One of Multnomah County’s newest commissioners ran for office on a platform that included improving the community’s safety net, with a focus on healthcare, mental health and homelessness – all drawing on her background as an emergency room physician. Now that Dr. Sharon Meieran has been sworn in and reported for duty on the county’s all-woman governing board, she’s starting to grapple with the how to turn those ideals into policy.
Meieran, who hopes to continue working at least a few shifts each month at Kaiser Sunnyside Hospital, recently sat down with The Lund Report to discuss what she’s learned on the job so far, and how she hopes Multnomah County can improve.
The following questions and answers combine Meieran’s responses to questions asked during an in-person interview, as well as additional thoughts she sent by email. It’s been edited for length and clarity.
The Lund Report: Thanks for agreeing to see us on your first week of fully staffed operations after the snow. Before we get into the issues, do you mind if we get into your background – your personal background?
Meieran: I was a lawyer for seven years. Then I went to medical school. I was planning to go into psychiatry. There’s a long story about that transition – but when you graduate from medical school, you decide on your specialty. I decided on emergency medicine. I finished my four-year residency in Cincinnati in 2006, and I’ve been practicing in the ER since then, out here..
This is your first month on the job. Some of your early days, you couldn’t get into the office because of snow. Are you starting to adjust your expectations, your hopes, your priorities as you settle in?
It was an interesting couple of first weeks on the job. There’s a learning curve, obviously, with any new job. It's been exciting, interesting, and really inspiring to be around the energy of this Board of Commissioners.
The breadth and depth of what the county does is staggering, and I've been learning a lot about county functions, services, roles, and relationships to the broader community. As far as adjusting expectations, I'd say I'm trying to build my expectations by learning first, and using what I learn about strengths and gaps to inform the things I'd like to do in my new role.
You campaigned, in part, on healthcare, mental health care, homelessness. What’s the county’s role in these areas, and what could we be doing better?
The county plays a key role in delivering essential physical and behavioral health services to residents through clinics, pharmacy and dental services, immunizations, pregnancy support, inpatient and residential treatment, crisis services, transitional housing, and much more. We do this directly, as well as through contracts and partnerships with local coordinated care organizations (CCOs), service providers;
and other community based organizations. The way we pay for and provide these services is varied-- although a share of funding is county-based revenue, some of how we support important services comes through direct federal funding sources, some of it is supported by funding we receive from the state (including state funds and pass-through funding such as Medicaid).
So changes at the federal level may impact grants, state funding, and healthcare policy that affects who's covered and what's covered by insurance. This means the county could have essential programs with insufficient funding, and potentially increased demand. These are all really big unknowns, so the county will have to be vigilant, thoughtful, and resourceful about how we will make sure people can still rely on the county for essential services, when the payment options might shift substantially.
It sounds like some of what you do within the county may be legislative – voting on something – but some of this might be working behind the scenes, using the power of your seat, being a moral force, talking to people, getting people to work together. Is that right?
That’s absolutely some of it. I do not come at this from being a politician. I came at it as a citizen, looking at what’s going on with our systems and being curious – why don’t things seem to work better together. The initial process is exploring where those disconnects are. As a county commissioner, you are in a better position to look into it.
I want to ask about opioid addiction, which is a big problem both nationally and here, and which you talked about during your campaign. What have you seen through your practice?
This is something that has been going on for many years. It’s a complex issue. I was president of our Oregon College of Emergency Physicians, our state advocacy organization. Because we’re kind of a canary in the coal mine, we recognized this was a big issue early on. We’ve been trying to sound the alarm. We were some of the first to come up with statewide prescribing guidelines and considerations of safety and coordinating between different emergency departments. We were at the forefront of this epidemic for years, sounding the alarm. Finally, governments and the media have started to respond and acknowledge the scope and extent of the issue.
I’m concerned that this is a pendulum that has been swinging for decades. Historically, even people with cancer or severe chronic pain conditions could not get access to these very helpful medications because of fear of becoming addicted.
That shifted. The pendulum swung to giving everyone opioids. It’s what we were taught in medical school. When I moved to Oregon, we had to do mandatory education on pain control – which basically amounted to, ‘Give them opioids.’
The evidence isn’t there. These medications are effective in certain situations. They can be very effective. But there are other modalities to treat chronic pain. A lot of the issue is, there’s not insurance coverage for those modalities – for example, acupuncture, massage, physical therapy.
When people do become addicted, there’s no addiction services. You can’t stop giving them painkillers, or you’ll have people go into active withdrawal.
Most people who chronically use opioids started with a pain-related condition that their doctor prescribed for, and that use continues. There’s a lot of mythology around issues of opioid use and abuse and addiction.
Now, governments and political entities are starting to legislate how to prescribe and what can be prescribed. The pendulum is swinging back again. We need a rational, evidence-based best practice, to appropriately use these medications, which can be effective to treat chronic pain.
You’ve outlined how we got here and some of the paths forward. What does that mean at the county level?
Through the public health department and the work of Dr. Paul Lewis, health officer for Multnomah County, the county has been at the forefront of a lot of the efforts to address the opioid abuse epidemic in a rational way, working with the state to develop statewide guidelines.
It’s a matter of working with our public health department and patients and CCOs and different organizations, to ensure that what we do in Multnomah County is based on best practices, and that we provide appropriate services and alternatives to people. To the extent this is relevant at the state legislative level, which I believe it will be, I hope to advocate as both a physician and county commissioner, regarding these issues.
What are some of your priorities around mental health and addiction as these issues relate to homelessness?
Meaningful access to services. Some great people are providing great services, but not enough to meet the demand that’s out there, and maybe not enough meeting people where they are at. These are people who are the most vulnerable, who have significant difficulty reaching out to access services, particularly if they don’t have a roof over their head. Our responsibility is to reach out where they are and provide services necessary, to get them effective treatment so they can get back on their feet.
We’ve been abysmal at providing crisis services, as a county and as a nation. We treat them in jails, in the ER or leave the on the street. The Unity Center, which opens at the end of this month, is very exciting, because this is an opportunity to provide services to people in crisis, and to the extent that we have services available in the community, to provide outreach to people while they are recovering from a crisis, so we can work on the next crisis – connect them to housing, services or whatever we need. That is a real paradigm shift for how we treat people in mental health crisis.
We had a recent story in local media about a homeless woman whose child was born stillborn, and it appears that this woman had untreated schizophrenia. If this woman doesn’t want to be on medication or seek treatment, that’s her choice unless she’s a danger to herself or others. Is there a role the county can play there? That seems to be a not insignificant portion of the homeless population – people who may not want treatment if it would force them onto pills.
That is a huge dilemma. This is an area that we need to be actively exploring right now, in conjunction with the city and with the state, coordinating our resources. An issue I grapple with as a physician, is that that very difficult line between not wanting to infringe on someone’s individual rights, but at what point do they become a danger to themselves or others to the extent that you do need to take more control? We need to explore that as a community. We need to involve people with lived experience of mental illness, in addition to providers of mental health care services, law enforcement, and different health care organizations, to figure out that balance.
As a county commissioner with a deep insight into this area, I can play a role in convening some of these groups and being an active mediator of these conversations.
Outside of mental health and addictions, what are some of the issues you see tied to homelessness?
I think our state and our region's housing affordability crisis is driving a lot of issues we see related to homelessness-- every point along the spectrum is pinched, from shelter capacity, to transitional and temporary housing, to rental assistance programs, to out-of-reach market rents and unpredictable disruptions in tenancy for many individuals and families. It's a major priority of the county to take action on housing at the state and local level, and it's something I'll be focused on.
Nobody knows what is going to happen to healthcare in the United States – if the Affordable Care Act will be repealed, if it will be replaced, what the new rules are going to be. How does that affect your ability to act? Do you have to put everything on hold until you know what’s going on, or can you move forward when so much is in turmoil?
Your guess is as good as mine as to what is going to happen federally with regard to the Affordable Care Act. There are so many unanswered questions. Our job now is just to move forward and provide the services we have already provided, to our vulnerable population, and follow closely what’s going on.
What heartens me is that Oregon has been a real leader in healthcare transformation from before the Affordable Care Act. We have a strong track record of innovation, which I think will put us in good standing, as good a standing as there can be, given what may come down the pipe.
Whether it’s codifying in legislation some of the requirements the Affordable Care Act at a state level, or however we decide to approach it, for right now I know that at a state level, and absolutely at a county level, we are dedicated to providing essential services to the most vulnerable.
What other health issues are priorities for you?
Unintended pregnancy rates in Multnomah County, in Oregon, in the United States in general are substantial. Over the past three decades, close to 50 percent of pregnancies are unintended, which is a shocking number. When a pregnancy is unintended, by the time a woman realizes she’s pregnant it’s too late for some interventions which could enable this pregnancy to be more healthy, to improve birth outcomes, to improve infant mortality. Unintended pregnancy is a much higher risk for congenital birth defects, for complicated deliveries, and it’s one of the leading causes of intergenerational cycles of poverty. It’s particularly high for low-income women and women of color.
Before coming to the county, I did a lot of work as medical director of the Oregon Foundation for Reproductive Health. They did focus groups with hundreds of women across Oregon, and hundreds of primary care providers, asking how you talk about pregnancy intention. We found that primary care providers don’t really talk about this. If it’s pregnancy stuff, patients are expected to talk to another provider. We ask women how they talk to their provider about pregnancy or birth control, they say, ‘We don’t talk about that unless they ask.’
There was this huge disconnect. So we asked, what would happen if we routinely asked women in primary care, of childbearing age, ‘Would you like to become pregnant in the next year?’
If yes, great, let’s make this the healthiest pregnancy possible – here’s some folic acid, let’s get your diabetes under control. If not, great, there’s some very effective methods of contraception out there, let’s find one that meets your needs. You are equally embracing a woman’s choice to become pregnant or not to become pregnant. This facilitates conversations about domestic violence, mental health, substance abuse and many other important issues.
Our pilot studies showed that women love to be asked the question. That has taken off nationally and in some regions of Oregon. I think that’s an important conversation to be having in Multnomah County. It ties into the anti-poverty mission of the county, and will help women and families.
Another key physical health priority of mine is "Tobacco 21"-- raising the age at which a person can legally purchase tobacco from 18 to 21. Multnomah County has been exploring this idea at the local level, and this "T 21" policy is something the Legislature is also considering. Tobacco use is the leading preventable cause of premature death in America, and we know many addictions start early. Policy like this can save lives, and it's fiscally smart. I'm very interested in keeping the momentum going around local and/or statewide efforts in this arena.
Do you have other priorities beyond what we’ve discussed?
I’m also very interested in public safety, including use of force against people in mental health crisis. In our jails, a significant population has mental health or addiction issues, which crosses over. I’m interested in disaster preparedness. We’re in the Cascadia Subduction Zone for earthquake risk. We need to prepare for that. It all ties together.
You’ve been very civically engaged over the years. Now that you are in this elected office, are you going to have to pull back from some of the groups you’re involved with?
Probably. I’ve been working closely with the county attorney to make sure I fully disclose everything I’m involved with, and that nothing I’m involved with is in conflict with my role as a county commissioner.
Thank you so much for your time.
You’re welcome.
--- Reach Courtney Sherwood at [email protected]. Follow her on Twitter at @csherwood.
