Tri-County Breakup: Douglas, Adams and Arapahoe Setting Up Own Health Departments

Masks and business closure mandates contributed to the break up of Tri-County Health Department
Masks and business closure mandates contributed to the break up of Tri-County Health Department Tri-County Health Department
John Douglas, the executive director of the Tri-County Health Department, is ready to go down with the ship.

"The ship is indeed sinking, but I think we’re seeing plenty of lifeboats, and we want to honor — to continue the metaphor — the value the ship provided while it was floating for seventy-some-odd years, and what we’ve been able to accomplish," says Douglas, a medical doctor and longtime public-health professional. "We're continuing to help the residents and, in some cases, provide better services."

Douglas has been steering Tri-County, which has provided services to Adams, Arapahoe and Douglas counties for decades, since October 2013; today it serves an area with a population of over 1.5 million people. But Tri-County was a casualty of political fights and changing feelings about the role of public health during the COVID-19 pandemic, and Douglas will stay on the job just through the end of this year, before those three counties take on the job of providing all of their own public-health services.

Douglas County, with a population of close to 370,000 today, was barely a blip when Tri-County was starting out. "Douglas County is grown up now. It’s time for us to have our own health department," says Lora Thomas, a Douglas County commissioner who's a Republican.

Counties around Colorado that are not large enough to operate their own health departments typically band together to form a joint health agency, with economies of scale that individual county health departments can't achieve. However they're set up, the departments are responsible for inspecting restaurants, tattoo parlors and other businesses; helping prevent and manage disease outbreaks; and managing vital records, among other tasks. And during a pandemic, the agencies handle vaccines and testing.

In 1948, Adams, Arapahoe and Jefferson counties joined together to form a public-health agency, the Tri-County Health Department.  A decade later, fast-growing Jefferson County left the group and set up its own health department. And then in June 1965, as Douglas County was recovering from the devastation caused by the South Platte River flood in that then-sparsely populated section of the metro region, the Douglas County Board of Commissioners decided to join the health department. Douglas County, which had a population of just under 5,000 in 1960, officially became a member of the Tri-County Health Department in 1966.

As Douglas County's population exploded, and as Arapahoe and Adams counties grew, too, fissures over politics and priorities began to develop. In 2004, Douglas County first explored forming its own health department. But after an analysis showed that such a department would cost Douglas County three times as much money as it paid into Tri-County, the Douglas County Board of Commissioners stuck with the shared health department.

"It’s a complicated set of counties. Three counties, 26 municipalities, 12 hospitals, 300-some-odd schools. A lot of entities in the community that you really need to get to know and to work with," says Douglas. "I guess I got to understand pretty early that there were some different — for want of a better term — political views in the three counties."

Douglas was no stranger to political views when he joined Tri-County: He'd just come from ten years as the director of the division of STD Prevention for the Centers for Disease Control and Prevention. "During the Bush administration, there were issues about condoms and sex ed and things like that. I discovered the closer I could stick to the public-health side, the better," he recalIs. "I think that worked pretty well."

But he soon encountered new challenges with Tri-County.

The first major political controversy came in 2019, when a bipartisan group of Colorado lawmakers introduced a sex-education bill that included prohibiting schools from "emphasizing sexual abstinence as the primary or sole acceptable preventive method available to students." That meant that if schools were going to teach about abstinence, they also had to teach about safe-sex practices.

"We had just finished doing a very deep dive [into] why certain neighborhoods in our three counties continue to have very high rates of teen pregnancy," Douglas recalls. The survey found that communities with higher rates of teen pregnancy — mainly ones in Adams County — often featured parents struggling to talk with their teenage children about sex and vice versa.

So Douglas thought it made sense to testify in favor of the legislation, but didn't notify county officials of his plans.

"I think I hadn’t adequately perceived that there was going to be a pretty strong difference of opinion," he says now.

"We were all upset about that. There had been no discussion. Our county didn’t support that radical sex-ed bill for kids," recalls Thomas.

"We felt like he should have said he isn’t speaking on behalf of these counties, because he hadn’t, for lack of a better word, cleared that with us," recalls Nancy Sharpe, a Republican Arapahoe County commissioner. "We talked about that and said, in the future, if there was testimony, if he was going to testify on a bill, he would contact us and we would talk about whether that was something that Arapahoe County would support or not support. It ended up being sort of a policy that was established after that controversy."

The bill passed through both the Colorado House and Senate, and was signed into law by Governor Jared Polis.
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Dr. John Douglas has led Tri-County Health Department since 2013.
Tri-County Health Department
Then came the pandemic, when mask mandates and mandatory business closures sharply divided the country. The Tri-County counties were no exception, and the split was aggravated by the fact that Douglas County is red, Arapahoe County is purple and Adams County is blue.

As COVID-19 hit in March 2020, the Tri-County Health Department, which is governed by the Tri-County Board of Health, a body with nine members appointed by the three counties' boards of commissioners, issued a "shelter in place" order to combat the spread of the virus.

Immediately after that move, some Republican state lawmakers asked the Douglas County Board of Commissioners, which was then and still is composed of three Republicans, to withdraw Douglas County from Tri-County. That rebellion fizzled after Governor Jared Polis issued a statewide stay-at-home order just days later.

But in July 2020, following a Tri-County Health Department announcement that it would mandate masks across the three counties, Douglas County rebelled again. This time, the commissioners told Tri-County that it was giving the department the required one-year notice of withdrawal.

Ironically, director Douglas had actually recommended to the Tri-County Board of Health that Douglas County be included in the mask mandate only if that county's commissioners chose to opt in, since Adams and Arapahoe counties had far more COVID-19 cases at the time.

But the board overrode his advice, voting 5-4 in favor of a mask mandate for all three counties, with only unincorporated parts of counties and individual municipalities having the option to opt out. In an attempt to prevent a breakup, the board then crafted a policy allowing entire counties to opt out of new public-health orders.

"That was, we thought, still a troubled situation. But we thought that was a reasonable response," Douglas says.

Then in August 2021, heeding advice from the CDC, the Tri-County Health Department enacted a mask mandate for students in schools. Douglas County wanted to opt out, but by then Tri-County had eliminated the opt-out provision.

"Honestly, it made sense to me, because we knew that kids staying out of school was the worst thing that could happen to them," Douglas recalls. "When our board passed that and Douglas County quickly said they’ll opt out of it, it became apparent that the opt-out strategy was precluding our ability to carry out what state statute said about our public-health abilities." But at that point, Douglas County decided to get out of Tri-County altogether.

Even with Douglas County leaving, Arapahoe County commissioners wanted to stay with Tri-County.

"We’ve always had a good relationship with Tri-County," says Sharpe. But a few months later, the Adams County Board of Commissioners, which had previously broached the idea of leaving Tri-County, decided to form a separate health department. Since a joint health department has to comprise at least two contiguous counties, Arapahoe County was left with no option other than to withdraw from Tri-County, too.

"I don’t know that we would have said, 'Yeah, let’s do this on our own.' But now that we are where we are, we are taking advantage of the opportunity we have to establish our own health department and do it in a way that is going to be lasting," says Sharpe.
Commissioner Lora Thomas is serving on the new Douglas County Board of Health.
Douglas County
Like the counties it served, the department had grown, too, peaking during the pandemic with 400 employees and up to 250 contractors performing COVID-related duties. And while the Tri-County budget was around $42 million prior to the pandemic, it grew to over $60 million in 2022. Some of that money came directly from the general funds of the three counties, while state and federal dollars, as well as private grants, accounted for much more.

Now the three counties are racing to have their individual health departments fully operational by January 1, 2023, since December 31 is the Tri-County Health Department's last day of operation.

Adams County plans to hire approximately 171 employees for its health department and spend $20 million in the first year. That's much more than the $3.8 million that Adams County paid into Tri-County in 2022. But according to Lynn Baca, a Democratic Adams County commissioner, once the department has been set up, the county will end up spending between $3.8 million and $8 million annually.

At the same time, Adams County will be able to specify where it puts its funds. Says Baca: "We want something on teen pregnancy and air quality. We want to consider the social determinants of health. How does homelessness affect health in the county? How does air quality affect health in the county?"  Because it is home to numerous industries, including the Suncor oil refinery in Commerce City, Adams County has major air-quality issues.

Douglas County has far less industry and a much wealthier population. Michael Hill, who had most recently been serving as the health agency director in California's San Luis Obispo County, has been running the new Douglas County Public Health Department since February.

"I've committed to the commissioners that it won’t cost any more to the county’s general fund as they were paying into Tri-County," Hill says, noting that Douglas County has typically paid $2.5 million into Tri-County. "I’ve come up with a ballpark $5 million cost to operate this organization, and I already have over $2 million in funding commitments from the state. I've estimated $750,000 to $800,000 in fees. My goal is to keep it under $2.5 million [for the county]."

Hill says he was attracted to the Douglas Country job because it would give him an "opportunity to build a health department from scratch and to try and build it with a 21st-century mindset." He plans to avoid politics.

"It’s my job to help the Board of Health understand the ramifications of their actions," he says. The Douglas County Board of Health has five members, including Thomas and fellow Commissioner George Teal, with five alternates. "In the end, they are the Board of Health. As long as they don’t tell me to do something immoral, unethical or illegal, it’s my job to get it done," Hill adds.

Sharpe is chair of Arapahoe County's new Board of Health, which recently appointed Jennifer Ludwig as the county's public-health director; she'd been deputy director at the Tri-County Health Department.

Director Douglas and his team have been working with the human resources departments at Adams and Arapahoe counties to place other Tri-County employees. "I think that’s encouraged more people to hang on," Douglas says. "As we get toward the second half of the year, I'm somewhat concerned the attrition may increase."

Douglas himself is ready for an "extended sabbatical," he says, but he plans to continue working in public health in some way.

"I’ve enjoyed this job at Tri-County — until, really, the last year — more than any other job I've had. The spectrum of things that impact the health of the public is large, even in a relatively healthy, wealthy population like the one that lives in the U.S. and Colorado," he notes. "It’s been a great way for me to feel like I'm making a difference in the world."
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Conor McCormick-Cavanagh is a staff writer at Westword, where he covers a range of beats, including local politics, immigration and homelessness. He previously worked as a journalist in Tunisia and loves to talk New York sports.