Last year, 61.5 million American adults experienced a mental illness. Nearly 30 million of them never received treatment. That gap shows up first in county emergency rooms, jails, and shelters, and county governments are the ones left to catch it.
In a recent webinar, leaders from Cabarrus County, Greater Watertown Community Health Foundation and Bamboo Health sat down with the National Association of Counties (NACo) to discuss strategies for addressing behavioral health needs. And Bamboo Health sat down for a webinar titled “Doing More with Less: How Counties Can Successfully Address Behavioral Health Crisis Response Needs.” The conversation moved beyond the national numbers and dove straight into what county leaders can actually do about them.
John Eller, County Manager of Cabarrus County, North Carolina, and Ben Wehmeier, President and CEO of the Greater Watertown Community Health Foundation, an independent nonprofit serving Wisconsin’s Dodge and Jefferson Counties, met with Kevin Denmark, SVP of Behavioral Health at Bamboo Health, to discuss the most pressing challenges facing healthcare leaders today.
The urgency behind the conversation is hard to overstate. Congress’s H.R.1, widely known as the “One Big Beautiful Bill,” or OBBBA, enacted the largest restructuring of Medicaid in a generation: $911 billion in federal Medicaid cuts over the next 10 years, with the Congressional Budget Office projecting 11.8 million people will lose Medicaid coverage by 2034. Roughly 70 million Americans, about 1 in 5 people in the country, currently rely on Medicaid, and counties administer much of the nation’s behavioral health safety net: the clinics, jails, shelters, and crisis teams that catch people when the rest of the system doesn’t. As Denmark put it, “Counties really are effectively the emergency rooms when the larger public health system fails, particularly in mental health, and we’re seeing it, and we’re watching it happen.”
Here’s what these leaders had to say.
Q: If resources weren’t an issue, are counties the right place to address behavioral health needs?
- John Eller: “It really depends,” Eller said, comparing county lines to zip codes: “Some counties invest really heavily in multiple services, including behavioral health, while the county right next door can only do the minimum.” Rather than start from what officials assume matters most, his county starts with what residents say. A recent community health needs assessment identified behavioral health as the top concern, followed by childcare, housing, and transportation. He also flagged a gap that’s easy to overlook: even residents with Medicaid coverage often can’t find a provider who accepts it. “Just because somebody has Medicaid doesn’t mean they have access to care,” he said, pointing to pockets that function as “Medicaid deserts.”
- Ben Wehmeier: Wehmeier agreed the data has to come first, and that it can be sobering. Wisconsin averages roughly 400 residents per mental health provider statewide; in the two counties his foundation serves, that ratio runs closer to 750 and 850 per provider. Rather than treat that shortage as fixed, his region has leaned on a three-decade-old cross-county partnership to conduct regular community health assessments to surface gaps early and build the trust needed to act on them together. “There’s an advantage of that partnership and collaboration that’s kind of built into the fabric of how we align these resources,” he said.
Q: How are you evaluating and using new funding streams — such asRural Health Transformation Program (RHTP) dollars, opioid settlement funds, and what’s left of ARPA?
- Ben Wehmeier: American Rescue Plan Act (ARPA) dollars helped his region create nearly 500 childcare slots and seed an employer-sponsored care pilot. RHTP funds move fast, in some cases with two- to three-week response windows, which means counties that walk in with priorities already identified have a real competitive edge. Opioid settlement dollars have been especially significant in his state, where the vast majority of counties were party to the underlying lawsuit and a large share of settlement funds flow directly to counties; his region used that funding to stand up a youth crisis stabilization facility, add school-based behavioral health positions, and expand referral capacity through a local clinic partner. “Who should lead this work, and who can sustain this work post-grants, is very important as we have these conversations,” he said.
- John Eller: “You can’t rely on one source of funding anymore,” Eller said. “It’s not just Medicaid, it’s not just local dollars, it has to be federal, state, local, nonprofit, all the above, even philanthropic dollars.” His county has built a community-wide initiative blending opioid settlement, RHTP, and local funds to support community paramedicine, screening and follow-up care in the detention center, school-based care, re-entry services for justice-involved residents, and support for pregnant women and new mothers. He cautioned that RHTP is being administered so differently from state to state that it’s hard to build a shared playbook, which makes local relationships and a clear list of priorities even more important.
Q: What are the biggest challenges you’re seeing on the ground?
- Ben Wehmeier: Wehmeier’s answer started with data, not buildings. Understanding the financial risk to the county, and the human cost of sending residents out of the area for care, drove the decision to expand local senior behavioral health capacity rather than continue referring residents to hospitals scattered across the state. But he was candid about what’s still hard: multiple electronic health record systems across the region’s counties and medical systems make coordination a real lift, and the story that ultimately moved the county board wasn’t just financial, it was the human one. “That data was huge,” he said, “but it also created a humanistic standpoint of why it mattered to this region going forward.”
- John Eller: “We’re so crisis-based and driven,” Eller said. “We’re just stomping out the fire of the day, of the month, of the week, of the year.” His answer to that cycle is a no-wrong-door philosophy that starts with the resident, not the org chart: “We don’t want the member who’s walking in… to have to worry about which system or agency they need to contact.” He argued that redirecting even a fraction of the energy that counties spend on firefighting into front-end infrastructure — data, technology, and prevention — would produce meaningfully different outcomes and reduce burnout for staff who are “always on.”
Q: What solutions are counties building, and where does technology fit in?
- John Eller: Eller’s team has adopted a “start with the end in mind” approach: define what a true no-wrong-door system would look like, then build backward from there. That mindset has surfaced gaps his county didn’t fully appreciate until they started measuring them, and it’s drawn other counties into a regional collaboration around shared data and blended funding. He also pointed to an underused resource: people with lived experience willing to help with system navigation and care coordination. “I think they’re an untapped resource that I hope many of us will start engaging,” he said.
- Kevin Denmark: Denmark connected the dots back to Bamboo Health’s own experience running a real-time, statewide coordination network in Delaware that links behavioral health, emergency department (ED), corrections, and social services data. The harder question for most counties, he said, isn’t whether they can get the data, it’s who owns the “action layer” once they have it. He also pointed to a role for agentic AI in absorbing administrative and paperwork burden, freeing licensed and peer staff to spend more time on direct care. “The human can practice humanity,” he said. “I’m not saying the AI should be doing any of the clinical work, but they can really help with the back-office things.”
Q: What should county leaders ask their own teams this week?
- John Eller: “What are we spending the most time on, and why?” Eller said that’s the question he comes back to, followed by asking why agencies aren’t sharing more information, and whether the county has a closed-loop referral system so people don’t fall through the cracks between one step of care and the next. “The Achilles heel of analysis paralysis is having so much data at your fingertips, and you never do anything with it,” he said. “How can we use data to actually make really good, informed decisions?”
- Ben Wehmeier: Wehmeier pointed to a priority-based budgeting exercise his region ran with department heads, which surfaced duplicated services and partnerships that hadn’t occurred to anyone before. Just as important, he said, is building trust with partners before the next funding opportunity appears, becoming a reliable “trusted partner” so those conversations don’t start from scratch every time.
The full conversation covers even more ground. and crosses the intersection of program design details and leadership habits that make cross-agency collaboration stick. Watch the full recording here.
