Health Policy Solutions

By Katie Kerwin McCrimmon

Gov. John Hickenlooper vetoed Senate Bill 11-213 on Tuesday, saying that the bill, which would require families to share the cost of their children’s health care under the Child Health Plan Plus program, would negatively affect access to health insurance for a vulnerable population.

“Expecting low-income families in Colorado to contribute when it comes to providing for, and placing a priority upon, their health care, makes sense,” Hickenlooper said in a letter to the General Assembly. “What is troubling about this legislation, however, is not the policy intent, but the practical, and negative impact, it will have on children in low-income families.

His veto came on heels of release of a study that found that parents at all income levels are deliberately going without or delaying medical care for their children as health costs rise.

“Families aren’t choosing to spend their money on going to the doctor when someone is sick because of how much it cost them to see the doctor last time,” said lead researcher, Lauren E. Wisk, a doctoral student and graduate research assistant in the School of Medicine and Public Health at University of Wisconsin, Madison. “They’re sacrificing their health because it costs too much to be healthy.”Once medical costs exceed 10 percent of family income — regardless of how high that income is — the analysis shows that people across the U.S. are either forgoing or postponing medical care.

Even families with health insurance are skipping care.

Wisk unveiled the study results during the annual meeting of the national Pediatric Academic Societies in Denver this month.

The concept of rationing health care has become a hot topic as Republicans and Democrats spar over how to rein in health costs as they debate U.S. Rep. Paul Ryan’s controversial proposal to change financing for Medicare. While policymakers argue over rationing, it’s clear that families poring over bills at kitchen tables are already rationing care for themselves.

“Whether or not we think we’re doing this on a policy level, people are doing this on a family level,” Wisk said. “Some people are making hard choices. We’re seeing health care rationing because costs are high and people’s incomes are not rising as fast.”

Under SB 11-213, families of four earning about $46,000 to $56,000 per year would have had to pay new monthly insurance premiums of $20 for their first child, $10 each for additional children and a maximum of $50 per month.

Hickenlooper said he would work with the legislature to develop a better cost-sharing plan and present it to the Joint Budget Committee by Nov. 1, 2011.

“The focus will be to implement a change that is minimally disruptive, administratively efficient, effective and elegant, and supports the goal of ensuring that kids have access to coverage,” he said in the letter.

Opponents of the measure argued that the bill wouldn’t save the state significant money and would cause about 1,500 families to drop CHP+ for their children. People who are uninsured often seek care in emergency rooms where health costs are highest. Proponents of the measure say that families should care enough about their children’s health to share in the cost of public insurance programs. Some proponents say families who earn $50,000 per year are spending some money on luxuries like movies, flat screen televisions and alcohol, and should be required to contribute to rising health expenses.

For her study, Wisk and fellow researchers used data from 6,273 families across the country with at least one child. The data are weighted, meaning that each family statistically represents others, so the results equate to a survey of nearly 12 million families in every geographical region of the country. The Medical Expenditure Panel Survey includes data from 2001 to 2006 prior to the Great Recession. Since then, health costs have climbed while many families have suffered lost jobs or declining wages.

Wisk is planning to continue the study with newer data as it becomes available, and she expects to find even more pronounced results.

“I imagine that we’re going to see more families have delayed or forgone care,” she said.

Among the key findings:

• At all income levels, once health costs rise above 10 percent of income, families are 40 percent more likely to delay or skip seeking health care.
• When a parent’s health insurance is intermittent, family members are more likely to delay or do without medical care.
• Families do better at obtaining health care when all family members share the same health insurance plan. (Programs like CHP+ in Colorado serve as safety nets for children and insure them separately from their parents. Wisconsin has a model called BadgerCare+ that enrolls parents and caregivers in the same insurance program.)
• Having a child with ongoing “activity limitations,” which can range from obesity to asthma, diabetes or autism, increased the likelihood that families skipped or delayed care.
• Rationing strikes people at all income levels. But, the poorest families were more likely to delay or go without care than families at or above 400 percent of poverty levels. (A family of four with an income of about $88,000 per year would be at the poverty level.)

Wisk has been particularly interested in “spillover effects.” If a family is dealing with a child who has a severe illness, caring for that child can lead other family members to delay or skip care.

“The well-being of one family member can affect the health and well-being of the whole family,” she said. “It’s unfortunate. People have to pay a lot of these costs. Especially when you have catastrophic events, people have to make choices. They have a certain amounts for housing, food and utilities. There’s not a whole lot (of income) that is flexible. Sometimes people are making sacrifices in terms of actually going to the doctor.”

Wisk said that policymakers across the country are considering cost-sharing measures like the Colorado measure. She plans to follow up by looking at exactly what happens when people delay or skip care. Does their health suffer?

“It’s tricky,” Wisk said. “Cost-sharing seems like a good way to finance these programs. But increasing the costs even a small amount could be a significant burden to families.”

By Bob Semro

In an earlier column, we discussed the Ryan budget plan and its broader implications for health care and the Affordable Care Act. Here, we focus on Colorado and its potential impact on Medicaid.

Even supporters of the budget plan, dubbed the Path to Prosperity by Rep. Paul Ryan, R-Wis., say that it is not likely to become law. It overwhelmingly passed the House in April but was rejected in the Senate on Wednesday. However, it remains the Republican blueprint for the budget, and changes to Medicaid funding are a key component.

In 2010, 526,200 Coloradans received health coverage through Medicaid, and that number would surely decline under the Ryan budget plan, primarily by funding Medicaid through block grants and by dismantling the Affordable Care Act, which expands Medicaid eligibility for American families. (Nationally, 31 million to 44 million fewer Americans would be eligible for Medicaid under the Ryan plan.)

For Colorado and other states, a key component of the Medicaid structure is the maintenance-of-effort requirement, or MOE.  The MOE is a federal guideline that prohibits states from reducing Medicaid eligibility levels or setting more restrictive enrollment requirements that would make it more difficult for people to enter the Medicaid program.  In January, in a development unrelated to the Ryan budget plan, 28 state governors (not including Gov. John Hickenlooper) petitioned the president to remove those maintenance-of-effort requirements.

Here’s a snapshot of some of the Coloradans served by Medicaid in 2010:

• 51,100 Colorado seniors received health coverage through Medicaid; that represents. 9.3 percent of all seniors in the state.
• 85,700 Coloradans with disabilities received health coverage through Medicaid; that represents almost 29 percent of all residents with disabilities.
• 9,610 Coloradans who are nursing home residents are covered by Medicaid; that represents 59 percent of all Coloradans in nursing homes. In our state, the average annual cost for a semi-private room in a nursing home is $72,300. That cost will only increase over time.

Under the national Affordable Care Act and Colorado’s Health Care Affordability Act of 2009, an additional 339,200 Coloradans, the large majority of whom are likely to be uninsured, will be eligible for health coverage under Medicaid by 2020. Currently, the cost of treating uninsured Coloradans is passed on to those businesses and individuals who have health insurance. Without the national health care reform law, insured Coloradans would continue to pick up the tab – paying an additional $1.8 billion by 2020.

Opponents of the Affordable Care Act contend that the Medicaid expansions will force Colorado to take on a heavy financial burden. There will be extra costs, but the state is not responsible for the entire price tag. The federal government will cover the full cost of the expansions until the end of 2016.  In 2017, states will be required to cover 5 percent of the Medicaid expansions.  That percentage will increase annually until the state’s contribution reaches 10 percent in the year 2020. In terms of actual dollars, Colorado would pay an estimated $72.5 million (not including the hospital provider fee) to cover thousands of Coloradans, most of them uninsured, in 2020.

Should the Affordable Care Act be repealed, Colorado would face three options:  pay the entire cost of covering that population, cover a smaller number of people, or not cover any at all, leaving thousands uninsured.  In the first case, Colorado would need to absorb the entire $1.67 billion cost. In the latter two cases, some of the cost of uncompensated care would be passed down as a hidden tax to providers, businesses and individuals.

If Medicaid funding were reduced to block grants and if federal MOE requirements were eliminated, benefits for almost 137,000 seniors and people with disabilities, as well as the other 389,000 Coloradans in the program, would be put at risk.  While Medicaid block grants would be less costly at the federal level, costs would certainly be transferred to the states.

According to the non-partisan Congressional Budget Office, “Federal payments to states under the (House block grant) proposal would be significantly lower than under current law.”  In order to maintain current Medicaid service levels, states would need to consider reducing spending in other areas, reducing benefits, limiting eligibility or cutting payment rates for doctors, hospitals and nursing homes. If federal maintenance-of-effort requirements were eliminated, states would likely meet those additional financial burdens not only by reducing benefits but by making enrollment in Medicaid more difficult.

Balancing the budget in this way doesn’t reduce or eliminate costs, it merely shifts the burden. The bottom line is that vulnerable people who can’t afford insurance coverage will pay for it with their health, and people who are insured and businesses that cover their employees will pick up additional costs in the most expensive way possible – emergency room care.  Strategies like these don’t solve problems they just pass them on.

Bob Semro is a policy analyst at the Bell Policy Center, a nonprofit, non-partisan policy research center based in Denver.

By Charles Reyman

When you receive services from health care professionals, would you rather be treated as a “person” or as a “customer”?

I ask the question because words matter. When we apply this simple principle to managing our own health, words – the raw materials that help build innovation and influence behavior – take on particular importance.

In matters of health, where meaningful human interaction is critical, the words we choose to frame that interaction matter. The current vocabulary of health uses words like “patient” or, as a more recent health care manifestation of who we are as Americans, “consumer” or “customer.”

While perfectly appropriate in many cases, these now commonplace word choices fail to capture the full scope of what’s at stake when seeking medical care. What they succeed in doing, however, is to help perpetuate a familiar scenario: We go to a doctor’s office, clinic or hospital to receive health services we’re told we need by the professionals who work there.

While there, we, as “patients,” and all that word implies, assume the passive role of bystanders to our own health. After all, “patients” don’t ask questions or challenge authority in any of its health care forms. “Patients” don’t engage in their own health. “Patients” simply go along quietly for arguably the most important ride of their lives, just as they have done for much of this nation’s history.

On the other hand, references to “consumers” or “customers” position health as a mere commodity to be purchased like this month’s latest flat screen. As the Nobel Prize-winning economist, Paul Krugman recently wrote in his New York Times column, “There’s something terribly wrong with the whole notion of patients as ‘consumers’ and health care as simply a financial transaction.” That transactional vocabulary, according to Krugman, has been a contributing factor to people assuming the role of health care “consumers” and “customers.”

And if words indeed drive behavior, then health care “consumers” do exactly what the word implies – they consume, drive demand, and increase costs in the process. As Krugman wrote, “The idea that all this can be reduced to money — that doctors are just ‘providers’ selling services to health care ‘consumers’ — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.”

Here at the Colorado Health Foundation, we’ve made the editorial decision to substitute the word “person” or “people” or “individual” for “patient,” “customer” or “consumer” in the information resources we’re responsible for. We do so to encourage repositioning people in the driver’s seat of their own health and to help de-trivialize this most important of human interactions.

Our hope is that, over time, we can contribute in a small way to the building of a new health care vocabulary, one that captures the importance of personal involvement and that accurately speaks to the sheer scope of the issue.

And we do so because words matter.

Charles Reyman is vice president of communications for the Colorado Health Foundation.

By Katie Kerwin McCrimmon

The Somali women gather in the living room of a townhome in Denver’s Lincoln Park neighborhood, just across Colfax Avenue from the Auraria Higher Education Center. The scarves on their heads shimmer like the nearby downtown skyscrapers on this Saturday evening in May.

The host has created a centerpiece of lemons in a glass vase and will serve dinner to her guests, an iconic American meal: pizza.

Some of the women have brought their children. One cuddles a month-old baby, her seventh child. The host has both a self-assured college-aged daughter, who is studying at Colorado State University, and a toddler daughter, who happily jumps from lap to lap. A 10-year-old fourth-grader sits next to her mom, eyes wide as she takes in the chatter.

The gathering of about a dozen people feels like a small party or an informal book club meeting until the guests of honor start speaking.

“You have to watch your men and your teenagers,’’ says Zahra Kulane as she discusses the key topic for the evening — HIV.

Kulane has lived in the U.S. since 1993 and has been training for two years in Denver to work as a community health outreach worker. Her husband owns a successful Denver restaurant and she has lived here far longer than most of the other women. She speaks excellent English and knows her way around the community.

Each month, Kulane and her fellow community health workers attend training sessions to increase their knowledge of health issues. Some are also studying to become nurses or to work as certified nursing assistants. Each month, they hold small gatherings, like this one, with friends and friends of friends to spread the word about a concept that is new to most of these refugees and immigrants: preventive health care.

Back home in Africa, many people only visit a hospital or see a doctor if a family member is dying. The concept of preventive health care or screenings for early detection of diseases like cancer of the prostate or breast  is a foreign concept to many new immigrants.

Altogether the 14 community health workers speak 20 languages. They get paid small stipends each month for both the training classes they take and the ones they teach. On this night, Kulane makes her presentation in Somali. Her topic this month is HIV, although she tells the guests ahead of time that it’s a general health talk. She doesn’t want to scare them away.  The workers have studied a variety of health issues from obesity and nutrition to cardiovascular disease, diabetes and breast, cervical and prostate cancer.

Assisting Kulane for her May program is Dr. Oumar Ouattara. A doctor from the Ivory Coast, he came to the U.S. in 2004 and earned a masters degree from the Colorado School of Public Health. He now heads the health outreach program for the Colorado African Organization, a Denver nonprofit that supports African refugees and immigrants throughout the state.

After Kulane talks, Ouattara holds up a chart from the Centers for Disease Control with a disturbing bar graph. It shows the rates of new HIV infection by race and ethnic group in the U.S. Stretching way beyond any other line is the bar representing black men, both those born here and African immigrants.

HIV rates among black women also far outpace infection rates for white or Hispanic women. According to the CDC, blacks accounted for nearly half of all people living with HIV and 45 percent of those with new infections. The rate of new HIV infections for black men was six times as high as that of white men, while black women are nearly 15 times more likely than white women to contract HIV.

In Colorado, African women are at even greater risk than men. Of the 59 new HIV cases documented among immigrants from Africa between 2005 and 2010, 32 were among women, while 29 were among men. Nearly half of those new cases emerged among Ethiopians, the African immigrant group that has been in Colorado the longest. Many African societies are patriarchal. The wealthier the men, the more likely they are to have multiple sex partners, says Kit Taintor, executive director for CAO. The behavior among men puts their women in great danger for contracting HIV.

“The highest risk factor for HIV is being an older married woman,” Taintor said.

That makes outreach to women especially important. At the evening gathering, Ouattara delivers a message that he hopes the women will spread among friends and family members.

“HIV is just like diabetes in America. It is a chronic disease. If you take medication, then you can live with it,” he said.

Studies that CAO and others have done show that Africans both here and back home believe that HIV will kill them.

“They see it as a death sentence. If you have a death sentence, why would you want to get tested? If they know something is wrong, many will not go to the doctor until death is knocking,” Taintor said.

Ouattara and the community health workers are working to turn that attitude upside down. Again and again, their message is clear: get tested, get treated, prevent additional infections. People can live with HIV and AIDS.

Zahra Kulane holds a fellow community health worker's daughter during a tour of an Aurora clinic where immigrants can get free HIV tests.

Kulane delivers her kicker.

“Early detection is important. You can test for HIV even before there are symptoms. Every six months, go check,” she said, telling the women exactly where and how they can get themselves tested and encouraging them to urge their husbands or teens to do the same.

At this point, the conversations in the room take off. The women are abuzz about HIV and their thoughts about their husbands and other men in the African immigrant community.

“They are reckless,” says one woman. There is a sense among these women that many men both in Africa and here in the U.S. have sex with multiple partners even if they are HIV-positive. The women are clearly angry that some men knowingly infect their wives.

Still, in Somalia, Zahra Adam says a woman wouldn’t dare ask her husband to be tested.

“You’d get divorced right away if you said anything to your man. They get offended. They are very arrogant,” she said.

But, with her young daughter at her side, she says she’s sees African women changing their attitudes once they arrive in the U.S.

“Here the women have more power,” she said.

A model borrowed from the Latino community

Two years ago, Taintor of CAO and others were brainstorming about how to better spread key health messages among African immigrants, especially women. CAO had done some health education lectures in formal settings, but they found that men filled the rooms. They needed a way to reach more women and looked to programs that have been used to combat diseases like diabetes among immigrants from Mexico.

The idea of training women to be lay community health workers is called promotores de salud and is used in Colorado and across the country at clinics that serve Spanish speakers.

Not only does the concept help boost health education, it may also encourage more people from minority communities to enter health fields where shortages are expected to worsen sharply in coming decades.

Spreading information through word-of-mouth is also quite common in Africa, said Taintor who has lived in Malawi and Uganda.

“The best messages are going to be oral and through women. They’re the caretakers of the family. They talk amongst themselves and they’re the backbone of the family and the country,” she said.

The same method works well for immigrants who are not yet fully integrated into their new homes. Taintor estimates that there are now about 35,000 African immigrants in Colorado, nearly all of whom live in Denver. The population has grown by about 300 percent over the past decade. But it’s not easy to reach people. Funding for the community health workers comes from the Colorado Department of Public Health and Environment, which has spent about $70,000 on the program.

“They don’t listen to local radio stations. Often they’ll have music streaming online or will tune in to Al Jazeera for news,” Taintor said.

The diverse languages among African immigrants, who come from as many as 55 different countries, can also be a stumbling block. That’s why Taintor and Ouattara have deliberately sought out health workers from multiple countries who speak so many languages.

More than once, the health experts have found that political squabbles from Africa have affected gatherings here. For example, one of the health workers tried to set up a meeting for a discussion on prostate cancer in the Eritrean community. She had done a home presentation and it was so popular that members of the community asked her to give the presentation again for a larger audience. But, a flare-up between rival Eritrean factions prevented the second talk.

Holding small sessions in homes has worked especially well. Sometimes the health workers struggle to get women to come to their talks because they are so busy. Feeding them a good meal is key. Some of the health workers cook traditional African meals, but they seldom can afford an extravagant meal since they only get $30 in reimbursements and receive low monthly payments for their outreach work.

Preventive care a new concept for some immigrants

An evaluation of the program found that both the health workers themselves, and members of their audience are boosting their knowledge of key issues.

“Both the community health workers and community participants were beginning the process of reexamining many of their ideas about health and nutrition. The health workers expressed increased confidence about presenting information to their community and felt a strong sense of satisfaction and accomplishment,” the evaluators wrote.

“People are asking all these great questions and everyone is feeling empowered by the information,” Taintor said. “Opening the door to having these conversations is huge.”

In the future, Taintor is hoping that the health workers can play a bigger role serving as navigators who can accompany patients to doctors’ visits and help them understand the culture of U.S. health care.

“There are so many issues: access, lack of transportation and language barriers. I will hear of people who show up at a clinic and wait for two hours, then say, ‘the receptionist was mean to me.’ For many of these people, going to the doctor is not an enjoyable experience. They do not see it as worth taking time out of very busy lives to go. We’re brainstorming about how to handle that,” Taintor said.

Little by little, however, the concept of preventive care is trickling through the community.

“When we grow up here, we learn about cancer and preventive health,” Taintor said. “In Africa, children learn about malaria and cholera. The community health workers are providing a basic education so (immigrants) can learn about preventive care. Once they move here, malaria is not going to kill them, but diabetes might.”

In the past, if an immigrant women saw a flyer for a free breast cancer screening at her mosque, she might not have understood what it meant or how it related to her. But, after hearing a presentation on breast cancer from a community health worker, that same woman might follow through and get a mammogram.

Nike Kotun is one of the community health workers. She moved from Nigeria three years ago and is now studying at Metro State College to get a Bachelor of Science in nursing.

During one of the training sessions for the health workers, she and the other women toured a clinic called It Takes a Village in Aurora. The clinic offers free HIV and STD testing and counseling. They then take their knowledge and pass it back to people in their communities. Another training session focused on trauma. Many of the refugees have dealt with rape or war.

“Telling our stories is one of the most helpful things we can do,” said Lauri Benblatt, a Boulder therapist who has used art and dance to work with refugees and earthquake victims in Africa and Haiti. “It is scary, but you have to relive the memory.”

Kotun and the others take the lessons they learn, then pass them on.

“We give references on where people can get help,” Kotun said. “Sometimes people confide in us. If it’s an issue I cannot handle, I just talk to Dr. Ouattara.

“I like the program,” Kotun said. “I really like making a positive impact on people’s lives. We create awareness on how people can live and live well.”

By Katie Kerwin McCrimmon

When a robber pointed a gun at Oumar Ouattara while he was working the graveyard shift at a busy 7-Eleven on Denver’s East Colfax Avenue, Ouattara begged the gunman not to shoot and wondered why he had ever left his native Ivory Coast.

Like many immigrants, Ouattara had to take any job he could to survive after arriving in Colorado.

Unlike some immigrants, Ouattara was highly educated and had left behind a good life in his native Africa. A doctor, he was married and owned a four-bedroom home. On a lark, Ouattara entered the annual U.S. lottery that awards 55,000 green cards to immigrants from diverse countries. In 2004, on his first try, he won the right to live and work in the U.S.

He came with his wife and their first child. At first they had to live in a host’s home, squeezing together into one room.

Back home, Ouattara had had both comfort and respect.

Dr. Oumar Ouattara of the Ivory Coast visits It Takes a Village clinic in Aurora.

“In Africa, a physician is like a god,” Ouattara said.

In Denver, Ouattara had to struggle to survive.

“This is the price you have to pay. This is the sacrifice you make to move your life forward,” he said.

Ouattara took his first paycheck and moved his family into a one-bedroom apartment. While working difficult, sometimes dangerous jobs — far removed from his health expertise — Ouattara crafted a plan for a future.

His medical degree from Africa would not allow him to work as a doctor in the U.S.  Rather than starting over and essentially going to medical school again, Ouattara decided to educate himself in a different area — public health. He knew that learning about prevention of critical health problems like HIV would give him great knowledge to take back to Africa someday.

Ouattara earned a master’s degree from the Colorado School of Public Health in 2009.  He and his wife are buying a home and now have two children. And Ouattara found work in his field at the Colorado African Organization, a nonprofit founded by Africans to help immigrants adapt to their new homes in Colorado. Ouattara is CAO’s community health manager and works to drive down rates of HIV while boosting education about issues ranging from breast and prostate cancer to managing diabetes.

Among the programs he runs is one that deploys more than a dozen lay community health workers into Denver’s African community to boost health literacy among women and to ensure that new immigrants know how to access the complex health system in the U.S.

Ironically, when CAO Executive Director Kit Taintor was searching for the right person to head the community health worker program, she wanted a woman. But, she found Ouattara instead. His enthusiasm and warm smile are contagious. He empowers female health workers, whom he trains then dispatches into their communities. As a male doctor, Ouattara has brought a secret weapon to the program.

The women conduct regular monthly teaching sessions in their communities. The programs are aimed at educating women, but often men attend as well. Both Taintor and Ouattara said that many African men who come to the U.S. bring with them patriarchal stereotypes that men are superior. When Ouattara attends outreach sessions with the women, he essentially gives the women his blessing.

“What he’s able to do is answer all the higher-level medical questions that come up. He also backs up the women and gives them respect. As a man, Oumar is helping because the men are sitting there nodding. It allows the women to build up their credibility in the community,” Taintor said.

The outreach sessions have proved tremendously helpful to open doors so immigrants can seek critical preventive and diagnostic care in the U.S.

“The meetings have become an informal place to ask hard questions,” said Taintor. “A woman might say, ‘My husband is peeing all the time (a possible symptom of prostate cancer).’ The health workers can tell them, ‘You need to go to the doctor and this is where you can go.’’’

Ouattara said there are three key barriers that prevent immigrants from seeking health care here: social and cultural barriers, financial challenges and language barriers.

He said the African health system is entirely different. Few people there think of seeing a doctor to prevent illness. Rather, you see a doctor when you are sick. And Ouattara says the entire family engages with you. If a patient is in the hospital, the family provides the patient’s food and supports the care.

Dr. Oumar Ouattara shows African immigrants the disproportionately high number of HIV cases among African immigrants and African Americans at a health outreach evening at a woman's home in Denver.

Ouattara said there are other simple differences. For instance, Africans will often bow their heads and not look directly into the eyes of a caregiver.

“If I look down, I am giving you my full respect,” Ouattara said.

But, U.S. caregivers often find this behavior disconcerting. They want to look their patients in the eyes. Ouattara urges Africans to learn new ways.

“You can bring your culture here. But you also have to adapt to the new culture.”

Ouattara and the community health workers are finding that immigrant women are taking more ownership for their health issues. For instance, the community health workers counseled one woman who had met a fellow African immigrant online. The man lived in another state and the two had never met in person, but planned to marry. The health workers encouraged the woman to ask the man to take an HIV test before their marriage. The woman followed their advice. As soon as she suggested the test, the man disappeared. While the woman was sad that the relationship had crumbled, she told the health workers that she was relieved to have avoided possible HIV exposure.

In another case, Ouattara and the health workers halted a potentially dangerous tuberculosis outbreak. They learned of an older woman who was home with severe coughing, fever and weight loss. She was afraid to go to the hospital and thought that without money, she could not get care.

Ouattara correctly suspected TB and reassured the woman.

“TB is a public health issue. We will take care of you,” Ouattara said.

Educating women so they can become leaders in their communities gives them confidence and puts them on the front lines for improving health access for immigrants.

“Africans are more integrated into the U.S. health care system,” Ouattara said. “Women are in the middle of everything — children, husbands, families. We know that if the women get the message, then the husband gets the message too.”

By Bob Semro

Many people don’t realize that the budget proposal put forth by Rep. Paul Ryan, R-Wis., passed by the U.S. House of Representatives in April, is the also the most significant piece of health care legislation since the passage of the Affordable Care Act.

Even though the Ryan budget plan as now constructed is not likely to become law, it represents an official alternative and warrants real debate. Most of the conversation has centered on changes to Medicare, but the impact on other federal health care programs and the Affordable Care Act itself is even more profound.

Here’s how the Ryan budget plan would affect the Affordable Care Act, Medicaid and Medicare.

The Ryan budget plan would repeal these provisions of the Affordable Care Act:

• Individual responsibility: This provision requires most legal U.S. residents obtain health insurance. The additional insurance premiums collected through this provision would help private insurance carriers cover the costs of individuals with pre-existing conditions or poorer health. Repeal would end the most significant source of funding for provisions that require coverage of pre-existing conditions, guarantee of coverage regardless of health status, and forbid dropping of coverage because of a change in health status.
• Health insurance exchanges: With one notable exception (a new Medicare exchange),the Ryan budget proposal would prevent the establishment of health insurance exchanges.
• Medicaid expansions: The budget proposal would repeal provisions that would expand Medicaid coverage for most non-elderly people with incomes below 133 percent of the federal poverty level.
• Funding cuts: Specific funding for temporary high-risk pools, which serve people with pre-existing conditions, re-insurance for early retirees, and many prevention and public health activities would be eliminated.
• Small-business tax credits, low-income subsidies: Tax credits for small employers that offer health insurance would be eliminated, as would premium subsidies for lower income individuals and families.
• Subsidies that would close the Medicare prescription drug donut hole: Subsidies for the coverage gap in Medicare Part D, also known as the Medicare Drug Benefit Donut Hole would be repealed.

It’s worth noting that the non-partisan Congressional Budget Office (CBO) has said previously that the Affordable Care Act would help reduce the deficit in the long term.

The Ryan plan has a goal of balancing the federal budget by the year 2040. To do so, it also would initiate the most drastic restructuring of Medicaid and Medicare since the creation of those programs.

This restructuring would begin at a time when the number of uninsured Americans, as well as enrollment in Medicaid and Medicare, has hit an all-time high. According to the most recent Census data, the number of people without health insurance has increased to 50.7 million, largely as a result of the economic downturn. The number of people covered by Medicaid has increased to 42.6 million people, with another 43 million covered under Medicare.

In 2013, the Ryan budget would convert all federal funding for Medicaid into block grants. These state grants would be adjusted annually based only on the rate of inflation and population growth. History has shown that such formulas do not keep up with true costs, especially when it comes to medical and health care costs.

Thus, the proposal would clearly shift the cost burden to the states. According to the CBO, “Federal payments to states under the proposal would be significantly lower than under current law.” In order to maintain current Medicaid service levels, states would need to reduce spending in other areas, reduce benefits, limit eligibility or cut payment rates for doctors, hospitals and nursing homes.

In addition, Medicaid spending would not automatically increase to meet needs during economic downturns, as under current law. Under the Ryan plan, to meet increased demand in lean times, many states likely would have to reduce benefits or eligibility levels, out-of-pocket costs would rise for low-income Medicaid enrollees, and providers would confront more costs for uncompensated care.

Beginning in 2022, the Ryan plan would convert the Medicare entitlement system into a voucher system for people currently under the age of 55. The proposal would also gradually increase the age of eligibility for Medicare.

As an entitlement program, the Medicare program pays for a percentage of every doctor visit or medical service. Under the Ryan plan, health care coverage for seniors would be provided by private insurance, with the government paying a certain “premium support” for each enrollee.

According to the CBO, “most beneficiaries who receive premium-support payments would pay more for their health care than if they participated in traditional Medicare. A private health insurance plan covering the standardized benefit would be more expensive currently than traditional Medicare.” As a result, the CBO concluded, spending for a typical Medicare enrollee covered by the standardized benefit under the proposal “would grow faster than such spending for the same beneficiary in traditional Medicare.”

The Ryan proposal has been described as a “serious” effort to address the critical problem of the national debt. It’s early in the process, but as it stands now, in terms of health care, the plan comes with significant costs for some of the most vulnerable Americans in our society.

Bob Semro is a policy analyst at the Bell Policy Center, a nonprofit, non-partisan policy research center based in Denver.

By State Sen. Betty Boyd

America’s health care system is good in many ways, but affordable and easy to navigate it is not, especially for Coloradans in the individual and small-group health insurance markets. That’s why Republican Rep. Amy Stephens and I set aside political differences this session to pass Senate Bill 200 creating the Colorado Health Benefits Exchange.

The health exchange is a bipartisan, uniquely Colorado solution to the challenges in the health care industry in our state.

In fact, it is the only exchange bill in the country to have passed through split chambers, a testament to Colorado’s ability to get things done for the common good rather than for the benefit of just one party.

Once up and running in 2014, the health benefits exchange will provide a one-stop shop for individuals and small businesses that want to compare prices and benefits packages, pool risk, and more easily and inexpensively purchase health insurance. The exchange will offer a choice of plans, facilitate competition to improve quality and lower costs, and offer a simple, navigable interface to help Coloradans purchase the health plans that best suit their needs.

This legislation is remarkable both for its bipartisan support, including that of Gov. John  Hickenlooper, and for the historically broad coalition that supported the policy and encouraged its passage.

Consumer groups, including the Colorado Consumer Health Initiative and the Colorado Coalition for the Medically Underserved, among many others, supported the legislation for its promise to make insurance more accessible and more affordable for the 800,000 Coloradans who lack coverage.

The coalition also included some of Colorado’s leading business associations: the Colorado Competitive Council, the Colorado Association of Commerce and Industry, the Denver Metro Chamber of Commerce, Colorado Concern, and the National Federation of Independent Businesses. Business groups are offering their support for the health exchange in the hope that it will free small business owners from the administrative and financial challenges of providing health insurance for their employees.

More than a dozen other groups with stakes in health care in Colorado have supported the legislation, together representing millions of Coloradans. Like Rep. Stephens and I, they believe that the exchange will make individuals healthier, our economy more robust, and Colorado a better place to live.

To be clear, the exchange is not run by the government nor will it offer government-sponsored health insurance plans. That means the exchange will not be funded by Colorado general fund dollars. All Coloradans who have insurance will be able to keep that insurance if they so choose.

By design, the bill itself is comparatively lean, weighing in at 11 pages (the federal Affordable Care Act, by contrast, was roughly 2,000 pages). We kept it brief because legislatures are better at addressing big picture problems while delegating the details to experts in the field.

Initially the exchange will serve over 300,000 Coloradans who are on the small-group or individual markets. It will not serve Coloradans on Medicaid and CHP, Medicare or ERISA plans.

Senate Bill 200 establishes a 12-member board of directors comprised of a range of experts who will represent the diverse stakeholders in Colorado’s health care landscape. The board, to be seated this summer, is charged with figuring out many of the details, like who to hire as management, what software to buy, how to reach out to and engage customers and partners, and how to apply for and allocate grant dollars.

The board does not have free reign and the legislature and state auditor will continue to exercise oversight and scrutiny of operations and finances to ensure that the board is acting in the best interests of those it was created to serve — Coloradans in the individual and small-group markets.   Senate Bill 200 asks the governor and legislative leaders who make the board appointments to consider the array of skills necessary to bring the most knowledgeable and skilled leaders to the table.

We believe that Senate Bill 200 has created a good foundation for the Colorado Health Benefits Exchange, but future legislatures will no doubt return to add protections or remove red tape or otherwise make improvements, as circumstances require.

The establishment of the health exchange is an important step in addressing the access, cost and quality challenges in our current health care/health delivery system. It may not be a perfect bill, but we think it’s a strong step forward and arguably the most important piece of legislation to emerge from the General Assembly in 2011.

Sen. Betty Boyd (D-Lakewood) is president pro tempore of the State Senate and chair of the Health and Human Services Committee.

By Katie Kerwin McCrimmon

After arriving in the U.S., the Cuban refugee’s darkest moments came when he had to scrub dishes and install wood floors. He missed being respected in his community and practicing medicine, especially caring for babies.

Then, when he moved to Denver in 2007 after brief stints in Miami and New Mexico, the doctor with nearly 15 years of medical training in Cuba who is a specialist in both family medicine and radiology, couldn’t get a single employer to call him back.

All Dr. Edilberto “Edy” Diaz Rodriguez wanted was a basic health care job like drawing blood or working as a medical assistant.

“I would apply for 20 or more jobs a day. Nobody called me,’’ said Rodriguez, now 41.

Even preliminary interviews led nowhere.

“I felt like when they heard my accent, right away, they said, ‘OK, we’ll call you,’ but they didn’t mean it,” he said. “I was so disappointed when I came here.”

Before escaping Cuba via Venezuela, Rodriguez had heard that foreign-trained doctors would get help re-launching their careers in the U.S.

“It wasn’t true,” Rodriguez said.

After floundering for years, Rodriguez finally is on track to take the required tests and apply for a U.S. residency in family medicine so he can once again practice. He eventually found work in Denver as a medical assistant at a private clinic and is now a technician at the Bonfils Blood Center in Denver.

A national program pioneered in San Francisco called Welcome Back now has a Colorado affiliate among its nine programs across the country. The Colorado program helps refugees like Rodriguez find their way back into medical professions.

The Colorado Welcome Back Center opened in October and is run by the Spring Institute for Intercultural Learning and funded by a $200,000 grant from the Colorado Refugee Services Program. So far, Colorado Welcome Back has helped 40 medical professionals take steps to return to their fields. The center offers an educational case manager who works one-on-one with refugees to figure out what schooling they will need to obtain U.S. licenses and helps troubleshoot problems they are having. Sometimes the medical professionals find they want to venture into a new health career that requires fewer years of education, rather than starting over again with their education. Colorado Welcome Back also offers English classes and programs that explain the complicated U.S. health care system.

Dr. "Edy" Diaz Rodriguez was both a family physician and a radiologist in Cuba. But, when he arrived in Denver, no one would consider him for jobs far beneath his skill levels. He finally is on track to reignite his medical career after obtaining school records from Cuba.

“We cannot offer shortcuts to people. The U.S. has very high standards of health care practice that all health care providers need to meet,” said Susan Downs-Karkos, director of Colorado Welcome Back. “We can offer information and support as they take the steps necessary to get their health care career back on track.

“For some people, it may not be realistic to become a doctor again. It may take too much time, and money. But rather than giving up on health care careers altogether, we help them understand their options and that their unique language and cultural skills can be a huge asset.”

Today the Migration Policy Institute and the J.M. Kaplan Fund are honoring the national Welcome Back program with a $50,000 E Pluribus Unum Prize. The prize honors groups that help integrate newcomers.

The Welcome Back program benefits the refugees. But, it also could help Colorado fill critical jobs.

Data from the Colorado Health Institute predicts that Colorado will have a shortage of 2,200 primary care providers by 2025. Colorado already has too few registered nurses. By 2018, this shortage is expected to triple, with Colorado needing an estimated 6,300 nurses according to the most recent study of the Colorado Health Professions Workforce Policy Collaborative. Shortages are also expected to increase among dental and behavioral health providers.

On top of filling gaps, foreign-trained health professionals may improve care for other immigrants or people of color who live in the U.S.

“We know that there are long-term ethnic and racial health disparities in the quality of care that is provided,” Downs-Karkos said. “Diversity in the health care work force is part of the solution to that problem. And this is a great way to diversify our health care work force.

“We already have people who have the passion and experience to work in health care. What they need is some retraining to be able to provide high quality care.”

Downs-Karkos said healers around the world often are revered and seen as leaders in their communities. Putting them back to work can counter the displacement that many like Edy Rodriguez feel once they have fled their homeland.

“There is a huge sense of loss when they come to the U.S. and are not able to practice,” she said. “It can be personally devastating and hard on families economically. It’s very difficult for them to work in low-wage, low-skill jobs knowing that they have so much potential.

As the Colorado program has developed, Downs-Karkos has been surprised at how emotional the education sessions often are. She said the refugee will seem perfectly fine until they recount their frustrations at finding a way to use their skills in the U.S.

“Many break down in tears. These people have overcome a lot of hardship to come to the U.S. They come from countries where there has been war trauma. They have people back home whom they worry about. They have a responsibility to help their family as much as they can.”

Edy Rodriguez felt exactly that pressure when no one would consider hiring him.

“I have to take care of my family in Cuba,” he said of his mother, a younger brother and a sister who is a successful musician, but has been forbidden to travel because of Rodriguez’ decision to flee Cuba.

Rodriguez was born and raised in Bayamo in the province of Granma. At 18, he started his medical training. In Cuba, college and the first years of medical school are combined in a six-year program. After that, Rodriguez had to do two years of “social service” where he worked as a doctor for the Army. He then did a three-year residency in family medicine, followed by another year of mandatory service, then a three-year residency in radiology.

While working as a family doctor in Cuba, Rodriguez was much like the old small-town doctors once portrayed in Life magazine. He lived in the community with his patients. The medical office was on the first floor and his living quarters were upstairs. Whenever people needed him for any reason day or night, they came to his home. While the hours were long, Rodriguez found that he loved the contact with his patients. He missed that later when he worked as a radiologist and spent much of his time alone reviewing images. Eventually, Rodriguez’ hospital asked him to go work as a doctor in Venezuela.

Unmarried and then 33, he jumped at the chance, knowing he might eventually be able to flee to freedom. In addition to the economic struggles that his families and others in Cuba faced, Rodriguez said he found the restrictions on free speech most oppressive.

“I like to think and say what I think. You can’t do that in Cuba. You are part of the system,” he said.

Rodriguez said that the Cuban education and health systems are strong in many ways.

“But you have to pay a really high price,” he said.

While he aches to see his mother, sister, brother and nieces and nephews, he has no regrets about leaving. With his income from his job at the blood center, Rodriguez now is able to send about $100 a month to his family, which he says amounts to a huge sum for them. His mother has been able to buy a washing machine and an air conditioner.

After arriving in the U.S., Rodriguez met an American woman whom he has now married. She later got a job in Denver and while there are few Cubans here, Rodriguez fell in the love with cycling and running in the mountains.

His biggest struggle on the road to practicing as a physician again was getting a copy of his transcripts from Cuba to prove that he had attended medical school there.  It took years and a $300 payment. Once, the documents arrived with the proper signature, but the U.S. authorities said too much time had elapsed.

“It was almost a miracle, but the signature wasn’t good,” he said.

So his wife recently made a trip to Cuba to hand-deliver the transcript request and fee. This time, the signed documents came through, and Rodriguez can now take exams to prove his knowledge.

Through the Welcome Back program, Rodriguez has gained essential support on his journey and has befriended a group of doctors from around the world. They meet to study at the University of Colorado medical school library in gatherings that look like United Nations sessions.

One of Rodriguez’ closest friends is a doctor from the Congo who is just ahead of him in the process and shares medical books.

Rodriguez wakes at 4:30 a.m. on workdays to get some studying in before starting his 12-hour shift at the blood center at 6:45 a.m.

He insists he will take the exams just once.

“I’m a fighter. I can do this,” he said.

By Diane Carman

Dr. Muthanna Jabbar was approached by some men outside his home in Iraq on the day his life changed forever.

“They pulled me over and said, ‘Are you Muthanna?  Quit working with the Americans or we’re going to kill you.’”

Jabbar turned and walked toward his home a few yards away. “I was almost closing my eyes, anticipating a bullet or something in my head,” he said. “When I reached my kitchen, I thought, ‘It’s a miracle. Nothing happened. They left.’”

It was just the first of many miraculous circumstances that led him to Fort Collins, Colorado Welcome Back and his first steps on the rugged path toward a license to practice medicine in the United States.

Jabbar, 34, graduated from the Al-Mustansiriya University College of Medicine in Baghdad in 2002, specializing in general practice and surgery. His experience in the nearly six years he worked in Iraq was primarily in the emergency room — trauma medicine. In Iraq, he said, “We have a lot of issues. It’s a busy, busy field.”

His last job was as medical director of the police academy medical department near the Al Taqaddum Air Base where his patients included both Iraqis and Americans. It was his care of Americans that put his life in danger.

After he was threatened, Jabbar quit his job and left home immediately. He lived with his sister for four months while he assembled the necessary documents to leave Iraq.

On Aug. 26, 2008, he boarded a bus for Turkey. Forty-eight hours later, in the early hours before sunrise, he arrived in Istanbul. He got off the bus and sat, alone and bewildered, on a grassy spot near the transit center. He stayed there with his luggage beside him for 2 ½ hours trying to get his bearings.

Finally, he asked a taxi driver for help. The driver took Jabbar to a hotel to sleep. From there he found his way to the office of the United Nations High Commissioner for Refugees and the halting first steps toward a new life.

Of all places in the United States to land, Jabbar chose Fort Collins because one of his brothers had lived there for five weeks while he participated in a youth leadership exchange program in 2009. His mentor was Julie Sullivan, an instructor in ethnic studies at Colorado State University. When she heard that Jabbar was seeking asylum, she offered to help him get settled.

“Julie is a wonderful person,” Jabbar said. “She picked me up at the airport and introduced me to the Fort Collins area.”

Jabbar lived with Sullivan for a month in early 2010 as he sought work and a place of his own. She introduced him to hiking and biking, and helped him make an array of valuable professional contacts.

His sister and brother-in-law and their two children recently moved to Fort Collins. They were practicing physicians in Iraq and hope to navigate the licensure process as well.

Jabbar’s parents and two brothers remain in Iraq and, in the interest of their safety, he declined to have his photo taken.

Now he works part time at Lutheran Family Services, which has a resettlement agency in Greeley, and he is doing research on the impacts of pain medications on the cardiovascular systems of patients at St. Luke’s Medical Clinic. He also is studying for the medical licensing examinations, hoping that good grades will help him land a coveted medical residency.

The process for licensure is “like a long channel that’s a little bit kinky, but there is light at the end,” he said. “I’m optimistic. I’m a go-getter and I don’t give up easily. These challenges will make me a better person, a stronger person.”

Jabbar said he believes he can get good scores on the medical exams. “This is doable. It’s a matter of studying very, very hard.”

The more difficult part is landing a residency. “That is a competition, and by the end of medical school, U.S. students have had internships or some kind of U.S. experience.

“If I’m lucky, I’ll get a residency in Colorado, but I’m ready to go to Alaska – anywhere – for my residency,” said Jabbar. “I don’t mind.”

Then, when he completes the process and has his license to practice, he’d like to come back to Fort Collins. His dream job: “working in a hospital, mainly in the ER.

“I’m alive and happy,” he said, “but real life for me is to be a doctor again. It’s how I get my fuel.

“I see a patient in the ER and see the change on his face, in his expression, when the pain is gone. I can’t imagine my life without it.”

By Brian T. Schwartz

Would you donate to a charity that allows parents well over the poverty line to pay just $25 per year for their child’s’ medical insurance? What if many recipients previously paid for such insurance themselves, and spend hundreds of dollars a year on booze, sweets and entertainment?  If you pay Colorado taxes, you’re forced to fund such a charity – the state-run “Child Health Plan Plus” (CHP+).  Senate Bill 11-213, which is awaiting the governor’s signature, would increase CHP+ enrollment fees for the wealthiest of eligible households, and rightly so.

Families earning up to 250 percent of the Federal Poverty Level are eligible for CHP+. Annual enrollment fees for one child are just $25 per year, and $10 more for any additional kids.  For families making between 205 and 250 percent of the FPL, SB 11-213 would increase this fee to $20 per month for one child, $10 per month for each addition child, with a maximum of $50 per month.

Critics in the Denver Post claimed that the “new monthly premiums … would be more than these families can afford.”  Recent data from the Bureau of Labor Statistics’ Consumer Expenditure Survey suggests otherwise. The lowest income households, making less than $5,000 per year, spend on average $156 per month on alcohol, tobacco, sweets and entertainment.

The proposed fee increase would affect households earning more than twice the federal poverty level, or more than $30,000 for a two-person household – one parent and one child. Families in this income range spend, on average, $191 per month on the above luxury items.  Even if the childless households spent three times more on these items than those with kids, the spending by households with kids would still be $95 per month. These numbers are even higher for families eligible for CHP+ earning more than $30,000.

If parents eligible for CHP+ can spend $100 per month on beer, cigarettes, sweets, and movies, surely they can spend $20 for their child’s health plan. In fact, they do. The Congressional Budget Office found that between half and three-quarters of children in families with income between 100 percent and 300 percent of the federal poverty level had commercial health coverage in 2005.

Even more parents would buy commercial coverage if state-run child health plans didn’t unfairly compete with and crowd out commercial insurance. The CBO concludes that for every 100 children enrolled in SCHIP, “there is a corresponding reduction in private coverage of between 25 and 50 children.” A study co-authored by MIT economist Jonathan Gruber, who has consulted for the Obama administration, estimates a crowd-out rate of 60 percent. Or as policy analyst Michael Cannon puts it, SCHIP covers “four uninsured Americans for the price of 10 — a lousy deal even by government standards.”

Increasing CHP+ enrollment fees will reduce crowd-out, as some parents who forgo enrollment will buy private coverage instead. For example, in 2005 Missouri introduced monthly premiums for its version of CHP+. Enrollment fell, but “increases in other types of insurance coverage prevented an increase in the share that were uninsured,” report Urban Institute researchers.

Critics of SB 213 claim that monthly fees would burden CHP+ administration, as some parents drop coverage to avoid monthly fees, but later re-enroll.  Limited re-enrollment periods can address this.

But this misses the larger picture: It’s clear that CHP+ clients can afford higher fees. Why does CHP+ allow eligible parents to value entertainment and satisfying bodily appetites more than securing their own children’s health?

One reason is that federal matching assistance gives CHP+ perverse incentives to waste Coloradans’ tax dollars. When CHP+ spends a dollar, the feds give them a dollar taken from a taxpayer in a different state.

A second reason is that unlike private charities, CHP+ need not prove their worth to persuade people to donate. Rather, Coloradans could end up in prison for not “donating” to CHP+.  The message is that some parents are entitled to have others finance their kids’ medical care.  Both the children, and Colorado taxpayers forced to fund CHP+, deserve better.

One way is to make CHP+ compete for donations by instituting a statewide tax credit for donations to charities focusing on children’s medical care.  A taxpayer would receive a full tax credit for each dollar he donates to an eligible charity, and CHP+ loses that dollar of Colorado tax revenue. The credit would be capped according to one’s income and the portion of tax revenue that would have reached CHP+.

If CHP+ is so worthwhile, it surely can withstand some competition, especially since it would have large advantages over competitors. First, CHP+ would still receive matching federal funds. It would still receive donations from taxpayers who don’t care enough to spend the time researching worthwhile alternatives to CHP+. So if you support Colorado’s Child Health Plan Plus, how about letting it compete with private charities?

In the meantime, if the state must compel taxpayers to fund CHP+, Senate Bill 213 would increase enrollment fees so eligible parents can more sensibly weigh the costs of their kids’ health care against the costs of booze, tobacco, sweets and movies.

Brian T. Schwartz blogs at the Independence Institute’s PatientPowerNow.org website