Every 20 minutes, someone dies from overdose – but treatment isn’t keeping pace

The Bend Bulletin, Oct. 20, 2016

The abuse of prescription pain killers and illegal drugs has tripled the rate of opiate overdoses in the U.S. since 2000.

Every day, 78 people die of heroin or prescription opiate overdose, a rate of about one person every 20 minutes.

Yet, the nation’s capacity to treat opioid addiction has not kept pace. A report issued last week by the Democratic staff of the Senate Committee on Finance highlights a treatment gap of more than one million Americans addicted to opiate drugs but not receiving the treatment they need.

“This is not spin. Those are hard numbers that indicate that the overwhelming majority of people are waiting in line for treatment and can’t get it,” Sen. Ron Wyden said. “This is really urgent, and we need to push back every which way.”

Treatment for opioid addiction can include individual or group therapy, outpatient or residential treatment or inpatient hospitalization. But there is strong evidence that medication assisted treatment, which uses prescription drugs to impact the opiate receptors in the brain to minimize the euphoric effects of drug use and ease withdrawal symptoms, might be the most effective approach.

The Food and Drug Administration has approved three medications — methadone, buprenorphine and naltrexone — to treat opiate addiction, but significant barriers exist preventing patients from accessing any of the three. Patients can get methadone or buprenorphine through opiate treatment programs, commonly referred to as methadone clinics.

But the number of treatment programs haven’t kept up with demand. In 2000, Congress passed the Drug Addiction and Treatment Act, which allowed physicians to apply for waivers to prescribe buprenorphine in office settings, but the number of doctors taking that step has been underwhelming.

Naltrexone has fewer regulatory restrictions, but is expensive and many health plans won’t cover it.

“Far more patients are in need of treatment than can currently access it,” researchers led by Christopher Jones with the FDA’s Office of Public Health and Analysis wrote in the American Journal of Public Health last year.

According to the most recent National Survey on Drug Use and Health, the rate of past year opioid abuse increased from 634 per 100,000 individuals 12 and older in 2003, to 892 per 100,000 in 2012, with 2.3 million people addicted in 2012.

But Jones and his colleagues found that in 2012, the maximum number of patients that could be seen by doctors with waivers was about 1.09 million. Another 311,000 patients were seen in methadone clinics. That represented a best-case scenario that still left some 914,000 individuals in the treatment gap.

It’s likely the shortfall is even greater. Physicians with waivers can treat up to 30 patients with buprenorphine in their first year, and then can apply for a waiver to increase that total. Congress increased that limit from 100 to 275 in 2016.

Surveys show, however, that prior to the expansion, physicians with waivers treated 57 percent of their maximum case load, and one in four physicians with a waiver saw no patients at all. About 55 percent of doctors with waivers agree to be listed on a federal treatment locater that links patients with services in their area. That increases the potential treatment gap by another half million patients, to as many 1.4 million people.

In Oregon, 13 out of every 1,000 individuals were addicted to opiates in 2012, second only to West Virginia, but the capacity for buprenorphine treatment though waivered physicians could treat fewer than four of those 13. While Oregon has 15 methadone clinics, most are operating at 80 percent capacity or higher. In 2013, 85 percent of the state’s residential beds and 75 percent of hospital inpatient treatment beds were full, leaving little room for additional growth.

Oregon has the highest nonmedical use of prescription painkillers of any state, but only one in 10 individuals with opiate addictions receive treatment. Oregon ranked 49th in the percentage of patients who needed care that received it, in the latest national drug use survey. As as result, opioid-related deaths continue to climb, reaching 522 in 2014, up 13 percent from the previous year.

Rural concerns

The problem is compounded in rural areas of the country. A 2015 study from the Rural Health Research Center at the University of Washington, found that fewer than half (46.6 percent) of U.S. counties had at least one physician with a waiver. Thirty million people, just under 10 percent of the population, resided in counties with no waivered physicians, and 82 percent of those counties were rural. Moreover, the majority of rural counties also lack mental and behavioral health professionals, leaving few options for treatment.

Nationwide, 2.2 percent of physicians had obtained waivers, concentrated mainly along the the coasts, with large swaths through the middle of the country with almost no waivered physicians. Ten Oregon counties, mainly in the eastern part of the state, had none.

Holly Andrilla, a biostatistician who worked on the analysis, said about a third of all waivered physicians are the only ones with waivers in their county.

“They don’t have any backup,” she said. “That’s really problematic, if they go on vacation, or if they retire or they move.”

Andrilla and her team recently surveyed rural physicians to find out why more aren’t signing up for waivers. She said most doctors were concerned about the risk of diversion. Buprenorphine, commonly known by the brand name Suboxone, has a street value because it can help addicts with withdrawal symptoms in between heroin use.

Physicians also cited the lack of other mental health providers that could deal with the depression or other mental disorders that often accompany opiate addictions. Without the help from behavioral health specialists, many felt ill-equipped to handle such complex patients on their own in a primary care setting.

While treatment centers in Central Oregon generally don’t have waiting lists for addiction treatment, Rick Treleaven, executive director of Redmond-based BestCare Treatment Services said there aren’t nearly enough methadone clinics to meet the need.

“The number of providers in the state hasn’t changed in 15 years,” he said. “We added Bend Treatment Center here but Ontario lost theirs.”

Insurance coverage

Recent data shows about 50 percent of those on the Oregon Health Plan who have an opiate addiction are receiving treatment. Commercial plans, on the other hand, continue to place severe limits on access, particularly to medication assisted treatment, despite parity laws that require equal coverage for physical and behavioral health services. Veterans Affairs and Medicare, which covers individuals with disabilities as well as the elderly, also have significant barriers for accessing treatment and for treatment providers to get paid.

“So it’s not the poor people, it’s the middle class that often have more limited access,” Treleaven said. “If someone gets into an accident at work and is disabled, and then they get strung out on painkillers and they want treatment for that, well, they’re on Medicare so no access.”

The federal parity law for mental health and substance abuse treatment was passed in 2008. The Affordable Care Act passed in 2010 also listed substance abuse treatment as an essential health benefit that all plans must cover. But health plans still use a variety of tactics including prior authorization, requiring patients try other less expensive types of treatments first or limits on the number treatments or the duration of therapy.

“None of this has been tested in courts of law,” said Dr. Dennis McCarty, director of the Substance Abuse Policy Center at OHSU. “I think the insurance companies are vulnerable, but they’re going to make it difficult to access the benefit, until they are told they can’t.”

In other areas of the state, the limited supply of treatment slots is already leading to longer wait times.

“People try to get into treatment and they say come in for an intake appointment in four weeks, or if you try to get into residential treatments you can go on a waiting list for two or three months,” said Eric Martin with the Addiction Counselor Certification Board of Oregon. “That in and of itself is evidence of the need. You double or triple the number of your heroin addicts, but you don’t double or triple the number of methadone clinics.”

A national study published earlier this year, found 40 percent of individuals with addictions waited three to seven days for an initial appointment, and 12 percent waited longer than a week. The wait time for treatment averaged 43 days, and more than a third had not been linked with treatment after three months. Many simply gave up.

“One set of challenges stacks up on the other,” said John McIlveen, a policy analyst who serves as Oregon’s State Opioid Treatment Authority.

Expanding capacity

Methadone clinics are expensive to open and require a critical mass of patients nearby to justify the costs. Increasing the number of physicians with waivers could bring treatment to underserved areas faster, but doctors have not been enthusiastic about signing up.

To obtain a waiver, physicians must undergo an eight-hour training and adhere to a number of regulations that make it more complicated to prescribe than a cholesterol or diabetes medication.

“It doesn’t fit into the clinical workflow very well,” said. Dr. Amy Kerfoot, with Northwest Permanente and a member of the Oregon Medical Association. “The patient population can sometimes be challenging … They don’t always play well by all the rules.”

Many doctors say they fear losing their regular patients if they apply for the waiver and wind up with a waiting room full of drug addicts.

“The reality is they already have the waiting room full of addicts,” McCarty said. “If they’re prescribing opioids, they have patients addicted to opioids in their practice.”

Dr. Todd Korthuis, an addiction medicine specialist with Oregon Health and Science University, said doctors need more support to incorporate addiction treatment into their practices. He recently spoke with a rural physician seeing more than 1,000 patients in his primary care practice. Although the doctor was nearing retirement, he obtained a waiver and now treats 15 patients with buprenorphine.

“For him to go to the 30 patients he’s allowed to see, and still take care of all his little old ladies with diabetes and heart disease, it’s just overwhelming, so he feels like 15 is kind of his limit,” Korthuis said. “But that’s a success story. A lot of doctors don’t want to do the training, because they don’t want to see those patients in their waiting room.”

Increasing access, he says, needs to start with medical training. Most doctors had little training in addiction during medical school, and the field of addiction medicine is relatively new. OHSU is approved to train four addiction specialists per year, and has a surplus of applicants. But the medical school only has funding for one slot.

OSHU also has an addiction consult medicine line, which doctors can call to get help managing their patients. Starting this winter, addiction specialists will meet via video link with physician practices to go over their cases and help resolve problems funded by a federal grant.

Local efforts

That could help physicians in Deschutes County, which remains one of the hot spots for opiate abuse and overdoses within the state.

“If we could connect all the people who were motivated or willing to get engaged, who could benefit from medication assisted treatment, we would probably be woefully inadequate in our current supply,” said Dr. Mike Franz, medical director of behavioral health for PacificSource Health Plans, who chaired a medication assisted treatment workgroup for the Central Oregon Health Council.

The group is now working to increase capacity in the region through a hub and spoke model. Bend Treatment Center, as the hub, would start patients on medication assisted therapy and treat the more complex cases. Established patients would be handed over to the spokes, primary care providers and specialty behavioral health providers in the community with waivers.

Wyden is pushing for Congress to provide $920 million in funding to increase treatment capacity. The Comprehensive Addiction and Recovery Act passed earlier this year included a number of initiatives that would reduce the supply of opiates and increase the capacity for treatment and prevention. But Congress recessed this summer without passing the spending bills to fund the act’s provisions.

A continuing resolution provided $7.1 million in funding for the opioid addiction efforts, including $3.27 million in treatment grants. Oregon would get about $11 million of the $920 million. The state was also recently awarded a targeted capacity enhancement grant that will focus on underserved areas including Central Oregon.

“We looked at the places that have the toughest access, the highest hospitalizations and the highest death rates,” McIlveen said. “That’s where we went to focus our efforts in those areas.”

(Editor’s note: This article has been corrected. The original version misidentified John McIlveen’s title. He works for the Oregon Health Authority Health Systems Division and serves as the State Opioid Treatment Authority. The Bulletin regrets the error.)

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Homeless outreach in Lane County: White Bird Clinic’s CAHOOTS

Turning Point

By: Ben Lonergan

Sitting quietly in the passenger seat of a squeaky, white van, Brenton Gicker types quietly on a laptop as police dispatch rattles off instructions over the radio. Gicker, an eight-year veteran of White Bird Clinic’s Crisis Assistance Helping Out on The Streets (CAHOOTS), is employed by the city as a crisis worker and Emergency Medical Technician (EMT) with CAHOOTS. CAHOOTS, a local outreach outfit, supplements city operated police and medical programs by providing crisis counseling, outreach services, and medical care to at risk, displaced, and homeless community members. Gicker and his partner Maddy Slayden typically serve 12-hour shifts where they can encounter everything from welfare checks to rides to rehabilitation centers and housing centers.

Nearly 60 percent of the calls that CAHOOTS workers respond to involve those who are homeless either chronically or in a short term capacity. “The homeless community looks a lot of different ways,” Gicker said. “It’s very complex.” While Gicker’s work with the homeless delivers him more facetime with at risk populations than the typical first responder, he finds that his perceptions on the homeless have not changed much.

“I reject the conservative, right-wing caricature of homeless people as being unmotivated losers and criminals who just behave badly because they’re bad” Gicker said, “[but] I also reject liberal-left caricatures of homeless people all being innocent victims of injustice and capitalism”

Gicker, a long-time resident of Eugene, Oregon, initially became interested in CAHOOTS while working for another White Bird Clinic program. After having piqued his interest in CAHOOTS, Gicker began to join CAHOOTS teams for ride-alongs furthering his interest in the program. Gicker remembers initially being drawn to the experience due to its similarities to the movie “Bringing out the Dead” (a film about paramedics in New York City Gicker watched as a teenager). Three to four years after his first ride-along, a position opened at CAHOOTS and Gicker began working for CAHOOTS in 2008 as a crisis intervention worker.

“Working for CAHOOTS reinforced my interest in doing social work,” Gicker said. “And [it] also led to me developing an interest in medicine.” Gicker took his experiences with CAHOOTS to pursue medical trainings, first as an EMT, then followed shortly by his licensure as a Registered Nurse.

Although Gicker now works part time at Riverbend Hospital he continues to put his time and effort into CAHOOTS, and hopes to see the program grow and expand over the coming years. “I plan to continue working for CAHOOTS for a long, long time,” Gicker explained. “I want to see the program continue to grow locally and I also want to see it exported to other areas since I think CAHOOTS style programs could be successful in many places.”

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CAHOOTS to begin 24-hour service in Eugene January 1

KVAL, Dec. 12, 2016

CAHOOTS (Crisis Assistance Helping Out On The Streets), a free, confidential mobile crisis clinic staffed by counselors and medics, is extending will begin operating 24 hours a day in Eugene beginning January 1.

“Things like homelessness never sleeps. People are always homeless. Suicidality never sleeps. Mental health doesn’t sleep,” CAHOOTS Crisis Councelor Ben Adam Climer said. “People can get us all hours of the day. It’s going to be super nice for us to be able to say, you can call for us whenever you need us.”

In June, Eugene’s City Council increased CAHOOTS funding by $225,000 a year. This allowed CAHOOTS to transition into a 24 hour, 7 days a week service.

CAHOOTS members say due to the volume of calls they get, the extension to a 24-hour service is absolutely necessary.

“We’re always looking to grow. This community is always going to be in need of a different approach,” CAHOOTS Program Manager Tim Black said. “When we went to two vans in 2011, we were getting maybe 10 to 20 calls a day. And five years later we’re seeing 30 to 40 a day on average in Eugene.”

CAHOOTS members say the new shift will bring new challenges, like training more teams and finding resources late at night. But, they say the benefits outweigh any problems.

“We can help that person get some place a little earlier in the day, we can help them get access to services a little earlier in the day,” Climer said.

CAHOOTS was established in 1989 as a collaboration between White Bird Clinic and the City of Eugene. CAHOOTS responds to mental health crises, substance abuse, family mediation, calls for aid from people who are homeless, and much more.

CAHOOTS in Eugene is dispatched through the Eugene non-emergency police phone line at 541-682-5111.

CAHOOTS also operates in Springfield as CAHOOTS Metro, but CAHOOTS Metro is not switching to a 24 hour schedule. Black says they’re hoping to extend CAHOOTS Metro hours from 12 to 16 hours sometime in March 2017. CAHOOTS Metro can be reached through the Springfield Police non-emergency number at 541-726-3714.

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Misc docs – do not publish do not delete





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Garlington Health and Wellness Center and Cascadia Affordable Housing

Cascadia Behavioral Healthcare is planning for a new facility that combines treatment, resources and housing.

Ground is scheduled to be broken this summer on 1.5 acres in Northeast Portland. A two-story,

29,000-square-foot center will provide integrated primary care, behavioral health and wellness services. Next door, a four-story apartment building will hold 52 units – including about 10 for individuals with mental illness and 10 others for veterans; The remaining ones will be available to low-income residents.

Cascadia’s CEO, Derald Walker, said the Garlington Health and Wellness Center and Cascadia Affordable Housing will provide “a new model of integrated care for those most in need.” That ties in with Cascadia’s mission “to provide healing, homes and hope for people living with mental health and addiction challenges.”

Cascadia Behavioral Healthcare manages about 600 Portland-area apartments for the mentally ill, but Garlington Center will be the first to provide on-site services to the mentally ill as well as low-income housing for the general population.

“This is the first clinic to combine both services in this specific model that I know of,” Walker said in a statement.

Cascadia’s other developments are solely for people with mental illness and this is the first development that also includes affordable housing, which Walker said is needed in the area.

The $21 million project is receiving $500,000 from FamilyCare Health, $250,000 from an anonymous donor, $250,000 from Meyer Memorial Trust, $100,000 from the Mitzvah Fund of the Oregon Community Foundation as well many smaller contributions.

The foundation has raised about $1.7 million of its own. Officials expect to secure in six months approximately $1.8 million more so that construction can finish by fall 2017, Walker said.

Architectural plans for the Garlington Center, at 3034 N.E. Martin Luther King Jr. Blvd., were released last week by Scott | Edwards Architecture. Principal Lisa McClellan described the project.

“The site is like a series of several rooms with a courtyard between the housing and clinic, which was a community garden site,” McClellan said. “We will recreate the community garden and also have outdoor plaza areas as an extension of the wellness center.”

The two-story wellness center will have a through lobby from the parking lot to Martin Luther King Jr. Boulevard, she said.

“The wellness center will be primarily on the ground floor with the integrated behavioral health center on the second floor,” she said.

The new center will offer medical and counseling teams and preventative care and healthy lifestyle classes as well as a kitchen, food pantry and exercise room.

The apartments not filled by mentally ill residents or veterans will be open to the “general affordable population,” McClellan said.

The fourth floor of the four-story apartment building will be a common room for residents, she said. Support offices will occupy the ground floor.

“There is also potentially a small retail component on the northwest corner between Morrison and Monroe (streets),” she said.

The apartments will be comprised of six studios, six two-bedroom units and 40 one-bedroom units, McClellan said.

“There is also a strong desire to incorporate public art … visible from the southwest corner of Martin Luther King” Jr. Boulevard, she said.

McClellan said she is excited to work on the all-new project.

“They’ve been there about 14 years and they want to expand their services and provide wellness as well,” she said. “It’s designed to front on a prominent corner of MLK, the public face of the Garlington Center complex. I’m excited to have been able to create an integrated campus with a courtyard in between.”

Garlington Health and Wellness Center and Cascadia Affordable Housing
Location: 3034 N.E. Martin Luther King Jr. Blvd.
Cost: $21 million
Anticipated construction start: fall 2016
Anticipated construction finish: fall 2017
Owner and developer: Cascadia Behavioral Healthcare
Architect: Scott | Edwards Architecture
Engineers: ABHT Structural Engineers, Capital Engineering, Interface Engineering
Landscape architect: 2.ink Studio
General contractor: Colas Construction

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Our View: State hospital closure makes little sense

Op Ed from Medford Mail Tribune, December 11, 2016

As predictable as Gov. Kate Brown’s budget proposal is, with its mixture of sin-tax increases and various spending tweaks, one big budget cut came as a surprise. Brown proposes to permanently close a new state mental hospital in Junction City less than two years after it opened, eliminating 422 jobs and leaving patients with nowhere to go.

The $130 million hospital was built to serve “Southern Oregon.” Several sites in the Medford area were considered, but in the end it was built about as far north as it could be without officially being in the northern half of the state. So perhaps we should be grateful we’re not seeing the loss of that many good jobs in the local economy. But there is no comfort in that, because the decision is a bad one for so many reasons.

The hospital houses 81 patients at present, with a capacity of 100 beds. It was designed to serve 174, but the Legislature has never fully funded it. It is a state-of-the-art facility, with a cafe, outdoor spaces, a special room with tinted lighting and soft music to reduce stress and other amenities designed to make patients as comfortable as possible.

Brown has said she prefers to see patients get mental health treatment in community-based facilities rather than institutionalizing them. But community-based treatment is already overwhelmed – as can readily be seen on the streets of the state’s larger cities – and Brown’s budget does not provide for any additional funding.

What’s more, state Rep. Val Hoyle, D-Eugene, a chief backer of the hospital, told The Register-Guard that a majority of the patients there now have committed crimes and been found guilty except for insanity, meaning they require a secure facility. If the Junction City hospital closes, that means the troubled Oregon State Hospital in Salem is the only place that can accommodate them.

Brown has proposed closing the hospital in 2018, saving $34.5 million a year, most of it in personnel costs. That would help the state’s strapped health care budget, but it would do so at the expense of vulnerable patients – and put communities at risk if underserved patients are left to fend for themselves.

The Legislature would have to approve any plan to shutter the hospital before it could close. Lawmakers will face plenty of hard budget choices when they convene for the 2017 session early next year. It won’t be possible to avoid some painful cuts, but the budget should not be balanced on the backs of Oregon’s most vulnerable citizens.

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A bad proposal – Closing psychiatric hospital would hurt health care

Op Ed from Eugene Register Guard, December 8, 2016

Gov. Kate Brown’s plan to close the Junction City psychiatric hospital to help fill a $1.7 billion gap in the state budget came as a shock to just about everybody — the people who run the hospital, state legislators, patients’ families and the Junction City mayor and council.

This isn’t the best idea she’s ever had.

For starters, the taxpayers have shelled out $130 million for the facility, which is not yet two years old and employs 330 people. These same taxpayers are already in an ugly mood about the more than $700 million wasted on projects such as the still-unbuilt Columbia River Crossing bridge, the Cover Oregon insurance exchange, the first attempt at rebuilding U.S. Highway 20, and the state’s dubious Business Energy Tax Credit program.

Chief among the flaws in Brown’s proposal is that it hinges on removing people from the state mental health system and dumping them on community health care systems — which are already stretched to the breaking point.

Brown estimates that closing the hospital would save the state about $34.5 million a year, mostly from employee wages and benefits. None of those savings are earmarked for community mental health facilities.

The Junction City hospital currently houses 81 patients. Most — 46 — have been judged by a court to be guilty except for reason of insanity. Of these people, 21 have committed violent offenses requiring mandatory prison sentences under Measure 11.

Thirty-three patients are civil committments, meaning they have been sent to the hospital by authorities or families for treatment, with the goal of returning to the community. They have committed no crimes. (Two additional patients are classified simply as “other.”)

It’s not clear where these patients will go if the Junction City hospital were to close.

Brown has expressed a preference for community-based mental health care. But offenders who have been sent to the psychiatric hospital by court order can’t be released into the community. The most likely outcome would be to send them to the psychiatric hospital in Salem, the only other state hospital with secure beds. But that hospital also is generally full, which could mean sending other patients currently housed there back to the community to make room for incoming patients from Junction City.

Where the resources are going to come from to serve these patients, and others who will be looking for community-based mental health care, is a large question.

Several Register-Guard readers have already weighed in on the proposed closure, saying there aren’t adequate mental health resources locally and that the new hospital was literally a lifesaver for family members.

A new audit of the Lane County community mental health program backs them up. The audit concluded that community-based mental health care, with a focus on recovery that includes intensive case management, is the most effective way to treat and manage serious and persistent mental illness, The problem is, Lane County doesn’t have either the trained staff or the money to meet demand. This is true throughout the state.

The Curry County Pilot, for example, reported earlier this year that patients waiting there for space in a state mental hospital were ending up in the local hospital’s “hold room” — which has no windows, doors, restrooms or security — back out on the streets, or in jail.

The country has suffered from inadequate mental health care for decades mainly because of two factors. A series of court cases in the 1960s, while well-intentioned, made hospitalization more difficult and relied on the incorrect assumption that there would be adequate community resources as an alternative. And changes in federal funding, culminating in the Budget Reconciliation Act of 1981, slashed spending for community-based mental health care.

Mental health is a serious issue. Looking to balance the state budget at the cost of a facility, and programs, that are helping Oregonians is a bad idea. Legislators, Democratic and Republican, should turn thumbs down on it.

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Hospital Closing Would Accelerate State’s Direction on Mental Health

From the Lund Report, December 2016

It’s unclear if the Legislature will actually approve the closure of the Junction City as the same forces that won $130 million to build it over the concerns of the mental health community will fight to save it. But it’s possible it could be used as a prison hospital while patients are treated in the community with funding from Medicaid through CCOs.

By Chris Gray

The state would only be accelerating a direction that the state had already planned to go if Oregon moves forward with closing the Junction City hospital by summer 2018, according to a spokesman for the Oregon Health Authority.

“Prior to the opening of Junction City, the facility was described as a short-term solution for residential beds that would be alleviated as community-based treatment capacity increased,” explained Oregon Health Authority spokesman Robb Cowie.

Bob Joondeph, the director of Disability Rights Oregon, said the position of his organization felt validated. “We opposed it being built in the first place. We thought it was expensive and the wrong allocation of healthcare dollars,” he told The Lund Report. “The closure represents the direction that the state should be going.”

But Chris Bouneff, the director of the National Alliance for Mental Illness — Oregon, said it was hard to react to the announcement without knowing how serious Gov. Kate Brown was with the proposal.

“It’s not a surprise because as everyone predicted, building Junction City put the state in a precarious position financially that was not sustainable. It truly is something the state has to pay for itself,” he said — unlike other services for people with Medicaid, the bulk of which would be paid for by the federal government.

The state would save $34.5 million by closing the psychiatric hospital in June 2018, barely three years after the state spent $130 million in construction costs to open it.

The Junction City psychiatric hospital has 81 patients, including both civil commitments and people who have been convicted of crimes but for insanity.

Brown’s budget continues investments in the community mental health system first proposed by former Gov. John Kitzhaber, but the budget doesn’t include any new money specifically earmarked for mental health services.

The budget does keep the Medicaid program running at full strength, and since many people with severe mental illness qualify for the Oregon Health Plan, this could provide the means for funding necessary services for them through coordinated care organizations. Any services funded through Medicaid are primarily paid by the federal government, which refuses to pay for care in state institutions.

Aid & Assist Population Hits Record High

Meanwhile, the number of people that local authorities are shipping to the state hospital so they can be stabilized for trial hit a new record high in October, climbing to 241 after dipping below 200 people for most of the summer. Joondeph said 40 percent of these individuals are forced into the state hospital on misdemeanor charges, which are typically dropped when they do appear in court, only to be placed right back on the streets without connecting them with services.

Brown’s budget includes a number of heavy lifts besides the Junction City closure, raising the question of whether her proposals are at all realistic or just a conversation-starter.

Her healthcare policy advisor, Jeremy Vandehey, declined to be interviewed for this article.

Brown comes in with a mandate from her narrow but decisive 51-44 victory over Republican challenger Bud Pierce, but will serve just two years before having to appear before the voters again in 2018.

Her budget proposes just shy of $900 million in new revenues, including $35 million from tobacco taxes and $34 million in new liquor taxes.

At the same time, she wants to grow the state bureaucracies, adding 7 percent more employees at the Oregon Health Authority and 3 percent at the Department of Human Services. Salaries at the Oregon Health Authority have soared under Director Lynne Saxton by 29 percent since 2013.

Conservative editorial writers and leading Republicans such as Senate Minority Leader Ted Ferrioli, R-John Day, have blasted the governor for not taking up public pension reform, likely kicking that conversation to the Legislature where Sen. Richard Devlin, D-Tualatin, will have a tough job putting together a budget that can actually pass.

The budget disruptions are driven in part by a $1 billion reduction in federal spending for Medicaid, as the state is being asked up to pick up a greater share of the healthcare costs for low-income residents. Democrats and labor leaders asked the voters for a $5 billion corporate tax increase — Measure 97 — but were soundly defeated.

“The Governor proposed a balanced budget that was built on difficult choices,” Cowie added. “These choices are a product of the tight budget constraints the state is facing over the next two years.”

All revenue measures require 60 percent of legislators in each chamber, which Democrats cannot pass on their own. Opposition to the Junction City closure is also likely from labor groups and the legislators who built the hospital over the concerns of mental health advocates. Even opponents of the hospital’s construction, including Sen. Sara Gelser, D-Corvallis, wonder if closing the hospital in 2018 is moving too fast, according to the Eugene Register-Guard.

Prison Hospital Solution?

Bouneff said the Junction City hospital was always built as a way to provide jobs for people in Lane County — not because it was the best way to provide mental health treatment.

The state budget is also strained by increasing costs for the mass incarceration of its residents, caused by mandatory minimum sentencing laws such as Measure 11. Kitzhaber attempted to roll back some of those, but ran into opposition and the state will likely have to build more prisons.

It’s possible the Junction City hospital could be converted into a Department of Corrections hospital, which could save some of its 330 jobs while freeing up space in the existing prison network for new prisoners.

“Everyone’s saying it was a wasted investment — well, no, it was designed for multiple purposes,” Bouneff said.

Joondeph said the state also has up to 40 inmates being treated at the Behavioral Health Unit at the Oregon State Penitentiary in Salem. “These are the inmates with the most severe combination of mental health and behavioral challenges in the prison system,” he said. “There are over 200 inmates who are placed in specialized settings for mental health reasons and many, many more with mental health diagnoses.”

The state also has more than 900 inmates who are older than 60, many of whom will likely need long-term care and hospitalization before they’ll ever return to society.

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