PORTLAND, Ore. — Multnomah County's behavioral health system desperately needs help, according to Commissioner Sharon Meieran, and she wants the state of Oregon to step in and do whatever is necessary to straighten it all out.
Meieran, a frequent critic of county leadership, has a background as a lawyer and an emergency room doctor. Her qualifications aren't specific to behavioral health, but she's made that issue — and homelessness — core to her political platform as commissioner.
The Story's Pat Dooris sat down with Meieran last week to speak with her about a Jan. 19 request she made to Gov. Tina Kotek to bring in state resources and untangle the knot that she believes the county's behavioral health system has become. Dooris and Meieran also touched on the county's decision earlier this month to close warming shelters during a week of winter weather.
"I've sent out a desperate call for help," she said.
Meieran explained that in Oregon, county governments are the primary local authorities for behavioral health, the umbrella that includes both mental health services and those related to substance use. In other states, including Massachusetts, the state has direct control of behavioral health resources at the local level.
Oregon's model allows each county to approach behavioral health in somewhat different ways — ideally, this means that they're responding directly to local needs with the resources they have on hand.
"I personally think that that's a great approach. I believe in local control, actually, over these sorts of things, so long as there's some centralization and someone overseeing all of these with a larger plan to ensure they fit together," Meieran said. "So we need both of those things, leadership at the (state level) and coordination, and functioning counties that are able to make the systems work."
Instead, Meieran argues, Oregon has had neither state-level coordination nor responsive county governments.
"I mean, we've had neither for longer than many people can remember, or as long as ... for decades," she continued. "There hasn't been a prioritization or investment at the state level, there's been deinstitutionalization with the belief that we should invest in our local communities, that's where we should be providing mental health services. And if we do that, people will not need that kind of institutionalization."
The move away from state-operated psychiatric hospitals perhaps had promise, but it was not accompanied by the kind of local investment needed for it to have much in the way of success. Communities did not have the resources to replace what was lost at the state and federal level.
"And places like, say, Multnomah County ... we didn't do it right, even with the money we did have," Meieran said. "So, it's a combination. If we had systems of function in our local communities and deinstitutionalization but the investment in the local ... our system could work. It is possible, we've seen examples where it works, but Oregon in general has had such horrible behavioral health leadership."
Meieran blamed former Gov. Kate Brown for failures at the Oregon Health Authority "verging on criminal incompetence," but added that it is no excuse for counties failing to do their jobs as local behavioral health authorities.
Brown would no doubt disagree with Meieran's characterization, and deinstitutionalization far predates her ascension to the governor's office in 2015. In an exit interview with Dooris, Brown said much the same thing as Meieran about the move away from psychiatric institutions and a failure in state support for counties.
According to Meieran, some counties in Oregon have run their behavioral health programs with great skill. She cited Washington, Clackamas and Lane counties in particular as examples of coordination done right.
What's the plan?
When she first ran for commissioner, Meieran thought that her experience in the ER would help guide Multnomah County's behavioral health system. But she described having a rude awakening, realizing that there wasn't any plan in place to speak of — no shared vision. So the county commissioned a third-party analysis of the mental health system, which she said resulted in something like 70 recommendations, big and small.
"So I got a group together of leaders in the community and peers, people with lived experience, and said 'OK, these are people I've known from working for over a decade in the system itself, and as an advocate. These people are doers and we can change the system. So let's create this, what a system should look like.' Had a catchy name. It was Blueprint for Better Behavioral Health, 'Analyze, Align, and Act' — all that alliteration — and the goal was action, because all of us have sat on more committees and task forces than you can even think about," Meieran said. "So we were doing that work. Created, actually, even the matrix of prioritizing things, putting them together, creating the plan Multnomah County is required to have. And then, you know, COVID happened. And then some other work started and the chair decided not to support that work anymore ... my work, not support my work — and it all shifted."
During this period, Deborah Kafoury was Multnomah County chair. Her seat was up for grabs in November 2022, and fellow commissioner Jessica Vega Pederson beat Meieran in the race by nearly 27,000 votes.
Commissioners are limited to two terms, and Meieran has less than a year left in her second term. She said she was hopeful that with a new chair, there would be a renewed opportunity to kickstart the Blueprint for Better Behavioral Health, but that hasn't happened.
"She was not interested," Meieran said. "And I've provided the information, the background, the people involved — who are all people that are involved in this work — the state-level leaders, and she said that she would be coming up with a strategic plan around behavioral health. Unfortunately, that has not come to pass."
Admittedly, the Multnomah County Health Department has struggled with a leadership vacuum. The Interim Director of Behavioral Health, Heather Mirasol, has been in that role for less than a year, following several years of turnover and instability. Ebony Clarke, who headed the county's behavioral health programs from 2018 to 2020, went on to head the entire health department before being tapped for behavioral health director at the Oregon Health Authority. She was the last person to hold the position on a permanent basis for any significant length of time.
"There's been no prioritization of hiring," Meieran said. "We still don't have a behavioral health director. And for the local mental health authority, there has been no prioritization of that. It's one of the biggest crises facing our county, affecting everything we do — homelessness, I mean, all of it. And we don't even have leadership. I don't even know where to go to ask a question about behavioral health in the county. And I used to be very tied into the people doing the work."
Asking for help
Meieran frequently points out that county commissioners have very little power in policymaking. The county chair is the chief executive and does most of the day-to-day administration. So, Meieran is left agitating for her idea of a cohesive plan, one she doesn't think the county has or intends to make.
"Multnomah County right now does not have the ability to get its act together, create a plan and implement it. It doesn't have the relationships or trust in the community of leaders, it is not able to do that," Meieran said. "And given that the local mental health authority responsibility is based in statute and it's a state-mandated allocation of authority ...
"I went to the governor and I know she cares and I know her wife is deeply involved. She's actually a mental health care provider and is doing work herself. And I know she gets it. She's trying to do all the central city work and give attention to this area and this region. And I just said this is, this is the thing: Multnomah County needs to succeed for the state to succeed everywhere else. They're actually starting to get their acts together. Counties are doing great work. We need Multnomah County to work and it's not going to happen with the system we have, so I didn't ask the state to take it over, but I asked the state to intercede and figure out what's the fix."
While Meieran has been critical of Multnomah County's role in overseeing its work, the best explanation of what the county has been doing since pivoting away from her own "Analyze, Align, and Act" can be found in the Behavioral Health Emergency Coordinating Network, or BHECN, which delivered its recommendations in October.
Originally focused on replacing Central City Concern's long-shuttered sobering center, BHECN broadened its focus to a range of different behavioral health proposals after there were no takers for the proposed replacement. Some elements of BHECN's later proposal have already been funded and are now in the works.
Last May, Gov. Kotek and Congressman Earl Blumenauer wrote a letter to both Vega Pederson and Portland Mayor Ted Wheeler, one that was critical of the local behavioral health response. They recommended that the local leaders appoint an addiction czar to begin breaking down barriers and making progress on the issue, something that Wheeler and Vega Pederson studiously ignored in their reply.