DES MOINES — Signs of friction are starting to show in some of the multicounty regions that three years ago were established to deliver mental health care services throughout Iowa.

Advocates nonetheless believe the wounds can be healed and the regional system remains a better option for Iowans in need of mental health care than counties going it on their own.

For years, mental health services were unique to each of the state’s 99 counties. Then the state shifted to a regional method of care delivery. The counties grouped themselves into 14 regions with the expectation that collaboration would save money and provide more efficient and consistent mental health services.

But some regions have been dealing with pronounced upheaval.

In Northwest Iowa, Woodbury County supervisors voted to leave the three-county Sioux Rivers region, citing disagreements with the region’s leadership.

Three counties in North Iowa recently raised the possibility of leaving the 22-county County Social Services region. During a meeting with state health officials in late September, supervisors and other mental health care staff from Hancock, Winnebago and Worth counties expressed concerns with the region’s staffing, funding and care delivery. Some local officials asked if there is a process by which they could break off and establish a new, smaller region.

In Eastern Iowa, Scott County has, at times, drawn the ire of some of the other counties in the five-county eastern region. Scott County previously had a lower per-resident limit on how much property tax revenue it could raise for the mental health region, which led some counties to call for banishing it.

Even after the state tweaked the law to allow Scott County to raise more property tax revenue for mental health care services, the issue in Eastern Iowa lingers.

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Despite lobbying for the law’s change, Scott County said it does not plan to immediately raise property taxes.

Often, indeed, it seems the disputes boil down to money; for example: rural counties frustrated because they feel like they are footing the bill for services being delivered in urban counties within the region.

That may speak to a bigger problem, said Peggy Huppert, executive director for the Iowa chapter of the National Alliance on Mental Illness. Huppert said she thinks too often county leaders remain territorial instead of operating like members of region.

“A lot of regions, they’re not acting like regions. They’re acting like a confederation of counties,” Huppert said.

Huppert said the mental health regions also are coping with significant changes to health care, like the state’s move to privately managed Medicaid, changes to accountable care organizations and upheaval with the federal Affordable Care Act and its Medicaid expansion.

However, Huppert said, if counties are frustrated with the system, she does not think breaking off will be any better.

Linn County Supervisor Ben Rogers tends to agree with that,

Rogers, who serves on the regional Mental Health/Developmental Disability board, said Iowa’s mental health system is far from perfect.

“The state of Iowa has underfunded the mental health system for over 20 years. To try to make that up in five years is a very tall order,” he said. “So what we’re finding as a region ... to provide services that the state has been either unwilling to fund or has been reducing funding, that’s putting a lot of pressure on counties.”

Despite those challenges, Rogers said he feels regionalism has provided benefits — namely better collaboration of services and coordinated funding.

In addition to providing core services, which are mandated by the state to provide urban and rural residents a base level of services, the East Central Region that includes Linn and Johnson and seven other counties provides “core plus” services.

“Our region is not only what’s required, but also because we have a very large and diverse population of needs, we are also funding a lot of core-plus services that smaller regions or other regions simply aren’t. That’s what makes our region unique in some respects,” he said.

To the south, Johnson County Supervisor Rod Sullivan believes the transition to regions has been beneficial, albeit with hiccups.

“We have certainly had our share of philosophical differences but for the most part I think we’ve provided a pretty good service to the people who live in these nine counties,” he aid.

Sullivan said mental health care is much like physical health care in that professionals in specialized areas aren’t always found in smaller communities, so patients have to rely on larger ones around them.

“With that being said, I think we’ve done a really good job of equalizing and getting services out to people and making sure that the system is as strong as it was before.”

Huppert said she thinks the regional system has done much good and that the regions are being led by “some very good people.” But she also sees the friction impacting some regions.

“Clearly it’s fraying,” she said.

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Despite the issues facing some mental health regions, state Rep. David Heaton remains confident the system is best for Iowans in need of mental health care.

Heaton is a Republican from Mount Pleasant and a chairman of the legislature’s health care budget committee.

“I think the regional system is the best thing we’ve ever done,” Heaton said. “I think that the regions are providing services that alone (counties) never would have been able to provide. I think there’s a lot to say about the counties collectively dealing with their mental health needs.”

Heaton acknowledged an urban-rural divide within some regions over funding. He noted the Legislature attempted to address that during the 2017 session by allowing some counties to increase their property tax revenue for mental health services — and not leave it capped at the 1996 level, as it had been.

But he called that a kick-the-can-down-the-road approach, saying lawmakers should devise a better solution.

One key hurdle in the way of such a solution, Heaton said, is the share of lawmakers adverse to increasing taxes.

“The problem we have is that because we have a freeze on the mental health levy, cities who have more demand and more clients and more population and more needs cannot raise their levy to provide the resources to take care of those clients that are within their county. So our rural counties feel extra pressure on them to contribute funding toward those urban counties to provide for those people who live in those urban areas,” Heaton said. “Sooner or later this issue is going to resurface and we need to deal with it.”

Madison Arnold and Mitchell Schmidt of The Gazette contributed to this report.