When Gov. Kate Brown set up her Behavioral Health Advisory Council in October 2019, advocates and medical professionals hoped Oregon would finally spark meaningful change in a system plagued with failure.
The state recruited several dozen people from across government, the behavioral health sector and advocacy groups. Physicians, Oregon Health Authority experts and behavioral health providers, including executives from Unity Center for Behavioral Health, Cascadia Behavioral Healthcare and PacificSource Community Solutions, teamed up. Brown’s executive order gave a lofty charge to the council: By this October, produce an “action plan” for Oregon’s behavioral health system, one with “concrete actions, policies and potential investments” for people with serious mental illness and substance abuse disorders.
So far, though, it’s turning into another missed opportunity.
The state is terminating the effort early and has offered the council a hastily developed plan that some members see as inadequate.
Some participants in the 35-person council are dismayed that they didn’t have a chance to provide enough input into the plan, and they are worried their work will end without accomplishing substantial change.
Steve Allen, the authority’s behavioral health director, announced that the council would end its work in July without accomplishing everything it set out to do. He gave two reasons: The council had missed meetings due to the pandemic; and the authority and Brown want to examine the state’s behavioral health policy through “an equity lens” that ensures access for all communities, including minorities and people of color. Oregon, like many other states, has prioritized racial equity in the wake of the death of George Floyd and protests for racial justice.
The council’s goal from the start was to get policy and budget ideas to the governor to potentially put into her budget proposal during the 2021 legislative session, which sets the next two-year budget. The council can still send something to the governor’s office, but time is running short and it will not be as sweeping as members originally hoped.
No one disputes the need for equity. At same time, some council members say there is a sense of betrayal and a squandered opportunity to reform the state’s behavioral health system. They had higher hopes for a state that consistently ranks at or near the bottom of the ladder in national ratings by the respected nonprofit group Mental Health America.
Oregon’s problems run the gamut. Patients lack access to care, and there is a shortage of outpatient community mental health programs. Such programs can help keep people out of jail and the Oregon State Hospital. Residential programs and the state hospital face a constant demand for services, and recruiting staff to work in these high-pressure environments can be difficult.
To advance, advocates say, the state needs to go beyond advisory bodies and red tape and spend more time talking directly to patients.
“Until they’re willing to roll up their sleeves and come down off their mountain and go to where the people are, I can’t see them responding” in a meaningful way, said Chris Bouneff, a council member and executive director of the National Alliance For Mental Illness Oregon. “It’s absolutely critical that those in power dispose with formal advisory bodies and really look at this as what it is: It’s an actual customer transaction.”
State officials hope to salvage the council’s work. At its July 13 meeting via Zoom, Brown made an appearance to thank members for their work. She also acknowledged that she’s aware of the “sadness, frustration and maybe a little bit of anger about closing this process out.” She said she appreciated the group sharing its expertise and promised that its work would play a key role in her plans.
In reality, Brown’s comments drastically understated the frustration and communication breakdowns. The misfire was epic: State officials drew up a plan to spend $200 million of state and federal taxpayer money on different behavioral health programs and services and presented it to the council for its blessing at its July 13 meeting.
The intent was to give the council an accomplishment of sorts despite a premature end. Instead, skeptical council members were dissatisfied and surprised. They demanded more details and publicly blasted the spending plan as vague and inadequate, falling short of their original mandate.
Now, council members wonder what the future holds, both for the group and behavioral health care reforms in Oregon.
“I felt that (with the council) there was an opportunity that things might be done differently because so many of these people have been having these same conversations for years and are really tired of it frankly,” said Dr. Sharon Meieran, a council member and a Multnomah County commissioner and emergency room physician.
Meanwhile, top officials at the Oregon Health Authority and the governor’s office are scrambling to repair the damage and explain themselves.
Council’s Work Unravels
Full of enthusiasm, the council started monthly meetings in October 2019.
The state had a budget surplus and a new director of behavioral health, and the council had the backing of the governor, who’d declared that shoring up Oregon’s behavioral health system was a priority.
After the pandemic hit in March, they missed a couple monthly meetings, a move that allowed behavioral health providers in the group to shift their focus to COVID-19.
They met again on June 22. By then, the pandemic had sparked nationwide concerns about mental health as people lost jobs and were forced to avoid close social interaction. By then, protests in major cities across the nation, including Portland, had brought a focus on racial equity and justice.
Further, COVID-19 hit communities of color disproportionately. Both factors played a role in the authority’s pivot to make sure that everyone has access to health care.
Allen told the council that he had not done enough to incorporate equity and equal access to care into the council’s work, according to meeting notes and interviews with meeting participants. Tina Edlund, the senior health policy advisor for the governor, also spoke about the change in direction. She told the council it would need to restructure its work, according to meeting notes.
Allen told the council that it would need to finalize its policy option package in July and that the state’s work on behavioral health would move forward with a change in structure, membership and leadership, according to meeting notes. Attendees at the meeting described the atmosphere as surreal: They were stunned that the rug was being yanked out from under them. Meeting notes indicate one participant pushed back, saying that the state was fracturing the government’s response by ending the council and creating a new group with an equity focus.
The meeting on July 13 was even more chaotic. Some members said they were concerned that the $200 million proposal lacked critical details and would not substantively change the system. The council does not have the final say on how the state will spend money, but its endorsement would give added weight to any budget proposals lawmakers take up in 2021.
The council’s work to reach an agreement about what to support will continue at an August meeting.
The proposal includes expanded residential facilities for young adults up to age 25; 47 more residential beds for psychiatric care; money to keep 12 behavioral health clinics in a federal pilot program running; incentives for mental health professionals who work with rural and marginalized populations; and more housing support.
Members don’t dispute that Oregon needs more affordable housing, behavioral health services and worker incentives. But in interviews, they said the plan seemed designed simply to shovel more money into existing programs without substantive reforms.
For example, the plan has no money directly earmarked for substance abuse disorders, which troubles Dr. Reginald Richardson, who was hand-picked by Brown to be the executive director of the Oregon Drug and Alcohol Policy Commission.
“This is profoundly disappointing,” Richardson said at the meeting, when participants broke into several small groups to go over the proposal. A reporter with The Lund Report observed that group’s discussion via Zoom.
In an interview, Richardson said: “I think our system absolutely needs $200 million and more for mental health, but this is supposed to be a behavioral health council. Substance use disorders are not reflected in these large buckets.”
Richardson noted the Oregon Drug and Alcohol Policy Commission has a statewide strategic plan, but lacks the funding to put it in motion. He had hoped the council would push for that money. At this point, he said he doesn’t know what the next steps are, beyond trying to seek state dollars from the Legislature.
“That’s a really good question,” he said. ‘I’m not sure, to be quite frank with you. I don’t know.”
Path Forward Changes
The Oregon Health Authority and governor’s staff quickly realized they needed to make changes to gain support for the pared-down plan. They had hoped the council would approve the package at the July meeting, but have since scheduled a follow-up meeting for Aug. 10.
Last Thursday Steve Allen sent an email obtained by the Lund Report to committee members, notifying them of the meeting and stressing that the council can provide more feedback about the proposal.
The letter, signed by Allen and Edlund of the governor’s office, acknowledged that the group deserved “deeper insight and information” about the recommendations.
In an interview with The Lund Report, Allen said several factors played into the dynamic leading up to the July meeting. A key part, he said, is the timing. The pandemic forced the group to miss two months of meetings and the October deadline was approaching. Meanwhile, to emphasize equity in the behavioral health system, he said, would require too much time to meet that deadline. For example, the option of adding more people to the council would take too long, given the time constraints, he said.
The other complication is that the council originally planned to enter a second phase of its planning before the pandemic. That work would have examined programs and services and specialized areas like outcomes and data, payment structures and accountability, with an eye toward access.
During the first phase before the pandemic hit, the group worked in small groups, called “affinity groups,” which looked at issues tied to the workforce, housing and programs and services. That initial legwork was intense. The council examined 10 years of data and reports.
Allen said the groups came up with ideas, and authority budget staff assigned prices to them.
But he cited concerns that the proposals came out of the small groups within the council, and that the full body didn’t have a chance to hear all the conversations that went into each item.
In hindsight, Allen said the group needs more time to talk about the proposals. The next steps include explaining to the council how the pricing of items works, talking about the proposal details and prioritizing the items.
Allen said the authority misjudged the level of support on the council for the $200 million proposal..
“We got it wrong,” he said. “We moved in believing that we had general agreement from our members that that package of recommendations -- that they had fit with what they wanted … We clearly misjudged that.”
The governor’s office declined to make Edlund, who represents Brown, available for comment or an interview. In an email, Liz Merah, a spokeswoman for the governor, said behavioral health remains a priority for Brown.
“The work that needs to be done to address the disparities in Oregon’s behavioral health system is far from finished and, moving forward, our office will be continuing this work with a specific focus on putting equity at the center and serving communities who are most at-risk,” Merah said.
Allen said he understands the frustration of council members. Before the pandemic, the stars appeared to align in 2019 for behavioral health reform. The state had a healthy budget surplus, Brown ordered the council to get to work and Allen started as the new behavioral health director.
“Then bam -- right in the middle of it -- a pandemic,” Allen said.
Though council members understand that the pandemic affected the process they’re deeply disappointed that an endeavor that many of the top experts in Oregon worked on for months unraveled without helping patients who end up boarding in emergency rooms, for example, because there is no one to treat them and they have nowhere to go.
“I have seen the results of this as an emergency room physician, seeing people come into the emergency room department in a (mental health) crisis,” Meieran said.
You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1.
A large majority of the
A large majority of the Behavioral Health Advisory Council members are provider stakeholders eager to protect their turf. This is akin to inviting foxes to design a chicken coop.
The problem with Oregon's "Behavioral Health System" is access, access, access; to wraparound services as well as clinical care. This is because provision of these services is narrowly limited to just a few providers creating a bottleneck. If all patients could see whoever they want the problem would disappear. Providers (of both clinical and wraparound services) would have to accept the OHA Behavioral Fee Schedule for medicaid payment. All mental health providers in Oregon should be required to take medicaid and medicare patients up to 20% of their patient load at which point they could start a waiting list. Patients hospitalized on Aid and Assist Holds should have outpatient commitments and/or participate in mental health courts instead of inpatient hospitalizations. Governor Brown needs the balls to slice through the mental health Gordian knot and change the WHOLE system with no attention to provider or system stakeholders, only attending to the needs of patients. The way out is clear.