Parting Thoughts From a Former Lund Reporter

From patients to prisoners, reform efforts raise questions as large as the changes they propose
The Lund Report
April 14, 2011 -- I left Salem and the healthcare beat at The Lund Report last week for a long-term reporting gig on the California coast, but Monday night I once again found myself furiously jotting down notes on legislation.
 
Much like the special subcommittee of Oregon legislators who are meting out a healthcare transformation law as we speak, the Golden State's leaders are making changes in the public safety arena that are characterized by Monterey County officials as "profound" and "transformative." And much like the county leadership in Oregon reacted when presented with a proposal that seemingly addressed state budgetary issues without assessing their social impact on counties and municipalities, the reactions of Monterey County's public safety leaders to said changes were characterized by pessimism and concern.
 
On April 4, California Governor Jerry Brown signed into law AB 109, which will in effect shift the responsibility of dealing with low-level offenders from the state Department of Corrections to county jails and juvenile facilities.
 
The intent of the bill is clear: to shave an estimated $13 billion off of the state's nearly $27 billion shortfall by releasing thousands of inmates into supposedly cheaper county care. But local law enforcement, district attorneys and juvenile justice staff fear its consequences could be dire, especially given the budget cuts and layoffs they must implement before or in tandem with the governor's mandate. Fears of increased crime and recidivism - the county already boasts a staggering 80 percent rate of repeat offenses - loom large.
 
Oregon's healthcare transformation process is significantly different from California's "prison realignment" plan, but certain parallels are striking. Governor John Kitzhaber, aided by the recommendations of his Health System Transformation Team, is calling for counties to work with the state to achieve the "triple aim" objectives of better health, better care and better costs for patients while simultaneously slashing the Department of Human Services budget by nearly 40 percent and mandating 19 percent reimbursement cuts to healthcare providers who serve Medicare and Medicaid patients.
 
Many of Oregon's county human services and mental health providers are struggling with the cognitive dissonance of Kitzhaber's triple aim, as well as envisioning just how they will provide even the bare minimum of services to their neediest and highest-risk populations.
 
"The hard reality to come is how will the state take the citizens whose health it is responsible for, and both cut costs dramatically, improve the quality of care, and do this immediately, with a budget crisis breathing down the state's neck," said Dr. John Hassett, a physician with AAIM Care in Portland.
 
Similarly, Monterey County District Attorney Dean Flippo noted, "This [legislation] was not planned with the thoughts of the safety of the citizenry in mind; it was generated by budget concerns."
 
Another common thread between the states' situations is the as-yet unanswered question of just how counties will be impacted by these statewide reforms.
 
In a stark embodiment of the old adage "all politics is local," Monterey County officials broke down AB 109's directives in the context of their municipal realities. The bill asks county Sheriff Scott Miller to assume control of more low-level offenders, which could mean stuffing more inmates into an already overcrowded jail that, in his words, "is a crumbling facility by all accounts."
 
The jam-packing of inmates into substandard facilities is but one bone of contention between local officials and the state. Manuel Real, the county's chief probation officer, is concerned about "getting sustainable funding to operate outcomes-based programs" that aim to prevent people from committing crimes and doing time.
 
The governor has pledged funding for community-based crime prevention programs - programs that Monterey County, whose recidivism rate is nearly 80 percent, desperately needs -, but AB 109 does not identify a source for that funding. This has Real and other officials worried that it's an unfunded mandate that will decimate public safety in the name of short-term savings.
 
In Oregon, the recently released budget from the Ways and Means co-chairs calls for significant cuts to state programs that also give funding to county-level public health, safety and community mental health programs. (True, the plan drawn up by the Health System Transformation Team promises roughly $34 million in savings, but given the size of the local and state budget holes, many contend that's nowhere near enough to offset the coming cuts.)
 
 With counties facing their own deficits, and with no real direction from the state on how to implement integrated, evidence-based care with fewer resources, local officials and advocates are fearful that hard-won successes in community-based healthcare will be undermined by Oregon's attempt at large-scale reform.
 
"County mental health programs … have been successful in dramatically reducing costs while improving the care of the target population and reinvesting all savings in improving access and quality of mental health care to a broader range of citizens," said Jan Kaplan, director of Curry County Health and Human Services. "Transformation will either enhance (or maintain) these triple aim successes or could seriously damage the infrastructure that has attained them."
 
"We fail to see how any 'savings' that might allege to have accrued from these efforts would be re-invested in our home & community-based long term care system," added Jerry Cohen, the Oregon state director for AARP.
 
Then there's the question of timing. Both California and Oregon are attempting to implement massive changes in an extremely small timeframe, but there appears to be very little coordination between the state, county and municipal budget schedules, and how those concurrently align (or collide) with application deadlines for federal waivers that will be needed to implement the aforementioned changes.
 
Marina Police Chief Edmundo Rodriguez characterized the public safety situation in his city as "a perfect storm;" Oregon healthcare stakeholders have echoed this sentiment at numerous public healthcare meetings, and in interviews with The Lund Report.
 
One thing everyone can agree on, however, is that there's no shying away from the current fiscal crisis and the coming deficits that loom large over legislators and stakeholders alike. That's why leaders in California and Oregon are encouraging citizens to get involved.
 
Scores of Oregonians have been writing letters to legislators, testifying at budget hearings and rallying on the Capitol steps. At Manday's prison realignment meeting, Rodriguez stressed that "The public needs to do their part as well." He implored those present to "have conversations with your state reps to make sure your opinion is expressed and known."
 
As a normally neutral journalist, I don't advocate for activism through my work. But for once, I'm going to break ranks and echo Rodriguez. Readers, your opinions do matter. Oregon is embarking on the most significant overhaul of its healthcare system in decades, and your well-being hangs in the balance. Educate yourself about the issues. Ask the tough questions. Call your representatives and make your voices heard. And continue to send your story ideas and on-the-ground observations to The Lund Report. We’re committed to telling the stories that matter, and no one knows them better than you.
 
Rebecca Robinson is now a staff writer for Monterey County Weekly, an independently owned alternative newsweekly covering communities on California's central coast.

 

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Re-Thinking Psychiatry is a symposium coming up, to be held at the downtown Unitarian Church facility in May. Robert Whitaker, author of Anatomy of an Epidemic will be speaking here in Portland again, sponsored by a wide range of groups interested in a recovery model for emotional challenges. The issue of excess disability and inappropriate treatment has been troubling to consumers and direct-care workers for some time. In addition, the practice of taking emotionally troubled people to emergency rooms makes little sense. Holding people in rooms with sophisticated medical equipment for long periods is a waste at best, unless there are true medical issues in addition to the emotional issues. With government lay-offs, some properties controlled by governments are under-utilized but still heated, ventilated, and cooled. In addition, in these times of high unemployment, volunteers and peers may be highly motivated to conduct goals-groups and other programs designed to help people recover. If Trieste, Italy, can have a recovery-through-work program that contributes taxes, it is quite difficult for me to understand why we can't have such a program here. If Northern Finland can send two care workers to family calls for assistance, early in a potential crisis, and resolve issues with better outcomes than ours, we could move more quickly to make such programs available here. To some extent, we have some of these resources now, but it is in the private sector and is as yet unavailable in the public sector. We also need a prescription-auditing program that makes sure pain is sufficiently medicated, but that over-medication is not allowed to continue beyond the cautionary warnings in medication inserts, as a beginning. Oregon does better on the issue of under-medication of pain, which carries risk of suicide and other poor outcomes. We may do a bit better on over-medication as well, but the U.S. in general is not good on this issue, and there is likely much improvement that can be made. Last, but not least by a long shot, we need to start trusting everyday Oregonians to choose gatekeepers. I would choose the the Traditional Chinese Medical Practitioner who has gotten me through the winter without major virus issues and with help for my arthritis that did not involve stomach and kidney pain. The side effects I am saved beyond those my parents suffered are truly remarkable. While we have over-burdened family-practice M.D.'s, if we apportion those elders (which I am) to a wider circle of practitioners that consumers can choose as gate-keepers, we open the practice of M.D.'s for those who choose that way. I see little risk in pilot-projecting this sort of direction. I take responsibility for myself when I choose my gatekeeper, and I would be happy to sign a waiver saying exactly that. What's more, if I am willing to be public about that, I open another avenue for someone else to see if what I do will work for them, at lesser cost than the present system. If that means someone else has a lesser wait to be seen by someone of her choice, we all win, so far as I can see.