Douglas, Arapahoe and Adams counties ready for own health services following split
At the stroke of midnight on New Year’s Eve, an institution that has provided public health services to millions in the metro area since Harry Truman occupied the White House will fizzle and fade to black — like a firework in the night sky heralding the start of 2023.
In place of the soon-to-dissolve Tri-County Health Department will rise three new public health agencies — serving Arapahoe, Adams and Douglas counties — each born of the tumultuous politics of a global pandemic.
The new entities must be operational by Jan. 1.
“We’re ready,” said Jennifer Ludwig, director of Arapahoe County Public Health. “We’re ready to open our doors.”
The journey to this point has been long and uncertain, triggered in late summer 2021 when Douglas County pulled out of Tri-County as a protest of the agency’s decision to impose a mask mandate in schools. The politically conservative county had long battled government-imposed coronavirus restrictions by then, be it restaurant closures, vaccine requirements or mask orders.
Its split from Tri-County essentially forced the hands of Arapahoe and Adams counties to do the same.
Despite early misgivings about the ability of the three counties to launch their own public health departments in less than 18 months, they say they are ready to go in the new year — ready with services to combat communicable diseases, sexual diseases and mental health challenges while also doing the more pedestrian tasks of restaurant inspections, air quality monitoring and vital records documentation.
Critical to that readiness is the fact that much of the real estate and medical equipment used by Tri-County will transfer directly to the counties. And the three new directors say they have managed to secure most of the state and federal grants and contracts that were long awarded to Tri-County — a funding source that makes up the bulk of their budgets.
Even more important, in many ways, was the transition — largely to Arapahoe and Adams counties — of nearly 300 of Tri-County’s 360 employees, which should provide continuity in care.
“By retaining most of the original agency staff, this makes it easier for the new agencies to staff up and retain useful knowledge and skills,” said Glen Mays, a professor of health policy at the Colorado School of Public Health. “All three new agencies have hired experienced health directors as leaders — two of whom formerly served as senior leaders in Tri-County.”
Ludwig was Tri-County’s deputy director and the Adams County Health Department is helmed by Dr. Kelly Weidenbach, who was director of planning and information management at Tri-County.
“Most people did land on their feet,” John Douglas, Tri-County’s executive director since 2013, said of his rapidly dwindling staff.
Douglas County more streamlined
But hopeful pronouncements are one thing — delivering a similar, or better, level of service than what Tri-County did for 75 years will only become apparent with time.
“We have an extraordinary breadth of programs that the counties will have the challenge to provide,” Douglas said. “We’ll see how many gaps there are when the dust settles.”
Mays said there are three major things to watch for entering the new year: staffing, financing and community relationships — like the ones Tri-County forged with local medical providers, businesses, nonprofits and the faith community.
“All things equal, I expect that the three counties collectively will need to secure somewhat higher staffing and funding levels than were seen at Tri-County in order to maintain the same level of service, due to the economies of scale that Tri-County was able to realize,” he said. “For example, three medical directors are needed now across the three counties, rather than just one.”
Arapahoe County’s health department is budgeted for about 180 employees while Adams County’s department could have as many as 200 people by the time hiring is finished.
Douglas County is only staffing at 40, which Mays said makes it an interesting outlier.
“Douglas County leadership appears committed to operating their agency at or below the funding level that was previously provided to Tri-County, so it will be important to monitor whether that agency can operate more efficiently than its predecessor or whether it will reduce its level of service in some ways,” he said.
Michael Hill, who was appointed to lead the Douglas County Health Department in February, said his agency will be funded by approximately $1.8 million in taxpayer monies as opposed to the $2.5 million the county had contributed to Tri-County annually.
He attributes the savings to the needs and demographics of the county’s nearly 370,000 residents, which trend whiter and more affluent than Arapahoe and Adams counties. Eighty-five percent of the Douglas County Health Department’s expenditures will be directed to environmental services, like inspections of restaurants, daycare centers, tattoo parlors and septic tanks.
“There’s a very low uptake of clinical services here,” Hill said, noting that 95% of county residents have private health insurance.
Instead of providing clinical services in-house, Hill said Douglas County is contracting with Stride Community Health Care to cover the medical side of things. Other than one public health nurse and a medical officer, “there are no medical providers on staff.”
Hill said the health department will use county resources for tech support, communications and financial accounting, keeping its budget to $7 million a year. The lion’s share of that total is $5.2 million in state and federal grant programs.
The Douglas County Health Department will prioritize mental and behavioral health, injury prevention among the elderly and chronic disease prevention, including diabetes and cancer.
“That’s what the community said are the high priority items for them,” Hill said.
More needs in Arapahoe, Adams counties
Arapahoe County Public Health is placing a greater emphasis on clinical services than its neighbor to the south. It wants to hire 84 nurses, nurse practitioners and medical assistants while having a chief medical officer on contract. It will take over full Tri-County medical clinics in Aurora and Englewood, while also maintaining offices in Greenwood Village and Aurora.
With a 2023 budget of $21.3 million, Ludwig said 70% of that will come from grants, contracts and fees for service. Arapahoe County will allocate $6 million to the health department from its general fund, which is nearly $800,000 more than the county contributed to Tri-County in 2022.
“So, for that number, we’re getting most of the same services but for Arapahoe County residents only,” Ludwig said.
While it has been “heartbreaking” to see Tri-County unravel, Ludwig acknowledged it was challenging for a single agency to serve 1.5 million people with diverse needs, from Brighton to Larkspur.
“Douglas County is much different from Arapahoe County and Arapahoe County is much different from both,” she said. “The advantage of a single-county health department is the ability to be responsive to individual needs.”
Those needs are perhaps most apparent in Adams County, which in 2019 saw its white population dip below 50% for the first time while its Latino population eclipsed 40%.
“Cultural differences can account for different health outcomes,” Weidenbach said. “Adams County has historically experienced poorer health outcomes than the other two counties and the commissioners wanted to address that. They were looking for a health department built around community needs.”
It will focus on diabetes prevention, a school health program, mental and behavioral challenges and air quality monitoring, an issue that has become more visible as mostly low-income Latino neighborhoods in Commerce City have become more vocal about emissions from the nearby Suncor oil refinery.
“There’s more industry in general in Adams County,” said Weidenbach, who led the Casper-Natrona County Health Department in Casper, Wyo., before joining Tri-County.
With a 2023 budget of $27.3 million, the Adams County Health Department will be the largest of the three counties in terms of funding and staffing.
“We’re excited to open and provide continuity of services,” Weidenbach said.
Another Colorado split
Splitting up public health agencies is not unique to Colorado.
South Carolina legislators recently considered a split of the state’s Department of Health and Environmental Control, while in March, Alaska Gov. Mike Dunleavy issued an executive order breaking up the state’s Department of Health and Social Services into two entities.
Several cities in Los Angeles County last year explored breaking from the county’s public health department to form their own, with West Covina actually doing so. The wayward cities’ central complaint revolved around what they saw as overly restrictive COVID-19 measures.
Those concerns were central to the decision last month by Archuleta and La Plata counties in southwest Colorado to dissolve San Juan Basin Public Health, which serviced both counties for 75 years. Each county has until Jan. 1, 2024 to have public health services in place.
“We share a boundary, but we are very different counties,” said Marsha Porter-Norton, commissioner for La Plata County. “They have over the years had a desire for less regulation and a lesser level of public health.”
Porter-Norton said Archuleta County started the discussion about going separate ways in 2021, when it formed an investigative committee to explore the idea. Tensions, she said, went back more than a decade but “the pandemic laid bare a lot of philosophical differences in general.”
La Plata County, home to Durango and with four times the population of its neighboring eastern county, intends to form its own public health department over the next year. Archuleta County Commissioner Warren Brown acknowledged that with just 14,000 people, his county will face challenges trying to do the same.
“The first challenge is having adequate funding. Archuleta County is a small county, and our revenues are much smaller than that of La Plata County,” Brown said. “The second significant challenge we will face is finding skilled staff.”
But the commissioner said the county, home to Pagosa Springs, is “a resilient community and I am confident we will be able to work through this obstacle potentially using some reserve funds.”
Mays, from the Colorado School of Public Health, said full-service health departments can be very difficult to staff and finance in small and rural areas that have limited tax bases and workforces.
“I anticipate that the dissolution in the San Juan basin will be more difficult to navigate than the dissolution we’re seeing with Tri-County involving large and relatively affluent jurisdictions,” he said.
As far as Douglas’ future goes after nearly a decade at the helm of Tri-County, the 70-year-old physician said he will enter “a period of reflection” once 2022 is in the rearview mirror. One thought he keeps having concerns the politicization of the pandemic — and the singular role masks played in bringing down an agency that has been around since 1948.
“The mask became the symbol of government overreach,” he said. “When I see people with masks, I’m reminded of the role that prevention device played in the demise of Tri-County.”
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