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County Jails and the Affordable Care Act

affordable-care

Introduction
In 2014 the Patient Protection and Affordable Care Act (ACA) will provide new health insurance coverage options for millions of individuals through an expansion of Medicaid eligibility and the establishment of State-based health insurance exchanges. This brief will examine ways that counties may be involved in eligibility determination and enrollment processes for these newly eligible individuals, focusing particularly on issues related to enrolling qualified individuals held in county jails as pre-adjudicated detainees and inmates preparing to reenter the community.

Specifically the brief will assess some of the potential issues and challenges county jail and human services staff may face in terms of enrollment procedures. The brief will also highlight examples of existing countybased enrollment strategies that may be able to serve as models for developing processes to enroll individuals in county jails who become newly eligible for health insurance coverage in 2014.

ACA Coverage Expansion and Potential Effects on County Jails
The ACA’s significant expansion of health insurance coverage has many important implications for counties, as county governments provide the local health care safety net infrastructure, public health functions, and other health care services, as well as often govern, finance, and operate local coverage and enrollment programs. Counties also run and finance local jails, which are responsible for providing health care coverage for the approximately 13 million individuals who are booked into these facilities each year.1

By 2014 the ACA requires that health insurance exchanges be established in each State, and States can either opt to create and run their own exchange or allow the Federal government to develop and operate the exchange in the State. Exchanges are intended to be regulated insurance marketplaces where individuals without employer-sponsored health insurance will be able to obtain coverage or small businesses can obtain coverage for their employees.2 Premium credits will be available for individuals and families with incomes between 100–400 percent of the Federal poverty level (FPL) based on a sliding income scale to help them purchase coverage through the exchanges.

There is a specific ACA provision related to the exchanges that could significantly impact county jails, which states that “…an individual shall not be treated as a qualified individual, if at the time of enrollment; the individual is incarcerated, other than incarceration pending disposition of charges.”3 This provision will likely allow eligible individuals in custody pending disposition of charges to enroll in a health insurance plan offered through an exchange prior to conviction, or maintain coverage if they are already enrolled. A substantial number of individuals who enter into county jail custody have serious medical and behavioral health needs4 and would benefit greatly from treatment to address these conditions. Additionally, as counties are responsible for providing health care services for county jail inmates and the overwhelming majority of individuals in jails lack any type of health insurance coverage,5 this provision could potentially reduce county jail health costs.

In 2014 the ACA also expands Medicaid eligibility to include all individuals under age 65—including adults without children—who have incomes up to 133 percent FPL.6 Many individuals involved in the criminal justice system will fall into this category of adults who will be newly eligible for Medicaid, because a large majority of jail inmates are young, low-income males7 who did not previously qualify for the program. However, unless future administrative actions change existing Federal rules, while these individuals will be eligible to enroll in the program they will not be able to receive Medicaid benefits in 2014.

Presently some county jail inmates meet Medicaid’s eligibility requirements and are eligible to enroll in the program, but they are not covered by Medicaid. This is because Federal law does not allow for Federal Medicaid funding—Federal Financial Participation (FFP)—to pay for medical care provided to individuals who are “inmates of a public institution,” which is commonly referred to as the “inmate exception.” This results in counties covering the full cost of jail inmates’ health care services rather than eligible detainees receiving coverage through Medicaid.

box1When an individual enrolled in Medicaid is detained, the majority of States terminate Medicaid benefits, despite Federal guidance that allows for the suspension of Medicaid for individuals involved in the criminal justice system whose eligibility for the program is not linked to Supplemental Security Income (SSI).8 This benefit termination occurs primarily because of the inmate exception, as well as because some States’ information management systems may not be designed to accommodate benefit suspension. individuals. However unlike the provision allowing eligible preadjudicated inmates to obtain health insurance coverage through plans on the exchanges, the ACA does not provide further clarity regarding Medicaid and the pre-adjudicated population.9 This means that while many individuals in jail pending disposition of charges will meet the new Medicaid income requirements in 2014 and will be able to enroll in Medicaid, any medical services they receive will not be covered through the program while they are incarcerated (barring an existing exception mentioned in Box 1).

Enrollment Processes and Procedures for Newly Eligible Individuals
Through the ACA’s expansion of health coverage, many individuals incarcerated in county jails will become eligible to enroll in either Medicaid or plans available through the exchanges. This expansion poses both opportunities and challenges in terms of eligibility determination and enrollment of individuals who newly qualify for coverage. The ACA requires a coordinated eligibility determination and enrollment process for both Medicaid and plans offered on the exchanges. This means that determining individuals’ eligibility for either Medicaid or a product on the exchange is intended to be a one-time streamlined screening conducted through a single application that is consumer-friendly and that minimizes administrative burdens. To facilitate the eligibility determination process, the U.S. Department of Health and Human Services (HHS) will operate a data services hub to provide functions for the exchanges such as verifying citizenship and tax information.10 Particularly in States where county human services agencies currently determine whether families are eligible for Medicaid, counties will likely continue to help certain individuals with enrollment in some way because of the ACA’s requirement of a “no wrong door” approach for individuals applying for coverage. However, how county jails may be involved in the enrollment process remains a question, and their role has likely not yet been considered much in State-level exchange planning efforts.

Issues Related to Enrolling County Jail Inmates Eligible for Health Coverage
Conducting eligibility determination and enrollment is outside of the traditional scope of the core function of jails. While some jails already help enroll eligible individuals into public assistance programs such as Medicaid as part of their pre-release planning services, it is important to recognize that jails must focus on their primary purpose and direct the majority of their resources to inmate population management and public safety concerns.

However, many county jails experience a substantial number of individuals who cycle in and out of detention due to untreated mental health and substance abuse problems. Although health coverage does not guarantee access to services, enrolling these individuals into appropriate health plans may increase the likelihood that they will be able to obtain more consistent physical and behavioral health care. Increased access to appropriate treatment also has the potential to reduce the re-arrest rates of these individuals and consequently lessen the overall burden on county jails.

Considering these factors, counties may want to take the initiative in beginning to plan for the development of processes to enroll individuals in jail pending disposition of charges who fall into the eligibility category for exchange plan coverage. Additionally, regarding Medicaid, even though recently issued Federal regulations state that current rules regarding FFP and inmates are not changed through the ACA, county jails can continue to enroll those who are Medicaid-eligible into the program to help expedite access to treatment and maintain continuity of care upon their release from incarceration.

The following paragraphs outline some of the potential key issues related to enrolling eligible individuals involved in the criminal justice system into the new health coverage options that will become available beginning in 2014. There are a number of other challenges not addressed here related to ensuring that the ACA’s expansion of health coverage translates into meaningful access to medical and behavioral care for the unique needs of this population, such as having an adequate and qualified health provider workforce as well as potential complications associated with handling medical records and billing.

Ensuring County Jails Are Considered as a Point of Contact With Newly Eligible Individuals

The ACA specifically requires States to provide targeted outreach to facilitate the enrollment of underserved and vulnerable populations in Medicaid or the Children’s Health Insurance Program.11 To fulfill the intention of this provision, exchange planning by State administrators should include consultation with a wide range of local level stakeholders, such as county officials, community providers, as well as criminal justice authorities.12

For example in Massachusetts, which established a State-based health insurance exchange in 2006, evaluations of enrollment data show that a substantial portion of low-income young adults with behavioral health issues were not receiving substance abuse treatment and were much less likely to be enrolled in health programs than the general population.13 Since a large portion of jail detainees have many of these same population characteristics, evidence from Massachusetts’ experience appears to demonstrate the importance of including the criminal justice system in enrollment efforts.

Also, some of the individuals who will be newly eligible in 2014 may not be aware that they qualify for health coverage. A number of these individuals will have interactions with the criminal justice system, and their time in custody could be an important opportunity to provide them with information about health coverage options. As States develop their overarching enrollment outreach strategies, they should recognize that it will be important to connect with staff at local jails and the wider justice system, such as public defenders, probation officers, and others.

Lack of Staff Capacity at Jails to Assist With/ Conduct Screening and Enrollment
A number of jail inmates will require assistance in applying for health coverage, as they may have limited literacy skills and/or lack experience using computers,14 or correctional authorities may determine that all enrollment activities should be conducted specifically by jail staff. However many jails have staffing constraints and may have limited personnel available to engage in the additional work associated with conducting the enrollment of eligible inmates. The ACA does establish a Navigator program to provide funding to entities that have the capacity to provide outreach and application assistance. Entities with experience enrolling individuals into Federal programs—such as county human services agency staff—may opt to participate in the program and could potentially assist with enrolling eligible individuals in jails. Yet it will be important to remember that some county human service agencies, nonprofit organizations, and other entities serving as Navigators may lack experience working with jail populations and there may be challenges associated with establishing better connections between these agencies and correctional authorities.

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Barriers Related to Jail Environment and Jail Population Characteristics
While jails may serve as an important place of interaction with a substantial portion of the newly eligible individuals, there will be enrollment challenges due to the nature and constraints of the jail setting. First, high turn over rates are common in jail populations— a substantial portion of jail detainees are released within 48 hours, although the average length of detention varies from 2 weeks to 2 months.15 Since a significant number of individuals are released in a matter of days, for a large portion of the justice-involved population there may not be sufficient time during their stay in custody to conduct eligibility determination and enrollment in Medicaid or an appropriate health plan on the exchange. Also, some county jails that currently conduct Medicaid enrollment just prior to an inmate’s release have encountered complications associated with inmates’ scheduled release dates frequently changing, making it difficult to track individuals and connect them to coverage in a timely way. Another challenge is that some inmates will not have the appropriate documentation needed for enrollment, as they may lack or not have on hand at the time of their arrest any form of government issued identification.16 Furthermore, for a variety of reasons, some justice involved individuals might be reluctant to enroll in health coverage.17

Information Technology Challenges
Assuming that jail staff do become involved in enrolling eligible individuals into new health coverage options, one of the issues that will need to be considered is the information technology capacity of jails. For some jails there may need to be new hardware installed to connect with the State exchange. There also may be some complications associated with county information technology staff permitting electronic linkages to the exchanges and issues related to establishing appropriate protections to ensure private health data are not compromised. Counties that opt to enroll eligible incarcerated individuals will need to work with State exchange planning commissions and State Medicaid agencies to develop streamlined electronic enrollment processes and procedures.

Challenges Associated With Eligibility Changes
Individuals in jail pending disposition of charges who are in the exchange eligibility category should be able to enroll in an exchange plan or if already enrolled in one be able to maintain this coverage, although how exactly plan benefits and billing would operate for this population is unclear. However if an individual is adjudicated guilty the ACA requires that the enrollee must report this to the State exchange as she/he would no longer be eligible for coverage. In practice this would most likely require correctional facility staff or other eligibility determination workers associated with the jail to report this eligibility change to the exchange. Yet Federal rules also allow a member of the enrollee’s household to report the eligibility change and the State exchange itself is permitted to verify incarceration status via certain data sources.

Regardless, questions remain about how exactly this reporting process and coverage termination would occur within the jail setting. The rules further state that inmates are permitted to apply for exchange coverage to help coordinate potential coverage upon release from incarceration and that newly released qualified individuals are eligible for a special enrollment period.

The ACA also requires that individuals self report when their income changes to account for potential changes in the amount of premium subsidy support available to help them purchase exchange plan coverage. This reporting is necessary because they may experience an income increase or drop that affects whether they are eligible for either Medicaid or exchange plan coverage. For individuals in jails, similar to reporting changes in eligibility status, it is unclear how this income change reporting might occur. Additionally with income shifts there are other complications associated with maintaining coverage of health services for incarcerated individuals.

For example, if an individual is held in custody preadjudicated for a substantial period of time and enrolled in an exchange plan, without any income this person would likely eventually fall into Medicaid’s eligibility category while they are in jail.18 Yet because of existing Medicaid coverage limitations for all incarcerated individuals, any health services they might receive would be unable to be reimbursed by Medicaid.

Final rules related to the exchanges attempt to minimize coverage gaps for individuals who move from exchange plan coverage to Medicaid by allowing for the last day of exchange plan coverage to be the day prior to the start of Medicaid coverage, if the individual is eligible for the program. States could also potentially help reduce the administrative burden associated with eligibility shifts by ensuring that there are some plans offered that participate in both Medicaid and the exchange market. Both of these options could potentially help individuals held pre-adjudicated for long periods of time in that they would at least be able to remain enrolled in coverage.

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Potential Model Eligibility and Enrollment Systems and Processes
While there may be commonalities across jurisdictions, there can be no standard set of specific enrollment procedures and protocols, and planning initiatives will be distinctive to each county. In addition to having different considerations based on jail size, every county has different types of relationships established within their criminal justice and health care systems and operates under unique State constraints. The following is a sampling of local and State practices that may be able to serve as models for counties and States as they plan for ensuring that vulnerable and underserved populations eligible for health coverage in 2014, such as incarcerated individuals, are enrolled as efficiently as possible.

Interagency Partnerships and Medicaid in the New York City Jail System
In most jails, the department of corrections or the sheriff’s office is responsible for the provision of health care services to all inmates. In New York City (NYC) however, the Department of Health and Mental Hygiene (DOHMH) is responsible for medical, mental health, substance abuse, dental, discharge planning, and transitional health care services for all inmates in the city’s jails. This helps facilitate a comprehensive public health approach to health services for the incarcerated population. Along those lines, the DOHMH with assistance from the local department of social services invests substantial resources into Medicaid eligibility screening and pre-enrollment services for mentally ill inmates who account for about one-third of the NYC jail population, totaling approximately 30,000 admissions per year. The DOHMH has State-funded discharge planning staff who facilitate the screening and pre-enrollment of eligible incarcerated individuals into various public entitlement programs including Medicaid. Discharge planning services, including benefits screening, generally begin after the inmate has been in custody more than a week, and negotiated arrangements with the State help address initial enrollment barriers related to lack of identification. Upon release, many pre-screened inmates receive temporary pharmacy cards to help them obtain needed psychotropic drugs prior to their Medicaid determination and the city’s Service Planning and Assistance Network can assist mentally ill inmates with discharge planning services that they were unable to get while in jail, including the completion of Medicaid applications.

Additionally, as New York is one of the few States that suspend rather than terminate Medicaid benefits upon incarceration, Medicaid beneficiaries incarcerated less than 30 days are able to retain their status. Individuals who are in custody more than 30 days can have their benefits suspended, enabling them to generally reinstate coverage and gain access to care more quickly upon release from jail.

Comprehensive Reentry Services: Allegheny County, Pennsylvania
Well-designed county jail reentry programs may be able to serve as models for enrolling eligible inmates in 2014. For example, Allegheny County, Pennsylvania, established the Allegheny County Jail Collaborative (ACJC) in 2000 to better coordinate reentry services for county jail inmates. The Collaborative is composed of representatives from the Allegheny County Jail, the county Department of Human Services (DHS), the Court of Common Pleas (Criminal Division), and the county Health Department. The ACJC has initiated comprehensive planning that includes reentry programming, which begins when individuals enter county jail. The wide range of service coordination provided to incarcerated individuals includes helping them apply for medical assistance and connecting them to substance abuse treatment and/or mental health services. Social workers at the jail assist in completing Medicaid enrollment applications and supporting documentation prior to a planned release and send the information to the local County Assistance Office.

Allegheny County DHS Justice Related Services and community-based service coordinators may then also assist or accompany individuals to the in-community office appointment with the local County Assistance Office to complete the application process for Medicaid and to coordinate appropriate treatment and support services post-release. In addition, the Allegheny County Jail has developed a Discharge Center where staff help individuals with their release by assisting with such items such as medications, transportation, and appropriate clothing for their release. These types of practices in Allegheny County and other counties which have robust reentry support services can serve as models for how enrollment could occur in jails in 2014. Additional information regarding the Allegheny County programs is available at www.alleghenycounty.us/dhs/jail.aspx.

Post-Release Enrollment: Alameda County, California

California’s Bridge to Reform program is a Medicaid Demonstration Waiver that is designed to help the State plan for implementation of the ACA’s health care coverage expansion provisions. One of the primary initiatives of the program is the Low-Income Health Program (LIHP) coverage expansion effort that uses Federal Medicaid matching funds available through the waiver to help expand health care coverage for lowincome individuals in the State prior to ACA Medicaid eligibility changes in 2014. Alameda County is one of the many counties in the State that have LIHPs, and their program, HealthPAC, is an expansion of the existing County Medical Service Program and aims to cover all county residents with income under 200 percent FPL. The program has a component that focuses on enrolling individuals just after their release from jail during their probationary period, specifically focusing on the AB109 population.19 While the effort is a pilot program, county leaders view the initiative as a positive step toward connecting justice-involved individuals to appropriate health care services that could potentially be expanded in the future.

Preparing for 2014: Salt Lake County, Utah

In Salt Lake County, Utah, the Division of Behavioral Health Services within the county’s Department of Human Services has helped lead efforts to plan for how the justice-involved population within the county will be affected by the ACA’s expansion of Medicaid and creation of health insurance exchanges. By actively communicating with their State Medicaid office, they were able to gather information demonstrating that most inmates in the county’s jail system will fall into the new Medicaid expansion population category. To develop strategies for enrolling these newly eligible individuals, they have created a health care services integration coordinator position to help anticipate and plan for some of the issues that the jail will need to consider in 2014. Additionally, the county is currently actively enrolling eligible inmates in Medicaid so that they will be able to receive benefits upon their release. This process has been facilitated by the county directly employing State Medicaid eligibility determination workers by paying the Medicaid administrative match rate, as well as by working with other community partners.

Conclusion

There are a number of challenges to be addressed in terms of developing enrollment processes for incarcerated individuals who will become newly eligible for health coverage through the ACA and there are still unanswered questions related to the law’s implementation.
Consequently many counties will not be ready to enroll all eligible individuals in jails by 2014 or may choose to wait to develop enrollment strategies for this population group until after the ACA’s coverage expansion provisions have taken effect. However, there are a number of reasons that some counties may choose to consider beginning enrollment planning efforts for justice-involved individuals. The ACA’s expansion of health coverage can better connect individuals involved in the criminal justice system to appropriate medical and behavioral health care services, which in turn has the potential to reduce recidivism rates as well as county jail health care costs. Considering the
many possible public health and criminal justice system benefits, counties may want to begin taking incremental planning steps now and continue to move forward on developing enrollment processes and procedures for eligible individuals in county jails even after 2014.

Additional Resources

For further information on this topic and related
issues, please see—

  • NACo’s health reform implementation page: www.
    naco.org/healthreformimplement
  • NAC’s criminal justice programs: www.naco.org/programs/
    csd/Pages/Justice.aspx
  • Community Oriented Correctional Health Services
    (COCHS): www.cochs.org

Footnotes

  1. Bureau of Justice Statistics, Prison and Jail Inmates at
    Midyear Series: Jail Inmates at Midyear 2009—Statistical
    Tables. http://www.bjs.gov/index.cfm?ty=pbdetail&iid=2195.
  2. Initially the exchanges will primarily serve individuals
    purchasing coverage on their own and small employers; in
    2017 States will have the option to allow businesses with
    more than 100 employees to purchase insurance from an
    exchange.
  3. PPACA § 1312(f)(1)(B).
  4. National Commission on Correctional Health Care, The
    Health Status of Soon-To-Be-Released Inmates: A Report to
    Congress, Volume 2 (2004).
  5. McDonnell, Maureen, Laura Brookes, Arthur Lurigio, and
    Daphne Baille. “Realizing the Potential of National Health
    Care Reform to Reduce Criminal Justice Expenditures and
    Recidivism Among Jail Populations.” Community Oriented
    Correctional Health Services Issue Paper. January 2011.
  6. In 2014 States will be allowed the option to create a Basic
    Health Plan for uninsured individuals who have incomes
    between 133–200 percent FPL, who would otherwise be
    eligible for premium tax credits on the exchange. The Basic
    Health Plan will offer individuals Standard Health Plans,
    and benefits for these plans must be at least equivalent to
    the essential health benefits package determined by the
    Secretary of the U.S. Department of Health and Human
    Services and that premiums do not exceed those in the
    exchanges.
  7. “The Implications of Expanded Medicaid Eligibility for the
    Criminal Justice Population: Frequently Asked Questions.”
    Community Oriented Correctional Health Services. May
    2011.
  8. States such as New York, Oregon, Minnesota, and Florida
    have adopted policies to suspend rather than terminate
    Federal benefits; additionally, in Ohio a memorandum of
    understanding allows for the suspension of benefits.
  9. NACo submitted comments in response to the proposed
    regulations related to Medicaid eligibility changes and
    eligibility determination for the exchanges advocating
    that the Centers for Medicare & Medicaid Services (CMS)
    should explicitly prohibit States from terminating Medicaid
    eligibility solely due to incarceration, that individuals
    pending disposition of charges should not be considered
    as inmates of a public institution and that incarcerated
    individuals should have the opportunity to apply for coverage
    either through plans on the exchanges or Medicaid.
    NACo’s comments can be found at www.naco.org/healthreformimplement.
    However in response to these comments
    published with the new Federal rules related to Medicaid
    eligibility changes on 3/16/12 CMS stated that issues
    related to FFP not being available to incarcerated individuals
    were beyond the scope of their rulemaking, and
    asserted that: “An individual is considered an inmate when
    serving time for a criminal offense or confined involuntarily
    in State or Federal prisons, jails, detention facilities,
    or other penal facilities, regardless of adjudication status.”
    Similarly, in response to NACo’s comments published with
    the new Federal rules related to the exchanges on 3/12/12
    CMS stated that the term “incarcerated, pending disposition
    of charges” will be clarified in future guidance. At the
    time of publication of this brief, no other administrative
    actions related to this topic had been issued.
  10. Also, in September 2011 the HSS proposed a partnership
    model for the health insurance exchanges called for in the
    ACA. The partnership model is intended to provide States
    with additional exchange design options and will allow for
    States to perform some of the exchange functions and have
    the Federal government operate other functions. For more
    information, see www.healthcare.gov/news/factsheets/2011/09/
    exchanges09192011a.html.
  11. PPACA § 2201(b)(1)(F).
  12. McDonnell, Maureen, Laura Brookes, Arthur Lurigio, and
    Daphne Baille. “Realizing the Potential of National Health
    Care Reform to Reduce Criminal Justice Expenditures and
    Recidivism Among Jail Populations.” Community Oriented
    Correctional Health Services Issue Paper. January 2011.
  13. Executive Report of the Working Group on Health Reform
    and Criminal Justice: Implications for the Delivery
    of Behavioral Health Services to the Criminal Justice
    Population Cycling through Jails. Community Oriented
    Correctional Health Services. September 2011.
  14. Ibid. and “The Implications of Health Reform for the 9
    Million People Who Cycle Through U.S. Jails Each Year:
    Frequently Asked Questions.” Community Oriented
    Correctional Health Services. May 2011.
  15. “The Implications of Expanded Medicaid Eligibility for the
    Criminal Justice Population: Frequently Asked Questions.”
    Community Oriented Correctional Health Services. May
    2011.
  16. “The Implications of Expanded Medicaid Eligibility for the
    Criminal Justice Population: Frequently Asked Questions.”
    Community Oriented Correctional Health Services. May
    2011.
  17. Some incarcerated individuals may be unwilling to enroll
    in Federal assistance programs due to issues such as delinquent
    child-support payments or their involvement with
    gangs. (Executive Report of the Working Group on Health
    Reform and Criminal Justice: Implications for the Delivery
    of Behavioral Health Services to the Criminal Justice
    Population Cycling through Jails. Community Oriented
    Correctional Health Services. September 2011). Also, some
    jails that have tried to enroll incarcerated individuals at the
    time of their release from jail found that after their release
    individuals were reluctant to stay and complete any necessary
    enrollment paperwork.
  18. In final Federal regulations pertaining to the exchanges
    issued 3/12/12, the U.S. Department of Health and Human
    Services indicated that it would consider comments regarding
    maintaining coverage for incarcerated individuals leaving
    custody in future guidance.
  19. AB109 is a bill passed in 2011 by the California State
    Legislature to address the U.S. Supreme Court order that
    mandated that California reduce its prison population by
    May 2013 to address overcrowding issues. The law moves
    inmates considered to be low-risk from State prisons to
    county jails, and this is sometimes referred to as “prison
    realignment.”

This issue brief, authored by Anita Cardwell, NACo
Community Services Program Manager, and Maeghan
Gilmore, NACo Community Services Program Director, was
completed in March 2012 and produced through the support
of the Public Welfare Foundation. It is reprinted here with the
express permission of the National Association of Counties
(NACo). Any opinions in this document are those of the contributors
and do not necessarily reflect the views of the Public
Welfare Foundation or NACo. Reprinted with permission
©2013, National Association of Counties, D.C. 20001.
NACo recognizes the following contributors for their time and
contributions to the development of this publication:

  • Those who contributed from Alameda County, California,
    with special thanks to Rachel Metz, Alameda County Health
    Care Services Agency and Lori Jones, Director, Alameda
    County Social Services Agency.
  • Those who contributed from Allegheny County,
    Pennsylvania, with special thanks to Mary Jo Dickson,
    Administrator, Allegheny County Bureau of Adult Mental
    Health Services.
  • Those who contributed from New York City, New York, with
    special thanks to Cecilia Flaherty and Cynthia Summers,
    NYC Department of Health & Mental Hygiene.
  • Those who contributed from Salt Lake County, Utah, with
    special thanks to Patrick Fleming, Director, Salt Lake County
    Substance Abuse.
  • Paul Beddoe, NACo Associate Legislative Director.
  • Tom Joseph, Waterman & Associates.
  • Cathy Senderling, California Welfare Directors Association.
    NACo is the only national organization that represents county
    governments in the United States. Founded in 1935, the
    association provides essential services to the Nation’s 3,069
    counties. Specifically, NACo advances issues with a unified
    voice before the Federal Government, improves the public’s
    understanding of county government, assists counties in finding
    and sharing innovative solutions through education and
    research, and provides value-added services to save counties
    and taxpayers money. For more information about NACo, visit
    www.naco.org.