In February, Chris Bouneff got a phone call from a man whose wife has bipolar disorder. She had been managing it well with private health care, the caller said, but then the couple both lost their jobs, and their insurance was about to lapse. He wanted to know where else they could go for the mental health services his wife needed.
"He's calling, saying, ‘What do I do?'" recounted Bouneff, who is the executive director of the National Alliance on Mental Illness' Oregon branch. "What do you say to someone like that? ‘Sorry'?"
Oregon's supply of public mental health and addiction services already falls far below the demand - the Department of Human Services estimates that they meet less than 30 percent of the need. The economic recession and 9.9 percent state unemployment rate mean that growing numbers of people are finding themselves in the position of Bouneff's caller, but the drastic budget cuts proposed for addictions and mental health services mean that help may soon be even scarcer.
The result, Bouneff and others say, could be crisis - both for individuals with mental illness and for the system as a whole.
Federal stimulus money will allay some of this year's budget woes, but the legislature still needs to address an over-$2.5 billion shortfall for the 2009-11 biennium. Gov. Ted Kulongoski's 2009-11 recommended budget, released in December, suggests cuts across the board, and some of the heaviest fall on addiction and mental health services. Among the proposed reductions are a 50 percent cut to acute inpatient psychiatric care, an 83 percent cut to alcohol and drug treatment, and a 90 percent cut to outpatient mental health care for adults without Medicaid coverage.
Care providers and advocates have called the cuts devastating, illogical and even Draconian.
Mary Monnet is the executive director of LifeWorks Northwest, which provides mental health and addiction treatment to 12,500 Oregonians per year. She says hundreds of LifeWorks' clients could lose services like residential addiction treatment, which the proposed budget revokes nearly all the funding for.
"There may have been a few beds reduced in the past, but we have never seen this kind of ... wholesale elimination of a service element that's one of the more vital parts of the recovery community," Monnet said. "This is huge."
Overall, 20,000 people statewide would lose mental health and addiction services under the governor's recommendations. A proposal to expand the Oregon Health Plan could restore treatment to some of them - but only about 10 or 15 percent, according to Richard Harris, DHS' interim assistant director for addictions and mental health.
Cuts to specific facilities won't be determined until after the budget is set, so no one can say exactly who will be cut off. But Jason Renaud of the Mental Health Association of Portland says that in previous rounds of budget cuts, the hardest-hit have been people with "severe and persistent" mental illness, and people seeking treatment for the first time - two groups that are difficult to treat, but usually have no other options.
If services are cut, some people will lose medication coverage. Others in residential treatment will either be relocated - as is the plan for the 60 mental health patients at the Blue Mountain Recovery Center in Pendleton, which could shut down to save money - or turned out entirely.
"People will fall back into using emergency rooms, because their problems aren't going to go away just because services do," Harris said. "We'll end up with people inappropriately in hospitals, in jails. The safety net becomes the services that are left, and they'll become overburdened."
Advocates argue that cutting community-based treatment won't save the state any money in the long run, because hospitals and law enforcement agencies will have to pick up the slack. Those systems are already strained - as the state rebuilds the Oregon State Hospital, the Legislature is proposing $500,000 for a combined prison and psychiatric complex in Junction City.
The effect of cuts to community programs, Harris said, could be a shift back toward institutional treatment in hospitals and prisons, which the country has been moving away from for decades.
In addition, Harris said, the more people go without treatment, the more acute mental health issues will become.
"As the dollars get stretched thinner and thinner," Harris said, "there are going to be individuals who don't get the services and create problems in the community" - either because they actually commit crimes, or simply because others are "uncomfortable being around active mental illness."
Since the 2006 death of James Chasse, whom police fatally injured when they arrested him, the police bureau has trained its officers on responding to people in mental health crisis. Bouneff says that has seemed to help, but as more people go without treatment, the dynamics could change.
"I think it'll be telling to see how people react," he said, "because we're going to put a tremendous stress on the system."
In downtown Portland, the pressure is already on. Pastor Steve Trujillo, who co-chairs city hall's Public Safety Action Committee (PSAC), says the group has heard increasing numbers of complaints about people "acting crazy," following and harassing other people, or creating other disturbances.
"It's kind of like the water's being turned up, and we're seeing the boiling effect," Trujillo said.
Members of PSAC, which includes law enforcement, social services and business representatives, express frustration that people they think need mental health treatment aren't receiving it. Instead, Trujillo says, police end up called to situations that really warrant social workers.
At the Feb. 10 PSAC meeting, Central Precinct Commander Mike Reese told the group he was tired of "people cycling through the police and the criminal justice system over and over again, and there's no intervention."
In some ways, the committee has the same goals as mental health advocates: They want people who need treatment to get it, and they want the mental health system to take care of those people before they have run-ins with law enforcement.
But PSAC is exploring a controversial strategy - trying to change the law so that it's easier to commit people involuntarily.
The standards for civil commitment have become more stringent over the years out of concern for the civil liberties of those committed. Under current law, people can be mandated into treatment against their will if a judge deems them an "imminent danger to self or others."
PSAC thinks that's not enough. They began discussing civil commitment after a spike in suicide attempts last summer, which Reese said might stemmed from the financial collapse of Cascadia, the state's principal provider of mental health services. Since then, Reese said, the suicide rate has dropped back down.
Trujillo says he sees many people who are mentally ill at his downtown ministry, and even if they aren't dangerous, some of them are "too ill to know that they need help." If they could be held and stabilized with medication, he thinks, they may decide they want further treatment.
Advocates say that approach is shortsighted, and it would have little effect in reality, because there aren't enough resources to treat people. David Hidalgo of Multnomah County mental health and addiction services spoke to PSAC at the February meeting.
"People get committed, they get discharged if there's no services, and they're back out on the streets," Hidalgo said. "I don't know that trying to push the state to tighten civil commitment laws will result in people getting better."
More productive, Hidalgo said, would be to advocate for the preservation of treatment funding and comprehensive services. He said committing more people "is actually in the opposite direction."
Some committee members were unsatisfied with that answer.
"Today, how do we stop this?" asked Mike Kuykendall, Trujillo's co-chair and vice president of the Portland Business Alliance.
David Owens of the Old Town/Chinatown Neighborhood Association acknowledged the need for more funding, but said the question on the community's mind would be a simple one: "How many dollars for pills to take ‘the crazy people' off the street?"
Hidalgo emphasized repeatedly that any increased power of commitment is an encroachment on the civil rights of those committed.
"What about the right for the community to feel safe?" Trujillo, who did not attend the last PSAC meeting, said in an interview. If the committee finds that commitment isn't an effective solution, he said, they might look at other strategies, like advocating for long-term funding.
However, Trujillo said, "People are funny. They want their problems resolved. So if ‘Joe' is coming to their business, peeing in their hallway, scaring people every day, they're going to get frustrated ... Can't there be a solution to that too? Is the solution just (to) put up with it?"
If you ask Bouneff, it may be.
"In the direction we're going right now, there is no short-term solution," he said. "Things are going to get worse before it gets better."
Over the summer, the state legislature will adjust the governor's recommended budget as it sees fit, and advocates are hopeful that some mental health money can be salvaged. But in a tight budget where funding one interest means squeezing out another, Bouneff says it can be difficult to advocate for mental health, which is not always as "palatable" as other needs.
"We're not going to load buses (of people to testify at the legislature) like education is going to do," he said. "We're not holding bake sales."
What the next few years will look like for the mental health system still depends greatly on the legislature's decisions.
"A good-case scenario is that we stabilize such that we go into the next biennium with the same amount of money as the last biennium," though that would still lag far behind demand, Bouneff said. "In a worst-case scenario, more people are reaching crisis, and we're having more high-profile cases like James Chasse."
Even if the budget recovers down the line, Harris points out, once things such as residential treatment facilities are eliminated, restoring them is not as easy as turning back on the lights. Rebuilding the infrastructure and recruiting new staff, especially to rural areas, could take huge investments, Harris said.
"Once it's gone, it's probably not going to come back," he said.
Despite the grim outlook, Bouneff thinks there could be positive aspects to the budget crunch. It may spur legislators to reexamine how the mental health system works now and consider changes in the future, he said, like integrating mental health care with physical health care - which Bouneff thinks would both be more efficient and give consumers more options for treatment.
"Sometimes a crisis is the best time to bring about large change," Bouneff said. "There's hope, but that's hope that's several legislative sessions down the road."
By Mara Grunbaum
Staff Writer
