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How Counties Intend to Address the Nation’s Mental Health Crisis

Suicide, overdoses and intake of anxiety medications have all gone up during the pandemic. Counties are having to deal with those challenges and many others, at a time when many of them are losing population and face constrained resources.

A person pouring pills into their palm out of a pill bottle.
As the pandemic reaches the end of its third year, it’s clear that the nation has suffered not only a public health crisis but a serious mental health challenge as well. Nearly one out of four adults took some form of prescription medication for mental health in 2021, which represented a 50 percent increase just from 2019. Adolescents and other young people are struggling as well, with suicide now the second-leading cause of death for Americans aged 15 to 24.

“We’re seeing huge spikes in behavioral health caseloads, with substance abuse and mental health,” says Matt Chase, executive director of the National Association of Counties (NACo).

Counties are key providers of mental health services, through community health clinics, hospitals and prisons. But a third of the nation’s population lives in counties that have shortages of mental health professionals. And paying for mental health is about to get more challenging. The end of the federal pandemic emergency order in May will cut off enhanced funding for Medicaid.

“The largest funder, by far, of behavioral health treatment is Medicaid,” Chase says. “As millions of people come off the Medicaid rolls, they’re going to end up in the county social safety net system.”

Today, NACo is launching a new National Commission on Mental Health and Wellbeing, which will promote policy goals such as mental health coverage parity and building the field’s workforce. It also hopes to promote “a cohesive national and intergovernmental strategy.”

NACo is hearing from President Biden and top administration health officials during its legislative conference, which continues in Washington through Tuesday.

“We know money’s not going to be the only answer,” Chase says. “But we’re going to need better collaboration. We’re going to need federal, state and local governments working together. That’s why we’re launching this national commission.”

Governing spoke with NACo’s leadership to discuss the full range of challenges counties are facing. Following are edited excerpts from that conversation.

Governing: Can I ask how your budgets are looking? Obviously, there’s a huge range of counties in terms of size and geography, but what is the overall picture now? It seems like recession fears are easing and the inflation rate is slowing.

Denise Winfrey, Will County, Ill., board member and president of NACo: Certainly in Illinois, the budget is healthy. And in terms of the recession, you’re right, I believe it’s easing. But that doesn’t mean that we don’t have needs, or that there are not gaps that need to be filled. For counties, what we’re doing is trying to make sure that residents get what they need in transportation, mental health and housing, as well as all kinds of infrastructure projects that will improve the quality of life for residents. So we’re stretching those funds as far as we can, to provide for people.

Chase: Revenues are holding steady, but what we really need is more attention on the demand side. In many places, though not all, what we’re seeing across the board is an increased demand for county services. Aside from behavioral health, we’re seeing tremendous demand for food and nutrition programs, with the cost of food being the one area where inflation is still really sticky. We’re seeing a need for transportation, while water and sewer, along with housing affordability, remain huge priorities. So we’re really seeing tremendous pressures on the demand side.

And then within county government, we employ one out of every 50 adult Americans, but we have tremendous vacancies. The private sector has recovered from the recession, or from COVID, but state and local government, particularly counties, are still lagging way behind.

Governing: Can you talk about the workforce shortages? One of the main budget pressures on governments is wages in a tight labor market.

Larry Johnson, DeKalb County, Ga., commissioner and past president of NACo: We’ve had to raise our police starting salaries to $50,000, from probably $42,000. Now we have salaries at the top in the region, but that’s how far we’ve had to go. The other part is just trying to find mechanics to work on our county vehicles. We’re trying to do apprentice programs with our junior colleges, which have really yielded us some great benefits.

It’s just a shortage. One of the things that counties can offer you is a good benefits plan. The salaries may not be where you want to be, but long-term, retirement, it’s one of the places you want to be, and we try to sell it as much as we can. But a lot of folks are choosing to go the entrepreneurial route, especially the millennials and Gen Zs. They’re not looking to work for somebody 15 to 20 years. I mean, we have an older workforce. For a lot of younger folks, we’ve got to make county government a lot more, for lack of a better word, more sexy for people to come into.

Winfrey: In our sheriff’s department, for a county of 700,000, we’re down about 200 persons. Trying to get people to come and stay is hard. Young people will come in, they’ll get the training, finish the academy, stay a year, and then they move on to a place that’s able to offer more money, different schedules, not as much overtime and a better quality of life for them. People who have been there longer, obviously their pensions are at stake, so they are stable, but they’re not going to be there forever. So that’s a struggle for us.

Another area where we are really struggling to provide staffing is in the nursing industry, and with teachers. In our area, all four of our higher ed institutions have come together as a unit, and we’re putting in funding. For people who are willing to go into nursing or into teaching, we are forgiving that tuition. In return, they teach and work in our hospitals and our schools.

Governing: You may have seen that Josh Shapiro, the new governor of Pennsylvania, has waived the requirement that state workers have college degrees. Is that something you’re looking at, for jobs where it’s appropriate?

Mary Jo McGuire, Ramsey County, Minn., commissioner and NACo first vice president: We actually are assessing every single job description that we have, because our job descriptions are really outdated. We don’t need a lot of those qualifications that we require. We have a huge, diverse population that we’re trying to recruit from. Every county should look at how you’re actually recruiting and who you’re weeding out, even before they get to the interview.

James Gore, Sonoma County, Calif., supervisor and NACo second vice president: You know, a lot of times it’s not the four-year universities anymore, it’s using the junior college as a hub. We fund what’s called the Career Technical Education Foundation, which connects up high school studies and the businesses in our community. We have employers that can’t find people to apply who are local, and there are people who have a frustration that they can’t stay local.

Governing: At this point, a lot of the country has moved on from the pandemic, at least psychologically. What is the burden on your health departments at this point?

Gore: While there is the desire to move on from the pandemic, I personally would just start by saying it’s not out of people’s minds in my community. There are more people engaged than I’ve ever seen, especially with the underserved populations. Counties are really the safety net of last resort. We take care of anybody who’s not taken care of, and so our programs on mental health, on behavioral health, on screenings and other things are greater than ever. But the question is, how do we sustain that?

Johnson: When we talked about prevention three or four years ago, they thought it was some pie in the sky, but now we understand that if I get this test, I get this screening, if I take this shot, this can help us in preventing a lot of diseases. We used to ask people to come to the public health clinic, but now we go out to them with mobile clinics. The public health infrastructure is different than the medical model. Do you want to wait to have to go to the emergency room? Or do you want to have a public health clinic that focuses on prevention?

Governing: One of the other challenges counties face is drug abuse, with death from overdoses continuing to climb, especially from fentanyl. How are you dealing with that?

McGuire: In Minnesota, we’ve gotten an opioid settlement that’s really going to help us with prevention and dealing with the effects of this, but it’s a huge issue. I think we do need to follow the public health model of education and prevention. And then we have to, of course, deal with the aftermath of it all, but it’s still with us.

Chase: Coming back to our national commission, again — we can’t trade one drug for another. What we are seeing is a huge spike, and not only in illegal drugs. We’ve seen a 20 percent increase in anxiety medication prescriptions for our youth, as well as an increase with adults. And now, as they lose their health care, and they lose access to professionally prescribed medication — which is still going up at rates that are probably unacceptable — then they’ll move to illegal drugs. So we can’t medicate our way out of our mental health crisis. We have got to figure out better life skills. We’ve got to figure out better environments.

And going back to your budget question: Our four officers are from larger, wealthier counties. But 50 percent of all of our counties across America are either stagnant or declining in population, including metro areas. So we’re seeing this increased demand, while half of our counties’ economies are not growing. And it’s going to be harder and harder to deal with the social issues that we are confronted with.
Alan Greenblatt is the editor of Governing. He can be found on Twitter at @AlanGreenblatt.
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