End of the Year 2023 Message from Commissioner Dr. Sharon Meieran
As we close out 2023 and look toward the New Year - my final year on the Multnomah County Commission - I want to share my reflections, express my gratitude, and let you know what I’ve been working on to build up our community and support those most in need. True to form, this will be a lengthy newsletter, as there’s much to discuss. Think of it as a few op-eds rolled into one and pace yourself accordingly. :)
1. Adopting a Comprehensive Plan to Address Homelessness - “Connecting the Dots”
I’ve been calling out the need for a comprehensive plan to address homelessness for years, and I’m not sure what’s been more concerning - the tacit acknowledgment by local government leaders that is in fact no plan, or the failure to try to introduce one, even in the face of such a massive void. Over the past year he County has spent hundreds of millions of dollars on one-off projects and vaguely described programs with little accountability for how that money is spent. I voted “no” on the County’s $3.5 billion budget because I felt it did not meet basic standards of accountability or fiduciary responsibility. I was shocked by reports that the County was unable to spend millions of dollars on homeless services when our community has never seen such critical need. And as money kept falling into the County’s lap due to unanticipated revenue from the Metro Supportive Housing Services Measure tax, I was outraged that the County continued to spend money month after month without an overarching plan. I voted against these investments because I do not believe they will move the dial on our most pressing problems. But have continued to uplift a plan. I tried to introduce the plan at a September Board meeting, where the Board was considering how to spend over $50 million in unanticipated revenue. The County Chair (who runs meetings) did not allow me to display the poster I created, and so I outlined my proposal in my November newsletter. I followed up with a virtual Town Hall earlier this month, entitled Connecting the Dots. It was an incredible success, and I thank those who attended virtually, asked great questions, and joined the conversation! If you weren’t able to attend it’s not too late - you can watch the Town Hall here. Email me at District1@Multco.us with any comments or questions.
There is a viable way to move forward, and I will continue to push for a real plan to move the needle on our homelessness crisis in 2024.
2. Responding to the Ambulance Crisis by Changing Our Staffing Model
For over a year, Multnomah County has been seeing a substantial increase in 911 calls where no ambulances are available to respond to emergencies; and when ambulances do respond, they are delayed. Almost a year ago I called for a real solution: A temporary change in our ambulance staffing model that would urgently get more ambulances on our streets. But action on this matter can only be directed by the EMS Medical Director or the County Chair. As these leaders have pushed back against my proposal, the crisis has worsened. Below I will share some background - including what actions I’ve taken and what you can do to help.
Currently, Multnomah County requires that two paramedics staff ambulances for all emergencies. Paramedics have significantly more training than EMTs and can perform additional medical procedures. This staffing has become increasingly problematic due to a national paramedic shortage, coupled with issues unique to Multnomah County - an increase in emergency calls, an increase in patient need, and unsafe and stressful working conditions. Changing to a one paramedic/one EMT (“one/one”) staffing model would safely get more ambulances on our streets within weeks to months, leading to improved working conditions and improved patient outcomes.
I’ve been dismayed that neither the County Chair nor the EMS Medical Director, Dr. Jui, have asked outside experts about the viability of this model. Rather than pursue this simple action that could save lives, they have elevated statistics and pointed to technicalities that are misleading and often irrelevant. Here is some information that can help you make sense of the situation based on my experience as an emergency physician and my extensive research on this topic:
A one paramedic/one EMT model is the national norm. A two paramedic staffing model is an outlier, employed in relatively few jurisdictions with completely different emergency medical response systems than Multnomah County. Trying to compare Multnomah County with any of these outliers is like trying to compare apples and footballs.
Although a faster response is better, the vast majority of emergencies don’t medically require a response within eight minutes (a technical standard used in contracts), even in cases calling for “advanced life support” (ALS). Meeting an artificial time constraint in a contract shouldn’t factor into decision-making about saving lives. What’s important is what’s medically relevant. Even most ALS emergencies do not require the services of two paramedics.
Cardiac arrest patients, often cited as the major population in need of a rapid response, require CPR and defibrillation as soon as possible, both of which can be performed by lay people. The sooner CPR and defibrillation occur, the better the result. This in fact supports the one/one staffing model to get people defibrillation, CPR and definitive care in a hospital faster.
Even if two paramedics are indeed required, the Fire Bureau has confirmed that they respond to ALL CALLS INVOLVING A TRUE LIFE-THREATENING EMERGENCY. This is based on actual responses to real emergencies. The statistic that Fire Bureau trucks only respond to 45% of 911 calls - commonly claimed by County leadership - may be technically true, but ignores the substantive fact that the vast majority of even those calls do not require urgent intervention or critical lifesaving maneuvers requiring two paramedics on scene. Fire Paramedics go to ALL the emergencies that matter.
People will not be harmed by temporarily switching to a one/one staffing model. In fact, harm will be reduced and lives potentially saved by getting faster access to care. I am concerned that County leadership continues to focus on contract technicalities, research that is not on point, and often irrelevant statistics. Especially when it potentially causes real harm.
On December 14, I formally submitted a Proposal to Change Ambulance Staffing under Multnomah County’s Ambulance Service Plan (ASP). You can access the Proposal here, and watch my comments at the December 14 Board meeting here (skip to 2:02:47).
This requires the following next steps: (1) Dr. Jui must review the Proposal and determine if a more detailed evaluation of the alternative staffing model is warranted; (2) If so, he must convene a group of outside experts to analyze the Proposal and make a recommendation to him based on their evaluation; (3) If Dr. Jui agrees with the recommendation, he must instruct the County Board to adopt the Proposal.
In my view, Dr. Jui and the Chair should have urgently convened a group of experts months ago. But they can still act with urgency. Dr. Jui could email EMS Directors and experts across the country today, inviting them to attend one or two Zoom meetings in January and/or February. They could issue a recommendation by the end of February. There is no excuse for failure to act.
I will not pursue the matter further if external experts recommend that Multnomah County continue with its current staffing model. But if a temporary alternative is recommended, then we must get it implemented stat! This is truly a matter of life and death.
When people call 911, they expect and deserve an emergency response. If you agree that urgent action is needed, PLEASE email the Chair, my fellow Commissioners, Dr. Jui, the EMS Administrator Aaron Monnig and/or show up to Board meetings to testify virtually or in person. Your advocacy matters.
3. City and County Intergovernmental Agreement (IGA) on Homelessness
A few weeks ago a joint session of Portland City Council and the Multnomah County Commission met to discuss proposed updates of the agreement governing the relationship between City and County in regard to the Joint Office of Homeless Services (JOHS).
I anticipated the usual canned slides, buzzwords, and diagrams, along with a call for a “reset” touting newfound collaboration. I thought I had steeled myself for the largely performative presentation. But it was worse than I imagined.
I witnessed the profound misunderstanding of our homelessness system by leaders who should know better; I listened to the acceptance of statistics and goals that existed only in the realm of fantasy; and I heard yet another version of the same old story.
You don’t have to go far back to find an almost identical roll-out of an almost identical process using virtually identical sound bites; it was called A Home For Everyone (AHFE).
A whopping $30 million was to be invested by City and County in AHFE, and providers were giddy at the prospect of so much money. The former JOHS Director, Marc Jolin, claimed, "It's the most comprehensive and systematic work that we as a community have ever done…If we get all the money we need, we'll know how to spend it." (Portland Mercury, Nov. 2015)
Ten years later, with a budget of over $250 million for homelessness at the County alone, and with the County failing to be able to spend the massive amounts of money landing in its lap even as more rolls in, we are waking up to a Dystopian Groundhog Day.
A few weeks ago the Chair and Mayor issued a joint press release celebrating their groundbreaking “reset”. And City and County Commissioners seem poised to approve a new agreement that has nothing to do with creating a functional JOHS - it accepts that the so-called “Joint” Office of Homeless Services is, in fact, a County department. It focuses on specifics around shelter - incorporating numbers that do not pass the smell test, such as promising a 50% reduction in street homelessness from a baseline that itself is blatantly inaccurate. It highlights a Shelter Strategy that isn’t one. And it seeks to reanimate the failed AHFE.
In terms of reducing homelessness by 50% in two years, this claim is at best delusional, at worst deceptive. Nothing in the City or County’s history suggests they can succeed at lowering the number of people living unsheltered by even 10%, let alone 50%. And that’s even if their claim that they have a baseline By Name List identifying the number of people living outside wasn’t flagrantly false. As I’ve shared with you before, the information claimed to comprise the County’s so-called By Name List is neither accurate nor complete. But most egregiously, it leaves out the most vulnerable and in need of counting - hundreds to thousands of people not already connected to County services. The City and County STILL have not taken the most basic action of proactively counting and understanding the needs of people living outside. Without that fundamental baseline information, any promise to make any kind of meaningful difference rings false.
The next item on the list - the commitment to create a cohesive shelter strategy - seems so foundational that it should go without saying. Given that it apparently needed to be said, I find it troubling that what’s being proposed is being described as a “strategy”. For me, a strategy needs to start by identifying how many people are living unsheltered, who they are, and what they need (a real By Name List); identifying what shelters already exist, including what services are provided, how many beds there are, and cost per night per bed; understanding how much money is available; and then leveraging the money to optimize shelter. The City and County’s “strategy” is virtually the opposite of a holistic, coordinated, comprehensive approach.
Finally, the agreement purports to establish a new governance structure to address homelessness - the Homelessness Response System. Yet even the most cursory glance shows eerie similarity to the now defunct AHFE. AHFE failed because of poor implementation and leadership, but the concept and design actually made sense. A few tweaks might actually have resulted in an effective advisory structure. The current proposal offers a worse design, while making all the same mistakes.
As I watch with dismay as we start down the same path, I reflect on why people who should know better are pushing this proposal. The only conclusion that makes some sense to me is that the approach perpetuates a convenient failure that, while not ending homelessness, has driven political success.
JOHS and AHFE have been ineffective at solving homelessness. We just saw the most damning standard of all reflected in the latest Domicile Unknown report - an exponential increase in death of people living outside. However, JOHS and AHFE have been very effective at deflecting attention from political failure. The system has allowed political leaders to pretend like the past seven years never happened - declaring a “reset” and sounding positive and collaborative - all while abdicating responsibility for the human tragedy that unfolded under their watch.
I wish I could sit and nod and utter a few sound bites about collaboration and resets. I would like nothing more than to be supportive of a plan, knowing that people who are the most vulnerable in our community will not die in squalor on our streets. But right now we are heading in the wrong direction, and someone in the political sphere needs to speak this uncomfortable truth.
The good news is that viable solutions do exist. True collaboration and meaningful action are possible, but only if we critically evaluate our processes and openly confront the convenient failure underlying the work we are doing. Rather than casting critical thinking as somehow the enemy of collaboration, we need to embrace the rigorous evaluation of information, application of reason, and questioning of assumptions that are essential to a functioning democracy and ultimately lead to enhanced collaboration and better solutions.
If we continue down the current path, government leaders will look back in another three years, bemoan the results of another failure, and call for another reset. Someone new will be making campaign promises with great sound bites but little substance, deflecting blame and making excuses. They will say “We just need to give it time because it’s taken so long to get to this point” or “I need some time to learn the ropes” or “I’ve come to understand how complex the system really is” or - what I fear most - “we have a new form of government and it can’t be expected to change things overnight”. Our sincere desire for the appearance of collaboration will override our common sense, and we will sink deeper into failure.
For the new year, I implore my colleagues to do their due diligence before signing on to the agreement. I’ve sent them my recommendations, which can be accessed in full here and which are summarized below.
4. My recommendations for the IGA:
Change the name of the Joint Office of Homeless Services because it’s not a Joint Office - it’s a County department. How about the “Multnomah County Department of Homelessness and Housing Services”?
Proactively create a baseline count of all people living unsheltered in Multnomah County (a true By Name List!) within 6-12 months.
Incorporate the Homelessness Management Information System and Point In Time Count (two separate inaccurate, incomplete, and ineffective databases) into a single current comprehensive list.
Create a shared agreed-upon count of all shelter beds available in Portland, subcategorized into type, populations served and cost per night per bed.
Create a shared agreed-upon count of all Transitional Housing, including bridge housing, recovery housing, and anything else that might be included in this catch-all phrase. Decide on a shared definition.
While the baseline count of people living unsheltered is pending, use the Point In Time Count as a very rough estimate and set a realistic numeric goal for getting individuals off the streets. Back up this recommendation through clear reasoning and evidence.
Commission an external forensic audit of where the $300+ million in JOHS budget has gone and tie it directly to services provided and outcomes. I find it extremely disturbing that the County cannot effectively point to what hundreds of millions of dollars in revenue - particularly from the Supportive Housing Services Measure - has bought us.
Commission an exhaustive analysis by an external source that makes actionable recommendations for a cohesive and functional data system that is (i) accurate, (ii) evidence-based, (iii) interoperable, (iv) navigable, and (v) contains public facing dashboards that are easily digestible.
Order a forensic or other external audit focusing on organizations contracting with the JOHS and the City in regard to homelessness operations/support/outreach/inreach services to ensure they are using resources effectively and achieving agreed-upon outcomes that align with a shared vision.
Formally consider creating a body overseeing homeless policy and investment OUTSIDE of local government under ORS 190. Objectively detail the pros and cons of adopting this approach vs. what is currently being proposed. Present this to City and County Commissioners, ideally at a joint briefing, within three (3) months.
Clearly identify the similarities and distinctions between AHFE and the current proposed HRS and how these were taken into account in devising the current proposal, including what efforts are being made to address the major issues that led to AHFE’s failure.
Create a more streamlined, informed and effective advisory and governance approach, utilizing the strengths of the AHFE model, but fixing its weaknesses. I proposed an alternative model years ago. It was informed by my volunteer work with Portland Street Medicine and my service on the AHFE Executive Committee, seeing what kind of leadership and accountability was needed and who was missing from the table. I have attached that proposed alternative here and believe it is a viable and effective approach:
Whatever the joint effort is called, it should not be the “Homelessness Response System.” Having “Response” as a key element of a new body’s name only serves to reinforce public perception of local government as reactive. If we want to do things differently, let’s reflect that in the name.
Conclusion
2023 was in some ways a year of vindication: Scathing audits of the Joint Office of Homeless Services, County contracting and County budget processes echoed what I’ve been crying out for years. My concept of a “Shelter Ecosystem” has been adopted into mainstream conversation. “Alternative Shelter” is being lauded and supported, rather than written off. The Governor, County Chair and Mayor publicly acknowledged Fentanyl as a public health emergency. Recovery Housing has been elevated to prominence as one of the most crucial elements we need to invest in at the intersection of behavioral health and homelessness.
Over the course of 2023 I was proud to see programs I’ve championed gain traction:
Microvillages showing dramatic success, with an opportunity to systematize and expand this unique form of alternative shelter.
Recommendations for changing the County’s system of contracting resulting from the external evaluation I sponsored in last year’s Budget.
Bringing learnings from the Sobering Center Summit I attended in Washington, DC back to Multnomah County to help direct action rather than fall into more meetings.
Receiving a legal analysis confirming that the County has the authority to issue risk bonds in regard to the Critical Energy Infrastructure Hub, which poses a catastrophic health, safety and environmental threat when the Cascadia Subduction Zone earthquake finally hits.
Unfortunately, although the language being used to talk about major issues is finally changing to reflect what I have been fighting for, the words themselves have not yet translated into action. In the face of crises in behavioral health and homelessness, and despite use of the term “crisis” more times than I can count, County leadership has failed to enact any critical or successful policy over the past year in housing, mental health, addiction, corrections health, public health, or emergency medical response.
The Chair’s policies, as supported by her Budget,have left record numbers of people dying on our streets and in our jails; millions of dollars spent to house 300 people in her signature housing proposal resulting in 18 being placed; permanent health department and behavioral health leadership positions unfilled for an entire year in the face of public health and behavioral health crises; and a critical ambulance shortage.
The status quo is not acceptable.
I hope that the Chair truly engages with Commissioners to introduce a comprehensive plan to address homelessness; release an emergency approach to the Fentanyl crisis; and develop a holistic plan to address addiction and mental illness. Meaningful plans will empower the Board to allocate funds where they will have the greatest impact in saving lives, reducing harm, and enhancing the wellbeing of all Multnomah County residents.
I look forward to embracing my final year as the Multnomah County Commissioner for District 1. As always, please reach out with any questions, comments or concerns. You know I love to hear from you.
I wish you and your families a very happy New Year, filled with peace, joy, and love.
With gratitude,
Dr. Sharon Meieran
Multnomah County District 1 Commissioner