Health Policy Solutions

By Katie Kerwin McCrimmon

CORTEZ – A large touch-screen monitor on the wall of an exam room flashes a grim health picture.

Data charts show that the 14-year-old boy is severely depressed and obese. His blood pressure is high. In the waiting room, he has punched in answers to screening tests on a digital tablet. By the time he arrives in the exam room, the results have been tabulated and are accessible on the monitor. His frank answers reveal a teen who needs help fast. He is suicidal, coping with poor physical health, and abusing alcohol and marijuana.

Providers can use the touch-screen panel to drill deeper into the data or to give the boy and his family health resources on the spot.

An entirely new type of clinic in an unlikely place — one of Colorado’s poorest counties in the southwestern corner of the state — could provide help for this boy and countless people who are struggling with both physical and behavioral health challenges.

To understand Axis Health System’s Cortez Integrated Healthcare Clinic, you must first understand what it is not. It is not a medical clinic with some behavioral health experts who float around. And, it is not a mental health facility with a few doctors on staff.

Rather, it is an entirely new model of care in a facility designed from the ground up to give patients “whole person,” “technology-enabled” care. That means that during each visit, patients get fully integrated behavioral and physical health care in a single building. The patient’s needs drive the visit. A team of providers – including both behavioral health experts and medical staff – can work together in extra-large exam rooms, flowing in and out of flexible spaces as necessary.

So, the 14-year-old boy can receive medication and nutrition counseling from medical providers to help with his weight and blood pressure problems along with substance use treatment and therapy for his depression. The physical and behavioral health problems profoundly affect each other, so it only makes sense to treat both.

“We can’t let this kid leave before we have a safety plan,” said Pam Wise Romero, Axis’ chief clinical officer and one of the leaders who developed the design and technology concepts for the clinic.

“This is fairly radical. Nationally, there are not a lot of models like these,” said Dr. Larry Green, a national expert on integration of behavioral and physical health and a faculty member at the University of Colorado’s Department of Family Medicine.

Green is director of Advancing Care Together (ACT), a $3.9 million, four-year demonstration project, which is funding 11 innovation sites across Colorado. The ACT program aims to find “secret formulas” so Colorado sites can provide a playbook for integration across the country. The Colorado Health Foundation is funding the ACT program.

Health Policy Solutions (which also receives funding from the Colorado Health Foundation) is monitoring progress and challenges at the innovation sites. The projects launched in September. (See related coverage: Treating mental health woes could save billions and Behavioral health coaching key to doctors’ success)

Pam Wise Romero uses a touch-screen monitor in an exam room at the Cortez Integrated Healthcare Clinic to view a patient's personal health profile. The profile blends both behavioral health and medical data to give providers and patients a better picture of their overall health. The clinic, which opened this year, aims to provide "whole person," "technology enabled" care. Many of the patients are low-income people with behavioral health challenges.

Green likens Wise Romero and the leaders at Axis Health System to pioneers who have already ventured into the frontier.

“To the extent that ACT and these innovators are trying to get across a river that has been a boundary holding everyone back, they are on the far bank. They’re settling new territory,” Green said. “This is an example of stunning leadership.”

Certainly, there are profound challenges with the Cortez model that range from technology snafus to billing problems, but Green and others view the concept as ambitious and revolutionary.

“While there’s a wow factor in the brand new building and the flat screens  — and that symbolizes and signals that it’s modern, new and fresh— all of those things are accoutrements of what’s really going on. Their thinking really starts with the patient. What does the patient need? They are not adding a room on to a house. They have built an entirely new house.”

Blended visits for ADHD and allergies

On a recent Friday afternoon, three high-energy children dart around an exam room at the Cortez clinic for a visit with their pediatrician. Stephen is 12, Jason is 11 and Samantha is 8. All three have ADHD and need checkups every three months because their medication can have adverse effects on the children’s hearts. So doctors must constantly monitor their health and fine-tune the prescriptions. Along with ADHD, Samantha has asthma, Stephen has allergies and all three have learning disabilities.

Their mother had the children on her own. She has bipolar disorder and when she was failing to take her medication, her own mother had to step in to care for the kids. Judy Mead, 52, is now the full-time guardian for her grandkids on top of her full-time job at Wal-Mart. Life is chaotic, to say the least.

“I’ve had them for five years now. My own kids had ADD. The hyperactivity along with it was new,” said Mead, who lives in nearby Dolores.

While she relishes caring for the children, she says it would be nice if they were calmer.

“Two are constantly fighting. If you have all three together, it’s that much more nerve-racking. Every day is a challenge.”

Before the Cortez clinic opened this year, Mead had to take the children for behavioral health appointments to the old mental health building, which was dark and musty with sagging floors. Then, she would cross town to take the children to their doctor. While her bosses at Wal-Mart accommodate her need to leave work for medical appointments, the separate health systems meant taking twice the time off.

Walking into the new integrated health center, with its vaulted ceilings, natural light and spacious exam rooms is soothing. Getting all the care for the children in one location is a lifesaver.

“I won’t have to make so many appointments. We can all touch base at once and get a full picture at the same time. Any problems can be taken care of right then and there with some very knowledgeable people.

“I have a very positive feeling,” Mead said. “The doctors are always so kind. They take the time to see what the kids are like, what’s going on with them. They’re not just asking me the questions. They’re actually listening to the children and getting feedback from them.”

Asking the right questions

Dr. Kristen Roessler is one of the pediatricians at the Cortez clinic. She used to work in private practice in New York and also trained at the University of Chicago and worked for the Indian Health Service.

“Integrated care is smart medicine. It’s holistic medicine. It gets at the root cause of what’s going on,” Roessler said. “In private practice, I would see 40 patients a day. I felt like it was a factory.”

In contrast, appointments are longer at the Cortez clinic and at Axis’ integrated school-based health clinics in Durango where Roessler also works.

In the past, working as a pediatrician in private practice, Roessler said she and her partners never asked questions about behavioral health problems.

“In the town in New York, we had no child psychiatrist, no child therapist, only one psychiatrist. There was nowhere for me to send kids. To put it bluntly, we just didn’t ask because we had no resources to handle all the answers we would get.”

Caring for newborns, Roessler urged her partners in New York to follow recommendations from the American Academy of Pediatrics and screen the mothers for post-partum depression. While the mothers have their own doctors, they don’t see them nearly as frequently as they see their baby’s doctor.

Roessler said her partners voted her down.

They couldn’t bill to screen the mothers, and while a healthy mom is certainly essential for a healthy baby, the pediatricians felt they had little to offer depressed moms.

Now in Cortez and Durango, working for a nonprofit health system, Roessler operates on an entirely different paradigm. Multiple screening tests are standard for patients of all ages. If a child comes in for strep throat, that child will also be screened for emotional issues. If students are referred to clinics for problem behavior at school, they automatically will get screened for health issues. Depression screening is as basic as obtaining vital signs.

“I don’t feel uncomfortable asking the questions anymore. If someone gives me positive answers (indicating behavioral health problems), I can help them,” Roessler said.

Even though Cortez is a rural area far from specialists, the clinic can tap in-house behavioral health experts and a psychiatrist who staffs the office at least once a week. State-of-the-art video conferencing also enables providers to consult with specialists who don’t live in the area.

Roessler has been working in integrated medicine for four years now and said she and her co-workers improvise all the time.

“We’ve been working out the bugs. Sometimes, we will see the patients together or if I have to do a procedure and the child is scared, the behavioral health person can come in and talk with them and do breathing exercises. It’s been very successful to defuse family tensions,” she said.

Integrated care also helps her prevent and correct medical mistakes. For instance, Roessler saw a teen girl who was told she had ADHD and was given medication for that. She was having chest pains and heart problems. Working with a behavioral health counselor, Roessler figured out the girl didn’t have ADHD. She had a thyroid problem. And the wrong medication was making her sick.

“(With integrated care) we’re going to look at you as the whole person. We’re going to look at your body and your emotions,” Roessler said. “I really don’t think you can look at anyone of any age and not ask about what’s going on in their life.”

Erasing stigma

Janice Christiansen oversees the nursing department at the Cortez clinic and also has an adult child who relies on the center for care.

“When I heard about this concept, it was ‘Hallelujah,’ ” she said. “It’s all about what the patient needs.”

Stephen, 12, Jason, 11, and Samantha, 8, need frequent checkups to ensure that medication for ADHD is not harming their hearts. Their grandmother, Judy Mead, is their guardian. Before the Cortez clinic opened, she had to visit both the old mental health clinic and the doctor's office. Now all three children can get care for both behavioral and physical health at the Cortez Integrated Healthcare Clinic.

Christiansen has a 27-year-old son, Randon, who is schizophrenic. He was doing well until his senior year in high school. Christiansen and her husband at the time were going through problems in their marriage and Randon’s behavior started to become erratic. He had always been a star athlete. He was on track to attend college on a baseball scholarship. Then, he lost interest in school and pulled away from his family. Christiansen feared that he was into drugs and frustrated with his parents’ problems. Soon she learned he had moved to Phoenix and was living on the streets. Her older son found him and brought him home. One bitter cold January night, Christiansen found the door to her house wide open. Randon was gone. She jumped in the car and found him walking in bare feet.

“Look mom, I found your golden rings,” he said.

Her heart sank. Suddenly it was obvious. He wasn’t on drugs. He was having a psychiatric crisis. Soon after, she got the diagnosis of schizophrenia.

“I was devastated. He was a totally different person. I had to come to terms with the fact that he would never be who he was. I had to accept the new Randon. It’s been up and down.”

The family lives in Mancos. Finding adequate care in a rural area can be a huge challenge and Christiansen felt like all of Randon’s friends abandoned him because they didn’t understand his mental illness. He now lives in an apartment adjacent to his mother’s house.

The first time Christiansen walked into the new Cortez clinic, she was awed by the new construction and the new concept.

“It’s beautiful. It’s spacious. It’s clean. It’s inviting and there’s no stigma.”

For people in small towns, walking into a clinic that everyone knows is for people with mental health problems can bring great shame. Integrated clinics help erase that stigma.

Poor health outcomes led to new creation

Axis Health System opened its doors as the Southwest Colorado Mental Health Center in 1960, providing service in Archuleta, Dolores, La Plata, Montezuma and San Juan counties. Traditionally, the system provided mental health and substance abuse treatment.

Then, Pam Wise Romero and Axis CEO Bern Heath started brainstorming about how they could do better. They realized that their clients were dying young of treatable diseases. At first, they tried placing behavioral health providers in primary care practices and federally qualified health centers in their area.

“But there’s only so much you can do when you’re a guest in someone else’s clinic,” Wise Romero said.

About five years ago, Heath met the director of Cherokee Health Systems, a group of clinics in Tennessee that has evolved from a mental health clinic founded, like Axis in 1960, to a national leader in health integration and a provider of physical, dental, behavioral and school-based health care. Axis’ leaders became convinced that integrated health care was the answer to improving outcomes for their patients.

“And, if we really wanted to test our own ideas, we probably needed to have our own clinic,” Wise Romero said.

Among Wise Romero’s ideas was a very muscular IT component. She dreamed up the concept of a “visit card” and a “personal health profile.” The idea was simpler than the reality. Electronic medical records are advancing, but the computer systems designed for behavioral health don’t communicate with the digital systems for physical health. This means that workers at the Cortez clinic have to enter information from one system into the other manually. The Cortez clinic also employs a full-time tech genius to make sure their advanced systems are always working to enhance patient care.

“We didn’t want technology for technology’s sake,” Wise Romero said.

When patients arrive, they fill out a paper visit card, which has a code on it that can then link to each patient’s digital records. On the card, patients write their top three or four goals for the visit. These items can relate to physical or behavioral concerns. Then, clinic workers hand each patient a clunky tablet (deliberately not sleek so it won’t get stolen) called a Patient Tool. This system allows patients to complete screening tests before their visits begin.

As soon as the patient hands the tablet in, clerks upload the information, which gets scored and matched with the patient’s digital record. Once the patient goes back to an exam room, a team of health workers decides how to proceed.

A handful of rooms are designed for specific purposes. For example, there’s a therapy room with a one-way window and walkie-talkies so a therapist can sit in an adjacent room and watch interaction with a parent and child. Then, the therapist can coach the parent on specific responses to help the child. That’s called Parent Child Interaction Therapy.

There are other rooms with couches and Kleenex that look like standard therapy rooms. There are procedure rooms to stitch up cuts. There are toys for play therapy tucked beneath exam tables in rooms that look like extra-large exam rooms. There’s a classroom for group medical visits or group therapy. The key is that the providers don’t “own” any particular space. They move depending upon a patient’s needs.

“The room’s function is to support the care you’re getting,” Wise Romero said.

Once the patient arrives in the appropriate space, providers can swipe the visit card and all the results from screening tests show up on the touch-screen monitor.

Since Axis is a safety net provider, many of their clients are low-income people, some of whom have not received any recent health care. One woman came in for an annual well-woman exam, but it turned out she hadn’t been in for years. Anxiety about the visit may have sparked bizarre behavior. When the doctor stepped into the room, the woman was naked and cleaning the sink.

“In a typical clinic, you wouldn’t know what to do,” Wise Romero said.

At Cortez, the medical provider was able to step out, huddle with the behavioral health expert and change strategies for the visit.

“The behavioral health provider was able to come in, calm the woman down, get her on the exam table and help her have a pap smear, which she hadn’t had in at least five years. Mission accomplished,” Wise Romero said.

Attention then turned to the woman’s behavioral problems. It turned out she had bipolar disorder.

Along with billing and technology challenges, staffing can be tricky. People who work in an integrated setting need to be comfortable with changing roles and on-the-spot decision-making.

“There’s no prescription for how to do this. We want to do what’s best for the patient and all their different needs,” Wise Romero said.

Sometimes providers don’t know how to handle a situation and “want to run screaming from the room,” Wise Romero said.

“You have to be open. We tell people to hang in there because nobody knows how to do this. All I can tell you is that we’re going to put our trust in our care team,” she said.

“The experiment is better than the silos” that have long separated physical and mental health care.

Dr. Green, the ACT director, sees Axis’ high-tech personal health record as the “Rosetta stone” that providers anywhere should use in the future.

Each of the 11 innovation sites is pioneering a different method for integrating behavioral and physical health.

“It’s like a one-animal-at-a-time Noah’s ark,” said Green. “We saw a diverse set of ideas in locations and settings around Colorado. We don’t have two or three of a particular type of integration.”

But, he said, that’s where the real game-changing ideas come from. They bubble up from people desperate for solutions.

“Where did Facebook come from? Where did Apple come from? Where do most brilliant ideas come from?” Green asks, then answers his own questions. “A person or two. Innovation defies institutionalization. Institutions impede innovation. It makes complete sense that a place like Cortez, Colorado would come up with an idea like this.”

By Kristina Lybecker

A shot in the arm for Colorado’s economy may well come from trade decisions made literally on the other side of the globe.

Negotiations are continuing on the Trans Pacific Partnership and health care is a key pillar of the talks.  Increasingly, economic leaders are using new trade agreements and a means to promote improved health care.  The theory is that improved health quality around the world is a vital component to reinvigorating  national economies.

Why does this matter to Colorado’s economy?

For our state, TPP presents an opportunity to protect and grow the state’s bioscience industry, which is an expanding component of the state’s economy.  The bioscience industry directly employs 20,000 Coloradans and spurs the creation of another 80,000 indirect jobs – combining for $7 billion in payroll.  Colorado is home to more than 600 bioscience companies that are active in biotechnology, medical devices, diagnostics, agricultural-biotechnology and pharmaceuticals.   In addition, Colorado research institutions  such as the University of Colorado and Colorado State University spin out 20 new bioscience companies each year.  This is why Colorado has so much at stake in the Trans Pacific Partnership talks.

As trade negotiators put a higher priority on health policy, and an increased focus is placed on wellness and improving the quality of life in countries around the world, this presents an expanded demand for products from Colorado companies.  The focus of these new trade agreements must be to foster effective public policies and strong collaboration to bring medical innovations to patients in the Asia-Pacific region, which, in turn, helps create a healthier workforce and economic growth.

This seems the heart of common sense.  Yet there are a number of major hurdles to achieving success and helping Colorado bioscience companies grow.

Many factors constrain access to safe and effective medicines.  Among the challenges are poor distribution networks for medicines, rooted in a lack of basic infrastructure, transportation, hospitals, clinics and health care professionals. Taxes or tariffs may be levied on donated medicines or on medicines that are supplied at cost and the increased expense associated with those levies is then passed directly to health care institutions and patients. Discriminatory and non-transparent regulatory regimes, unnecessarily burdensome customs requirements and other trade barriers also hinder the provision of both innovative and generic medicines to those who urgently need them.  At the same time, substandard and spurious medicines impede access to real lifesaving medicines.  Beyond forgoing the therapeutic value of genuine medicines, counterfeit drugs may harm or even kill unsuspecting patients.

It is this latter issue – and the resulting need to put a premium on high standards of intellectual property protection – that is vital to safeguarding Colorado companies’ innovations and investments.

Intellectual property plays an important role in providing the incentives necessary for the development of new medicines, especially cutting-edge biologics. An effective, transparent and predictable intellectual property system is necessary for both manufacturers of innovative medicines, medical diagnostic tools and biotechnology.  It is also essential to the creation and growth of a more robust, innovative health care sector which will contribute to further economic growth in the Asia-Pacific region.

Without question, trade policy alone cannot address the challenges surrounding to access to medicines and must be coupled with foreign assistance and development programs, other foreign policy initiatives and direct engagement with other countries on public health issues.  Nonetheless, the Trans Pacific Partnership provides an excellent opportunity to move from ambitious goals to enhanced public health and greater economic prosperity, for the bioscience industry here in Colorado and throughout our nation.

Kristina M. Lybecker is a professor in the Department of Economics & Business at Colorado College.

By Virginia A. Moyer, M.D.

Amid the many messages you will hear about screening for prostate cancer in the coming days, I hope these stand out most prominently: Science finds that there is at a best a small potential benefit from prostate cancer screening and there are substantial known harms. We need a better test, and we need better treatment options. We can do better.

The panel that I chair, the U.S. Preventive Services Task Force, has just issued a recommendation against screening men of any age for prostate cancer using the prostate-specific antigen (PSA) blood test. The draft of this recommendation was posted for public comment in October. Since then, we have read the many comments received, reviewed newly released evidence, and arrived at this conclusion:

Many men are harmed as a result of prostate cancer screening and few, if any, benefit. The evidence shows that at most 1 man in 1,000 screened will avoid a prostate cancer death over the course of 10 years, and in the best and largest study done in the U.S., no benefit was shown. Of the same 1,000 men screened, two to three will have a serious complication of treatment such as a blood clot, heart attack or stroke, or even death, and up to 40 will have erectile dysfunction, urinary incontinence or both. About 30 to 40 men in 1,000 will also have less serious but bothersome harms from a prostate biopsy, such as infection.

We need a better test, and we need better treatment options.

Cancer is a frightening word, but not all cancers are deadly. Prostate cancer is rarely aggressive enough to cause death within the course of a man’s natural lifespan. Three-quarters of men older than 80 and a third of men between ages 40 and 60 have cancer cells in their prostate, and yet men have only a 2.8 percent lifetime risk of dying from the disease. Currently, there is no way to know which men have a cancer that may benefit from treatment.

Until we have a better test and better treatment options, the USPSTF has recommended against screening for prostate cancer. Whether or not to be screened for any condition is a decision each person must make with his or her clinician based on individual values and preferences, but we are urging all health care professionals to be forthcoming about the facts around prostate cancer risk, the relatively small benefit of detecting the cancer, and the significant known harms of screening and treatment.

To be sure, there are gaps in the existing evidence on this topic. One particular area of concern is that African-American men have a higher risk of developing prostate cancer and dying from it. The same is true for those with a family history of the disease. There is no evidence to suggest, however, that these men have an increased benefit from current prostate cancer screening or that the balance of benefit and harms is any different for them. We need more research to improve the health of men at high risk for prostate cancer and to eliminate health disparities.

Some critics of our recommendation have suggested that we based our decision on an urge to cut costs for insurance companies and government programs such as Medicare. Cost is not a consideration in our evaluation of the scientific evidence. Our mission is to improve the health of all Americans by sharing evidence-based recommendations with them and empowering them and the clinicians who serve them to make informed decisions.

The members of the USPSTF are human; we face the same concerns and fears about health challenges that you do. This topic is not something we take lightly, and this decision was not reached in a cavalier fashion. It is based on science and rooted in the knowledge that while we all want to help prevent deaths from prostate cancer, we need to recognize that current methods of PSA screening and treatment of screen detected cancer are not the answer.

We can do better.

Dr. Virginia A. Moyer is chair of the U.S. Preventive Services Task Force, an independent panel of experts in prevention that reviews and makes recommendations for clinical preventive health services.

By Katie Kerwin McCrimmon

The Denver mother keeps EpiPens and Benadryl in her fanny pack, in three places in the car and in every room of the house.

Skye Barker Maa lives on the front lines of a battle that is escalating in the world’s richest countries and unheard of in some of the most poverty-stricken parts of the globe.

She has two severely allergic children and no explanation for why seemingly normal foods could kill her kids.

“It doesn’t make sense to me. I’m not allergic to anything. There are no allergies on my side of the family,” she said.

Her husband has some milk intolerance, but it’s not a big deal.

Yet, their older child, Sebastian, now 3, can’t drink a quarter of a teaspoon of milk without going into shock.

The problems began at just three months when Barker Maa was breastfeeding and noticed that Sebastian got rashes and became very fussy if she ate dairy products. So, she cut them out of her diet. Then, at age 2, he ate a tiny piece of banana bread with walnuts in it and started to go into anaphylactic shock. Doctors at National Jewish Health later determined that he was severely allergic to tree nuts, peanuts, milk and shellfish.

“Oh, and there was a brief stint with amoxicillin,” Barker Maa said, describing what appeared to be an allergy to antibiotics.

Their daughter Sloane, 2, has severe asthma and a peanut allergy.

The family lives in the urban chic Stapleton neighborhood and Barker Maa has become the kind of parent who’s omnipresent at her son’s preschool. Before every birthday party or school celebration, she springs into action like a super hero fending off danger.

“Please don’t give my kid a cupcake,” she tells parents and teachers. “It could kill him.”

Researchers at the nation’s premier hospital and research center for asthma and allergies, National Jewish Health, are puzzled by the mysterious epidemic that strikes wealthy countries where sanitation and food supplies are best.

Hay fever, eczema, asthma and food allergies, which were mostly unheard of 100 years ago, have doubled in prevalence, says Dr. Erwin Gelfand, chair of pediatrics department at National Jewish.

Hay fever, eczema, asthma and food allergies, which were mostly unheard of 100 years ago, have doubled in prevalence, says Dr. Erwin Gelfand, chair of pediatrics department at National Jewish.

New data from the U.S. Centers for Disease Control and Prevention recently revealed that the percentage of adults and children with asthma has climbed to its highest point ever, growing from 7.3 percent in 2001 to 8.4 percent in 2010.

And a mild spring across the U.S. has created a spike in seasonal allergies triggering a rash of sneezing and itchy, red eyes.

Researchers don’t know yet why the developing world is inundated with allergic diseases and asthma while these conditions are rare in places like rural Africa.

“Why the western world and not the developing world? Are we too clean? Are we getting all these vaccinations? Have we shifted the balance?” Gelfand wonders.

He and others are hunting down possible culprits that range from suspicious links between acetaminophen and asthma, to environments for babies that could be too clean, to waiting too long to introduce new foods to babies. Perhaps the super-doses of folic acid, which have dramatically helped reduce birth defects, have inadvertently increased allergies.

Even obesity may be to blame since extra pounds are linked to increased inflammation and higher allergy rates.

Regardless, says Gelfand, prevention is key. That’s why researchers around the world are working to solve the allergy-asthma mystery.

One consistent finding is that children who grow up on farms drinking fresh, non-pasteurized milk seem to have some protection from allergic diseases. A simple visit to a farm or purchasing farm-fresh milk is not enough. The mothers and newborns have to spend significant time in that environment.

“What is in on farms with livestock?” Gelfand said. “Is it related to exposure to the (livestock) droppings? Is there a different bacterial content that somehow has a protective effect?”

Studies in Kenya of the Masai people reinforce the protective effects of contact with bacteria.

“When they’re out in the rural areas, living in dung huts, allergy is lower than if they live in the city,” Gelfand said. Rural people certainly experience other health problems,  including parasites.

But, for allergy researchers, rural locales may hold a piece of the puzzle.

“It would be very nice to know how to harness that to newborns and prenatal mothers,” he said. “Through vaccinations, one might do something.”

In cities, our houses are more airtight and our diets have changed.

“Have we somehow changed the flora in our guts to avoid some protective effects?” Gelfand said.

A study by Dr. Gideon Lack of King’s College London, who previously studied and worked at National Jewish, compared 10,000 Jewish children who lived in similar communities in London and Tel Aviv. Peanut allergies were ten times more common among children in the United Kingdom. When Lack explored the disparity, he found that Israeli parents frequently give their infants a peanut-flavored snack called Bamba.

Lack then theorized that early exposure to peanuts may be protective rather than harmful, a notion that turns typical allergists’ advice on its head. American mothers learn to introduce new foods one at a time and delay allergic foods such as dairy, fish, peanuts and tree nuts until toddlers are older.

The National Institutes of Health is now funding a new study of babies at high risk for allergies. Half are avoiding peanuts while the other half are eating them regularly from 11 months to age 3.

Answers will be vital for a growing population of sufferers.

Gelfand said more than 40 percent of people in the U.S. will develop some sort of allergic disease in their lifetime. The most common is rhinitis, but food allergies, eczema and asthma are all on the rise. Medications for asthma have improved dramatically, but require careful compliance from patients. On the other hand, medications to treat seasonal allergies and eczema aren’t particularly effective, Gelfand said.

“The issue for us now is understanding enough to intervene and prevent these diseases,” he said. “Drugs are never going to catch up with the diseases. There’s no cure and nothing works 100 percent of the time. We need to answer the question, ‘are we doing things that are inappropriate in the early years?’ ’’

For instance, grandmothers used to say that a little dirt was good for kids. But, some parents determined to keep their kids safe and healthy have become obsessed with hand-washing, Clorox wipes and anti-bacterial soap. Could an ultra-clean environment be harming us?

“You can almost trace this epidemic to 50 years ago,” said Gelfand. “With civilization and advancement, we’ve gained so much. But along with it, we have probably paid a price too. How do we affect the balance?”

As Skye Barker Maa pushes her daughter, Sloane, on the swings at Stapleton’s Central Park, she says she’s eagerly awaiting answers that explain the allergy epidemic.

“There have to be better ways to mitigate allergies than stabbing 50 jolts of adrenaline into your child,” she said.

Not a fan of overmedicating her children, she nonetheless is giving them medications for reflux, seasonal allergies and asthma and said she knows countless parents in the same boat.

Her wish for her children: “I would hope they wouldn’t have to medicate their kids so much,” Barker Maa said. “It’s crazy.”

By Gena Akers

We’ve come a long way in health care.  As Lewis Lapham writes in “The God in the Machine,” “Together with the cornucopia of drugs for all seasons (Zoloft, Lipitor, Botox, Viagra, etc.) the American health care shopping mall now offers expensive diagnostic tests (CT scan, bone scan, spinal tap, etc.) that allow upward of 6 million Americans to enjoy the benefits of high-priced bodily home improvements — titanium knees, Peruvian kidneys, two-hour erections and a sunny disposition.”

Not for everyone, though.  Without affordable and comprehensive insurance or an understanding of state and national safety net programs, thousands of people in the San Luis Valley postpone their needed check-ups, dental appointments, prescription refills… all in the name of cost.

Fortunately, health care is changing and the high cost is being addressed.  Just look at Grand Junction.  Founded in 1896, St. Mary’s Hospital and Regional Medical Center in Grand Junction has made national news for lowering costs and improving care.  They did it by covering everyone and emphasizing primary care.  By getting their physicians to focus on preventive care and chronic disease management, Grand Junction sees better health outcomes among its patients.

Our elected officials and leaders have been working for nearly 100 years to create a national health care system similar to what Grand Junction residents currently enjoy.  They may not agree on how, but the immediacy and need for change is clear.

In Colorado, we have worked hard to solve our own problems.  Before federal health care reform was passed, two initiatives secured Colorado’s place as a leader in creative thinking on health care.  In 2008, the Blue Ribbon Commission on Health Care Reform presented recommendations to Colorado’s General Assembly on how to expand health coverage and decrease health care costs for Colorado residents.

A year after the recommendations were presented, our elected officials passed the Colorado Health Care Affordability Act, which among other things, expanded Medicaid for both children and adults.

Since then, Colorado has shown a continued commitment to expanding coverage and decreasing costs.  Our kids can more easily get the care they need, when they need it (Medicaid and CHP+ expansion as well as the 2011 Child-Only Health Insurance Plans Law), and in 2014 all Coloradoans will be able to shop for and compare health insurance plans in the same way they shop for and compare plane tickets.

You should feel confident that no matter what the Supreme Court decides in June on federal health care reform, you live in a community and state that is committed to improving health care for you and your family.

Gena Akers is the project coordinator for SanLuisValleyHealth.org, an education and advocacy website dedicated to increasing access to health for all residents in Colorado’s San Luis Valley.  SanLuisValleyHealth.org is a project of the San Luis Valley Regional Medical Center and funded through The Colorado Trust. She can be contacted at gena.leneigh@gmail.com. 

By Diane Carman

The average American is fat, sedentary, drinks too many sweetened soft drinks, eats too many French fries and knows it all too well.

“Most people in the U.S. want to lose weight,” said Elizabeth Kealey, a registered dietician and professional research assistant at the Anschutz Health and Wellness Center.

The problem is they just don’t know how.

Researchers at the center are testing strategies and documenting results, and while they don’t claim to have the obesity cure at their fingertips, they have identified several approaches that appear to work for a significant population that wants to lose weight.

A sense of urgency is driving the research. A recent study forecast that by 2030, 42 percent of Americans will be obese and that the cost of treating them could add $550 billion to health care costs in the next two decades.

Elizabeth Kealey

The center’s approach “is not surprising,” said Kealey. “Moderation and variety – those are the cornerstones of a good diet.”

It’s getting there that’s the hard part.

Clinical researchers have found that the secret is baby steps, “small changes,” she said.

“We identify a couple areas that are realistic to each person.”

Kealey, who teaches classes in the Colorado Weigh program, has found that if people are genuinely interested, they can develop healthier lifestyles, lose weight and keep it off. But before they can change their habits, they have to recognize what they’re doing wrong.

Auditing food intake

Most of the time, Kealey starts by evaluating the beverage category in their diets. For some reason, most people don’t count liquid calories, whether they arrive via sweetened soft drinks, fruit juices, energy drinks or cocktails.

“If you want to lose weight, evaluating beverages is a good place to start,” she said. For many people, simply switching from cola or energy drinks to water can make a dramatic difference in daily caloric intake.

The next step is to take a hard-eyed look at portion sizes.

Kealey said one of the exercises she leads in her classes is to have participants serve themselves portions of breakfast cereals, fruit juice or other foods and then measure or weigh them. “It’s a fun exercise,” she said, because people usually are amazed at what the recommended portion size of, say, granola is compared to the usually much more generous portion they’ve poured.

“I always get a lot of comments on that lesson,” she said.

She also works with participants to help them improve their overall diets by including at least five and optimally nine servings of fruits and vegetables a day while reducing fats, starches and sweet treats.

The goal is to prepare or purchase foods that are satisfying and taste good, but are nutritious and not as fat-and-calorie dense as common restaurant or fast-food offerings.

Good taste is key

Bistro Elaia at the Anschutz Health and Wellness Center creates guilt-free foods that focus on flavor.

Kealey and other nutrition researchers worked with the staff from Bistro Elaia at the Health and Wellness Center to develop menus and adapt recipes to encourage healthier eating and enable Colorado Weigh participants and others to enjoy eating and still achieve their weight-loss goals.

“We offer food in three different categories: ultra healthy, healthy and healthier (than the usual alternatives),” said Paolo Neville, executive chef at the café located on the first floor of the center.

“We started with the concept that the food has to really taste great,” he said. “It has to be addicting. It shouldn’t have the stigma of being health food.”

Some of the guidelines were to reduce fat (“There are no fryers here,” Neville said.), reduce salt, adjust portion sizes away from the “supersized” servings that have become common in restaurants, and put the emphasis on organic grains, vegetables, fruits and plenty of seasonings.

The bistro also clearly posts calorie counts for everything on the menu. “We’re all about transparency here,” the chef said.

One example is the popular chicken corn chowder (238 calories per bowl). Neville said he purees some of the vegetables and stirs in fat-free yogurt at the end to give it the creamy taste and texture people love without using heavy cream, or thickeners like flour and butter.

Bistro Elaia Chef Paolo Neville

For sandwiches, he said, they shopped around to find whole-grain breads that weren’t too high in calories “to give us some breathing room for the fillings.” Then he revised classic recipes for aioli, using the typical olive oil and egg yolks as a base, but punching up the seasonings and flavorings “so we don’t have to put so much on the sandwich.”

With something like the “for fromage” sandwich, they used stronger cheeses, like blue cheese and goat cheese. “We cut the amount of cheese on the sandwich by close to half without sacrificing flavor.” It weighs in at 490 calories.

Breakfast items also feature plenty of vegetables. The Egg White Shuffle has spinach, dried tomatoes and feta cheese with egg whites on a whole-wheat English muffin and tops out at 264 calories.

Since the bistro opened last month, Neville said the response has been “fantastic. We’ve been doing very, very well.”

Bistro Elaia’s catering business has been operating for several months and appeals to businesses and organizations that want to encourage healthy eating among their employees and clients, director Carrie Cohen said.

Carrie T. Cohen, Bistro Elaia restaurant manager and catering director

One of the events they catered was a lunch for executives from McDonald’s, which helps fund the center. On the menu were chicken Provencal, salad and carrot cake.

“They loved it,” she said. “Everybody always asks what we served the McDonald’s people.”

Diet alone not enough

Along with encouraging greater awareness of what participants are eating, the Colorado Weigh program emphasizes regular physical activity. “It’s not just diet alone,” said Kealey. “It’s the physical activity piece, the biological piece, the motivational piece.”

For Maureen Ediger, director of external affairs for the School of Public Affairs at the University of Colorado Denver, the 12-week program has been eye-opening.

“It’s nothing radical. There’s nothing you can’t eat,” she said. “It’s a matter of adjusting portions and writing down everything.”

The simple task of keeping a log of everything she eats and all her activities each day (recorded on a pedometer she wears) provides an incentive and a level of accountability she didn’t have in the past.

It also has given her a sense of accomplishment.

When life at work or at home with her husband and four children feels overwhelming, focusing on her own health feels great, she said. “It’s one part of my life that I can control.”

“It’s a matter of making little choices throughout the day. That’s why it’s working.”

One example of a little change that has a big impact is her new coffee routine.

“I’ve always liked coffee with half and half,” Ediger said. “Now I drink it with skim milk or black. Once I realized how much fat and calories I was consuming in that daily habit alone, I started making a different choice. Now I think if I tried to drink coffee with half and half, it would be disgusting to me.”

All of the recommendations in the Colorado Weigh program are based on the latest research on obesity. Kealey said the program was developed by James O. Hill, director of the Center on Human Nutrition at the Health and Wellness Center; Dr. Holly Wyatt, a specialist in internal medicine; and Assistant Professor Bonnie Jortberg, a dietician at the University of Colorado School of Medicine.

Participants set goals for increasing their activity levels through walking, biking, dancing – or any way they choose.

“I can’t get an hour out of my day for a workout,” Ediger said, “but I can take 20 minutes in the morning, I take the stairs throughout the day at work and then do another 20 minutes of exercise in the evening.”

Maureen Ediger

She tries to incorporate activity into other parts of her life, choosing to run an errand on her bike instead of in her car and to get the kids involved in fun runs, hikes and cycling outings on weekends.

“All these new habits really benefit the whole family,” Ediger said.

Among the recent findings included in the program is research that suggests while a daily workout routine — or as health officials recommend, a 30-minute walk five times a week – is good, those activities may not be enough to counteract the damaging impact of spending eight hours a day sitting at a desk. A recent study found the risk of cardiovascular disease is 64 percent higher among men who spend more than 23 hours a week in sedentary activity (not including sleep) compared to those who spend 11 hours or less per week sitting.

“It’s not necessary to spend eight hours a day at the gym,” Kealey said, “but we all need to get up and move, not just sit.”

Results from the participants in the Colorado Weigh program are used for the studies on weight loss and obesity at the Health and Wellness Center. While the weight loss goal in the 12-week program is 8 percent, Kealey said that average weight loss for participants is 6 to 7 percent. Ediger’s weight loss in the program was 10 percent.

Follow-up on weight maintenance under Colorado Weigh is less thorough. However, a different database used at the center tracks people who have lost 30 pounds or more and kept it off for at least one year. The National Weight Control Registry tracks more than 5,000 people who meet those criteria. The average weight loss among them is 66 pounds.

Kealey said research on weight loss, nutrition and general fitness is an increasingly important field in health care, where the CDC estimated in 2008 that the annual cost for obesity-related conditions was $147 billion.

“We have a long way to go, but there is evidence that making those small changes, realistic changes is the key. We know if you make your expectations too large, you won’t succeed.”

By Gena Akers

Have you been worried about the fact that you are a mortal being?  Here’s some comfort sent by way of Seneca, some 2000 years ago: “You will not die because you are sick, but because you are alive.”  Now, don’t you feel better?

Well, Seneca almost got it right.  After reading a particularly upsetting article in the New York Times recently, I took the liberty of editing Seneca’s timeless words: “Gena, you will not die because you are sick, but because you are alive… and sitting in a chair.”

That’s right, my mere existence will account for about 94 percent of my death (humorous, non-scientific estimation.  No source necessary).  My office chair, home desk chair and kitchen stool… those four legged fiends get the remaining 6 percent.

To steal from Gretchen Reynolds, a fellow sitter, thinker of thoughts and writer of words, “ One lesson I’ve learned while writing about fitness is that few things impinge on an active life as much as writing about fitness—all that time spent hunched before a computer or puzzling over scientific journals, the countless hours of feckless, seated procrastination.”

But my writing is selfless.  I spend time sitting and writing so you, dear reader, can be thin, fit and immortal.  As a friend says, who spends her 9-to-5 life fighting childhood obesity, “all the skinny kids… that’s me.  All the fat kids… I had nothing to do with that.”

Well, you too, thin readers…  can say thanks to me and one of my occasional health-conscious ramblings for changing your life.  And for you not-soo-thin readers, I had nothing to do with those 5 extra pounds you gained last winter.

Okay, okay.  I got sidetracked. Selfless or selfish, I sit too much.  I really do.  It came with some annoyance to admit that it doesn’t matter how much I exercise, it matters how much I exercise and how much I don’t exercise—namely how inactive I am.

The University of Massachusetts did a study to see just how much a sedentary lifestyle affects overall health.  It measured the effect of physical inactivity by giving a group of healthy young men heavy platform shoes with 4-inch heals for their right feet.  The men were instructed to hobble around on their right feet with crutches for two days.  They were to leave their left feet dangling: no muscle contractions, no touching the ground.

After 48 hours, the scientists biopsied both legs and found multiple genes already being expressed differently.  The inactive left leg revealed lower insulin levels, slower metabolic activity and disrupted DNA repair in comparison to the right.  To honor Seneca, one could say “every man’s left leg was dying…” but that doesn’t get at the full truth.

A second experiment that shines light on the truth involved putting the back legs of lab animals in casts.  Soon after, the newly handicapped animals were already producing substantially less of an enzyme that dissolves fat in the bloodstream… an enzyme important for staving off cardiac disease and diabetes.

So, it’s really not the TV or TV dinners or awful commercials that are killing you.  It’s that you’re alive… and not producing enough enzymes to break down fat or a billion other things I didn’t learn about in my undergraduate philosophy courses.

You know what will help?  Standing!  A related study at the University of Massachusetts showed that when volunteers stood all day, (just standing, no walking or jogging) they burned hundreds more calories than their fellow sitters.  Standing isn’t even considered exercise, but on the scale from 1 to death, it puts you a lot closer to 1.

Well, if you’re like me, consider an office remodel.  Maybe, funnel the architectural foresight of the Shakers.  Hang your office chairs on the wall.  Then balance your computer on one of the office chairs.  Then stand, facing your freshly mounted chair and computer to send emails, edit project proposals, and whatever else you do through a keyboard to improve humanity.  After a few weeks, maybe hang up a picture of an open window next to your chair.  You don’t want to feel like you’re in timeout.

Whether you hang your chair on your office wall or take walk-around-the-office breaks every 15 minutes, you’re still going to die.  That’s nothing to be sad about.  Just make sure you can do what you want to do until then.  For most people, that involves some kind of movement, beyond pressing numbers or letters on a TV remote, smartphone or keyboard.

And don’t worry about me, this article only took two hours of sedentary writing.  I would write more but…. (the author of this article just left for a walk).

Gena Akers is the project coordinator for SanLuisValleyHealth.org, an education and advocacy website dedicated to increasing access to health for all residents in Colorado’s San Luis Valley.  SanLuisValleyHealth.org is a project of the San Luis Valley Regional Medical Center and funded through The Colorado Trust. She can be contacted at gena.leneigh@gmail.com. 

By Charlene Shelton

Medicaid saves lives – and money. The poor among us who don’t have the ability to pay for the most basic medical care instead frequent local emergency rooms.

And you get the bill.

You may think they go there because they’re lazy. But in reality, many of those patients are very sick because they can’t access a regular doctor in an office to get checkups and treatment for minor ailments. Instead, their minor illnesses flare up into major disease processes that require hospital treatment. Cha-ching!

And then there are the poor kids. Many don’t have health coverage or a medical home, especially if their parents are undocumented and afraid to apply for CHP+. So they are taken to the emergency room. Cha-ching!

You can’t buy prescriptions through the mail with Medicaid, so people who are homebound or live in isolated areas have to travel. They can’t always do that, so they miss their meds and get sicker. Then what? They end up in the emergency room. Cha-ching!

If Medicaid were managed effectively – like private insurance – people would have a medical home. They could go to the doctor’s office. They could manage their diseases, get check ups, get their teeth cleaned (avoiding serious heart problems that come with untreated dental disease) and they could avoid the emergency room. This would save you, the taxpayer, money.

If Medicaid engaged the very people that it serves and understood from them what their needs are and how they access care, maybe the government could design a system that actually works efficiently. This would save you, the taxpayer, money.

If Medicaid went after fraud more rigorously and treated the people committing fraud like the criminals they are, the system would have more resources to help people manage their health. This would save you, the taxpayer, money.

Blue Cross, Kaiser Permanente and other health care organizations have programs that use nurses and social workers to contact patients for follow-up from injuries, accidents, surgeries, mental illness treatment and hospitalizations. These patients have the benefit of knowledgeable professionals who help monitor their health concerns and answer their questions. They can help monitor drug interactions, infections or suicidal thoughts. This saves Blue Cross and Kaiser money. If Medicaid did this, it would save you, the taxpayer, money.

Medicaid reform is crucial and long overdue. But coming up with ways to cut benefits in hopes that it will cut the cost is not only wrong, it’s also misguided.

The way to cut costs is not to cut benefits, thereby making people sicker so that they have to go to the emergency room. It is by increasing wellness benefits, encouraging medical homes, treating beneficiaries like we treat everyone else, and by going after the fat cats that are raiding the system.

The way to cut costs is by monitoring and helping people understand how to handle their health problems and by extending services like dental care and attendants to help the disabled stay independent so that they are not spending thousands of dollars each month in nursing homes.

You decide – Cha-ching or save some money?

Charlene Shelton is a doctoral student in the department of Health & Behavioral Sciences at the University of Colorado Denver, researching health disparities in rural Colorado.

By Katie Kerwin McCrimmon

A bill aimed at thwarting cavities in babies became collateral damage in the fight over civil unions in Colorado late Tuesday night.

Senate Bill 12-108 had sailed through earlier hearings and was expected to pass in the House on Tuesday night, then be up for final approval today.

But the bill died along with nearly three dozen other measures that were held hostage during the civil unions standoff.

SB 108 would have provided funding for dental benefits for pregnant moms on Medicaid. Research has shown that mothers who have tooth decay and untreated cavities can pass bacteria to their babies, thus infecting their teeth and causing some babies and toddlers to lose all their baby teeth before age 3. Poor dental health of mothers also has been associated with premature birth, another highly expensive health problem.

Numerous dental experts from Children’s Hospital Colorado and the Colorado Dental Association had worked with advocates for low-income patients and members of the legislature’s Joint Budget Committee to find funding to help pregnant mothers take better care of their teeth.

“We are disappointed,” said Dr. Ulrich Klein, a doctor of dentistry at Children’s Hospital and chair of the pediatric dentistry at the University of Colorado School of Dental Medicine. “We have been fighting this battle for so long.”

Klein said the problem of dental cavities or caries “has epidemic proportions.”

“Caries is now more widespread than any other chronic disease,” Klein said. “It is a disease of poverty that goes with health illiteracy and general illiteracy.”

Despite the death of the bill, Klein is pleased that the issue has finally gotten attention from policymakers and lawmakers, and he hopes it will pass in the future.

Klein said very few people understand that cavity-causing bacteria can be transmitted from mother to child. Studies have shown that babies are especially vulnerable to bacteria from their mothers. One study found that children of mothers who had high levels of untreated caries were three times more likely to have cavities themselves.

So, if a mom has a untreated cavities in her mouth, then licks a pacifier or a spoon that she puts in a baby’s mouth, the bacteria can then transfer to the baby.

Some low-income mothers also tend to give their babies Sippy cups full of juice, which bathe infant mouths in sugar all day. Or, some prop bottles full of juice or formula in babies’ mouths as they go to sleep.

These habits can cause extremely costly problems for babies. Because children under 3 do not do well in dentist chairs for long appointments to have their teeth treated or removed, young patients often have to be sedated and cared for in expensive surgeries.

Klein said dentists now recommend that parents begin brushing their babies’ teeth as soon as the first teeth erupt at around six months. The first dental visit is recommended six months after the first teeth come in or no later than the baby’s first birthday.

In reality, Klein said very few low-income mothers see a dentist themselves, even if care is funded, and very few take their babies in for recommended dental visits. A study of California’s medicaid population found that 79 percent of pregnant mothers did not receive any dental care while they were pregnant. Survey respondents said they didn’t think the care was necessary or they couldn’t pay for the care. Another study in the Journal of the American Dental Association found that  Hispanic women were significantly less likely than black or white women to receive routine dental care during pregnancy.

“Because the problem is so multi-faceted, we haven’t found the magic bullet yet,” Klein said.

Among those who supported the bill was Dr. Jeff Call, a pediatric dentist from Colorado Springs.

While funding from Medicaid would not have guaranteed better dental health among low-income mothers and their babies, the measure was widely supported with backing from groups including the Colorado Children’s Campaign, the Colorado Consumer Health Initiative and the Colorado Coalition for the Medically Underserved.

“It was pretty important because there’s a lot of research showing that if pregnant women get dental coverage, it will reduce the risk of babies being premature,” said Aubrey Hill, health system analyst for the Colorado Coalition for the Medically Underserved.

She said there’s some speculation that the governor could revive the bill along with civil unions and the raft of other torpedoed measures. But said Hill: “It’s all speculation. We’re not sure what’s going to happen.”

By Katie Kerwin McCrimmon

Every second counted.

The baby boy was having trouble breathing. So, his parents raced to an urgent care clinic in Fort Collins where they were visiting family over the weekend.

Jacobb Prussman, then about a year old, was becoming listless as triage nurses looked on. But his parents said the nurses refused to care for him until a clinic worker finished checking them in.

And the worker kept insisting on knowing Jacobb’s mother’s name and her financial information even though his two legal parents stood before her with their son.

“We were pretty concerned and anxious because he was gasping for air at that point. It got really scary. We’re it. We’re just two dads. It was a surreal experience,” said Jason Cobb, one of Jacobb’s fathers. “He should have received care immediately. It was terrifying. Instead of focusing on our son, the focus turned to our relationship.”

Colorado’s civil unions bill — which died after a vitriolic showdown on the House floor Tuesday night but will come back to life in a special session starting as soon as Friday — would have had far-reaching health policy implications for families with same sex partners.

The fight over civil unions in Colorado and President Barack Obama’s endorsement of gay marriage today have sharpened the focus on same sex partnerships, medical rights and children like Jacobb who are the center of thousands of non-traditional families in Colorado.

Supporters of civil unions rallied at the Capitol on Tuesday. (Photo by Mark Eddy)

During a rally at the Capitol on Tuesday, advocates pledged that civil unions will prevail in Colorado. Governor John Hickenlooper on Wednesday afternoon got choked up as he said the issue was extraordinarily important and merited a special session.

“Everyone deserves the same legal rights in this country,” Hickenlooper said. “This is a circumstance where we are depriving people of their civil rights.”

Regardless of the outcome of the special session, activists expect civil unions to pass eventually.

“No matter what happens today or tomorrow, the unspoken truth in this whole debate is we will win,” said Jace Woodrum, deputy director for One Colorado, the state’s largest advocacy organization representing the lesbian, gay, bisexual and transgender (LGBT) community.

“Whether it is today or tomorrow or next year or the next, we will win. Gay and lesbian couples in this state will have full protection under the law. We all know it, and everybody in this building knows it,” he said.

So what was lost when the bill died Tuesday?

Security and automatic recognition by medical institutions for gay and lesbian partners and parents will have to wait. And, experts on health insurance say a civil unions bill would have a dramatic effect on reducing the number of uninsured people in Colorado. Today, an estimated 800,000 people in Colorado have no insurance and one in three Coloradans, or 1.5 million people are either uninsured or underinsured, meaning health costs are gobbling up more of their income than they can afford, according to the Colorado Health Access Survey.

For Jason Cobb and his partner, Jason Prussman, passage of civil unions would have brought great relief. Both Denver lawyers, they have for years carried proof of Jacobb’s adoption and their designated beneficiary agreement, spelling out their wishes in case of a medical emergency.

“It’s my security blanket,” Cobb said of the trove of papers he keeps close, especially when he’s traveling. He and Jacobb don’t look alike. So he has always felt vulnerable to questioning.

“If you get pulled over for speeding or something, you don’t want your child to end up in protective services. These are the kinds of things that keep gay parents awake at night. All parents worry about their kids. But there’s an extra level of anxiety that comes with being a gay parent. You don’t know when something is going to happen.”

On that day in Fort Collins, when the unexpected did happen, a supervisor finally intervened to get the family medical help. Jacobb apparently had a respiratory infection that worsened fast. He received treatments and recovered fully. He is now 5. Still, his dads had no power to force the health care worker to recognize them as Jacobb’s parents and give them equal treatment. The computer system had a space for one mom and one dad, not for a second dad. The worker either didn’t know how to accommodate a non-traditional family or wasn’t willing.

Executive order banned hospital discrimination

Blatant discrimination is supposed to be banned across the country.

In April of 2010, President Barack Obama issued an executive order that requires any medical institution that receives Medicare or Medicaid funding to give partners of gay men and lesbians visitation rights and respect patients’ choices about who may make critical health decisions for them.

But Colorado hospitals and medical facilities each have their own policies for how they deal with same sex couples, bisexuals and transgender people.

Activists say the right to create civil unions would have made protections for them automatic and would have helped people understand their relationships.

The law would have afforded same sex partners the same protections that married spouses do under all “laws, policies or procedures relating to emergency and non-emergency medical care and treatment and hospital visitation.”

Senate Bill 12-02 also provides additional protections related to health care including access to health insurance benefits; domestic violence protection; visitation rights in medical, mental health facilities and jails; the right to declare or withdraw medical treatment orders; eligibility for family leave; and the right to decide about organ donation for a partner.

But the greatest change would come in dramatically increasing access to health care.

“Civil unions would extend coverage. Period,” said Dr. Mark Thrun, a physician at Denver Health, who has two sons with his partner and serves as an expert advisor to One Colorado. Because Denver Health offers domestic partner benefits, Thrum is able to obtain health insurance for his partner and their sons.

But many other people in same-sex relationships don’t qualify for health insurance through their partner’s employer.

“If my relationship is legally recognized by the state, payers will need to treat me equitably relative to all other legally recognized relationships,” Thrun said.

LGBT people refused medical care

Poor access to health care is rampant among people in the LGBT community, according to the study, “Invisible – The State of LGBT Health in Colorado” released earlier this year by One Colorado.

It is unclear exactly how many of the hundreds of thousands of uninsured people in Colorado are gay, lesbian, bisexual or transgender. But the “Invisible” survey of nearly 1,200 people in Colorado’s LGBT community, found that more than 30 percent of bisexual Coloradans had no health insurance while 27 percent of transgender people did not have insurance. That was about double the rate for people who are heterosexual, lesbian or gay.

Among other findings from the survey:

About one in five LGB people surveyed said they had been refused health care.

• More than half —53 percent of transgender respondents — said they had been refused health care.
• Nearly three out of four LGBT Coloradans viewed legal fees and services needed to create designated beneficiary agreements, medical power of attorney or other legal protections for their partners, families and children to be a barrier to seeking health care services.
• Even with legal agreements in place, fewer than half of respondents were satisfied that they could participate in medical decision-making with their partner.
• Only 42 percent of respondents felt that health care providers would understand their legal rights and the rights of their partners despite arrangements made to ensure medical decision-making for themselves and their children.

The Colorado Consumer Health Initiative represents more than 50 health organizations and 500,000 health consumers in Colorado and advocates for affordable, accessible, quality health care for all Coloradans.

The group supported the civil union bill primarily because it would have expanded access to coverage.

“Clearly most people in the country and in the state get their access to health insurance through employer-sponsored insurance,” said Dede de Percin, executive director of CCHI and a member of One Colorado’s health steering committee.

Particularly among low- and moderate-income families, de Percin said, a spouse’s employer plan can be key to getting coverage for the both adults and the children in a family.

De Percin said that employers who offer health insurance to spouses and dependents also would have had to offer that same insurance to civil union partners.

“Companies could block this. They don’t have to offer insurance for dependents or pay for it,” she said. “But they’d have to block it for everyone.”

Individual businesses pay more in general to offer health coverage to dependents of their employees. And some allow access to insurance for spouses and children, but choose not to bear any of the costs. While health care costs have soared in recent years, many employers see good family health insurance benefits as a vital strategy for recruiting and retaining the best employees.

The Colorado Association of Commerce and Industry did not take a position on the civil unions bill. The Colorado Hospital Association has monitored the measure, but does not support or oppose it.

Legal agreements costly

Without the civil union bill, same sex partners in Colorado will continue to have the right to make health care decisions for each other and spell out their role as parents of their children.

But the cost and the complications of creating those agreements are high.

Dr. Rita Lee teaches medical students that knowing a patient's sexual orientation helps them provide better care. Lee and her partner had to spend thousands of dollars on legal agreements to safeguard their medical wishes and rights for their children.

Dr. Rita Lee is an internal medicine doctor at the University of Colorado’s Anschutz Medical Campus and an assistant professor at the CU School of Medicine. She estimates that she and her partner spent more than $7,000 on legal agreements to clarify their relationship with their two sons, ages 22 months and seven months. They had to codify a second parent adoption, create designated beneficiary agreements and living trusts and register as domestic partners.

“LGBT families spend thousands of dollars to cobble together legal protections for their families. Despite doing so, less than half of those (in same sex partnerships) were satisfied with their ability to participate in medical decision-making for their partner,” Lee said, citing findings from the “Invisible” study.

Without the civil union protections, families can spell out many agreements, but they can’t force employers to give their partners health insurance. Nor can they guarantee that medical providers will be educated about their unique health needs and sensitive about caring for them.

Lee teaches a course to medical students on how to take sexual histories of their patients and how to offer better care to members of the LGBT community. The course is relatively short and new at the CU medical school, having been offered for about four years. Lee considers it a cursory introduction to LGBT health needs, but she said it’s a start.

Some health providers are openly hostile to LGBT people. In the past, doctors sometimes told gays  and lesbians that they needed to change their sexual orientation or abstain from sex and relationships.

Some providers also never ask their patients about their sexual orientation. They don’t realize that knowing that information is central to offering high-quality care.

“You understand who their families are for decision-making purposes and who to call if there’s a problem,” Lee said.

Also, certain medical treatments are directly related to sexual orientation. For instance, men who have sex with men are supposed to get both the Hepatitis A and B vaccines, Lee said. Transgender people have unique medical needs relating to hormones and surgeries.

Lee has one patient who is transitioning from female to male. He needs both testosterone shots and pap smears. And males who have had surgery to become females will still have a prostate and will need monitoring to prevent prostate cancer.

“If you didn’t know that, you wouldn’t be able to properly take care of them,” Lee said.

Health providers not waiting for new law

Denver pediatrician, Mark Groshek, said that even without a civil unions bill, health care institutions are working to help providers be more sensitive to the needs of non-traditional patients. There is a lot of history of poor care to counteract and members of the LGBT community certainly live in fear of discrimination.

“Even if same sex couples don’t experience anything bad in the health care setting, they worry,” said Groshek, who is also on health steering committee for One Colorado.

“There are these horrible stories, most of them in other states, where something has happened. A couple is on a cruise (for example). One collapses and the partner is not allowed to be there when she dies. These things do happen and there are a lot of people in health care who are interested in not letting that happen,” he said.

Groshek works for Kaiser Permanente, but is not speaking on behalf of the institution. He said training sessions for providers are much more common today.  Such continuing education sessions focus on “culturally competent care.” Both additional training and “evolving” views from President Obama to other leaders are changing the dynamic for LGBT in U.S. health care systems.

“What we’re seeing in general across the country — and this depends on how conservative the community is — is that more people in health care and in society in general are becoming supportive of these rights and desires. It’s getting easier for people in the LGBT community to be treated like a spouse,” Groshek said.

Even if the civil unions bill dies again in special session, Groshek said advocates will continue to make progress.

“Things won’t be any different than they are now. People still have to spend a lot more money than people who are legally married to lay out in clear language what their desires are,” he said. “It’s not a step backwards…but many people (in health care) are not waiting for the law. They’re respecting what people want now.”