DES MOINES — Signs of friction are starting to show in the multi-county regions that three years ago were established to deliver mental health care services throughout the state.
But advocates believe the wounds can be healed and the regional system remains a better option for Iowans in need of mental health care.
For years mental health services in Iowa were unique to each of the state’s 99 counties.
Three years ago, the state shifted to a regional method of mental health care delivery. The counties grouped themselves into 14 regions with the expectation that collaboration would save money and provide more efficient and consistent services.
Some regions have been dealing with upheaval in recent months.
Woodbury County supervisors last week voted to leave the three-county Sioux Rivers region, citing disagreements with the region’s leadership.
Three counties in north Iowa recently expressed leaving the 22-county County Social Services region. During a 90-minute meeting with state health officials in late September, supervisors and other mental health care staff from Hancock, Winnebago and Worth counties expressed their concerns with the region’s staffing, funding and mental health care delivery. Some local officials asked if there is a process by which they could break off and establish a new, smaller region.
Scott County has, at times, drawn the ire of some of the other counties in the five-county Eastern Iowa region. Scott County previously had a lower per-resident limit on how much property tax revenue it could raise for the mental health region, which contributed to financial issues for the region and led some counties to call for banishing Scott County from the region.
Even after the state tweaked the law to allow Scott County to raise more property tax revenue for mental health care services, the issue in eastern Iowa lingers. Despite lobbying for the law’s change, Scott County said it does not plan to immediately raise property taxes and thus more funding for the region.
“I hope you state legislators and state employees understand the frustration we have as local officials. We’re very concerned,” Winnebago County supervisor Mike Strensrud told state officials at the north Iowa meeting.
Often it seems the disputes boil down to money; for example, rural counties frustrated because they feel like they are footing the bill for services being delivered in urban counties within the region.
That may speak to a bigger problem, said Peggy Huppert, the executive director for the Iowa chapter of the National Alliance on Mental Illness. Huppert said she thinks too often county leaders remain territorial and think like counties instead of operating like members of a multi-county region.
“A lot of regions, they’re not acting like regions. They’re acting like a confederation of counties,” Huppert said. “They’re still acting like individual counties. They are asking, ‘What are we putting into it? What are we getting out of it?’ ... They aren’t thinking or acting like a region.”
Huppert said she thinks some of that is tied to the roots of Iowa’s mental health care system, which originated with the treatment of individuals in county homes.
“You still pick up on that paternalism of, ‘Well, we want to take care of our people,’” Huppert said. “It’s not where it should be.”
Huppert said the mental health regions also are coping with significant changes to health care, like the state’s move to privately managed Medicaid, changes to accountable care organizations, and upheaval with the federal health care law the Affordable Care Act and its Medicaid expansion.
However, Huppert said, if counties are frustrated with the system, she does not think breaking off will be any better.
The regions need to have a strong population base in order to provide property tax revenue that will be enough to fund services, Huppert said.
“I certainly don’t think the answer is to break up the regions into smaller parts. That’s going in the wrong direction,” Huppert said. “I’d like to know how they’re going to do it better on their own. What is their valuation? What are they taxing their residents right now under the mental health levy? What are they receiving back in services from the region? I bet you they are receiving way more services than they are being taxed for. That was the whole idea behind regions. Because three small, rural counties are going to have a heck of a time providing the services that they should be.”
Huppert said she thinks the regional system has done much good — provided innovation and good services — and that the regions are being led by “some very good people.” But she also sees the friction impacting some regions across the state.
“Clearly it’s fraying,” she said.
Despite the issues facing various mental health regions, Iowa Rep. David Heaton remains confident the system is best for Iowans in need of mental health care.
Heaton is a Republican from Mount Pleasant and a chairman of the legislature’s health care budget committee. He was a central figure in the formation of the regional system.
“I think the regional system is the best thing we’ve ever done,” Heaton said. “I think that the regions are providing services that alone (counties) never would have been able to provide. I think there’s a lot to say about the counties collectively dealing with their mental health needs.”
Heaton acknowledged the urban-rural divide within some regions over funding. He noted the legislature attempted to address that during the 2017 session by allowing some counties to increase their property tax revenue for mental health services. But he called that a kick-the-can-down-the-road approach, and said state lawmakers should devise a better long-term funding solution.
One key hurdle in the way of such a long-term solution, Heaton said, is the share of state lawmakers adverse to increasing taxes.
“The problem we have is that because we have a freeze on the mental health levy, cities who have more demand and more clients and more population and more needs cannot raise their levy to provide the resources to take care of those clients that are within their county. So our rural counties feel extra pressure on them to contribute funding toward those urban counties to provide for those people who live in those urban areas,” Heaton said. “Sooner or later this issue is going to resurface and we need to deal with it.”
Otherwise even more of the state’s mental health regions could be dealing with fractions within their ranks.