Counties Key to Addressing Behavioral Health Needs on the Ground

By Sallie Clark

Counties are at the forefront of assisting individuals with behavioral health needs, annually investing $83 billion in community health systems, including behavioral health services. Through 750 behavioral health authorities and community providers, county governments plan and operate community-based services for people with mental illnesses and substance abuse conditions. County-based behavioral health services exist in 23 states that collectively represent 75 percent of the U.S. population. Counties also help to finance Medicaid, the largest source of funding for behavioral health services in the U.S., and serve as the local safety net, administering wrap-around human services support. 

These services are critical, as 1 in 5 adults in the U.S. experience a mental illness, with less than half receiving treatment in the past year. One in 10 experience a substance use disorder, with only approximately 10 percent receiving treatment in the past year. An estimated 8.5 million adults in the U.S. have both a mental health and substance abuse disorder.

While counties have always played a crucial role in delivering services and treatment to individuals with behavioral health needs, recent changes in the landscape have opened up even more opportunities for localities to assist these residents effectively. While much of the attention related to Medicaid expansion revolves around increased coverage for basic health care needs to a new category of low-income people, many states and localities have also realized opportunities to increase the availability and quality of behavioral health services, according to the Government Accountability Office. In the 26 states and the District of Columbia that expanded Medicaid in 2014, an additional 350,000 adults with mental health care concerns received care, according to the Pew Research Center. 

As the entry point into the criminal justice system, counties are uniquely positioned to make the most of Medicaid to improve outcomes for justice-involved individuals—a population with numerous behavioral health needs. Nearly 2 million adults with serious mental illnesses such as bipolar disorder and schizophrenia are booked into county jails every year, and the prevalence of people with mental illnesses in jails is three to six times higher than that of the general population. 

Once incarcerated, people with mental illnesses tend to stay longer in jail and upon release are at a higher risk of returning than justice-involved individuals without these illnesses. We also know that only about 4 percent of jail admissions result in prison sentences—in other words, 96 percent of jail detainees and inmates return directly to the community from jail. These statistics highlight the critical need for expanded access to mental health and addiction services for justice-involved individuals, which can help reduce recidivism and provide a return on investment for local taxpayers. 

Despite individual counties’ tremendous efforts to address this problem, we often run into significant obstacles, such as coordinating multiple systems and operating with minimal resources, especially in rural counties. In recognition of this critical issue, the National Association of Counties, or NACo, The Council of State Governments’ Justice Center and the American Psychiatric Association Foundation have come together to lead a national initiative to help advance counties’ efforts to reduce the number of adults with mental illnesses in jails. With support from the U.S. Department of Justice’s Bureau of Justice Assistance, the Stepping Up initiative builds on the many innovative and proven practices being implemented in counties across the country. More than 270 counties have passed resolutions or proclamations to participate in the initiative.

Across the country, counties continue to address behavioral health needs in our communities. Many localities are making behavioral health a major policy priority and are developing innovations in data collection, information sharing and justice system diversion. Jurisdictions across the country are developing comprehensive and accountable systems to connect primary and behavioral health care, as well as mechanisms to ensure that wrap-around services are part of treatment plans for individuals. Counties also have made the most of Medicaid’s flexibility by leveraging local funds to construct systems of care for populations that private insurance does not cover.

Additionally, many counties across the country are supporting efforts to enhance training for criminal justice, emergency responders and mental health system personnel on how to appropriately respond to crises involving individuals with mental health conditions. We are supporting a broad range of activities including jail diversion programs, mental health courts, creating or expanding community-based treatment programs, and providing in-jail treatment and transitional services to connect individuals to care in the most appropriate settings and thereby reducing the cost to counties of the revolving jail door and recidivism.

There is no one blueprint or template for reaching the vision of a comprehensive and coordinated system of care in localities. However, our nation’s counties are making progress and will continue to work—in partnership with our federal and state counterparts—to lower the cost of incarceration and ensure that individuals in our communities receive care in the most appropriate settings.

About the Author

Sallie Clark is the president of the National Association of Counties and an El Paso County, Colorado, commissioner.