After more than seven decades of collaboration, the Tri-County Health Department is disbanding over increasingly difficult to reconcile approaches to public health, leaving Aurora — a city of almost 400,000 people with land in Adams, Arapahoe and Douglas county — in an awkward position.
As the three counties prepare to go their own separate ways, Aurora will either have to navigate being served by three public health agencies or embark on the ambitious task of forming its own health department, similar to Denver and Broomfield, which each operate as both cities and counties.
Local elected and public health officials have mixed feelings on the best approach.
Aurora Mayor Mike Coffman was adamantly opposed to the split, saying earlier that the breakup of Tri-County would be “just awful” for Aurora.
“I certainly hope that we can work together and we can stay in some modified version of Tri-County Health going forward and not fragment the city of Aurora into three different health departments,” he said during public comment at the Adams County board of commissioners meeting where the county formally voted to exit.
Whatever approach the counties take will lead into uncharted waters, as the dissolution of a health department this size has never happened before in Colorado.
“It’s fair to say this is unprecedented,” said Dr. John Douglas, Tri-County’s executive director.
Douglas County voted to leave Tri-County in September after clashing with other members of the department over public health measures during the pandemic. Things came to a head in August, when the other board of health members overruled Douglas County’s representatives to impose a mask mandate in all K-12 schools.
A month later, Adams County voted to leave the department as well, a decision that left the Arapahoe County’s board of commissioners in the lurch.
“We’re going to be the adults in the room,” Arapahoe County Commissioner Jeff Baker said. “Now that doesn’t mean that we’re mad at anybody, but it seems like there could be a lot more partnership among the three counties that is not taking place. We’re going to look at what’s best for Arapahoe County.”
At its Oct. 26 meeting, the Adams County board of commissioners voted 5-0 to leave Tri-County and form their own health department. During the meeting, commissioners spoke about the need to focus on challenges specific to Adams County, including its high rate of child poverty and pollution from the Suncor Refinery.
“We need to start focusing on Adams County and we need to provide funding for the things that our citizens need in Adams County,” Commissioner Eva Henry said. “It shouldn’t be influenced by another county.”
Adams County regularly ranks lower than Douglas County and other metro counties in terms of various health metrics, Commissioner Steve O’Dorisio said.
“When Douglas County and other counties are ranked higher consistently when it comes to public health outcomes and we’re in the same organization, it means the status quo cannot continue,” he said.
Not since the influenza epidemic of 1918 has public health been so front and center. However, health departments do much more than manage pandemics, and undergird many of the county’s daily operations, from inspecting restaurants and pools, to monitoring septic systems, issuing birth and death certificates and tracking the prevalence of everything from rabies to sexually transmitted infections.
Tri-County will continue to provide public health services to the three counties through 2022, but Douglas County is now in charge of managing its own COVID-19 response. County and state legislative leaders there have opposed public health measures aimed at reducing viral spread, such as limiting the number of people in an indoor establishment and mask mandates.
Colorado House Minority Leader Patrick Neville, R-Castle Rock, and other top state Republicans in March 2020 urged Douglas County commissioners to “terminate whatever contract exists” between the county and Tri-County after a so-called shelter in place order was put in effect.
Each county has vowed to work with Tri-County to maintain a continuity of services throughout the transition. However, many questions still remain about the extent to which the counties will be able to do as much individually as Tri-County.
A report prepared for the Adams and Arapahoe county commissioners by an outside consulting firm suggests that setting up individual health departments will be more costly for all of the counties while delivering a lower quality of care.
The report, prepared by Highlands Ranch-based firm Otowi Group and delivered to the commissioners at the end of September, estimated that a two-county district with a similar level of services as Tri-County would require a budget of $42 million. An Adams County health department with reduced services would require $18.5 million, and Arapahoe County $22 million.
The transition cost as a result of the separation is $61 million, the report estimated, $50 million of which is a one-time payment into the state’s public employee retirement association.
Still, Arapahoe County officials have indicated that they are better positioned to absorb various Tri-County resources due to many of their central locations throughout Aurora.
“Most of the Tri-County Health Department’s buildings and staff are already in Arapahoe County, so I think it may actually be easier for us,” Baker, a former fleet and facilities manager for Arapahoe County, told The Sentinel before the Adams County vote this fall.
At least two of the current Tri-County Health facilities are owned by Arapahoe County, while many others are under lease agreements. That could help defray additional costs that are likely to ultimately trickle down to taxpayers, according to Baker.
“We want to have the least impact for our taxpayers,” he said. “What can we do to make sure that they’re not paying the divorce costs?”
County officials have been tight-lipped on the future of health services in the jurisdiction while consultants mull next steps. A series of public study sessions where commissioners will be able to respond and question the recommendations are slated throughout the winter, a county spokesperson confirmed.
But local health agencies and local nonprofits that serve the region are still bracing to pick up more of the slack in the meantime.
“Tri-County has always been a strong partner of STRIDE and we will continue to do what we can to meet the needs of community members across our five Aurora health center locations,” STRIDE chief healthcare officer Savita Ginde said in an email.
“I would be lying if I didn’t say we’re concerned,” said Kelly Phillips-Henry, CEO of the Aurora Mental Health Center, about the split.
Aurora Mental Health works closely with Tri-County to conduct suicide prevention programming and other mental health resources, and she’s worried that as separate departments the counties won’t be able to provide the same level of care to the region. It’s possible that local partners will need to step up and provide more services that were once handled by Tri-County, she said.
Phillips-Henry also expressed dismay at the causes of the split.
“Population-level health is much bigger than potential controversy over our current issues,” she said. “We need to be able to see long-term.”
Some other municipalities are in Aurora’s position. Berthoud is in Larimer and Weld counties, but the majority of the 10,000-person town’s businesses and homes are in Larimer County. Arvada and Westminster straddle both Adams and Jefferson counties, and are served by Tri-County and Jefferson County Public Health, but both have significantly smaller populations than Aurora.
In an email to the Sentinel, Westminster spokesperson Andy Le said that “honestly, it’s fairly straightforward over here.
“Residents and businesses follow the guidance of their respective county,” Le said. “Our residents have a fairly strong sense of which county they’re in because of schools, DMVs, and other such critical county services. The county line is Sheridan Boulevard which runs north/south straight through the city so there isn’t a potential for confusion due to geography.”
Glen Mays, a professor of health policy at the Colorado School of Public Health, said that one of the biggest concerns for Aurora is that it could end up being served by three different departments with very different resources or priorities.
“That could leave Aurora with having very uneven levels of public health services across the city depending on which county jurisdiction residents live in,” he said.
“Aurora city management will take direction from the Aurora City Council as a body in determining next steps for the city’s public health needs,” city spokesman Ryab Luby said. “It is too early for city staff to speculate. In the meantime, the Tri-County Health Department remains the city’s public health provider for each of the three counties the city covers through at least the end of 2022.”
To make sure the city’s needs are met, he said Aurora officials need to be very active in discussions with the three counties. An important issue will be determining what kind of representation the city has on the board of health of the individual public health departments.
“That’s one structural way in which Aurora could really have an influence over the activities and resources that those three county based agencies use,” Mays said.
Douglas, with Tri-County Health, said it’s unlikely that basic public health services will look much different across the three counties, even if they all form their own departments. Tasks such as restaurant inspections are heavily regulated by the state, and county departments have little latitude to change things.
It’s more likely that counties will devote more or less attention to things based on their demographics. For instance, one county might decide to prioritize teen pregnancy prevention or sexual health.
Douglas said that he would have preferred Adams and Arapahoe counties continue to work together in some form of partnership. He acknowledged that Adams County has some unique health needs, but believes that Tri-County could have tailored services to meet the different counties’ needs.
He was hesitant on the issue of whether individual counties would be able to provide the full range of services that Tri-County does, and said it’s too soon to speculate on what programs might get cut in the event that departments don’t have the funding or expertise to provide something that TCHD once did.
One of his biggest concerns is that separate agencies will be less competitive for grants, however. Only 23% of Tri-County’s revenue comes from the counties, the rest is from the state and federal and nonprofit grants. Because it is a large agency with a lot of highly qualified staff, Tri-County has been able to get grants to cover programming for many things it would not otherwise be able to address at the county level, such as chronic diseases.
“I’m a little worried about those sort of really important but harder to fund programs that might not be as sustainable if the counties went their own ways,” Douglas said.
The future of Tri-County as an institution is up in the air. It’s possible that it would continue to exist as an entity that provided services to two or three of the new county health departments, something that Douglas said he is in favor of.
“I think that it’s very likely that some part of the people who are serving Arapahoe County by the current Tri-County structure will continue serving them through whatever new structure evolves,” he said.
But he said his primary concern is helping the department’s staff navigate the transition.
“We can’t do what we’re doing right now if the staff are concerned and looking for other jobs,” he said. “I think it’ll be better for the three counties if we can hold the team together and figure out kind of a glide path into new jobs.”
Baker with the Arapahoe County board agreed.
“I feel the worst for the staff with the uncertainty in this whole pandemic era that we’re in,” he said. “They now have to think about: ‘Where am I going to be employed? Am I going to be employed? Where will I have to drive to go to work? Will I be able to work from home?’ You have to care for the people.”
According to documents from Tri-County’s Tuesday board of health meeting, the department is currently experiencing a staffing shortage. The department has had a turnover rate of 17% in 2021, and is currently seeking to fill nine job openings.
“Due to TCHD’s uncertain future, we have developed talking points for hiring managers and, thus far, have not had candidates turn down job offers for this reason,” a report from the director of human resources said.
The breakup could be seen as a referendum on the efficacy of local control. At the beginning of the pandemic, the state’s department of public health was in charge of almost all decisions about managing Colorado’s response to the coronavirus. In the spring of 2021, Gov. Jared Polis transferred authority to county health departments.
Douglas said that local control exacerbated the divisions between the counties, but didn’t create them. Throughout the pandemic he has refrained from openly criticizing Polis’ approach to the pandemic, but said that the more coordinated action local governments can take, the quicker the pandemic is likely to be over.
Local control has shown itself to have benefits and drawbacks, Mays, the Colorado School of Public Health professor, said. However, he said it’s unlikely to go away.
“Colorado has a long tradition of being a home rule state and having decentralized decision making,” he said. “I don’t see that changing radically.”
In a meeting with the Sentinel on Nov. 1, Polis demurred when asked if the state was concerned about Tri-County’s breakup.
Douglas has been at the helm of Tri-County for the past eight years. Before that, he worked at the Centers for Disease Control and Prevention in Atlanta for 10 years and at Denver Public Health for two decades.
Watching Tri-County fall apart over what are largely political disagreements has been “intensely discouraging,” he said.
Douglas worked in HIV/AIDS prevention at Denver Public Health, which had its own fractious politics, but he said this far exceeds what he saw in that era.
“It’s been an unprecedented situation both for our society at large to be so divided over responding to something like the pandemic, but also for what had been a really effective regional health department,” he said.
Are there things that Tri-County could have done differently to prevent the split?
“I’ll be asking myself that for the next 10 years,” Douglas said.
Staff writer Quincy Snowdon contributed to this report