental illness or serious 

emotional disturbances? 

Ms. HYDE. Goodness, no. We were trying to be honest and fair 

about the answer to the question. 

Mr. GRIFFITH. All right. And I appreciate that. 

Here is the reason that I am so concerned on these issues, and 

while I recognize that you all have said previously that it is getting 

better but it is not fixed, I do appreciate that. I was a, what we 

call in our neck of the woods, a street lawyer for many years. I can 

still see the eyes of the mother who dealt with, while she was a 

client of mine, for years her paranoid schizophrenic son who ultimately committed suicide. I can see a former client standing in the 

courthouse with his son crouched on a bench because he was back 

into the court system, not in the mental health system but the 

criminal court system, yet again, and not knowing what to do. I 

can see the faces of the deputies as they started to go out of the 

building to deal with a verbal fight in the parking lot of the courthouse where a son and a father were having a verbal altercation 

after a hearing in the criminal court system, and I had to advise 

the deputies to back off because of the mental illness of the son. 

He would have a violent reaction to the uniforms, not to the individuals but to the uniforms, but he would not be violent with his 

father, and they agreed to do that. And then my wife, who continues to practice law although I have come here now, last week 

was dealing with, in the juvenile system where she is a practitioner 

and a substitute judge, dealing with a child who attempted suicide, 

having a serious emotional disturbance, learning that they couldn’t 

deal with one plan that the hospital had come up with because he 

hadn’t been hospitalized twice in the last year, he had only been 

hospitalized twice in the last 13 months. And when I said are there 

questions, I have HHS and SAMHSA coming in, are there questions I should ask about what we are going to do about this child 

who is someone I know, and who may very well end up being successful at some point if we don’t do it right. I said are there questions I can ask, and her response was, no, they don’t have anything 

to do with this. 

I ask you, do you believe that you all need to be coordinating to 

such an extent that experienced practitioners in law would know 

that you have something to do with it when there is a suicide attempt, or that there might be a program to help? I asked those 

questions. Nothing came back. And I noticed in your report that 

you had something on the Garrett Lee Smith Youth Suicide Prevention Program listed in the GAO study, and I texted my wife and 

I said any of the contacts related to any of the cases you have done 

in juvenile court for the last 16 or 17 years, have you ever heard 

of this. Answer is no. So I present you with this indictment, and 

I hope to get some response at a later time because my time is up. 

And I yield back. 

55 

Mr. MURPHY. Thank you. 

Now recognize Mr. Tonko for 5 minutes. 

Mr. TONKO. Thank you, Mr. Chair. 

Dr. Frank, has the failure of some of our states to expand Medicaid eligibility in accordance with the Affordable Care Act affected 

in any way the ability to treat those with mental illness or mental 

health disorders? 

Mr. FRANK. Indeed it has. Just to give you a flavor. Among people with serious mental illness, in 2010 for example, call that the 

before period, nearly 21 percent of them were uninsured and they 

were disproportionally low-income. And so, in fact, the states where 

you are seeing expansion are getting more of those people covered 

than the states that aren’t. That opens up a lot of new opportunities for treatment because, as you know, Medicaid offers a broad 

package of services that are specifically, in many cases, tailored to 

people with serious mental illnesses. 

Mr. TONKO. Yes. And would you have any data that are directly 

speaking to the mortality rates in those states that you could provide to the committee? 

Mr. FRANK. I think it is too early to tell now, but just so you will 

know, we are doing an evaluation of the Medicaid expansions, and 

we are doing segments of that evaluation that focus specifically on 

vulnerable populations like those with serious mental illness. 

Mr. TONKO. Yes. And if I could ask the three of you, and I will 

start with Dr. Kohn, how do you define serious mental illness? 

Ms. KOHN. In our report, we used scientific definitions that we 

worked with SAMHSA to develop. It includes conditions such as 

major depression, bipolar disorder, schizophrenia, PTSD. We used 

a definition that goes about half a page of a footnote. It is a scientific definition. 

Mr. TONKO. OK. Dr. Frank? 

Mr. FRANK. Well, rather than give you the science, I will give you 

something that most of us would believe in common parlance. So 

typically, I think schizophrenia, bipolar disorder, major depression, 

some forms of major depression, some forms of trauma, PTSD, and 

a variety of other things depending on their functional capacity is 

what I think we typically think of serious mental illness. 

Mr. TONKO. And, Administrator Hyde? 

Ms. HYDE. Generally, it is a combination of diagnosis and functioning and history. So you generally have to look at all three of 

them to see what the functioning level is. The diagnosis is important but not in and of itself enough. 

Mr. TONKO. And so, therefore, is serious mental illness a static 

state? 

Ms. HYDE. Not necessarily. 

Mr. TONKO. OK. Well, there has been a lot of emphasis today on 

SAMHSA’s work on treating mental illness, and specifically serious 

mental illness, but we need to keep in mind, I believe, that these 

individuals represent a small portion of the overall population living with mental illness. And we also need to keep in mind that we 

will be more effective with these patients by treating them early 

in the course of their illness, and perhaps altering the trajectory 

of their condition, rather than reacting to crisis situations that 

arise time and time again. SAMHSA plays an important role in the 

56 

prevention and early detection of serious mental illness, and I have 

seen that in programs that reach my district. 

So, Administrator Hyde, can you discuss some of the ways that 

SAMHSA supports the prevention and early diagnosis of serious 

mental illness? 

Ms. HYDE. Yes, thank you for that question. One of the ways we 

are doing that is to implement the RAISE Program, which is the 

evidence-based practice that NIMH has developed, that is interventions both medical and psychosocial interventions done at an earlier point in the trajectory of an illness after a first episode. We are 

doing a lot of work in that area. We are also starting to look at 

what is called the prodrome, or prior to the first episode. NIMH is 

beginning to work in this area, and we are working with them to 

try to identify what would be the best way to look at that issue. 

We are also looking at healthy transitions, or the transition that 

young people have from age 16 or so to 25, which is where a lot 

of this early first episode happens, and we are trying to put programs on the ground to make sure that those families and those 

young people are supported as they move into adulthood. And so 

there are a number of programs like that where we are trying to 

get upstream. We are also doing a lot of jail diversion work, trying 

to make sure that individuals who may be headed for jail because 

of a mental health issue can be diverted into treatment and to appropriate community-based supports instead of jail. Same thing is 

true with homelessness. People who are homeless on the streets 

with serious mental illness, if we can get them housed in evidencebased supporting housing programs we can see very good trajectories, reduction of emergency room use, et cetera. 

So we have pieces of all of those kinds of programs working with 

our colleagues and other departments. 

Mr. TONKO. I thank you. And I believe we should not lose sight 

of the agency’s other critical activities, and how they advance your 

mission as well. So I thank you all for your responses. 

I yield back. 

Mr. MURPHY. Thank you. And we are glad you moved forward on 

that program with RAISE. We know it is something that this committee has raised, the appropriators funded it, and we are glad you 

followed through on what Congress told you to. 

I now recognize Mrs. Brooks of Indiana for 5 minutes. 

Mrs. BROOKS. Thank you, Mr. Chairman, and thank you for holding this hearing. 

In August of last year, I held a mental health listing session in 

Hamilton County, just north of Indianapolis, Indiana, and pulled 

together advocacy groups, family groups, doctors, and luckily, head 

of our state HHS component FSSA as a psychiatrist, Dr. John 

Wernert, and he participated in this session. And we talked about 

the pressing issues of mental health in our state and in our country, and ways that Congress could respond. And I have to tell you, 

a theme of that was the fragmentation issue. And even now, as still 

a relatively new Member of Congress, I am amazed at the number 

of people with mental health issues contact our offices, and come 

to our events, including recently a young woman who brought to 

a public meeting stacks and stacks and file folders of her correspondence with different agencies, trying to seek help for her 

57 

schizophrenia. And it broke my heart. And then when I read this 

GAO report about the fragmentation, and would just ask all of you 

to look once again at the chairman’s chart, and I would ask you to 

take that back to SAMHSA, and I applaud GAO for putting together, or attempting to put together, the comprehensive inventory, 

but if healthy people in a discussion have a hard time getting 

through the bureaucracy, how do mentally ill people and seriously 

mentally ill people get help? 

And so, Dr. Kohn, why was it such a challenge in GAO’s opinion 

to identify all of these different programs? What happened? 

Ms. KOHN. I don’t think it had been asked before, so OMB had 

identified where the spending was from the budget documents. I 

think this was one of the first times that the agencies were being 

asked, and so it took a lot of conversation. There was a lot of backand-forth. We had to develop a questionnaire and go agency by 

agency by agency, and work with them to try to get the information. 

So I think to some extent, they hadn’t been asked that before, 

at least not the folks we were talking to. 

Mrs. BROOKS. If I could, there was an organization called the 

Federal Executive Steering Committee that you pointed out in your 

report that was in place after another analysis of our mental 

health system early in the 2000s, and it was in place from 2003 

until 2008, and it seemed to bring together at very high levels the 

many agencies we are talking about, but it was disbanded or has 

not met since 2009. Is that correct, Dr. Kohn? 

Ms. KOHN. That is correct. It hasn’t met since 2009. 

Mrs. BROOKS. And so, Ms. Hyde, you indicate all of this coordination, but it seems to be at the highest levels only within HHS, is 

that correct? Why was that disbanded? Why was the Federal Executive Steering Committee, which brought together at the highest 

levels, why was it disbanded? 

Ms. HYDE. The Steering Committee had accomplished a lot, but 

much of the coordination work had moved into the programmatic 

area. 

Mrs. BROOKS. What do you think it accomplished? When we have 

seen the growing numbers, what did it accomplish and why would 

it disband? 

Ms. HYDE. Well, I think it had difficulty solving the problem. I 

think that is our whole point, is one Federal, high-level coordinating body by itself is not going to solve the problem. 

That group did identify programmatic areas where coordination 

needed to happen, and that began to happen at the programmatic 

level. We haven’t talked at all about what the issue beyond coordination is, which is the lack of services, the lack of support, and 

then as we are getting more people able to get access to coverage 

and services, then that is going to be a much bigger and more appropriate way to get services to people. 

Mrs. BROOKS. Well, and I would agree that there are a lack of 

services and a lack of support, but when there are billions of dollars being spent, and I guess I want to ask you, Dr. Frank, because 

you talked about, and my time is running short, you talked about 

populations and programs specific to populations, well, what if you 

are a middle-aged woman who is not a veteran, who is not a young 

58 

person, who is not homeless, who is not in the workplace, what programs are there for people who don’t fit into these populations? 

Mr. FRANK. Thank you. I actually start in exactly the same place 

you do with a broken heart for these people and families that face 

these problems, and have trouble navigating their way through the 

system. I think that is exactly it. I think where we were uncomfortable with the GAO report was that there wasn’t enough attention 

paid to that question you just asked which is, we have been trying 

to build health homes, we have been trying to build patient-centered medical homes so that there would be a place that people 

could rely on to help them navigate the system, get them through, 

and make sure their care is coordinated across the realm. And that 

is really a lot of the places we have been putting our investments 

in, coordination. 

Mrs. BROOKS. Thank you. My time has run out. We have, obviously, much work to do. 

I yield back. 

Mr. MURPHY. Thank you. 

Now recognize Mr. Yarmuth for 5 minutes. 

Mr. YARMUTH. Thank you, Mr. Chairman. I thank the witnesses 

for their testimony. 

Anybody who has been in this job for any period of time understands the extent to which mental illness impacts our various communities and the country as a whole. Tens of millions of people affected. And clearly, we have made progress. I was proud to have 

supported the Mental Health Parity Act that has made an enormous impact, and obviously embodying that in the Affordable Care 

Act with the expansion of Medicaid, in my state has made a remarkable difference. And, you know, I don’t think any of us would 

disagree with the notion that coordination is important, and evaluation of programs is important. We also can’t lose sight of the 

amount of resources that are committed to these kinds of activities. 

And I am a member of the Budget Committee and I have seen how 

budget cuts have affected many areas of our social safety net and 

our human services initiatives. Now we are down the return of sequestration in October of this year, and we had an experiment with 

it a couple of years ago. 

Dr. Frank and Administrator Hyde, would you talk to us about 

the impact of sequestration potentially on the treatment of mental 

illness throughout the country, and what happened a couple of 

years ago, what impact, if any, there was and what the new potential cuts are and how they could impact the same kind of care? 

Ms. HYDE. I can talk first about SAMHSA because that is the 

thing I know the best. But certainly, cuts in programs have made 

us tighten, it has made us do less grants, so less ability to help 

communities out there, less ability to do new programs. The one set 

of new programs we have been able to do is in the President’s Now 

is The Time plan, which I described. It also, frankly, makes us take 

a second look at how much money we spend on things that are not 

services, so it does make us tighten our evaluation efforts at times, 

and it just overall makes us deal with a system that is already significantly underfunded compared to a lot of the other, heart disease 

and other mortalities that we are trying to deal with. So I actually 

could give you some comparisons between how much we spend for 

59 

certain of these diseases and the numbers of people that we have 

associated with them, and I think you would be able to see what 

those impacts of those dollars are. 

Mr. YARMUTH. Dr. Frank, you want to comment? 

Mr. FRANK. I would agree with that. I do think it has hurt our 

evaluation efforts a bit. I also think it shows up in exactly some 

of the places we have been talking about here because we work 

with HUD on supportive housing, we work with Labor on supportive employment type of activities, and for each of those we 

have had to scale back. And so, for example, our plans to end 

chronic homelessness by next year have had to get scaled back because the number of housing vouchers has been scaled back. 

Mr. YARMUTH. All right, thank you for that. Going back to the 

question of evaluation for a minute, Dr. Kohn, I haven’t read the 

GAO report but it seems to me that it might be very difficult to 

accurately assess some of the efficacy of these programs because, 

say you are dealing with a homeless vet with PTSD, the program 

may be able to prevent that vet from committing suicide, but certainly hasn’t cured his mental illness. Do you have a model for 

evaluation of an efficacy of serious mental health programs in the 

GAO report, and I guess I would ask if you do, then I would have 

Dr. Frank and Ms. Hyde comment on whether this is a problematic 

thing. 

Ms. KOHN. The report doesn’t tell the agencies in this area to 

evaluate all of their programs all the time. We say that the agencies need to prioritize which programs should be evaluated and 

what is a time schedule for that, because they are costly, they are 

time-consuming, and so we are just telling the agencies to prioritize 

which programs do need to be evaluated. 

Yes, GAO has a number of reports and guidance that it has 

issued in terms of best practices for evaluation. It includes having 

an outside agency doing the evaluation, identifying best practices, 

what works, what doesn’t work in the program, making recommendations that the agency can act on in terms of how to improve the program. So there is guidance there. The other piece of 

the evaluation, of course, is leadership in driving the evaluation, 

asking the question and hearing the answer. 

Mr. YARMUTH. My time is up, Mr. Chairman. I yield back. Thank 

you. 

Mr. MURPHY. Thank you. I now recognize Mr. Mullin for 5 minutes. 

Mr. MULLIN. Thank you, Mr. Chairman. 

If you could, could you put that up for me? Ms. Hyde, do you recognize what this is here? 

Ms. HYDE. Yes, it is a—yes. 

Mr. MULLIN. It is a screenshot from SAMHSA’s Web site. I believe it is called building blocks for a healthy future, is that correct? 

Ms. HYDE. That is correct. 

Mr. MULLIN. Can you briefly tell me what that Web site does? 

Ms. HYDE. It engages young people and their parents in emotional health development. We do have a responsibility to do prevention—— 

Mr. MULLIN. What is the ages—— 

60 

Ms. HYDE [continuing]. In young people. 

Mr. MULLIN [continuing]. For that? 

Ms. HYDE. I don’t remember off the top of my head the complete 

age range, but it is the younger—— 

Mr. MULLIN. It is for substance abuse—— 

Ms. HYDE [continuing]. It is the younger kids. 

Mr. MULLIN [continuing]. For young children from the age of—— 

Ms. HYDE. Yes. 

Mr. MULLIN [continuing]. Three to six—— 

Ms. HYDE. Yes. 

Mr. MULLIN [continuing]. Which I am sure that is a high number 

that we have to deal with. I mean I have five kids from 10 years 

to 4 years old, and I am sure there is a high rate of substance 

abuse for 3-year-olds, yet do you know how much money we have 

spent on that Web site? 

Ms. HYDE. Actually, the science tells us that the earlier we 

start—— 

Mr. MULLIN. No, I—— 

Ms. HYDE [continuing]. The better. 

Mr. MULLIN. Do you know how much money we have spent 

on—— 

Ms. HYDE. I don’t know that off the top of my head. I can tell 

you—— 

Mr. MULLIN. Ma’am, you are the administrator. 

Ms. HYDE [continuing]. Though that is important that we are—— 

Mr. MULLIN. Ma’am—— 

Ms. HYDE. We are—— 

Mr. MULLIN [continuing]. You are the administrator—— 

Ms. HYDE. Yes. 

Mr. MULLIN [continuing]. And you don’t know how much that 

Web site costs. Because I went through that last night, and there 

is a whole bunch of songs on there which are all knock-offs of Old 

McDonald and Yankee Doodle, and I have a 3-year-old and I 

couldn’t keep her attention for no time at all on that. And guess 

what, you have had 15,000 visitors, that is it, to that Web site for 

an average of 3 minutes, at a cost of $436,000. Now, do you think 

that is using taxpayer money wisely? 

Ms. HYDE. Actually, we are going through a—— 

Mr. MULLIN. No, ma’am, that isn’t what I asked you. 

Ms. HYDE [continuing]. Something we call—— 

Mr. MULLIN. I said do you think that is a good use of taxpayer 

money? 

Ms. HYDE. I don’t know. Please let me finish the question and 

I will tell you. We are actually going through our Web sites right 

now. This is one of them. It is on the list to re-examine—— 

Mr. MULLIN. Going through, ma’am—— 

Ms. HYDE [continuing]. Whether or not—— 

Mr. MULLIN [continuing]. The money is already spent. Was it a 

good use of taxpayers’ money? $436,000. 

Ms. HYDE. I—— 

Mr. MULLIN. A total of 15,000 visitors. In Oklahoma alone, that 

would provide 176 outpatient services for the mental ill for a full 

year. 

61 

Ms. HYDE. That is what we are assessing and evaluating right 

now. We are going through each of those Web sites to determine 

whether or not they are appropriate or need to be continued, or 

eliminated or otherwise dealt with. 

Mr. MULLIN. How long does it take, ma’am, because we are continually putting money in there? We are managing the Web site. 

And what we want to do is efficient and be more efficient. 

We have heard throughout this entire hearing that we are here 

to help. We understand there is an issue, but what has happened 

is we are running into a roadblock, and instead of you admitting 

that there is a problem, what ends up happening is you get defensive about it. That is not helpful. That doesn’t prevent anything. 

All that does is cause a division between us. We are not here to 

make you look bad, we are here to find out and see if you are being 

efficient with the money being spent. And so far what I am finding 

out is no, no, it is not. It is not being efficient. 

I have a big stake in this. I have five kids that go to school every 

single day. These are real issues facing every parent out there, and 

yet we are wasting money on a Web site, or putting money out 

here, $436,000, you don’t even know how much you have spent, 

and you can’t even tell me if it is being efficient. Instead, you are 

saying you are going through it and evaluating. We have heard 

that over and over again today. We are going through it, we are 

going through it, we are going through it. You know what, as a 

business owner, if everything I was being evaluated on, I was having to go back and re-evaluate it, I would deem that as a failure. 

Maybe it is time to relook at the whole program and say is it really 

delivering the services, is it really coordinating with officials on the 

mentally ill. So far what I have heard, the answer to that is no, 

absolutely not. 

Dr. Kohn, you had mentioned, let me find it here, you noted that 

part of the problem with tackling serious mental illness is the 

Steering and Coordinating Committees that has been established 

to handle the response to the mental illness over the past decade 

are no longer active or focused mainly on substance abuse. Is that 

correct? 

Ms. KOHN. That is correct? 

Mr. MULLIN. OK. I yield back. Thank you. 

Mr. MURPHY. Thank you. 

Now recognize Ms. Clarke for 5 minutes. 

Ms. CLARKE. Thank you, Mr. Chairman. And I thank our witnesses for sharing your expertise with us this morning. 

My first question is to Dr. Frank. Unfortunately, many states 

have refused to expand Medicaid coverage under the Affordable 

Care Act, and according to the American Mental Health Counselors 

Association, nearly 3.7 million uninsured adults with serious mental health and substance abuse conditions will not be covered in 

states that failed to expand Medicaid. To me, that decision is astoundingly shortsighted. 

Dr. Frank, why is Medicaid expansion so critical to this population? 

Mr. FRANK. Well, in the Chairman’s opening remarks, he made 

a very strong case outlining how people experiencing serious mental illnesses have their work disrupted, have their education disVerDate Nov 24 2008 11:04 Jun 19, 2015 Jkt 037690 PO 00000 Frm 00065 Fmt 6633 Sfmt 6633 F:\MY DOCS\HEARINGS 114\114-8 CHRIS
62 

rupted, have their functioning disrupted. And so people who have 

trouble attaching to the workforce, attaching to the mainstream of 

society, tend to have low incomes, tend to rely on public programs 

like Medicaid. And so people in those circumstances have a chance 

to get the best evidence-based treatment if they are covered by 

Medicaid, whereas if they aren’t, those chances are much lower. 

And so I think that is why it is so important. 

Ms. CLARKE. Thank you, Dr. Frank. 

I want to switch over to Administrator Hyde and ask a bit about 

living in a community setting. The report doesn’t mention the 

Americans With Disabilities Act, the Olmstead decision, and how 

SAMHSA has been in the forefront of pushing for a service system 

where people with serious mental illness can live in a most integrated community setting. How does SAMHSA work to help people 

with serious mental illness living in the community? 

Ms. HYDE. Thank you for the question. We have taken a leadership role with a number of other Federal agencies both within HHS 

and outside, DOJ, Office of Civil Rights, to look at the Olmstead 

decision and try to implement it, and try to help states understand 

what they can do. We try to look at the housing needs and how 

people can develop housing, we try to look at the employment 

needs and income needs and how people can develop that, and we 

try to look at the social supports that individuals need in the community, and we provide training, and sometimes we call them policy academies, bringing states together so they can learn from each 

other, and trying to make sure that they have the information they 

need and the program designs that they need, because there are 

evidence-based practices to try to develop that. We also try to bring 

things like HUD vouchers and other kinds of resources to the table 

that SAMHSA coordinates with but doesn’t control. 

Ms. CLARKE. Well, that model is one that I think, particularly in 

a place like New York City where I am from, is a preferable one. 

There seems to be a reliance on the criminal justice system to sort 

of be that community living environment, and we have found that 

there have been a lot of challenges within our city’s jail systems, 

for instance, with individuals who have been incarcerated and not 

treated, and the conditions under which they have had to live have 

really compounded their illnesses. So I want to commend you for 

your vision here, and make sure that as we go forward, we look at 

a broader view of practices that do work. It is unfortunate that the 

report didn’t mention it. 

I wanted to circle back. I know my colleague, Mr. Tonko, spoke 

to intervention, particularly in preventing recidivism. I want to 

talk about early intervention for children, and get a sense of the 

work of the programs that you are doing through SAMHSA in early 

intervention. Could you speak to a little bit of that as well? 

Ms. HYDE. Yes, thank you again for the question. If you are talking about young children, we have a program called LAUNCH—— 

Ms. CLARKE. Yes, young children. 

Ms. HYDE [continuing]. Which is for zero to 8-year-olds. 

Ms. CLARKE. Yes. 

Ms. HYDE. Specifically to build emotional health development 

and to look at early needs that might be emerging there. We have 

some new work that we are doing on the framework of Now is The 

63 

Time to try to look at working with schools and communities to be 

able to identify emerging behavioral health issues before they become an issue. We have other prevention activities that IOM 

helped us look at, the Institute of Medicine, a few years ago, and 

bringing both behavioral health—well, substance abuse and mental 

health, because they often go together, so issues like what is happening in schools, bullying, parenting, bringing multiple systems 

together to help make sure that young person is able to grow and 

develop in a positive way. We are also doing a significant amount 

of work on trauma because we understand increasingly what trauma does to young people, and how it creates, actually, adult problems. We are also looking at the fact that, frankly, most adult behavioral health issues start before the age of 24, and in fact, 1⁄2 of 

them before the age of 14. So the younger we can start, the better 

we can build skills and resiliency, capacity, moving into adulthood. 

So we do a fair amount of that work. As I said earlier though, 3⁄4 of our dollars actually go toward persons, at least in our mental 

health environment, goes to persons with serious mental illness. 

Ms. CLARKE. I thank you for your work, Administrator. 

And I yield back. Thank you, Mr. Chairman. 

Mr. MURPHY. Now recognize Mr. Collins for 5 minutes. 

Mr. COLLINS. Thank you, Mr. Chairman. 

If you could, Ms. Hyde, just kind of keep the questions as brief 

as you can because of the time. I am going to start with a fairly 

simple one. Could you give yourself a grade of 1 to 10 on how good 

a job you are doing? 

Ms. HYDE. Tens being good? 

Mr. COLLINS. Yes. 

Ms. HYDE. I think we are doing 10. I think we have a lot—— 

Mr. COLLINS. OK, you are a 10. 

Ms. HYDE [continuing]. More work to do. 

Mr. COLLINS. That is pretty arrogant in my book, but we will put 

that aside. So you have said you are underfunded, you need more 

money, so I am just going to dive right in and say, as you have 

looked at programs the last couple of years, which ones you have 

just said here, you are going to look at this. How many programs 

have you looked at and terminated because they weren’t a good use 

of taxpayer funds in the last 2 years? 

Ms. HYDE. We actually have several programs that have been 

proposed for reduction, some of which Congress has reduced, and 

others of which have continued to be funded. 

Mr. COLLINS. Could you give me a list, if you could, of those that 

are being recommended and those that have actually had their reductions? 

Ms. HYDE. OK. 

Mr. COLLINS. And when you say you are underfunded, are you 

constantly looking at and evaluating each program like the one 

that Representative Mullin said $436,000, which I think it is pretty 

obvious was wasted money? Are you looking at those, and who is 

doing that evaluation? 

Ms. HYDE. Yes, if you look at the GAO report, I think you will 

see that SAMHSA is actually doing more than—— 

Mr. COLLINS. Who in your organization? Do you have like certain 

people? 

64 

Ms. HYDE. It depends on the situation. In some cases—— 

Mr. COLLINS. Well, either you do or you don’t—— 

Ms. HYDE [continuing]. We do it internally. 

Mr. COLLINS [continuing]. Have certain people. 

Ms. HYDE. Some cases ASPE does it, and other cases—— 

Mr. COLLINS. Who is going to evaluate this sing-along program? 

Ms. HYDE. Well, as I was trying to explain, we are starting the 

process of evaluating—— 

Mr. COLLINS. No—— 

Ms. HYDE [continuing]. That. 

Mr. COLLINS [continuing]. Who? Who will evaluate that, how 

quickly will it be evaluated, and when could you provide this committee an answer on whether that program will be terminated and 

that money, since you are underfunded, redeployed? 

Ms. HYDE. We will be glad to answer that question for you. 

Mr. COLLINS. And when will I expect that answer? I mean you 

are a 10, so it should be tomorrow. Is that fair if you are a 10? If 

you were an 8, I could give you a week or so but since you are a 

10, is it fair to say you could get that to me tomorrow? Who is 

going to evaluate it, when will we get the answers? I am just asking you, can I get that answer tomorrow? 

Ms. HYDE. We will get you an answer as soon as we can. 

Mr. COLLINS. I guess the answer is no. Well, I think you just 

went from a 10 to about a 7. 

As I look at doing evaluations, best practices, are you identifying 

best practices that other states can learn from? Like this state, this 

program in South Carolina is exceptional, they are really working 

well, let us roll this out across the country. Are you identifying actively best practices to assure that taxpayer money is being well 

spent, and since you are underfunded, it is even more important? 

Ms. HYDE. Yes, we have a registry of evidence-based practices 

that we are actually in the process of redoing because we need to 

do a better job on that. 

Mr. COLLINS. You need to do a better job, but you are a 10, so 

that is interesting. Can you provide me a list of the best practices 

that you have identified, very specific, not just general let us all 

do better, specific best practices that you have shared with other 

agencies? Could you get that to me tomorrow? You said you already 

have a list, could you get that to me tomorrow? 

Ms. HYDE. We will do our best to get it to you as soon as we can. 

I don’t—— 

Mr. COLLINS. So you can’t get it to me tomorrow. You just 

jumped from a 7 to a 5. I am asking for direct answers. You said 

you have it. If you have it, you should be able to get it to me at 

1 o’clock this afternoon. So either you do or you don’t have it. Do 

you have it? 

Ms. HYDE. We have the list. I don’t know if I can—— 

Mr. COLLINS. So can you get it to me today? 

Mr. MURPHY. Well, let us—— 

Ms. HYDE [continuing]. Do some electronic version—— 

Ms. DEGETTE. Mr. Chairman—— 

Mr. MURPHY. Well, let—— 

Ms. DEGETTE [continuing]. We have a standard practice in this 

committee—— 

65 

Mr. MURPHY. We will expect that. 

Ms. DEGETTE [continuing]. For witnesses to respond to questions. 

Mr. MURPHY. Thank you. 

Mr. COLLINS. Quickly and directly. I am just saying, do you have 

it? 

Ms. HYDE. I can get you a list of what we have, yes. 

Mr. COLLINS. Tomorrow? 

Mr. MURPHY. I think she said she will get—— 

Ms. DEGETTE. Mr. Chairman—— 

Mr. MURPHY [continuing]. That. We will expect that—— 

Ms. DEGETTE [continuing]. We have a standard practice, I would 

ask—I would urge all of the Members—— 

Mr. MURPHY. Yes, I—— 

Ms. DEGETTE [continuing]. Of this committee to hold to that 

standard practice—— 

Mr. MURPHY. That is OK. We will expect that information. OK. 

Ms. DEGETTE [continuing]. And to respect the witnesses. 

Mr. COLLINS. Yes, and I would appreciate more direct answers. 

I haven’t actually had too many employees or witnesses who would 

say they walk on water, and on a scale of 1 to 10 are a 10, so I 

am just taking you at your word. I thought you were going to tell 

me you were an 8. I am surprised at the 10. 

So all I am suggesting is best practices work. You say you are 

underfunded. We have an example here of $436,000 that I think, 

generally speaking, will come back, and I would like that as quickly as possible, as wasted taxpayer money that could been redirected 

elsewhere. So I would appreciate a prompt response as soon as you 

can get it to me, and that would be my request. 

And I yield back. 

Mr. MURPHY. Thank you. We are going to do a second round of 

questions here. I know some Members are coming back—Mr. 

Cramer is here now. All right then, we will have Mr. Cramer. Go 

ahead, I will recognize you for 5 minutes. 

Mr. CRAMER. Thank you, Mr. Chairman, and thank you to the 

witnesses. 

I just have one question for Ms. Hyde I was reading the HHS 

budget justification, and in your opening, I think you said something to the effect that—and maybe you could tell me what you 

said, what percentage of the SAMHSA budget was dedicated last 

year to SMI? 

Ms. HYDE. SAMHSA’s budget is in four buckets. Generally 

speaking, we talk about the substance abuse part of our—— 

Mr. CRAMER. Right. 

Ms. HYDE [continuing]. Budget as being a little less than 70 percent. So the vast majority of our budget is substance abuse. Of the 

30 percent or so that is mental health, 3⁄4 of that goes to serious 

mental illness. 

Mr. CRAMER. That is what I thought—OK, thank you for that 

clarification. Because in the budget justification put out by HHS 

where it talks about SAMHSA, it never mentions serious mental 

illness. Can you reconcile that omission with the commitment that 

you are talking about today? That just seems like somebody is not 

as committed to it perhaps as you are. Or am I mistaken? Because 

66 

I couldn’t find it. I couldn’t find any mention of SMI in the budget 

justification from HHS. 

Ms. HYDE. The particular programs that there are some programs that are very specifically for serious mental illness or serious emotional disturbance. That is the general rubric. The block 

grant programs are that. It is a huge program. What we talked 

about, the primary behavioral health care program is specifically 

for that. A number of other of our programs we have already talked 

about serve people with serious mental illness, but they are not 

targeted to those individuals. 

Mr. CRAMER. I guess it is the lack of reference or mentioning 

even raises for me the question of the seriousness of the commitment to this particular issue, which is not a small issue, this is a 

very big issue, a very big concern for me. If you want to elaborate, 

I am willing, otherwise I yield back. 

Ms. HYDE. Just a quick—— 

Mr. CRAMER. Sure. 

Ms. HYDE [continuing]. Response. The—— 

Mr. MURPHY. You can respond. 

Ms. HYDE. The program I told you for fiscal year 2016, the reason I was hesitating, I didn’t know which justification you were 

talking about, CJ 15 or 14 or—— 

Mr. CRAMER. Yes. 

Ms. HYDE [continuing]. Sixteen. The new programs that I was 

telling you about, specifically the crisis one, specifically mentions 

serious mental illness. I have that here if you would like to see it. 

Mr. CRAMER. OK, very well. Yes, what I am talking about is, the 

SAMHSA in brief never mentions serious mental illness. And I 

just—again, what it raises for me, and I think a lot of us are struggling with this, is the serious level of commitment to SMI, and we 

hope going forward that there is a greater acknowledgement and 

greater evidence that this commitment is real and it is going to be 

dealt with in substantive ways, as opposed to what we did last 

year. 

I yield back. 

Mr. MURPHY. Thank you. Gentleman yields back. 

I do want to say that it is a tradition of this committee to let witnesses complete their things. That is why I am even asking, after 

Members have finished their time, to give more time to do those 

things. And so if there was things that the witnesses do want to 

finish up, we will be respectful of that because we do want to hear 

your comments on this. The second round, let me raise something 

here because part of this is some of the committee’s frustration 

with getting responses. 

Ms. Hyde, so these are a few questions about what we have requested from you. In emails my staff received this morning from 

someone who I think is on your staff, someone named Brian Altman who—just so I understand, does Mr. Altman work for you or 

at least represent you when it comes to the committee? Does that 

name sound familiar? 

Ms. HYDE. Mr. Altman is here with me today, yes. 

Mr. MURPHY. OK, good. And he has been in that position, I 

guess, for at least this last year from what I understand. So as you 

may know, we wrote Mr. Altman on March 20, 2014, almost a year 

67 

ago, to ask for some very specific information, following up on a 

meeting that was had with several SAMHSA officials that very 

day. We sent our request with as much specificity as possible to the 

department, and specifically to Mr. Altman, to respond. Since then, 

I have to say, this committee is very disappointed, we have received very little of what we have requested, despite our repeated 

efforts to follow up on that request. I am not sure I have a record 

of every communication of my office and the department on this 

matter, but we followed up on April 7, June 12, June 16, June 26, 

July 14, July 22, and September 18, and again, despite all of this, 

we still don’t have the overwhelming majority of the information 

we requested, or a satisfactory explanation of why it doesn’t exist. 

So I was really astounded this morning to be told that my staff 

received an e-mail from Mr. Altman at 8:15 saying the following, 

‘‘We are still reviewing the multitude of reports you have requested, and will provide the reports as soon as possible.’’ He further writes, ‘‘We have checked with program staff and there are no 

documents regarding technical assistance provided to the disability 

rights center in Maine following the Bruce case.’’ Now, you are familiar with the Bruce case, we spoke about this before. This is the 

one where the Disability Rights Center, in the medical record of 

the hospital it says someone advised him when asked, are you 

going to harm yourself, he said no, someone advised him, are you 

going to hurt someone else, and he said no, under the advice of 

someone from that agency. He then went home and shortly thereafter killed his mother. He was on medication, wasn’t in treatment, 

et cetera, and so you can understand our concern that we have 

asked almost a year ago, tell us what SAMHSA is looking into this. 

Now, I understand part of the issue is I don’t think states are required to tell you what they are doing, and I think that is important because they receive significant funding from you. So I hope 

you understand our committee’s frustration. This is a serious case 

involving a homicide, and someone who was advised by an organization that you fund to stop care, despite the pleas of the family 

and the pleas of the treating psychiatrist to say this is a dangerous 

person. So please understand the seriousness of our request. We do 

want to make sure that you understand. You are busy, I understand, but this committee will make sure we get those records, and 

you will comply with that, right? I appreciate that. Thank you. 

Now, with regard to this organization, Dr. Kohn, you say in your 

report that PAIMI—I think that is one of the things—you look at 

some of the evaluations done, I think you even mentioned that they 

are one of the ones that seems to have a report that has good accountability written in there, am I correct? 

Ms. KOHN. We identified an example of an evaluation that was 

done that was consistent with some of the principles that GAO has 

talked about. We didn’t evaluate that program or the quality of 

that evaluation, we simply cite it as an example. 

Mr. MURPHY. So are you aware that the people who did that 

evaluation are people, several of them who are funded by 

SAMHSA, are part of these programs? Were you aware that—I 

don’t know if you dug deep enough to know who these people were, 

but several of them appears were on the payroll or have direct 

funding related to this. Are you aware of that? 

68 

Ms. KOHN. We just cite it as an example. We didn’t hold it 

up—— 

Mr. MURPHY. I—— 

Ms. KOHN [continuing]. As a—— 

Mr. MURPHY. I didn’t think so. That is OK. I didn’t think so. 

Ms. KOHN [continuing]. We didn’t draw any conclusions about 

the program. 

Mr. MURPHY. But it was nonetheless listed. When you say 1⁄3 of 

the programs, I think, actually had evaluations done, and, Dr. 

Frank, you said that the programs within HHS have many of these 

evaluations, but as I look at this list, Ms. Hyde, I am looking at 

people who—first of all, the evaluation team, I don’t see a single 

psychiatrist or psychologist there. I see a couple of social workers. 

I don’t know if they practice still. I see several attorneys, but in 

answering the question, protection and advocacy for people with 

mental illness, I want to know if they are advocating for those people to get better. 

This case of Mr. Bruce and other cases they have had around the 

country, I want to make sure that they are saying if they are in 

jail and they are getting abused, we are standing up for you. If 

they are in an institution being ignored, we are going to stand up 

for you. But the key should be getting care. And I look at this and 

I must admit this looks like the fox guarding the henhouse. 

And so, Dr. Kohn, I hope you will take another look at this because I see people here that really should not be telling you whether or not a program works. Of course they are going to say it 

works. They get funding from it. Some of these actually are the— 

the person, Curtis Decker, who runs the PAIMI Trade Association. 

Of course he is going to say he is doing a great job. I look at other 

people who say they received money from SAMHSA, the projects 

they work on with SAMHSA. So it is a concern that I think when 

we see these evaluations, and an internal evaluation is no use, and 

particularly because—I think it was perhaps you, Ms. Hyde, or, Dr. 

Frank, saying it is important that outside organizations look at 

this. I agree wholeheartedly. That is the way we should look at 

this. Is the research done correctly, and bottom line, are we getting 

results. Not just what they are doing there, and I think under 

these programs too, and we were talking about prevention, I want 

to know if we are getting results. I wish we knew how to prevent 

schizophrenia. I know last summer we identified 108 genotypes of 

schizophrenia. I wish we could cure it but we can’t cure it. We can 

certainly do early interventions and minimize, for a while, not 

awareness of it, but try and delay some of the symptoms. But we 

don’t take of these otherwise, and so that is some advice to you. 

And I recognize Ms. DeGette. 

Ms. DEGETTE. Mr. Chairman, I think this is the best subcommittee in the House. This is the subcommittee where Mr. Dingell made his name, and I like to think of myself as the heir to 

John Dingell’s legacy. And in all his years on this subcommittee, 

he never took the cheap shot, he never attacked witnesses personally, he never put them into traps, and I was appalled today at 

the—and you have been with me on this committee for 2 years. 

You know you have never heard me say something like this. I was 

appalled at the way two of the new Members of this subcommittee, 

69 

Mr. Mullin and Mr. Collins, conducted themselves today, because 

this is a serious and legitimate investigation. This is an investigation about the way our Federal agencies are handling serious mental illness, and to bring them in and to refuse to allow these very 

serious, high-level government officials to answer questions, to trap 

them in to a when did you stop beating your wife type of answer, 

it is disrespectful to the witnesses and it undermines this committee’s grand tradition. So I am glad you said something about this, 

but, however, both of those individuals were gone by the time you 

did. So I hope you admonish them that is not in the grand tradition 

of this subcommittee. 

Now, having said that, I want to follow up on their questions. 

The first one I want to follow up on, Administrator Hyde, is the 

question that Mr. Mullin was asking you about that chart. You 

were attempting to answer the question and he would not let you 

do that. So I am going to ask you, I think that Mr. Mullin raises 

a good point, there are a number of programs including some online things that would seem to many of us to be unrelated to what 

SAMHSA should be doing on serious mental health issues. You 

were trying to say, I think, that you were evaluating these. Can 

you please let us know what you are doing with these online programs, what criteria you are using, what the purpose they have, 

and when you are going to finish that evaluation? 

Ms. HYDE. Thank you, Ms. DeGette. I was trying to say, yes, that 

in fact, we are trying to evaluate this. It is on our evaluation list. 

We are trying to take a look at it. I don’t have it in front of me 

here today the numbers he is putting out, so I can’t say if that is 

yes, no, or otherwise. We are looking at a number of our Web sites 

who have been actually held by a number of contractors, and we 

are bringing it inside so we can control a little bit more about what 

goes up on those Web sites. So we have had a very explicit approach to trying to get at the issue of are the Web sites and is the 

content what it should be. So we have done a fair amount of work 

about that, but we are in the middle of it, we are not complete, and 

this is one of them that is literally on the next list that we are 

looking at. 

Ms. DEGETTE. And what is your time frame for review and completion of that? 

Ms. HYDE. Actually, I just got the ability to get that scheduled, 

so I know it is scheduled for next week but I don’t have a specific 

time—— 

Ms. DEGETTE. So it is going to be soon. 

Ms. HYDE. With me. It is personally being scheduled with me—— 

Ms. DEGETTE. Now, some of these things that this committee 

has, frankly, been quite critical of that you are reviewing, those 

have been around for quite some number of years, is that correct? 

Ms. HYDE. That is correct, and sometimes what appears on its 

face to be a coloring book or a song, sometimes there is actually 

science behind the use of those for young children, for message and 

for outcomes. I don’t have the answer here today in front of me 

whether this one fits that mold or not. 

Ms. DEGETTE. Well, perhaps—— 

Ms. HYDE. I wouldn’t write it off—— 

Ms. DEGETTE. Yes. 

70 

Ms. HYDE [continuing]. On its face. 

Ms. DEGETTE. So perhaps when you do finish that evaluation, 

you will supplement your testimony and let us know if you think 

that is worthwhile or not. 

Ms. HYDE. I will. 

Ms. DEGETTE. And the chairman also asked you, and we did ask 

you in the last hearing about that case where apparently it was a 

contractor of SAMHSA apparently told the person to stop taking 

their medication. Can we get the information on that to see if 

SAMHSA had any awareness of that, and if there are other situations like that, or how you are choosing those contractors? I think 

that would be helpful to this committee. 

Ms. HYDE. We are working on that. I know it has taken a while. 

We want to be absolutely clear though, because we understand the 

seriousness of the question we are being asked, so to the extent 

that we are reviewing bunches of records, and if we see anything 

that looks inappropriate, we want to go back and check it even yet 

again to make sure that it is or is not—— 

Ms. DEGETTE. And so when do you think—— 

Ms. HYDE [continuing]. So—— 

Ms. DEGETTE [continuing]. You might be able to get us that information? 

Ms. HYDE. It is very high on our list to do. I can’t give you a specific date, but we have been working through it and we are pretty 

close to being able to give you an answer. 

Ms. DEGETTE. Thank you very much. 

Thank you, I yield back, Mr. Chairman. 

Mr. MURPHY. Thank you. I do want to say, we don’t mention 

Members’ names when someone disagrees with them, but we will 

follow up, but please understand, a lot of this that I think is our 

frustration is I think sometimes it is just a gut check. Like when 

you were before this committee last year when I asked you about 

the painting, the $26,000 painting of two people sitting on a rock, 

and you told me that was for awareness. I think there are some 

times we just want to see our leaders have a gut check to say, you 

know what, maybe that is not a wise spending of taxpayers’ money, 

and that I think sing-along songs with the circle, or whatever those 

other things are, do they really work? I think that is what we 

would like to hear more about. So we are looking forward to getting 

that information. 

And now I want to recognize Mr. Griffith for 5 minutes. 

Mr. GRIFFITH. Thank you very much. 

And I don’t think I will be quite as emotional this time as I was 

on the first round of questioning, but I do appreciate you all being 

here, and hope that you understand that even when we get a little 

excited and emotional about the issue, it is because we are trying 

to move the Government in the right direction, and there is sometimes frustration, but we are all, I think, everybody, you all included on the panel, trying to work into the right direction. 

Dr. Kohn, in 2013, the GAO issued a report finding that the Office of National Drug Control Policy could better identify opportunities to increase program coordination. GAO recommended that 

ONDCP assess the extent of overlap and the potential for duplication across Federal programs engaged in drug abuse prevention 

71 

and treatment activities, and identify opportunities for increased 

coordination. It is my understanding that ONDCP concurred with 

this recommendation, am I correct in that? 

Ms. KOHN. Yes, they did. 

Mr. GRIFFITH. And did the fact that ONDCP concurred with 

GAO’s recommendation mean that ONDCP totally agreed with 

GAO’s analysis, such as the overlap of Federal programs, always 

being a negative? 

Ms. KOHN. No, they identified that sometimes there are benefits 

to overlaps, such as reinforcing messages, that some of the goals, 

if the data were cut different ways, showed different—— 

Mr. GRIFFITH. So they didn’t—— 

Ms. KOHN [continuing]. Results. 

Mr. GRIFFITH. They didn’t agree completely. 

Ms. KOHN. No. 

Mr. GRIFFITH. But they did, as I understand it, state that they 

were willing to work with the agencies administering these programs to further enhance coordination even if it meant not eliminating complete overlaps, is that correct? 

Ms. KOHN. That is correct, and in our recommendation follow-up, 

that has been implemented. 

Mr. GRIFFITH. And I guess the question then comes, and that 

was the lead-in, Dr. Frank, so here we have a different agency reaction to a similar report. Couldn’t HHS have concurred with the 

GAO recommendation even while expressing differences on some of 

GAO’s analysis, just like the ONDCP did? 

Mr. FRANK. I think the issue here is—well, first of all, I understand your emotion and your commitment, and I only respect and 

admire it and that of the whole committee, so thank you for that. 

But I think the problem we had was, when you count programs 

and you count evaluations, and you do so selectively and you don’t 

go in behind, so what was in the evaluation, what are we really 

doing with the program, what are you really doing over here in 

Medicaid, we feel like you haven’t told the story and that is what 

made us uncomfortable, that we agree. Coordination is something 

that both Administrator Hyde and I have spent our careers working on. In fact, the way I met her was through a project to coordinate care for people with, at that time, chronic mental illness. And 

that was in 1986. 

Mr. GRIFFITH. All right. We will get to one more point, and then 

I hope I have enough time to make one statement. In a talk you 

delivered in March of 2013, you indicated, and it is on YouTube, 

and at about the 28 minute mark you spoke about the dangers of 

mission creep where the aim of targeting particularly high-risk 

groups becomes diluted to reach lower-risk populations as well. 

And you noted at that time that the mission creep could have disastrous results. Do you think you have your guard up, do you think 

it is possible that SAMHSA may be subject to similar pressures to 

engage in mission creep, and how does this impact their ability to 

support individuals with the most high-risk and severe mental illnesses? 

Mr. FRANK. I still believe the admonition, and I think it is a 

question that we have to constantly ask ourselves. Every time we 

make a sort of program decision, a budget decision, and a policy 

72 

decision, we have to ask ourselves are we working for the customers that are most important. And I think that is your question, 

and I think that we constantly have to ask ourselves that question, 

and we try to. 

Mr. GRIFFITH. And I appreciate that, and appreciate the self-examination is always a good thing even when it is sometimes painful. 

Part of your mission is to coordinate and to make sure things are 

efficient. Might I recommend, and maybe you are already doing 

this, and if so, please tell me, that you get a few street lawyers out 

there and it is probably not the right term, Mr. Chairman, but 

street clinicians, but people who are out there on the frontlines 

who might be able to help you figure out what is working and what 

isn’t working, particularly on making sure that folks know what 

programs are available. So that would be my suggestion to you. 

Mr. FRANK. Thank you for that suggestion. Just to remind ourselves, to give you an idea, a bunch of us, the deputy secretary, myself, our principal deputy, we went out on a homeless count the 

other night and we kind of walked the streets just because of that 

kind of inclination, and we try to visit programs, and I know Administrator Hyde does it all the time, and I think it is important 

because otherwise you forget. 

Mr. GRIFFITH. Well, and sometimes it is good to have the folks 

that are out there day in and day out because when it is somebody 

new or different, and it is human nature, they are going to whip 

out the spick and span and make everything look a little bit better, 

but when you have folks who deal with it day in and day out and 

over the course of years, they can give you an unvarnished or an 

un-cleaned up, spic-and-span type view of what is happening in the 

real world. But thank you. 

I yield back. 

Mr. FRANK. Thank you. 

Mr. MURPHY. Thank you. 

I am going to recognize myself again for 5 minutes. 

Dr. Kohn, when you reviewed the various agencies, did you see 

in there any review between agencies, for example, what we hear 

from states increasing instances of incarceration of the mentally ill, 

did you see that anybody is doing that investigation? 

Ms. KOHN. We did not identify that. 

Mr. MURPHY. Dr. Frank, or, Ms. Hyde, if you don’t, just let me 

know, so it is kind of yes or no or we don’t know. Are your agencies 

involved with looking at sort of a state-by-state report to the Nation, because we are hearing anecdotally, I am hearing from a lot 

of governors and secretaries who handle incarceration that they see 

increasing rates of people in state, county and local jails of people 

with serious mental illness. Is HHS conducting any study of this 

to give a report? 

Mr. FRANK. I will take that one. Yes, a couple of things. My 

agency, ASPE, is conducting a study right now on mental illness 

and violence, mental illness and criminal justice, exactly because 

we have been hearing the same thing you are. 

Mr. MURPHY. Do you know when that will be completed? Any 

idea? Within this year? 

Mr. FRANK. Within this year. 

73 

Mr. MURPHY. Obviously, we would love to see that. 

Mr. FRANK. We would be delighted to share it. Also, Administrator Hyde and I are actively involved in the Re-entry Council, 

which is an interagency council that is run by the Attorney General—— 

Mr. MURPHY. OK. 

Mr. FRANK [continuing]. That focuses on re-entry, and a disproportionate share of people that have serious mental illnesses. 

Mr. MURPHY. Let me raise another question here. With the Affordable Care Act, part of this is there is supposed to be parity for 

access. And, you know, we passed a parity bill here 6 years ago. 

It took 5 years, I think, for HHS to get us the regulations. I am 

still hearing a lot of concerns that parity is not taking place. Is 

HHS preparing any state-by-state evaluation of what states are 

doing with regard to meeting parity guidelines with the insurance 

companies that operate within the states? Is there anything happening with those that you know of? 

Mr. FRANK. CMS and ASPE sit on that group as well, continuously work with insurance commissioners to, A, do more technical 

assistance, and also find out what is going on and help them resolve complaints as they come in from consumer groups. 

Mr. MURPHY. OK. Another thing with this too is that with the 

ACA, a lot of people are finding themselves—they have a very high 

deductible, and I am hearing from a lot of psychiatrists, psychologists, social workers that people just aren’t coming in for their appointments because they say if I have a $5,000 deductible for me, 

or a 10 or 12 or $13,000 deductible for my family, they are just not 

coming in for care. Is that something that HHS is also investigating to find out what those numbers are, and what impact that 

is having upon care? 

Mr. FRANK. Yes. We are conducting several sets of analyses. One 

set of analyses we have been monitoring the trends and deductibles 

in private insurance broadly, and we are also looking at just the 

design of the benefit, both in the bronze and the silver plans within 

the ACA. 

Mr. MURPHY. But you know what I am saying, is—— 

Mr. FRANK. Absolutely. 

Mr. MURPHY [continuing]. It is very important. I think this committee—— 

Mr. FRANK. And it is very important—— 

Mr. MURPHY [continuing]. Would like to have that information. 

Ms. Hyde, you talked about, when you talked about this, in families in serious mental health crisis, you want to engage the family. 

One of the problems we consistently heard also is the families said 

we want to be engaged but HIPAA laws keep us from doing that. 

We keep hearing stories of someone who has suffered because a 

doctor says I can’t talk to you. And the families say, look, all they 

want to know is what medication is he on so I can follow up. When 

is the next appointment so I can get him there? I know in the past 

HHS has given us some clarification and said doctors can listen to 

family members, they are allowed to do that, but they can’t kind 

of in a cold basis if someone calls over the phone and give information. I get that. We should protect that. And nor should we release 

all the records. But is this something that we can be addressing to 

74 

say how do we at least get that information when, in absence of 

that information, that person becomes gravely disabled and it is 

necessary for treatment, how are we going to deal with that? 

Ms. HYDE. We worked with the Office for Civil Rights who actually was taking the lead on providing the clarification to practitioners about what you just said, Mr. Murphy, that practitioners 

can, in fact, listen and they can, in fact, get lots of information that 

can help them with treatment. I think there are a lot of clinicians 

who it is just easier to say I can’t talk at all. 

Mr. MURPHY. But it is that other part about—— 

Ms. HYDE. Part of what we are—— 

Mr. MURPHY [continuing]. Giving information. This is something 

I think we really have to address. 

Ms. HYDE. Yes. Part of what we are trying to do is develop some 

training and some ability to help practitioners understand what 

they can and cannot do, and also to see how—— 

Mr. MURPHY. This is—— 

Ms. HYDE [continuing]. They can utilize existing state laws to get 

at the issue of when someone cannot make a decision for themselves. 

Mr. MURPHY. I have a couple more questions. I will go to Ms. 

DeGette. 

Ms. DEGETTE. I am sorry, I have already done my second round. 

Mr. MURPHY. Well, I am doing a third and a fourth. 

Ms. DEGETTE. I need to go, so—— 

Mr. MURPHY. OK. 

Ms. DEGETTE [continuing]. I would suggest—— 

Mr. MURPHY. All right. Let me just say this. Dr. Frank, you have 

suggested that GAO has, to paraphrase you, missed the boat in its 

analysis of the coordination between Federal agencies by failing to 

coordinate with, among others, the Medicaid program. Now, this 

kind of goes into the struggle we are having at the Federal level, 

but let me ask you how you coordinate it on the ground, as you 

state. For example, I understand this morning the state of Kansas 

is debating removal of many mental health medications from its 

Medicaid program. Are you even aware that Kansas is proposing 

to remove these drugs? Apparently, the Federal Government pays 

55 percent of the cost of that program, but here is the Kansas proposal to even remove those. Are you aware of that? 

Mr. FRANK. I am not aware of that specific proposal. We have 

been concerned with the placement of psychiatric drugs on 

formularies generally, and have been examining that pretty carefully. 

Mr. MURPHY. OK. What was that one other thing I wanted to 

ask? One other question I want to ask about the—— 

Mr. FRANK. Mr. Chairman. 

Mr. MURPHY. Yes? 

Mr. FRANK. I would never say that Dr. Kohn missed the boat. I 

have known her for too long—— 

Mr. MURPHY. OK. 

Mr. FRANK [continuing]. To think that. 

Mr. MURPHY. All right. Thank you. We don’t want to have any 

aspersions about boats or sailors too. 

75 

Another thing, Dr. Frank, in your 2006 book, which we are promoting here, Better Not Well—— 

Mr. FRANK. Yes. 

Mr. MURPHY [continuing]. One of the things you suggest is this 

creation of a new Federal agency or authority, it doesn’t have to 

be a new agency, with budgetary oversight over all the programs 

that serve people with mental illness. Do you still think that is a 

good idea to give someone that authority so they can really, I guess 

I will use the word mojo, have to go to all these agencies and have 

to answer to someone and say is it working, is it not working, is 

it interacting well, are you meeting your targets, do you still believe that? 

Mr. FRANK. Well, at the time I wrote that in 2005 the world was 

a somewhat different place, and that was the—you got the rationale for why we were proposing that right. What has changed since 

is, for example, the Congress has done a variety of legislative 

things to sort of force some of that on the ground. The Melville 811 

Act, for example, forces housing and Medicaid to come together. 

And we have added so many institutions that now are coordinating 

better on the ground, that what I would like to do is see how that 

works out before adding another level of bureaucracy. 

Mr. MURPHY. Well, I am not talking about adding another level 

of bureaucracy, I am talking about someone who really has the authority to call for these things that people have to respond to. 

Mr. FRANK. Yes. 

Mr. MURPHY. Because my concern is that, what we are hearing 

from Dr. Kohn’s report is it is not being coordinated. I am pleased 

that some action just immediately took place, and that some of 

these agencies have not been meeting in 5 years, so we need someone who is singularly accountable to be that pivot point. I mean I 

say in my bill there should be an Assistant Secretary of Mental 

Health, which means someone within this agency that has that 

power and authority to go to DoD and VA and HUD and Education 

and Labor and saying we are going to sit down, we are going to 

hash this out, because somehow having at least 112 programs isn’t 

working when we look at the outcome measures and all those 

things to say that. So—— 

Mr. FRANK. Yes, as you can imagine, I am sympathetic to the 

view, but I really do think that we have changed—the idea that we 

had was in service of making sure that the dollars got funneled to 

the right place, to the right people, at the right time. And we are 

trying a different way right now to do that, and I would like to see 

whether it is successful, because, in fact, I have also seen a lot of 

programs where we tried to coordinate the bureaucracies up here, 

nothing happened on the ground. And so I would like to—this time 

start at the ground and then work my way up, and then see what 

happens. But it is a hard problem and I am interested in seeing 

how our efforts work out because I really think they are serious 

and they are important. 

Mr. MURPHY. All right. Well, I thank you for those things. I also 

know, Ms. DeGette, I am sure you also support the idea. We will 

work with getting SAMHSA those documents, and she is absolutely 

supportive. And that is the way we are. We want those documents 

we requested a year ago, and get the other responses here quickly. 

76 

I thank all of you for being here. This has been a very revealing 

report. Dr. Kohn, thank you so much. I do recognize a lot of work 

has to be done. You have heard that from Members here. And I 

think the best thing here is approach us with humility and honesty 

and saying, you know what, when we look at what has happened 

with mental health in America, it really is not good. From the 

thousands and thousands of families we hear, from the frustrations 

I hear from providers, from consumers, so many people saying this 

isn’t working. We have to change this. And so let us ease up on 

saying everything is fine, and let us really look at how we have to 

change this. And if it takes legislative changes, we are going to 

push those, and I am going to continue to push that. 

So I ask unanimous consent that the Members’ written opening 

statements be introduced into the record. And without objection, 

the documents will be entered into the record. 

And in conclusion, again, I thank 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 the 

witnesses all agree to respond promptly to the questions. 

And with that, this committee is adjourned. 

[Whereupon, at 12:29 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

PREPARED STATEMENT OF HON. FRED UPTON

Today we continue our examination of federal efforts to combat our nation’s mental health crisis. This hearing is a natural outgrowth of the committee’s investigation into the federal mental health system. Our work began following the heartbreaking December 2012 tragedy in Newtown, Connecticut, and we remain committed to addressing the problems that contributed to that tragedy. 

Severe mental illness is, and should be, a top priority for U.S. public health 

spending. Unfortunately, the $130 billion a year being spent on mental health surveillance, research, prevention, and treatment activities, income support and other 

social services has not solved the problem. In Southwest Michigan, I’ve met with 

my local public health officials and local law enforcement and they agree that more 

needs to be done to grapple with these difficult issues. 

Today we gather to discuss how we can better prioritize our taxpayer dollars to 

address the threat of untreated severe mental illness. 

Thanks to the bipartisan efforts of this committee, and the nonpartisan expertise 

of Government Accountability Office, we now have some answers. GAO reports that 

there are at least two significant problems facing our federal agencies and their 

spending that addresses mental health. First, high-level interagency coordination 

for programs supporting individuals with serious mental illness is lacking, and 

SAMHSA, which is charged with promoting coordination on these matters across 

the federal government, seems largely to blame. Second, agency evaluations of programs specifically targeting individuals with serious mental illness are too few in 

number and often lacking in quality or completeness. 

Although the Department of Defense and the Department of Veterans Affairs graciously accepted the GAO recommendation targeting their shortcomings, as identified by this report, HHS has explicitly rejected both of GAO’s recommendations. 

GAO stands by its recommendations, and we’re going to hear about those recommendations today. 

We are looking for answers. In light of the seriousness of the GAO’s findings, we 

must ask: why do HHS and SAMHSA think that there is no room for improvement 

in the areas identified by the nonpartisan government watchdog? 

The untold suffering of the families and individuals impacted by the programs discussed in this report is simply too great, and the cost to the federal purse is too 

high, to allow us to continue on our present path. Lives are at stake, and we can 

and must do better. I thank Chairman Murphy for his dedication to this important 

matter that hits so close to home for millions of American families. 

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