Health Policy Solutions

By Katie Kerwin McCrimmon

PUEBLO — She started cooking at age 7 and taught herself to drive at 12.

“Somebody had to go to the grocery store,” says Trish, now 28.

She says her mom was a drunk and her dad wasn’t in the picture. Trish has three older siblings, but when her parents broke up, they also split the kids: two each. The sister who lived with Trish was much older and mostly hung out with her friends.

So Trish started taking care of herself and everyone else at a young age.  Life is no different now.

Trish is studying graphic arts in college, working a job that pays $8.03 per hour, raising her 17-month-old son Caden and trying to preserve her relationship with her live-in partner, Ron, 48. He admits to repeatedly cheating on Trish, but is a loving father to her son and is also attending college and working to transform his life after serving nearly a third of it in prison.

In the spring, Trish felt like her responsibilities might crush her.

Then at Pueblo Community College, where she works and goes to school, she happened to see a flyer with phone numbers dangling from the bottom like fringe.

“It said, ‘Stressed out? School work or personal life got you down?’ There was a little 1-800 number on it. I wanted our relationship to work out,” Trish said. “I keep everything to myself, which is really hard. I thought maybe if I could get somebody to talk to us, we could make it.”

Thanks to Mental Health America of Colorado’s Pro Bono Outreach Program, Trish and Ron have been receiving free therapy sessions since June. Dr. Mary Jane Kruse, an experienced therapist, is donating her time. (Click here to read more about their therapist. Solutions is identifying the couple only by their first names. They agreed to allow a reporter to sit in on their therapy and to discuss their personal challenges.)

The program started 25 years ago in the Denver area and recently expanded to Pueblo. The first of its kind in the nation, the pro bono program has become a nationally recognized model. Initially, the program targeted homeless adults. Today it serves seniors, children and a full spectrum of low-income adults, touching people in places of need from homeless and domestic violence shelters to autism support groups and schools. The most recent expansion, however, is reaching people like Trish and Ron, who are struggling with basic challenges and can get help in a private practice setting.

Mental health needs rise as economy falters

As economic troubles have mounted over the last three years, pressures on the poor have increased and calls to Mental Health America Colorado’s hotline have spiked. Few low-income people have access to counseling that can serve as a life raft for them.

“What if you’ve lost a job and you have no insurance? If you’re anxious and you have economic problems, the private practice model allows us to screen clients and connect them with a professional,” said Jacy Conradt, community relations manager for Mental Health America Colorado. “This program allows us to help people with depression, anxiety, job loss, family-related issues.”

Screeners find long-term help for people with more serious mental illnesses. The pro-bono program is designed to provide immediate help to people with relatively straightforward mental health dilemmas. It connects qualified callers with volunteer mental health professionals who give six free sessions.

“Being able to offer and connect people to services at a critical point can save a life. When you’re with a professional, good things can happen,” Conradt said.

The Pueblo expansion has included outreach to Spanish-speaking therapists and clients.

Last year, more than 1,600 people received services through the pro bono program in Colorado. Most were in the Denver area, but new programs are now reaching people in Pueblo and Glenwood Springs.

For Trish and Ron, the therapy has given them great relief. They continue to meet every week or two with Kruse and are confident that they can preserve their relationship and provide a good home to Caden.

“We’ve learned a lot of communication skills,” Trish said. “He’s gotten in touch with a lot of personal problems that he’s held onto for a long time. He wants to be a better guy. He’s a full-grown man. He doesn’t need to come to therapy. But he knows it’s helping me. And when we’re good and strong, we are good and strong. We’re a very good family.”

Adds Ron: “Being able to come and get treatment, to get some therapy for no price is actually priceless. It’s going to pay off in the end. You’ve saved a relationship and a family.”

A “beautiful childhood.” Adulthood behind bars

The image that haunts Ron is one he can never change.  He was behind bars awaiting trial on cocaine possession charges when his father became sick from a common lung ailment called chronic obstructive pulmonary disorder in 2001 and ultimately died. Ron’s father had always been healthy. He hunted regularly until he was 74. But the breathing difficulties changed him.

“My sister told me that she was taking him from the car to the house and he was so weak, he couldn’t walk. My dad needed me and I let him down,” said Ron.

He describes his childhood as “beautiful.”

“No one in my family was ever in trouble,” Ron said. “I like being accepted. I would go above and beyond to do stupid things to be noticed. He started getting in trouble as a juvenile, then continued breaking the law as a young adult.

Ron had loving parents. He said his mom, Geneva, was a great cook famous for her tuna casserole. She died of a heart attack at 57. His father, who worked for the city, lived until he was 80.  Even while Ron was in prison, his father carefully tended Ron’s car, keeping it tuned, clean and ready for Ron’s release.

His parents owned a home in Pueblo. Ron has inherited it. But, while he was in prison, a woman who was supposed to be caring for the house let it go. Half re-roofed, the house sat open to the elements and became unlivable. Ron and Trish are trying to fix it up. But they don’t have enough money yet to finish the job. So, they pay $450 a month for an apartment. Cash is often short. Trish had to apply for emergency funds to pay the rent for September and received a notice that the utilities would be shut down. She borrowed money to keep the lights on.

Like most couples, they fight about money. Ron likes to smell good and wants to spend $40 on cologne. Trish grew up wearing Goodwill clothes and wants to pay bills first. She says she could buy two boxes of diapers with the money Ron would spend on cologne.

Like the half-ruined house, Ron feels that he’s thrown much of his life away. He came from a good family, but squandered his parents’ and sister’s support by landing in prison on drug and burglary charges.

Kruse doesn’t have time to dwell in the past and still help Ron and Trish. Instead she teaches them to understand why they behave the way they do, then creates a treatment plan so they can move forward on a fresh path into the future.

“Mary Jane asked me how my dad would feel if he knew that I was still kind of stuck,” Ron said.

“He would want me to live my life to the fullest. He would be so proud of me now. ‘You’re going to college? You’re eight months away from being a college graduate?’” Ron said.

But Ron acknowledges that his parents would be disappointed with his poor treatment of Trish.

“I never saw domestic violence or my dad drinking or disrespecting my mom,” he said.

“Right where I’m supposed to be.”

Ron lost most of two decades serving prison sentences in the 1990s and 2000s. He was behind bars from 1991 to 1999 for burglary. He had been using and dealing drugs and went to collect money for a friend. But he barged into the wrong apartment. Ron was not armed and didn’t take anything from the apartment, but still received a 10-year sentence. Not long after his release, he was using cocaine again. The second time, he received an eight-year sentence for cocaine possession.

Ron got out in April of 2009 and met Trish soon afterward at a Pueblo bar where she was working. The two hit it off and soon were living together. Almost immediately, Trish learned she was pregnant by her previous boyfriend. She told Ron the truth and expected him to leave. Instead, he decided to stick around and become a dad. He had gotten another woman pregnant years earlier right before he went to prison. That daughter, who turns 21 next year, has never forgiven him for his long absences.

“I’ll never put another child through that again,” Ron says. “I definitely have dedicated myself to Caden. When I don’t see him, even for a little while, it really hurts.”

Caden shares Ron’s last name and their love is clearly mutual. Trish recalls a recent morning when Ron was already gone and Caden was searching for him, calling out “Da Da” and pretending to put on Ron’s hat and shirt.

Ron’s attentiveness to Caden won over Trish.

“I think he really wants to change his past. He wants a restart. This is a great opportunity to move on from doing bad things. He’s always talking about how he wants to stop making bad choices,” Trish said.

Of course, Ron’s dedication to Trish seems to lapse when it comes to women.

Because he lost so much freedom during his years of incarceration, he believes he’s entitled to seize any sexual opportunity that comes his way.

“I struggle every day. I like being admired, especially by females. I like it when they show me attention,” Ron says.

During a recent therapy session this month, Trish arrived angry and frustrated.

“We’re right back where we were. We might as well go back to session No. 1,” she tells Kruse.

Trish has found out Ron’s been in touch with two women, both of whom happen to be named Jessica. Ron says they are no threat. Trish says they’re poison.

“I found text messages and voice mails. He lied. I’ve already done all of this before,” she says.

Her past boyfriends have always been cheaters. Ron’s infidelity plays into her worst fear: that men will always betray her.

“I always have jerks. That’s how people are with me. I can work and work and work and I’m always going to get a C,” Trish says.

What she hates most is deception and having to rage at Ron to find out the truth.

“I can handle pain and suffering. I can’t handle being lied to and being the dummy. I can’t look stupid,” she says.

Ron is sheepish.

“I don’t want to be disrespectful to my lady, but I know my actions are. I don’t get up in the morning with this black heart and think, ‘Oh, I’m going to hurt you.’”

“I feel that’s an excuse,” Trish responds. “When you sit and talk to another woman, you are out to get me.”

Kruse intervenes.

“It could cost you everything,” she tells Ron.

He acknowledges that he needs help to stay on track. He knows he needs a strong woman and credits Trish with helping him stay away from drugs since his last time in prison.

In fact, in every aspect of his life, except his relationship with Trish, Ron is doing great. He is almost finished with his associate degree in social work at Pueblo Community College. He is working for AmeriCorps and leads groups with troubled teens. He pushes young men to stay in school and avoid the mistakes he has made.

Yet, he acknowledges that he’s sometimes out of control himself.

“I need somebody to ride on the back of the saddle with me and hold the reins,” he tells Kruse. “Sometimes I let go of the reins.”

She calmly replies, “There’s a lot more you can both do to work this out.”

She tells them that they are both learning to stop their old patterns of behavior.

By the end of the session, both Trish and Ron are drained, but Trish isn’t nearly as angry and Ron feels hopeful that he can be a better partner.

“I feel a little relieved. It was nice to hear his side without me cutting him off and being irritated,” Trish said. She feels more emboldened to stop nagging and instead give him friendly advice.

Ron, in turn, is determined to earn Trish’s respect.

“I know that I’m in the best place where I’m supposed to be with my life and with my family.”

He insists he’s going to stop hurting Trish, making her doubt him and making her cry.

Kruse nods.

“It’s like a sharp tool to your foundation,” she said. “We want to make this work. Don’t give up.”

By Katie Kerwin McCrimmon

PUEBLO — Mary Jane Kruse headed back to school in the 1980s when her son was in the second  grade.  Back then, her son was fascinated with anatomy, so she figured he’d become a doctor someday.

Instead, a week ago, Kruse became the doctor in the family — earning a PsyD in psychology — and collecting her diploma at age 62.

Kruse had taken a handful of college courses before getting married and having her son. But she never finished her degree. So, she started taking classes at a junior college while working for the school district as a computer specialist.

Now, this brand new doctor, who has 15 years of experience in counseling, drug and alcohol treatment, ER work and trauma, is volunteering her time as part of Mental Health America Colorado’s pro bono mental health program. The program links mental health professionals who are willing to donate some of their time to needy individuals and families. The professionals provide six sessions for free to help people cope with an urgent need.

Kruse currently is providing pro bono therapy to two clients, including a couple who shared their experiences with Solutions. (Read more.) Kruse sits in her rocking chair in her office exuding the warmth and wisdom of a grandmother.

Originally from Iowa, Kruse moved to Colorado in the 1970s, then suffered her own personal tragedy when her husband died in a skiing accident. She then moved from Denver to a ranch in the town of Manzanola in the Arkansas River valley about 30 miles east of Pueblo. Along with her partner at the time, she raised quarter horses and Labrador dogs.

“There were 600 people in the town. There was an opportunity to be out in the country,” Kruse said. “It was really a great escape for me. I had always been a city person. I felt safer there, comfortable raising my son in a smaller area.”

Kruse also began expanding her professional horizons.

By 1996, she had moved to another small town called Fowler and was graduating from Colorado State University Pueblo. She went to work in a hospital behavioral health unit. She also began working on substance abuse issues with offenders coming out of prisons and jail and later worked on behavioral health issues in a hospital emergency room.

“From 2004 to 2010, I was working in the ER and I saw such a great need for follow-up care. We could refer people, but they couldn’t follow through. I think this pro bono program will help,” Kruse said.

Kruse was long familiar with Pueblo because it was the big city in her area and a place she frequently visited. She moved to the city full time in 2007 and opened her private practice in 2010.

“Trauma and addiction are my specialties,” said Kruse.

She works with children, adults and families who are experiencing the full gamut of mental health challenges.

Kruse says the most common thread among her patients is a family history of addiction and resulting trauma.

“There’s an inordinate amount of child abuse and neglect due to addiction,” Kruse said. “Systemic alcohol use is at the root of many problems. It’s transgenerational. People who are addicts tend to have higher rates of abuse and neglect. These neglected children tend to raise themselves. We see addicted mothers and fathers and grandmothers and grandfathers. It seems to permeate the whole community.”

Even when money is tight, addicts continue to use.

“I never could figure out how people could get drugs and alcohol when they had no money to feed their kids and take care of their children,” Kruse said. “It’s very frustrating.”

Despite that tough climate, Kruse has not given up on changing the culture.

“When you have one success, it keeps you coming back. I would never lose heart because I have an optimistic point of view.”

She concedes that the poor economy is aggravating mental health woes and preventing people from seeking care.

“People are more concerned with just keeping a roof over their heads and food on their table. Thus mental health issues are pushed to the background unless there’s a crisis. Then, they end up in the ER.”

Kruse learned about the pro bono mental health program when the Pueblo coordinator sent her a letter. Because she’s still building her private practice, she had some openings in her schedule and was eager to treat some clients for free. Kruse also works part time for El Pueblo Boys and Girls Ranch, a well-known residential treatment program for troubled youth.

“My private practice is just beginning. Even though it’s important that I have paying clients, it’s important that I contribute to my community as well. I’ve worked hard to get this education. I don’t mind sharing it with others.”

Without the pro bono program, she said people in need would have to wait at least three months to receive any kind of mental health care.

“When people are in crisis, they can’t wait three months,” Kruse said. “I saw a need. This is a good program where I can help one person at a time when they’re navigating these tough waters.”

The mental health providers are supposed to provide six free sessions. But Kruse is more generous with her time.

“I base it on need,” she said. “I’ll see my clients until we both feel it’s time to terminate.”

By Donald J. Mares

The continuing economic recession still has many Coloradans struggling with the strain of job loss and financial uncertainty. At Mental Health America of Colorado (MHAC), we receive an average of 60 calls each month from individuals across the state who are unemployed and experiencing mental health related symptoms: depression, stress and anxiety. This stress also shows up in the form of physical symptoms: insomnia, backaches or headaches. And I know from being in the trenches running the state’s Labor and Employment Department during this recession that this is the tip of the iceberg.

For unemployed workers, the mental health pressures of joblessness are a personal burden, but also a burden on the whole family. Children sense when a parent is distressed due to work and finances. Additionally, extended family members and friends are often called upon to provide emotional and financial support, and even a place to live when loved ones lose a job and home. Suddenly, family relationships are strained and it becomes difficult to focus on the job hunt.

Many of the calls we receive from individuals seeking counseling related to unemployment contact us because they do not have health insurance and do not know where to turn for mental health assistance. In many cases, an adult finds himself living with family members when he’s used to being independent. As a state, we must be proactive in providing access to mental health services for these workers so that they can keep their focus on finding work again. Access to mental health care is essential to individuals’ and families’ emotional and physical wellbeing.

Where do families and individuals find help? MHAC’s Pro Bono Outreach Program, which recently expanded from the Denver metro area to Glenwood Springs and Pueblo, connects therapists with those seeking counseling. There have been many success stories for people who have qualified for the free, short-term counseling. Family relationships have been preserved and unemployed workers receive life changing tools to navigate the challenges they face.

Also, Metro Crisis Services Inc., a program spearheaded by MHAC and many community partners, has opened Metro Crisis Line: a free, professional, 24/7 line to receive calls from people with mental health and substance abuse crises in the Denver metro area. In addition to experienced counselors, they have a comprehensive resource directory designed to connect people to mental health, substance abuse and community agencies. Each month, they assist more than 700 callers who need everything from basic resource information to crisis counseling. Having a professional counselor available “in the moment” can make a life-changing difference.

It is not uncommon to experience anxiety, grief or depression while unemployed or during financial hardship. In fact, it is fairly common. It should not, however, be acceptable for unemployed Coloradans to suffer in silence. If you, or someone you know, is struggling, urge him or her to seek help. Mental wellness and resilience is the best investment we can make for ourselves, our families and for a happier, healthier and more productive Colorado.

Mental Health America of Colorado www.mhacolorado.org

Pro Bono Outreach Program: 1-800-456-3249

Metro Crisis Services www.metrocrisisservices.org

Metro Crisis Line: 1-888-885-1222   Free. Experienced. 24/7.

About Mental Health America of Colorado

Donald J. Mares is the president and CEO of Mental Health America of Colorado, a 58-year-old organization dedicated to mental health and wellness. MHAC is the catalyst and voice for the Colorado mental health movement. Through education, advocacy, outreach and prevention, we provide resources to Coloradans affected by the entire spectrum of mental health issues.

By Richard D. Lamm

Let me answer for myself, up front, one of the most commonly asked questions in health care: What health care would you deny if it were your mother? My answer is the universal answer: Deny her nothing; I want her to have everything! Of course we all would do everything to save a loved one.

But you cannot build a health care system, or any public system, one mother at a time. This is an unfair and unrealistic standard for public policy. I would also want to locate a police station near my mother’s home, and I would wish to double her Social Security check, and I want a floodlight in her backyard and an emergency response system in her every room.  And I would hope not to pay for any of it.

But applied to all of our mothers, that road leads to national bankruptcy.  The “mother test” is a good yardstick for your own money but not a sustainable yardstick for a health plan however heartfelt. Every health plan must look dispassionately and intelligently at what is and what is not to be funded. They must set rules and parameters that apply to all their members equally: mothers cannot be exempted. If some medical procedure is futile, or inappropriate, or has only a slight chance of succeeding, those procedures can legally and morally be excluded from coverage for all the membership. We can neither give “mothers” a different standard of care, nor can we bring up the standard of care for all subscribers to the “what if it were your mother” standard.

We are all free to provide our mothers extra safety, income, housing, clothes, but we cannot use either a health plan or government money to do so. When we pool funds, as we do with taxpayer monies or health premiums, we have to set and live by rational distributional roles.  No commonly collected pool of funds (taxes or premiums) can maximize all beneficial care to all stakeholders. This is a reality that must be understood by both citizens and doctors.

American doctors were trained in a culture that maximizes everything in health care. As Hafdan Mahler, former head of the World Health Organization, noted: “Everywhere, it appears, health workers consider that the ‘best’ health care is one where everything known to medicine is applied to every individual by the highest trained medical scientist in the most specialized institutions.”

It goes without saying that this is an unsustainable yardstick. The price of doing something with commonly collected funds is always that we cannot do everything. The price of joint action is the need to set limits.

Both Medicare and health plans owe a duty to their policyholders, including our mothers, but not only our mothers. We cannot pay limited premiums and limited taxes and receive unlimited care. We cannot make our fondest hopes and dreams the common dominator for demands on common resources.  We are entitled to our equitable share and no more. The good news about modern health care is that we can expect a lot. The bad news is that we cannot expect everything.

A wise person once told me “maturity is a recognition of our limitations.” A mature nation must recognize that no health plan and no nation can meet the mother test.

Richard D. Lamm is the former three-term Governor of Colorado. He served from 1975-1987. Lamm is co-director of the Institute for Public Policy Studies at the University of Denver. A lawyer and certified public accountant, Lamm’s research and teaching have focused on the dysfunctional nature of American institutions, with special emphasis on health care reform and allocation of health care resources.


<div><strong> Opinions communicated in Solutions represent the view of individual authors, and may not reflect the position of the University of Colorado Denver or the University of Colorado system.</strong></div>

By Katie Kerwin McCrimmon

Parents in the U.S. continue to be nervous about fully immunizing their infants and toddlers even though links between vaccines and autism have been proven to be fraudulent, according to a study this summer in Health Affairs.

Of the parents surveyed in the study, most reported at least one concern about vaccines ranging from fears that children get too many shots in one visit or too many before age 2 to worries that vaccines may not have been tested enough and might cause chronic diseases.

Up to 5 percent of parents planned to reduce the number of vaccines their children received while at least 2 percent planned to skip all vaccines.

Lead author Allison Kennedy, an epidemiologist in the U.S. Centers for Disease Control and Prevention’s Immunization Services Division, said parents need better answers to their concerns, and help understanding why it’s so critical to fully immunize children before age 2.

“That is when children are very vulnerable to contracting severe disease,” Kennedy said.

Frustration with parents who refuse vaccines has prompted a new trend among some doctors around the country. A handful have begun booting children from practices if their parents refuse immunizations.

Dr. Steve Perry of Cherry Creek Pediatrics spends considerable time discussing vaccine safety with parents. He does not believe in dismissing parents who don't vaccinate. Rather, he views discussions as teaching opportunities.

In Denver, Dr. Andrew Lieber of Rose Pediatrics, has taken the hard line approach in order to protect other patients.

“By 4 months, if I can’t help you come to terms with the scientific fact that vaccines are helpful, then I haven’t done my job educating you,” Lieber told MedPage Today.

About twice a year, Lieber said he has to tell parents to find a different doctor.

“I feel like I have a bigger responsibility to all the other kids walking through my waiting room,” Lieber said.

He said he started asking patients to leave about 11 years ago after a family who wasn’t vaccinating came in with a child who had chicken pox.

It’s difficult to tell how many physicians are turning away families who don’t vaccinate. A 2001 survey by the American Academy of Pediatrics found that 23 percent of doctors “always” or “sometimes” tell a family that they can’t be their doctor if the parents decline vaccines.

Lieber told MedPage Today that he’s not refusing to see patients.

“I’m begging to treat the patients. But the parents are refusing to let me.”

Polarization over vaccines is especially profound in Colorado. Only 65.2 percent of Colorado’s infants were fully immunized in 2009, putting Colorado 30^th among the states on vaccinations. In 2002, Colorado ranked dead last for immunizing young babies.

Meanwhile, exposure to vaccine-preventable diseases is a credible risk. In February, Colorado health officials had to issue warnings to anyone who had traveled through Denver International Airport because a New Mexico woman with measles had traveled from London through the airport while sick with the highly contagious disease. In California in 2010, 10 infants died from the most severe outbreak of pertussis, also known as whooping cough, in more than six decades.

The Health Affairs study found that parents are increasingly getting information about vaccines online.  Armed with information, many Colorado parents want to carefully mull vaccination decisions with their pediatricians and family physicians.

Lieber did not answer interview requests from Solutions. But other Denver pediatricians say it’s their job to educate parents, not to turn them away.

Dr. Gini Taylor, a pediatrician with Children’s Medical Center in Denver, said encouraging immunizations is the most important job she does every day.

“Preventing smoking is next. And getting people to wear seatbelts is third. Immunizations make the biggest difference in health care outcomes of anything we do. Immunizations have changed the world,” Taylor said.

When parents have concerns about vaccines, she turns the questions into the ultimate teachable moment.

“I understand physician frustration. I just don’t agree with it,” Taylor said.

“I let the parents know that there’s overwhelming evidence in support of vaccines. I listen and I ask them, ‘Why are you scared?’ There’s so much misinformation on the Internet. It’s scary for them,” Taylor said.

Often after two or three visits, she finds reluctant parents have changed their minds.

“We start with the baseline that all parents want to do the best for their children. My response is to help them understand what they are refusing. I want them to understand what diseases they are accepting (if they choose not to vaccinate). I listen to them and hear about the myths and direct them to good information.”

For instance, she tells parents that Haemophilus influenzae type B, a bacterium known as HiB, used to be the No. 1 cause of deafness in children. Now, because of vaccines, it’s completely preventable.

She explains that if babies get HiB, they will most likely die before diagnosis. She talks about the era when children frequently contracted polio and how Colorado has been a hotspot for pertussis in years past, possibly because of our location in the center of the country with people frequently traveling in and out of the state.

“I’m an advocate for your child. I want to tell you why you don’t want to refuse this,” she said.

Any parents who continue to refuse a vaccine must sign a paper acknowledging the risks of the diseases to which their children will be vulnerable.

Other Denver area physicians agree that they have an ethical obligation to work with families who plan to skip vaccines.

“We struggle with what to do with families who don’t want vaccines. But we are the children’s advocate and want them to be healthy. Those children deserve to receive pediatric care,” said Dr. Steve Perry of Cherry Creek Pediatrics in Denver. “I try to view it as a teaching and learning opportunity. I think it’s punitive to dismiss the family.”

Perry said dealing with vaccine questions has become a primary issue that he deals with every day. Some parents are choosing to delay vaccines or alter the schedule so that their children don’t receive as many vaccines at once.

“It takes more and more time and more visits,” said Perry, who is on the board of the Colorado chapter of the American Academy of Pediatrics and on the policy board for the Colorado Children’s Immunization Coalition.

The AAP has found in surveys that 85 percent of pediatricians have reported encountering a parent who refused or delayed one or more vaccines and 54 percent encountered a parent who refused all vaccines. AAP policy encourages pediatricians to document parents’ vaccine refusal and continue to educate them at each appointment, not to stop treating children whose parents have refused vaccines.

Perry warns parents that if they change the schedule, the costs will rise and they’ll have to visit his office more frequently, which increases the likelihood that their babies will be exposed to sick children.

He spends considerable time reassuring parents with the simple message that vaccines are safe and prevent potentially fatal diseases: “Get vaccines and get them on time.”

Dr. Marc Avner of Greenwood Pediatrics in Centennial, Littleton and Parker, believes we’ve been victims of our own success with vaccines.

“I don’t know of anything that has helped kids as much as vaccines,” he said.

As a result, most parents no longer see the scary diseases that vaccines prevent and therefore, their knowledge about the diseases has declined.

“Families are very concerned. I tell people that No. 1, I want them to ask questions. The bottom line is that we all want what’s best for kids. I wouldn’t recommend and promote things that I wouldn’t do for my own kids,” he said.

Avner finds that listening to concerns can be very powerful.

“It allows them to feel more comfortable with the decision to vaccinate,” he said.

“We encourage vaccinations for all our patients. If a family adamantly refuses, we’re not discharging them. But there is an element of risk. If kids aren’t vaccinated and they come into an office or they go to school, they put other people at risk,” he said.

“The bottom line is we try to sit down, listen, answer questions, assuage concerns and discuss the facts in a non-challenging or berating manner.”

By Katie Kerwin McCrimmon

The Denver woman who has brought sound to life for generations of babies might have missed her groundbreaking career had the line to study audiology been longer.

Downs, now 97, was headed back to school for a master’s degree age 35 after raising her own children when she strolled in to the University of Denver.

“I went to register and found the shortest line. It was speech pathology and audiology. I became an audiologist by chance,” said Downs. “I just wanted to do something. You can be any age and make a difference.”

Downs has proved just that for decades. She famously jumped out of a plane to celebrate her 90^th birthday and continued to play tennis well into her 90s, earning kudos as the top-ranked player in the U.S. over 90.

Today, public health experts from Colorado and the Centers for Disease Control and Prevention will gather in Denver to honor Downs and showcase exceptional work that helps children with birth defects and developmental disabilities.

Marion Downs knew that early intervention would help the brain and speech development of children with hearing loss. Research later proved her correct and screening at birth is now standard in the U.S. and around the world.

Downs started the first infant hearing screening program in the country in Denver in 1963. Today, more than 95 percent of all babies in the U.S. are screened for hearing loss at birth, a direct result of Downs’ determination to find and help children with hearing deficits as early as she could.

After earning a masters in audiology from DU in 1951, Downs became convinced that children should be screened as babies. She was seen as a revolutionary for fitting babies who were just weeks old with hearing aides.

“If they have a problem, it’s best if they are identified early because the brain is only plastic in the early one or two years of life. Neurons that aren’t used will drop off. So it’s important for the brain to be stimulated,” Downs said.

“That’s why we try to find babies as soon after birth as possible. At birth is the only time we’ll get them all. By the time they’re going to school, it’s too late,” Downs said.

Downs intuitively knew that early intervention was critical. But, early in her career, she was not viewed as a medical authority. So she and an army of Junior League women, who helped test newborns in Colorado by observing their reaction to a loud sound, had to convince male doctors that they were right. Researchers including Dr. Christine Yoshinaga-Itano of the University of Colorado, soon confirmed that early detection and intervention for hearing loss was vital.

Downs later literally wrote the book on the topic, “Hearing in Children,” which has been updated decade after decade and translated into multiple languages. Screening newborns for hearing loss has also become standard around the world.

In 1959, she became a faculty member at CU’s School of Medicine, where she taught generations of medical students. She now has a center named for her, the Marion Downs Hearing Center. The center’s foundation is building a new headquarters at the Anschutz Medical Campus, which aims to be the world’s most comprehensive center for people of all ages who are deaf and hard of hearing.

Design for the new Marion Downs Hearing Center

Experts credit Downs with almost single-handedly alerting the medical world to the speech and language deficits that hearing loss could trigger.  To ensure that pediatric hearing loss would remain a priority for pediatricians, Dr. Downs in 1969 proposed that a national committee be established to review and recommend best practices for screening in newborns. Her advocacy led to the creation of a national Joint Committee on Infant Hearing.

Public health experts frequently refer to her as Dr. Downs, but this respected teacher of doctors who holds several honorary PhDs, never became an M.D. In fact, back in the 1950s and ’60s, medical authorities doubted her ideas.

“We had a lot of opposition. We were seen as non-medical people. Doctors were very suspicious of us,” Downs said.

In the early years, she didn’t have good instruments to make and record infant reactions to loud sounds. Initially, she standardized a 90-decibel sound, comparable to a hammer loudly striking a nail. She trained women from the Junior League of Denver to watch for babies to startle or wake from sleeping in response to the sound.

“Of course, that was just a subjective observation. That isn’t very scientific. We were delighted when they started to be able to computerize the responses to the sound,” Downs said.

“As time went on, there’s been wonderful research,” Downs said. “Studies have shown that the earlier babies are identified and trained (to hear) the better they use language and use their brains. That clinched it as far as the medical profession was concerned. That really helped children.”

Today Marion Downs is 97. For her 90th birthday, the public health pioneer went skydiving. She was rated No. 1 in the country in tennis in the over 90 division. Downs believes a healthy body contributes to a healthy mind.

Today Downs isn’t planning any skydiving trips, but her mind is as sharp as ever. She loves to read and stay as active as possible. She is convinced that a healthy body leads to a healthy mind. She has three children, 11 grandchildren and 26 great grandchildren. Downs picked an e-mail address that reveals her philosophy in two simple words: “hear today.”

She continues to meet adults and children who have benefited from her work. Just last week, she received a letter from a 50-year-old businessman who credits his success to Downs’ work.

“He thanked me for being found at birth,” Downs said. “He said he got along beautifully and got his hearing aide right after birth. That’s the kind of thing that makes you feel you have validated your parking ticket.”

By Bob Semro

How a law is implemented can be more important than the language of the law, and for that reason, we urge Colorado regulators and residents to monitor the rollout of the Affordable Care Act.

Thanks to a letter sent  on behalf of state insurance commissioners, we learned that a provision of the law, section 1334, bears watching. As it stands now, implementation could have a negative impact on how well Colorado’s new health insurance exchange serves its citizens and legal residents.

Section 1334 was designed to improve competition between health insurance carriers, which is an important goal of the ACA. It requires state-based insurance exchanges to offer at least two multi-state health plans when they begin operating in 2014. (It also requires that at least one of the multi-state plans be a nonprofit entity, that plans be licensed by states and that they meet the requirements of a “qualified” health plan.)

The reasoning behind section 1334 is that in many states a limited number of insurance carriers command the large majority of the market. The law’s drafters felt that the inclusion of multi-state plans would increase competition in the new insurance exchanges. The provision would be particularly effective in states where a very few carriers would otherwise control the majority of the market. Ideally, that competition would spur carriers to improve their plans and lower rates for consumers.

However, a loophole in the ACA could allow these multi-state plans to have a significant competitive advantage, create an uneven playing field and disrupt the state health insurance market. This potential problem was identified  by the National Association of Insurance Commissioners (NAIC), the group that sets standards and organizes the regulatory and supervisory efforts of state insurance commissioners.

The loophole is that section 1334 does not specifically require multi-state plans to be subject to the laws and regulations of those states where these plans would be employed.

The concern is that multi-state plans could be exempt from state consumer protection laws and regulations such as those governing unfair trade and claims practices, network adequacy, external review, marketing and other areas.  If allowed to operate under different standards, multi-state plans could gain a significant competitive advantage.

In addition, an uneven playing field could create “adverse selection,” where multi-state plans could attract healthier, less-costly customers while other plans would be left to cover less healthy, higher-risk and higher-cost customers. That could lead to higher premiums for many residents, and possibly force some insurers to leave the state market.

Even without this loophole, multi-state plans will have a competitive advantage. They will be offered by some of the nation’s largest insurers, and the very design of multi-state plans will allow these insurers to better spread their administrative costs across a larger number of customers.

State laws and regulations, like those in Colorado, have been developed to address unique consumer protection concerns, based on demographic criteria, business and labor markets and consumer expectations.  These laws and regulations should pertain to multi-state plans as well.

According to the NAIC, “Exempting Multi-State Plans from any of these consumer protections in a state, or substituting a single national standard for the more tailored approaches taken by the individual states, would leave some consumers with fewer protections than others, confuse them, and result in an unlevel playing field that could give the largest insurers additional competitive advantages in the marketplace, stifling competition in health insurance markets and weakening consumer protection.”

We hope that the concerns of the NAIC will be heeded and addressed. In this case, the Affordable Care Act would not have to be amended, since the law leaves the regulation and implementation of multi-state plans to the federal Office of Personnel Management. In developing regulations, OPM would have to require that multi-state plans abide by the rules in the states where insurance is sold.

The greater lesson is that how a law gets implemented has direct impact on individual Americans, and implementation happens mostly outside of our view and attention. We need to pay attention to how laws get rolled out, how regulations are written and to make sure that loopholes are closed and that laws don’t come with unintended consequences.

Bob Semro is a health policy analyst with the Bell Policy Center, a nonprofit, non-partisan think tank based in Denver.

By Jan Lewis

Schools have a responsibility to address the mental health needs of students.  Given the prevalence of mental disorders in children— especially disorders due to traumatic experiences — and the manner in which such disorders interfere with learning, attention to mental health needs is an important aspect of improving academic success.

Research in neurobiology over the past decade confirms that adverse early childhood experiences alter brain structures and chemistry.  Young children who lack consistent care-giving (due to parental mental illness, drug use, incarceration) and those who experience trauma related to violence in their homes or neighborhoods often have difficulty forming attachments, regulating their emotions and attending to instruction.

Students who have been traumatized by exposure to violence or abuse, but have not received help in processing their experiences, are vulnerable to variety of stimuli (loud noises, raised voices) that remind them of the trauma. These often trigger reactions that are disruptive to other students.  A recent study documented that classroom behavior of children exposed to domestic violence decreased their peers’ reading and math scores and increased misbehavior in the classroom.

National surveys of American youth indicate that up to 34 percent have experienced at least one traumatic event.  A recent large study of low-income families found high rates of trauma-related post traumatic stress disorder in children aged 5 to 18.  Unaddressed trauma often sets children on a downward spiral in which trauma-linked behaviors are addressed in punitive rather than supportive ways.  The numbers tell the story:  an estimated 75 to 93 percent of youth entering the juvenile justice system have experienced some degree of trauma.

Recognizing the negative impact of trauma on academic success, the University of Colorado School of Public Affairs launched an innovative pilot project in January 2010 to help address the needs of traumatized students in selected Front Range schools.  The END Violence project provided training and consultation to 28 schools selected out of 57 applicants.

During my 18 months of work in five Pueblo schools I found that a majority of teachers in selected schools welcomed training in recognizing and responding to behaviors of traumatized students, noting that such information was not part of their teacher preparation.  Seasoned teachers, counselors and administrators in lower-performing (turnaround) schools affirmed that the emotional needs of students must be acknowledged and addressed simultaneously with academics in order to achieve higher levels of student success.   The availability of school-based therapists was a boon for both students and teachers, and should be sustained.

Incorporating training on student mental health was challenging in turnaround schools where many professional development hours were devoted to district- and state-mandated topics.  A district-wide — or better yet, statewide — commitment to creating trauma-sensitive schools would help insure that all school personnel receive the training needed to recognize and respond appropriately to traumatized students.  Additionally, teachers need support in dealing with secondary trauma or compassion fatigue arising from work with needy children.

Those who have watched “Waiting for Superman” or read “Whatever It Takes” are aware that the future of our country depends on transforming education — especially in schools serving poor neighborhoods, where the accumulated costs of high dropout and incarceration rates continue to drain public coffers.  Such transformation, according to the experts, involves (among other things) cradle to college support for high risk/poor families, whose numbers have increased since the 1980s.

Pueblo, along with many other communities in Colorado, has embraced two evidence-based programs that provide support to parents of young children: the Nurse-Family Partnership (for parents of children 0-2) and Incredible Years (for parents and teachers of children 3-8).  We must strengthen and sustain these programs.  Parents of older children also need support, especially as children entering the teen years are increasingly exposed to drug use/abuse, bullying and dating violence.  Safe Dates is an evidence-based curriculum recommended for middle schools.

Without intervention, mental and emotional disorders can cause distress and disability that last for decades.

Mental health care lags behind physical health care in investment, quality, access and political will.  But we can and must change this reality for the sake of our children and their futures.

Jan Lewis is a psychiatric/mental health nurse specialist who worked with the University of Colorado’s END Violence Project in selected Pueblo schools from January 2010 to June 2011.  She previously served as statewide mental health consultant for the Nurse-Family Partnership and in various roles with the American Psychiatric Association.

 By Lloyd Burton

One of the Denver cityscape’s most compelling icons is the gold dome atop the state capitol.  It’s a colorful reminder of Colorado’s mining heritage.  And it also reminds us of the boom-and-bust cycles that financed Colorado’s growth to the point that it could support a more diversified economy.

To those familiar with what goes on beneath the dome, however, it carries an additional significance.  It’s a pointed reminder of who is literally on top in Colorado law and politics when it comes to the supremacy of mineral rights development over nearly every other land use.

Historically, policies made beneath the gold dome have almost uniformly deferred to those who gilded it in the first place— Colorado’s mineral extractive industries.  As in other Western states historically dependent on mining, rights to the minerals (including oil and gas) lying beneath the surface of the land in Colorado can be sold separately from the lands overlying them—the split estate doctrine.  Further, whenever there is a conflict between owners of the surface estate and the mineral estate underlying it, by law it is the mineral estate that prevails.

Thus, we have the living history lesson now being visited upon homeowners along the Front Range.  Drilling rigs and gas wells are sprouting up like trees and shrubs in an industrial forest, advancing on suburban developments built for the enjoyment of open spaces that suddenly no longer exist.  Rural residents of the Western Slope have been painfully schooled in these legal realities for decades.  Now our mining past is coming face to face with our suburban present on the outskirts of our major cities east of the Continental Divide.

The capitol’s gold dome is now crumbling under the weight of age and decades of structural inattention, and must undergo costly and time-consuming repairs.  Can the same be said of our century-old mining laws crafted under that century-old dome?

In recent years some Western Slope legislators have advocated measures to give homeowners a little more environmental health protection and a little more bargaining power when an oil and gas company agent shows up at their door announcing that they are about to become the proud hosts of a hydraulic fracturing operation.  Each time, their legislative efforts have been easily rebuffed by extractive industry interests that, since they adorned it in 1908, have been very much at Home Under the Dome.

Though the supremacy of the mineral estate remains the fixed star in the firmament of Colorado natural resource law, that legal terrain is otherwise nearly as much an uneven patchwork of overlapping or absent statutes, regulations and doctrines as is the state map of who owns what surface and mineral rights to what parcels of land.

While provisions of the federal Clean Water Act and Safe Drinking Water Act would otherwise ensure the protection of surface and groundwater quality at and near hydraulic fracturing sites, in 2005 the Congress exempted that practice from the jurisdiction of both.  In so doing, Congress denied to the EPA the use of the two most powerful federal laws available to protect the public health from real and potential harms associated with fracking.

So the burden of striking a balance between the fostering of a lucrative industry and protecting public and environmental health from its side-effects has fallen almost entirely to the states.

Colorado took some steps in that direction in 2007, in reconstituting the membership of the Oil and Gas Conservation Commission, and undertaking a rulemaking for the governance of fracking that mandated consideration of public and environmental health effects.  Further, other government agencies such as the Colorado Water Quality Control Commission, the Air Resources Board, the Division of Wildlife, and the county health departments in oil and gas development regions of the state also play some regulatory role.

And just as it is not possible to speak of “the government” in monolithic terms, one cannot speak of “industry” in that way either.  Since the most recent, technology-driven (ie., fracking) boom in oil and gas exploration and retrieval got under way here in Colorado and elsewhere, it has been clear that some of the major industrial players have tried to do right by way of mitigating the environmental effects of their operations, while apparently others could care less.

Back stories on the Deepwater Horizon disaster in the Gulf of Mexico last year revealed that while most of the major oil companies with deepwater drilling rigs off Alaska and in the Gulf were running fairly safe and environmentally responsible operations, BP was a company known for cutting worker safety and environmental protection corners at every turn—paying fines as a negligible cost of doing business rather than complying with the spirit as well as the letter of the law. They killed their own workers more than once in their pursuit of profits at any cost, and laid waste to the environment in the process.

Fracking-related disasters of the kind that have already occurred in Pennsylvania and elsewhere have yet to occur in Colorado, although less sensational environmental damage surely has.  Some industry players in Colorado have taken the lead in adopting best practices and being decent corporate neighbors.  But new players are entering the field, and in a big way.  We are yet to learn whether or not they will bring BP-style sensibilities to bear on the Colorado landscape.

Absent effective federal protections, it is now left almost entirely to the rulemaking and rule enforcement discretion of state regulatory agencies to ensure that our present, more environmentally protective, way of life does not succumb to our more environmentally destructive history.  But the problem with leaving everything to agency discretion is that sometimes agencies have more discretion than they actually want, and are thus more susceptible to the force of prevailing political winds than they would like to be.

Sometimes, more forceful and articulate direction in the form of new general policies crafted either by the legislature or by the voters is needed.  Such actions can either reinforce the status quo, or significantly alter it.  From a spring bear-hunting ban to hog farm regulation and renewable energy mandates, some of Colorado’s most progressive environmental policy reforms have in fact emanated from the ballot box.

The Colorado Capitol Dome is both a literal and figurative landmark.  Beneath it, among other things, lies a crossroads.  It is the point at which our past experience intersects with our current values and cultural trends, and from which our representatives fashion our policy paths to the future.   And if it doesn’t happen there — for better or worse — Colorado voters do have a habit of taking matters into their own hands.

In the case of oil and gas extraction from beneath the Colorado landscape, that path may consist of yet more deference to the primacy of mineral rights that is our historical and legal inheritance.  Or we may instead choose to bequeath to our children a renewed and reformulated heritage that puts all of our environmental values on a more equal footing.

Lloyd Burton is a professor and director of the program concentration in environmental policy, management and law at the School of Public Affairs at the University of Colorado Denver.