Health Policy Solutions

By Francis M. Miller

This week’s Supreme Court ruling validates President Barack Obama and the Democratic Party in their pathway to reforming health care. It all pivoted on Chief Justice John Roberts Jr., and if it had gone the other way, the law would have been overturned. Talk about sudden death!

Protestations from the Republicans that they will seek repeal are basically a day late and dollar short. The chicken’s head has been cut off but the chicken is still running around like he is alive.

Barring some landslide victory in November that changes the balance of power in the Senate or Presidency, the die has been cast. This phase is over and Republicans should meditate on why they did not enact their conservative vision when they were in power.

During the terms of Presidential George W. Bush and Gov. Bill Owens, the Republicans had eight-year periods when they could have exerted leadership. They took little action.

There is a story line running through this narrative. The first is the tortured and warped path taken by the United States over the past 70 years in attempts to bring the abundance of modern health care technology to all Americans.

Prior to World War II, Blue Cross, the first national nonprofit insurer, had a natural monopoly that unitized the risk pool and spread risks and costs across everyone who bought insurance. It was a single-payer system of sorts. But, the twin actions of competing insurers and corporate benefit programs eroded and fragmented that system. Low risk individuals and small groups were lured away.

After ERISA, self insurance was allowed in 1974. Large corporations and labor unions could self-insure and pocket the savings. Over the years, large private payers and insurers alike negotiated discounts and cost-shifting became so severe that anyone buying health care on his own was put at a serious disadvantage.

Over the past 20 years healthier and lower-risk patients have been removed from the risk pool leaving commercial insurance for individuals and small groups with premium increases that were double other payers.

Increasingly low income and healthy individuals who cannot afford insurance have abandoned the system.

This is the adverse selection spiral that the Affordable Care Act attempts to arrest and reverse through the individual mandate. What we should take note of is that this vicious spiral was initiated in the first instance by the cherry-picking of risks by insurance companies and the move to self-insurance by corporations and labor unions.

We must realize, however, that the individual mandate is like the little Dutch boy putting his finger in the hole in the dike. It does not arrest or reverse the underlying hydraulics that are driving underlying health care inflation. The United States spends over 17 percent of its GDP on health care, which is 40 percent greater than the 13 leading social democracies of Europe who spend 10 percent.

For a capitalistic country that prides itself on competition and productivity improvement to achieve poorer health incomes yet spends so much leaves one bewildered. The underlying structure of the American health care system is fundamentally flawed and it is not just in the financing of insurance. It is rooted in the tendency to use intense hospital services far too much and to ignore wellness and prevention and other alternatives.

Let me make a prediction: The battle between being insured or uninsured is now going to shift to which insurance plan you embrace. Over the past 20 years we have increasingly shifted from the community hospital to the insurance plan to finding a loyal agent to integrate health services. That will now intensify.

I believe the only substantive change the Republicans will be able to enact will be to authorize the selling of insurance across state lines. That will be the beginning of the end for state level health insurance regulation. The price the states will pay for their failure to deal with the health care issue will be the intrusion of the federal government, which will use its subsidies and taxing power to determine which benefit plan is acceptable. That is also what happened in the case of Medicare for the elderly and Medicaid for the poor.

Health care is now the largest employer in the State of Colorado and nearly half of all new jobs come from health care. There are 153,000 businesses in the state, 70 percent of which have less than 10 employees each. But, there are 400,000 sole proprietor businesses being launched in garages and mini-storages. An estimated 800,000 people in Colorado do not have health insurance and it is this group that the Affordable Care Act affects.

The coming advent of health exchanges and consumer co-operatives enabled by the Affordable Care Act will serve to reshape the health care landscape over the next 20 years in ways we never imagined.

I am an independent politically, but if I were advising the Republicans I would suggest two things. First, quit beating a dead horse when it comes to the Affordable Care Act. Second, turn your attention to finding new and innovative ways to encourage the health care system to be more productive. A truly lean health care system could become an export industry in our 21st century economy.

And reducing the portion of the GDP we will spend on health care, soon to be 20 percent,  will free up billions for other purposes. Focusing on this aspect is the highest and best use of your time.

Francis M. Miller is the past president of the Colorado Business Coalition for Health and the vice chairman of the Colorado Health Data Commission. He founded the first consumer cooperative for health care called the Alliance and is the current president of Health Smart Co-op.

By Michele Lueck

The U.S. Supreme Court’s decision to uphold the Affordable Care Act (ACA) and especially the individual mandate provision stands to affect Colorado’s health care system – and hundreds of thousands of the state’s residents – on a variety of fronts.

The Colorado Health Institute estimates that about a half-million uninsured Coloradans will gain health insurance by 2016.

These newly-insured Coloradans – those who will become eligible for an expanded Medicaid program, middle-income individuals and families who will qualify for government subsidies to purchase insurance, and employees of small and some larger businesses who aren’t currently offered coverage – will most likely have significant implications for Colorado’s insurance market as well as how health care is delivered in the state.

The Supreme Court ruling created more certainty for the Colorado Health Benefit Exchange (COHBE). Authorized by state law but funded initially through the health law, COHBE is scheduled to open a new marketplace designed to provide affordable insurance by late 2013. A good portion of the newly-insured will most likely buy their coverage through COHBE.

Finally, tens of millions of dollars in ACA-related grants will continue to flow to Colorado organizations, funding their efforts to improve the health care system. Many programs in Colorado are testing models to make health care more efficient, less expensive and better able to provide good health outcomes. CHI expects this forward-looking work to continue.

Five Questions Facing Colorado

With its ruling, the Supreme Court provided some important answers. But the Colorado Health Institute anticipates that Colorado’s policymakers, leaders and citizens will need to answer a number of other questions in the coming years in order to implement the law by 2014 and make it work best for Colorado, including:

1.       Will Colorado choose to participate in the Medicaid expansions outlined in the ACA?

2.       Will the Colorado Health Benefit Exchange be open by October 2013?

3.       What will be included in Colorado’s definition of Essential Health Benefits?

4.       Will the tax penalties be sufficient to encourage currently uninsured Coloradans to purchase coverage?

5.       Constitutional issues aside, will the ACA survive ongoing battles over implementation?

With today’s decision, the legal challenge may be over, but the implementation battles remain. And the outcome will make a difference for the approximately 830,000 Coloradans without health insurance as of 2011.

Elections – from presidential and congressional to the state level – will most likely determine how the law is implemented beginning in 2014. Switching from a Democratic administration to a Republican administration could affect the law almost as much as a Supreme Court ruling striking it down would have. Especially crucial will be whether funding is allocated to pay for the provisions in the law.

Even more basic, will Coloradans find that health insurance really does become affordable? Will they be persuaded to buy health insurance rather than pay the penalty, or will they decide it makes more financial sense to pay the penalty?

How will those decisions affect the operation of Colorado’s new health insurance marketplace and its ongoing viability?

Will Colorado be ready to care for a half-million or so newly insured, with all of the implications those numbers hold for the state’s health care workforce and its capacity to provide care, especially in currently underserved areas of the state.

The answers to these questions – and hundreds of others – will become clearer as the ACA heads toward 2014, when the majority of it is slated for implementation.

Michele Lueck is president and CEO of the Colorado Health Institute.

By Diane Carman

When  Melissa Hart attended the oral arguments before the U.S. Supreme Court on the Affordable Care Act last March, she noted that Chief Justice John Roberts’ questions “reflected serious concerns.”

“I still didn’t predict this,” said the associate professor and director of the Byron White Center at the University of Colorado School of Law said Thursday morning, an hour after the ruling was released.

The 5-4 ruling, in which Roberts joined Justices Ruth Bader Ginsberg, Stephen Breyer, Sonia Sotomayor and Elena Kagen in upholding the heart of the act – the individual mandate – came as a surprise to most legal analysts who anticipated the decision would turn on whether the mandate was valid under the Commerce Clause.

The justices ruled that it was unconstitutional under the Commerce Clause, but the majority accepted the secondary argument made by the Justice Department lawyers — that it constituted a tax.

“The way courts consider whether something is a tax is sort of a functional approach,” Hart explained. In terms of the Affordable Care Act, she said, “in fact, if you choose not to get health care, you must pay a tax not to do that. It’s just as if you choose to donate to a charity, you get a tax benefit. That’s how the tax code works in positive and negative ways.

“Justice Roberts’ opinion focuses a lot on how people are not lawbreakers if they choose to pay a tax and not pay for health insurance. It’s not a criminal penalty. They’ve simply chosen to follow the law in a different way than other people might.”

Hart said the ruling vividly illustrates the difference between judicial activism and judicial restraint.

CU Professor of Law Melissa Hart

“Courts are supposed to construe laws whenever possible to avoid rulings of unconstitutionality,” she said. “They are not supposed to look for opportunities to rule laws unconstitutional. That’s a longstanding basic element of what a judge is supposed to do.”

Hart said that courts are not meant to “interfere with the constitutional job of a duly elected legislature.

“I think it’s a victory for the rule of law,” she said. “I think the ruling demonstrates that despite people’s fears, this court is taking its role seriously. It’s a good example of judicial restraint: If they could find grounds to uphold the law, they uphold it.”

That doesn’t mean that the decision was an easy one for the justices, however.

Hart noted that the fact that the dissenting justices – Anton Scalia, Clarence Thomas, Samuel Alito and Anthony Kennedy – chose to issue a dissenting opinion written as a group clearly announces the depth of their opposition.

“It’s rare for any court to have an opinion written by a body rather than by a justice,” she said. “It shows how hard-fought this decision was. It reflects just how angry they are about how the decision came out.”

The court also ruled that the provision of the act, which denies all federal Medicaid funds to states that do not fully implement federal Medicaid expansion programs, was unconstitutional.

Hart said that while this is a blow to the act, it would be “a surprising choice” if states decided to opt out of the programs to expand Medicaid coverage.

“The way it is structured, the federal government is footing the bill for quite some time. I don’t think we’ll see a lot of states choosing not to participate.”

By Katie Kerwin McCrimmon

The U.S. Supreme Court’s 5-to-4 ruling upholding the Affordable Care Act inspired celebrations Thursday among Obama supporters who toasted a major victory, while stunned conservatives vilified Chief Justices John Roberts Jr. as a “turncoat” for siding with four liberal justices. They vowed to take the fight against Obamacare to the political arena.

In Colorado, the ruling clears the way for sweeping multi-million dollar health reform to move forward. Only one part of the massive law appeared to be in doubt. Analysts in Colorado and around the country were trying to figure out exactly how the ruling on Medicaid expansions would affect them. The health law requires states to provide health coverage for a much larger number of poor people under Medicaid programs, which are funded by both federal and state governments. The justices found that the federal government can require those expansions, but can’t threaten to take away current Medicaid funding if states fail to allow new people into already cash-strapped Medicaid programs.

Gov. John Hickenlooper said in a statement that millions of Coloradans have already benefited from the Affordable Care Act (ACA) including thousands of young adults and people with pre-existing conditions who have been able to qualify for health insurance, seniors who have taken advantage of preventive screenings, and hundreds of thousands of Coloradans who no longer have lifetime limits on their health coverage.

“More Coloradans will benefit when the Affordable Care Act is fully implemented in 2014,” Hickenlooper said. “We will continue to operate within the law’s framework and with the General Assembly while making state-level decisions that work for everybody.”

Hickenlooper said there is still more work to be done on cutting health costs, which have been outpacing economic growth for years.

Colorado Attorney General John Suthers, who on behalf of the state of Colorado had challenged the landmark health law along with 25 other states and the National Federation of Independent Business, said he was deeply disappointed and called the ruling a “very strange result.”

“I was very surprised by how they did it,” Suthers said, noting that President Obama and Congress had always claimed that the requirement that all individuals would have to buy insurance did not amount to a tax.

“I don’t think this bill would have ever passed had Congress called it a tax,” Suthers said.

Nonetheless, “the court has spoken. That’s the end of the line. There are no more appeals,” Suthers said.

Now, the fight over health reform will land squarely in the political arena, Suthers said. He believes that the debate will become even more hard-fought since the Supreme Court has declared the mandate a tax and not upheld the law under the Commerce Clause of the U.S. Constitution.

“I do think it becomes more of a volatile issue, having been based on a tax,” Suthers said. “Americans understand taxes.”

Suthers attended the oral arguments before the Supreme Court in March and listened to the debate over whether the justices would consider the mandate a tax. He thought it was unlikely that they would, but then it became clear on Thursday that Roberts was willing to make a compromise with the liberals. He refused to uphold the mandate under the Commerce Clause, but agreed to go along with the liberals if they would call the mandate a tax. Suthers called that a “pyrrhic victory for the states.”

“One has to believe that this is the result of a very, very dynamic compromise in the court,” Suthers said. “The bottom line is that the mandate is upheld as a tax.”

Tony Gagliardi, Colorado state director for the National Federation of Independent Business, said he was also disappointed.

“This is a sad day for main street businesses. It’s a sad day for the freedoms of the American public,” Gagliardi said.

“It will just be an exacerbation of the uncertainties on Main Street. I wouldn’t look for job creation to take an enormous jump.”

Gagliardi said that the NFIB will continue to challenge health reform through regulatory and legislative means.

“We respect the decision, but we will continue our fight for actual, legitimate health care reform. This act does nothing to address the real cost of health care.”

Colorado’s health exchange board is proceeding at full speed to build a new health insurance market by October of 2013. Health exchange managers have signed a $66 million dollar contract with the technology firm, CGI, for technology work to help build and run the exchange through 2018. CGI is also building a $94 million exchange system for the federal government. Exchange executive director and CEO Patty Fontneau noted that the CGI contract is “one significant piece of a series of contracts that will implement and operate the exchange through 2018.”

Fontneau said it’s impossible at this point to predict exactly how much it will cost to build and run the exchange. Under the Colorado law that created the exchange, funding cannot come from the state. So far, Colorado has been developing  the exchange with a $1 million federal grant that was followed by a $17.9 million follow-up grant from the U.S. Department of Health and Human Services. Those funds will keep the exchange funded through October. Then, Colorado will need new federal funding to keep the health exchange viable.

Gretchen Hammer, who is chair of Colorado’s health benefit exchange board and executive director of the Colorado Coalition for the Medically Underserved, said the Supreme Court ruling clarifies Colorado’s path to reform.

“This decision really allows us to stay on track with the work that we are already doing to build a new insurance marketplace. It’s full steam ahead,” Hammer said.

“We are very proud of the work that we have been doing in Colorado to improve the health care system. We are a leader in terms of access to care for underinsured and underserved patients and in providing medical homes. So, we are really pleased that all of those good things that are currently in place can continue,” Hammer said.

Among other reactions to the high court ruling:

U.S. Rep. Cory Gardner, Republican from Yuma:

“Today’s decision is very disappointing. The Supreme Court effectively granted Congress unprecedented power to tax people who don’t spend money and buy what Congress wants them to buy. But just because something is deemed constitutional does not make it good policy. Our fight to curb the overreaching power of government will continue. While today’s decision may have been a setback, the vision of our Founding Fathers and their notion of limited government still lives in the hearts and minds of many Americans. This ruling only energizes us for November.”

U.S. Sen. Mark Udall, Democrat from Eldorado Springs:

“The Affordable Care Act has expanded health coverage for thousands of Coloradans and made preventive care more accessible and affordable for millions of Americans across the country.  I am pleased to see that the U.S. Supreme Court affirmed the bill’s constitutionality.

“We have already seen the positive impacts of the law, including keeping prescription drugs affordable for our nation’s seniors and prohibiting insurance companies from denying health insurance to children with pre-existing conditions.  I look forward to working with my Senate colleagues, and the administration, to ensure that this important law continues to be implemented in a smart and effective manner.”

Patty Fontneau, executive director and CEO of the Colorado Health Benefit Exchange:

“The high court decision allows us to stay on track with the work of building a new health insurance marketplace that increases access, affordability and choice for Coloradans and fulfills the vision of our state enabling legislation, Senate Bill 200.

“When we open for business in October 2013, our marketplace will make it easier for individuals and small businesses in Colorado to shop for and purchase health insurance. We have a tremendous amount of work ahead of us and we are grateful to be able to stay focused on opening an Exchange that meets the needs of Colorado.”

Dede de Percin, executive director of the Colorado Consumer Health Initiative:

“This is the best economic news we could have heard. Coloradans will have more money in their pockets because we will continue to reap the benefits of increased access to more affordable health care. Colorado families now will have the peace of mind that they will be able to get the care they need when they need it … Colorado has already begun expanding Medicaid coverage because as a state, we believe families should be able to get the health care they need. The Medicaid finding on reimbursements will not affect us. And not only has the Court upheld the law but Colorado has spoken – voters rejected an anti-health reform initiative and passed bipartisan legislation to establish an health benefits exchange. We will continue to move forward with increasing access to quality health care for all Coloradans.”

Colorado House Majority Leader Rep. Amy Stephens, Republican from Monument, who helped sponsor the law creating the Colorado Health Exchange:

“Today’s ruling by the U.S. Supreme Court sets a dangerous constitutional precedent that will derail our fragile economic recovery.

“Federally mandated health care oversteps congressional authority and will hamstring entrepreneurship and impose impossible-to-manage costs for all employers here in Colorado and across the country.

“House Republicans will continue to look for ways Colorado can fight federally mandated health care and introduce consumer-driven solutions that respect states’ rights and best fit Colorado’s unique needs.”

Anthem Blue Cross and Blue Shield in Colorado, which has about 950,000 members in Colorado:

“From the early days of the debate on health care reform, we’ve stated our desire to build a health care system that provides access to all Americans and ensures high quality, affordable health care. Anthem Blue Cross and Blue Shield in Colorado will continue to move forward with our efforts to improve our nation’s health care delivery system…

“The road to implementing health care reform will be a challenge; however, we look forward to working constructively with policymakers and other key stakeholders to build a health care delivery system that provides security and affordability to all Americans.”

Elisabeth Arenales, health program director for the Colorado Center on Law and Policy:

“We celebrate the ruling because it means that all Coloradans have the security of knowing they can get the care they need when they need it.

“In the past two years, the Affordable Care Act has helped nearly 2 million Coloradans gain access to health care, expanded services and peace of mind. That includes:

• More than 40,000 young adults in Colorado under the age of 26 have gained health insurance.
• In 2011 alone, 39,000 Colorado Medicare recipients saved over $22 million on their prescription.
• 291,000 children in Colorado with pre-existing conditions can never be denied coverage.
• Many Coloradans are opening the mail this month to find rebates from their insurance companies.

“These are a few of the positive changes that are a direct result of the Affordable Care Act.  Colorado can now continue moving forward implementing other provisions of the act and ensuring that all Coloradans are secure in the knowledge they have access to quality, affordable health care when they need it.”

The Colorado Trust:

“This morning the U.S. Supreme Court upheld the Affordable Care Act, affirming this landmark law. The court’s ruling represents a significant step forward in helping to provide more affordable, meaningful health coverage for Americans, including the nearly one-third of Coloradans who are uninsured and underinsured.

“Most of the provisions required through the Affordable Care Act closely align with the recommendations of Colorado’s own Blue Ribbon Commission for Health Care Reform, including Medicaid expansion. Today’s ruling assures that our state will have access to federally funded Medicaid expansion, and underscores the need to maintain our commitment to Medicaid, working within the realities of our state budget.

“The Colorado Trust stands firm behind its commitment to work closely with partners to achieve access to health for all Coloradans. The court’s ruling offers renewed hope for realizing this goal, and underscores the importance of providing Coloradans with good information, encouraging them to speak up about health care challenges and to be actively engaged in achieving workable solutions.”

Colorado Organization for Latina Opportunity and Reproductive Rights executive director Lorena Garcia:

“The Supreme Court’s decision to allow the Affordable Care Act to stand is a victory for Latinas and their families, including the 50 million Americans currently without insurance.

“Today, one in three Latinos in the United States is uninsured, more than any other racial or ethnic group.

“Colorado women should have access to the health services they need, without postponing care, unable to pay for treatment, and making care more costly and dangerous in the long term. We look forward to participating in conversations as we build an exchange in Colorado that focuses on increasing access to quality health care for all Coloradans.”

Stat Sen. Irene Aguilar, M.D., Democrat from Denver:

“This is a wonderful outcome for 480,000 of our 829,000 Coloradans without health insurance. The Patient Protection and Affordable Care Act will help working families afford health insurance, and allow Colorado to expand its safety net for those living in poverty.  Colorado can move forward on its work on the exchange without further delays and diversions. The Supreme Court’s decision will help our economic recovery tremendously.”

“The ACA has given Coloradans security in their health care that they have never experienced before, prohibiting insurance companies from dropping those who get sick, using annual or lifetime limits to bill people into bankruptcy or discriminating against individuals with a pre-existing conditions.”

Polly Anderson, chief policy officer for the Colorado Community Health Network: 

“By upholding the constitutionality of the ACA, the U. S. Supreme Court has assured that 32 million uninsured Americans, including 510,000 Coloradans, will have the opportunity to gain insurance coverage over the next few years. The decision also assures continued expansion to primary and preventive health care and that consumers will have vital protections and benefits under the law.

“Nearly $50 million in grants from the ACA has gone to communities across Colorado to expand existing community health centers and to build new centers to care for more people in Colorado. Health Centers are working hard to provide access to high quality, affordable primary health care in underserved communities, regardless of people’s insurance status. The continuation of the ACA means that Colorado community health centers will continue to provide health care homes to the 600,000 people who visit community health centers now.”

Vicki Cowart, president and CEO of Planned Parenthood Votes Colorado:

Cowart called the Affordable Care Act “the greatest advance in women’s health in a generation” and said the ACA will have a “profound and concrete impact” on millions of people’s lives.

“The law will provide access to birth control and cancer screenings without co-pays, guaranteed direct access to OB/GYN providers without referrals, and an end to discriminatory practices against women, such as charging women higher premiums and denying coverage for pre-existing conditions.

“This decision will have a profound and concrete impact on millions of people’s lives. Affordable, quality health care will now be available to millions of women who had no coverage or inadequate coverage before. Today, we are closer than ever to realizing the promise of health care for all.”

By Bob Semro

More small businesses say they will offer health insurance for their employees once the Colorado Health Insurance Exchange is up and running in 2014, according to a Kaiser Permanente survey of business owners.

The survey found that, after hearing a short description of the exchange, the number of employers who said they would offer health benefits to some or all employees jumped to 59 percent, up from 52 percent.

More striking was the change in the percentage of employers who don’t plan to offer coverage. Currently, 48 percent do not provide coverage. After coverage is available through the exchange, only 25 percent said they would not offer health benefits.

However, too many employers remain unaware of benefits under the exchange. More than half (56 percent) of eligible business owners were not aware of tax credits available to them.

The health insurance exchange will begin operating in 2014. It will enable small businesses to shop for health insurance among competing companies online or through a broker. It has been compared to shopping for the best fare on an online travel website. Under the Affordable Care Act, many small businesses are eligible for tax credits, good between 2010 and 2013 and any two years after 2014, to help pay for employee coverage.

The survey polled 300 businesses with two to 50 employees and was conducted in May. The maximum sampling error was +/- 6 percentage points.

Here are other findings:

• Only 5 percent of all Colorado small businesses are taking advantage of tax credits available now. About three-quarters of businesses eligible for credits do not offer health insurance. Many small business owners are not sure if they are eligible or mistakenly believe they are not eligible.
• 63 percent of all Colorado small businesses are eligible for tax credits under the Affordable Care Act but do not offer health benefits. These owners were asked if they were likely to shop for insurance through the exchange if they knew their company qualified for tax credits; 58 percent said yes.
• 71 percent of business owners who expect to provide coverage in 2014 favored a provision in the exchange that would allow them to set an amount they would pay for each employee’s health insurance and receive a single consolidated bill. Employees then would choose their insurance through the exchange. (Among all small business owners, the percentage is 56 percent.)
• 58 percent of all employers favor coverage through the exchange that offers greater prevention and wellness services. For those who expect to offer coverage in 2014, favorability jumps to 71 percent.
• Business owners prefer a smaller number of plans to make comparisons to a greater number that made comparisons more difficult – 56 percent of all small businesses vs. 61 percent that expect to offer coverage.

We think the survey produced some interesting findings, notably that small businesses are generally receptive to Colorado’s health exchange as a mechanism for providing and expanding coverage to employees. This is important because the Colorado Health Benefits Exchange was created by the Colorado General Assembly and is not directly tied to the constitutionality of the Affordable Care Act. Colorado’s exchange would likely continue regardless of the court’s ruling.

Based on the survey results, however, it is clear more small business must learn about the exchange and how it can help them. The survey indicates, for instance, that a large number of Colorado employers are not aware of tax credits available to them. It may be that information simply is not getting through.

Or it may be that some complexities accompanying the credits discourage some businesses from signing up. The ACA offers a 35 percent tax credit to eligible small businesses that apply between 2010 and 2013. After that period, the law provides a 50 percent tax credit for any two-year period after 2014. The limited duration of these credits might be too short to lure some employers. Also, eligibility for the tax credits is based on company size, average income for full-time employees and other criteria that may not apply to all employers. Based upon this formula, not all eligible employers would receive the full tax credit.

Whatever the reason, if the survey is correct and 56 percent of employers eligible for credits are not aware of them, it shows that much more work needs to be done to explain the benefits of this provision – for businesses as well as employees.

The survey also shows that many employers favor a flat amount paid per employee (or defined contribution) toward health insurance, with employees choosing the type of coverage they want. This approach provides flexibility, but we caution that without adjusting payments to keep pace with insurance costs, employees could face increasingly burdensome costs for covering themselves and their families.

Bob Semro is a health care policy analyst with the Bell Policy Center, a non-partisan policy research center that advocates public policies that reflect progressive values.

By Dr. Elizabeth Kraft

Whooping cough.  It sounds like the name of a disease that might have carried off two of the seven children of a family in the Victorian era.  It’s more of a comical than a frightening name for a disease, but it shouldn’t be.  Whooping cough — or its scarier medical name Bordetella Pertussis — kills about 200,000 babies a year.

Pertussis starts with the same symptoms you get from a cold:  a runny nose, a low fever and maybe a mild cough. Those symptoms can last for one to three weeks, during which time the patient is very contagious. The disease is transmitted through the secretions from the lung or the droplets from sneezing or coughing. After the cold symptoms come the bursts of rapid coughing. This phase can last up to three months. Sufferers can turn blue and vomit.  In their hunger to get air, they try so hard to breathe in that they make a whooping sound. Babies between 6 and 12 months are at highest risk for serious illness and may not have this awful cough early on, but may stop breathing. They can suffer brain damage or die.  Recovery for those without permanent damage can take weeks to months.

A laboratory test can confirm pertussis. Doctors can also treat with antibiotics based upon the level of illness.  People who have come in contact with people with pertussis should also be treated within three weeks of exposure.

Why, you ask, hasn’t modern science found a way to stop this?  In fact, there is a way. A vaccine against pertussis was introduced in the 1940s, and the number of pertussis cases in the United States fell from about 200,000 a year to under 5,000. The original vaccine required multiple doses and protected against pertussis for five to 10 years.  (Unlike chicken pox, which usually gives lifelong protection, people who catch pertussis can still get it again. So neither the disease nor the vaccine gives long-term protection.)  So almost all of the babies who die from pertussis each year are in countries that cannot afford the vaccine.  Almost all, but not all.

Since the vaccine doesn’t last forever, the Centers for Disease Control and Prevention now recommends a vaccine for teenagers and adults in addition to the series of vaccines given to babies and children.   If we can improve our vaccination rates, we can stop the spread of this preventable, deadly disease.

Have any of your friends had a persistent chronic cough this year?  Are you around children, or are you around anyone who is around children?  Do you want to reduce your risk of having an exceptionally unpleasant prolonged cough that can lead to rib fractures?  Do you want to do the right thing?  If you’ve answered yes to any of these questions, ask your doctor for Tdap, a vaccine to prevent pertussis.

Elizabeth “Cissy” Kraft, M.D., is medical director for Anthem Blue Cross and Blue Shield in Colorado, which has about 950,000 members in Colorado.  Dr. Kraft is board certified in family medicine.

By Katie Kerwin McCrimmon

A multi-million-dollar cash infusion is flowing into Colorado’s safety net health system just under the wire as the Supreme Court is poised to rule on the Affordable Care Act.

By Thursday,  if the Supreme Court invalidates the landmark health law, the flow of new funding to provide care for Colorado’s poorest children and adults could screech to a halt.

But last week, health managers from Olathe to Steamboat and from Kiowa to Sheridan and Englewood learned they would get nearly $3 million to open clinics on a fast track — within 120 days.

In a last-ditch effort to tap the muscle of the Affordable Care Act (ACA), U.S. Health and Human Services Secretary Kathleen Sebelius pumped nearly $130 million into communities across the country. The Obama administration estimates the new clinics will add more than 5,600 jobs across the country and serve more than 1.25 million patients.

In Colorado, the community health system provides care for up to one in 10 Coloradans, or about 600,000 people.

“We serve one-third of all the Medicaid patients, one-fourth of the CHP+ (children’s health plan) patients and one-third of the state’s low-income uninsured,” said Polly Anderson, policy director for the Colorado Community Health Network, an umbrella group for Colorado’s health systems that will now grow from 15 to 17 systems that run more than 131 sites.

Anderson said rumors of new grants started to surface in recent weeks when federal officials asked for updates from clinic managers.

“We knew it was possible,” Anderson said. “It’s a little surprising, but we’re thrilled.”

Almost all of the patients in the community clinics come from the growing ranks of the poor and uninsured, including a record number of children who live in poverty.

Altogether since its passage in 2010, the Affordable Care Act has pumped $46.5 million into Colorado’s community health system. With the additional $3 million this week, that number now approaches $50 million. The community health systems that provide care to Colorado’s swelling ranks of uninsured people are among the groups that have the most to gain or lose depending on the ruling from the Supreme Court.

The justices are expected to hand down their decision on Thursday. They could strike down the most controversial portion of the law — the individual mandate that requires everyone in the U.S. to buy health insurance. Or, they could uphold or invalidate the entire health law, which will have far reaching impacts for health workers who treat the uninsured.

Dr. J.R. Franco treats a young patient at the Clinica Family Health Service’s Thornton Clinic.

‘Uninsured are everywhere’

Hidden near bustling shopping centers from Park Meadows to Southlands, the uninsured serve affluent residents in the retail and entertainment meccas that fill Denver’s southern suburbs.

Just like in Colorado’s mountain resorts, an army of service workers props up the affluence, creating a world of haves and have-nots.

“The uninsured are everywhere. They are there when you go into a restaurant, a shopping center or a movie theater. They are the service people you are interacting with, the people you give tips to, the people you like so much,” said David Myers, president and CEO of the Englewood-based Metro Community Provider Network. “We pass through life and yet don’t see how people are really living. That’s the invisible part. You don’t really know their stories. “

Because of the new grant of about $440,000, Myers is now hunting for an existing building that he can quickly convert into a new health center to serve these workers in south Arapahoe County. He already has a medical staff ready to open the clinic.

Myers got a double dose of good news in the past week. His agency also won a $1.2 million innovation grant with different funds from the ACA.  That grant in concert with Rutgers University, will support efforts to slash expensive ER visits in Aurora by providing intensive support to patients who cost the system the most money.

In South Arapahoe County, Myers and his researchers found a growing need for help.

“Some of the developments are very affluent and some are not. There’s a census tract that has a poverty rate of 16 percent, which is very high, next to one with a poverty rate of 2 percent,” Myers said.

“There seems to be a dynamic of the middle class being squeezed out,” Myers said.

For instance, his researchers looked at three elementary schools in their target area near where Smoky Hill and Arapahoe Roads intersect with E-470. The percentage of children who qualified for free and reduced lunches grew by a stunning 34 percent in a recent four-year period.

Areas from the Tech Center to Centennial are full of restaurants. Using data from the Colorado Restaurant Association, Myers estimated that nearly 17,000 people work in the area’s food service industry.

“That becomes a barometer for us. Restaurant workers are the classically uninsured,” he said.

Altogether, the Metro Community Provider Network serves about 38,000 people in 10 sites throughout Jefferson and Arapahoe Counties along with the cities of Aurora and Lakewood.

The number of patients served will grow with the new expansions. Forty percent of current patients are children. Sixty percent have no insurance at all while 30 percent have Medicaid. Almost none have private insurance.

Myers and his colleagues in community health centers across the state are all eagerly awaiting the Supreme Court decision. If the justices strike down the law, it’s unclear what will happen to anticipated funds.

“If they throw the whole thing out, then it raises questions about what has been allocated,” he said.

Most community health clinic managers are steaming ahead, assuming that what has been spent has been spent and that they must proceed to provide care for the poor.

“We are going to continue moving forward. We will go with hope, but it is really an unknown how the decision will affect the funding,” Myers said.

Regardless of where people stand on the ACA, Myers and others in the community health system say everyone who wants to cut health expenses and “bend the cost curve” should want a robust, high quality network of clinics.

“The best thinking is that (the answer) is primary care. It’s access to care. It’s keeping people healthy. That’s what community health centers do. If people are uninsured and they hit the hospitals, there’s an expense to that.”

From pigeon-infested building to health and dental clinic

At Clinica Family Health Service’s Thornton Clinic, teams of health providers fill cavities, provide prenatal care and attend to sick children in the middle of a construction zone paid for courtesy of an earlier $3.7 million grant from the Affordable Care Act.

Clinica is another of Colorado community health networks, which provides care to about 35,000 low-income patients a year in parts of Boulder, Broomfield and Adams County. Nearly all of the patients work, but don’t have health insurance. About three-quarters are Hispanic.

On a recent morning, paramedics wheeled a gurney through a plywood tunnel into the established part of the clinic while construction workers in white helmets built the newest additions to the building, nearly doubling it in size. Paramedics had to transfer an infant, who was struggling to breathe, to a nearby hospital.

Clinica’s building near Interstate 25 and North 88^th Avenue was once a Safeway, then a DMV building and swimming pool supply store. Clinica bought the abandoned building in 2000. Pigeons were roosting in the ceiling. It was full of asbestos. Now the 15,000 square-foot building houses dental, behavioral health and medical services. By December, another 13,000 feet of space will be open and will accommodate thousands of additional patients.

For pediatric dentist, Dr. J.R. Franco, additional dental chairs will translate to many more children seen and a dramatic savings in costly dental problems.

“Most kids here have not had prior dental visits,” said Franco, who previously worked in Arkansas and Texas.

Franco has seen children as old as 11 who have never once been to a dentist. He had one child under age 6 who needed $10,000 in dental work because the child’s tooth decay was so severe. About once a week, he has to spend his day at a nearby Children’s Hospital Colorado sedating kids and handling the worst cases.

“In the long run, my big thing is prevention,” said Franco as he sat in a tiny office half under construction.

Down the hall, in a larger room in the clinic, a group of about eight Spanish-speaking pregnant moms gathered with their doctor, their older children and a teacher who was conducting a group visit for them. Shiny apples and cheese sticks sat on a table so the women could have a healthy snack and a lesson on nutrition during pregnancy. One by one, the mothers documented their own blood pressure and weight, then stepped behind a curtain to lie on an exam table and have their bellies measured. Dr. Anne Hansen checked fetal heartbeats and spoke to each mother one-on-one about how she was feeling.

At Clinica, providers adopted the concept of group visits several years ago. They found that for diabetes patients and pregnant moms, in particular, interaction with one another could save providers money while helping produce better health outcomes.

At this visit, each of the women is newly pregnant. All receive detailed booklets full of information about birthing techniques, wellness and healthy eating during pregnancy. The group will stay together all the way through their babies’ first birthdays. One group recently celebrated their babies’ fifth birthdays together.

Down the hall, in another exam room, Felicity Ortega, 34, has just finished her annual well-woman exam.

A single mother who was widowed six years ago, Ortega is now a full-time student who hopes to become a graphic designer. She lives in nearby Northglenn with her two children, ages 16 and 14.

Ortega learned about Clinica after she struggled to find a good doctor with whom she could build a relationship. Struggling with no health insurance and supporting herself as a dental assistant, Ortega said she became depressed after her husband’s death. Since coming to Clinica, she’s been able to see the same nurse practitioner for the last three years.

“Most people hate coming to the doctor. For me it’s like coming to see a friend. She may stab me sometimes (to get blood),” she said. “I love it here. She knows your name and you build that relationship.”

Ortega’s provider, Carrie Ann Matyac, worries that if the ACA is ruled unconstitutional, health problems among the uninsured will only get worse.

She said ACA funding has directly helped her provide better mental health care and has helped provide nutritionists who are battling the obesity epidemic.

“There are a lot of people who struggle,” Matyac says.

If the Supreme Court strikes down the ACA, Ortega fears places like Clinica won’t have the resources to help the uninsured.

“I’m a full-time student. I’m a single mom. There would be no place to help people like me.”

By Katie Kerwin McCrimmon

WESTMINSTER — Every year, Mark Henault, co-owner and chief financial officer for a thriving Colorado business, spends a solid month researching and selecting health insurance plans for the next year.

It’s a painful job. First there are the inevitable cost spikes. Last year, one employee was hit while riding his motorcycle. It wasn’t a catastrophic accident, but with a short hospital stay and follow-up visits, the bills quickly soared to $180,000. Henault’s business was hit with a 100 percent increase.

“One bad year and you’re dead,” said Henault.

So much for the previous year’s plan. He couldn’t accept a doubling of prices. Instead, he shifted gears and found insurance through a “professional employer organization” that brings companies together to get better benefits. Henault then has to make sure that each employee fills out detailed health questionnaires that can be more onerous than tax forms. People with illnesses sometimes have to go back seven years reconstructing doctor visits and medication regimens. If they exclude one detail, they might not be covered.

Henault’s company, Syncroness, designs and engineers high-tech products from toys to rocket parts and medical equipment. Henault could be spending his time generating new business, but to attract the cream of the crop workers he needs, he must have a top-notch health plan. That can be a challenge for a small business that just this year surpassed 50 employees, now boasts 65 and could have added a dozen more jobs if health costs weren’t so high.

Mark Henault is the chief financial officer for a growing Colorado business. Syncroness designs high-tech products ranging from toys to rocket parts and medical equipment. Here, Henault shows how doctors use the paddles on a defibrillator to resuscitate patients. Henault supports the Affordable Care Act because he’s hoping it will give him access to more affordable health insurance. Top-notch insurance is key to attracting the best employees.

Henault is hoping the U.S. Supreme Court upholds the health reform law for the simple reason that he needs more health insurance choices and a streamlined process.

“Health care is now our second expense behind salaries. It’s crazy. It’s starting to get stupid expensive. We’re hoping the health exchange will benefit us by giving us bigger group-buying opportunities,” he said.

From the White House to the Capitol buildings in both Washington, D.C. and Colorado, elected officials and health policy experts are eagerly awaiting a ruling from the U.S. Supreme Court that could be the most significant in decades. The justices are expected to rule within days on whether President Obama’s landmark health legislation, the Affordable Care Act, is constitutional or not. The justices could invalidate the part of the law that requires all individuals to buy health insurance or they could invalidate or uphold the entire law. In the U.S., businesses have for decades provided health care to employees. Now business leaders are at the center of the debate.

Employees need motivation to cut costs

In a giant warehouse filled with boxes and shipping supplies just off Interstate 70 in northeast Denver, Jim Noon, owner of Centennial Container, has the opposite point of view. With just 12 employees, his health insurance costs also are soaring.

But he thinks the Affordable Care Act is the problem, not the solution.

First, there’s the name. Noon think it’s a joke since it does nothing to make health care affordable.

But, second, he thinks the more government gets involved in health care, the less motivation people have  to shop for less expensive care.

“When everything is free once you’re sick, if a guy gets up at 2 in the morning and goes to an emergency room and that’s a $10,000 visit, that’s part of the problem. President Obama’s way of fixing it is to make it totally free for everyone,” said Noon. (Noon’s representation of the act does not acknowledge the requirement that everyone carry health insurance.)

Meanwhile, business owners like him are forced to pay ever-increasing costs that he fears will only rise if the law is upheld.

“I am not one of those people you’ll hear say, ‘Let’s go back to the good old days before we had health care legislation.’ The good old days were really, really bad,” Noon said.

Year after year, as health costs have risen, Noon, has been able to offer less to his employees. He used to cover 100 percent of the health insurance costs for all of his employees and their families.

Business owner Jim Noon wants the Supreme Court to declare the entire health law unconstitutional.

“Then we took the children off. Then we took the wife off. Then we raised the deductible,” he said.

Now employees can pay to get their spouses and children covered, but Noon said he has “no takers” because it’s too expensive.

What few people realize is that health costs bump up at certain age levels. Noon has found that when an employee hits a new age category, like a 24-year-old turning 25 or a 59-year-old turning 60, there’s a giant increase in insurance costs.

“I will get a renewal and there will be a 40 percent increase. Health insurance costs (on average) only went up 7 percent, but seven of my 12 employees will have hit a new age bracket and our costs go way up,” said Noon.

He created his company 27 years ago with the idea of finding problems and turning them into solutions. He buys cardboard and shipping supplies that have been misprinted or are somehow defective. Then he fixes the cardboard — essentially recycling it before it gets recycled — and resells it to other shippers who can use it.

His solution for the health care mess?

“I’m hoping they strike down the whole law,” Noon said. “It makes a bad situation totally socialist.

“Then we need to send everybody back to the drawing board to fix it. We have to have more personal involvement (in paying for health care) or the cost is just going to be horrible,” Noon said.

Small businesses want help

A new survey of 300 Colorado small business owners conducted for Kaiser Permanente predicts that more small businesses will offer health insurance to employees if they have access to a competitive health exchange, as planned under the Affordable Care Act (ACA) in 2014. Colorado also passed its own law creating the exchange, so even if the Supreme Court invalidates the entire law, Colorado’s health exchange will still be in place, but funding for it that is set out in the ACA could be jeopardized.

Currently in Colorado, only about 37 percent of small businesses offer health insurance to their employees. Another 15 percent give insurance to some, but not all employees. The survey found that with the help of a competitive exchange, nearly 60 percent of employers said they would offer health insurance.

Employers are eager to offer employees more wellness programs and plans that can help with disease prevention, according to the survey.

“These findings support the notion that the state health insurance exchange can provide small employers and their employees the same options and benefits that large companies now enjoy,” Kaiser Permanente Colorado Group President Donna Lynne said in a written statement. “This marketplace can give them more choice of plans and make it easier for them to offer their employees insurance.”

Choice of insurance carriers is important too. Sixty-seven percent of small business owners planning to offer benefits in 2014 want employees to be able to choose among multiple insurance carriers.

Along with choices, small businesses want help in reducing the administrative burdens of providing health insurance. Specifically, the businesses that were surveyed in April and May said they want Colorado’s health exchange to handle enrollment and provide owners with a single, consolidated bill, regardless of the number of different insurance carriers employees select.

Dueling views on what small businesses want

As the nation awaits the ruling from the Supreme Court on the future of health reform, lobbyists have released clashing studies on what business owners want.

A left-leaning group called that Small Business Majority released survey results this month saying that half of small businesses want the Supreme Court to uphold the ACA while only one-third want it overturned.

“Contrary to popular belief, small business owners do not want the high court to throw out the Affordable Care Act,” John Arensmeyer, CEO of the Small Business Majority, said in a written statement. “They see this law as helping everyone have coverage and bringing down health care costs—something that has been one of their top concerns for years. We hope Supreme Court justices understand how important this law is to small businesses who need relief from high health care costs.”

The Small Business Majority survey, like the Kaiser poll, also found strong support for health exchanges.

On the other side is the National Federation for Independent Business (NFIB), which along with the State of Colorado, is a lead plaintiff in the lawsuit that seeks to overturn the health law.

NFIB Colorado Director Tony Gagliardi says that NFIB surveys have found that more than 90 percent of small businesses want the health law overturned.

He said small business owners fear the law will cost them additional taxes and that few small businesses will qualify for tax credits under the law.

“There are a lot of hidden taxes (in the ACA),” Gagliardi said. “The act does nothing to lower insurance costs and does nothing to lower the cost of health care. Even the administration cannot show where this act will lower the cost of insurance and lower the cost of health care. What they’re relying on is the smoke and mirrors of subsidies.”

As essential as French bread

Back on the front lines of the small business debate, Robert Tournier is focused on dinner.

For 33 years, Tournier has owned Le Central, a restaurant just south of downtown Denver that has survived in good and bad times by billing itself as “the affordable French restaurant.”

Tournier has always provided health insurance for all his full-time employees. To him, health coverage is as essential to life as a crusty baguette is to a proper meal.

“I’m all for health insurance,” Tournier says somewhat mystified that there is even a debate about the question or about what the Supreme Court should rule.

He thinks the individual mandate is absolutely key and hopes it will be upheld.

“If everybody has to have insurance, then it will cost the same, just like workers’ comp or car insurance. Health insurance is a must.”

Tournier said his health costs have increased dramatically and he’s had to ask employees to pay more. He covers about 60 to 70 percent of the health insurance costs and many employees now skip the coverage rather than paying for their own share.

“Fifty percent don’t want it because they cannot afford their share. It’s a big burden,” Tournier said. “When I started the business, I used to give insurance to everyone. Now insurance is going insane. The increases don’t make any sense. It doesn’t match the cost of living (increases).”

Tournier said there have been times when he has had French employees for whom it was cheaper to get health insurance in France, even while working in the U.S., than to be covered in the U.S.

“I do what I can. It’s a big chunk.”

Better off scrapping the law and starting over

For Harold Jackson, executive chairman of Buffalo Supply Inc., a distributor of high-tech medical equipment based in Lafayette, the idea that everyone should be covered is good in principle.

But he opposes the health law for a variety of reasons and wants to see it struck down.

“In my opinion, the law is so screwed up that we’d be better off scrapping it and starting over,” said Jackson.

He has 16 employees and pays for health insurance for the employees and their families. It’s an expensive benefit and premiums have increased as much as 20 percent a year.

“We can’t live with that indefinitely,” Jackson said.

His biggest disappointment with the health law was that it didn’t address the critical need to bring costs down. He recently read a report that found from 2003 to 2009 alone, costs have tripled for basic health procedures like giving birth to a baby, having gall bladder surgery or getting a knee replaced.

“Our costs just keep going up and up and up,” Jackson said.

As a result of out-of-control cost increases, he’s concerned that taxes on small businesses like his will continue to rise.

He wants to ensure that people with pre-existing conditions get the health coverage they need, but he thinks it’s critical to make sure sick people don’t buy health insurance only when they need it and drop it when they don’t.

Everyone needs to become more aware of the costs of health care, Jackson said.

“We need people to have some skin in the game in order to have them be good health care shoppers.”

Jackson hopes the law will be overturned, but thinks it’s just as likely to be upheld in part or in whole.

“It really doesn’t matter what the court does. Congress is still going to have to take action to fix it.”

By Gena Akers

One of the main purposes of health care reform is to get more people covered.  Without some kind of coverage, individuals are more likely to put off going to the doctor or scheduling preventive services like mammograms or colonoscopies.

As far as getting people covered, health care reform is working.  The Congressional Budget Office estimates that by 2019 health care reform will have provided coverage for two out of every five people who would have been uninsured had the Affordable Care Act not passed.  So as far as making sure you can get the care you need, when you need it, health care reform is doing a great job.

But, one job health care reform can’t do is change you.  And why should you or I or any of us change?

The simple answer is because the choices we make have a lot to do with how healthy we are.  Besides lifestyle choices, the medical world talks a lot about the importance of preventive care.  The idea is that if we can just make sure John Doe and Jan Doe never get diabetes, then we’ll never have to treat them for diabetes or any diabetes-related complications.  This makes sense, especially since the Centers for Disease control estimate that more than 7 out of every 10 health care dollars spent are on chronic diseases that could be prevented.

But how well can health care organizations prevent you from smoking or gaining too much weight.  The answer: not much.  The difficulty rests with the fact that things like your genes, the environment, your diet and how much you exercise all play a significant role in you preventing yourself from gaining too much weight and developing hypertension or from smoking and developing esophageal cancer.

And for your doctor, the prescription is simple.  Many times, the best thing your doctor can do is take you for a walk.  Unfortunately, he/she doesn’t get paid for that.  Does this mean we’re stuck?  Not unless you think you’re stuck.

Having access to health involves more than having great health insurance or more specialists than you can shake a stick at.  The third and in many ways most important piece is what you do for yourself.  Accidents will always happen.  You can’t always avoid pneumonia, and cancer always is an unplanned and unwanted surprise.  But, before we buy into the promises and plans of our elected officials, we need to buy into ourselves and our ability to take charge of our health.  Yes, we need a health care system that supports us.  But, we can’t expect that system to do all the work.

The parks across Colorado are full of kids and their parents running around and laughing, of young adults and college students playing Frisbee, of retired couples taking their dogs for a walk.  Join the ruckus.  Dust off your tennis shoes, analyze the contents of your fridge, and remember: there is no golden ticket to perfect health.  There are just choices, luck, and ownership.

Just like with your car or your house, take pride in your ownership of your health.  Take even more pride in remembering that besides just the choices you make, your voice and opinion counts in determining how our larger health care system meets you and your family’s needs.

For more information on how to take charge of your health, visit sanluisvalleyhealth.org/get-healthy/.

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 Gena Akers

My friend Kristie recently told me about a discussion she had with one of her 25-year-old friends. Her story reminded me why it’s so important that our health care system continues to change and improve.

“The other day, I was in an argument with this guy and he was saying that Obamacare should be completely repealed because it is unconstitutional. I asked him who pays for his insurance. He said he did and he didn’t get any government handouts. I told him, ‘Oh, so your job offers affordable health care plans? You’re lucky.’ He said, ‘Well, no, but my dad’s does and I’m covered on that.’ ”

Kristie’s friend has insurance not because the government handed him anything, but because health care reform requires insurance companies to extend coverage to people like him.

Like Kristie’s friend, I am one of 6.6 million young adults who have been able to stay on their parents’ health insurance. Unlike Kristie’s friend, I know the only reason staying on my parents’ insurance is even an option is because elected officials were committed in 2010 to making sure young people like me can see a doctor when we need to and get the care we need to stay healthy.

I’m in the age range some like to call “the invincibles.” We do not often seek health care and we often mistakenly believe we won’t need it.

To be honest, neither of these decisions makes us immune to real health care challenges — we just don’t see health care as a major worry until we’re face to face with real illness or injury.

Recent studies have shown that what folks 19 to 25 years old really fear is debt. Just like older adults the biggest health care barrier we face is cost.

The Commonwealth Fund reports that one-third of those ages 19 to 29 reported problems paying their medical bills. Many respondents had to use all of their savings or found it difficult to pay off other forms of debt, like student loans.

Covering young adults up to age 26 is one of health care reform’s most popular provisions. But, what about health coverage for people that are covered under other, less well-known provisions? What about folks with pre-existing conditions or families of three that make less than $25,390 (133% of federal poverty) a year?

Many people initially believed that without strong federal and state regulations, these individuals would have an increasingly difficult time getting the care they need. Fortunately, in the last few weeks, three major insurance companies have stepped in with a surprise: no matter what the Supreme Court decides, many of the changes wrought by the 2010 healthcare overhaul are here to stay.

Although Aetna, Humana and UnitedHealth Group haven’t promised to continue every important provision of health care reform, such as covering children with pre-existing conditions or insuring sick adults, the announcement sends a clear signal that whether or not the law is repealed, a precedent has been set that will not easily disappear.

The three companies, which cover a combined 48 million customers, have already promised to end retroactive terminations of policies and phase out dollar limits on lifetime benefits. Because of the benefits that real people are receiving from health care reform, people like you have spoken out and insurance companies are getting the message that we don’t want to lose the real gains health care reform has provided.

There is still work to be done, but it’s encouraging to see insurance companies voluntarily changing their practices. When Coloradans can get the care they need, when they need it, we’re all better off in the long run. And, it doesn’t matter if you are 25 or 75 years old.

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.