Oregon’s mental care a tarnished model

From The Oregonian, November 19, 2006

Over the past three years, thousands of Oregonians have lost access to drop-in centers, counselors and other services created to treat people with mental illnesses before they become a serious danger to themselves or others.

The changes result from the lingering effects of budget cuts by the Legislature and the growing expense of closing the dilapidated Oregon State Hospital. But the consequences can be seen daily on the streets of Portland and other communities, where police increasingly encounter the mentally ill and more of them end up in jails.

Mental health officials say Oregon has taken an about-face, turning a system once praised as a national model for preventive care into one of triage, with police, crisis workers and emergency rooms feeling the brunt.

“We’re spending a lot of resources to build new projects for people as they leave the state hospital,” said Bob Nikkel, administrator of the state’s Office of Mental Health and Addiction Services. “That’s well and good, but they’re expensive projects. . . . We haven’t invested enough in the front end to keep people well.”

In response, Nikkel’s agency is proposing a 32 percent increase in state mental health spending over the next two years, with the bulk of the new money focused on community programs that have been squeezed.

The death last month of a 42-year-old man with schizophrenia who was fatally injured by Portland police during a street arrest has again placed the condition of Oregon’s mentally ill population in the public eye.

James P. Chasse Jr. lived in subsidized downtown housing and had access to medication and professional help. As such, he was better off than many low-income Oregonians who are not so ill as to require hospitalization but instead depend on the web of state-funded mental health services provided in local communities.

The shrinkage in the system dates to 2003, when Oregon lawmakers moved to plug a recession-racked budget. They made it harder to qualify for medical insurance under the Oregon Health Plan, cutting 80,000 low-income residents from the rolls, including an estimated 13,000 who regularly used mental health services.

Separate cuts left some 2,000 mental health workers and drug and alcohol counselors without jobs. And lawmakers eliminated monthly stipends for the poor that many mentally ill people used to buy medicine or pay rent.

In the years since, lawmakers have poured millions back into mental health. But it has not offset all the reductions. Much has been eaten up by the cost of moving patients out of the state hospital, where conditions had become bad enough to prompt a civil rights lawsuit and an ongoing U.S. Justice Department investigation.

By the end of 2009, officials hope to cut the hospital’s population of nearly 800 in half by placing patients in community facilities such as group homes or medium-security centers. Now, there are not enough such places to go around.

Troubled in Portland

In Portland, it’s unusual to walk through some downtown areas without seeing people with untreated mental illnesses –often complicated by alcohol or drug addiction –slumped in doorways or mumbling at bus stops.

Police encounters with the mentally ill are on the rise, averaging about 40 a week last year in Portland. Calls to Project Respond, which provides mental health specialists to assist officers, are up 40 percent this year, according to Cascadia Behavioral Healthcare, the largest provider of mental health services in Multnomah County.

Recent budget restraints forced Cascadia to close four community drop-in centers for people with severe and chronic mental illnesses. Before the closures, the centers on a typical day served up to 300 people debilitated by brain disorders such as schizophrenia or bipolar disorder.

“A lot of the guys now are just walking around downtown,” says John Shatokin, 58, a mental health client who attended the drop-in center in Southeast Portland until it closed. “They’re not getting pills or going to classes. They’re just wandering around and getting sicker.”

Jerry Wiseman, 48, is a frequent visitor to the city’s last remaining drop-in center at the Royal Palm Hotel in Northwest Portland. He said it’s one of the few places he can avoid being hassled by police.

“It’s very difficult because it seems like society doesn’t want us anywhere else,” Wiseman said. “They’d rather not see us and our problems.”

Cascadia’s medical director, Dr. Maggie Bennington-Davis, said the situation shows the system’s fragility.

“When you stop paying for things, you put pressure on every other part of the system –hospital emergency rooms, jails, police, alcohol and drug, homeless shelters,” Bennington-Davis said.

The situation can be desperate for those who need help and those trying to provide it.

Recently, a man in his 50s with schizophrenia showed up at a downtown Cascadia clinic asking for medication and a place to sleep, according to agency officials. Two emergency rooms had turned him away, the man said. When told there was nothing to offer him, he stabbed a caseworker in the chest with a pen.

Police arrested him for felony assault, and he ended up in jail –a common outcome.

A recent state report determined that up to 20 percent of all jail and prison inmates in Oregon are mentally ill. That is higher than a national estimate cited in a May publication by the Justice Department, which said 10 percent to 15 percent of people who are jailed have a severe mental illness.

Once a “shining example”

No one believes jails are the place to treat the mentally ill, especially in a state that 10 years ago had established itself as a leader in treating people with brain disorders in community settings.

“Most of us saw Oregon as a shining example in the country for community mental health,” said Dr. John Talbott, a professor of psychiatry at the University of Maryland at Baltimore and a nationally recognized expert. “Then we saw you get the stuffing kicked out of you.”

Talbott recently delivered a largely critical speech in Portland about Oregon’s mental health system, saying the state relies too heavily on long-term hospitalization to treat difficult cases of mental illness.

Community mental health took a cut of $30 million, or 18 percent, three years ago. The effects were widespread. Some mental health clients lost access to medication. Others were evicted from group homes.

Although lawmakers put money back into the system in the current budget, not everything was restored.

The General Assistance Program, which provides stipends for disabled and low-income people who are unable to work, was eliminated. The benefit was only $314 a month, yet it allowed caseworkers to access treatment and housing programs that require mentally ill Oregonians to pay a percentage of their income to remain eligible.

General assistance also helped plug another gap in the system. The chronically mentally ill may apply for and receive federal disability benefits under Social Security. The benefits, usually at least $800 a month, are a lifeline. But qualifying can take as long as three years in Oregon because of a large case backlog.

Mentally ill people depended on the general assistance money to make co-payments and pay rent until federal benefits began. “Now they have nothing,” said Leslie Ford, Cascadia’s executive director.

Alcohol and drug services for those who work but earn too much to qualify for Medicaid were reduced $3 million at the end of 2003. That put more than 1,000 drug and alcohol counselors out of work and eliminated nearly 10 percent of the state’s treatment beds, state officials said.

Experts say that up to half those with mental health problems also are substance abusers. The alcohol and drug services haven’t been restored.

The community mental health cuts forced agencies across the state to lay off another 1,000 people who worked directly with mentally ill people. Caseworkers who once managed 30 or 40 clients now handle more than 100.

Also eliminated was the state’s Medically Needy Program, which covered more than 9,000 Oregonians who had unusually high medication expenses but didn’t qualify for Medicaid. “Several thousand people who lost that program had mental illnesses,” said Madeline Olson, a deputy state mental health administrator.

The Oregon Health Plan was designed as a way to expand eligibility for health coverage under Medicaid to the working poor. But the 2003 cuts limited enrollment to 20,000, down from 100,000, and stricter rules make it harder for patients who do qualify to stay on the plan, Ford said.

“If they make one mistake, like missing a premium payment, they’re off it,” she said.

The collective result of all the cuts, Ford and others say, is that thousands of people with mental illnesses can’t get help until they are so sick that a judge commits them to a hospital for their own safety. But with the Oregon State Hospital slated for closure, and alternatives still works in progress, that creates new pressures.

State hospital overcrowded

The Oregon State Hospital houses nearly 700 patients and has long struggled with inadequate staffing, poor physical conditions, overcrowding and violence.

Most residents are forensic patients –those who have been found guilty of crimes except for insanity. Empty beds for civil commitment patients are virtually nonexistent, which leads to crowding in acute care hospitals and emergency rooms.

Eleven months ago, the Oregon Advocacy Center, a federally financed watchdog group for people with disabilities, sued the state to force a staffing increase and improve safety and quality of care at the hospital.

The Legislature acted quickly. Meeting in emergency session last spring, lawmakers approved $9.2 million from reserves for staff and community placements for patients who could be helped in less-restrictive facilities.

The lawsuit was settled, but scrutiny remains intense. The Justice Department alerted Gov. Ted Kulongoski in June that it would investigate whether patients’ constitutional rights were violated at the hospital. Department investigators visited the hospital last week.

Improving conditions at the hospital will help patients. But state officials say they must also create new inpatient and community-based alternatives for current hospital residents and future patients.

The state hired a San Francisco architectural firm last year to assess what to do with the hospital. That led to a bipartisan plan to replace the hospital with four new facilities at a cost of up to $334 million. Decisions about the location, design and financing for the facilities are on the 2007 Legislature’s agenda.

Oregon spends large sums on mental health and addiction –$352 million in the current two-year budget, not counting federal dollars. The biggest share, $174 million, goes to community mental health.

The latter sum includes a $40 million increase from the prior budget, but officials say about 40 percent of that is being absorbed by the state hospital transition.

Nikkel’s office is asking for a huge increase –$113 million –in the 2007-09 budget submitted to Kulongoski. The bulk of that increase is targeted at community services.

“We can’t turn away from the hospital’s problems,” Nikkel said. “But it’s become clear that until we invest state general fund dollars in front-end services, we’ll never get ahead of this process.”

In 2004, the Governor’s Mental Health Task Force issued a “Blueprint for Action” calling for improvements in care for mentally ill Oregonians of all ages. But only two of its 10 proposals have been enacted. One is a parity law, effective next year, which requires private health insurers to provide equal coverage of both mental and physical illness. The other provision suspends rather than terminates Medicaid benefits when someone is jailed.

Parity helps Oregonians with private insurance but does not increase access to care for the poor.

“We need to be directing our resources into the development of community systems that keep people out of hospitals,” said Bennington-Davis. “We ought to be paying attention to what works nationwide –everything we know that does has been cut in the last year or so. We’re going in the wrong direction.”

Kulongoski declined an interview request. But Oregon Senate President Peter Courtney, D-Salem, who sponsored parity legislation in 2005, said he will push for mental health reforms in the upcoming Legislature.

“The whole system is in need of repair and has been for years,” he said. “Parity gave us a foundation and now we’ve got to build on it. I’m going to predict we’re going to make more progress in the next 10 years than we have in the past 75.”