Especially during election seasons, people (primarily candidates!!) are more than willing to take the lion’s share of the credit for projects and ideas. This seems true even when their involvement is as light as the touch of a butterfly’s wing. Yesterday, however, was a great example of success brought about by the participation and commitment of many people, whose collaborative spirit truly make a difference.
 
In 2014, Boone County joined the Stepping Up Initiative, a project championed by the National Association of Counties (NACo) and the American Psychiatric Association. Its purpose was to address the over-representation in the criminal justice system of individuals with mental health challenges. As a long-time, former Public Defender, I had seen the issue “up close and personal” through the lives and experiences of clients over the years. And, even prior to chairing the County-wide Judicial and Law Enforcement Task Force, so had Rusty Antel. In his decades-long history of representing individuals involved in the criminal justice system, he had seen and tried to address the issues related to those individuals with mental health challenges who represent a disproportionate involvement in the system.
 
When the county joined the Stepping Up Initiative, Rusty and I began the process of bringing together all of the stakeholders to gain a better understanding of the issues involved—from their multiple perspectives—as well as what resources we could bring to bear to develop solutions.   
 
Among the issues that we quickly recognized was the disproportionate amount of time individuals with mental health challenges spend in our county jail as compared to those charged with the same offenses but without a similar mental health history.
 
The data was clear, but the question became:
How could we reduce the days in jail (a huge and ongoing cost for the county) AND keep the community safe AND obtain a better outcome for the individuals involved? 
 
Little did we know that Rusty’s question posed during one of our brainstorming sessions would spur progress toward finding a piece of the solution:

“I wonder if we could bring everyone together to talk about these cases and see if they could be moved more quickly and efficiently.”
 
Since we were in the midst of a NACo-organized project, it was only logical that I contact NACo to see if any other county had already invented that particular model. 
 
The NACo staff in charge of Stepping Up suggested that I contact two counties that had been heavily involved in justice-related activities. The first county contact said, “No, we don’t have a program like that but, if you create it, please let us know. We’d love to try it out.” 
 
With the second county contacted––in Johnson County, Iowa––we found the wheel has been invented. Not only did they HAVE such a program, they were willing to share information and provide contacts within their county who could help us in setting up a program.
 
So, Rusty and I met with two local Boone County judges to gauge their interest and willingness to take on one more project––Chris Carpenter, who was the Presiding Circuit Judge at that time, and Leslie Schneider, a well-respected Judge in the Circuit without a criminal docket and who therefore would not have to recuse herself on any cases. We discussed Rusty’s idea and the Johnson County model with the two judges and they agreed to bring it to the entire court (the court en banc) for a decision about whether to proceed.

Judges Carpenter and Schneider also reached out to the judge assigned to the project in Iowa to better understand how the model worked.  The judges quickly rallied behind the idea, since, in Johnson County, the three goals we had articulated had been met––fewer days in jail, community safety maintained, and better outcomes obtained for the individuals. With their blessing, we had the green light to bring the rest of the stakeholders on board.
 
Members of the Prosecuting Attorney’s Office were enthusiastic about the project from the beginning. They signed up to be the conduits for that office for information and negotiation. Similarly, members of the Boone County Public Defender’s Office, including the District Defender, quickly came on board, as did members of the local defense bar. Sheriff Carey immediately authorized members of his corrections staff, including the Jail Administrator, to participate in the program, and the then relatively new Treatment Court Commissioner, Casey Clevenger, and her administrator became part of the team as well. Also, an integral part of the team was the mental health professional at the jail itself. These stakeholder representatives were joined by the court administrator, who monitored and coordinated the group’s activities. 
 
Each member of the group was given the opportunity to speak with their counterpart in Johnson County IA, to understand how the program had been implemented in their jurisdiction, and to learn from their experience. Because mental health information would be shared among participants, everyone involved signed a Business Associate Agreement, to address confidentiality concerns. 
 
Some three years after first joining the Stepping Up Initiative, the group still meets twice each month. In times of COVID-19, meetings are held by conference call or Zoom to discuss individuals referred to the group by judges, lawyers (both defense counsel and prosecutors), family members, jail personnel, mental health personnel, or by the individuals themselves. Just as in the Iowa experiment, the process has become ever better as the stakeholders have become more confident in themselves and in their colleagues. 

As members have seen the commitment to the three goals solidify for all involved, their confidence in the process has grown as well. They know that nobody at the table is working an angle and no one is using the process for personal or agency gain. As the goals are realized, so too is the process validated. The successes seen for individuals have become successes shared by the group.
 
Yesterday was just one more case in point.  One member of the group sent an email concerning an individual who simply couldn’t function within the jail setting because of mental health issues. With our three goals ever in mind and with community safety ensured, everyone involved worked to find a better, more appropriate placement for that individual.
 
This is not just government functioning at its finest. This is community working at its best. And it began with one simple question: “How can we do this better?”

Two years ago, the then-Director of Resource Management made the County Commission aware that a resident and farm owner near Harrisburg was interested in exploring the viability of wind energy in Boone County by placing a pole on his property to test wind speeds. I had heard for many years that, because of the barrier created by the Missouri River and the bluffs, Boone County would not have sufficient wind to make such a project economically feasible.

I was therefore surprised that a company would choose Boone County as the optimum site for this project. I was also surprised by the choice, given the denser population in Boone County than in surrounding counties, as well as the higher land values here. As I told representatives of the company, I would have thought they would first consider setting up business in more sparsely populated adjacent counties, rather than in Boone.

Those three factors seemed to make Boone County less than an ideal choice for the project. The company representatives claimed that new technology somewhat mitigated the effects of the river and the bluffs and they proceeded to enter into an agreement to explore wind capacity with that initial landowner.

At about the same time, because of my position as a Board member for both the Missouri Association of Counties (MAC) and the County Commissioners Association (CCAM), I also heard from Commissioners in the northwestern part of Missouri about the wildly varying degrees of success wind energy projects had had there. In one county the project showed signs of success, infusing the local economy with jobs and creating revenue streams for entities like county school districts.

For the other county, the project met with push-back, with residents speaking of the adverse health impacts on people and animals, of lowered land values, and of hidden costs for the project itself. As concerns about the potential for a wind energy project in Boone County mounted, a meeting in Harrisburg was organized, to which the Resource Management Director and I were invited.

Residents from northwest Missouri also attended. After that meeting, both the Director and I received and sought out information about wind energy from a variety of sources, including residents in the Harrisburg area. We then asked three community members to help us collate the relevant information available about wind farms and wind energy. The County Commission then charged the Planning & Zoning Commission with the task of considering what regulations pertaining to wind energy might look like if enacted here in Boone County.

The wealth of information collected was shared with the Planning & Zoning Commission which has considered that information as it has worked to craft proposed new regulations. It is anticipated that the draft regulations will be subjected to community review before being considered for approval by the County Commission. If approved, any request for placement of a wind turbine would need to show not only the benefit of renewable energy but would have to address the impact on the community, particularly neighbors; the impact on the environment, including wildlife; the impact on the road system; and the impact of connecting the turbines to the energy grid. Consideration of these factors would be necessary when or if an application for a wind energy system were presented for approval here in Boone County.

Some people have suggested that Boone County should ban wind turbines outright. It’s my belief that such an action would only cause Boone County to become embroiled in expensive litigation filed by those who seek to deny our citizens local control.

The better approach is to utilize the tools at hand through a responsible and responsive group of citizens—the Planning & Zoning Commission—which is charged with developing and then implementing a system to guide the consideration of such a project. I believe in my fellow citizens and I believe in allowing the representatives of our citizenry to reach a logical conclusion based upon the facts at hand.

​Since 2014, when Boone County joined the Stepping Up Initiative, a program sponsored by the National Association of Counties (NACo) and the American Psychiatric Association, our community has worked to address a local problem that exists across the country—the over-prevalence of individuals with behavioral health challenges in our county jail. 

The work is important for many reasons:  

First, detaining individuals does not treat the core behavioral health issues that landed them under law enforcement’s scrutiny and merely exacerbates those issues.

Second, in times of limited resources for law enforcement, requiring officers to act as mental health professionals diverts them from the jobs for which they have trained and were hired—we are not safer as a community by keeping these individuals in the criminal justice system.

Third, once these individuals are in the justice system, they utilize more resources than those without behavioral health challenges as they re-offend at higher rates and remain detained for longer periods of time.  

As we have discovered through our Stepping Up Initiative, diversion coupled with supportive services, is a better model—keeping us safer, utilizing resources more effectively and wisely, and producing better outcomes for the affected individuals.  

Our work with NACo has allowed us to influence another piece of the puzzle that has cost Boone County and other local jurisdictions dearly—the Federal Medicaid Inmate Exclusion Policy. In late 2018, I was appointed to a committee jointly comprised of members of NACo and the National Sheriff’s Association (NSA). The purpose of the committee’s work was to determine the impact of this policy on local jurisdictions and then seek a remedy for the impact.  

You likely have never heard of this policy. Turns out you aren’t alone—many members of Congress, the very entity that created the policy, don’t know it exists nor do they understand its impact. The policy, as its title suggests, cuts off any individual who is detained for more than 30 days in a county jail from receiving federal benefits (including but not limited to Medicaid).

Although in 2019, Missouri’s state legislature (through the leadership of local Representative Kip Kendrick) changed the cut-off to a suspension of benefits, the impact of the policy is nonetheless enormous. If an individual’s benefits are suspended, it typically takes at least 90 days before they can be re-instated. In that time period, an individual and his or her family can lose housing, lose access to medical care, including prescription medications, and lose access to SNAP benefits. Thus, the incarcerated individual, who was merely detained and NOT convicted, has lost access to the federal benefits to which he or she is entitled.  

NACo and NSA joined together to overturn this policy for two main reasons:  

1. The impact of the policy falls not only on the detainee and his or her family but on local government and local agencies, as well. Where before, the detainee was receiving federal benefits to provide services, now under the policy, if those services are provided at all, they are paid for locally, out of an ever-shrinking resource pool. 
   
   
2. Because the policy is directed toward detainees who have been detained more than 30 days, it creates disparities between those who can afford to bond out and those who cannot; it denies benefits to those who still have a constitutional presumption of innocence.  
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Our Task Force has lobbied the US Congress, urging our Senators and Representatives to repeal the policy because it is both unconstitutional and unfairly and inappropriately impacts local government. While we received commitments of support from some members in both Houses, thus far we have not gained support from our Missouri delegation. We continue to work to persuade them to support our efforts, which will help both individuals in our community, alleviating unnecessary hardships, and help the county and community at large by decreasing the county’s obligation to expend local funds for necessary services.

I am fortunate to have been surrounded by people—family members and friends—who encouraged me to learn and to enjoy learning from a very early age. I am also fortunate to have spent so much of my life here in Boone County, where education is not only a rite of passage but also an economic force for our community. Perhaps it is that pervasive presence of an education overlay, almost something in the water, that led me to return, again and again, to realize that “the capacity to learn is a gift, the ability to learn is a skill, and the willingness to learn is a choice.”

After undergraduate and graduate degrees in Spanish, a law degree, and then later a Masters in Alternative Dispute Resolution, I have been involved for the last several months with the High Performance Leadership Academy, a 12-week program sponsored by the National Association of Counties (NACo). My curiosity was piqued at the outset because the curriculum was developed especially for those involved in county government by Retired General Colin Powell, who showed such leadership capacity in the military and in government. 

The Academy is designed to empower “frontline county government professionals with fundamental, practical leadership skills to deliver results for counties and residents.” I thought, “hmmm, I can spend a bit of money and commit time to this project, I can learn, I can help others learn, and, if it means that the county benefits, why not?” So, I wrote the check, decided I would be a bit busier than normal, and I took the plunge.   

For three months, an eclectic group of county officials, managers in county government from across the country, and I took a deep dive into what it means to be a leader, how we could each become better leaders, and how we could empower those with whom we work to rise to a position of leadership. Each week of the program, we were exposed to the experience and expertise of a wide array of leaders, in government and industry, including General Powell, who, through oral and written commentary, helped us to craft our own personal statement of leadership and to understand how our leadership efforts can enhance or detract from the success of people, projects, and policies within our particular agency. 

We also met virtually, in smaller groups, one day each week, to discuss the information and how it related to current issues, each of us helping the others in our group to apply the learning and increase our individual capacity to work with colleagues and constituents to improve the quality of life in our communities. During one week, we even had the opportunity to participate in a mock negotiation, practicing some of the skills that the experts had modeled during the coursework. And, yes, that exercise was among the most fun for me as I utilized skills developed as a lawyer during several decades of practice and honed even further through work in mediation and arbitration.

Lessons Learned
Some of the lessons learned and reinforced during this course:

• A leadership mindset is about leading beyond your title, working beyond limitations, overcoming obstacles and excuses, and focusing on people.
• Every person in the organization is valuable and has a purpose.  Every person in the organization can be a leader.
• Set high standards; provide people with the tools and resources they need to accomplish stated goals; and empower them to meet and exceed those goals.
• Understand that people are motivated by different things (mission, acclaim, money) but, regardless of those differences, understand that everyone wants to be valued, that their efforts matter and their contributions add value to the organization’s purpose and goals.
• Absolute power is detrimental to leadership, the goal instead should be influence.
• Be trustworthy; be dependable; be authentic; help others flourish; be engaged. 
• The people with whom we surround ourselves either raise or lower our standards. They either help us to become the best version of ourselves or encourage us to become lesser persons. But no one becomes great on his or her own. The people around each of us helps to make us better. We all need others in our lives who raise our standards, remind us of our essential purpose, and challenge us to become as good as we can be.
• Leaders must never cease to learn and to build relationships.
• Leaders rely on others.  
  
  

My Leadership Principles
As part of the course, we each were encouraged to develop our own leadership oath—the core principles by which we function within our organization. For me, these principles became refined as follows:

1. Since we live in the state of Harry Truman, it is fitting that the first rule for me is, “the buck stops here.” 
2. Give credit, don’t take credit. Recognize team members.
3. Have a vision, empower others to have a vision, and share that vision widely.
4. Be honest and engender trust—with work colleagues and constituents.
5. Praise publicly, criticize privately.  Commit to finding solutions, not ascribing blame.
6. Be kind—to everyone, including yourself.  Understand that nobody is perfect.
7. If you want to create change, know why; have a compelling reason for the change; know how you will measure success with change; be prepared; share all phases of this process and understand that, for buy-in to occur, everyone must share a common interest.
8. Commit to listening—to ideas, criticisms, challenges, and emotions.
   
   

In the Age of Coronavirus
This learning opportunity came at an interesting time. COVID-19 had increased the county workload in many respects, so setting aside the time for the classwork was a bit more challenging. Nonetheless, each lesson provided a way to enhance existing and develop new leadership skills. Together, my county colleagues and I learned to pivot, even to pirouette, as the pandemic placed new obstacles in our paths. 

We learned to value the skills that each person brought to the table. We learned to take personal responsibility and to seek a collaborative approach to ensure projects were successful. We remembered to be grateful for the extra efforts by those around us in developing solutions to new and ever-changing circumstances. And, we remembered to be kind.

This process has also solidified for me an understanding of how county government operates and how planning for the future—sometimes known as strategic planning—can happen and be successful, especially in the context of Boone County.

County and City: Different Governmental Structures
Although often compared to the City of Columbia, Boone County’s governmental structure is unlike the City’s in many ways. The City, with the Mayor, City Council, and City Manager, has a relatively simple structure within which decision-making authority travels. By contrast, the county has 13 independently elected officials (not counting the judges), all of whom have independent authority. 

The County Commission, while having authority over physical assets of the county, like its buildings, and having ultimate authority to set the annual budget, does not control how the other officials choose to run their offices. Through time, and by recognizing the efficiencies and good stewardship of working together, all of our officials have agreed to work out issues dealing with information technology and personnel, through joint committees in which those issues are addressed. But there are other issues, on a higher level, that require the development of a broader understanding of long-term goals and vision for the county. The job is not yet done!
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Because of the unique structure of county government, with co-equal elected officials, as well as department managers who bring various viewpoints to the table, the development of a long-term plan cannot rest with nor even be promoted solely by the County Commission. It must be the result of a group effort, in which the input of all stakeholders is both sought and valued. Leadership, in this context, is NOT deciding the direction of the discussion. 

It is in encouraging the stakeholders to find benefit in engaging in the process. It is in convening a setting in which the conversation can occur. It is in valuing the input of all stakeholders, from department directors to elected officials.  It is in understanding when and why change must occur, and in knowing that stakeholders must be committed to that change for it to be successful. 

Most importantly I have learned that leadership is not an individual effort. It is a group activity, as we learn collectively, and foster leadership cooperatively by involving everyone on our team in a dedicated effort to move our county into the future––together.

We all stand on the shoulders of those who come before us. As a County Commissioner, I see this legacy day in and day out, from buildings planned, to policies implemented, to the county’s organizational structure. I see the faces of some of those Commissioners in that legacy—including Frank Graham, Dave Horner, Keith Schnarre, Ed Robb, Billie Tritschler, and Don Stamper. But one on whose shoulders I stand all the time is Karen Miller.  

Karen championed Boone County’s membership in the National Association of Counties (NACo). She was so passionate about NACo that she committed her time and talent for five years, first as an officer and later as President of NACo. As part of her platform, she promoted the importance of smaller counties with a rural population base, like Boone County.  

Karen introduced me to NACo early on and I was hooked. The opportunities for learning and for technical and monetary support from NACo and its partners came rapidly. I discovered, as had Karen, that the more effort Boone County invested in NACo, the more NACo gave back. And, over the last eight years, NACo has given back time and time again. This is a case in point…

Assessing Our Economic Recovery Needs
A few weeks ago, NACo contacted me and asked if I would participate in a special project that was being supported by the Bill & Melinda Gates Foundation. The project is designed to assess economic recovery needs at the county level in the face of COVID-19. To assess the county perspective, NACo invited representatives from eight counties across the country—Boone County, Missouri; Alameda County, California; El Paso County, Colorado; El Paso County, Texas; Howard County, Maryland; Johnson County, Iowa; Orange County, North Carolina, and Wise County, Virginia—to participate in a virtual focus group to share recovery concerns and plans for the near- and long-terms. 

My “Pre-Study”
To prepare for the national focus group meeting, I reached out to members of the community to obtain different perspectives on our county’s economic health and recovery plans and needs for their particular sector of the local economy. Included in my own personal focus group were Matt Jenne, local businessman and current chair of the Columbia Chamber of Commerce; Stacey Button, President of REDI (Regional Economic Development); Paul Land, Plaza Commercial Realty; Ted Webber, RE-MAX, a residential realtor; Brian Whorley, a start-up entrepreneur, founder and CEO of Paytient, and the director of business development and planning for Boone Hospital Center; and members of the Emergency Support Functions teams, working under the direction of the Office of Emergency Management here in Boone County. While these individuals provided insight into some of the nuances in our county’s situation, the national discussion that NACo facilitated demonstrated that what we are seeing here in Boone County is happening to a significant degree across the country. 

Broadband Access and Sales Tax Revenue
Two issues about which representatives of every jurisdiction in the NACo focus group spoke were the needs for adequate broadband coverage nationwide and for the ability of local government to capture sales tax revenues from online/remote purchases. Both of these issues existed pre-COVID-19 but their importance has been highlighted by the pandemic.   

We knew prior to COVID-19 that access to adequate internet coverage impacts educational and business success. Now, we have seen that individuals and families lacking adequate broadband coverage are disproportionately impacted by the pandemic when education goes online; jobs are done remotely; health care and mental health care are rendered through telemedicine; and job applications and COVID-19 funding opportunities are available online. Focus group members encouraged NACo and the Gates Foundation to push ever harder for Congress to develop a solution to this issue—which is so similar to the electrification efforts in this country in the early 20th Century—and to ensure that the solution is monitored and providers are held accountable.    

We also knew prior to COVID-19 that counties’ ability to pay for core services was becoming ever more difficult because of diminished revenue streams. This was particularly true in jurisdictions in which taxes on remote/online sales could not be collected. For the last two years, over 50% of sales have occurred online and, in jurisdictions like ours, which rely heavily on sales tax revenues to meet our budgetary obligations, that means we are relying on an ever-decreasing revenue stream to meet the same obligations—to maintain roads, run the court system and the jail, fund the maintenance of land records and personal records, run elections, and so much more.

Since COVID-19, not only has overall spending declined, but many more people are doing their shopping online, again, leading to a reduction in sales tax revenues to maintain those core functions of county government. Further, even as we move toward recovery, many of those who have shopped online for the last several months are likely to continue their online shopping habits.    

The Impact of Higher Education on Our Community
An issue that resonated for Boone County and several other jurisdictions in the focus group was the impact on community-wide recovery by the future of the University and the other institutions of higher learning. Matt Jenne noted that the economics of Boone County is driven by college students. Student housing, restaurants and bars, especially in the downtown area, retail establishments, hotels for events including sports, the arts and entertainment, are all impacted by what happens at MU, Stephens, Columbia College and Moberly Area Community College.  Our vulnerability, our Achilles’ heel, is the University—if its economic future looks dim, so does that of the community at large.

But Matt and Brian Whorley both noted that what might be perceived as the Achilles’ Heel can be the beacon of light to elevate and enhance the recovery of the entire community.  As Matt noted, our community might be deemed vulnerable if the learning experience goes entirely online or virtual because that means that fewer people are utilizing the housing, food, retail, and entertainment opportunities of our community. 

But, even with an educational experience that is mostly virtual, at a land grant university like ours, we have more opportunities for learning concentrated in our community than almost any place in the country. Where else is there a research reactor, a Journalism School, a Law School, a Vet School, a Medical School, and research centers from business to swine research? For Matt, the vulnerability is that we aren’t fully promoting our assets, including the research and development by faculty, students, and private companies that have allied themselves with the University that continue to flourish in our community. Brian echoed Matt’s comments, focusing on the community assets that still exist in Boone County, even in the midst of COVID-19.  
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Acknowledging Our Assets
Brian noted that this community is one that serves technology and innovation through its strong research “bench” both in the University and the private sector, and in the support of organizations like the various Chambers of Commerce and REDI. That support, combined with a lower cost of living and a wide range of amenities, makes the area ripe for growth. Brian pointed out that in the world of COVID-19, where Zoom or WebEx makes communication fluid as long as you have adequate internet access, being located in NYC or California are less advantageous. 

Thus, people in the start-up sector are considering a move to places like Boone County.  As Matt had said, it’s a question of marketing our community to attract those businesses and individuals. And, as all of the representatives on the focus group had stated, it’s contingent upon our having reliable and adequate broadband access.

The Importance of Communication
Stacey Button confirmed the need for better messaging—inside and outside the community—to position us for a stronger recovery in a COVID-19 world. She noted that, while there has been communication to minority and women-owned businesses about resources, including federal and state grant funding and opportunities for innovation and creative solutions to identified needs, that communication could be improved. At the same time, REDI has become a center for connecting businesses with resources and connecting workers with jobs. 

When needs are articulated, whether it’s personal protective equipment (PPE) or the staples of everyday life, like milk, businesses are pivoting, finding ways to re-tool their production lines to meet identified needs. Stacey also agreed that the quality of life in this community is something that continues to be an asset that will draw people from across the country and encourage them to move to Boone County. 

The Impact on Housing and Retail Sectors
Ted Webber, a local realtor who specializes in the residential market and co-hosts the Real Estate show on KFRU every Saturday, spoke about the current market, and offered some insights about what those market trends might reveal. Ted noted that the inventory of houses available for sale has dropped by about 40% from the level seen in 2019.  While he would usually see 800-900 houses on the market, today that number is around 500.  His conversations with potential sellers have revealed that, since COVID-19 hit, more people have decided not to put their houses on the market, by and large because they didn’t want to have people in their houses.

If they have made any changes, it has likely been to remodel. Craftspeople and remodelers are therefore experiencing huge amounts of work. Ted stated that houses marketed at $300,000 or less are moving very quickly and that it’s a seller’s market.  Higher priced houses, although moving a bit more slowly, are nonetheless moving.  When asked who the buyers of all of these houses are, Ted revealed that most of the buyers are new to the community, coming here for new jobs.  He indicated that, to his knowledge, very few of those individuals had been impacted by layoffs in local businesses and institutions.  

Paul Land, who specializes in commercial realty, stated that, as COVID-19 took root in our local community, he and some others began a communication process in earnest, encouraging the commercial real estate community to make decisions in 30-day increments, and, especially for those with resources, to “step up and do good.” As Land stated, when someone has been good to you, has always been on time with their rent, and has worked well with you, the season of pandemic is a time to do the right thing. 

That attitude has helped many of those in the business community to survive—through rent forgiveness, short-term rent relief, the Payroll Protection Program and more. These solutions have helped to stave off fear, both in business owners and in their workers.  Land noted that there hasn’t been a one-size-fits-all solution since the businesses involved are so different, but, as long as businesses are willing to pivot, to make a change, to adapt to the orders put in place by the Health Department, they can manage the damage done by the virus and they can survive.  

Land acknowledged that the hospitality and retail sectors have taken the biggest hits but believes every industry will have to develop its own protocols that work for that industry. A willingness to adapt is key to survival. He noted that some of the changes that have already and will continue to occur, like teleworking, can be unsettling since the picture this creates, with parking lots 20% full, is not what we are used to. But, Land reiterated, it’s all about learning to live with change.

Health and Other Service Needs
What our local social service experts and representatives in the focus groups spoke about with one voice is the coming wave of need that will hit local service providers as individuals and families begin to feel the full effect of the end of the moratorium on foreclosures, repayment of utilities, rent forgiveness, and their need for health and behavioral health services.  

They also spoke to an issue that the U.S. Chamber of Commerce has identified as a critical need to ensure the economic health of a community. Even in times not affected by a global pandemic, across the board access to quality childcare is essential.

All agreed that the brunt of the wave of need for resources will hit local communities hardest, with local providers and local governments expected to manage the outsized request for services. In many states, Missouri included, state legislators and governors have acknowledged the fiscal impact of the pandemic in part by cutting budgets in two areas—higher education and social services. Thus, while the need will have grown exponentially, the resources will have been cut.  

How Can NACo Help?
At the end of the national focus group meeting, we participants were asked how NACo and the Gates Foundation could help us navigate the economic impacts of COVID-19 on our communities. We reiterated our request that Broadband access be front and center for the federal government, with transparency and accountability in the implementation of any plan being of primary importance. We noted that rural electric cooperatives had done similar work in the early 20th century and thus, the model for success exists. 

We asked for technical support from NACo and the Gates Foundation and for peer support from jurisdictions across the country, to learn from our colleagues who have already experienced some success in finding a path forward. And, we asked that our voices be heard––because we are the boots on the ground. We live in our communities, we are the ones who know our communities best, and we are the ones most dedicated to ensuring that the needs of our local communities are met. I’m confident that NACo is a hugely valuable partner in that process. 

I grew up in and around the hospitals in Boone County.  I still remember my physician Mom running the Emergency Room at what was then called the “Medical Center,” her first gig here in Columbia, and my Dad as the Chair of the Urology Department at that hospital, where he remained until his death in the mid-1970’s.  But despite my parents’ professional ties to University Hospital, I had a proverbial foot in Boone Hospital as well.  Boone was my Dad’s hospital of choice for several cardiac episodes, and I came to know it well, in addition to Regional Hospital (as it was then known), before his death.  

I knew early on how fortunate I was to live in a community that had such assets—on one side of town, a teaching and research hospital, and on the other side of town, decades before Regional/”Women’s and Childrens’” was built, another hospital that served as the backbone for the region, a hospital with the core purpose of serving EVERYONE in the community.  Not only did I learn about these assets firsthand, I was taught that these assets, their core values, and purposes must be maintained.    
Over the last few years, I’ve gained another perspective that further adds to my understanding of how precious these assets are to our community. 

My brother Ian currently serves as the hospital administrator for a large hospital in San Antonio, Texas.  As some of you will know, Ian comes to this position after a first career as a urologist in the Army Medical Corps, then as Chief of Urology at the University of Texas, San Antonio, and decades as an internationally-known oncologist,  When he began his newest “career,” he brought with him those decades of practice, but he also brought the understanding, as did I, of growing up in a time and in a community largely defined by its medical care.

A Brief History of Boone Hospital
A “Cliff Notes” version of the history of the Boone Hospital might be helpful in better understanding its current situation. In 1917, the state legislature first authorized counties to issue bonds to fund the building of health facilities.  Dr. Frank Nifong, a strong proponent of this statutory change, would later be named the first medical chief of the subsequently named Boone Hospital.  With the new statute in place, Boone County was among the first in Missouri to pursue this opportunity, and, on April 29, 1919, Boone County voters approved bonding for $100,000 to build the new hospital.

Five appointed trustees selected a site—four acres along East Broadway—and, after discovering that additional funds would be needed to build the hospital, asked voters to approve another $75,000 in bonds to build a 40-bed hospital.  With voter approval, construction began May 30, 1920 and the hospital opened in December 1921, where on Christmas Eve, David Etheridge became the first “Boone Baby.”  

Although expanded over time, the original hospital building still stands on the Boone Hospital site. Five trustees, now elected by Boone County voters, are responsible for the management of the hospital. In recent history, however, the trustees entered into a negotiated, leased-management agreement with St. Louis-based BJC Healthcare, one of the nation’s largest nonprofit healthcare organizations. As part of the agreement, the County of Boone receives an annual payment in recognition of its ownership of and the initial investment in Boone Hospital made by the people of Boone County.  Of that annual payment, a portion goes into the general revenue fund and a portion is designated specifically for healthcare-related issues in the county.  

As the leadership of BJC Healthcare indicated their desire to end the lease agreement, the trustees began to seriously explore options and opportunities—another lease with a different company? A stand-alone hospital? Far from being a simple decision, the timing of the decision, even pre-COVID-19, added layers of complexity to the process.  

The Intervening Factors That Brought Us to This Point
Until the passage of Amendment 2 on August 4, Missouri had not expanded Medicaid even though 38 states, including all surrounding states, had already done so.  Failure to expand Medicaid created several problems for hospitals: 

First, it led to the demise of many smaller hospitals around the state since those hospitals were still providing care to individuals who arrived in their emergency rooms but were unable to pay.  This uncompensated care cost was a liability that few hospitals could absorb.  Even a hospital as well-resourced as Boone Hospital has felt this impact.  

Second, since BJC is headquartered in St. Louis and, because Illinois had expanded Medicaid, it undoubtedly made financial sense for BJC to focus its attention on metro-St. Louis and Illinois rather than on mid-Missouri and Boone Hospital.  

Another factor that the trustees have had to consider as they navigate toward a new reality for Boone Hospital is that, through the years, the delivery of medical services has changed drastically. No longer is the hospital the only place in which medical care is dispensed.  Even surgeries that traditionally were performed in hospital operating rooms have often been moved to operating suites within private physician offices.  

With the advent of COVID-19, we have seen a further erosion of the reliance on hospitals as a bastion of medical care, as telemedicine has taken hold on a scale heretofore uncontemplated by even the most forward-thinking service providers. 
 
A Pathway to the Future
As has been reported often and thoroughly, the trustees have explored and rejected the path for Boone Hospital that would have placed leadership in the hands of an outside corporation through another lease agreement.  Instead, the trustees have started down the path toward a stand-alone hospital, one that would give Boone Countians—and indeed, people from around the region—an alternative to University Hospital for the delivery of high-quality medical care and first-rate surgical experiences.  While neither writing in stone nor signing on the proverbial dotted line, the trustees have promised to continue the commitment to the community, in the form of the annual payment to the County that had occurred under the BJC lease.  

For this new form of management to succeed, several things must occur:  First, as my brother Ian discovered as he took over the hospital in San Antonio, the trustees must reach out to the physicians in Boone County and bring them back into the fold.  Even as the practice of medicine has changed, everyone understands the need for the hospital, and both sides of the equation—both the hospital administrators and the physicians—must come together to find that economic and medical balancing point where private practice and the hospital can be sustained and can thrive.  Having trustees who have been part of the medical community here in Boone County and are well-respected by their peers is an asset that cannot be under-valued.  They can and must reach out to their colleagues to bridge the divide that has grown in recent years under BJC’s leadership.  

Second, as the trustees have already indicated, their skillset must be amplified by community members with expertise in finance, information technology, and similar fields in order to position Boone Hospital for growth and success.  

Third, the trustees must work with University Hospital to find a way to ensure that both hospital systems can thrive.  The patient base for these hospitals is not just local, it is regional.  

Finally, it is incumbent upon us, the people of Boone County, to support this hospital as it embarks on a new pathway forward.  
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Boone Hospital has been and remains a crown jewel in our community.  It has faithfully served generations of Boone Countians and we remain its stalwart champions. Its dedicated staff continue to provide excellent care for all who enter its doors.  I know that is why my Dad chose Boone for his care.  That is why my brother and I chose Boone for our Mom’s care in her final days.  So many Boone County and mid-Missouri families feel as we do. Boone Hospital’s future depends on our widespread support as we undertake a new management model in a new healthcare era. The future of Boone Hospital is up to all of us.

Supporting Boone seems only right.