Health Policy Solutions

By Diane Carman

Roy Leckonby grew up ski-racing in the Northeast and joined the ski team when he came to the University of Colorado as a student in the 1990s.

“I remember on that first day of training at Eldora, looking up at the mountains of the Indian Peaks Wilderness and thinking that I could be up there skiing in all that powder instead of doing the same run all day,” he said.

What followed was a decade-long, adrenaline-fueled, sometimes insanely wild ride to the very edge of the sport’s limits.

Leckonby survived.

Barely.

With the X Games beginning in Aspen this week just days after the death of freestyle skiing celebrity Sarah Burke, who suffered a fatal injury during practice on the Eagle Superpipe at Park City, Utah on Jan. 10, the inevitable question echoes across the Rockies: Have extreme sports gone too far?

Spokesmen for ESPN, sponsors of the games, declined to comment “out of respect for the Burke family.” But the loss of Burke casts a shadow over the competition and focuses attention on extreme terrain, the adequacy of protective gear and the risks of a sport whose popularity is growing rapidly among children and adults here and around the world.

Early competitors were self-taught

In the mid-’90s, extreme skiing and snowboarding were such new sports, few coaches or teams existed. Leckonby and his college roommate taught themselves the stunts: cliff-skiing, catching air, doing flips – creating what would become the now familiar, jaw-dropping moves in extreme sports competitions.

In the winter of 1995-96, Leckonby entered his first extreme competition, a three-day championship at Crested Butte.

There were about 125 skiers participating in the men’s competition, he said. “Each day they cut the field by one-half and those remaining moved to progressively more difficult terrain.”

He placed 22^nd  – “I had a bit of a knack for it,” he said – and he was hooked.

Not only was the skiing intoxicating, Leckonby said the parties were awesome.

“I loved the atmosphere, the parties at night, the camaraderie,” he said. “You’ve got the competitive side, but not only were you competing against each other, but we all were competing against ourselves.”

They all knew how to ski a tight line on a wicked-steep slope, Leckonby said, “but the competition always was to do it more aggressively, to bring it all together and to look good.”

Recreational skiers hooked, too

With the rise of the X Games, extreme sport competitions in the Olympics and TV coverage of the spectacles, growth in freeskiing and snowboarding has exploded in the last 15 years.

Jennifer Rudolph, communications director for Colorado Ski Country USA, the nonprofit trade association for the ski industry, said that ski resorts across the West have worked hard to meet the demand for bigger halfpipes, more elaborate terrain parks and access to more advanced terrain.

Colorado has 46 terrain parks in the 22 Ski Country-member resorts. They include eight halfpipes and two superpipes with 22-foot-high ice walls like the Eagle Superpipe at Park City. One of the superpipes is at Copper Mountain; the other is at Buttermilk, where the X Games are held.

The designs of terrain parks often take cues from skateboard parks with high walls, rails, bumps and pipes. Some use snow-covered logs and woodpiles for the elements, Rudolph said. Others even recycle things like satellite dishes and worn-out lift equipment to create new challenges.

Each resort enforces its own rules on access to the parks, with some requiring users to complete a safety course, some mandating  protective gear, and all of them posting signs and warnings to prevent skiers from accidentally entering the parks and finding themselves in terrain well beyond their ability.

“Keeping the guests safe is our No. 1 priority,” Rudolph said. But ultimately, it’s up to the skiers to use good judgment. “What it really boils down to is the safety of the individual rider is that person’s responsibility.”

The National Ski Areas Responsibility Code tries to remind skiers that, while the ski patrol is there to help injured skiers, it’s up to the skiers to keep the sport safe.

The legal system formally recognizes the inherent risk in the sport as well by limiting the liability of ski areas under state statutes.

Helmets optional

Among those urging the use of helmets by all skiers and snowboarders is Kevin Pearce, who credits his helmet for saving his life when he took a catastrophic fall on the Eagle Superpipe while training for the Olympics in 2009.

Pearce, who is still recovering from a traumatic brain injury, said with the “level snowboarding is going to,” helmets are essential equipment.

Few in the industry dare suggest that they be mandatory, however

It’s “the age-old question of using regulation and enforcement or relying on common sense,” said Bruce Evans, associate professor and vice-chair of the Department of Emergency Medicine at the University of Colorado School of Medicine and senior medical director of emergency services at the University of Colorado Hospital.

While he leans toward common sense, he suggests that those who want to participate in extreme sports absolutely should wear helmets.

“I don’t think anyone in the ski industry or the state legislature — at least in the U.S.  — is ready to mandate things like helmets at this point,” he said. But athletes increasingly are getting the message.

Dr. Bruce Evans

“The reality is that helmets reduce the number of traumatic brain injuries for recreational skiers, snowboarders and bicycle riders,” he said. “Those are just the hard numbers.”

Helmets are hardly a panacea, however.

“A helmet has important but limited protective capability,” said Dr. James Kelly, an expert on concussions and director of the National Intrepid Center of Excellence of the Defense Centers of Excellence. He is on leave from his position as professor of neurosurgery at the CU School of Medicine.

A long-time advocate for the use of helmets in sports, Kelly recognizes their limitations.

After all, Sarah Burke was wearing one when she was fatally injured. Her death was caused by “extraordinarily low-frequency injury” more often associated with whiplash, Kelly said.

Burke, 29, fell while practicing on the superpipe, hitting her head on impact. She lost consciousness and was not breathing when rescuers reached her. She died Jan. 19 , reportedly of complications from a torn vertebral artery.

Still, Kelly supports ski resorts that require children in ski school to wear helmets. (Kelly has been a consultant to the Aspen Ski Co. for a decade, teaching ski patrol members how to treat concussions.)

Dr. James Kelly

Faster, higher, riskier terrain

The incidents with Burke and Pearce also have drawn attention to the terrain park designs and the superpipes in particular.

“If an athlete is 25 feet off the deck (above the top of the 22-foot-high halfpipe) and lands on his or her head, some would argue that a helmet might not make any difference,” said Evans. “You can’t build body protection that will prevent every injury.”

It’s one reason why some Colorado ski resorts require guests to demonstrate a certain skill level and undergo safety training to gain admittance to the most challenging terrain.

Leckonby said that skiers and snowboarders who don’t wear helmets are “idiots,” and that the sports are moving toward finesse – not just speed, height and danger – in competitions.

“In the freeskiing movement for a long time people thought the best ones were those who went off the biggest cliffs,” he said. “In recent years, more style has come into the sport, with more flips, spins and grabs.

“We don’t need 22-foot walls to make a jump look good or to be 20 feet out of the pipe to show your skills, talent and how much style you can put in a jump,” he said.

“Bigger is not necessarily better.”

There will always be those who are drawn to extreme risks, however, said Evans. “That’s always been part of the game. It’s been called the ‘Gladiator Effect.’”

Realizing that, Evans said he works hard to help his 8-year-old son learn to compete safely. If he chooses to become an extreme athlete, he’ll have his father’s support.

“My responsibility as a parent is to help him understand how to do it by providing him with good training and with the safety equipment he needs, and trust that he makes good choices.”

Leckonby was lucky

All through college and beyond, Leckonby kept skiing harder, more and more aggressively, and competing across the West.

Roy Leckonby skiing at Crested Butte

For a long time, his only real injuries were torn anterior cruciate ligaments, one in each knee. They were the kind of injuries any weekend athlete might experience on an ordinary ski slope or tennis court.

Then he was skiing in a competition in Taos in 2008. He was on a heinous mountainside – steep with exposed rock faces with narrow strips of snow cutting between them. He spotted his line, shoved off, made one turn and launched himself into the air. He tumbled on his landing, coming to an abrupt stop when he smashed his head on a rock.

He was airlifted to a hospital in Albuquerque in a coma, where doctors found he had multiple fractures in his C5, C6 and C7 vertebrae and contusions on his brain. He survived, though it took a year to recover.

“I was a pretty lucky dude to be alive,” he said.

The crash marked his retirement from active participation in the sport.

Now 34, he still has the urge to compete. “It’s a mental struggle,” he said.

A frequent judge at ski competitions, he said he visualizes himself skiing those tight lines, making the jumps, and in his mind he always nails the landings. “I’m convincing myself I can do it.”

It’s just a head trip, though. He said he had a great powder day skiing in-bounds last weekend, but he doesn’t jump off cliffs anymore.

On the night after Sarah Burke died, Leckonby and dozens of other freestyle ski enthusiasts were at the Boulder Theatre for a benefit screening of “Winter,” a documentary featuring Burke and her husband, Rory Bushfield. Tears were shed as the stunned audience watched the beautiful, iconic figure on the screen.

“Her death is a huge loss to the sport and to women and to the progress that happened because of her leadership in sports,” said Leckonby, senior director of operations at RealD in Boulder. “It was very emotional. We all were just trying to make sense of it.”

So the question begs to be asked. Given his near-death experience, was it worth it?

“It was absolutely worth it,” said Leckonby.

The X Games are scheduled to begin tomorrow.

By Dr. Chris Urbina and Kate Paul

While many Coloradans focus on their 2012 New Year’s resolutions, community and public health leaders across the state are pledging to improve the oral health of all Coloradans.

Diseases of the mouth get little attention compared to the many other medical issues, but these diseases directly impact the economic health of our state. In 2010, Americans spent an estimated $108 billion on dental services. Oral diseases, pain and infections account for 164 million lost work hours nationally and about 7.8 million lost school hours in Colorado.

Because oral diseases are almost entirely preventable, this is a public health and finance battle we can and must win.

Gov. John Hickenlooper is focusing his leadership on improving oral health, and the Colorado Department of Public Health and Environment recently named oral health one of the state’s 10 Winnable Battles. Many foundations, nonprofits and individual dentists have committed resources to helping Coloradans maintain good oral health — especially for those who can least afford dental care.

Delta Dental of Colorado joined the battle by launching a $3 million fund to provide two years of free dental insurance to needy people across the state. The Delta Dental of Colorado Fund is approaching its three-month anniversary, and already more than 3,500 Coloradans have signed up to receive assistance.

In Colorado, 42 percent of adults lack dental insurance. Research shows that a vast majority of people who have dental insurance report seeing a dentist twice a year or more. These regular checkups are a crucial component to maintaining good oral health and one that is all too often abandoned when times are tight.

Dental disease hits low-income Coloradans harder than any other group. And like other public health issues, low socio-economic status residents too often find themselves receiving emergency dental care rather than the preventive care that helps to head off more expensive problems and medical complications.

Children are of particular concern. Dental disease is the most common chronic childhood disease, surpassing even asthma. In 2010, only 3 percent of Colorado children had visited the dentist by their first birthday as recommended. By age 5, one-third still had never seen a dentist.

By following some simple steps, parents can help protect their children from dental disease:

• Do not share spoons, forks or cups – germs that cause tooth decay can be passed from parent to child
• Never put a baby to bed with a bottle filled with anything but water
• Only put formula, milk or water in a baby bottle – no juice or sweet drinks
• Don’t dip pacifiers in honey or sugar or clean them with your mouth
• Cut down on sugary drinks, including soda, juice and sports drinks
• Everyone in the house should brush twice daily and floss

Good oral health and access to quality dental care is a problem that is completely within our grasp to solve. Through innovative public/private partnerships, dedicated health professionals and the support of educated community members, we will achieve real change and improved oral health for all Coloradans.

Dr. Chris Urbina is the executive director and chief medical officer of the Colorado Department of Public Health and Environment. Kate Paul is president and chief executive officer of Delta Dental of Colorado. For more information about the Delta Dental of Colorado Fund, visit www.deltadentalco.com or call 720-489-4713.

By Sasha Dillavou

Goals from injury prevention to reducing unintended pregnancies are among the “10 Winnable Battles,” identified Tuesday by the Colorado Department of Public Health and Environment.

“Many public health and environmental health agencies at the local level already have embraced certain of these battles where they will be focusing some of their efforts in the next few years,” said Chris Urbina, executive director and chief medical officer for the Department of Public Health and the Environment. “In addition, we are working with our counterparts at the Colorado Department of Human Services and the Colorado Department of Health Care Policy and Financing to coordinate our efforts in these areas.”

The “10 Winnable Battles” include clean air, clean water, infectious disease prevention, mental health and substance abuse, obesity, oral health, safe food and tobacco as well as injury prevention and unintended pregnancy.

“Colorado’s local public health officials are excited to work with our many state-agency partners to address the winnable public health battles. These state level battles will help guide prioritization in our local communities and keep us connected to our neighboring agencies across the state,” said Jeff Kuhr, public health director, Mesa County Health Department.

The department used health data measurements to identify the winnable battles and will track progress through measurements of health outcomes and environmental progress.

By Diane Carman

When the Colorado Springs City Council voted 9 to 0 last week to endorse a proposed lease agreement between the University of Colorado Hospital and city-owned Memorial Health System, it moved the Rocky Mountain region one step closer to a tectonic change in the landscape of health care.

If Colorado Springs voters approve the plan, the University of Colorado Hospital (which is affiliated with the university, but is an independent legal and financial entity) will assume administration of the nonprofit Memorial Hospital.

That would be one more step in the long-term drive to expand the University of Colorado Hospital into a statewide nonprofit health care and education network.

“It’s a very compelling, strong bid,” said Phil Lane, chair of the Regional Leadership Forum in Colorado Springs and a member of the task force convened to study the future of Memorial Hospital.

The University Hospital bid was one of several submitted to the city. Others came from Centura Health, HCA-HealthOne, and the Sisters of Charity of Leavenworth Health System.

“Every bidder had a fair opportunity to put his best foot forward,” said Lane. “They all were very strong bids. But we felt the University of Colorado Hospital’s bid was the most compelling.”

In addition to the financial compensation to the city that was part of every proposal, the University Hospital bid includes a plan to establish a branch campus of the CU School of Medicine at the University of Colorado Colorado Springs. If it comes to pass, it will represent the first stage of a four-decade effort on the part of Richard Krugman, dean of the CU School of Medicine, to expand the reach of the med school beyond its Denver location.

University of Colorado Colorado Springs campus

“As long as I’ve been here, which is 43 years, the School of Medicine has had a responsibility and a mission to deal with the health care needs of all of Colorado,” said Krugman. “For about 30 years as I’ve traveled around Colorado, I’ve been saying, if we have Colorado in our name, it should refer to the state, not the boulevard.”

For most of Krugman’s tenure, the CU School of Medicine was “the only medical school for 500 miles,” he said. “We started thinking that there are better ways to do what we’re doing.” Placing advanced students in clinical rotations and ultimately developing branch campuses around the state has been a goal of the school for years.

Economic package

The University Hospital bid for Memorial Hospital calls for “total economic consideration of $1.79 billion.”

It includes an initial lease payment of $74 million, a $5.6 million annual payment for 30 years, a $1.12 billion capital commitment over the lease period, $3 million per year to establish the branch campus of the medical school at UCCS, and a profit-sharing plan projected to produce $2.5 million in revenues per year for the city. The bid also calls for University Hospital administrators to develop strategies to deal with the pension liability of the hospital, including possibly allowing some employees to remain in the Public Employees’ Retirement Association.

The community also is eager to capitalize on perceived economic development opportunities from the University Hospital/School of Medicine proposal. A recent story in the Colorado Springs Gazette detailed the impact of development of the Anschutz Medical Campus on the surrounding area, citing a figure of $4.6 billion so far.

Lane said Memorial Hospital “has not kicked out a lot of money” to the city over the years, and that the University Hospital bid is “an improvement over the current financial situation.”

Despite that, he said, “In any deal you get certain things and you give certain things. There is an understanding and recognition of that.”

In return for the financial compensation, the city will relinquish some control over what happens at the hospital, he said. Still, “with the University of Colorado Hospital proposal, there will be a significant amount of decision-making that remains in Colorado Springs. I feel like it’s a fair trade-off.”

Lane said the city hopes ultimately to have a “full-fledged adjunct campus of the medical school with full-blown residency programs.”

The benefits to the community would be far reaching, he said. Physicians often choose to practice where they do their residencies, “which translates into a good, steady stream of physicians for the region, more young professionals in the community … and an opportunity for enhanced research dollars and programs in Colorado Springs.”

Also, since the Beth-El College of Nursing and Health Sciences is strong and has a long history with Memorial Hospital, it is expected to expand and thrive in association with the CU School of Medicine.

Gradual development

If Colorado Springs voters approve the plan, the branch medical school campus would develop slowly.

Krugman said the School of Medicine already has about 500 short-term medical student rotations all across the state.

These are two-, four-, six- and eight-week blocks in hospitals and medical practices.  A branch campus in the Springs would allow students to do most or all of their clinical rotations there – not just the short-term rotations.

This would create more opportunities for residencies over time, which is one factor that has inhibited the ability of the med school to expand enrollment and meet the need for more health care workers in the future.

“If all goes extremely well,” Krugman said, the first students to be ready to do their clinical work in the Springs would be the class entering the medical school in 2013. That means they would begin their clinical rotations there in the spring of 2015.

Richard Krugman

“We actually have 12 medical students who commute here from Colorado Springs and they already want to do as many rotations in Colorado Springs as they can,” he said, so even without expanding the enrollment, some students can be expected to request assignments in Colorado Springs.

Enrollment at the med school would not increase significantly until the branch campus is fully accredited, Krugman said.

Challenges still lie ahead

While the City Council’s unanimous approval is important, the plan is a long way from implementation.

Krugman described the best-case scenario:

“If everything goes amazingly smoothly, if through the magic of spasms of political collaboration this doesn’t become a polarized, political football in Colorado Springs, and if negotiations between University Hospital and the city go well and they agree on a lease that everyone is willing to accept, and it goes to a vote of the people and nobody tries to suborn that by saying, ‘Just say no,’ which is one of our favorite things to do now, the $3 million could arrive at the School of Medicine this summer.”

That would allow the school to begin the process of organizing the faculty and programs so that current students could begin test-driving small-scale rotations in Colorado Springs.

System changes anticipated

While the Colorado Springs proposal winds its way through the approval process, the University of Colorado Hospital administration is continuing negotiations with the Poudre Valley Health System in Fort Collins to form another joint venture. The expanded role of the organization will result in a name change. The University of Colorado Hospital soon will become the University of Colorado Health System.

University of Colorado Hospital

In its bid for the Memorial Hospital lease, the University of Colorado Hospital pitched the “strategic benefits” of an alignment with the health system, which includes its partners: the Children’s Hospital Colorado, the University of Colorado and, if all goes as planned, the Poudre Valley Health System.

“…We offer a vision for developing a strategic statewide partnership that will transform health care delivery, proactively respond to environmental changes and provide long-term benefits to our local communities, the state and all Coloradans,” the bid says.

While the partnership allows for close collaboration, all the hospitals will maintain their separate boards and administrations. Economies of scale are anticipated, however.

“Scale matters in this business these days,” said Lane. “At a minimum, a combined entity of significant more scale can hopefully reduce costs to businesses, individuals and the citizens in our region.”

Krugman said having the branch campus of the medical school in Colorado Springs (or anyplace else in the state that a branch might be created) improves the quality of health care for that region.

“The best way (for a provider) to be sure to be up to date in health care practice is to have a student with you,” he said. Students bring the latest developments in health care to a practice and often challenge physicians to consider new approaches to medical care.

Ultimately, once the branch campus is accredited, an additional 24 to 48 medical students could be enrolled in the CU School of Medicine, which has grown from enrollment of 132 students a few years ago to 160 students today.

Support for the branch campus would come from the $3 million per year allotment from the Memorial Hospital revenues, tuition and fundraising.

Krugman said fundraising could allow for such things as new classroom space, a simulation center or an endowment for the program. “If somebody wants to come up with a $75 million gift, he could have his name on the clinic branch campus in Colorado Springs.”

No date has been announced for the ballot measure to put the proposal before Colorado Springs voters.  Lane said he expects it to appear on the ballot no later than November.

To date, no formal opposition to the bid has mobilized. “There are folks who would prefer this didn’t happen,” said Krugman. “I think it’s fair to say HCA would rather have Memorial for itself and I suspect they could afford to do some just-say-no PR. So who knows what will happen?”

Ed Kahn

Ed Kahn, special counsel to the Colorado Center on Law and Policy, said that while the quality of care provided by the University of Colorado Hospital is unquestioned, its mission as a teaching hospital has limited access to care to the indigent in the past.

Kahn said the center sent a letter to the Colorado Springs City Council noting that Memorial Hospital has had a good track record of providing charity care to the people of Colorado Springs and that “while University Hospital and the med school don’t discriminate against poor people, their mission is to be a teaching hospital.”

The organization urged the council to stipulate that charity care will continue to be a priority at Memorial under any new lease arrangement.

Despite the challenges that lie ahead, Lane remains optimistic.

He said the lease agreement presents an opportunity “for improved health care for this region and up and down the Front Range.”

Still, he cautions people not to expect things to change overnight.

“We still have a long way to go,” he said, “and even if it comes to fruition, the benefits will accrue over time.”

By Bob Semro

Under the Affordable Care Act, the lion’s share of each insurance premium dollar must be spent on health care.

That notion might seem obvious, but previously there was no national standard for what is termed the “medical loss ratio,” or MLR. The ratio measures the split between health care spending and administrative and other costs. (Incidentally, MLR is an old insurance term that comes from the accounting departments, where spending on medical care was considered a loss deducted from income.)

Last month, the federal Centers for Medicare and Medicaid Services issued the final MLR regulation for the Affordable Care Act (ACA), and it has the potential to reduce premiums for consumers and businesses.

Under the ACA, health insurance carriers will be required to spend at least 80 cents on medical care for each premium dollar charged to consumers in the individual insurance market. That would leave 20 cents to cover profit, marketing and overhead. (For the large-group market, the MLR would be 85 cents of every premium dollar.) Companies that do not meet the MLR requirement will be required to pay a rebate to their customers beginning in August of this year.

As of 2009, Colorado’s top 10 health insurance carriers had MLRs ranging from 80 to almost 92 percent, so meeting the new MLR may not be especially difficult for them.

Nationally, about 45 percent of consumers who purchase insurance in the individual market are enrolled in plans that spend more than 25 cents of every premium dollar on administrative costs. In the most extreme cases, some insurance plans spend more than half of every premium dollar on administrative costs.

The basic question that regulators wrestled with before setting the MLR was what qualifies as “health care service” and what constitutes an administrative expense, marketing or other cost. It is not always clear-cut, and the issue could still affect the MLR rule.

In November, the National Association of Insurance Commissioners endorsed a resolution urging Congress and the Department of Health and Human Services to exclude broker and agent commissions and fees from the medical loss ratio rule. The resolution states: “Congress should expeditiously consider legislation amending the MLR provisions of the PPACA in order to preserve consumer access to agents and brokers.” If broker commissions and fees are excluded from administrative costs, it would allow increased spending on administration and have the effect of reducing the amount spent on medical care.

The resolution was not unanimous, passing on a 26 to 20 vote of state insurance commissioners, but there is little doubt that it will be used to support national legislation seeking this change.

Consumer groups contend that if this kind of legislation were implemented, it would hinder the very purpose of MLRs, which is to increase the amount of money insurance companies spend on medical care. It would also have the potential to reduce the rebates paid to consumers.

Projected rebates to customers whose insurance carriers do not meet the MLR targets are hardly insignificant. Nationally, it is estimated that up to 9 million Americans could receive rebates totaling between $600 million and $1.4 billion. Those forecasts may be high, since there are indications that some carriers have lowered the rate of premium growth, in part to avoid paying out potential rebates.

Here are some of the features of the recently established MLR requirement:

• Rebates to consumers are tax-free.

• Transparency is increased. Consumers are notified of rebates, and insurance companies are required to publish their MLRs and a history of their performance.

• “Mini-med” plans (coverage designed for workers in low-wage jobs) will have to phase in the annual benefit cap provisions of the Affordable Care Act.  Mini-med plans had previously been given a waiver for implementing those provisions.  All annual benefit caps will be eliminated in 2014.

• Levels the playing field between for-profit and non-profit insurers for states that tax premiums.

The ACA’s medical loss ratio provides a real opportunity for bending the cost curve for premiums for consumers and businesses and will play a vital role in making health insurance more affordable, as long as attempts to minimize its effectiveness are checked.

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

By Katie Kerwin McCrimmon

Colorado lawmakers may have little enthusiasm for tinkering with the state law that regulates medical marijuana facilities even as the federal government cracks down on facilities less than 1,000 feet from a school.

Senator Pat Steadman, D-Denver, who supported House Bill 10-1284, which sets regulations for the industry, said it’s premature since the 2012 session just began, but he’s heard little enthusiasm from fellow lawmakers to reopen the debate.

“There’s not a lot of desire in the legislature to reopen the medical marijuana regulations and make changes,” Steadman said.

Steadman, who supports full legalization of marijuana, said the federal crackdown was “disappointing, but not surprising.”

He hoped Colorado’s regulation of the medical marijuana businesses would protect them from federal action.

“One would have hoped, but the feds are the feds and they’re going to do what they want to do,” Steadman said.

He believes the proximity of dispensaries to schools isn’t a key issue. He believes that buffer zones create a “false sense of security.”

“There’s nothing magic about 990 feet or 1,001 feet. Generally it feels somewhat nanny state to prescribe a certain radius and to think that you’ve solved the problem or prevented a harm,” Steadman said.

Meanwhile, the medical marijuana industry is split over how to react to the crackdown.

Robert Corry, a lawyer who represents dispensaries, told 9News that he’s advising clients to ignore the threat. He called the crackdown a “colossal bluff.”

Michael Elliott, executive director of the Medical Marijuana Industry Group, which represents about 50 dispensaries and bills itself as the largest industry group in the state, released a statement Friday saying the group supports state law and wants to keep medical marijuana away from young people.

“The Medical Marijuana Industry Group  supports keeping regulated substances out of the hands of unauthorized users and out of schools.

“We strongly support Colorado law regulating medical marijuana, as do the vast majority of voters,” Elliott said.

Colorado’s law recommends that dispensaries be located at least 1,000 feet away from schools, but allows local cities and counties to develop their own regulations. Colorado Springs, for example, allows dispensaries to be just 400 feet from schools while Denver has allowed numerous facilities closer than 1,000 feet because they opened prior to any Denver or state law regulating medical marijuana.

By Katie Kerwin McCrimmon of Solutions and Rebecca Jones of Education News Colorado

The federal government is cracking down on medical marijuana dispensaries in Colorado for the first time, today ordering 23 dispensaries near schools to shut down within 45 days or face criminal prosecution and seizure of their property.

U.S. Attorney John Walsh sent warning letters to the unidentified dispensaries and said in a news release that many are closer than 1,000 feet to K-12 campuses.

“When the voters of Colorado passed the limited medical marijuana amendment in 2000, they could not have anticipated that their vote would be used to justify large marijuana stores located within blocks of our schools,” Walsh said.

Federal authorities are working to identify all marijuana stores within 1,000 feet of a school, he said, and today’s warnings “are merely a first step to address this issue.”

“The office will continue to insist marijuana stores near schools shut down,” he said.

Walsh cited data showing many school districts in Colorado “have seen a dramatic increase in student abuse of marijuana, with resulting student suspensions and discipline” since medical marijuana facilities opened.

An ongoing investigation by Education News Colorado, Solutions and the I-News Network found a 44 percent jump in all drug-related incidents at K-12 schools statewide over the past four years. That increase occurred from the 2008-09 school year through 2010-11.

The figures from the Colorado Department of Education don’t specify the drugs involved, but several school and health officials interviewed across Colorado attributed the increase to marijuana use.

“We’ve really seen our numbers go up,” said Judy Mueller with YouthZone, a Glenwood Springs nonprofit that works to keep young offenders out of juvenile court. “It is medical marijuana that their friends or friends’ parents got. They’re telling us it’s easy to get. They’re getting it from an adult’s stash.”

The investigation also found that other dispensaries could be targeted under the crackdown. As many as 56 medical marijuana facilities in Colorado are located within 1,000 feet of a school, according to an I-News analysis of school addresses and licenses issued to more than 700 medical marijuana facilities statewide.

Today’s action sets up a potential showdown between federal and local authorities, though legal experts agree that federal law – which clearly states marijuana is illegal – trumps local law.

Federal law also imposes enhanced penalties for any drug use within 1,000 feet of a school.

State law recommends a 1,000-foot buffer between medical marijuana facilities and schools, drug rehabilitation centers and child care centers. But the law allowed local authorities to set their own rules.

So Colorado Springs, for example, allows marijuana facilities within 400 feet of schools while Denver has several closer than 1,000 feet. Those facilities have been allowed to continue operating because they opened before the state law was enacted.

Among other findings of the investigation:

• Up to 45 public schools are within 1,000 feet of a medical marijuana facility. The range — depending on how you measure the distance — is from 31 to 45. Because there are multiple medical marijuana facilities near some schools, the total number of medical marijuana facilities within 1,000 feet of Colorado schools is up to 56.
• Most of the schools closest to dispensaries are in Denver and Colorado Springs. For example, North High School in Denver and Palmer High School in Colorado Springs have marijuana facilities within 1,000 feet.
• Overall, 370 of the 1,692 public school buildings in Colorado lie within a mile of a medical marijuana dispensary or product infusion manufacturer. That’s 22 percent – or between one-fourth and one-fifth of all schools.

Rumored for weeks, the Colorado crackdown follows similar federal action in California.

Colorado medical marijuana industry officials had hoped that they would dodge federal enforcement because they say the state tightly regulates the marijuana industry.

Mike Elliott, executive director of the Medical Marijuana Industry Group, which describes itself as the largest and most influential group in the state, said people in the industry support regulation.

“We are looking into the situation now. We fully support keeping regulated substances out of the hands of unauthorized users and schools,” Elliott said in a written statement.

“Towards that end, MMIG is in the process of putting together, and will announce soon, the details of a public education campaign to help educate medical marijuana patients about how to keep their medicine safe and secure.”

School officials welcomed the news of a crackdown.

“We are supportive of the law as written and are glad to see the U.S. Attorney enforcing the buffer zone,” said Antonio Esquibel, executive director of the West Denver Network Schools, including North High School.

U.S. Rep. Jared Polis, D-Boulder, has tried to pin down the U.S. Attorney General regarding federal enforcement of medical marijuana businesses that comply with state law.

Polis released a statement today saying that he supports keeping dispensaries at least 1,000 feet away from schools.

“Both federal and Colorado law state that dispensaries are not allowed within 1,000 feet of schools, which is a policy that makes sense, that I support, and with which all businesses should comply,” Polis said. “The Justice Department has repeatedly made clear that dispensaries that are in compliance with state law are not an enforcement priority. Colorado’s tough system of medical marijuana regulation is the best way to keep drugs out of the hands of minors.”

National and local studies in Colorado show that marijuana use among minors is on the rise.

Dr. Chris Thurstone, who runs a drug and alcohol treatment program at Denver Health, said that 95 percent of the young people in his program are being treated for  marijuana abuse or dependency. He walked around East and North high schools in Denver and was shocked at the number of dispensaries located near the schools.

Thurstone can’t prove the proximity of dispensaries has caused the spike in marijuana abuse among his patients, he said, but he cited research showing teen marijuana use rises when it’s easily available, socially acceptable and perceived not to be harmful.

“There’s been lots of debate about how close to a school it should be,” Thurstone said. “Should it be 500 feet, 1,000 feet? Should we grandfather in the people who are already there? It kind of blows my mind that that’s a debate.”

About the data:

The analysis compared the locations of public schools in Colorado compiled by the state Department of Education to the addresses of medical marijuana dispensaries and infused product manufacturers from the Colorado Department of Revenue using  ARCview GIS software and its geocoding technology.  Not all marijuana facilities could be mapped because of problems with the addresses. Duplicate schools at the same physical address were not counted twice and online schools were not included in the analysis. Using the GIS software, the analysis electronically calculated the distances between schools and marijuana addresses.

It calculated a range of schools that could be within a 1,000 feet of a medical marijuana facility since the software calculates distances between addresses and the state law measures from property line to property line.

By Brittney Petersen and Cody Belzley

For the second year in a row, Colorado has been celebrated – and rewarded – for its success in ensuring children can get the care they need to stay healthy and can see a doctor when they get sick.

Colorado has been awarded $26.1 million in federal funding from the Department of Health and Human Services for implementing five policies that make it easier for families to access affordable, quality health care and help the state to stretch taxpayer dollars further by cutting red tape. The result is more kids covered, improved government efficiency and a $26 million windfall for a state budget that desperately needs it. It’s good news all around.

We are also way ahead of the curve nationally.  Colorado was one of 23 states awarded a federal bonus for meeting criteria established in the 2009 federal reauthorization of the Child Health Insurance Plan and demonstrating a significant increase in the number of children enrolled in public insurance programs. The policies that qualified Colorado for the money included commonsense changes like removing the asset test, eliminating need for in-person interviews when applying for the programs and aligning policies across Medicaid and Child Health Plan Plus (CHP+).

Of the 23 awards, Colorado’s bonus of $26.1 million from the Department of Health and Human Services was the third-largest — behind only Maryland and Virginia — and was nearly twice the amount awarded to Colorado last year. The additional federal revenue is welcome news to Colorado policymakers who are struggling to balance the state’s budget in the face of continuing economic hardship around the state, which has led to a growing demand for safety net programs, including Medicaid and CHP+.

Thanks to the leadership of state policymakers and the partnership with community leaders over the last three years, Colorado has shown that policy change can make a meaningful difference in the lives of children. According to 2011 data from the Colorado Health Access Survey, while the overall number of uninsured Coloradans rose significantly from 2009 to 2011, the number of uninsured children ages birth to 18 held fairly constant, rising from 7.9 percent in 2009 to 8.2 percent in 2011. This is the lowest increase in the rate of uninsured experienced by any age group and is a reflection, a least in part, of the new policies enacted during the same period to expand access to and improve operations of public insurance programs in our state.

While these policy changes and the resulting federal bonus is certainly good news to celebrate now, they are also clear signs that more work remains to be done – both in terms of extending coverage to the more than 112,000 Colorado kids who are still uninsured and in terms of continuing to improve efficiency in public coverage programs. Luckily, there is reason to be optimistic on both fronts.

Colorado’s Health Benefit Exchange is moving ahead and will provide a new point of access for affordable, quality coverage for all Coloradans, including kids, when it is up and running in 2014. New consumer protections provided by the Affordable Care Act ensure that kids can’t be denied insurance coverage for previous medical conditions and that young adults can remain on their family insurance to age 26. And recently passed state laws that are slated for implementation in the years ahead will further streamline eligibility across Medicaid and CHP+ and ensure 12 months of coverage for kids in Medicaid.

However, to realize the promise of these changes, lawmakers and agency officials must be committed to fully implementing the policies in place.  We need our leaders to hold strong and not back down from their commitments to ensure that all kids have access to the health care they need to grow up healthy and strong.

As the 2012 legislative session gets underway, we hope the momentum of the past few years and the positive results we’re seeing in the data give policymakers the encouragement and fortitude they need to continue this progress on behalf of Colorado’s children.

Brittney Petersen is the Covering Kids and Families project manager at the Colorado Community Health Network. Cody Belzley is vice president for health initiatives at the Colorado Children’s Campaign. Covering Kids and Families and the Colorado Children’s Campaign are proud to be leaders of All Kids Covered, a statewide coalition dedicated to improving health coverage and access for Colorado children. 

By Mark Wolf

Dr. Ken Gershman pores over the data. He knows what is coming, knows generally what form it will take and knows it could be deadly.

Gershman, director of communicable diseases at the Colorado Department of Public Health and Environment, tracks half-dozen indicators looking for trends that will yield clues to the type and severity of flu season Colorado is likely to face.

“Every season is different and until it happens you can’t tell if it’s going to be mild, medium or large. Right now it’s too early to tell,” said Gershman.

Dr. Ken Gershman

Typically, the flu season begins in November with the number of cases picking up either after Thanksgiving or after Christmas. “It tends to peak in late January and mid-March, anywhere in that six- or seven-week period. Last season it was late February,” he said.

Of the six indicators the department tracks, one gets special attention.  “The main indicator that tells us about severity is reported hospitalizations from flu so when we talk about cases of flu there’s no way to count everyone who’s sick with flu because a lot of people are sick at home,” said Gershman.

“We’ve been tracking hospitalization since the 2004-05 season. We have a range of numbers and if the numbers are exceeding that by a lot, that would be an indicator either the season is peaking early or it’s going to be a more severe season.

“Last year (considered a moderately severe season) we had a little over 1,000 hospitalizations, as many as we had seen in any of the other high flu seasons not counting the pandemic when we had over 2,000.”

Youngest, oldest most vulnerable

Looking inside the data, the department pays close attention to the age of patients hospitalized for flu.

“We expect the highest rates to be in the very youngest and very oldest:  a U shaped curve. Infants and people over 65, especially over 80 tend to have a high rate of hospitalization. If we saw something different than that, it wouldn’t necessarily indicate a more severe season but a different kind of season.

“Interestingly in the (H1N1) pandemic a couple of years ago older folks seemed to have some protective immunity from earlier in life when they were exposed to similar viruses that had been circulating in the 1920s after the 1918 pandemic. The higher rates in hospitalization than typically expected were people in their 20s, 30s, 40s and 50s. That’s what somewhat characterized the pandemic as different from a regular flu season.”

Results thus far from laboratory testing of confirmed flu cases lead Gershman to believe Colorado is likely to face a Type A predominant season.

“So far we’re seeing almost all Type A flu, almost no H1, the pandemic virus of 2009. We’ve seen a teeny bit of (H1) and we’ll probably see more Type B. Nationally there’s a little more Type B than we’re seeing in Colorado,” said Gershman.

“Sometimes the Type A will peak first, then we’ll have later a Type B virus.”

Based on the current data, the vaccine available for this flu season appears to be an effective combination to combat the strains being reported.

“The information to date is the vaccine match will be good,” said Dr. Bill Burman, director of the Denver Department of Public Health. “It’s a highly mutable virus that changes all the time. One of the challenges is to try to stay one step ahead of the virus.”

Even with a good immunization match and absent a pandemic, people don’t pay enough attention to flu season, said Burman.

“Influenza is the Rodney Dangerfield of infections. We’re so used to it that we don’t give it its due. It is a significant event every flu season. There will be excess hospitalizations, cases of pneumonia and deaths every year. If it was a brand new illness we’d say, ‘What is going on?  We have to combat that.’ ”

According to the Colorado Department of Public Health and Environment, Colorado had 69 influenza-associated deaths during the 2009-2010 flu season, including 23 in the 25-49 age group and 12 in the 17-and-under group.

“I would describe (the 2009 H1N1 pandemic) as a novel strain of the virus. It shifted enough that it was unfamiliar,” said Joni Reynolds, then-director of the state public health department’s immunization section.

“Eventually we had plenty of vaccine but we actually saw the disease spreading in the community before we had vaccine available.”

The 2009 flu season started much earlier than usual.

“We got hit first in the spring, it really subsided in the summer then started up in the fall when kids were going back to school. In August and September it really began to spike and vaccine didn’t become available until later in September,” she said.

“It also affected populations differently. Typically we would see older and younger stratas, but we actually saw many cases of middle-aged adults and we saw an unusually high number of pediatric deaths that year with 12 children dying of flu where we usually see one or two cases of pediatric deaths in a given year,” said Reynolds, who was appointed the department’s director of public health programs in July 2011.

“It was a convoluted vaccination strategy because we had different risk tiers with health care workers as one of the critical risk tiers. What we saw in New York City over the summer was quite alarming with their emergency rooms being overrun and inundated with people that were sick. The concern was if we didn’t have health care workers vaccinated, then they would get sick and we wouldn’t be able to staff and take care of the other sick people.”

Though 2009 was a unique event, Reynolds said lessons learned from that flu season have been carried forward, especially in planning on a community level.

“We were really forced to do that during H1N1. The state health department became the conduit for all vaccines into the state. Currently and in all other seasons, it’s a blend. We need vaccines from the state to go to public providers like public health departments and community clinics, but then private doctors buy their own vaccines and it comes in through a private sector route.

“The reality was during H1N1 is it all came through one place and it required a coordinated effort at a community level. Who’s going to be able to find the pregnant women in our community because they’re at high risk? Who’s going to vaccinate the health care workers? Carrying those lessons forward to say if we can do this strategically as a community about vaccine supply and where our risk populations are, we’re going to better serve our community than each one of us considering the best way to use the vaccine that we each have,” she said.

Year in and year out, the best tool for controlling influenza in a community is vaccination, said Burman. “People who are sick should stay home and not go to work. Hand-washing makes a difference.”

Quicker methods for vaccine development sought

Flu vaccines are traditionally produced by using fertilized eggs but the first U.S. facility to make vaccines by using cultured animal cells has been dedicated in Holly Springs, N.C.

“The timelines to get to which strain to put in the virus to have a completed vaccine is a race to beat the next year’s flu,” said Burman. “The hope of cell-based vaccine is you could move that (timeline) more quickly. A number of other vaccines such as hepatitis B are cell-based so there’s a track record there.”

The number of people receiving flu vaccinations through Denver Health are down somewhat this year, said Bryce Andersen, clinical nurse coordinator for Denver Public Health Immunization Clinic.

“Our numbers are a little low. We haven’t had many reported flu cases and people are sort of not taking it as seriously,” he said.

“It’s pretty typical that people don’t think of being vaccinated until season starts or (they hear)  it’s going to be a bad season. On average it takes two to three weeks to build up enough immunity so if they wait until the last minute they could be exposing themselves to the flu virus.”

Supplies of the shot and mist vaccine are plentiful, said Andersen. “The whole metro area has plenty. The shipments came in ahead of schedule so there are no excuses. Kids usually prefer the mist because they don’t like shots. Adults still prefer to get the shots. They watch their kids do it and don’t like the idea of liquid in their nose.”

Range of indicators monitored

In addition to tracking influenza-related hospitalizations, the Colorado Department of Public Health and Environment monitors a number of other flu-related indicators.

“Kaiser Permanente gives us electronic data every week about how many people meet our definition of influenza-like illness that aren’t laboratory confirmed.  Out of all their office visits, let’s say they see 10,000 people in Denver area, they will tell us how many people meet our criteria of an influenza-like illness and we can calculate a percentage and track that week by week,” said Gershman, the department’s director of communicable diseases. “It gives us an inkling of people who aren’t sick enough to get hospitalized but are sick enough to go to the doctor and they’re out in the community with influenza-like illness.”

A group of hospital laboratories report each week on how many specimens they test and how many are positive for the flu virus. If the hospitals get a positive test they are requested to send the specimen to the state’s lab for state-of-the-art molecular testing to track circulating strains of flu in the state, said Gershman.

The state requests nursing homes report any influenza outbreaks.

“Nursing homes are sort of a vulnerable population both because it’s a residential setting where people are close together and a population that even though they get vaccinated they’re still sort of susceptible to the flu,” said Gershman.

Since the Fujian flu outbreak in 2004 resulted in a higher than expected rate of pediatric deaths, the Centers for Disease Control and Prevention have asked states to track that category.

“We ask hospitals and coroners to report any suspected pediatric deaths that might be from flu,” said Gershman. “Put all of those together and it gives us the best picture of flu activity we can get.”