Health Policy Solutions

By Katie Kerwin McCrimmon

Tea Party activists helped propel a bill forward in the Colorado House Tuesday that opponents said would essentially dismantle Medicare while allowing Colorado to opt out of implementing the federal health law.

At stake would be an estimated $9 billion in annual health spending in Colorado. Under HB 11-1273, known as the HOPE Act, Colorado would join states in an interstate compact that would supersede federal health laws.

Opponents said the bill would essentially gut Medicare while supporters said the bill merely allowed Colorado to take back control over health spending decisions that should be made locally.

“It’s not a renegade kind of thing,” said House Majority Leader Amy Stephens, R-Monument, one of the sponsors of the measure. “States have the right to get together and decide these issues together.”

Stephens conceded that using an interstate compact to try to govern health care is an entirely new strategy. In the past, compacts have been used to manage shared resources, like water in the West, or transportation matters in the Washington Beltway region.

If the bill passed, Colorado would then opt out of implementing the Affordable Care Act. Instead, Colorado and the other compact states would get fixed block grants of money to control their own health spending from Medicare, which provides health care to the elderly, to Medicaid and CHP, which are public health insurance programs for the poor, disabled people and children.

Dueling legal scholars testified at a hearing to determine if Colorado should create an interstate compact to bypass the federal health law. From left to right, Mario Loyola, of Texas, Scott Moss, of the University of Colorado Law School and bill sponsors, Rep. Amy Stephens and Rep. B.J. Nikkel.

“That’s an enormous public policy matter…and one that warrants significant conversation,’’ said Elisabeth Arenales, director of health programs for the Colorado Center on Law and Policy, who urged House members to vote against the measure.

Among others who spoke were Tea Party activists from Craig to Canon City. Some of them clutched instruction booklets, distributed by a national group called Health Care Compact Alliance. The Alliance is being supported and funded nationally by the Tea Party Patriots, the nation’s largest Tea Party group, and a Texas construction company heir, Leo Linbeck III, whose family has supported conservative causes ranging from a “Fair Tax to the Swift Boat Veterans for Truth.

The Alliance’s how-to manuals told supporters how to push the Compact legislation in their state, gave them legislative drafts, sample press releases and instructed them on how to win over their local elected members and spin their message.

But, when the activists spoke, their message splintered. One man said he was a Tea Party member, but opposed an edict from the national Tea Party since local control is a vital value of the movement. He urged lawmakers to oppose the compact alliance. Another Tea Party activist spoke in support of the bill. She said Colorado needed to take control of health spending because she’s on Medicare and fears that the national health law includes provisions which would allow her doctors to kill her to save money. (The Affordable Care Act does not include any so-called death panels.)

The 3 ½ hour hearing also featured dueling constitutional experts. One came from Texas, where the movement is being funded. Another from Colorado opposed the legislation, saying that while the bill’s language claims that compacts need only be approved by Congress, compacts must be approved by the president. In this case,  President Barack Obama would never support a compact that seeks to upend his signature health bill.

Ultimately, the Republican-dominated committee voted to send the measure to its next committee, Appropriations, by a 7-to-6 party line vote.

The Republican sponsors of the measure, Majority Leader Stephens, and Majority Whip, B.J. Nikkel, R-Loveland, sprang a new version of their bill on committee members and opponents just before the hearing. The new language — which parallels language in the how-to manuals — turns the bill into a copycat measure of a bill recently passed in Georgia and makes it nearly identical to a draft being pushed in legislatures around the country.

Stephens and other supporters sought to downplay the implications of a compact.

“It provides flexibility on funding,” said Stephens. She insisted that any major changes approved by an interstate compact would then come back to the Colorado legislature for approval.

Stephens, meanwhile, is simultaneously supporting a bill that would establish a Colorado Health Exchange. That bill passed the Colorado Senate this week and now moves to the Republican-controlled House. Stephens has predicted that the exchange bill will pass the legislature. While most experts see a health exchange as the first step of implementing the Affordable Care Act, Stephens believes it’s a free-market measure that will help small businesses find more affordable health care options. She believes a health insurance exchange could thrive even if Colorado opts out of implementing the Affordable Care Act.

Among the experts who testified on Tuesday was Mario Loyola of the Texas Public Policy Foundation.

Loyola testified that interstate compacts have a long history in our country. He said 200 are currently in force. He said compacts require congressional consent, but could be an excellent strategy for helping states withdraw from provisions of the health law so they can “regulate health care in the way they see most fit.”

Lawmakers on the committee questioned why Colorado needed to opt out of the health law since a majority voted in November not to opt out.

Loyola testified that the framers of the constitution never gave the federal government the power to regulate health care.

“All Americans would be better off if health care regulation were returned to the states,” Loyola said.

Opponents of the interstate compact produced their own expert.

Scott Moss, an associate professor at the University of Colorado Law School, testified the Colorado law would be unconstitutional because of its claim that it wouldn’t need presidential approval. He submitted a letter to committee members.

“My sense is that if it’s enacted, it will go nowhere because the president won’t sign it,” Moss said.

What’s more, he said the compact would be unlikely to be approved unless President Obama is voted out of office in 2012.

“There’s no circumstance where I can see that Congress keeps the Patient Protection and Affordable Care Act and allows this compact,” Moss said.

What’s more, he said that backers were wrong to claim that a compact could easily be changed after it’s adopted.

“Once a federal compact is enacted, it can’t be amended (without Congressional consent),” Moss said.

Among the lawmakers who was most divided Tuesday was Rep. Laura Bradford, R-Collbran in Mesa County. The Grand Junction area has become known as a national model for providing affordable health care to both the indigent and people with insurance.

“My constituents are afraid of any interference (from either the federal government or the state),” Bradford said. “It is with great trepidation that I will vote yes on this and let it go to the House floor for further debate.”

By Katie Kerwin McCrimmon

DENVER – The young mother sings the ABCs to her baby as he gazes adoringly at her with his big brown eyes.

“I think he knows I love him a lot,” she tells the nurse who has visited her regularly since she became pregnant.

“You teach him that. You teach him how to love, how to trust,’’ the nurse says. “You are an amazing, amazing mother.”

Tasheyla Parham, now 19, seems stunned by this compliment. She lets it wash over her.

“I amaze her,” she says to herself in disbelief. She is smiling and tears well in her eyes.

“Nobody was there for me,” Tasheyla confesses.

Indeed, chaos has swirled around her for much of her life.

Her mother has seven children from four different fathers. Tasheyla always has felt like the black sheep.

She didn’t know her father existed until she was in the second grade. She remembers her grandmother was braiding her pigtails when someone handed her the phone and said her dad wanted to speak with her.

“Who?” she thought. Her dad has spent much of her life in jail.

At 14, Tasheyla ran away from home with her 12-year-old sister, going to bed hungry in abandoned houses as the pair tried to dodge foster care.

At 17, Tasheyla became pregnant, while living on the streets. Her boyfriend comes from a similar background and also lived in foster care.

“We both know how it feels not be loved,” Tasheyla said.

Tasheyla Parham said her son, Amir has changed her for the better. "Nobody’s going to give him a red carpet. I have to make a life for him.”

Despite such powerful currents pushing against her, Tasheyla is determined to create a different life for her son, Amir, now 7 months old. His name means “prince” in Arabic. She took the first step by quitting smoking during her pregnancy. She works hard to take good care of Amir and herself. He is thriving and giggly.

“When he was born, something just turned on inside of me. It was just, boom,” Tasheyla said, cuddling Amir. “He’s changed me for the better. Nobody’s going to give him a red carpet. I have to make a life for him.”

Nurse visits provide stability to once homeless teen

Guiding Tasheyla through the many challenges she has faced since pregnancy is Courtney Sheffield, a registered nurse, who visits with Tasheyla and Amir regularly through the Nurse-Family Partnership, an intensive program created in Colorado and now spreading throughout the country and internationally. In Colorado, money from tobacco taxes helps fund the program. New funds designated in the Affordable Care Act will lead to expansions in similar programs here in Colorado and across the country.

During her visits, Sheffield offers critical medical and developmental advice and encourages Tasheyla to stimulate Amir’s brain while keeping him healthy, safe and happy.

The program is based on long-term randomized controlled trials — the gold standard in research — that prove that intensive support for first-time, low-income moms dramatically changes the outcomes for both mothers and babies. The nurses work individually with their moms from pregnancy through the most challenging newborn and toddler stages until the children turn 2.

Sheffield has received special training on how to help moms like Tasheyla. She likes to say that she meets moms “where they are.” She presents facts and backs them up with research. She’s never judgmental. She doesn’t hand down edicts on proper parenting. Rather, she asks questions and helps mothers find their own confidence.

“I’m not here to judge you. I’ll give you information,” she said. “We all come from some place. Tasheyla’s so self-aware. She can be exactly what she chooses.”

Tasheyla is used to people giving up on her. But Sheffield is her rock.

Urban Peak, a program for homeless teens, helped Tasheyla learn about the nurse visitation program. Since Tasheyla and Courtney first met when Tasheyla was 34 weeks pregnant, Tasheyla has lived in 10 different places. With each move, Sheffield has tracked Tasheyla like a private detective. Once she had to call Tasheyla’s boyfriend’s employer to find her. The message is clear: “I’m not letting you go.”

On a recent visit, Tasheyla was giddy to share her latest news. She greeted Sheffield at the door of her new place.

“You’re going to be so proud of me,” Tasheyla said.

She had just paid her own rent for the first time in her life. Urban Peak had helped her find a subsidized one-bedroom apartment in Denver’s Uptown neighborhood. She had opened her own bank account. She was watching an episode of the popular MTV series, Teen Mom, when she saw a mother like her become unable to support herself financially.

“I thought, ‘I can open my own bank account.’ ”

She did not add her boyfriend to the account.

“This is my secret stash, my ‘just in case money.’ ”

“That’s so huge,” Sheffield says.

Tasheyla and her boyfriend are also working to complete their GEDs and are hunting for jobs. They do not live together, but he helps her care for Amir. For a time after the birth, Tasheyla stayed with her “baby dad” at his mother’s home. But she said he and his friends sometimes partied too much. She wanted Amir in a better environment. And she wanted to find herself.

Nurse Courtney Sheffield plays with baby Amir. She has tracked his mother through 10 moves to help her succeed as a first-time mother.

At this new place, even though she has her own bedroom, she often sleeps on the couch, both out of habit and to be close to Amir, whose crib is in the living room.

One person to believe in you

On this day, she is getting him ready for a well-baby check-up that afternoon. He’ll get immunizations. She and Sheffield go over what to expect and what medications would be safe if he seems fussy after his shots.

They also talk about feeding. Tasheyla breastfed Amir for the first three months. Sheffield then made sure she was mixing formula correctly. She said it’s very common for low-income moms to try to make the formula last longer by not mixing it at full strength.

Sheffield also helped coach Tasheyla on how to handle well-meaning relatives who were pressuring her to introduce foods like fried chicken.

“They tell me, ‘Girl. He wants it. Feed that baby.’ ”

“Maybe his body isn’t quite ready for it,” Sheffield says.

Tasheyla rehearses her new response: “Don’t feed him. Don’t give my baby chicken. This is my son and I’m learning.”

The nurse and mom also talk about how Amir will soon be moving much more and how Tasheyla can make her new place safe for him. They discuss tummy time and reading. Amir loves the rhythmic, alphabet book, “Chicka Chicka Boom Boom.” Tasheyla says that sometimes he doesn’t seem to have the patience to sit and listen to the whole book.

“You can let him turn the pages,” Sheffield says, reminding Tasheyla that it doesn’t matter if he wants to skip pages. The interaction between the two of them is key.

Tasheyla has been singing to Amir since he was in her belly. She notices that he recognizes the ABCs now: “That’s his jam.”

With Sheffield’s encouragement, she has learned to talk with him as much as possible.

“The more you talk, the more you sing and interact, the more that helps with his development,” Sheffield says. “He’s a happy, happy baby. You’re doing such a good job.”

Again and again, she reminds Tasheyla of a simple, but powerful message.

“You’re his teacher. You have the ability to shape him.”

Parenting is a challenge for all new moms. But Tasheyla’s background can make it harder.

“My mom had her first baby at 15 so we all grew up together.”

When Tasheyla became pregnant herself as a teen, she felt that her mom rejected her and her friends thought she had made a mess of her life. She’s patching up the relationship with her mom and is creating new dreams.

She wants to go to school and become a certified nursing assistant. She enjoys working with older people and would like to work in a nursing home. She hopes someday to be a supervisor or own her own business.

“I want to own the world,” she says.

As for Amir, she wants stability for him.

“I want him to live the life that I didn’t get to live,” she said. “I want him to be comfortable, to have money and a family. I want him to finish school. I want him to be on the chess and debate teams, to play baseball and soccer.”

She imagines his future graduation ceremonies, from kindergarten and beyond.

Sheffield has faith that Tasheyla will achieve her goals and tells her this regularly.

“She seeks out help. She’s extremely smart,” Sheffield said. “Having that one person believe in you can make all the difference.”

Tasheyla believes Sheffield has given her a gift.

“I’m thinking more of Amir than I am about myself,” she said. “She’s like my fairy godmother.”

By Robert Hill

Last year, more than 266,000 U.S. children suffered physical or mental abuse and neglect at the hands of their parents or caregivers. More than four such kids die every day from these causes.

Between 2001 and 2008, more than 200 children in Colorado died from abuse and neglect, according to the Every Child Matters Education Fund. These tragedies too often befall victims too young to speak up, seek help or fight back. According to the 2007 Child Maltreatment Fatality Report by the Colorado Department of Human Services, 90 percent of child maltreatment fatalities in Colorado occurred among children ages 5 or younger, with the majority of the abuse inflicted on infants. Each of their short lives and tragic deaths tell of unspeakable suffering.

This pattern of death and abuse within families doesn’t have to continue. In fact, this cycle of tragedy can and should be entirely preventable.

As co-founder of Invest In Kids and board chairman of Nurse-Family Partnership, both Denver-based nonprofits, I applaud the State of Colorado for the steps it has taken in recent years to improve child welfare statewide. In addition to implementing effective child protection programs that remove children from harm’s way, I strongly believe in effective programs that prevent child abuse from occurring in the first place — by empowering children and families to succeed. When it comes to child maltreatment, prevention is always preferable to treatment after the fact.

The Nurse-Family Partnership community health program (NFP) is one such method that research shows can help reduce rates of child abuse and neglect. NFP pairs registered nurses — in communities in Colorado and nationwide — with low-income, first-time mothers from during their pregnancies through the critical first two years of the child’s life. The majority of mothers served are teenagers ill-equipped to cope with the responsibilities of parenting without this help.

The NFP nurse home visitors help these young women improve their prenatal health and obtain essential prenatal care; teach families about proper nutrition, child health and development; strengthen parenting skills and coping mechanisms; and assist mothers in achieving their educational and employment goals so that they can support their families. Enrollment in the NFP program is voluntary, free of charge to the mother, and utilizes locally employed registered nurses who receive specialized training from the NFP National Service Office in Denver.

Nurse-Family Partnership has been rigorously tested for more than three decades in three randomized, controlled trials. Its results are extraordinary, including reductions in childhood injuries; emergency room visits for injuries; pre-term births among women who smoke; childhood cognitive and emotional disorders; childhood language delays; and much more.

In the earliest trial of subjects in the NFP program (in Elmira, N.Y.), researchers documented a 48 percent long-term reduction in state-verified rates of child abuse and neglect. There was also a 56 percent relative reduction in emergency department encounters for injuries and ingestions during the children’s second year of life.

In the second NFP trial, in Memphis, there was a 28 percent relative reduction in all types of health care encounters for injuries and ingestions, and a 79 percent relative reduction in the number of days that children were hospitalized with injuries and ingestions during children’s first two years. The third NFP trial — which took place right here in Denver — documented significant decreases in smoking among mothers who enrolled in NFP, as well as improvements in child cognitive functioning and language development.

These numbers undoubtedly add up to many young lives saved. In fact, in the Memphis trial, children in the control group (i.e., comparable children not enrolled in NFP) were several times more likely to die by age 9, compared to children who had been visited by NFP nurses.

Colorado state legislators had the vision and leadership to fund Nurse-Family Partnership beginning in 2000 to serve families throughout our state. NFP nurses currently serve families in 50 Colorado counties, and have assisted about 13,000 families to date statewide. Earlier this year, the Colorado Joint Budget Committee demonstrated a strong commitment to this inspiring prevention program despite the difficult economic climate, voting to maintain current NFP funding levels statewide.

In the last decade, Colorado families enrolled in the program have made considerable strides. Among many outcomes for NFP families in Colorado are a 47 percent reduction in domestic violence during pregnancy, and 91 percent of children being born full term and at a healthy weight. These types of findings mean healthier infants, and safer family environments for them to grow up.

The federal government also has taken note of how effective a program like NFP can be. Last year, a provision in the Patient Protection and Affordable Care Act created the Maternal, Infant and Early Childhood Home Visitation Program. This five-year, $1.5 billion mandatory funding stream is now enabling states to implement, maintain or expand evidence-based home visitation programs such as Nurse-Family Partnership. Colorado has applied for and received this important funding to continue its longstanding support of NFP and other evidence-based home visiting programs.

Both Nurse-Family Partnership and Invest In Kids, which oversees NFP program implementation and replication statewide, are committed to improving the health and well-being of Colorado children and families and preventing child abuse and neglect. These organizations will continue to work to bring NFP and programs like it to even more Colorado families in need. Today in America, four more innocent children died at the hands of their parents or caregivers. With the help of evidence-based programs such as Nurse-Family Partnership, I firmly believe that someday, this number can be cut to zero.

About the writer: Robert Hill is board chair of the Nurse-Family Partnership, co-founder of Invest In Kids and a partner at Hill & Robbins, P.C.

By Katie Kerwin McCrimmon

A program  incubated in Denver to help mothers and babies thrive through intensive nurse visits is now growing across the country thanks to a $1.5 billion shot in the arm from the Affordable Care Act.

The Nurse-Family Partnership, a national program based in Denver, now serves more than 22,000 families in 32 states. That number is expected to rise as additional funds flow to every state to fund home-visitation models like the one pioneered by Dr. David Olds, director of the Prevention Research Center for the University of Colorado School of Medicine.

More than 30 years of research in New York, Tennessee and Colorado have shown that investing in long-term nurse visitation programs for first-time, low-income mothers results in better outcomes for both mothers and babies. Olds and other researchers have found dramatic reductions in child abuse and neglect, fewer childhood injuries, improved prenatal health, fewer subsequent pregnancies, increased maternal employment and improved school readiness.

“It’s a significant step forward for children and families to have this new federal maternal infant and early childhood home-visiting program,’’ said Dr. Libby Doggett, director of the Pew Center on the States’ Home Visiting Campaign, a division of the Pew Charitable Trusts in Washington, D.C.

“What’s particularly significant about this is it’s focused on evidence-based policies. Everybody wants to do good things for children and families. In our rush to do that, we sometimes put money out without really knowing…how it’s going to make a difference,” she said.

The Pew Center seeks to provide states with data on programs that work so they can spend scarce dollars well.

“We know this is a highly impactful intervention,” she said. “The data-driven policies and investments in high quality parent education start positive chain reactions that result in stronger families. It’s hard to change adult behavior. This is one of the most effective ways to do it.”

The Nurse-Family Partnership is one of seven programs authorized under the Affordable Care Act for use in the majority of the new visitation programs. It’s the most highly rated.

“The evidence is clear that some are better than others,” said Doggett.

While Doggett said the outcomes are strongest for the Nurse-Family Program, some other programs — including Parents as Teachers and Healthy Families — are more widely available.

Pew’s Home Visiting Campaign has created a state inventory of home visiting programs. That analysis shows that 46 states are now spending $1.4 billion on various home visiting programs. All 50 states have applied for their share of the new $1.5 billion in federal funds, meaning that spending could double across the country over the next five years.

A voluntary program, the Nurse-Family Partnership, pairs first-time mothers with trained nurses who visit them in their homes to provide support, medical advice and behavioral guidance during weekly and semi-weekly visits from pregnancy through the baby’s second birthday.

A 2005 RAND Corp. study found that the Nurse-Family Partnership has a big bang for the buck. On average, the cost to help each mother and baby for 2 ½ years from pregnancy through the child’s second birthday is about $4,500. Nationwide, it ranges from $2,900 to about $6,500. For every dollar spent on high-risk mothers, the program saved $5.70.

A separate 2004 study by the Washington State Institute for Public Policy found that the Nurse-Family Partnership ranked best for return on investment and keeping kids out of the public welfare system. The study evaluated a wide range of programs from pregnancy and teen substance abuse prevention to preschool programs and found that the Nurse-Family Partnership saved $3 for every dollar spent.

“The reason Congress passed (the home visiting section) of the Affordable Care Act is because of the strong evidence from the Nurse Family Partnership that these investments produce returns in both health and development, and reduced costs,” said Dr. David Olds, who pioneered the research that has led to nurse visitation programs across the country.

Even more poignant than the economic benefits are the countless stories of babies and mothers who are thriving thanks to the close bonds they form with their nurse partners.

‘Moms need to be sober’

Take Rita Erickson, for example. Now 30, she was just out of jail, homeless and addicted to meth and alcohol when she learned she was pregnant.

Erickson told her probation officer that she didn’t know anyone who was sober, and begged for help kicking her 12-year habit. The officer connected her with the Nurse-Family Partnership and got her into a drug rehab program. Erickson said she was looking for motivation and support to quit and stopped using drugs and alcohol early in her pregnancy. Her nurse visited her in rehab and as she struggled to build a new life afterwards.

“For a while I didn’t have anywhere to live. She was chasing me around town trying to do visits,’’ Erickson said. “She was very positive. She gave me lots of encouragement: ‘You’re making the right choice by not talking to the dad. You’re doing the right thing. Stay positive.’ ”

Erickson’s former boyfriend continues to be in and out of jail and she ultimately had to get a restraining order to keep him away from their daughter.

She says she’s never been able to count on her own mother.

“It’s been my whole life. She leaves me and she comes back.”

Erickson’s nurse, Valerie Carberry, became the constant female force in her life. Erickson was afraid to give birth and Carberry helped her understand birthing options and prepare. After Erickson’s daughter was born nearly three years ago, Carberry helped her learn to breastfeed and got her a breast pump.

With each new stage of development, Carberry was there to give support, information and guidance.

Today Danika is nearly 3 and is already speaking in full sentences, counting to 10 in English and Spanish and knows her colors and shapes.

“We read every night,’’ Erickson said. “She likes to read to me. We have books and games and a project box so she can do crafts any time she wants.”

Erickson is also thriving. She and her daughter now live in their own apartment. Erickson is studying business at Red Rocks Community College and hopes to go on to Regis University and someday get her MBA. Recently, she was one of just two students at Red Rocks and a handful around the state to receive the prestigious Phi Theta Kappa All-Colorado Academic Team award for 2011.

The Nurse-Family Partnership taught her a critical lesson.

“It’s important for moms to be sober. If they don’t pass that on to their kids, we’ll have generations of drug addicts or alcoholics,” she said.

Demand outpaces funding – Colorado program turns away thousands

In Colorado, the Nurse-Family Partnership is available to mothers in 50 of the state’s 64 counties, said Lisa Merlino, executive director of Invest in Kids, the group that implements the nurse visitation program in Colorado.

Funds in Colorado currently come from the tobacco settlement trust fund. This year, the fund will pump $13.4 million in nurse visitation throughout the state. The funds have been ramping up since 2000, starting at $2 million that year and slated to grown to $19 million by 2015.

So far, nearly 13,000 women in Colorado have benefited from the program.

“There’s a tremendous impact that we have seen from pregnancy to infancy to toddlerhood,” Merlino said.

But there are also long waiting lists. Since the program involves such deep and long relationships between the mothers and nurses, the program cannot begin to serve everyone who would qualify.

In 2009, for example, the Tri-County Health Department in the Denver area turned away 1,300 referrals to the program. Most are young, poor, unmarried and have no GED or high school diploma. On average, the mothers are 18 and on Medicaid.

Statewide, the program is able to serve about 2,640 mothers a year. “We’re seeing a very small percentage of the eligible population,” Merlino said.

That’s where federal funds from the Affordable Care Act could help the program grow.

In Colorado, the governor’s staff is leading the efforts to create a state plan and apply for the new federal grants. The minimum for which Colorado should qualify will be about $1.8 million. The funds step up over time.

Visitation advocates, like Merlino, are hoping that the federal government awards funds based on a competitive model, like the Race to the Top funding in education, rather than a straight per capita formula.

“We feel very confident that based on the historic work of Invest in Kids and the success of local departments of health that we can put forth a very competitive proposal,” Merlino said.

Colorado has one of the most advanced and widespread home visitation programs in the country. Pew’s national inventory shows that Colorado is spending far more than the national average in this area: $270 per low-income child per year compared with $170 per child nationally.

The Nurse-Family Partnership model is also expected to be popular as states ramp up their visitation programs both because of its 30-year track record of research and because it is the only federally-authorized program that begins when mothers are pregnant.

Merlino said it’s tremendously gratifying to watch graduate after graduate do well and to know that their children will do better in school, stay out of jail and ultimately will better nurture and support their own children.

“The vast majority of savings come when you keep kids out of the juvenile system at 15,” Merlino said.

The clinical trials continue to evaluate the long-term benefits to both mothers and children in Colorado, Tennessee and New York.

The short-term benefits are also dramatic.

“We have healthier birth outcomes and significantly higher immunization and breastfeeding rates. Because of all of this rich data, we know this saves us money in real time.

“The program is based on self-efficacy and empowering women for life. It’s not just a short term fix,” Merlino said. “We watch the women succeed and sail.”

Colorado advertises itself as a healthy state, attracting mountain climbers, skiers, and outdoorsy types. But new data finds that just because Colorado is lean, that doesn’t mean its entire population is healthy. The Colorado Health Foundation’s 2010 Report Card showed that the Rocky Mountain state is a health paradox — with a population of healthy adults, but unhealthy children. Read the PBS report.

If researcher Robert Lustig is right, then our excessive consumption of sugar is the primary reason that the numbers of obese and diabetic Americans have skyrocketed in the past 30 years. But his argument implies more than that. If Lustig is right, it would mean that sugar is also the likely dietary cause of several other chronic ailments widely considered to be diseases of Western lifestyles — heart disease, hypertension and many common cancers among them. Read the New York Times story.

By Sen. Shawn Mitchell

I see just a few problems with Senate Bill 200 to create a Colorado health insurance exchange: the policy, the drafting, and the politics. Otherwise, it’s a great idea.

Proponents argue exchanges will create an insurance marketplace where insurers and consumers can interact in an open and competitive market with convenient comparisons and easy shopping. Most activists for limited government and health care freedom see a different picture:  Lucy holding the football and beckoning gullible Charlie Brown for one more kick. There are good reasons for such wholesome pessimism.

Liberty activists start with the observation America lacks a free market in health care or anything close. Government has long been a major player in controlling, funding, regulating and delivering health care and insurance. Conservatives believe most the problems cited by critics of the “free market” are actually distortions introduced by government, either as original well-intentioned policies, or by ripple effects and new layers of regulation aimed at solving unintended consequences of earlier layers. Add inevitable rent-seeking (legislating for privilege and profit) by powerful interests in a complex industry, and our current ills are the foreseeable result.

Opponents fear that exchanges are just the next layer: a government solution to government problems. But it’s worse than déjà vu. Exchanges are likely to exacerbate the problem of political distortion. They concentrate heath care issues into a perfect little shooting gallery that will prove irresistible to politicians, bureaucrats and rent-seekers. The same crew that has brought us to our current woe now wants to create its own reality video game of health insurance. Government will build the stage so citizens can pursue happiness and health care.

Forgive my doubt. It’s kind of like the feeling of gun owners who oppose the government keeping them all on a list, or maybe Soviet era Jews being wary of going to government sponsored “sanctuaries” to protect them from “hostile factions.” I made that one up, but you get the point.

Here’s a better idea. Why doesn’t government pare back the distortions it inflicts in the real world, instead of trying to create a new and better playing field in a legislated world? Free choice in goods and services spontaneously creates some amazing “exchanges,” efficiencies, innovations and advances.

Which brings us to the drafting of SB 200. Advocates argue there are good and bad exchange designs. Some are too government-heavy and smack of single payer, while others are “free market” and supported by the “business community.” But SB 200 is very slight on substance and detail. It sets up a commission to design the exchange. Lobbyists at the capitol proudly announce the commission’s makeup is “business friendly.” Well, that’s not Rock of Gibraltar inspiring. Pharma and Big Insurance were right at the table passing Obama’s health care bill too, cutting deals and slicing pie. Now they’re reportedly quietly opposing repeal or roll-back, because the bill brings them big new controlled markets. Sometimes business has different priorities from defenders of freedom.

Further, there’s no escaping that exchanges are a cog in the machinery of Obamacare. States are mandated to make their own or be defaulted into the federal exchange. Proponents argue this proves we should pass SB 200 and establish a Colorado exchange rather than be governed by bureaucrats from Washington. But opponents see that acting now is submitting to the policies and the premises of Obamacare. If it’s established—and accepted—that Washington has the power and authority to control national health care and mandate the purchase of insurance, there will be no stopping the grab. To repeat, the same Congress, bureaucracies and rent-seeking interests that lurk in the real world will soon continue open season on the revenues, deal-making and headline opportunities that flow through exchanges.

That makes this a critical moment to push back. And Americans are, with substantial success. Referring to the politics of exchanges, I meant the effect on political outcomes. It’s not about posturing, but about helping to shape policy in Congress and perceptions in the courts.

One of the driving forces behind the turnover of Congress last election was public disgust at the naked power grab and bare fisted politics that punched Obamacare across the finish line. The fight is on to repeal or defund the federal bill, or to lay the groundwork for future elections over that issue. Twenty-six states have joined a lawsuit to seeking to overturn the federal abuse. Courts across the land are grappling with the weighty issues. Contrary to smug predictions, several have struck the law down in serious, thoughtful opinions. Now is not the time for citizens and states to salute and fall in line. While Congress struggles, as the Supreme Court weighs, political currents shape reality and make a difference.

As an individual and as a Coloradan, I want to be part of a vibrant spirit of reform and resistance in perhaps the most important public policy battle of our lifetime. SB 200 is a step toward surrender.

Sen. Shawn Mitchell is a lawyer and a Republican lawmaker from Broomfield.

I’ve been working around health care issues in general and patient safety issues specifically for years now, but it’s still an eye-opening experience when I interact with the health care system directly.

Recently, while my family was on vacation, my wife started experiencing intense lower back pain.  When she put the level of pain on par with the labor and delivery of our two children, I figured she was serious.

We visited a clinic and, while waiting the in the lobby, I noticed stack of brochures entitled, “Speak Up: Help Prevent Errors in Your Care.” It’s produced by the Joint Commission, an independent, not-for-profit organization that certifies more than 18,000 U.S. health care organizations and programs.  The Joint Commission states:

Everyone has a role in making health care safe.  That includes doctors, health care executives, nurses and many health care technicians.  Health care organizations all across the country are working to make health care safe.  As a patient, you can make your care safer by being an active, involved and informed member of your health care team.

I’ve learned through my work about the importance of patients or patients’ families or friends taking an active role in their care, but I was glad that this information was so readily available to others.

My wife was seen by the doctor, who prescribed a muscle relaxant and pain medication.  Driving away, she opened the first prescription and saw that it had half as many pills as the label said it should have.  Then she noticed that the second prescription had twice as many pills as label indicated.  It didn’t take much detective work for us to quickly determine that the medications were mislabeled.

We returned to the clinic and informed the staff of the mix-up, which was quickly corrected.  But what if my wife hadn’t counted the pills?  What if we hadn’t been active participants in her health care and had just blindly followed the instructions on the containers without considering that the clinic could have made an error?

Certainly, one would hope that the clinic would learn from this mistake and keep a mix-up like this from happening again.  But we’ve learned that we need to play a role too.

About the writer: Eric Anderson is a principal at the consulting firm, SE2.

This piece originally appeared on ThinkAboutItColorado.org, the online home of a public awareness campaign designed to spark a statewide conversation about patient safety and to drive reform in this critical area.

By Molly Maher

Getting to yoga class is not always easy for Diane Sieg.

“There are days I’d much rather hide my head than exercise or do anything else,” she said.

But for the public speaker, author and coach, physical activity is a balancing force in her life.

“I’ve always been involved in health and fitness because of my own issues around depression,” she said. “I learned at a very young age that moving makes me feel much better.”

Her background led her to develop a life-balance approach that includes consistent physical activity, like practicing yoga no matter how difficult it can be.

“It’s a hard road because people who don’t feel good don’t want to move,” she said. “We all have to remember what it is that keeps us going and moving in the right direction.”

She now brings this approach to coach clients of the Wellness Treatment Center, where people with depression, anxiety and other mental health issues are led through a six-step program based on the research of Dr. Stephen Ilardi, associate professor of clinical psychology at the University of Kansas and author of The Depression Cure.

Should we live more like our ancestors?

When Stephen Ilardi was majoring in math and economics as an undergraduate at Emory University, psychology was not on his radar.

Then, while volunteering at a psychiatric hospital, his curiosity led him to non-degree classes and eventually to graduate school at Duke University, where his interests shifted to the “bigger picture issue of depression.”

The big picture is bleak, with increasingly high incidence of depression and inconsistent results from anti-depressant medication.

“We have an epidemic that is burgeoning throughout most of the industrialized world and nothing we are doing seems to be making much of a dent,” he said.

This depression epidemic, which Ilardi notes is the single leading cause of medical related disability in the United States, is not a result of modern society’s higher self-awareness or of a culture of excessive complaining, he said.

Rather, it is at least partially a result of the disconnect between modern society and our hunter-gatherer past.

“There’s arguably been no selection pressure in post-agrarian society,” he said. “[Modern society] is badly adapted to post-industrial 21^st-century life.”

He and his research team set out to answer the question: Is it possible to create a successful depression treatment that returns some of these protective hunter-gatherer habits to an individual?

Once he’d identified that question, Ilardi said six different protocols quickly emerged as “robustly supportive” of good mental health. Among these is intensive physical activity.

Participants in his six-part program typically work out with a trainer, which Ilardi says can give them the extra motivation a person with depression needs.

Although sometimes participants may “feel like crap when they first start,” Ilardi said they usually feel better after a few consistent workouts.

“Virtually all of our patients have reported they actually begin to see some benefit,” he said.

Teen physical activity may lower chance of chronic depression

Dr. Andrea Dunn, senior scientist at Klein Buendel, a communications firm in Golden, first studied the effects of exercise on neurochemistry and depression by observing wheel-running rats in 1987.

Her research since then has tested the effectiveness of exercise as a depression intervention.

One research project addressed the results of different exercise doses on depression using methods similar to those used to study prescription drug treatments. The results showed that the dosage did not have as much effect as the frequency: exercise three times or more per week produced a positive response, whether it was a low or high dose of activity. The low dosage measured was the public health dose recommended by the American College of Sports Medicine.

Today, Dunn is conducting a study funded by the National Institute of Mental Health. The subjects are Denver-area teens and the objective is to determine ways to treat their depression before it becomes a chronic problem: DOSE (Depressions Outcome Study of Exercise) for Teens.

Dunn said typically depression begins in childhood or adolescence and patients wait four to five years on average to seek treatment. If a person suffers two or more episodes of depression, it likely will recur – if only episodically — for a lifetime.

Dunn’s study will include participants 12 to 21 years old who are not currently in counseling, though there are exceptions for those on anti-depressants.

The goal is to include 20 to 25 young people who will exercise regularly for 12 weeks. Researchers will use interviews and the Hamilton 17 Rating Scale for Depression to measure the level of symptoms throughout the process.

How physical activity treats and prevents depression

Exercise is generally accepted as a good thing for most people. It has been linked to lower risks of diabetes, cancer and Alzheimer’s.

Though casual enthusiasts long have claimed that there is a mysterious connection between exercise and happiness — the runners’ high, for example — more and more work like that of Dunn and Ilardi is drawing scientific connections between physical activity and mental health, particularly in treatment for depression and anxiety.

Dr. MacAndrew Jack, a faculty member in the Contemplative Counseling Psychology department  at Naropa University in Boulder, said that not only does exercise, even moderate levels like walking, activate reward endorphins that make you feel good, it also helps create a mind-body connection that leads to increased mental well-being.

“What’s going on in your mind is much more related to your body while you’re exercising,” he said, though he notes that the strength of the connection may vary. It may be less powerful when a person is on a Stairmaster watching CNN, for example, than if he is fully preoccupied with physical activity.

Jack, who researches breathing patterns and their expression of and influence on our emotional life, said that the limbic sensors connection to breath regulation are also connected to emotional sectors. Breathing becomes more entrained during exercise, which increases harmony in the brain, he said.

Jack also cited the ability of exercise to broaden a person’s perspective. Dunn said that depression causes a very narrow focus, something exercise expands.

Exercise helps induce nerve growth factors associated with mood and memory, and it encourages the release of endocannabinoids that can cross the blood-brain barrier, perhaps contributing to a “runners’ high,” Dunn said.

Similarly, Dr. Neil Weiner, the director of clinical services at the Depression Center at the University of Colorado Anschutz Medical Campus, attributes some of the psychiatric value of exercise to its effect on the hippocampus, where growth there increases the connectedness of neurons.

He adds that exercise often leads to other antidepressant results, like increased self-confidence and a sense of mindfulness.

Trends in physical activity as treatment in health care field

Research has found direct, positive results in lifestyle- and physical activity-based treatment programs.

Ilardi says the participants in his research, who represent a population with severe, chronic and treatment-resistant depression, have had about a 75 percent response rate.

Sieg said Ilardi’s plan has worked impressively at the Wellness Treatment Center, which is open to anyone interested in improving his quality of life.

“As long as they follow, they get better,” she said. “I’ve been amazed at the results.”

At the end of her 12-week study on adults, Dunn saw the participants’ scores on the Hamilton Rating Scale for Depression  drop a mean of 47 percent.

Dunn said that recently – after 25 years in the field — she has seen increased acceptance of the connection between physical activity and mental health.

“Trying to gain credibility with the psychiatric community, to have more respect from them…it’s taken a long time,” she said. “It seems sort of ridiculous, because the two are so inextricably linked.”

Weiner pointed out that the Cochrane Review, an industry standard for quality research, reviewed all studies related to physical activity and depression up until 2010. It showed that the majority of studies met basic research standards and their aggregate success rates were quite high, however only two studies met rigorous research standards, and their results were much lower.

No matter the status of research, Weiner says most therapists with extensive education around depression believe in the benefits of exercise.

Meanwhile, Ilardi has seen practical application of his research. He knows of least five treatment centers that use his protocols to treat depression, and more are reaching out to integrate it into their preexisting programs, a sign that there is recognition of alternative treatments for mental health issues.

“I think I’ve seen among psychotherapists a feeling of great openness when they hear me talk about the actual research and the potential for a lifestyle-based approach to depression,” he said. “Many feel empowered.”

Ilardi is married to a nurse practitioner in a psychiatric private practice. She integrates some lifestyle-based approaches, Ilardi said, but at least every other week she jokingly says, “You’re ruining my practice.”

Often her patients want to try something like his six guidelines before taking medication. If the exercise program is successful, her patients will need only one follow-up appointment and seek no further treatment.

He said his wife will make more from a session where she prescribes medication than from one where she does not. For her, the choice to use lifestyle approaches gives greater client satisfaction, making up for these economic factors.

In a prescription-based practice, “It’s crazy to adopt a lifestyle approach to depression,” Ilardi said.

Weiner said that the Depression Center regularly provides psychotherapy and behavioral activation therapy side by side.

Sometimes they are used in coordination with anti-depressants, and sometimes the therapies may not include strict exercise. Rather they may focus on mindfulness techniques, socialization or simple movement, like getting up to get the mail daily.

Patients need to understand that mild to moderate depression can have equal response rates from psychotherapy or behavioral therapy as from antidepressants, Weiner said.

“Patients should be educated about the facts of psychotherapy, of cognitive behavioral therapy,” he said. “We give the patients a choice.”

By Katie Kerwin McCrimmon

DENVER — House Majority Leader Amy Stephens, who may hold the future of Colorado’s health exchange in her hands, predicted Tuesday that Colorado lawmakers ultimately will support the online health insurance marketplace and said her coalition is not fractured.

“I’m thinking we can (get it through the legislature). I’m working really hard on adding clarity and answering some of the concerns of the bill. You have to do that. The Governor’s Office knows that and they’re very much with me,” said Stephens, R-Monument, who is sponsoring the bill in the House.

The exchange bill, SB 11-200, easily passed out of its second legislative committee Tuesday by a vote of 14 to 4, garnering support from all nine Democrats and five Republicans on the joint House-Senate Legislative Council Committee. All five Republicans who voted in favor of the bill are members of the House, which may bode well for ultimate passage.

The bill now goes to the full Senate, where it is expected to win approval in the Democratically-controlled chamber. Then it heads to the House, where Republicans dominate.

Senator Betty Boyd, during a lighter moment as her health exchange bill moved forward Tuesday. "I'm still true to our agreement," Boyd said regarding her coalition with Rep. Amy Stephens, who has zigged and zagged in recent weeks on her support for her own bill.

Stephens last week reversed her previous position and said she will not insist on amendments that would have required an opt-out of the Affordable Care Act. The opt-out is popular with some conservatives and Tea Party activists. It would have been a deal-breaker for Democrats, who defeated the amendments on a party-line vote in the Senate.

Stephens said Tuesday that the bill will need some tweaks before it passes the House, but said, “I don’t see it changing tons.”

“I think the bill as written is good policy. Sometimes you have to continue to work on your bill, particularly when you have the kind of stirred-up emotions that have gone on with it,” she said.

Sen. Betty Boyd, D-Lakewood, who is sponsoring the bill in the Senate, declined to comment on Stephens’ recent zigs and zags.

“I’m still true to our agreement,” Boyd said. “I will not answer for her.”

Stephens said she expects a tough sell with some House colleagues, who have been flooded with e-mails “full of grand conjecture” from Tea Party activists.

“There has been a lot of misinformation…and some extreme views about what the bill does and does not do,” Stephens said.

“One website had (our bill as) the full implementation (of the Affordable Care Act). You’re saying a 2,000-page bill from the feds is all locked up in little old SB 200? I don’t think so.”

Now that unrelated budget issues are close to resolution in both the House and Senate, Stephens said she can once again focus on the health exchange bill.

“Now we have a breathable moment.”