NewPublicHealth Q&A: James McDonough, Chair of NACo's Healthy Counties Initiative

Jan 30, 2014, 1:28 PM

NewPublicHealth is on the ground at the NACo 2014 Healthy Counties Initiative Forum. The theme of the forum this year is “Improving Health in a Climate of Change.” Ahead of the meeting we spoke with James McDonough, county commissioner in Ramsey, Minn., and chair of the Healthy Counties initiative about the meeting and the health changes he is seeing at the county level.

NewPublicHealth: Can you tell us how the NACo Healthy Counties Initiative got its start?

James McDonough: Three years ago the president of NACo at that time, Lenny Eliason, from Athens County, Ohio, really was concerned about how the majority of health care dollars were being spent on treating preventable conditions and the whole issue of the wellbeing of our constituents and our employees. So he elevated the issue of wellness and health in counties as a presidential initiative. Typically those are short term and last for a year or two, but NACo has embraced this and has continued this on as a task force to really embed it in the work that we do—elevating how counties can have an impact on wellness in communities.

NPH: What are the current goals?

McDonough: To really elevate and get the county commissioners and county managers throughout the country to just pause and take a look at what they're doing and what they could be doing. We’ve been talking about how we can do a better job supporting counties that are already doing great work in this area and helping share those best practices, and then helping counties that haven’t really taken a look at what their role is. That can help us have a better impact on getting ahead of some of the major preventable diseases in our communities.

NPH: How important is county-level action when it comes to health?

McDonough: For the most part, counties really are responsible for the public health departments within their communities. Throughout the country we operate almost 1,000 county hospitals and close to 700 county nursing homes, so we have a lot of responsibility for public health and—just as important—we employ more than 30 million people throughout the country.

Action, responsibility and efforts vary county to county, but for example, in Ramsey County, Minnesota, where I’m the County Commissioner, we run the public health department working with our cities, the state and with the federal government. So for us it’s a really big opportunity to be the convener as well to lead the Healthy Cities Initiatives as well to a larger regional more focused and concentrated effort.

NPH: The focus of the forum includes some critical topics such as behavioral health and key health issues in jails. How much of a financial burden do these health issues place on counties?

McDonough: Behavioral health in itself is a big issue for counties. We are really in many, many communities, the behavioral health board, as well but I think for me, in Ramsey County and at a national level, it’s really this confluence of parity in a person’s wellbeing. We should no longer be looking at behavioral health, mental health, separately from physical health. The reality is people who suffer from cancer or diabetes have no more of a choice in what is happening to them than someone with schizophrenia or depression or, often, substance abuse. So this confluence is really recognizing and bringing awareness to the community at large that what’s at issue is a person’s wellbeing, whether it’s physical or mental health.

And jails, in so many cases, are our providers in the community of mental health services because a lot of the people suffering from mental health issues end up either in our emergency rooms and hospitals or they end up in our jails. Both are extremely expensive ways to deal with mental health issues, but also very inappropriate ways to deal with them.

So we really want to elevate that whole issue. A critical fact here is that if people are on Medicaid or some other forms of government benefits, once they enter the jail they lose that benefit, so then not only is it our responsibility to provide that service but it becomes our financial responsibility. And we’re working on this at the federal level because these are people that have not been convicted of a crime yet. We don’t believe people should be losing their benefits unless they’ve actually been convicted of a crime.

NPH: Based on your experience as chair, how much are people hoping to learn from what other counties are doing in all of the areas you’ll be discussing at the forum?

McDonough: You know, I think that’s exactly why the Healthy County Initiative has continued on past the initial presidential initiative and really started to have its permanent place as a task force. Because a forum like this will attract the people that are really on the cutting edge and being effective in these areas, but will also attract counties that really have a concern about what’s going on in their community but just aren’t quite sure about where to go. This is a really good way to get up to speed really quickly without having to reinvent the wheel.

NPH: Has data from the county health rankings helped inform any efforts of the initiative?

McDonough: I was actually in Dayton County, Minn., late last year when some of the presentations of the County Health Rankings came out, and absolutely, the information helps provide access to health factors that need to be improved. It really gives counties a snapshot of what’s going on currently in their counties and really encourages counties to form collaborative partnerships within their communities, to address particular health problems that pose a particular risk in their county. I think the county health rankings are absolutely an invaluable tool that we’re encouraging counties to embed them in their decision, policy and budget making to help make a difference in the health in their communities. It really gives them a good data-driven resource and tool to really understand what’s going on in their communities.

NPH: What’s going on in your own community health initiative that you would point to that you think is working well and that other counties might model?

McDonough: In Ramsey County we have 3,400 employees and I'm a strong believer that the best way to lead is by example. That means you've got to start at home, and so working with our employee groups, with our unions and with all our employees in general, we've moved to a system here in our health care coverage to start focusing in on wellness, to focus on preventing a lot of the preventable illnesses that we deal with, and there’s a financial piece that’s attached to that.

All county employees take a wellness assessment every year and if their spouses are covered under our insurance, their spouses take that assessment as well. Out of that assessment there are usually eight recommendations that the individual can do in their lifestyle or make some changes that would have a positive health benefit for them and they have to pledge to work on one of those, which results in lower co-pays throughout the year. That has actually been really well received by our employee groups and I think most of our employees, after doing this for the past three to four years, would engage in healthier behaviors whether there was a financial incentive on their co-pay or not. It has really brought an awareness that they can take ownership on their health and wellbeing.

The other thing I really am quite proud of is the work we've done in our community on parity of mental physical health. By separating the two in our society, we’ve created a stigma that has prevented people from even seeking help. So we've worked really hard in Ramsey County and in Minnesota to see mental health and physical health as “all is one.”

We had a county hospital now run by a nonprofit entity, but it’s still our safety net hospital and county commissioners sit on the board. When the hospital redesigned, it made a decision to do the same design for the mental health as for the physical health facilities, and now you cannot tell whether a particular bed is a mental health bed or a bed to treat cancer or heart disease. The floors, the artwork in the hallways, every single thing was built to be identical and that’s not the way mental health beds were treated in hospitals in the past. You knew when you were in the mental health wing because it was built differently. And that has made an impact by sending a strong message that when someone is suffering from any type of illness whether it’s physical or mental, they can seek out that treatment and we can provide that treatment in a respectful and dignified way. And anecdotally we know that people receiving mental health care are just much more at ease, family members are much more at ease, and we think the data will back up the fact that we truly believe we are getting better results because of the approach here.

NPH: After the forum, what’s next for the Healthy Counties initiative?

McDonough: In March, NACo will be holding its legislative conference in Washington, D.C., and that’s another opportunity for our task force to get together. And part of that March meeting will be a strategic conversation about where we go as more of an embedded task force in NACo rather than the original temporary one to two year task force we initially were.

This commentary originally appeared on the RWJF New Public Health blog.