A revolt by Oregon’s biggest counties —and smaller ones too — has caused the Oregon Health Authority to push back a deadline to renew a key legal agreement dictating how behavioral health services are delivered to Oregonians.
Oregon Health Authority officials had been trying to rewrite the six-year contract spelling out how counties spend money received from the state. In essence the changes would enlist counties’ help in a way that would limit state officials’ exposure to embarrassing contempt fines issued by a federal judge, by reducing the time that mentally ill people are stuck in jail without treatment.
In short, with the Oregon State Hospital routinely failing to meet court orders to admit patients on a timely basis, state health officials want counties to pick up the slack — and prioritize services to those criminal defendants over others needing mental health services.
Counties, however, complained that the state’s changes would lead to cutting services for vulnerable people and increase the costs passed onto local governments. Not only that, they say it would create an unfunded mandate and tie locals’ hands in how they operate an array of mandated local behavioral health and substance use disorder programs.
In response to the county’s concerns, the state announced Friday that it was extending the signing deadline by six months, giving the state and county officials until Dec. 31 to negotiate more amenable terms. The state had wanted to have the agreements signed by July 1, but no counties have signed on. The current financial agreements would be extended until the new one is signed.
“The current CFAA draft is not acceptable as it will harm some of the most vulnerable people in our community,” Marion County spokesperson Jon Heynen told The Lund Report. “Marion County will continue to work with other counties to push hard for needed changes.”
The financial agreement in question is the basis for local contracts with community mental health providers who form the network of behavioral health services across the state. Those providers are often county agencies, but also include tribal organizations and private nonprofit providers.
In the proposed agreement, the state wants counties to prioritize court-ordered patients, including the “aid and assist” population who need treatment to be restored to mental competency before facing criminal charges in court. Aid and assist criminal defendants are now the largest population at the state hospital, surpassing civilly committed patients and overwhelming the hospital’s capacity.
“If we have to prioritize certain populations with no funding limits, based upon what the state gives us, we can, in essence, create other crises because we won't have the funds to pay for those other types of services,” said Anthony Jordan, interim behavioral health director with Multnomah County.
Jordan listed off numerous services that would get second or lower consideration, including safety net services, crisis care, youth services, and prevention and substance use disorder programs. If prevention programs are reduced in order to keep the focus on the state’s hospital’s priorities, the unintended result could be creating even more patients for the state hospital, Jordan said.
“In Multnomah County, we have a high-need population for behavioral health,” Jordan said. ‘We would have to try to find some other ways to fund those services.”
A cost study commissioned by the Oregon Health Authority released in December found a $32.4 million gap between funds provided by the state and the costs to counties of fulfilling state-mandated programs.
The state’s new two-year budget provides $400 million for community mental health provider services.
State hospital woes trickle down
The state hospital’s problems have had a ripple effect across the state.
For two decades, the state’s largest psychiatric facility has been the subject of court scrutiny due to continued failures to admit patients within a week of being found unable to aid and assist in their own criminal defense. It has also been the focus of disturbing reports over its operations, staffing and safety issues, including the deaths of three patients there in the past year.
A controversial federal ruling in 2022 tried to alleviate capacity problems by setting discharge deadlines for certain patients based on their charges or criminal record, regardless of whether they’d been successfully restored to stand trial. While the move opened up beds at the hospital by moving patients out, it also put a strain on local behavioral health workers and created what some called a revolving door of people who reoffend only to go to jail and undergo a new round of evaluation and oversight by local officials.
Frontline programs administered by community mental health providers were already struggling to keep up with the increasing need for services.
Earlier this month, a federal judge ruled the hospital was in contempt for failing to timely admit criminal defendants, and ordered the state to pay $500 a day for each person who spends more than a week in jail after being ruled incompetent to stand trial. The state is appealing the order.
The state’s effort to make counties and community mental health programs address the contempt order jeopardizes the quality of care in the larger state system and will exclude vulnerable patients from being able to receive care, according Chris Bouneff of the Oregon chapter of the National Alliance on Mental Illness. He said the state is letting a federal case focusing on just one subset of patients dictate conditions affecting all the others. Because while the state is under pressure to meet the court order and address “forensic” facing charges, there is no penalty for not serving the other people in the community.
“The court doesn't care about civil patients; the court cares about forensic patients, and that's it,” Bouneff said, adding that the way things are going, “we will reach a point that the only way to enter into any acute services in the state of Oregon is through the criminal justice system.”
Already, separate from its contract with counties, the state has ordered residential treatment facilities located around Oregon to prioritize care for criminal defendants released by the Oregon State Hospital, prompting fears of poor outcomes and unsafe conditions for patients.
Said Bouneff, “For community residential right now, the first in line to access those services is somebody coming out of the state hospital. The only people coming out of the state hospital are forensic patients, people in the criminal justice system. Pretty soon, all that capacity will fill up, and that means that we will have no resources really focused on keeping people out of the criminal justice system. We will just have this singular focus on the criminal justice system.”
Not enough state money to go around
A recording of an April 30 meeting between state and county officials obtained through a public records request showed showed that the language proposed by the state would put counties on the hook for providing services even if their state funding ran out.
Rob Sinnott, an attorney for Multnomah County, also indicated that the state’s proposed contract appeared to conflict with state law.. “Our obligation ends if there’s no funding, and that’s essentially what the legislature has said,” Sinnott said at the April meeting.
Responding to questions from The Lund Report, the Oregon Health Authority cited a provision in the proposed agreement asserting that counties are not required to use local funds to fulfill the agreement.
Cherryl Ramirez is the executive director of the Association of Oregon Community Mental Health Programs, which was consulted in the drafting of the proposed agreement. She said at the April meeting that while the association agreed with changes that would increase flexibility for counties, they are concerned about the financial pressures and priorities placed on local service providers.
“Without additional funding, there’s only so much flexibility the medium to large counties will have,” Ramirez said at the meeting. “They could probably pour all of their money into aid and assist, and then they won’t be serving the rest of their community. And nobody wants that.”