UPDATE (10 a.m. PT) — As Oregon officials have scrambled in recent days to address a snarled mental health system, they've been clear: More people should be receiving care in their communities rather than being sent to the Oregon State Hospital.
But as a $23 billion budget for the Oregon Health Authority works its way to likely passage, mental health advocates around the state note an irony: Lawmakers are on the verge of cutting significant funding for the very kinds of programs Oregon wants to use more often.
Tucked into the OHA budget is a $15.4 million cut to county-based mental health programs. The money being axed, advocates say, is slated for efforts that might be most effective at keeping people out of the state hospital — safety net services like intervention when someone is in crisis, helping to divert people with mental health issues from the criminal justice system, and assistance keeping vulnerable people in housing.
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"It is unconscionable," said Multnomah County Commissioner Sharon Meieran, an emergency room doctor who has made mental health a focus as an officeholder. "Out of one side of their mouth, the Legislature is saying mental health is such a tremendous problem and we need to be doing everything we can to address our mental health system. Then they cut the resources to the communities on the ground. It makes no sense."
It’s possible the money is on the chopping block precisely because those programs are working.
State forecasters believe fewer people with severe mental illness will be civilly committed to state custody in coming years — a predicted caseload drop of 10.6%, or more than 100 clients per month.
The accuracy of similar forecasts has been questioned in years past, and forecasters acknowledge there’s a risk this one is “artificially low.” But according to the state’s funding formula, the prediction dictates that county-based mental health programs lose funding.
To those working within Oregon’s already overwhelmed mental health system, the connection makes little sense. While it’s true that lawmakers are investing millions more this year in efforts to stabilize people with mental health issues who find themselves in the criminal justice system, the programs potentially impacted by the $15 million cut serve a broader segment of the population.
Multnomah County, the largest recipient of the funds, estimates it could lose at least $3 million if state lawmakers approve the budget cuts. That’s around 13% of the county’s adult safety net funding, according to spokeswoman Julie Sullivan-Springhetti.
The money currently pays for a wide range of services — from a mental health call center and mobile outreach program to evaluations for possible civil commitment and programs that help keep people housed.
“The main impact for most of these reductions will be client assistance funding, which supports individuals with serious mental illness maintaining safely in the community,” Sullivan-Springhetti said. “Lots of folks could become homeless without these funds.”
The cuts would impact services around Oregon, according to Cherryl Ramirez, executive director of the Association of Oregon Community Mental Health Programs. The trade group represents 32 county-based mental health service providers throughout the state.
While Ramirez can’t say specifically how reduced funding might affect local service providers, she notes each one is bracing for impact. And she notes that budget cuts could result in higher state caseloads, as local programs are increasingly unable to intervene and steer people away from escalating crises and potential run-ins with the law.
“Some of our programs might have to cut the very services and supports that might prevent people from having to go to the state hospital or jail,” Ramirez said. “That would be unfortunate. Then the caseload would sure go up, but that’s not where we’re trying to go in the system.”
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Silas Halloran-Steiner, Yamhill County’s director of health and human services, told of a woman his staff worked with recently. At times suicidal, the woman looked to be on track to being civilly committed to state custody. Instead, Yamhill County enrolled her in peer-assisted crisis intervention and she is now set to graduate from a treatment program.
“We have an individual who otherwise could have been [placed] into the civil commitment process” if not for local care, said Halloran-Steiner, who estimated 5% of his agency's funding could disappear under state cuts.
Even the state’s top budget writers question the logic of the funding formula that ties reduced institutionalization to less money invested in community-based programs. The OHA’s budget this year includes instructions that the process be reviewed, with findings presented to lawmakers next year.
“I don’t disagree that this is weird,” said Sen. Elizabeth Steiner Hayward, D-Beaverton, a physician and one of three chairs of the Legislature’s budget committee. But, she added: “We’re stuck with the structure that we have.”
The proposed cuts come just as lawmakers and public health officials are emphasizing the necessity of more community-based resources in easing the state's mental health woes. The issue has come to a head as the Oregon State Hospital, the mental health facility run by the state health authority, has been flooded with criminal defendants deemed unable to assist in their own defense.
Under judges’ orders, the hospital is required to stabilize those defendants to the point they can understand the charges against them. But because the hospital is routinely full, it’s not able to accept these so-called “aid and assist” cases within the seven-day window set by a 2002 court ruling.
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"We have, as of today, 38 people who were waiting awaiting admission to the hospital," OHA director Patrick Allen told OPB's "Think Out Loud" on June 13. "About two dozen of those have been held longer than seven days. And on average right now we're admitting people after they've been in jail for about three and a half weeks."
Earlier this month, a Washington County judge found the hospital in contempt of court for not accepting aid-and-assist patients within that time frame. The hospital also faces a federal lawsuit.
The crisis could directly impact the funding for county-based programs, some advocates believe. After all, if there’s no space for new civil commitments, their numbers are bound to go down, and funding to local programs will follow.
“Is it well-care and healthy outcomes [reducing civil commitments]?" Halloran-Steiner asked. “If so, we should reinvest in the community. If it’s reduction of access … then I don’t think we want to cut community access or funding.”
In response to the court cases, Allen said the state hospital is opening up more beds for patients. But lawmakers also might steer money toward the issue. The OHA budget includes a nearly $8 million increase that Allen says will go to counties to help them stabilize “aid and assist” defendants locally.
Legislators are also considering Senate Bill 973, which would create a program in the Oregon Criminal Justice Commission aimed at reducing the interactions people with mental health problems have with the criminal justice system. The bill currently contains $10 million in grants that could be awarded to counties, tribes and regional partnerships.
“It’s important to emphasize that we’re making substantive investments,” said Steiner Hayward.
But to some who watch the system, the new money aimed at criminal defendants, while important, could be better targeted at preventing people with mental illness from being arrested to begin with.
“We’re putting some resources into stage four and ignoring stage zero,” said Sarah Radcliffe, managing attorney at Disability Rights Oregon. “What community mental health does is prevent people from actually reaching the jail door.”
When appearing on "Think Out Loud" last week, Allen did not appear aware that his agency was slated to receive $15.4 million less for county-based mental health programs next year. That amount is a vanishingly small piece of his agency’s $23 billion budget.
“I think the current status of that is that cut is not on the table, but some of these things change minute by minute,” Allen said. In fact, earlier that day, a budget subcommittee had adopted a recommended budget that included the cut.
Asked about the statement, OHA spokeswoman Saerom England said the agency hopes to backfill the cuts with funding from other places.
“OHA has other funding sources for mental health programs, including federal grants,” she said. “Unless something unexpected happens before our budget is finalized, we anticipate keeping county programs funded at current levels for at least 18 months.”
That might be the case, but lawmakers passing the OHA budget out of subcommittee last week voiced universal worry about the funding cuts.
“It just seems kind of ironic that we’re facing a state contempt of court in this issue, and we have decreasing budgets,” said Rep. Cedric Hayden, R-Roseburg.
Rep. Rob Nosse, D-Portland, agreed, calling it “a problematic area of our budget.”
But lawmakers also say this isn’t the end of the story. Steiner Hayward said that the Legislature wants to hear more from counties in coming months to determine whether data suggests more money needs to be put to county programs. That could happen via budget adjustments moving forward.
That sentiment was echoed by Sen. Lee Beyer, D-Springfield, when lawmakers passed the OHA budget — cuts and all — out of subcommittee last week.
“For me, this is an area of discomfort,” Beyer said. “I am not real happy with this piece. But there’s work that is going on to fix this and I suspect we’ll hear back between now and the start of the next session.”