“A lot of regions, they’re not acting like regions. They’re acting like a confederation of counties,” Huppert said. “They’re still acting like individual counties. They are asking, ‘What are we putting into it? What are we getting out of it?’ ... They aren’t thinking or acting like a region.”

Huppert said she thinks some of that is tied to the roots of Iowa’s mental health care system, which originated with the treatment of individuals in county homes.

“You still pick up on that paternalism of, ‘Well, we want to take care of our people,’” Huppert said. “It’s not where it should be.”

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 health care law the 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.

The regions need to have a strong population base in order to provide property tax revenue that will be enough to fund services, Huppert said.