Health Policy Solutions

With the advent of new genetic tests, it’s increasingly easy to gauge whether you’re predisposed to developing certain conditions — diabetes, say, or breast cancer. For adults, that knowledge can be simultaneously overwhelming and empowering. Read the report from Time.

Most people would agree that donating an organ to someone in need is a selfless act. There’s no medical upside in giving up one of your kidneys or part of your liver, lung or pancreas. It’s a risk people take so that someone else — often but not always a loved one in desperate need — may live a better, longer life.

It’s said that no good deed goes unpunished, however, and living donors sometimes find themselves unable to find affordable — or any — health insurance after the fact. Insurers sometimes claim that the donation is equivalent to a preexisting medical condition and either reject an application outright or offer coverage with a very steep premium. Read full report from The Washington Post.

President Barack Obama said he challenged Republicans to try to repeal his landmark health care reform in private budget talks last week, taunting his opponents with a question: “You think we’re stupid?” Read entire story from Reuters.

Cancer cells are riddled with genetic errors, and each tumor has its own unique set of mistakes. Reading those errors, scientists believe, will help them not only understand how a tumor came to be, but also how best to poison it. Read full report from Los Angeles Times.

Emily Fennell, 26, last month became the first person in California to have the revolutionary surgery. Six weeks and many hours of therapy later, she has no regrets. Read more from Los Angeles Times.

The New York Times reports on President Barack Obama’s new deficit reduction plan. Read more…

By Diane Carman

Before he started medical school, Peter Marshall pictured himself as a surgeon.

“We had a family friend who was a surgeon. He introduced me to medicine and I worked for him in the summers,” he said.

Then one day while Marshall was studying at the University of Missouri-Columbia School of Medicine, he attended a lecture by a family medicine doctor who worked in a rural area.

“He was telling stories about working in that environment, and how you can make such a difference in the community,” he said.

The work was varied — delivering babies, doing minor surgical procedures, and treating children, the elderly and anyone who needed his care. “It stuck with me. I thought, ‘I can do that.’”

Dr. Peter Marshall

Fast forward eight years, and that’s exactly what Dr. Marshall is doing in Pagosa Springs. He landed there at least in part because of the Colorado Health Service Corps, which places health care professionals in medically underserved communities and provides tax-free loan repayment plans as part of the compensation.

Pagosa, as the locals call it, is 35 miles north of the New Mexico border and is nearly surrounded by the San Juan National Forest and the Weminuche Wilderness Area. It makes the community attractive to outdoors enthusiasts, but all that wild land on its outskirts means it’s isolated from urban amenities – including shopping, entertainment options and comprehensive health care facilities.

State program expanding

The Colorado Health Service Corps has grown dramatically from a program that contracted with four to six health care providers a year for the past 20 years to one that will contract with about 100 in 2011.

“The state program has always been fairly modest,” said Stephen Holloway, director of the primary care office of the state Department of Public Health and Environment. “It used to be less than $150,000 a year. In 2011, we expect to grant about $3.8 million, so it’s a significant expansion.”

The growth was made possible by an innovative public-private partnership and an infusion of federal matching funds under the Affordable Care Act, Holloway said. “It occurred to me a couple years ago that really any source of non-federal dollars could be used for the federal match.”

So he developed relationships with the major health foundations in Colorado, including the Colorado Health Foundation, the Colorado Trust and the Comprecare Foundation, to boost the state investment. The state budget includes $120,000 a year for the loan repayment program.

Need still not met

Despite the growth of the program, Holloway said the need for health care providers across the state remains acute.

“About 85 percent of the land area (including areas in 54 of 64 counties) of Colorado is a designated health care provider shortage area.”

Those are anything but random designations. To be determined a health care provider shortage area, a region is found to have insufficient providers to meet even minimal standards of care. “The standards are pretty high,” he said.

A typical family practice physician in, say, Douglas County would serve about 1,500 patients, Holloway said. In contrast, to be designated an underserved community, generally the ratio of doctors to patients is one to 3,000 or 3,500.

In addition to physicians, the program also provides for placement of dentists, dental hygienists, nurse practitioners, physicians assistants, psychologists, social workers, psychiatric nurse specialists, licensed professional counselors and certified nurse midwives.

House Bill 1281 would expand the program to provide student loan forgiveness to qualified nursing faculty members who would agree to provide nursing education programs in medically underserved areas in the state.

The primary regions of Colorado that are not designated underserved, Holloway said, are the Front Range urban areas and the resort towns in the mountains. The areas with the most acute needs are in the San Luis Valley, the southeastern plains and portions of Adams County near Commerce City.

Opportunities benefit young providers

While people in the rural underserved areas look at the Health Service Corps program literally as a life-saver, for many health care providers entering the field with six-figure student loan debts, it can mean the difference between eking out a living until their debts are retired, and being able to buy a house and start a family.

“It’s a pretty enticing deal,” said Marshall. “It doesn’t completely wipe out my loans from medical school, but the vast majority will be wiped out.” Marshall was eligible for $35,000 in medical loan reimbursement a year for three years under his contract. His total student loan debt was in excess of $125,000.

Holloway said the maximum benefit is $50,000 of loan reimbursement per year for three years. The average cost of a physician’s education is $150,000 to $200,000, he said, “which is like having a mortgage.” It’s a key reason why medical students gravitate to high-paying specialties, such as dermatology or orthopedic surgery, and away from primary care medicine.

“A family practice provider generally makes $130,000 or $140,000 a year compared to $400,000 for a general surgeon,” Holloway said, so it takes a lot longer for a primary care doc to retire those debts.

Town benefits from program

The value to the town of Pagosa Springs is “absolutely huge,” said Town Manager David Mitchem. “He will see approximately 4,200 patients here over the course of a year, and that means people don’t have to travel a long distance to get their medical care. It’s a great value to the community.”

Pagosa Springs is a town of about 1,800 residents that, at many times in its history, has lacked sufficient numbers of medical professionals. All of Archuleta County has only about 12,000 residents, Mitchem said, so the surrounding area is rural and not likely to attract physicians pursuing specialties or high-income careers.

“We’re really blessed that this program has brought Peter to the community,” he said.

Long-term commitment the goal

The Health Service Corps is not satisfied with merely placing health care providers in underserved areas for three-year stints. “We actively try to work against that,” said Holloway.

The program managers try to recruit health care providers who are likely to put down roots in the rural communities and stay there. They look for applicants who grew up in Colorado or got their training here; persons who may have experienced life in an underserved community; or those who demonstrate a passion for serving low-income clients.
Then they maintain close contact to resolve problems that might arise.

When a physician in a rural area faces challenges like a tremendous on-call burden, long hours and a really broad scope of care, “there’s a risk of burnout,” said Holloway. “We try to anticipate that and if we detect a challenge, we look at ways to strengthen the professional network or find educational opportunities to ease the stress.

Stephen Holloway

“I’m proud to say we’re high-touch with providers.”

At the same time, they work to attract and cultivate good employers for the Health Service Corps providers. Among the factors that can keep health care workers in communities after the three-year contracts are whether a spouse was able to find a job, if their children are happily incorporated into the community and whether the provider has support from colleagues and other medical professionals.

Holloway said the program surveys providers as they begin, during the middle of their service and when they leave. He plans to add surveys in the fifth year to determine why health care workers stay in underserved communities.

Making the Health Service Corps work will be a high priority as the Affordable Care Act is implemented. “If we assume that health care reform is going to stay on track over the next five years … we expect to see a bulge of new demand for care,” Holloway said.

Many of the previously uninsured people have chronic conditions that will need extra attention.

Commitment a personal decision

Peter Marshall said he’s enjoying the experience in Pagosa Springs, but he is trying to be thoughtful about his career. His workload is intense with about 60 hours a week spent seeing patients at the clinic at Pagosa Springs Medical Center plus rounds at the hospital there. But the environment has a lot of appeal.

“When I have time off, I enjoy being outside,” he said. “I find it recharging and rejuvenating. Hopefully things will work out and I’ll end up being in Pagosa a long time.”

Marshall’s wife, a nurse, works part time at the small hospital in Pagosa Springs and picks up additional work at the hospital in Durango, about an hour away.

Marshall grew up in Missouri, but did his undergraduate work in Colorado where he got hooked on the outdoor lifestyle here. He returned to the state to do his residency and, when the opportunity arose to move to Pagosa Springs and retire his student-loan debt, he and his wife took the leap.

“We both like it here. It’s a really pleasant community. People are really appreciative that a younger couple would come to a small town and settle down,” Marshall said.

That appreciation alone is worth a great deal to the young physician. “When it comes to a career, it’s a lot different from clustering in the city and competing with other doctors for business.”

In Pagosa, he’s a familiar face around town.

“It happens a few times a week, people come up to me and say, ‘Thank you for coming here.’ They really worry that they won’t have medical care close by,” he said.

By Katie Kerwin McCrimmon

The future of health insurance in Colorado is as unpredictable as the House majority leader.

If Rep. Amy Stephens, who is the Republican co-sponsor for Colorado’s health exchange bill, continues to frustrate her colleagues with her frequently changing tactics  on health reform legislation, Colorado’s health exchange could be DOA.

If that happens, Colorado would have three options: Gov. John Hickenlooper could create an exchange by executive order; Colorado could do nothing and the federal government will automatically create and run a Colorado exchange; or state lawmakers could punt the issue to next year’s legislature when an election year may make the issue even more partisan.

Establishing a framework for Colorado’s health exchange was not expected to be controversial. The exchange will be an online system where uninsured individuals and small business employees will be able to shop in real time for health insurance by Jan. 1, 2014.

Business leaders have been huddling with consumer advocates for months working out the details. There was hardly any opposition at the first hearing in the Senate. Then, the bill got snagged in Tea Party politics and the national debate over the Affordable Care Act.

For those who haven’t followed the Colorado health exchange drama, here’s a recap of the recent plot twists.

Sen. Betty Boyd, D-Lakewood, and Rep. Stephens of Monument are co-sponsoring SB 11-200.

But weeks before she was slated to co-sponsor the exchange bill, Stephens co-sponsored the HOPE Act, which would dismantle health reform in Colorado. Health exchanges are required under the Affordable Care Act and are seen as the first step toward implementing the act. Therefore, Stephens’ support of two conflicting measures was puzzling.

Analysts suspected that Stephens introduced the HOPE Act to give her cover with the most conservative members of her party, whom she has said have “extreme” views on exchanges. Other Republicans think exchanges, which were first proposed by George W. Bush, are the most free-market element of the Affordable Care Act.

The HOPE Act didn’t protect Stephens. Some Tea Party activists in Colorado Springs became enraged with what they saw as promotion of “Obamacare,” their name for the Affordable Care Act.

So, on the day when the exchange bill was being heard for the first time in the Senate, Stephens seemed to torpedo her own measure when she sent out a letter insisting that she would no longer support the bill unless it stipulated that Colorado would “opt out of Obamacare.”

That’s a deal-breaker for Boyd. The bill appeared to be dead.

The latest development came on Tuesday when Stephens told the Denver Business Journal that she would no longer insist on the “opt-out” amendments. But she said she wanted some kind of language that would “decouple” Colorado’s exchange from the Affordable Care Act. A coalition of five business groups released a letter Tuesday supporting a Colorado-run health exchange. Their pressure may have sparked a renewed commitment from Stephens for her own bill. But, time will tell. The legislative session has weeks left, leaving Stephens time to reconsider yet  again.

A health exchange by executive order?

So, what will happen if the Colorado Legislature fails to create its own exchange?

Hickenlooper may have to follow Indiana’s lead and create Colorado’s health insurance exchange by executive order. Indiana Gov. Mitch Daniels set a precedent for other governors by signing his executive order in January. An opponent of the Affordable Care Act, he nonetheless decided that Indiana needed to move forward with implementation of its own exchange.

“The nation will be best served by the repeal of this expensive and unworkable law, or by its judicial overturn,” Daniels told NWITimes.com in Indiana. “But for now, there seems no alternative but to prepare for the possibility that Indiana will try to operate an exchange of some kind.”

Louisiana officials simply decided to return the cash and have the federal government run their state’s exchange. California is quickly building an exchange, while Utah and Massachusetts already have insurance exchanges. (Both may have to change their exchanges to comply with requirements under the Affordable Care Act).

Altogether, according to the National Conference of State Legislatures, 180 health insurance exchange bills are pending in 44 different states. Click here to see status updates in various states.

Here in Colorado, Hickenlooper and his health policy experts declined to comment for this story.

A  Democrat in a purple state, Hickenlooper is saddled with a divided legislature. Democrats control the Senate while Republicans control the House. All along, advocates for a Colorado health exchange tried to build a bipartisan coalition. Exchanges have been popular among some Republicans who want to boost competition and reduce health insurance costs for small business owners.

Another option aside from an executive order would be waiting until the 2012 legislative session. But, that is an election year and partisan rancor is likely to be even more pronounced. What’s more, analysts say a delay could be costly. Without a framework for a Colorado exchange, the state will lose federal planning grants. And, waiting a year could put the state far behind in building the complex tool, which must give consumers instant, real-time health insurance quotes or determine immediately if they qualify for public health insurance programs like Medicaid.

“It’s conceivable that a state could do it all at the last minute. But there are a lot of complicated moving parts here,” said Lee Goldberg, health policy director at the National Academy of Social Insurance, a nonpartisan think tank in Washington that has created a toolkit for states to provide information on how to build health exchanges.

Trend in other states: establish an exchange while fighting health law in court

Failure to pass a bill this year would create a very tight timetable.

“It puts a lot of pressure on the state in 2012,” Goldberg said. “The Massachusetts exchange is still evolving and being tweaked. It took them a good three or four years to get their exchange.”

Goldberg said even in states where opposition to the Affordable Care Act is fierce, most leaders are moving forward with exchanges.

“In Virginia, where their attorney general has led the charge against the law, they’re figuring out their exchange,’’ he said. “I would say a lot of states are officially opposing the Affordable Care Act, but they’re contingency planning and they’re trying to figure it out. If the (health law) is considered constitutional, they don’t want the feds running it and they won’t pass up the federal aid.”

Gov. Haley Barbour is another vocal opponent of the health law.

“He can’t stand the ACA, but the only thing he hates more is if the feds did it,” Goldberg said.

Defaulting to a federally-run exchange is an unpopular idea here as well. In a written comment from his spokesman, Michael Amodeo, U.S. Sen. Michael Bennet, a Democrat, said he wants Coloradans to work out their own state’s exchange.

“Sen. Bennet is hopeful both parties will come together to craft an exchange from the bottom up that provides Coloradans quality health care choices at an affordable price.”

And Bill Lindsay, a health expert, chairman of the Denver Metro Chamber of Commerce and president of Lockton Benefits Group in Denver, has a message for fellow Republicans.

“They are fighting the wrong battle. (Rep. Amy Stephens) was under tremendous pressure from people who said that anything you do that would appear to be supporting the President’s plan is not a place where Republicans ought to be. But what they’re missing is, what’s the alternative if we don’t act? A federally controlled, federally mandated program. That’s a much worse outcome,” Lindsay said.

“Unfortunately all of this has now devolved into a discussion of political ideology as opposed to saying how do we fix the health care and insurance situation we have in the United States,’’ Lindsay said. “I think that’s unfortunate.”

Colorado needs its own exchange

Lindsay believes Colorado needs to get moving on its own exchange now.

“We want to have a solution that is unique to Colorado,” Lindsay said. “It’s hard to do it quickly and not make mistakes. We need time to be deliberative. No one’s ever done this before.”

Lindsay, who has worked for years as a health insurance broker and served on Colorado’s 208 Commission for Health Care Reform, said Colorado’s needs are different than those elsewhere. For instance, most of Colorado’s uninsured people are individuals. Many work as contractors or freelancers. If Colorado establishes its own exchange, the state can also start by serving small businesses with 50 or fewer employees. A federal exchange would mandate Colorado to open the exchange to many more businesses, including those with 100 or fewer employees.

Lindsay believes Colorado will do better to figure out the system first, then add more potential clients.

As for an executive order, he thinks Gov. Hickenlooper may have to resort to that,  but it’s not ideal.

“He could have done that from the beginning. But, with this concept, you really want to have bipartisan support,” Lindsay said. “If he just signs an executive order, that makes it really difficult for him politically.”

Our bodies have an amazing capacity to freak us out. Maybe it’s a twitch that you’re sure means multiple sclerosis . Or a little mark that must be cancer.You could Google symptoms for days—and now your pulse is racing, so you can look that up, too. Unless you have a heart attack first…Whoa! Step away from the keyboard. Most twitches, bumps, and pops are actually harmless. Here’s when to see a doctor—and when to just relax. Read the entire report from Fox News.

You don’t have to be a Buddhist monk to experience the health benefits of meditation. According to a new study, even a brief crash course in meditative techniques can sharply reduce a person’s sensitivity to pain. Read full story from Health.com.