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To start their own public health agencies, Adams and Arapahoe could run into costs up to millions of dollars each, according to a report from a consulting firm that has studied the benefits and drawbacks of the counties' potential decisions to handle public health services alone.
Tri-County Health Department “has the size, breadth and depth of staff expertise, good reputation, grant writing and management capacity, and status as Colorado's largest health department that allows the agency to procure funding not generally available to other health departments in Colorado,” the report says.
Public health agencies draw upon a variety of funding sources, and public health leaders seek grant and contract funds that are related to existing and desired programs, according to the report.
In the single-county scenario, costs may stack up partly because developing single public health agencies “will require adding new organizational infrastructure and customizing existing infrastructure to support the unique aspects of public health,” the report says.
One part of the report points to “additional needed” revenue of $3.6 million in Arapahoe and $2.6 million in additional need in Adams.
“Some current funding lines are not guaranteed” in the single-county scenario, the report says.
It also lists roughly $1.5 million as “an estimated loss of program funds and fees that TCHD currently receives as a district health department.”
Asked whether raising taxes or budget cuts will be necessary to support a single-county health department, Arapahoe County Commissioner Nancy Jackson said in December that costs are unclear at the moment.
“It's a really good question and one we have ourselves, but we're way too early in the process,” Jackson said. She added: “I'd like to know that answer, and we're just not there yet.”
The text of Arapahoe County’s Dec. 14 resolution giving notice that Arapahoe plans to withdraw from Tri-County Health says:
“One of the options being considered includes continuing the Tri-County Health Department as a legal entity in some form other than a multi-county district public health agency … so that it may continue to exist and continue to provide public health services to one or more counties after December 31, 2022.”
It's unclear how accurate the consultant report’s estimates would be if counties decide to contract for services with Tri-County Health if the agency continues to exist in some form after 2022.
“The estimates in the report are based on TCHD's current staffing, funding, operations, scope and jurisdiction,” said a statement from Lisa VanRaemdonck, one of the consultants. “At this time, we cannot reliably say if it would be more or less expensive to contract with a differently organized and structured entity.”
The rebuilding of the public health agency structure in a wide swath of the Denver metro area appears likely to result in Adams, Arapahoe and Douglas counties all having the independence to make their own decisions on public health orders and how to provide health services for residents.
In an era when the Tri-County Health Department's name elicits intense backlash among some county residents, there could be political benefits to each county formally separating from the agency and shaping its own policies.
Even still, separating from Tri-County Health isn't an outcome Arapahoe County was sprinting into.
Arapahoe was the last of the three counties to formally provide notice that it will separate from Tri-County, a decision that will take effect at the end of 2022. The Arapahoe County Board of Commissioners — the county's elected leaders — voted to take the action in a Dec. 14 resolution.
Despite the vocal opposition to Tri-County's mask mandates in recent months, anti-mask sentiment didn't influence Arapahoe County's decision to pull out, according to Nancy Jackson, an Arapahoe County commissioner.
“It's (a) strictly legal process is what we followed,” said Jackson, the chair of the board. “I get it that masks are very controversial, and that actually had nothing to do with it.”
An Arapahoe County spokesperson in early September said a separation by Arapahoe wouldn't be driven by any policy disagreement with the health agency. Douglas County's exit of Tri-County Health would potentially create financial or budgetary problems for the other two counties, the spokesperson added.
What's more, officials say Arapahoe essentially had no choice but to exit Tri-County given the separations by its partner counties. That's because Tri-County's status as what's known as a “district health department” — one made up of multiple counties — was at odds with Douglas' exit and Adams' upcoming departure.
“There's certain rules and so on that guide a district, and since two of the three counties have pulled out, we are no longer a district, so we had no choice,” Jackson said.
It might have been plausible to maintain the structure if Adams County had wanted to continue — with some appropriate adjustments, said Luc Hatlestad, spokesperson for Arapahoe County.
“But once that was no longer an option, we began focusing on a single-county model. Tuesday's resolution was a step in that process,” Hatlestad said.
In Adams, the county commissioners brought forward a resolution at an Oct. 26 meeting to provide notice of Adams' decision to leave Tri-County. The vote was unanimous, according to Adams County Commissioner Emma Pinter. Adams plans to withdraw from Tri-County Health at the end of 2022.
Arapahoe has appeared less keen to cut ties with the health agency, saying in an October statement: “The Arapahoe County Board of Commissioners is saddened that our neighboring counties have chosen to end the productive 55-year partnership with the Tri-County Health Department.”
Arapahoe's resolution notes that under Colorado state law, a county has the power to withdraw from a district public health agency by adopting a resolution and providing at least one year's notice. Arapahoe came close to the deadline, given the situation with the other counties.
The series of withdrawals began with the Douglas County commissioners, who decided to immediately leave the health agency in September after months of disagreements over COVID-19 protection measures. Douglas County formed its own health department and that new board decided to continue contracting most public health services from Tri-County until at least the end of next year.
Tri-County Health has served its residents by providing no-cost cancer screenings, overdose prevention, free nurse visits, restaurant and child care facility inspections, and other services, according to an Arapahoe news release.
The path forward for the counties in a post-partnership world involves confronting the question of how to reorganize their health services structure, potentially contending with increased costs.
“In the short term, separate, single county public health agencies would have access to less public health revenue, and perhaps services, and would incur transition costs for start-up and (the) dissolution of TCHD,” an Oct. 12 report by the Otowi Group says. That's a consulting firm that has studied the benefits and drawbacks of the counties' potential decisions to handle public health services alone.
The report was considering a scenario where Tri-County Health dissolves, but it’s possible the agency could continue in some form.
Although the three counties appear on track to end up with three separate boards of health — the policymaking bodies that oversee local health departments — one or more of them may continue receiving health services from Tri-County, even after 2022.
The text of Arapahoe County's resolution says: “One of the options being considered includes continuing the Tri-County Health Department as a legal entity in some form other than a multi-county district public health agency …. so that it may continue to exist and continue to provide public health services to one or more counties after December 31, 2022.”
Douglas County's leaders have long clashed with Tri-County Health during the coronavirus pandemic, announcing plans in July 2020 to begin the process of withdrawing from the health agency after its decision to require mask wearing in public.
Some of Adams County's leaders felt frustration with Tri-County's recent policymaking, too: Some commissioners voted to opt out of the health agency's school mask order this August before Tri-County removed the ability of counties to opt out of its health orders.
But Adams' message wasn't anti-mask — County Commissioner Eva Henry said at the time that she agreed with the intent of the order and supports mask-wearing.
“It's unfortunate, you know, that politics got into our public health system — it shouldn't be there,” Henry told Colorado Community Media in October. “And that was one of the reasons I voted to opt out of the mask order, to put it back in Tri-County's hands, to take politics out of the public health orders. Commissioners shouldn't be making public health decisions.”
Henry told CCM she wanted to have the conversation “long ago” of Adams having its own health agency.
“Once a year, all the county commissioners get together and they talk about the budget,” in the three counties, Henry said in October. “And talk about what we'll fund and not going to fund. With Arapahoe County's budget restrictions they have, and Douglas County's views, it made those decisions very hard.”
Adams has different budget policies than Arapahoe County because Arapahoe is “not de-Bruced,” meaning the county has different restrictions under Colorado's Taxpayer's Bill of Rights, Henry said.
For Adams County's Pinter, watching other counties give less support or less-consistent backing to Tri-County Director John Douglas' policy recommendations was part of what motivated her to want to break from Tri-County.
“If you watch the votes of the duly appointed board of health members, those three Adams board of health members consistently voted together and in the interest of public health, in favor of Dr. Douglas' recommendations,” Pinter told CCM in October. She added: “If you look at the votes on the board of health members of Arapahoe and Douglas, the same consistency is not true.”
Asked whether Arapahoe commissioners wanted more independence on public health orders during the pandemic, Jackson said: “We have not had that discussion.”
“I will tell you as (board) chair, or as a person or as a citizen who lives in Arapahoe County, I just want a seamless transition,” Jackson said. “I want the people in Arapahoe County to experience the high level of service and care that they've always gotten. How it's done is the mystery box. But I personally don't have a vested interest in any of the ideas.”
Asked whether Tri-County Health — whose headquarters sits in Arapahoe — could become a department of Arapahoe County and become its public health agency, Jackson said it's not clear what will happen at this point.
“We've got a ton of different models we're looking at,” Jackson said. “That is probably one of them, but I would certainly not say that any particular model is ahead of the others at this point.
“This is a very complicated process, and we know everyone wants an answer today,” Jackson said. She added: “But the truth of it is we want to be very careful and look at the costs, look at the pros and cons, so that when we do set up a health department, it will stand.”
Christa Bruning, an Adams County spokesperson, has signaled that the county plans to enter into some type of partnership for public health services in the future.
“Adams County intends to contract with a local health agency for many of its public health services starting in January 2023,” Bruning said in October. “It's too early in the process to know who that health agency is.”
Until new health departments are formed in Arapahoe and Adams, Tri-County maintains the ability to issue public health orders such as mask mandates in those counties.
Reporter Elliott Wenzler contributed to this story.
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