No local government agency delivers more health care than Multnomah County.

Aside from running the jails, it's the biggest thing the county does.

According to its latest budget, Multnomah County will spend $265  million this year funding public health, clinics, mental health and addiction services. About $114 million comes from the county's general fund, while state and federal agencies largely provide the rest.

Yet the county's health-care mission has skidded sideways in the past year. Former health department director Lillian Shirley got arrested on a domestic violence charge last year (her estranged husband, the victim of her attack, declined to press charges) before she left to work for the state of Oregon. One of her top deputies, Sonia Manhas, engaged in an affair with then-Chairman Jeff Cogen, which cost both of them their jobs.

The county is busy erasing Manhas' legacy—its current budget does away with her old job—and voters in the May 20 primary must pick a replacement for Cogen.

The two leading candidates, Jim Francesconi and Deborah Kafoury, have both made changes in the county's health mission a key part of their campaigns.

Francesconi, who served as a Portland city commissioner from 1997 through 2004, has made economic development and closing of the income gap his key message. Kafoury, a former three-term state lawmaker and two-term county commissioner, says her experience in working on public health issues makes her the better choice.

So we asked them this question: 

If elected county chair, what's the first big change you'd make to the county's health department?

Deborah Kafoury: "Right now, the chair of Multnomah County is not focused on health-care transformation. The biggest change would be a focus on it. Health-care transformation is so huge and the effects of it have still yet to be seen on the county. For example, one in every 10 residents of Multnomah County gets their health care through the county through one of our health clinics. Presumably, the majority of those people are now going to have insurance, and so they can chose where they get their care. We need to be heavily involved to see that mental-health piece of health-care transformation come to fruition, because what's going on with [coordinated care organizations] is not full integration at this point." [The current county chair is interim Marissa Madrigal. Subsequent to publication, Kafoury called to tell WW that she wasn't referring to Madrigal but instead to former county chair Jeff Cogen, who resigned in September.]

Jim Francesconi: "It makes no sense to me to have mental health in one department and physical health in another. The first change I'd make is combining them. That's been done everywhere. You have to integrate family care with mental-health care and elevate the role of mental health. And really elevate the county's focus on mental health. I don't know how you talk about homelessness without talking about mental health and addiction. It's a big reason homelessness has gone up 8 percent in the past two years in this city."