Oregon’s many mental health crises

Editor’s note: Throughout 2023, OPB is taking a deep look at the biggest social and economic challenges facing Oregon today – their origins, their impacts and possible solutions. We start this week by looking at the gaping holes in the state’s mental health system.

For too many Oregonians, having a mental illness or substance use problem means repeated failed attempts to get help, then a crisis: an emergency department visit, isolation in a jail cell, or an involuntary stay at the state’s overwhelmed psychiatric hospital.

“You have to fail up in our system in order to get the care you need,” said Dr. Robin Henderson, the chief executive for behavioral health for the Providence health system in Oregon.

High quality data on the prevalence of mental illness and substance use disorders is hard to come by, but several key indicators the Oregon Health Authority tracks are headed in the wrong direction.

In 2011, 38% of Oregonians reported having poor mental health in the past month. By 2021, that proportion climbed to 46%. In 2011, 16% of high school juniors reported having unmet mental health needs in the past year. In 2020, that climbed to 23%. And during that same 10-year period, deaths related to alcohol in Oregon rose from 39 per 100,000 people to nearly 51 per 100,000.

To complicate matters, there isn’t one mental health crisis in Oregon — there are several. Which one seems most pressing depends on who you are and where in Oregon you live.

OPB talked to experts throughout the state to learn about the multi-part crisis. We heard about a lack of youth services, rising substance abuse, an overwhelmed state psychiatric hospital system, a lack of long-term care and housing options for people with serious mental illness and the specific issues faced by Oregon’s rural residents. We also explored promising strategies that could help solve these problems. OPB’s reporting on mental health will be published in four parts over the next several days.

The common element behind all of the crises is that the system is itself in crisis.

Prosecutors and some politicians have argued that the difficulty of having people committed to psychiatric care has contributed to the state’s homelessness rates, perhaps the most visible sign of the mental health challenges facing Oregonians. But some of the top thinkers in the state’s behavioral health system say the problems start long before civil commitment might be necessary. Health care and supportive housing for people with serious mental illness and substance use disorders have not kept pace with Oregon’s growing population and have even been cut in some cases.

“Our system is having a hard time staying in business,” said Chris Bouneff, the executive director of the Oregon chapter of the National Alliance on Mental Illness.

Bouneff and other experts say decisions made by insurance companies, coordinated care organizations or the politicians who control the state’s Medicaid program have led to too little treatment available in virtually every community in the state. Then the pandemic hit, triggering an exodus of health care professionals from some of the most stressful front-line positions in health care, including behavioral health.

“We’ve lost capacity,” Bouneff said.

At this point, the mental health system in Oregon does not provide mental health and addiction care at the same level it covers a problem with the heart, lungs or liver, he said.

This examination of Oregon’s failing mental health system was written and reported by Amelia Templeton, edited by Lillian Mongeau Hughes, produced for the web by Meagan Cuthill, with photos by Kristyna Wentz-Graff. This series exploring both the biggest problems facing Oregon and potential solutions is sponsored by the Oregon Community Foundation. And none of OPB’s journalism happens without you. Help us tell more stories like this one – and ensure stories like this reach as many people as possible – by joining as a Sustainer now.

Requiring parity with medical and surgical care is a recent idea. Until 2005, it was legal in Oregon for health insurance plans to arbitrarily limit the number of hospital days or outpatient visits they would cover for mental health, and to require higher copays for mental health visits than for other types of care.

“We haven’t been trying to do this for very, long or cared for very long,” Bouneff said.

Bouneff also points to the bargain Oregon struck with the federal government in 2012 as it prepared for about 200,000 more people to enroll in the Oregon Health Plan through federal medicaid expansion. In exchange for more federal dollars and flexibility, the state promised to cap the growth of Medicaid spending at 3.4% a year. But the cost growth cap has meant there is limited funding available for Oregon to build a community treatment system for mental health to replace the big, locked psychiatric institutions that were the standard of care in Oregon until the 1990s.

There are some changes coming to the system. In 2021, the legislature pumped $1.35 billion dollars into behavioral health services. And the state asked the federal government for - and got - an exception to that 3.4% Medicaid growth limit, to allow it to increase reimbursements to behavioral health care providers by 30%.

The problems explained in this series are significant, and the promising solutions would be expensive to scale up statewide. Systemic fixes would require a significant ongoing investment in the public mental health system, likely beyond what’s already planned.

“One of the most promising things right now is we have a new governor whose top three priorities are housing, substance abuse treatment, and mental health treatment,” said Emily Cooper, Legal Director at Disability Rights Oregon.

“If someone has a place to live and get treatment, they have a chance to recover, and no longer go through this revolving locked door of jails and the state hospital.”

Read each mental health challenge researched in OPB’s 4-part series below.

Crisis 1: Oregon’s kids are not alright

Crisis 2: The deadly toll of excessive alcohol drinking in Oregon

Crisis 3: Oregon’s revolving door for those with the most serious mental illnesses

Crisis 4: The deficit of mental health care in rural Oregon