Oregon should adapt Paycheck Protection Program to enhance care in behavioral health

The state is paying a steep cost for shorting mental health care and bold steps now are needed to help ‘fragmented’ system.

November 11, 2021 5:30 am
Oregon behavioral health

Oregon has made progress to bolster behavioral health care but urgent needs remain. (Getty Images)

As it relates to behavioral health, Oregon sits at a juxtaposition.

We recently concluded a legislative session of historic proportions. Never in our history have we enacted impactful policies such as stronger insurance parity requirements while allocating hundreds of millions in new investments for our publicly funded behavioral health system.

We closed the 2021 session with such promise.

Yet we live in a moment in which that promise is being lost as we watch our care system slip into an abyss. Not just a portion of the care system. The entire system, serving the lifespan. Residential and outpatient. Mental health, substance use disorders, and developmental disabilities.

The genesis of this is simple economics.

We’ve never come close to paying the true cost of care for behavioral health. And when you don’t pay the true cost, you create a care system that underpays its workforce and underperforms in terms of accessibility, quality, and outcomes.

Before health insurance parity, before the Affordable Care Act and essential benefits, before Oregon expanded Medicaid – this was understandable. Many Oregonians with behavioral health conditions didn’t have coverage of any kind. The best we could do was spend limited state general funds in hopes we helped some people.

Because we couldn’t invest enough, our system was highly fragmented. Kids suffered, adults landed in jail instead of in care, the state hospital was so overcrowded that the U.S. Department of Justice accused the state of civil rights violations.

The Affordable Care Act and Medicaid expansion solved the coverage barrier. But even as the state touted health care “transformation,” behavioral health was ignored.

Worse, the state handcuffed itself, committing to a severe Medicaid spending cap before we infused enough money into behavioral health to reflect actual cost. Instead, we tried to work around the cap by creating separate pots of funding with separate strings and separate requirements, further adding to the Rube Goldberg machine that is our care and financing system.

We’re better off given the vast expansion of coverage. But we’re mired in the same economics. We don’t pay the true cost of care.

We’re fragmented.

We can’t pay the workforce.

We underpay, and our system underperforms.

The outcomes are the same, but now the numbers are greater. Kids are suffering. Adults are filling jail cells because there’s no place else for them. Emergency departments are flooded with crises. Our state hospital only serves patients in the criminal justice system.

More Oregonians are homeless. More Oregonians die needlessly, lost to suicide, drug addiction, and other causes related to unmet behavioral health needs. Sadly, behavioral health is the one area of health care where we’re OK with these outcomes.

So where are we, and what should we do?

Before Covid, the bad economics played out slowly. We soothed ourselves with the notion that we had time to fix these issues. With Covid, what would take years to unfold economically struck within months.

We’re now in a labor market where the wage gap between our direct care workforce and major retailers can rage between $2 and $5 an hour.

With such a gap, where would you like to work? At a job that involves difficult and emotional work serving our state’s most vulnerable individuals and families, who have complex and highly acute needs?

Or at a job that pays a competitive wage?

To realize the promise of this past legislative session, we need a rapid and bold response that builds a bridge to the Legislature’s long-term actions. NAMI Oregon convened a broad-based workgroup to address that very issue, and we have one overarching recommendation.

To raise wages, we propose a Paycheck Protection Program-style grant program for providers that serve our publicly funded system. Across the board, across the lifespan, across systems – mental health, substance use disorders, and developmental disabilities.

Just like the federal PPP, these are direct grants that flow through each provider’s payroll. Unlike PPP, we invest enough money to raise wages to a competitive level given today’s labor market. And we do so for 18-24 months – long enough to buy time to permanently solve the reimbursement gap in our system.

NAMI’s workgroup recommends other actions to pursue over the next year, and there are major reforms we absolutely must confront. But reforms are contingent on solving the underlying wage issue. We can try to expand services. We can try to expand supported housing and residential care.

But if there’s no one to do the work, what was a promising moment for our state will pass us by.

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Chris Bouneff

Chris Bouneff is the executive director for the Oregon chapter of the National Alliance on Mental Illness. The organization offers free education and support programs for individual and families affected by mental health disorders through 15 local chapters across the state.