Health Policy Solutions

By Katie Kerwin McCrimmon

Under fire this week from conservatives, Colorado House Majority Leader Amy Stephens said Thursday that she will no longer support a health exchange unless Colorado “opts out of Obamacare.”

Senate Bill 11-200 passed out of the Senate Health and Human Services Committtee on Thursday on a party-line vote and will now go to the full Senate, which is controlled by Democrats.

But, Stephens, R-Monument, released a letter to her Democratic co-sponsor in the Senate, President Pro Tem Betty Boyd, D-Lakewood, saying she will only support the bill if a new provision is added:

“The provisions of SB 200 shall not be implemented, nor shall they have force or effect, until the State of Colorado requests, and the federal government grants, a full waiver from all terms, restrictions, and requirements in the federal Patient Protection and Affordability Care Act of 2010, and all rules, regulations and administrative guidelines issued thereto.  The Governor of the State of Colorado shall seek such waiver within 60 days of the enactment of this Act.”

Conservatives have taken to calling the Colorado exchange bill “Amycare” and have threatened Stephens with a primary battle if she supports the bill, which is seen as the first step in implementing the Affordable Care Act.

Stephens had signed on as the Republican sponsor for the exchange bill after also introducing a bill called the HOPE Act, which aims to dismantle health reform.

Sen. Shawn Mitchell, R-Broomfield, tried to attach a similar “opt-out” provision to the bill in the Senate committee on Thursday, but was unsuccessful.

Here is Rep. Stephens’ full letter:

March 31, 2011

Dear Senator Boyd:

The discussion surrounding SB 200 (the Health Benefit Exchange) is proof positive that the enactment of Obamacare has set the American debate about health care backward by light years.  For years, conservatives at all levels have touted the free market virtues of health care exchanges as a way to give private citizens greater purchasing power and greater access to private health insurance.  The concept of individuals banding together to cut the best health care deal possible for themselves and their family has been a staple of the House Republican platform for many, many years.

But enactment of the Patient Protection and Affordable Care Act – otherwise known as Obamacare – has so thoroughly contaminated the public discourse about the nation’s health care system that even simple and commonsense ideas like health care exchanges have become toxic and fraught with public policy peril.  This is more than a symbolic concern.  Many of my constituents and a few of my colleagues have told me that, while exchanges are themselves sensible public policy, the potential linkage of this legislation to Obamacare is far more damaging than whatever benefit is derived from the bill.  Some have worried that, even though the exchanges created in my bill are totally independent of Obamacare, that future legislators or governors (or even the federal government) could hijack this local control measure to implement Obamacare.  It is not in the plain language of the bill, but after all the overreaches that government has engaged in of late, it is an issue that I want to settle in this legislation in the clearest possible terms.

On this point let me be clear: Obamacare is unconstitutional, and it is bad public policy.  I applaud Attorney General Suthers and his colleagues around the nation for taking the fight to the courts.  I have supported legislation in the past to legislatively opt Colorado from its big government vices.

That brings us back to SB 200, and the fear that the health exchange legislation might be unwittingly used to support the implementation of Obamacare.  There is only one way to solve this problem, and that is to make absolutely sure that the health care exchanges are implemented only after the State of Colorado opts-out of Obamacare.  Specifically, I am requesting that the Committee add the following provision to the legislation.

“The provisions of SB 200 shall not be implemented, nor shall they have force or effect, until the State of Colorado requests, and the federal government grants, a full waiver from all terms, restrictions, and requirements in the federal Patient Protection and Affordability Care Act of 2010, and all rules, regulations and administrative guidelines issued thereto.  The Governor of the State of Colorado shall seek such waiver within 60 days of the enactment of this Act.”

In as much as I believe that healthcare exchanges are a good idea, in order to be a good representative of my district, I must ensure that these state exchanges are not hijacked for the unconstitutional purposes of implementing the federal health care legislation.

With this amendment, Colorado would become one of the first states in the nation to take up President Obama on his recent offer to allow states to opt-out of his health care bill.  For his part, Governor Hickenlooper expressed openness to the idea of an opt-out.  In exchange for the bold step of opting out of Obamacare, the State of Colorado will have health care exchanges that help patients get and receive affordable and reliable health care.  It is a win-win for the State of Colorado.

I strongly encourage the Committee to accept the above language.  If the Committee chooses not to add this important provision and still forwards the bill to the House, I will work all of the votes in my caucus to ensure that the Obamacare opt-out provision is added in the House of Representatives prior to returning to the Senate.

I continue to believe that health care exchanges are a commonsense policy, just as conservatives have advocated for many, many years.  And with the addition of the above provision, they can be implemented into law without federal intrusion, instruction or interference.

Thank you for your consideration.

House Majority Leader Amy Stephens

By Donald J. Mares

It is no secret that there is a strong connection between the mind and body. Religious leaders, philosophers, doctors and many others have discussed the mind/body connection for centuries. Yet the treatment of mental and physical health has been compartmentalized in modern Western medicine. In the United States, there are two systems of care: the behavioral health system and the physical health system.

These systems are perpetuated through insurance reimbursements, through laws, medical education and many other cultural and social institutions. The distinction between mental and physical health is both a product and promoter of the stigma associated with mental health. This distinction also creates many barriers to accessing high quality mental health care in the United States.

One of the most productive ways of closing the treatment gap for untreated mental illness is incorporating mental health treatment options with physical health care though an integrated model of service. The primary care level of service is one of the most logical areas to establish an integrated care framework. Primary care, as defined by the American Academy of Family Physicians, is care received at a patient’s initial contact with the health care system.

Primary care providers play an important role in identifying and treating mental health disorders. About 75 percent of all primary care visits involve a mental health component. Over 40 percent of people with depression and/or anxiety are first diagnosed by their primary care providers and over 20 percent of undiagnosed adults indicate that they would first see their primary care provider for help with a mental health issue.

Although primary care providers treat a large portion of mental health issues, they currently face many challenges in treating them, including insufficient insurance reimbursements, a high demand for care and a lack of specialty training. These challenges will increase as more individuals gain access through the National Patient Protection and Affordability Act.

There are models of successful integration: Some college campuses have integrated their student health care systems to include physical and mental treatment in one location with success. Community health centers and health maintenance organizations are also providing integrated care at many locations.

Mental Health America of Colorado has promoted integration through our programs and public policy work for several years. For example, MHAC helped create and advocated for the passage of Senate Bill 07-36, which requires companies employing 50 or more employees to offer mental health insurance coverage that is equal to physical health insurance coverage (commonly known as “parity” legislation). Gov. Bill Ritter signed the bill into law in 2007.

MHAC is committed to the principle that mental health is an essential part of every person’s whole health and well-being. Every Coloradan should receive mental health and substance abuse prevention, treatment and long-term support regardless of how they enter the health care system.

Treating the whole person through the integration of mental and general health care will save lives, reduce negative health outcomes, facilitate quality care and result in long-term cost savings.

About the writer: Donald J. Mares is the President and CEO of Mental Health America of Colorado, a non-profit organization providing 58 years of leadership to address the full range of mental health and wellness issues in Colorado.

By Molly Maher

Just a little more than a week after World TB Day, an active case of tuberculosis has been confirmed at the University of Colorado Denver.

After the student, whose identity is being kept private, was diagnosed, an unconfirmed number of students, staff and faculty who were at risk of contracting tuberculosis were notified and encouraged to get tested, CU Denver spokeswoman Jacque Montgomery confirmed.

This is the second case of active tuberculosis in the past 12 months reported to Health Center at Auraria. This compares to a record high of four active cases in 2000.

Dr. Randall Reves, director of the Denver Metro TB Control Program, said that the student, who did not live on campus, is suffering from a non-drug resistant strain of tuberculosis and would undergo short-course treatment.
The disease, transmitted from person to person through airborne bacteria over long exposure, is more difficult and expensive to treat if it becomes drug-resistant, according to the Centers for Disease Control.

“There is usually some delay in a diagnosis,” Reves said. He added that tuberculosis has the potential to be infectious for a longer period of time, and those who spend many hours or live with a patient should be tested.

“Measures that are being taken now are preventative,” said Martha Eaton, assistant director of the Student Health Center at Auraria. “We are not overly concerned, but we do take public health and safety very seriously on our campus.”

In fact, those contacted for testing may not have even met the clinical criteria for length of exposure to the diagnosed student, Eaton said, making the risk of infection low and the measures that have been implemented highly proactive.

The community members contacted have been very receptive to testing. They will receive blood tests rather than skin tests, which Eaton says research has proven to do a much better job at identifying latent TB in patients.

Latent TB infection occurs when the bacteria is inhaled, but is fought off and does not cause any sickness or symptoms. A person with latent TB cannot spread the disease, but may become sick if the bacteria multiply, the Centers for Disease Control report.

Reves adds that blood testing allows immediate results, rather than several weeks after a skin test. He also mentioned that it will give an accurate result despite some vaccinations that international students, a population with the highest risk for tuberculosis, receive that could interfere with testing.

The international population is not the only high-risk community, Eaton said. Also at risk are frequent travelers, health care employees, justice or correctional facility workers, or those who spend time in close quarters, such as homeless shelters.

Both Reves and Eaton are proponents of risk assessments and mandatory testing of college students, which would help identify this population and get them tested or treated before infecting others.

“TB cases in college students are largely preventable and we are not doing a good enough job of making sure that happens,” Reves said.

“Because students are very mobile…we may see a higher incidence of latent TB on a college campus compared to other areas,” Eaton said.

An effort was launched in 2000 to introduce mandatory testing based on risk assessment. “It ended up being totally worthless,” Reves said. “It just got watered down to nothing.”

The current system, which requires students to complete a risk form that is reviewed by the immunization staff, recommends that only at-risk students be tested, Eaton said.

If there is fear of an outbreak, the government can step in to require testing, she added.

A mandatory system is currently in place at the University of Colorado at Boulder.

Eaton mentioned several factors that make targeted testing difficult to mandate, including political or philosophical beliefs.

“When you mention the word targeted testing, it makes people have goose bumps on the back of their neck,” she said.

The proposal in 2000 was considered unconstitutional by some faculty members, and others expressed concern about alienating international students who know too much about the stigma of tuberculosis in their home cultures, Eaton said.

“We try to be culturally sensitive to all of our students, staff and faculty and make a policy in the spirit that we want to have the opportunity to talk,” she said.

Reves also mentions the economic burden of this process, but does not think this is reason to avoid it.

“It really is, I think, the responsibility of the university.”

Visit the Division of Tuberculosis Elimination for more information on testing, treatment and trends provided by the Centers for Disease Control and Prevention.

For more information, contact Martha Eaton, assistant director of Student Health Center at Auraria, at (303) 556-3875.

By Zeik Saidman

We lied, kidnapped, abandoned and then manacled and drugged my mother-in-law.  At least this is the way my wife describes the experience of placing her mother in a nursing home.

True, we did use the therapeutic fib (Alzheimer’s experts use this concept) to lure her to the nursing home facility. We told my mother-in-law that she was going to visit with the “nice man” who had come to her home to talk about senior services in the area.   In actuality, he was the director of the Alzheimer’s unit and his visit was to conduct an assessment for eventual placement.

The reality of that dreaded day was that we took my mother-in-law to a nice restaurant for lunch.  Afterwards, we drove along a beautiful river near the nursing home.  We parked to enjoy the scenery and listened to the 1940s music on the satellite radio.  She remembered many of the songs and hummed along with a beautiful voice, one part of her that had not been affected by the disease.  We left the scenic site with the music playing.

We arrived at the facility, which had been built in a pleasant middle-class neighborhood 60 years ago. It has that 1950s brick, square institutional look.

My wife and I brought her inside on the pretense of meeting the nice man. All was proceeding smoothly until a friendly receptionist said: “You must be the new resident.”   We gave the receptionist a look to quiet any further conversation; fortunately my mother-in-law missed the comment.

My wife had researched nursing homes in the area extensively and had found one with a five-star Medicare rating, the highest it gives.   Even rarer than the high rating, this facility also accepted Medicaid patients.  However, waiting to take the elevator to the second floor by the reception/nursing station, one is conscious of the elderly patients with limbs missing, sitting in wheelchairs. The staff wears slings around their necks to hoist residents. You are aware of medical equipment and personnel at ready to respond to the needs of the residents.

My wife had searched the Alzheimer’s literature and talked to experts and friends seeking advice on how to move a family member into a nursing home. There was no clear guidance, except for the universal consensus that there’s no way to prepare someone with Alzheimer’s for a move like this.

She drafted scripts in preparation for what she knew would be a volatile conversation.  As we entered the director’s small office and sat down, we told my mother-in-law that her home caregivers wouldn’t be available for a while, but she would be able to live here temporarily.  All the preparation went by the wayside.  She angrily stated that she wanted to go home. My wife calmly said that was not possible and that she would have to stay here for the time being.

Barely five feet tall and weighing under 90 pounds, my mother-in-law stormed out of the office.  She expressed her rage to the staff in the hallway as she sought a way out. She returned to the office several times, shouting, “There’s nothing wrong with my mind” and “I’ll jump out the window if I have to stay here.” My wife remained composed at her mother’s onslaught and tried to comfort her but she wasn’t having any of it and resisted any touching. Before we left, we heard the sound of ripping paper.    My mother-in-law had torn the “Welcome” sign off the door to her room and had shredded it into little pieces.  She deliberately placed the torn bits in my hand, looked me right in the eye and said “traitor,” repeating the act with my wife.   At the urging of staff, we reluctantly departed and promised to be back.

When my wife called later to check on her, she was told that the staff had placed a small bracelet on her ankle to monitor her movement.   Later, they called requesting permission to administer a sedative, because she had become distraught and combative.

For my wife, this was the hardest thing she ever had to do in her life—harder than losing her father to a brain tumor that killed him within six weeks of the diagnosis. The act of moving a loved one from her home of almost 60 years is highly emotional and guilt-ridden.  The stress continued the next day with a meeting with lawyers to make sure the myriad of paperwork had been submitted for her Medicaid application and finding a trustworthy realtor to sell her house in a severely depressed market because her assets must be depleted to receive government aid.

And the guilt remains.  My sister-in-law speaks wistfully of winning the lottery so she can get her mother out of the nursing home and back into 24-hour in-home care with nurse visits, which cost about $7,000 per month.  But my wife points out that during that 24-hour-a-day care,  her mother spent much of her time at home, sitting in her favorite chair.  Now my wife dutifully calls her every other day and regularly checks in with staff to monitor the situation, which has  improved in many ways due to the structure, medical care and social stimulation provided by the nursing facility.

She seems to have adjusted to her to circumstances, but still makes comments about going home, though she doesn’t press the issue. She is participating in activities such as singing and dancing. She is a people person and has begun to assist other residents. I am sure she will become a staff favorite.

Alzheimer’s is a cruel disease. It is a physical illness that slowly and insidiously destroys parts of the brain.  Sometimes my mother-in-law seems her old self and other times she is very confused.  Incontinence is part of the sickness.  For a modest and independent person, this is an ongoing indignity. The dedicated staff at the nursing home has come up with solutions to keep her clean and her self-esteem intact.

Both sisters agonized and regretted having to make the decision to move their mother. We’ve had heartfelt conversations with friends and family members about the choice we’ve made. Many told us stories about dealing with similar situations.

The Alzheimer‘s literature uses the metaphor of a tsunami. The projection is that one out of every two people over the age of 85 will have some form of dementia. As the baby-boomers, age this challenge will loom as one of the major health care policy issues to be resolved. The emotional and economic costs to families and society will be astronomical.

Can we come up with compassionate and reasonable answers to address this tidal wave of dementia soon to hit our shores? Difficult as it will be, it’s a challenge we must face.

Zeik Saidman is associate director of the Center for Public Private Sector Cooperation at the Buechner Institute for Governance at the School of Public Affairs.

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