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tv   House Appropriations Subcommittee Hearing on COVID-19 and Mental Health  CSPAN  April 12, 2021 12:01am-2:24am EDT

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>> this hearing will come to order. as the hearing is fully virtual,
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we need to address some of the housekeeping matters. the chair staff designated by the chair, they will use microphones when they are not in use to eliminate background noise. if i noticed that you have not an muted -- unmuted yourself, i will ask staff to help. if there is a technology issue, we will move to the next member until the issue is resolved. you will notice a clock on your screen that will show how much time is remaining. at one minute remaining, the clock will turn to yellow. when your time has expired, the clock will turn red and i will
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begin to recognize the next member. in terms of speaking order, we will start with the chair and members present. finally, members not present at the time the hearing is called to order. house rules require me to remind you that we have to set up an email address to submit in writing at any of our hearings or my cups. it has been provided in advance to your staff. what is that -- with that, i want to acknowledge the congressman and all of our colleagues for joining us today. before i begin, i would like to take a moment to recognize that today is march 11, it marks exactly one year since the world health organization declared covid-19 a global pandemic. since that day, many aspects of
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american life has changed. cities have shut down, thousands of illnesses have closed property has grown and more than 525,000 americans have lost their lives. with each passing day, the enduring consequences of this catastrophe are becoming more devastatingly clear. not too long ago, an 11-year-old girl came into the emergency department. she was there for something unrelated to mental health. the hospital made it a policy to give them a suicide screening. when doctors asked the girl if she had any thoughts of killing herself in the past few weeks, she said yes. she said she had been thinking about thinking -- she had been thinking about suicide for some time but did not know to talk
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about -- talk to about it. a growing concern in this country. the isolation, the closure, the challenges have only exacerbated the already existing problems. in 2019, 1 in 10 adults reported symptoms of anxiety or depression. in 2020, that number increased. some surveys have shown over 50% negatively impacted by their mental health. it is our nation's most vulnerable at risk. according to data published, suicidal thinking among young patients is up 25% or more from similar periods in 2019.
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another report found in 2020, pediatric emergency initiatives for things like anxiety and panic have increased by 24% for young children. 31% for adolescents, compared to 2019. in addition to our nation's children, this pandemic has been especially difficult for minorities, young adults and workers. black and hispanic adults are more likely to report symptoms of anxiety or depression than white adults. those who are essential workers are particularly affected. essential workers are more likely to say that they are having suicidal thoughts compared to non-essential
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workers. finally, young adults are reporting higher than normal levels of anxiety, depression and substance abuse as a result of the pandemic. it has been difficult for all of us, but it has been especially difficult for these groups and is leading to greater problems like substance misuse, drug overdose and domestic violence. there has been a double digit increase in domestic violence hotline calls since the beginning of this pandemic. the kids and those families are experiencing ongoing trauma without the rest bite that they might have previously gained through school. drug overdoses are up. overdose deaths are up 24% in 2020 compared to 2019. alcohol sales and consumption have skyrocketed, and while it is too soon to know how it has affected suicide rates, we do
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know that there has been considerable increases in the number of people who report thinking about committing suicide, just like that 11-year-old girl in my home state of connecticut. we are not sitting on the sidelines. for some time, we have worked to provide more funding and resources for the programs. we have provided significant funding and done this on a bipartisan basis. to address the emergency with the cares act. the december emergency bill and the plan that we passed yesterday. i look forward to president biden signing the american rescue plan into law tomorrow so that these resources can get out the door to our community.
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the affordable care act was integral in expanding medicaid, which in many states is the most significant source of coverage and funding for substance treatment. working together with my colleagues on this committee, we have supported a number of commitments. this includes a landmark, federal investment in social and emotional learning and the whole child approach to education and investing in communities and schools. a healthy transition as part of the now is the time initiative, following the tragedy in connecticut. i am proud to say that we have increased funding by $25 million over the last five years. an increase of more than 50%.
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we also directed resources to provide counseling and trauma services to unaccompanied immigrant children. we need to do more. i also agree that we must recognize the issues that do not exist in isolation from each other. it is why we created a new pilot program to help develop plans to address the social determinant of health in their community. while these investments are a step in the right direction, the behavioral health system has been underfunded for years. we need to provide the funding and resources. also to help treat what i suspect will be an exponentially increasing mental health crisis in the next few years. this is not something that will simply go away as soon everyone
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gets a vaccine. without proper treatment, trauma and complex trauma like the kind that we are seeing in so many children and adult, ken nast and compound for years, even generations. our most vulnerable are suffering. we owe it to them and to the resilience of our economy, workforce and society to ensure that they get the mental and physical health care that they need. we are fortunate to have an excellent group with us and i look forward to hearing your recommendation on how to build a stronger behavioral health system capable of meeting those needs in the years to come. you all seem to be in general agreement.
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we need to meet the demand for services. we look forward to hearing how you have responded to the crisis over the past year and what you see as our top priority, as we move forward. i want to yield to our young -- ranking member. with that, i yield to congressman cole. >> i would be remiss to say i'd really -- i really like those glasses this morning. pretty sporty. they make a strong statement. i want to thank the chair for holding this important meeting today. my focus has been on mental health. it is far from the only impact. some subtle effects are just being brought to light.
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we may not know all the consequences for decades to come. the information that we have is concerning. symptoms of anxiety and depression have increased considerably. survey respondents admitted to having started or to increase substance use. suicide is also increasing, particularly for adults aged 18 to 24 and minorities. overdose deaths, which had shown a small decline are now on the rise again. life expectancy is decreasing. after a year of lockdowns, isolation and physical distancing, the mental health impact is apparent. families having financial distress feel exhausted,
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frustrated and have mental strain. too many families are also dealing with the loss of a friend or family member. compounding these issues is the lack of providers to help with mental health and substance abuse. particularly for rural and underserved areas. in addition to our annual appropriations, there was $4 billion put towards these issues. over the next few months, it should become available to address rising rate, substance abuse and the need for mental health services.
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we can begin restoring some of the stability needed to return to normal. i am encouraged to vaccinate as many as possible. we might be just a few short months away from having the necessary vaccine supply. such an accomplishment speak to the resilience and i would like to extend a special welcome. one of the largest substance abuse facilities in the state. 26 locations across oklahoma. they provide a range of services, including outpatient, stabilization for adults and
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substance use residential treatment, prevention and health. recently recognized as one of the top places in oklahoma and initially ranked as one of the best addiction treatment centers. i want to thank the chair for taking such a bipartisan approach. i know that members appreciate the ability to have influence. i have said that we may not always agree with every -- on everything. i appreciate the thoughtfulness. with that i want to thank all of our witnesses for speaking today. i yield back the balance of my time. >> i want to thank the ranking member for the comment on my glasses. what i need to do, i have to get
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to work and put some color into this effort. it is a work in progress. i do. i think this is a critically important hearing. i think that we both saw it when we listened to the hearing on infrastructure, noticing the consistency of information from all of our witnesses. i felt the same way reading the testimony with the emphasis on mental health and what we should be doing. looking forward to the recommendations. thank you. i am delighted to welcome arthur evans junior. executive vice president of the association. at one point, he served as a
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deputy commissioner for the connecticut department. mike freeman, director who serves as the -- on the board of directors. he brings you five years of experience in the substance use disorder and mental health field. dr. lisa jackson, codirector, ucla, duke university national center for traumatic stress. a tri-university collaboration that provides state-of-the-art trauma treatment and prevention services and a statewide curriculum for those exposed to traumatic events. this is a program that is near and dear to my heart.
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they were able we were able to provide funds for the native american youngsters, those who have experienced trauma and violence. we worked together for years to build this program and it is wonderful to see how it has spread. i was interested in the work with youngsters at the border. i think now we need to be thinking about increasing the opportunity for your services with youngsters at the border. many more are coming these days. the ranking member introduced, but i want to say, it is a pleasure to have you at -- as a witness. we have worked hard to match our community health centers with
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behavioral centers. people in the senate and others on both sides of the aisle understand the benefit of coupling the community health center with behavioral health center. i will remind the witnesses that the entirety of your written testimony will be entered into the record. dr. evans, you are recognized. >> thank you for the opportunity to testify today. i am the ceo of the psychological association and one of the largest organizations representing the psychology just
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this morning, we released the results of our latest data, which shows that the pandemic has taken a particularly difficult hole. many said that their sleep had been affected by the pandemic. others experienced weight gain or weight loss. with those with weight gain, gaining an average of 29 pounds. central workers are more likely to be diagnosed with -- mothers who still have children home reported that their health has worsened over the course of the pandemic. 65% of hispanic adults said they
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have -- they could use more support during the pandemic. our nation is experiencing psychological trauma and stress. we know from previous research that this will continue and we will continue to have problems in the months and years to come. we must use an approach based on population health. we have approached mental health treatments with a model that is passive, reactive and does not take into consideration the proper context. it assumes that people will seek out treatment when research shows that they will not reach out for help.
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this approach focuses primarily on individuals in crisis. essentially ignoring people who are having a milder and earlier symptoms. additionally, this model fails to address the effect that community systems and social determinants play in people's mental health. we must add prevention strategy to the approach that we take to mental health. you must use of -- we must explore solutions at the community level to prevent unnecessary suffering. this health model has proven integral in saving lives and saving money. i co-authored an open letter to president biden with a former colleague.
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we talked about our expenses as senators. we talked about strategies that we employed, making investments in evidence-based care and making investments in early intervention care. law officials and employers, as well as staff and churches, childcare centers and community centers, training them to identify the people in need of mental health treatment. we implemented school-based services to reach children experiencing problems, much earlier and much more consistently. we made screening available through public kiosks, community outreach events and call centers.
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these preventative interventions belong with care. for example, the creation of an enhanced treatment program by our team resulted in a 36% drop in the use of services. it is essential that we take this approach to address the growing problems of problems and promote mental wellness throughout the nation. we can reduce the risk of people developing more significant problems. i applaud the many for looking into the impact and i would urge you to support future systems that prioritize our mental
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health, as a nation. we need to continue to make investments that address and target federal resources. we need to increase to allow system administrators to implement more early intervention strategies. we need to increase funding for programs critical to the workforce. we need to increase funding for programs, mental health services, including funding for ida -- i.d.e.a. >> i have to ask you to wrap up. >> we are brought -- we are
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ready to work with you and address access to care. i want to thank you for this opportunity to testify today. >> thank you very much. >> you are recognized for five minutes. >> thank you. my name is mark springer and i am the director of the department of federal health. i really appreciate the opportunity to testify before you today and will be focusing on the impact of the pandemic on substance abuse and substance abuse disorder. we have seen some really troubling trends like drug
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overdose deaths increasing in the first three quarters compared to the same three quarters in 2019. of particular concern is the impact they are having in the black community. death among black people increased 37%. a survey done in august and september revealed increase in substance abuse. of those surveyed, 56% said they were drinking more alcohol than usual. a little over 60% said they were misusing prescription drugs. these present distinct challenges. we work to develop a treatment for those with opioid disuse -- misuse disorders.
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ideally, the same day a person presents for treatment. next to the quick action, our department offered the flexibility to deliver services through email, text and telephone. we offer providers flexibility on timelines. in addition, we received a lot of help from congress. the december 2020 package and covid-19 relief package included critical investments. the substance abuse treatment grant. it allowed agencies like mine to get help where we need it most. it is a much primary prevention. it is a critical component.
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moving forward, here are my recommendations. we need support from the subcommittee. we are fighting an urgent and steep uphill battle. resources are still needed. i recommend a transition over time to investing funds in the block grant. while we are incredibly grateful for the grants, states would benefit from more flexibility to address all substances of concern. this subcommittee embraced this approach and we hope it can be done again in fy 2022. these agencies play a critical role in a comprehensive system of care.
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state alcohol and drug agencies like mine promote and ensure equality through standards of care. federal policies and programs that do not flow through, or at least coordinate, run the risk of duplicative or contradictory systems. finally, please support and bolster the role of the substance abuse and mental-health services administration. we focus on substance abuse disorders. the nation benefits from this strong agency. across the agency. we are particularly for the leadership of the acting secretary, whom i have known and respected for a long time. in the end, the census should be
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the default term of the discretionary grant and related program. thank you for this opportunity and i look forward to your questions. >> thank you very much. dr., you are now recognized. dr. jackson? >> sorry, i was on mute. >> you are recognized for five minutes. >> thank you. chairwoman, ranking members, thank you for this opportunity to testify today regarding the mental health crisis is associated with the pandemic. i am a child psychologist and codirector of the ucla national center for child genetics rest,
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the corded center. as you know, the agency was created by congress in 2000 to raise the standard of care and increase accesses to services. it is a federally funded child trauma initiative, includes 116 current grantees in over 200 former grantees working in hospitals, universities and community-based programs. americans living under prolonged threat of danger associated with this pandemic have reported anxiety, depression, grief, substance abuse and thoughts of suicide. feelings of safety are exasperated by the death of a left one, illness, partner violence,. child abuse and poverty. for children with trauma history, new laws can result in
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nightmares, outbursts and complicate reactions. caregivers struggle to buffer the effects of children suffering. i will identify several stresses we are observing, highlight efforts to mitigate these, and offer priority recommendations. first, children and families are at increased risk of dramatic stress. over 500,000 pandemic related deaths are overwhelmed -- overwhelming families. quarantine families risk increased conflict while economic strain increases risk of substance, neglect and family virus. racial and ethnic minority families are disproportionately impacted, covid-19 compounds the impact of racial discrimination and this -- systemic disparities. limited access to culturally and big west took the responsive mental health care, fear of institutional violence -- institutional bias and historical trauma. our nation's schools are facing
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unprecedented challenges. routines, milestones and learning have been disrupted. students may lack access to evidence-based mental health services, and it has been difficult to identify students experiencing maltreatment or suicidal ideation. finally, the pandemic impacts child nontreatment risk and child welfare. professionals believe abuse may be increasing. contact between children and their families has been reduced, while services supporting parents has been disrupted. in response to the true medic impact -- dramatic impact. we are tracking the pandemics impact on our centers, including secondary genetic stress. we are bolstering traditions of treatment, training and other services offered through
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telehealth and virtual training. we are disseminating resources to caregivers and personnel, in providing training and consultation at federal, state and local organizations. finally, we are documenting lessons learned, including things that should be maintained. while we await further evidence of the totality of mental health and consequences, i will conclude with six recommendations. one, and sure children and families have resources to meet basic needs. to, increase access to evidence-based trauma informed services for children and caregivers resulting from the complex interplay between the pandemic and other national crises and disasters. three, support schools in implementing trauma informed grams to address gaps in their education. for, support essential services.
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implements trauma informed practices and policies. five, support research to delineate mental health substance use and consequences of the pandemic on children, and identify effective interventions. last, prioritize needs about riskiest including minorities, disabilities, emigrants, lgbt to persons and persons living in poverty. i would like to send the subcommittee for your long-standing commitment to the needs of children and families who have experienced trauma. we stand ready to assist as we all work together to address mental health. >> thank you so much. the next speaker is recognized for five minutes. >> good morning and thank you chairwoman, congressman cole and distinguished members for the opportunity to speak today. i am the ceo at behavioral
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health services, a certified clinic in oklahoma. for many years, i worked closely with the oklahoma department of mental health and substance abuse services. it plays a critical role in overseeing behavioral systems. one of the benefits of federal funds is that we develop relationships, they understand but we do, they offer technical assistance, and they held us to very high quality standards. we are also grateful for the agency's role, and hope that ongoing covid relief efforts further bolster samsa's role. we were one of the first agencies to become -- under the federal planning and demonstration program in 2017. this program has been a lifeline for community treatment. prior to this initiative,
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payment models do not cover the true cost of the services, nor provide the funding for the services that were truly needed. the success of the agency has led congress repeatedly to extend, and appropriating over $1.5 billion for the expansion of programs since 2018. today, there are 340 offices in 40 states, washington dc and guam. the model provides integrated care coordination for physical, mental health and addiction treatment, in an effort to move the needle on the fact that americans with severe mental and addiction disorders die 10 to 25 years younger than the general population. however, the model will end on september 30 2023, a must congress extends the program. in my opinion, extending the model to all 50 states and
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territories, with funding well into the future is to allow for planning, could be the most significant factor in improving behavioral health care in our country. there has been a shortage of mental health professionals in the u.s. for many decades. the national survey on drug use and health has consistently shown that over half of adults who need treatment do not receive it. demand for care is rapidly growing, the number of mental health professionals is barely holding even. a 2016 report projects a shortfall of 250,000 mental health professionals by 2025. the cc bhc model is a great start in mitigating the shortage. and helpful strategy would be broader access to student on repayment, by broadening the benefit to all places regardless of the area. this covers the right of young adults that have seriously
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considered suicide in the last 30 days, has increased from 10% in 2018, two over 25% in 2020. before the pandemic, one in 10 adults reported symptoms of anxiety. today it is for intent. in the covid relief package was an investment of $1.65 billion for the substance of each -- substance abuse block grant. each dollar is vital and we are appreciative of the work the subcommittee has done. a bright light during this pandemic has been congress's approval of services to medicare and medicaid recipients through the use of telemedicine. i urge congress to properly allow the use of telemedicine, and that any further federal efforts to address the pandemics long-term impact will take into account the benefit of multi-year investment. in summation, the federal block grant to the state is critical to providing services to the vulnerable, the model is transforming our system.
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it is resulting in improved access to care, high-quality treatment through the use of evidence-based practices, better staff training, enhanced care for veterans, and saving lives. we must quickly address the workforce shortage to keep up with the demand that is so desperate needed, and understand that covid has had a significant and lasting impact on the mental health of americans. again, thank you for this opportunity. >> thank you very much. i want to say thank you to all of our witnesses once again. i think it is striking that all four witnesses have not only identified the problems, in very descriptive of what the issues are and what the pandemic has caused, but also, i am stunned at the consistency of the
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recommendations of how we should go forward. what are the kinds of things we ought to be doing. i would say that your testimony is very valuable in having our impact, when we put together the appropriations bill, what are the directions we should go in, without let me ask i will start the questioning. the impact is stunning. that said i will focus on children. we will -- we have worked hard to improve mental health for young people. these children are now at home. parents who are stressed and anxious, in some cases they are experiencing trauma in home, and don't have the same access to teachers, coaches, friends. their entire support system that may have been there in the past.
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particularly may have children with special needs, who are suffering from the effects of the pandemic. dr. jackson, because children are still developing, they are particularly vulnerable to the stressors of the pandemic. we know how important the early years are. can you explain how these current events can impact a child's development? what we need to do to keep them healthy. i'm going to ask a follow-up, what kind of long-term impact do you think this will have on this generation of children, what do you think are the longer-term needs for children and families after the pandemic is contained? >> thank you, chairwoman. i think children are not just little adults. we have to understand their experiences of stress and trauma
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within a framework. for example, they experience stressors of the pandemic in a different way. challenges such as quarantine and social isolation can have significant impacts, and if you think about if you get that in school with your peers, there are very important ways of moving their development of progression forward. what are they doing now? they are turning to their cell phones, social media for gaming, they have much more increase vulnerability to bullying. increased exposure to sexual material, producing the quality and appropriateness of their social engagement. we are hearing about the broadcasting of suicide attempts and self injury through the internet. as we think about these issues, we have to be recognizing, that
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we are setting patterns into play that are probably going to continue long past the ending of this pandemic. our parents really need assistance, when a community programming, we access to services as they look to ways to think about strategies to work with their children, to engage with them outside of the internet, to be involved with them when they are on the internet, to be looking at apps that are involved with education, thing about time limits, things like that. i think the issues around structuring. directions, as we move towards -- here interactions. we have to speak of development it -- develop mental oriented activities. we have to learn about how we interact again. we have spent a long time in isolation and children are going to need some help, and some structure, and emphasis on no shaming, no blaming.
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rep. delauro: to we have in your view, the kinds of resources or the current structure to be able to deal with the short-term issues you are talking about, and the longer-term issues, when the pandemic is contained -- you mentioned some of the things. what is the best segment? is an organization, who can help out? as it positions? what are the tools in which we can deal with short-term and long-term in your view. dr. jackson: this is an issue of looking at everyone from
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pediatricians, to schools, to mental health providers. child welfare, juvenile justice. the criticalness of pitting -- putting children back into the routine. they need that social and emotional learning, to be able to move forward. they are going to be dealing with new traumas that have occurred, cumulative on past traumas, and stealing with grief and stressed-out parents. what we are doing is bringing together an initiative that will pull together national stakeholders, experts, to define the impact of covid-19 on children and families. we are looking for identifying some key challenges for longer-term planning and generate recommendations for agency leaders. we look forward to sharing our findings with you.
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i think we have to be in this for the long haul. this is going to be very big, and the question of whether we have sufficient resources, i really question that. i feel like there are families who have not been known to the system who will now need to be known to the system. one important thing i will mention, his parents who are very stressed -- parents who are very stressed, essential workers or unemployed workers or remote workers who have been trying to multitask, as they take care of their young children, to joan -- children in remote school. they have been heroes, but there is lots of room for neglect, and violence in the home. they are going to need some support, and i think they are going to be carrying a lot of scars. many of them have not been able to provide for their family. 1.i will make that has been clear, in my therapist path, we
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are seeing children, and recognizing parenting help too. just because a child has medicaid does not mean a parents does too. they may not have access to the resources. rep. delauro: thank you very much. my time has expired. i would just say, at some point in any of your comments, the issue of medicaid and its expansion, i would love to get your thoughts on how that has helped to deal with access to behavioral health care. with that, let me recognize the ranking member, congressman cole. rep. cole: i too was struck with the recommendations, consistent and strong advice that we have sustained over time, to be able
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to do with the problems. i want to quickly ask each of our witnesses if they could very quickly give us two or three greatest impacts of the pandemic in your respective fields. where are the places we need to focus as a committee. i will start if i may, dr. evans, with you. dr. evans: i think the impacts are going to be widespread, i would really prioritize the people who are having their first episodes of mental health challenges. prior to the pandemic we had a problem, i noted in my testimony that there were too many people in our nation to experience mental health problems and stone access care until they are in crisis. when they are in crisis, in many communities it is still even hard and difficult to reach them.
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i think we have to put a big emphasis on early identification, identifying people when it is much easier to treat them, when we can prevent them from having more difficulty. putting a lot of emphasis on that particular population. rep. cole: let me go to you next. are you there? >> sorry, i was on mute. i would say much of what dr. evans just said, and not to repeat his words, but as far as something good that has come out of the pandemic, i want to say that i think telemedicine has been a godsend. we have learned how to do it really quickly, we know much better what works it's incredible.
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i would ask that this is encouraged in the future. rep. cole: we hear a lot of that and a whole range of fields. let me go next to mr. stringer. if you would give us again your thoughts on the greatest impacts the pandemic has had in the areas you have focused on. mr. stringer: thank you for the question. what this has done is pretty conditions of isolation, certainly unemployment. difficulty accessing services. hopelessness, those kinds of things are all enemies of recovery. those kinds of things are great opportunities to take substances in order to feel better or relieve the pain.
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those are the main factors i think that have contributed to this. the other one is the availability of drugs. the cartels, they always figure out a way to get the product, no matter the conditions. ranking member, that is probably the best i'm going to do. rep. cole: thank you very much. ms. jackson, from your standpoint. two or three of the biggest impacts that you have seen. dr. jackson: i would say the true medic nature and grief, particular on parents and providers is very significant. it reduces their capacity to do what they need to be able to do. i would also say, very
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significant impacts on systems. schools, mental health centers, hospitals, pediatricians, etc. those are busting at the seams. we know people have stepped up in a major way to be providing critical care, but when the pandemic is over, i think where they will be at and where the future need will be at, is going to be a mismatch. i think that is a very significant issue. telehealth will be something that we have to consider. i think we need data on virtual learning and telehealth, and where the role is for hybrid. rep. cole: i can certainly tell you, my area is heavily rural. i'm going to disappear for just a minute. i will be right back.
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[indiscernible] >> at like to raise an issue that is serious. i am very concerned about the impact covid-19 has had on the mental health of expecting and new mothers. maternal mental health, including postpartum depression and other anxiety disorders are the most common complications of pregnancy and childbirth. it affects one in five women which translates into 800,000 new mothers each year in the united states. tragically, suicide and overdose are the leading causes of maternal mortality for new mothers. recent studies have shown pregnant women and new mothers
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are experiencing increased anxiety and depression during the pandemic at three to four times the rate prior to the pandemic. women of color and women in poverty are disproportionately impacted by both maternal mental health conditions, and the pandemic. could you please describe how maternal mental health issues differ from other mental health disorders, and if they require different approaches and therapy to address. >> thank you for that question. maternal mental health issues are different in some important ways that we need to take into consideration. when i was commissioner for behavioral health in philadelphia, i funded programs specifically for women who were going through their pregnancies. as you noted, postpartum
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depression is the most common complication within childbirth. one of the other distinguishing aspects of postpartum depression is that many of the woman who are experiencing postpartum depression are experiencing it for the first time during childbirth, which means that they are not typically already connected to services. one of the things that i think is really important is that we have a multi-systemic approach to this issue. for one thing, we need to make sure we have integrated services, mental health treatment. particular, identifying women who might be at greater risk or in the early stages of showing signs of depression. i think we have to make sure that our practitioners, both physical health, ob/gyn's and
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pediatricians are aware of the prevalence of postpartum depression, and understand how to make connections to the mental health system. we need to make sure that mental health providers understand the unique issues that women and mothers who are experiencing postpartum depression have. for example, the level of stigma are very different than the general population. you are always talking about stigmatized conditions, it is particular difficult for mothers who have elevated expectations about how they should be responded after childbirth. i think that the most important thing is to make sure that we have the funding, when i funded those programs, there were some complications. particular medicaid funding, different types of services that you can bill for in a particular day. we had to do some very creative financing in order to fund those services.
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i would put at the top of the priority list, making sure we have a good weight to fund those services, and if we reduce those variables so services are available to women. >> you touched a little bit on what my second question was going to be. how do we improve maternal mental health awareness, diagnosis and treatment in this country, to ensure that the best possible maternity outcomes for every mother in the family? dr. evans: i think that mental health treatment, early screening and identification, keys to become part of a standard of care. no woman in my view should go to childbirth without questions and screening around mental health and whether they are having mental health challenges. that is a systemic thing that we can do, but we also have to make sure that practitioners, both
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mental and behavioral health writers understand the unique challenges that women face, that they have an education, and understand how to treat those women given the particular challenges there experiencing and childbirth. >> i see my time is up, ideal back. rep. delauro: congressman harris. >> thank you very much. i have a question, direct i guess to dr. evans and stocker my jackson. i am a little worried about what the affect of the school closings will be, in the isolation on youth on youth violence. let me just back up and say, what we see in adults, or have heard, is the fact that someone
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can infected with a virus makes you distrust other people. they pose a physical risk to you and whether you like to think it -- you think this person can adversely affect me. is that percolating, does that percolate down to children as well, as you remove them from school, about the fact that that other person can infect me, they can cause bad things to happen to my health or my parents'health. does that percolate down, and is it different at different ages? mothers lack of the ability to associate with your peers in a friendly, nonthreatening way, does that make a difference to different ages? when this is all over, our children going to go back to
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school and say i am still afraid of that other person, and what is the ramification on youth on youth violence because of this mistrust? dr. evans, if you could start. dr. evans: the general point that you are making is a very important one. that is the pandemic is going to have long-lasting mental health impacts on people, we know that. specifically how that will play out, we do not know. we don't have the studies. this is the first time in 100 years we have experienced it. we don't have long-term data that shows that. the issue that you are raising i think are good ones. what we do know, children have been under a significant amount of stress over a long period of time. one of the things that the sting wishes this pandemic from other types of natural disasters is the prolonged, chronic stress level that we have documented in
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the surveys, and others are documenting through other research. what we know about that long, chronic stress, is that the impact happened far after the crisis is gone. it's like veterans who have been deployed for a long period of time, they actually adjust to the stress level, but when the stressors are removed, that's when you start to see some of the challenges. we suspect that is going to happen with a lot of people in our population, and probably children as well, and it is a reason we have to make significant investments. in every child service so we can identify those issues early. >> i would echo those words, and thank you for speaking about
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these kinds of issues. but we are seeing with children is multi-prompt. -- multi-pronged. parents are scared, and makes them scared. they see parents fighting, they are going to fight as well. there is a role modeling issue, but i also think in these systems, whether it is in school, activities, children need to know they are psychologically and physically safe. the fear is going to be dropping some of these aggressive emotionally just regulate behavior. -- emotionally dis-regulating behavior i think where adults,. on the playground, on the halls at school, there is monitoring that can go on, so children can feel safe, both physically and psychologically, i think will be
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a critical element. >> thank you very much, ideal back. -- ideal back. rep. delauro: congresswoman barbara lee. rep. lee: thank you very much all of our witnesses. just for context, my professional background is clinical social work. my profession is of a trained psychotherapist. in the 1970's i founded a community mental health center, because we did not have any centers in the bay area that provided relevant, culturally appropriate mental health services for the african-american community, for people of color. this was in the 1970's. we had to develop treatment, and the reason i founded this is because we do not have any treatment approaches that include the impact of social determinants on african americans and people of color.
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racism, structural racism creates stress, creates trauma, creates physical illnesses, creates mental health illnesses, all of what we are seeing now, again. but also, it creates early death. for myself recently, in senator warren, we introduce a bill, the antiracism in public health bill. it is so critical to address racism and structural racism, both individually and structurally in our mental health systems. because what you all have recognizing and said, is that this certainly has a terrible impact on the mental health of people of color, racism. i think the rest of the country begin to understand how way down people of color are as it relates to white supremacy.
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we have begin to fund our programs, understanding this context, in terms of structural racism. what would you suggest that we include, to disrupt first of all the systems that have been in place, and also to build upon systems that we know will address the specific stress as it relates to racism, and people of color's daily life. this is an issue that has got to be dealt with right away and this year's budget, and i want to see something in our bill to suggest that our programs have this incorporated. dr. evans. dr. evans: [indiscernible] i did similar work when i was in private practice, creating models, specifically for african-american populations. often, african-americans have a hard time relating to more traditional services that did
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not acknowledge their realities. there are several things you said that i think are really critical. one of them is, i think it is important for physicians to understand social context, and understand those contextual issues. often, people are trained or not trained to acknowledge and acknowledge that. it's one thing that pushes people out of treatment. if people are seeking treatment and people are not acknowledging their realities, it's going to make it less likely for them to engage in treatment. from a policy standpoint, i think there are several things we need to do. one of them is to make sure that we are collecting the data. and bear aggregating the data. the big challenges we have is we don't really understand. for example, when i was commissioner we collected data and we woodfield mall that data to look at where people lived, and where the services were. one of the things that explain people not getting to services
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was not so much that they did not want the services, but the services were not in places where they could easily access them. we have to have that kind of data in order to make sure that people have access. and, we have to make sure that we have specific data, or specific funding for population to we know are a greater risk, for underserved. generic services are important, but often jeanette ever -- generic services do not get those unique issues that you have to overcome in order to reach specific populations. i would strongly recommend that. >> on racism specifically, antiracist policy. how do we get our mental health system to incorporate those? if we don't do that, people who are dealing with racism every day, in the trauma that results, will still walk around without load on their shoulders. dr. evans: the research is
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pretty clear and consistent, that racism that have an impact on people's mental health. i do not know that many -- that that is a part of most clinicians training. you probably know. social workers are actually better at that than other professionals. many of the mental health professionals do not have that understanding, that connection, understanding that we not only have to deal with people, we have to help people with the reality in which they live, and helping them navigate a life or they are experiencing those circumstances. >> thank you very much, madam chair. rep. delauro: we can follow up in a number of these areas. congressman fleischman. >> thank you, madam chair and ranking member cole. again, another outstanding
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hearing for this subcommittee on an issue, mental health and substance abuse, that billy has affected our nation pre-covid, and now cover like. -- currently. thank you for holding this. the pandemic is having a significant impact on the behavioral health of americans. a recent report found that anxiety disorder is approximately three times higher, depression about four times higher, overdoses are up almost 18% among adults compared to the same time last year. even before the current public health emergency, incidents of serious mental health illness at increased from 2018 to 2019. suicide rates have continued to increase, of 35% between 1999 and 2018. drug overdose death have climbed to a record high again last year. the mental health addiction
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equity act was enacted in 2008, and requires insurance coverage for mental health conditions, including substance use disorders, to be no more restrictive than insurance coverage for other medical conditions. yet, the medicare program limits beneficiaries to only 190 days of inpatient care in psychiatric hospitals for the lifetime. people with serious mental illness may easily go over medicare's ps 190 day limit. especially if they came medicare coverage at a younger age. when people with mental health illness cannot receive care in the right setting, they can end up in hospital emergency rooms, in jail, or sally on the streets. my question is for dr. evans. do you believe congress should reconsider the 190 day cap on inpatient psychiatric services, if so, what would that do for
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medicare patient care, specifically in light of the covid-19 pandemic? dr. evans: absolutely, i am so glad you are raising this issue. people who have psychiatric illnesses need to have access to the services that they need, and we should not place them at patients, arbitrary limitations on people's access to that care. is plainly discriminatory. we do not do this for other illnesses, we don't say if you have been hospitalized for cardiovascular disease were 90 days, you can't go in. we do that for mental illnesses, and it's just discriminatory, we need to stop it, and make sure people have access to whatever level of care they need, at that particular point. one other point i will make. one of the things that happens to people in the mental health
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system, because systems are so different around the country, in some communities that don't have enough outpatient and other types of services, may in fact have more data than other people in other parts of the country. it's a double whammy for people who live in communities who have inadequate access to mental health care, they may have overutilization of those psychiatric days, and then they have this arbitrary limit on access to care in the course of the treatment. >> thank you again for your testimony. i'm going to yield back the balance of my time. thank you for having this great hearing, i appreciated. rep. delauro: thank you so much congress and fleischman. in any case, before this is
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included i would love -- anyone else wants to deal with the issue of medicated -- medicaid expansion, i think that would be helpful for us to understand. [indiscernible] congressman? >> thanks for the hearing and therefore the witnesses. trying to get to two different subjects. last year, i worked with the chairwoman to include language in the fiscal year, spoke -- on the bus bill to ensure insurance coverage is in compliance mental health parity laws. as you know, the laws require care for mental health and substance use disorders at the same level of other medical and surgical care services, yet, after a decade later, we had
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seen the prevalence of mental health issues and substance use disorders rapidly increasing. there are insurers that are not compliant with the federal law. my question is for dr. evans and possibly for mr. stringer, how is the lack of access to insurance coverage and share it -- impacted mental health care, and has it been exasperated by the pandemic, or has access to telehealth coverage increased access? dr. evans: telehealth is absolutely increasing, and i hope that we continue that. access to health care is extremely important, and when i was eight clinician -- when i was a clinician at a triage facility, the first questions that we asked when we were trying to figure out where we needed to send someone was not what their diagnosis was, or what the level of intensity of the care would be.
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the first question we asked was what insurance they had. that dictates where you can go in terms of treatment services. if people don't have access to those services, because they don't have health insurance, often people don't get the care they need and end up having a lot of recidivism. the other point is very critical. what we know from our expense with parity is it is not just enough to have the laws, we have to have the enforcement. it's been very clear that over the last several years, since the parity act was implemented, it that we have to up the enforcement of parity, and we have two hold insurers accountable to making sure that the full range of services are available to people are also
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available on the mental health side, particularly the rehabilitative services and services allow people to step down and maintain their care in the community. >> thank you. mr. stringer, you have a brief comment? you maybe unmute. mr. stringer: i have only been doing this for a year now. i completely agree with the doctor. it puzzles me a bit, why there isn't parity naturally. good mental health care means better physical care with fewer callers. it puzzles me. i was in this business back in the early 1980's, when there are a lot of private-sector facilities around the country that we doing questionable things, and making a lot of money.
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i think that is probably the insurance companies and they have really clamped down. what some fortunate today as they are living in the 1980's in that regard. we need that care. >> thank you, very much. one question for -- the trevor product, the leading organization providing crisis intervention and suicide prevention services for lgbtq communities has said that since the onset of covid-19, the vibe of youth reaching out to their crisis services programs has significant increased, nearly doubled. as you know, lgbtq youth are four times greater at youth -- risk for things like suicide. how do we ensure these kids have access to mental health services, especially for kids who don't feel safe in their own homes? we are seeing that that is almost three times the rate with covid that lgbtq youth are feeling not safe at home. dr. amaya-jackson: thank you for that question.
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we know that lgbtq use and adults have long been burdened, self injury, suicidal thoughts and intent. they have higher rates of attempting suicide and experience trauma at higher rates than their straight peers. we know where we can intervene; in these places where youth are experiencing bullying, dramatic forms of societal stigma, bias, and particularly, family rejection, which is very problematic, and makes their ability to cope with some of these other things less possible. the other problem is, historically, professionals have been less successful in recognizing and meeting the needs of traumatized lgbtq youth that perpetuates many of their genetic experiences. i think the issue is making sure that our providers in our
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systems, yet again, are in recognition of this group in the high-risk, vulnerable population who needs access to evidence-based treatment, that they need training in their ability to work and engage with these youths. to get the conversations going with youth, so they know that it is ok, and they can feel safe in accessing care. >> thank you, madam chair. rep. delauro: [indiscernible] i am going to go to ms. clark.
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>> thank you so much, thank you for this hearing. this is incredibly helpful, and a topic of such importance to my constituents back home. i wanted to ask about the collision of two crises that we are seeing -- racism in mental health and how the impact it has, and the impact on access to treatment, and also the rising overdose deaths. my specific question is about black patients with opioid use disorder. that have been studies that show they are 35 times less likely than white patients to be prescribed assisted treatment that can help prevent relapses and deadly overdoses. what can we do as policymakers
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to combat the inequitable treatment of addiction in communities that are already dying at disproportionate rates from the pandemic? i will open it to anyone who might want to -- >> in missouri we have put together a task force in st. louis which is really our hotspot for overdose deaths among african-americans, in particular males. we have put together a task force of looking at that. one thing we have learned, and should have known a long time ago, the traditional treatment model, of having a brick-and-mortar building where people go, and something mysterious happens, you come out and you are supposedly cured -- that model does not work. it just does not work in those
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kinds of areas. there are transportation problems, there is a certain amount of stigma associated with getting substance abuse disorder treatment, and, african-american people, and i hate painting any group with a broad brush, historically, african-american folks have been distrustful of the health care system. i think it is a fair statement. we need to take treatment to them. we need to make sure that it is the kind of treatment that they would welcome. the message needs to be delivered by people that they trust. we have engaged a large group of clergymen and women in st. louis to help us reach into the community. we are doing everything that we can, using the evidence that we have, and i am optimistic we are going to make a difference. rep. clark: thank you, and along
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those lines. mr. stringer, before the pandemic when you're there were estimated 120 million people who live in areas without adequate access to mental health care. the vast majority are people of color, and rural communities. can you elaborate a little bit on how we can target federal support to help state and local public health officials, like yourself, in getting mental health care out to underserved communities? mr. stringer: an interesting question. my approach is in taking treatment to individuals. it's different how you take treatment to somebody in st. louis compared to how you take treatment to someone in northeast missouri. in a very rural area. the technology that we are enjoying now during the
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pandemic, and it is really having a big effect, if we can keep that technology, that allows us to take treatment out into rural areas. that to me is the answer. again, in inner cities, is probably more of taking treatment in person to people. mobile lands, think like that. -- mobile vans, things like that. rep. clark: thank you for that. my last question is going back to, as we are coming into a new administration, looking once again at disparate school discipline policies, and the impact of behavioral and mental health conditions, especially on black and brown youth. we know they are more likely to
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be funneled into the juvenile justice system, than to be provided mental health services. how can we work together going forward to make sure that we are giving every young person, every child that access, and, do you think we can work with these school discipline policies to have a true impact? dr. evans: i will jump in for a second. i think it is a really important question. in addition to making sure there are services in schools, we have to look at school discipline policies. african-american children, girls and boys, a new study has come out looking at girls who being expelled from school, african-american girls, is very significant. we can't talk about trying to protect people's mental health and not deal with the reality of
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the disproportionate, and often disparate discipline treatment. those two things go hand-in-hand, i think if we really want to address children's social and emotional health, we have to look at those kinds of issues as well. rep. clark: thank you so much. i see my time is expired. thank you for your indulgence. >> hello. is that me? someone is talking loud. thank you everybody. this has been quite a challenge, trying to do this on my cell phone. ok. you know what, mr. evans, is that correct?
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this is going to sonic a simpleton question. what is the opposite of evidence-based treatment? could you just give an example of what evidence-based treatment versus what is not? dr. evans: [indiscernible] evidence-based practices recognize that in most fields, including the behavioral health field,. a gap between what the science is and what the practice is. that gap is about 17 to 20 years. over the last, i would say two decades, our field has been really trying to close that gap. for example, when i was commissioner, we created an evidence-based practice of innovation. we spent about two mayan dollars a year -- $2 million a year
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trying to trade dividers so they were practicing at the top of where the science was. i think we are getting better at that, but i will tell you, it is very complicated and complex. there are a range of issues, from the infrastructure within treatment programs, to financing issues, to how people are trained. you have to deal with all those issues if you want to increase practice and get more people using those approaches. >> can you give me an example of an old treatment that would no longer be considered evidence-based? dr. evans: when i came into this field, we had very confrontational approaches to substance use treatment. you are kind of in people's face, confronting them. that help some people. but it also was not very effective, especially given what
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we know about trauma, and the reach him at his age and of people. it's a very good example of a practice that was widely practiced, with ever new understanding of trauma, so many people who come into substance abuse treatment, particularly women, who are in our treatment programs, have some form of trauma. that kind of confrontational approach can work against them. >> how can recommendations and how can we in congress influence evidence-based treatment rather than the treatment -- i won't
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say old-fashioned, but it seems like it doesn't really work. what can we do on our end? >> from my view, it really takes resources. in fact, it takes a lot of effort to change traditional treatment approaches. there are a couple of things that i recommend. one thing that i recommend we not do is mandate particular evidence-practices or even mandate a percentage of evidence-based practices. what would be more helpful is to have guidelines and then have resources that systems administrators, people who are running mental health systems, can use to provide the technical assistance to treatment providers. in my experience, we were able to literally train thousands of workers, of mental health clinicians, and change practice
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in dozens of mental health and substance use programs by using that approach. much more effective than simply saying, "do this practice." most of the time, providers don't have the wherewithal or resources to be successful without a coach. >> are these guidelines connected now and by one entity? mr. evans: they are not really presented now to the extent that providers are left to try to figure this stuff out. if you are in a system where you don't have either ship by the systems administrator to guide people and provide the support, it is very difficult. for example, one of the things -- what i did is we paid providers to train their staff, so if you are in a highly secret service system, as systems
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highly reliant on medicaid are, they take their staff off to get the appropriate amount of training, they lose revenue, so that is a disincentive to actually do it, but you have to understand how the financing works. those kinds of issues become nonissues so providers can focus on getting their physicians trained up in the appropriate amount of time that is needed for them to practice at the appropriate level. representative frankel: thank you very much. i'm going to follow-up with you on this. madam chair, i yield back. thank you very much. >> thank you. i know recognize congresswoman coleman -- i now recognize.
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congresswoman coleman: thank you. i think i want to ask dr. evans some questions, particularly concerning the issue of mental health and the african-american community. before we had this pandemic, the african-american community already had a pandemic. i did some work with mental health and suicide with black youth. i did some work on an emergency task force. i was just struck by the range of ages that were caught up in that. i'm also concerned about just access to mental health services for african-americans in general. for instance, what is it that we need to do to ensure that there is safety when an african-american is going through a mental health crisis, and the police respond to their door?
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what is it we need to ensure that there is greater safety when the police encounter a black person going through a mental health crisis? mr. graves: we have to train police. when i was commissioner, we trained about 40% of the police in the city during my tenure, and i and the police commissioner had a very close working relationship. officers going through training got mental health training, and then when they were on the streets for a certain period of time, they would get what is called crisis intervention training. made a huge difference. when i became commissioner, we were having on a regular basis citizens being shot and often sometimes killed by police who were responding who did not know how to respond to those issues,
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and i can tell you, during the last several years -- probably six or seven years of my tenure, we did not have one police shooting of a person who had experienced mental illness. it shows that the training does make a difference. congresswoman coleman: that is a best practice. is that being shared with other states and facilities? mr. graves: a lot of cities are doing it. it originated in tennessee, but many states -- cities are doing it. i think it just should be a standard. it makes a huge difference in the safety of the community. congresswoman coleman: do you agree there is tremendous under resourcing of black clinicians, social workers, psychologists? do you have recommendations for how we can encourage more and support more going into the field that would be more helpful in dealing with our communities,
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and why are they not going into those fields now? mr. graves: absolutely. a big part of it is just financing and getting through graduate school. the minority health care program is extremely important. that is a program we really ought to making -- not to be making significant investments in now because it is time for people to get into the pipeline, so we should be looking at a doubling or tripling of the minority social work program. we have to break down the understanding of mental health issues, so we have to deal with issues like trauma. in my tenure working in the field, we spent time doing community events where people talked about mental health issues. sometimes there were storytelling events that there were things people would be more likely to go to than a "lecture" on mental health or doing
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community art projects that gave us an opportunity to engage with the community. these issues -- we have to come at them in multiple ways. part of it is working with the community to help change attitudes, and part of it is making systemic changes like -- representative coleman: i don't want to cut you off, but i have so much want to ask. i have a bill out now redoubling efforts to get more practitioners or providers in the pipeline. i'm concerned about our kids. i'm concerned about how do we deal with the trauma of the pandemic, the trauma of the isolation, getting back to what the heck is ever going to be normal again, having our children to not fear being treated disparagingly at the educational system or with the law enforcement.
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where are the things we need to be doing? are there best practices in getting schools ready, educators ready to deal and looking for the signs of trauma, etc.? what should we be doing? i know that this is expired time. mr. graves: i will take that very quickly. we have to increase the mental health literacy of the population, and all the people in child services, child protection systems, the school system, we need to make sure all of those professionals have a basic understanding of the signs and symptoms of having mental health problems and know what to do when people experience that. additionally, we need to ensure we are doing the same thing for parents and we need to make sure we are having these kinds of conversations that destigmatize and normalize conversations about mental health in the african-american community. representative coleman: thank you. there's so much more i would like to ask, but my time is up.
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chair: thank you. congresswoman butler. representative butler: madam chair, and my next? dashcam -- am i next? the cdc announced there was a surgeon in overdose deaths. over 81,000 occurred in the u.s. in the 12 months ending in may 2020, which was the highest number of overdose deaths ever recorded in a 12-month period, which is hard to believe. in my home state of washington, there was a 38% increase from the previous year with fentanyl-involved deaths more than doubling, and this subcommittee has tried to take steps to curb the scourge synthetic opioids made in our communities, and these numbers contender -- continue to be
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concerning. mr. stringer, you mentioned it would be more efficient to transition over time to invest funds in substance abuse programs and block grants. could you maybe explain to me this point further and how the transition would be helpful to your agency's response to this crisis during the pandemic and then after? mr. stringer: sure, and thank you for the question. it's a very good one. the drug landscape is always changing, as you know. it will be stimulants for a while. opioids for a while, alcohol, of course, is always way up there, and things are different. we see patterns across the country that very, -- that vary, so transferring these grants over to block grants that go through state agencies allows us to be flexible in responding to those situations. if these current opioid grants
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were shifted over the block grant, i don't think i would do anything different until he got a handle on the opioid crisis, but when we did, that would give me the option to shift some funds over to something else, whatever the drug du jour is. the other thing that also ensures quality -- we were talking about practices -- evidence-based practices before. where things get squarely is where funds go to agencies that are not licensed or certified or accredited, and then we have no oversight over them. that's where things get squarely, and after evans was talking about, practices that are not evidence-based that is where you find most of them. that's a long-winded answer to your question, but it's a good one. thank you. representative butler: before the pandemic, we knew there were many vulnerable groups that were not receiving the care they
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needed. one that i focus on extensively are postpartum moms at risk of postpartum depression, anxiety, and substance abuse. we knew that 75% of mental health issues go untreated. one study found that treating postnatal anxiety issues cost early $2000 per mother and baby. how has federal funding been used to target groups of individuals that we knew were struggling even before the pandemic, and how can we build off what is working, and how can we give providers the flexibility they need to treat populations that may not be seeking health due to stigma and substance abuse issues? mr. stringer: in missouri, pregnant and postpartum women are just about our top population. we get those folks into treatment as quickly as possible and keep them as long as necessary until they are
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southerly -- solidly in recovery. i thing making them a priority is important, and they are, by the way, a priority of a block grant, so that helps. medicaid is an interesting situation because medicaid coverage stops, at least in missouri, after 60 days after birth, and, gosh, if you are just now getting into treatment, that's not nearly enough time. representative beutler: on that point, i'm supportive of a piece of bipartisan legislation that i think we voted through for extended medicaid coverage for at least that first year. when a 60% to 70% of problems occur in that year long time. that whole year is postpartum, and that would go a long way toward treating those women if we don't get them right off of medicaid within a month. if all the problems happened just in that month, that would be great, but it just is not reality.
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mr. stringer: i completely agree. rep resented of -- representative beutler: thank you. i yield back. >> thank you, madam chair. i appreciate you holding this hearing. dr. evans, i would like to ask about crisis care funding. i introduced a bill called the crisis prevention and suicide prevention act, legislation that directs 5% of the $750 million in mental health block grants to be used for crisis health services. i know you know this. that is why you have been funding help for mental health providers all over the country. specifically in my district, we have a community center for mental health in the quad cities where i live. it funds crises call centers and mobile units. i want to thank you for
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endorsing the legislation that we wrote out of our office, and i also want to thank the chairwoman for passing this set aside into law. my question is this -- how important is crisis care funding during and after -- because i think we should start looking a little bit ahead, cross our fingers, but during and after the covid-19 pandemic? and how much funding do you think we should provide to crisis care set-asides as we move forward? mr. evans: certainly. i thank you for your support for these services, which are really essential in the community. i recently had a personal situation where i was helping a family friend access services, and what happened from until health conditions unfortunately is that mental health systems are different in every community. it was really hard to figure out how you get access to help, and i think what this funding does is provides a floor for mental
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health systems to make sure they have the minimum kinds of services in place so when people are in crisis, they know how to reach out and maybe get help. i think it is very essential. i also think that it is important to think about what comes before and what comes after crisis services. to me, as someone who has run health systems for many years, that is as critical as the price of services themselves. -- as the crisis services themselves. often, there are not enough alternatives to crisis. many people in crisis services are there because there is simply no other alternative. i know people who will go to an emergency department and say that they are suicidal just to get help for their mental health issues. on the back end of crisis services, we want to make sure people have available services
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because what is happening is people go into crisis services facilities, and there's no aftercare immediately when that person discharges. it significantly increases the likelihood that person is going to recidivate. crisis services are essential. we need to have a basic way that everyone can access those services when they need them, but we also need to make sure we have alternatives and that we have continuity of care so people don't have to get into that cycle. representative bustos: the national institute of health says 60% of rural americans live in mental health shortage areas. rural america is my district. it is mostly rural geographically. we have 14 counties in the
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congressional district i serve, and nine of the 14 are considered mental health shortage areas. that's why in the december funding bill, i was lucky enough to be able to include language that encouraged health and human services to increase the behavioral health and training program presence in rural areas. i also introduced something that supports five years of loan forgiveness for providers who commit to serving rural areas. how else do you think we ought to be working with health and human services to combat mental health provider shortages besides what i just mentioned to you? mr. evans: i applaud you for asking this question. this is a high profile issue for the american psychological association. we have been working with
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associations to look at ways we can help get more providers and more variants. loan providers are important, but it is also important to make sure we have medicaid expansion. in rural communities, hospitals often are strained by the number of people who have -- who are uninsured, and those hospitals go away. often there is no behavioral health care provider in the community. we have to look at making sure that the individual is also covered and their services will be covered, and the providers that are in those communities, so we also need to make sure that we train providers to work in these communities because there are unique issues. farmers, for example, have a suicide rate that is significantly higher than the rest of the population. they have unique issues, and
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generic mental health services often are not responsive to the unique strategies or the unique issues that those individuals are facing, so we need to have a range of strategies to make sure we shore up those services and that the services are appropriate to the people in those communities. representative bustos: thank you so much. on that, chair, i yield back. >> thank you, madam chair. i want to thank the witnesses for participating today. i am particularly concerned about the impact that the lag of our local school divisions following cdc guidelines to reopen is having on our children, on their mental health , to separating in school activities, if it's school time social time with their peers, engagement in the arts, sport events, routine activities -- you know, these have all been drastically altered or pivoted,
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and these types of activities play just as important a role as the academic, and classroom experience, you know, affecting our children's mental health. while it is important to take public health recommendations seriously to stop the spread of covid, we must take a critical look at what comes as we take precautions to incorporate that activity so our you can get back to normal. the american journal of pediatrics completed a survey recently and 97 respondents recently said they had either seen a child or adolescent anxiety increase or greatly increased since the start of the pandemic, and a majority responded saying they had seen a change on anxiety levels with 95% saying it had increased or greatly increased. children's visits to emergency department's mental health concerns showed an increase of
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80% for children 12 to 17 over last year's numbers. i'm encouraged to see the topic of mental health discussed more openly, removing the stigma that surrounds the issue, but there's much work to be done. dr. evans, i recently was in touch with our governor in virginia, who has put through a particularly stringent shutdown and is lagging on reopening and following cdc guidelines, particularly when it comes to youth sporting events. the governor has only tapped 250 participants or 30% capacity rate for attendance, urging people to remain 10 feet apart at these events and masks, which
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is far beyond what is recommended. dr. evans, would you say that that prolongs social isolation due to the pandemic and places and knowing that stress on interpersonal familial relationships and threatens child of element, which is dependent on interaction with peers and others? you also said children's mental health is particularly vulnerable. can you elaborate how a local sporting event, being in the band, or being a cheerleader can impact students? mr. evans: sure. we know the negative impacts that social isolation can have on our mental health. i think in addition for children, we have to be aware of not only the stressors that they are experiencing, but they are also making important developmental milestones that are important in our development as people, and children, i think we have to be concerned about two broad areas. one is the mental health that we
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are talking about today, but we also have to be concerned about development disruptions in learning of the long-term impact that that will have. i think the implication of all of this is, yes, there are things that we have to do in terms of protecting our physical health, but the point you make about the impact is really critical and we will see these impacts over a number of years, not months, once the pandemic is over, and that means we have to have the resources to address both of those sets of issues. >> thank you. another area i am concerned about is the increase in domestic violence and the impact on children. i'm a former prosecutor of domestic violence, and i understand the importance of ensuring victims are taken care of, and the pandemic has only made it harder. isolation is a major risk factor in partner violence and family
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violence. unfortunately, isolation as a result of the pandemic may have exacerbated domestic violence situations. dr. jackson, you discussed how economic problems and other extremes may have contributed to domestic violence. can you address that and address ways to address that and get resources? dr. jackson: yeah, thank you for that really important note and question. children and families, when there's overcrowding, they are in quarantine, they are isolated, they are not having the social support, these are the things that create tensions and conflicts and often lead to violence, particularly where families already have pre-existing scenarios where there are tensions and job
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insecurity, potentially correlations in the past, and it ends up being a powder keg, and children are exposed to this violence, and families are experiencing the violence. the next step in what we can do is really going to be making sure that community support that we have trained to providers so people are accessing to bring these concerns to their community physicians, to their therapists so the therapist can address these issues, and that there is a common form system in place to handle these situations. >> thank you. i yield back. >> thank you so much, madam chair. i want to talk about an issue that is extremely important to
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me, and that is our foster children. the american academy of pediatrics and the foster care american initiatives identified mental health as the greatest unmet health need for children and teens in foster care. i have a bill that requires that we, who are the custodian of these foster children -- that we mandate that these children get mental health just like we get physical health screenings. dr. evans, can you explain why it is so important that we address these mental health needs of our children, especially those who are likely to experience trauma? i take in foster children every year as an intern in my office, and one of them told me the fact that i'm in foster care means i've had a trauma in my life. why are we as a government not
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stepping up? could you please share your feelings on this issue? dr. graves: i worked both in the child welfare system and the mental health system. the young person is exactly right. you can assume that every child who is in the foster care system has experienced some kind of trauma. one of the things people don't understand is that removing a child from their family, even when there may be neglect involved, can be just as traumatic and sometimes more traumatic than whatever the issues are that may have led them to the child welfare system. i believe strongly that they have to take a multisystemic approach to the issue, and limiting programs like therapeutic foster care, making sure every foster care parent has some basic understanding of
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mental health issues and knows how to connect their child to those services and that the child protection system has adequate resources to make sure those services are available to not only the child but to the child and their family. one of the things we did when i was commissioner was to work very closely with judges to make sure they were making the best decisions about how to place children and what were the services that children needed, so you have to work in multiple levels. you have to work the court systems to make sure they are making trauma-informed decisions. you have to do that in the mental health system. you cannot assume that just because a person is trained in mental health they understand the unique issues related to children under that system, and you have to make sure the people
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in the child welfare system are getting the training they need so they are making good decisions in terms of how the children are treated. >> dr. jackson, can you please respond to this as well? the thing that was just touched upon are legal systems and also the parent. do you have any comments on this foster care crisis i feel that we have in america? dr. jackson: yes, again, thank you for that question. it is multifold, right? it is experience of the children that have become cumulative overtime and lead to complexities in their behavior and emotions that makes it difficult for child providers and the families that are working with them to handle that. so it is how do we increase the
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capacities of foster parents, kinship parents, etc., to be better able to take care of these children, to make them feel psychologically safe as well as physically safe? we have programs and trainings, we have developed full on curricula that work with foster parents so that they can understand, you know, when the children start waking up crying and having nightmares or something like that, that they know what to do and how to handle that, how to talk to these children. it is about dealing directly with the children and helping the foster system and the childcare provider to be ready and able to work with children with these constant difficulties. the other issue is making sure the child well care -- welfare system is able to screen for
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trauma. they know how to makes resources available to them and really engage in efforts in working with these families, and the entire system from the front door that you walk into at child welfare program to the way that caseworkers are dealing with them, and the caseworkers themselves are often very overwhelmed with the numbers they see. they often have secondary traumatic stress, so the whole system really has to be addressed to help you trauma informed as well. representative lawrence: thank you so much. >> congressman hardy. representative party: thank you so much for posting this hearing, and thank you to the
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witnesses for contributing their testimony. i discussed provider shortages before, and i know congresswoman bustos touch on some of the challenges that our districts chair in rural areas, but i think the mental health shortage is incredibly acute. for every five mental health practitioners per 100,000 people there are in california, there's only three in my district. it is close to half where we have core providers per capita, and obviously, that has gotten worse during this pandemic where mental health needs for many of our constituents, especially the students and family members we have been talking about during this hearing, and i think that really is a profound statement on our values and being able to deliver appropriate and effective mental health treatments in rural areas. mr. stringer, and give -- i'm
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curious about your experience, given that you worked with the department of public health. can you give exams of how you and other state apartments succeeded in the long-term attraction and retention of mental health providers and what should be done by the committee to continue to bring us to that next level? mr. stringer: thank you for the question. i wish i had a better answer. we have done some things to make the situation better. one example is we have a critical shortage of child psychiatrists in missouri and around the country, so we work with the university of missouri columbia to develop what is called the child psychiatry access program where physicians across the state can sign up for this and a pediatrician who has a behavioral health problem in his office in northwest missouri can call or be on the phone or webex with a child psychiatrist at the university of missouri for consultation.
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i think it is things like that that art deco training programs that are helpful. it is just going to involve multiple things. in terms of the committee, you have already been really good about educational reimbursement and things like that. i think we have to take a multifaceted approach to this. part of it is certainly helping folks with tuition and things like that. representative harder: thank you. one of the models we have seen successful in our area is a program which is essentially community health workers targeted for the latino community, oftentimes the front line of the mental health challenges that we have seen, especially in this pandemic. i'm curious where folks have seen that model been successful,
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and what opportunities we might have to continue to scale up those sources of community health workers, especially in communities of color, to make sure we can cater to mental health needs in a real community-centered approach. for any of our witnesses that have suggestions around that. mr. stringer: in missouri, we have certified peer specialists. that is a big part of the answer to the workforce shortage that can be done quickly. we have certified peer specialists work with our professionals. they are people who have had some training and have lived experience with an mental illness or substance use disorder, and they work hand-in-hand with our mental health professionals, and they will go to emergency rooms, for example. they will go to a variety of community settings for the purpose of outreaching and engaging people in services.
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representative harder: any other witnesses have any other suggestions? dr. graves: what i would add is there is a movement at the mental health field to do what is called task shifting. there are things we do in the mental health world that do not necessarily need a person that is trained at a masters or doctoral level. it sounds like that program is taking people who may not have the high levels of training but might be very effective at engaging people. i think those kinds of strategies are really critical. i also think that telehealth is extremely important, and audio telehealth, particularly in rural communities and frontier communities, which we often do not talk about, where people do not have the broadband bandwidth
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to do regular telehealth, so making sure that telehealth in general is available is really important to addressing the shortage. represent a harder: thank you, mr. evans. back to you, madam chair. >> we do not have time for a second round of questioning, but let me ask of congressman cole, are there any last-minute comments or questions that you might want to ask? representative called: i would like to wrap up by thanking you for the hearing. a lot of great questions and observations were raised. i want to thank our witnesses and apologize for the long day. we all had to go in and out.
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i'm sure you will be generous in forgiving us in that regard. number one, the consistency of thinking of a variety of perspectives in this panel. i was thinking over several hearings about the things we see over and over again, the disparate health care outcomes, the workforce shortages in a variety of areas, most of which do a very good job probably in taking care of the research end of this and maybe not as good a job in recovery. we all know of tremendous problems in terms of matching up our workforce with our needs and with our population. there's still a lot of serious issues that will take sustained investment over a lot of years,
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but that may be -- well, let me put it this way, this pandemic is certainly going to cast a long shadow. a situation where we got the vaccines and to get to where we can put this behind us, the panel made it very clear the consequences of this will linger a long time and affect a lot of individual americans in very negative ways. again, i just thank our witnesses. you were all very, very helpful in highlighting the areas that this committee needs to take into account and focus on in a bipartisan way, so with that said, madam chair, i yelled back. >> i would like to thank the ranking member for his comments and cooperation in the past on
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these issues, and i know we will have cooperation going forward. i, too, want to say thank you to all the witnesses for joining us today. you are laying out a blueprint, and we need to be mindful of that blueprint. the scope of the resources, etc. , related to dealing with how we will prioritize this area going forward because this is now just for the moment short-term, and it is important. you have elucidated shum of the -- some of the short-term benefits in the post pandemic and what we will live with. i say that because it is critically important. chernobyl, hurricane katrina, september 11 have given us
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evidence to show that elevated rates of mental health problems go beyond the initial event and sometimes last for more than a decade or beyond. this is a same, similar, long-term disaster and what you have laid out and what people are dealing with and what that has already translated into in overdose deaths, people thinking about suicide, so i think the emergency which we recognize -- i want the witnesses to know we recognize the urgency and action that we need to take if we want to make an impact. we also know that we have a system that was already struggling over trying to meet the existing needs of mental health, but it was not front and center. in so many ways, what this
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pandemic has done is to really expose the shortcomings in our various systems, on implement insurance, public health infrastructure, health care disparities. all of these have and just exposed and exacerbated because of the pandemic. how we deal with improving the pipeline of providers and then how we look at the services, and i do want to mention this. just a summary to the ranking member. most of these issues fall in the valley week of this committee. the population health approach, which dr. evans spoke about. working with communities to identify someone with a problem
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before it becomes a crisis, and look at it in terms of populations that we know may be potentially at risk. we are talking about african-american communities, underserved communities, postpartum moms, you know, etc. a number of areas. so which part of the population and how we deal with that? it is not cookie-cutter. increase funding for school-based mental health. increased access for evidence-based,-informed care. we need to hear from all of you about us practices on trauma-enforced training. help us with that so we put the money in the right places. resources, you have been consistent on the block grant
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program, which is something that you all believe is a direction we need to go in. funding for resource programs that address the provider shortage, which is critical. prioritizing the needs of at risk, vulnerable groups, children and adults. that goes back to the population approach. increased integration of mental and physical health, and i will tell you because these are pieces we are funding already and we need to take a hard look at the certified community behavioral health clinics moving us toward this goal. the national center for child trauma and stress. this is working, and we need to be able to sustain grantees with funding, an important part of
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the long-term response. looking at samsung -- samsa and their role as the lead coordinating agency. how do we reduce stigma on all of this? it may be unfortunately that this is such a widespread issue at the moment that the issue of stigma may be lessened because we are going to see this short-term and long-term so people understand it, and one of the things to pay close attention to is at least the data now shows that the suicide rates have not really increased. however, there has been an increase in people thinking about suicide, and as i understand it -- and i'm not a professional in this area, but after the event is over, you see
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increased suicide as a result of what happened. it may not be happening now, but we are going to see that. there are a number of these issues -- a couple of them, telemedicine are issues, medicare, medicaid, that you talked about, and mr. stringer, i know we voted on it, but it has not yet been implemented. everyone is alerted to the medicare and medicaid expansion really being helpful because then you can take resources and use them elsewhere, which is so critically important. but telemedicine, medicare, medicaid, it is not part of our jurisdiction, but we can certainly have an impact on the committees and subcommittees that do have that jurisdiction. i cannot thank you enough really
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for what you do every single day , and what we want to do is be partners with you, and i don't want the conversation to end after this hearing, but as we look toward the appropriations bill for 2022, we would like to be able to take advantage of your knowledge and expertise in where we place -- the resources are not unlimited, but help us to identify where we can utilize our resources in the best way to address short-term, long-term, and use this as an opportunity to build some of the architecture in this area that we need to have for the future. again, my thanks to all of you and to all the members of the subcommittee, in particular to our ranking member, for your
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interest in this area. we are going to move at it and be in touch with you, but don't hesitate to be in hosted by amen
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university. >> welcome to a conversation with house majority whip james clyburn. i'm david barker, president -- professor of government here a you and the director of the center for presidential studies -- we are thrilled to host a cement tonight -- event tonight. we are honored to be joined by someone who has been strengthening that square for several decades. whether you want to call him a kingmaker or a washington whisperer or something else, , congressman clyburn showed his last year that his voice might be the most influential one in the entire democratic party. when he talks, people listen.

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