From the Lund Report, May 10, 2011

Clackamas County’s director of human services says the bill might cause the social safety net to “implode”

Those involved with Oregon’s county mental health services are extremely concerned that the legislature’s attempt to reform healthcare will decimate their ability to provide services for the mentally ill by taking away Medicaid funding.

As it is currently drafted, the transformation bill (House Bill 3650) doesn’t specify the relationship between counties and the “Coordinated Care Organizations” (CCOs) that would be responsible for integrating physical, oral and mental healthcare for Oregon Health Plan members and the dually eligible (those receiving both Medicaid and Medicare services).

“There’s nothing specific in the language that would say CCOs would have to contract with counties,” said Mark Nystrom, policy manager for the Association of Oregon Counties.

Inevitably, counties could lose Medicaid dollars to pay for mental healthcare services. “Without Medicaid funding, the system will collapse and those most in need of services will not receive them,” said Claudia Black, Multnomah County’s lobbyist.

Oregon’s counties receive Medicaid dollars and funding from the state’s general fund, and use their own general funds, to provide mental health services. Those services may include residential care for people transitioning out of the Oregon State Hospital, case management, crisis services and supportive and wrap-around services.

County mental health advocates thus criticized the bill’s current version and are pleading with legislators to modify the bill and recognize their responsibility as a local mental health authority.

“We’re just hoping that we can work on language with you that recognizes our responsibility and coordinates with the CCOs,” Joanne Fuller, Multnomah County’s chief operating officer and immediate past director of county human services, told the Joint Committee on Health Care Transformation last Wednesday.

Cindy Becker, Clackamas County’s director of human services, feels “hopeful” legislators will amend the bill and allow counties to continue receiving funding for mental health services.

Otherwise, the consequences of leaving the most chronically and seriously mentally ill people untreated are dire.

“They don’t go away,” Becker said. “They go to the most expensive parts of the system. They go to the hospital, the emergency room, the Oregon State Hospital, jail and the morgue.”

Counties have statutory responsibility for all mentally ill people

Counties are statutorily required to provide all mental health services – not just to those on the Oregon Health Plan, and they invest $43 million of their general fund dollars, Nystrom said. Multnomah County spends nearly half that figure at $24 million.

Each county provides services differently. “It isn’t mandated how they provide the services, just that they provide it,” Nystrom said.

A county may provide all of the services, contract with a community organization, or a blend.

The Medicaid funds counties receive aren’t used strictly for Medicaid clients. Counties also serve the “indigent and uninsured,” which Nystrom estimated account for 30 percent of its population. They include the homeless, migrant workers and other marginalized populations.

“We serve the most vulnerable folks,” Becker said. “We’ve created local systems that really integrate services and funding for individuals regardless of their insurance status. People who are uninsured look exactly like those on the Oregon Health Plan. Their service needs don’t change.”

And while Medicaid funding might be used by counties to hire a mental health caseworker, that person doesn’t see Medicaid recipients exclusively—they may also provide treatment for indigent clients, Nystrom said. “You’re not going to improve the services by cutting out a source of funding.”

Mental health and the intersection of public safety

The counties also collaborate with the criminal justice and public safety systems to such a degree that Nystrom and others worry that taking mental health away from the county’s jurisdiction would jeopardize mentally ill people.

“We work very closely with public safety,” Becker said. “We provide behavioral health and mental health when people go to jail.”

“The relationship between community mental health departments and the judiciary [department] is very delicate,” said Sen. Alan Bates (D-Ashland).

The Portland Police Bureau’s Project Respond program, for instance, pairs mental health counselors with police officers who come into contact with mentally ill people who may be in crisis.

Funded by the city of Portland and Multnomah County, it’s unclear whether this program would be managed by CCOs or if there’d be enough funds left if Medicaid was stripped away.

Such collaborations “provide better health outcomes for individuals,” Nystrom said.

Community mental programs would become split

The result of taking Medicaid funding away from the counties would also result in a “bifurcated system,” Nystrom said.

Counties would continue to be responsible for treating the uninsured, while a CCO would provide services to Medicaid clients.

“We’d be duplicating services,” Nystrom said. “That doesn’t make any sense.”

And there aren’t enough county and state general fund dollars to fund the system. “[Those dollars] alone are unable to fund the system,” Becker said.

“I don’t know if any county can afford to do it on their own,” Nystrom said.

The Association of Oregon Counties and other groups have lobbied Governor John Kitzhaber and the Oregon Health Authority to the point where Nystrom believes they understand the county’s perspective, but said legislators still need to be educated.

He isn’t certain if they get the picture. “It’s hard to say. It feels a bit like a poker game right now.”

At last Wednesday’s meeting of the Health Care Transformation Committee, it became clear that co-chairs Rep. Mitch Greenlick (D-Portland) and Sen. Laurie Monnes Anderson (D-Gresham) don’t intend to preclude counties from becoming a CCO, or simply contracting with them.

“I don’t think counties should be precluded from taking this on if they decide they want to pursue it,” said Sen. Chip Shields (D-Portland).

“That’s not my intention,” Greenlick responded.

“My general feeling is that the administration of community mental health should be done through the CCOs and be cooperative with the counties,” Bates said.

But the metropolitan counties aren’t interested in becoming CCOs, Becker said, because “the financial risk is significant.”

Counties want explicit written agreements with CCOs

County advocates want to see clear language in the bill that would require written agreements between the counties and the CCOs that allow counties to continue providing mental health services using Medicaid dollars.

“I can’t imagine it any other way,” Nystrom said.

They also want to continue using a blend of funds, including Medicaid dollars, to provide care to the uninsured.

“We see a great opportunity in working with the CCOs,” Becker said. “We just want to make sure the relationship is formalized.”