Health Policy Solutions

By Polly Anderson

Critics of the Patient Protection and Affordable Care Act call it too radical, too expensive and a threat to high quality medicine. But in truth, federal health reform emphasizes a return to the caring, personalized, evidence-based medicine that is well established at Colorado’s community health centers.

While some are still debating the merits of expanding Colorado’s Medicaid program to a larger percentage of the poor, Colorado community health centers are not waiting to move forward.  A growing pool of evidence tells us that our model is the future, and we’re preparing for a groundswell in patients, be they through insurance plans sold on the exchange or through Medicaid. They are attracted to a modern practice based on traditional medical values.

Sometimes we think of our approach as old fashioned Our docs tell us they work here because we fulfill their original vision as medical students: to heal people without regard to income or insurance status.

With a 45-year track record, the core value that drives Colorado’s community health centers is the belief that everyone deserves health care. We believe that patients thrive when they have a relationship with a caring primary care provider who, with a dedicated team, coordinates all their care.  That it’s better for patients when they can get all their medical care – drugs, counseling, lab tests and dentistry — in one place.

Our providers also know that it’s important to measure the effectiveness of everything we do. We strive to provide the right care at the right time. We welcome family members and encourage them to participate in our patients’ medical decisions. We understand that it’s just as important to promote wellness – diet, exercise and disease management – as it is to chase illness.

We’ve been on this path for decades, but now there’s growing proof that this old-school style of medicine is actually the future of health care.

Last month, the Denver Post described how Dr. David Homer, a primary care physician in Telluride, closed his decades-old fee-for-service medical practice to head the Uncompahgre Medical Center, a federally qualified community health center in the rural frontier town of Norwood. Homer said he liked the team-based approach, electronic medical records and the knowledge he was practicing evidence-based care. Fee-for-service medicine, he said, is “not the future.”

Then, earlier this month, a study published in the American Journal of Preventive Medicine found that community health centers demonstrate equal or better performance on select quality measures than private practices. This in spite of serving patients who have more chronic disease and socioeconomic complexity. Stanford University published research in the journal because it is impressive showing that health center doctors followed professional and federal recommended practice guidelines more frequently than their private practice peers. With all other things being equal, patients served by community health centers are healthier and get better preventive care.

“Having worked in community health centers, I can see how it makes sense,” said Dr. Randall Stafford, a professor of medicine and one of the study’s authors, in an article in Inside Stanford Medicine. “These are centers where physicians are not as profit-driven and many have incentives more in line with providing quality care.”

Finally, there’s the news in June that five communities in Colorado will get new community health center sites to serve thousands of uninsured patients.

The future of health care is already here at Colorado community health centers, where our back-to-the-future model combines innovative solutions, modern technology and traditional medical values. The evidence just confirms what our patients and staff have known for years.

Polly Anderson is chief policy officer for the Colorado Community Health Network, the unified voice for Colorado’s community health centers and their patients. Reach her at polly@cchn.org.

By Diane Carman

While political leaders across the country furiously debate how – or even whether — to provide health care coverage for the uninsured, Denver Health, the state’s largest safety net provider, welcomed a new CEO this week.

Arthur A. Gonzalez will be charged with running a critical institution where 42 percent of its patients are uninsured at a time when state revenue projections are weak and the future of Medicaid expansion is in serious doubt.

He succeeds Dr. Patricia Gabow, who is retiring in September after serving as CEO of Denver Health for 20 years. He will begin the new job Sept. 4.

With the presidential election four months away and the future of health care reform hanging in the balance, “it’s too early to tell” how federal health care reform, including implementation of the Affordable Care Act, will affect safety net providers such as Denver Health, Gonzalez said. “As the federal government looks at the consequences and the fallout of those states that expand Medicaid eligibility and those that don’t, it may change the nature of the rules.”

Measures including funding incentives, withholding other kinds of payments or other means of encouraging states to expand access to Medicaid could be implemented, he said.

“We don’t know what the final reaction will be.”

In the meantime, Gonzalez, who has 39 years of experience in health care administration in Texas, Arizona, Louisiana and, most recently, as CEO of Hennepin Health System Inc. in Minneapolis, said the organization will do scenario planning to prepare for however circumstances change so Denver Health can maintain the services the community needs.

The challenge, he said, will be to maintain quality and expand access while continuing to reduce costs.

Denver Health uses a model that doesn’t just look at a simple formula of cost divided by people served, he said. “We ask, ‘What about the cost of waste?’ ‘What about the cost of rework?’ ‘What about the cost of needless complexity?’ ‘What about harm?’ ”

If those costs can be reduced, “everybody is better off,” he said.

Hubert A. Farbes Jr., chairman of the board of Denver Health and Hospital Authority, emphasized that Gonzalez was the unanimous choice of the board.

“The board is … charged with a mission that we want to preserve our role in the Denver Metro Area and the state as a whole as the safety net institution of choice,” Farbes said. The selection of a new CEO was critical in determining “how we will operate and adjust our operations to maximize the prospect for the institution to survive.”

Despite the pressures on safety net providers, Gonzalez said, “Denver Health is a great model.”

In an effort to maximize efficiency and continuously improve performance, Gabow instituted the LEAN program, a comprehensive strategy developed by Toyota that uses data-gathering to reduce errors, improve patient satisfaction and eliminate waste.

Gonzalez plans to build on that progress, he said. “We want to get everyone working at the top of their license and we want to continue to try to organize teams in better ways. I also hope to become even leaner than we are today.”

The new CEO said he doesn’t anticipate any changes in the role Denver Health plays in the community.

“I don’t see any changes coming in the safety net mission, the medical and health education mission, or the research mission. They are fundamental,” he said. “I recognize that we are not only in and of the community, we are owned by the community. We are here to help the community and collaborating with the community can help us.”

It’s only by continuing and expanding that level of collaboration and listening to people in the community that Denver Health will be able to address the significant health care needs, he said.

And while the future of health care reform is uncertain, especially for safety net providers who are committed to providing universal care despite unpredictable government programs and volatile forces in the health care marketplace, he said he is energized by the challenge.

“I’m the kind of person who doesn’t worry about the doomsday scenario,” Gonzalez said. “I have great faith we’ll get through this. There are a lot of creative solutions. I’m optimistic we’ll get there.”

By Katie Kerwin McCrimmon

AURORA — The Colorado community devastated by a mass killing will now become one of only four sites selected for the most promising revolution in health care: hotspotting.

The movement began with a different senseless shooting in 2001 in Camden, N.J., a city that tops the country for both crime and poverty.

It’s a place filled with urban ruins, where a tree is shooting up through a once-stately Carnegie library, where budget cuts recently forced the layoffs of half the police department and where gunshots frequently pierce the night sky.

“We also end up with all the people no one else wants: the mentally ill, sex offenders, those recently released from prison,” said Dr. Jeffrey Brenner, a family doctor, who lives and works in Camden and has become the accidental revolutionary who is turning the U.S. health system upside down.

Dr. Jeffrey Brenner, the pioneer of ‘hotspotting,’ is seeking to turn the U.S. health system upside down. He spoke this week at the Colorado Health Symposium sponsored by the Colorado Health Foundation.

Brenner came to Colorado this week to attend the Colorado Health Symposium in Keystone sponsored by the Colorado Health Foundation.

Started with a shooting

On a February night in 2001, a 22-year-old black man was shot while driving through a neighborhood on the edge of Rutgers University. Brenner lived a couple of doors away and a neighbor called him to help.

He raced out with his stethoscope and was horrified to find the police doing nothing as the young man lay dying in a pool of blood. He had been a Camden success story, a young man poised to graduate from Rutgers with hopes of someday becoming mayor of his hometown. Brenner screamed at the cops: “Why didn’t you guys do anything?” They claimed they didn’t want to dislodge the bullet.

“To me, it showed an unbelievable disregard for human life,” Brenner said.

Brenner’s basic impulse to care for fellow human beings is at the core of his work and the new experiment in Aurora, which will be overseen by health experts at Rutgers and the organization Brenner founded: the Camden Coalition of Healthcare Providers.

From St. Therese’s Catholic Church in north Aurora, just a mile from where accused Aurora shooter James Holmes lived, Aurora Health Access, a faith-based group of parishioners, community organizers and immigrants from Mexico,  is trying to give people in their community what they do not have now: a true, functioning health system.

“We are called upon as people of faith to care, to relieve the pain of the sick,” said Rich McLean, a retired military systems analyst, who lives near St. Therese’s and is joining with his neighbors and the interfaith activist group, Together Colorado (formerly Metro Organizations for People), along with its health partner, the Metro Community Provider Network.

Faith-based volunteers and community organizers are at the core of an attempt to use ‘hotspotting’ to cut ER use in Aurora. Activists hope to use cost savings to create an affordable health system in Aurora where residents could get more affordable, higher-quality care. From left to right, St. Therese’s parishioner, Barbara Hoover, Together Colorado community organizer, Eliana Mastrangelo, parishioner Graciela Moreno and parishioner, Rich McLean.

The Aurora experiment aims to save millions in hospital costs while also giving people better care. Volunteers, health workers and church activists will put into practice the hotspotting concept that Brenner pioneered.

Inspired after witnessing the young Rutgers student’s death, he started mapping crime and health data and found that a handful of people were costing the system the most money.

In Camden, Brenner found that 1 percent of the people were racking up 30 percent of health costs, amounting to millions of dollars a year. He has found that same statistic to be true in other communities, and it may very well turn out that a tiny percentage of Aurora’s sickest patients also cost the health system here the vast majority of the expenses.

A preliminary survey by the Aurora Health Access coalition found that from July 2010 to June 2011, residents in two target Zip Codes, 80010 and 80011, visited emergency rooms 30,694 times at nearby University of Colorado Hospital and Children’s Hospital Colorado. Frequent ER users who lived in the two Zip Codes — those who visited an ER five or more times in a year — accounted for 43 percent of all the visits among the frequent ER users in Aurora.  In the 80010 Zip Code, about one-third of people live at or below the federal poverty rate.

The three-year experiment in Aurora is just beginning and www.HealthPolicySolutions.org will track the group’s progress. The federal Centers for Medicare and Medicaid Innovation awarded Rutgers a $14.3 million grant in June to pilot the Camden model in four communities: Aurora; San Diego; Allentown, Pa.; and Kansas City, Mo. The goal is to find the costliest patients; save $70 million on their care in the four communities; and reinvest the savings to provide better health care.

Many of Camden’s “high utilizers” lived in two of the city’s buildings, a nursing home and a high-rise with subsidized apartments for seniors. Many qualified for both Medicaid (the health insurance program for the poor) and Medicare (the program for seniors).

Brenner started finding the patients with the most frequent ER visits and hospital stays and did the unthinkable. He gave them more care, not less. A team of nurses and health coaches made house calls, accompanied the patients to doctor visits, streamlined their medication and helped them get well so they could stay out of hospitals.

The health team finds unconventional cures, such as helping a man with severe asthma get his mold-infested home repaired so it would stop triggering his debilitating asthma attacks.

“Our story is not a story of poverty. It’s a story of broken health care and disorganized care,” Brenner said during his visit to Keystone.

Brenner’s idea of saving millions from the health system is controversial because he aims to give people more care from nurses and inexpensive health coaches.

 Lost hospital profits

Cutting health costs will mean lower profits for specialists and hospitals.

“Hospitals are like hotels or airlines. Is the place full? Are there well-paying patients in the inn?

“There’s a lot of money to be made from a sickness system,” Brenner said. “It’s going to be a very wrenching change to think about how we transition all of this to a different system.’’

He compares the change to the de-institutionalization of psychiatric care. It has taken 30 years to try to build a new community-based structure to replace the expensive old psychiatric hospital model. And mental health systems remain fractured from medical systems.

The fundamental problem with health care now, Brenner says, is that the fee-for-service model, where doctors get paid for procedures, rewards expensive tests, hospital stays and specialist visits while failing to keep people well. Before he had to shutter his own family practice in Camden, he said he made more money running from room to room to room treating colds than he did sitting down and spending time with the patients who needed him the most — those with complex and difficult health problems.

“That patient slows you down,” Brenner said. “We set a really high price if you cut, scan, zap or hospitalize someone.”

But primary care providers get reimbursed as little as $19 for a patient visit. Both doctors and patients feel that the system is cheating them, Brenner said.

‘So much desperation’

North Aurora does not have high-rise buildings full of the poor. Instead, struggling people live in squat one-, two- and three-story brick apartments just off of Colfax Avenue or they are homeless and congregate near the city’s parks.

Many are new immigrants from Mexico. Many are older, but don’t yet qualify for Medicare, like a man in his late 50s who lost his long-held job at a restaurant when joint problems made it hard for him to be on his feet all day. Now he’s unemployed, sleeping in his daughter’s living room and can’t afford to get care for his painful joints. Another resident was having a heart attack, but stayed home out of fear that without a Medicare supplement, care would be impossible to afford.

“A lot of folks in our community have never been to a doctor. The care we have here is in the ER,” McLean said. “Denver has a health system and we don’t. Aurora is as big as New Orleans and Syracuse and Pittsburgh.”

When the poor and uninsured in Aurora are sick and can’t get an appointment at clinics with long waiting lists, they go instead to ERs where they get minimal care, then can be hounded by debt collectors, McLean and his fellow activists say.

Door-to-door outreach

Eliana Mastrangelo is the lead health care community organizer for Together Colorado. She and volunteers walked door to door in two of Aurora’s poorest Zip Codes to survey residents about their health needs.

“We met one gentleman, an undocumented Latino with no health insurance in his late 40s,” Mastrangelo said.

“He hurt his hand so he went to the ER. He was charged $1,400. He had no X-ray. They gave him pain meds and sent him home.”

The workers felt the man got poor care at an exorbitant cost, a double whammy. The man is paying his bill, little by little, month by month.

Volunteers who surveyed the Aurora residents said they consistently heard that people want a family doctor whom they know and trust. They want to pay a fair price to see a provider, but don’t know where to find that care or how to access a confusing system. All they know is that the ER is open 24/7 and with few other options, if people are in pain, they will go to the ER and wait hours to be seen.

McLean said he knew he had to make it his mission to help people in his community with health care when he got a call while driving on a road trip through New Mexico in 2007.

“St. Therese’s had started up a health care campaign,” McLean said.

A 15-year-old girl was on the phone. The parish priest had given her his phone number.

“I don’t know who to turn to,” the girl said. She told him she been diagnosed with ovarian cancer. Her parents spoke no English and she had no health insurance.

“What help can you give me or I am supposed to go and die,” the girl said.

“It just blew me away, this very personal thing and she had to call a stranger,” McLean said.

He was able to get the girl care through Children’s Hospital and she is doing well. But McLean found a new calling.

“The need is so great. There is so much desperation,” he said.

Graciela Moreno is a nurse and parishioner at St. Therese’s. She’s one of the leaders of the Aurora movement.

Originally from Mexico, Moreno settled in Aurora because her brothers and sisters moved there. They found it affordable and homey. Moreno says fellow immigrants are utterly shocked that there is no basic health system in the U.S.

She has a 16-year-old son with asthma. Because of her medical background, she is able to help him keep his asthma under control, but she has had friends who have had to go to the ER for ailments like urinary tract and ear infections.

“I’ve struggled a lot to get medical services. If everyone struggles that much, it’s got to be difficult,” Moreno said.

Fear of deportation also keeps some immigrants from even trying to access the health systems, Moreno and the other volunteers said.

Faith-based advocates mobilized

The four new hotspotting initiatives are all taking place in communities with strong faith-based community groups like Together Colorado that are members of the PICO (People Improving Communities through Organizing) National Network.

It’s no accident that faith and community organizing are at the core of this health revolution.

“We believe that in order for there to be true health reform, the people who are going to be most reliant on it are the ones who should shape it,” said Kamara O’Connor, lead organizer for PICO’s Bring Health Reform Home project.

“What we’re trying to do is shift our country toward more primary and preventive care,” said O’Connor who also spoke at the Colorado Health Symposium.

While the movement is revolutionary, O’Connor said it’s also a back-to-basics concept where people get high-touch simple care from people they know and trust.

“A hundred years ago, the doctor would always visit a patient at home,” O’Connor said. “What we’re really aiming for is a cultural shift. We’re trying to get away from a bureaucratic system about paperwork where people are anonymous to a system that really values people and builds relationships.”

Brenner says hotspotting alone can’t fix health care. But, it provides a glimmer of hope that we can fix a broken system that otherwise will bankrupt us.

“It’s hard to be caught in a system that’s not working. It’s frustrating for the doctors and frustrating for the patients,” Brenner said.

“Hotspotting…is a strategy so you can target different areas of need,” Brenner said. “When you build a great program to deal with very frail elderly patients, that’s hotspotting. When you build a great program to take care of babies who are coming out of the NICU (the neonatal intensive care unit) and whose moms and families are overwhelmed, and you want to keep that baby from getting rehospitalized, that’s hotspotting. Hotspotting is making sure the people who are in need get their needs met.”

By Katie Kerwin McCrimmon and Diane Carman

Colorado leaders have failed to tackle gun fatalities as a public health threat and gun deaths in Colorado and nine other states now exceed automobile fatalities, according to data from the U.S. Centers for Disease Control and Prevention and the Violence Policy Center.

Coloradans are reeling from the Aurora theater massacre, the third mass shooting here since 1999 when Columbine shattered the country’s psyche. Yet Colorado’s governor told a national television audience on Sunday that he thought there was little that could have been done to prevent the recent killings, and conspicuously absent from the state’s 10 winnable public health battles is any mention of gun deaths.

Delbert Elliott

“Colorado could do something to deter gun violence,” said Delbert Elliott, director for the Center for the Study and Prevention of Violence at the University of Colorado in Boulder. “The tragedy in Aurora has highlighted for some people that we don’t ban assault rifles. We don’t have controls on ammunition purchases.”

Colorado health leaders should look at California as a model, says gun opponent, Kristen Rand, legislative director for the Violence Policy Center, a gun violence prevention center based in Washington, D.C.

“California is where this whole history of horrific mass shootings started. Now, apparently, Colorado is the capital with Columbine and the theater shooting. Colorado needs to move aggressively to implement a real assault weapons ban and restrictions on high capacity magazines,” she said.

“It’s certainly going to happen again until people stand up and say we’ve had enough bloodshed,” Rand said. “Gov. Hickenlooper should sit down and look through some gun catalogs and Internet sites and see what is being marketed and see what people in Colorado are buying. If he did, he’d be frightened. This is not going to end with this shooting.”

James Holmes, the neuroscience student accused of killing 12 and injuring 58 in Aurora last week, legally purchased assault weapons and more than 6,000 rounds of ammunition over the Internet. According to police, he had those packages delivered undetected to his home and school. Had Holmes military-style weapon not jammed, police have said he could have mowed down scores more people who were trapped in the dark theater.

Colorado officials from the federal Bureau of Alcohol, Tobacco, Firearms and Explosives refused to comment on Holmes’ recent gun and ammunition purchases citing a gag order as prosecutors make their case against Holmes. Colorado representatives of the National Rifle Association and Dudley Brown of the Rocky Mountain Gun Owners  did not return calls from www.HealthPolicySolutions.

Public health prevention efforts have driven automobile deaths down in Colorado and across the U.S. while gun deaths have increased.

‘Weakest gun control laws of developed countries’

Public health experts say the markedly different trends in auto and gun deaths are telling. In one case, experts in government and industry have worked together to make driving much safer, with sweeping efforts to mandate seat belts, combat drunk driving and limit teens driving with other teens. In Colorado, for example, safety measures have cut the rate of auto deaths in half since 1995.

But, when it comes to deaths from firearms, there has been no concerted effort to limit gun purchases or even to address violence prevention, safe guns storage or gun safety and education measures that all sides support. As a result, rates of deaths by firearms continue to climb.

David Hemenway

“We have by far the weakest gun control laws of any developed country,” said David Hemenway, professor of health policy at the Harvard School of Public Health who has made the public health issue of guns a focus of his research throughout his career.

Unlike the broad-based approach to reducing traffic fatalities, “we have almost no money for research,” Hemenway said. “The CDC is afraid to even say the word ‘guns.’ ”

In Colorado, gun deaths have been climbing, rising from about 440 in 2000 to about 550 in 2010, according to data from the Colorado Health Information Dataset.  Meanwhile auto deaths are declining, down from 714 in 2000 to about 480 in 2010, even as Colorado’s population grew from about 4.3 million to just over 5 million during that decade.

Colorado has relatively low homicide rates compared to the rest of the country, but has one of the highest suicide rates in the U.S. More than half of the men who commit suicide use a gun, while one-third of women kill themselves with a gun.

Prevention is the cornerstone of winning any public health battle, Hemenway said.

“You clearly try to think about prevention instead of just waiting for a crime to happen and prosecuting it,” he said. “The public health effort tries to go as far upstream as possible and think of all the ways to prevent serious problems from happening.”

Scientists often use the motor vehicle analogy, he said. To reduce vehicular deaths, communities don’t just focus on drivers, but on the safety features of vehicles and highways, the availability of emergency medical care, education, law enforcement and other ways to reduce deaths and injuries.

“Nobody thinks drivers are any better than they were when I was growing up,” Hemenway said, but over the past 60 years, “we’ve reduced deaths per motor vehicle mile driven by 90 percent.”

In contrast, Americans are reticent to tackle gun deaths. But efforts elsewhere have been effective. Hemenway pointed to successful measures in Australia.

From 1979 through 1996, 13 mass shootings were reported across Australia. Since 1996, when stringent gun-control laws were implemented, including a mandatory buy-back of all semi-automatic firearms, no mass shootings have occurred.

“Civil libertarians in Australia think we’re crazy” to equate liberty with gun ownership, Hemenway said. “They say there’s no freedom if you’re afraid to go out on the street at night.”

While legislation to restrict access to guns is unlikely in the U.S., Hemenway said efforts to change social norms around guns could have some effect. He cited the highly effective designated driver campaign over the past several years.

“We want an 11^th commandment for gun safety that says friends don’t let friends who are going through a rough spot have easy access to guns,” he said.

Hemenway said the movie theater mass shooting reveals just how difficult it is to identify deranged killers before they act.

“It doesn’t look like it ever will be very easy to figure out who’s going to do this,” he said. “The easiest way to prevent these incidents is to prevent people from having legal access to these incredibly lethal weapons, like they did in Australia.”

Gun proponents say weapons save lives

Proponents of gun rights say the fallacy of the public health argument is that guns can also save lives.

Dave Kopel, research director for the Independence Institute, associate political analyst for the Cato Institute and an adjunct professor of law at the University of Denver Law School, said he has been following the debate about the public health issues surrounding guns for 25 years.

Dave Kopel

“The public health thinking says that when you have gunshot injuries the cause is bullets hitting people,” he said. “But there are a couple of problems with that.”

One, he said, is that “guns work both ways.”

“In the wrong hands, guns are really dangerous and destructive, but in the right hands, guns are enhanced public safety.”

Kopel said the reason the “gun control issue is not that big a deal in the public debate is that through compromise and consensus we have decided to protect lawful use, especially defensive use.”

“The public health analysis in my view is too one-sided. It looks only at the downside. It doesn’t look at the other side.”

Kopel said any analysis of the roles of guns in public health should be “holistic.”

Politicians don’t want to ‘go near’ guns

Yet, says John Straayer, a political analyst and professor at Colorado State University, the idea that guns make people safer has never proven true in mass killings. Theoretically people in the Aurora theater could have been armed.

“I don’t remember anybody firing back in any of these instances. It doesn’t happen.”

Straayer said the gun lobby has wielded its power successfully here and across the country.
The NRA is maybe the most powerful interest group in Colorado. The bills we’ve had in the legislature have loosened rather than tightening any kinds of restrictions on guns.”

While Straayer “absolutely” supports gun control measures himself, he thinks it’s unlikely that politicians here or elsewhere will forge ahead on the issue.

“They don’t want to go near it, even when you talk about issues like safety locks,” Straayer said.

The gun lobby has done a masterful job of convincing politicians that any conversation about safe storage of weapons or safety locks is a “slippery slope.”

“There’s not a real vested, organized, consistent and persistent constituency for it,” Straayer said.

So, support for controls tends to flare up after an incident like Columbine or the Aurora theater shooting, then attention fades and the public forgets.

Straayer thinks that’s because mass killings are so rare and people naturally assume they will never be the victim of such an event. They are much more invested in day-to-day issues like gas prices and unemployment rates.

While Hickenlooper has drawn some criticism for hedging on whether Colorado could have done anything to prevent the Aurora tragedy, Straayer said he “probably did the judicious thing.”

“He kept the focus on the victims and the victims’ families, caring about them and coming together,” Straayer said. “Using (Aurora) as a launching pad for legislation in that context wouldn’t have been well-received.”

Nonetheless, Straayer thinks the governor and public health leaders must take the opportunity in coming weeks to more closely analyze why Colorado has been the setting for yet another mass killing and how public policy could help prevent future mass shootings, along with much more common gang incidents, fights and domestic violence that leave well over one person a day dead in Colorado from guns.

Dr. Chris Urbina, executive director and chief medical officer of the Colorado Department of Public Health and Environment, declined to talk about gun safety as a public health issue. His spokesman also declined to respond to questions about why gun safety is not one of Colorado’s 10 winnable battles.

Straayer said elected officials and those in the public sector are reticent to lead.

“Leadership is all about getting the public to care about things. I think that’s a sadly-missing element in modern American politics. You run polls to see what people think and if there’s support there, you run with it because it pays off with votes.

“
“That’s not leadership. That’s political careerism.”

To some extent, Straayer thinks the Aurora killings are a “sad coincidence.” But the summer of 2012 has been a heartbreaker.

“It’s been fires, fires, fires and tremendous destruction. We just get over that and the skies clear and now this happens. (President) Obama had a jump on a plane twice in a month to console us,” he said.

After Columbine, ‘nothing was done’

David Winkler of Thornton was a founding member of the gun-control advocacy group SAFE Colorado after the Columbine shootings. He now does public policy research.

“After the Columbine shootings, I got involved. I was a high school student at the time and hadn’t been very political before then.”

“I started driving to high schools and meeting people in parking lots, inviting them to get involved.”

Students from SAFE Colorado went to Washington, D.C., the summer after Columbine and met with members of Congress, President Clinton and Vice President Al Gore.

“At the federal level, nothing was done,” Winkler said. “In fact, some laws already on the books were allowed to expire.”

In Colorado, SAFE succeeded in getting an initiative on the ballot to close the gun-show background check loophole. Amendment 22 passed with support of 70 percent of the voters, one of the most popular initiatives in the state’s history, Winkler said.

“A lot of people blame gun owners and the NRA (National Rifle Association)” for the easy access to firearms in the United States. “But that’s misleading. The largest influence comes from the industry – gun and ammunition manufacturers, sellers and dealers.  Their push is for more guns sold and more bullets in the magazines. They want almost no limits on that.”

“So much of what’s sad about this debate is that people are saying no one thing could have stopped it. But there are lots of things that might make the next crazy person not have access to so much firepower.”

Preventing violence in children

Ken Gordon, who was minority leader in the Colorado House in 1999, carried a bill calling for mandatory background checks for anyone purchasing firearms at gun shows. The measure died in the Appropriations Committee for lack of support.

Ken Gordon

“Most people of both parties are afraid they’ll lose elections based on this issue,” said Gordon.

While leaders were skittish about supporting most gun control measures in 1999, Gordon said “it’s worse now.”

“With so much money in politics, it selects for people who don’t have strong principles and are willing to cater to special interests.”

“The gun lobby makes a living by frightening law-abiding hunters into believing that liberals from Boulder and San Francisco and New York are going to take away their guns,” Gordon said, “when the point is to stop people from having assault weapons and 100-round clips because there’s absolutely no good reason for them to have them.”

Gordon now works with CleanSlateNow.org, an organization that mobilizes support for candidates who don’t accept money from special interest groups.

For Del Elliott, the key to prevention goes far beyond guns. His violence policy center supports programs proven to work with young children.

The problem now is that school leaders are so focused on boosting test results that many are not carving out the time to teach children about non-violence and bullying prevention.

Elliott is also a big believer in anonymous tip lines. He cites the work of Safe2Tell,  a Colorado-based hotline that started after Columbine. Since 2004, tips to Safe2Tell have prevented 28 planned school attacks.

“Even in these mass shootings, someone almost always knows it’s about to happen. They know that plans are being made. We don’t know yet if that’s the case for the Aurora shooting,” Elliott said. “But, if any law enforcement person had known all of the things that we now know about Columbine, there would have been an intervention.

“We have to make much better efforts on prevention,” Elliott said. “If we can raise our children to believe that violence is not a solution to the difficulties that they face, if they never consider that as an option, then gun control ceases to be an issue.”

By Katie Kerwin McCrimmon

AURORA — The sound of police and news helicopters buzzed over the Anschutz Medical Campus on Friday and dogs searched locked-down research buildings as workers at the Rocky Mountain region’s premier medical research campus grappled with the reality that the suspected Batman killer had, until last month, been one of their own.

James Holmes, 24, had been a student at the University of Colorado’s graduate program in neurosciences. He had lived just one block west of the leafy campus full of new high-rise buildings and adjacent to two of the leading hospitals in the Denver area, the University of Colorado Hospital and Children’s Hospital Colorado, where one child shot during the chaos had died.

James Holmes, 24, the suspected Batman shooter, was a neuroscience graduate student at the University of Colorado Denver’s Anschutz Medical Campus.

Anschutz workers tuned in to news feeds, horrified that what may become the largest mass shooting in U.S. history happened so close to them. Meanwhile, 23 of those who were shot were being treated at CU’s hospital.

“It’s sad. It’s senseless. I’m tired of people being killed,” said Carol Reagan, a program manager at Anschutz.

She and two friends sat outside during a break and wondered if they had ever seen Holmes walk by them. Neighbors described him as “geeky” and quiet, the kind of person you would never notice. He looked like so many of the young students, doctors and researchers who stroll this campus in scrubs or white lab coats.

“It’s just evil,” said one woman, whose own 16-year-old son had asked to go to the movies the night before. The woman, who asked not to be identified, told her son, “No” because she had to work the next day. Now both of her children, ages 16 and 13, are asking, “Are we ever going to be able to go to the movies again?”

Even the midnight show seemed the most innocent of outings, a safe getaway for young people excited about the debut of a hot new action flick.

Another worker who also did not want to be identified said she wanted to keep her 11- and 9-year-old close since shootings can happen anywhere from schools and grocery stores to movie theaters. All the women — who live close to both the medical campus and the movie theater  — said it was hard to leave their children on Friday morning as they headed to work.

“You pray all the way in and you pray all day long,” one said.

The medical campus’ chief of police locked down two campus buildings so dogs could search the labs and offices.

“Many of you have noticed the increased police on campus as a result of the tragic movie theater shooting. Our thoughts are focused on the patients and the families who have lost loved ones,” Police Chief Doug Abraham wrote in a note to faculty staff and students.

“The alleged shooter involved, James Holmes, spent time as a graduate student at the Anschutz Medical Campus. He voluntarily left in June 2012, his building access was then terminated and he was in the process of completing withdrawal paperwork. He is currently in police custody and we do not believe he has been on campus since mid-June.”

Even so, Abraham wrote that out of “an abudance of caution” all non-essential staff should leave two campus buildings so specially trained dogs could search them.

Aside from the buzz of helicopters overhead, the Anschutz Medical Campus was eerily quiet on Friday. The leafy campus is a sharp contrast to the low-income neighborhood just west of the campus where suspected Batman shooter James Holmes had been a neuroscience until last month.

Blocks away, police prepared to defuse bombs in Holmes’ booby-trapped apartment and planned to shut down North Peoria Street, the major thoroughfare adjacent to the medical campus.

University officials sent out a statement noting that the CU hospital and partner medical institutions “worked diligently through the night and morning to assist victims and their families.”

“For their expertise and care, we say thank you.”

University officials said they were cooperating fully with the Aurora Police and other authorities as they continue their investigation.

“We are also focused on the health and safety of our students, faculty and staff. Our campus police department, counseling services, and leadership are working on meeting all of the campus community’s needs. This includes an increased police presence and a specially-trained dog-sweep of university buildings.”

By Chris Lindley

Most pregnant women across the United States listen to and rely on sound medical advice from their doctors and other health experts when determining how to protect the health of their unborn babies. “Don’t drink during pregnancy” is a message based on evidence that resonates with most expectant mothers and contributes to the health of future generations.

The Colorado Department of Public Health and Environment would like to reinforce that message with a critique of a recent study that suggests moderate drinking during pregnancy is not harmful to young children.

On June 20, a Danish research article titled, The Effects of Low to Moderate Alcohol Consumption and Binge Drinking in Early Pregnancy on Executive Function in 5-year-old Children, written by Skogerbo, et.al., was published in the British Journal of Obstetrics and Gynecology. The study drew media attention after the U.S. Department of Health and Human Services posted a news item on its website titled, “Moderate” Drinking During Pregnancy Has No Effect on Young Children. These findings and the accompanying media coverage sent a confusing and potentially dangerous message to pregnant women.

Before that message permeates society and risks the health of young children, the following limitations to this recent study should be considered:

• Study investigators themselves caution that the findings should not be taken as proof that light drinking during pregnancy is safe or that a safe level of alcohol use during pregnancy exists.
• Small sample sizes of moderate and heavy drinkers were not statistically sufficient.
• Half (51 percent) of the children born to mothers participating in the study were tested for cognitive and developmental deficits. Researchers acknowledge that mothers of children not functioning at age level might have been more likely to decline participation in deficit testing.
• The study relied on self-reporting of alcohol consumption during pregnancy.  Research shows that self-reporting of alcohol consumption frequency and quantity is often underestimated.
• The Kesmodel study clearly states that deficits related to fetal alcohol exposure may emerge after age 5 years.

Years of research and numerous epidemiological and clinical studies show harmful effects to a growing embryo from alcohol exposure. These effects may be present immediately after birth, at infancy or later in life, especially if the damage involves the central nervous system.

Studies show that there is a 6-to-10 percent chance that a fetus exposed to very high repetitive doses of alcohol will develop prenatal and postnatal growth deficiency, specific craniofacial dysmorphic features, mental retardation, behavioral changes and a variety of major anomalies.  With lower repetitive doses there is risk of slight intellectual impairment, growth disturbances and behavioral changes.  Prenatal exposure to alcohol also is associated with higher levels of conduct disorder symptoms in offspring.

Colorado women may not review or critique studies when deciding whether to drink during pregnancy. Instead, they rely on what they hear from their families, friends and doctors, and what they read, hear or see in the media to guide their decisions. Most would agree that excessive drinking is bad for their babies, but may not know if an occasional glass of wine crosses the line.

Studies like these blur that line and cause women to question their conscience.

The U.S. Surgeon General, the American Congress of Obstetricians and Gynecologists and other health experts advise abstinence for pregnant mothers who want to protect their children from fetal alcohol spectrum disorders. Until research conclusively contradicts that good advice, CDPHE will continue to clearly communicate to Colorado women that alcohol and motherhood do not mix.

Chris Lindley is director of the prevention services division at the Colorado Department of Public Health and Environment.

By Mark Wolf

Most maladies are unencumbered by shame  and stigma. Yet for many men to acknowledge they are uncomfortable with the way they’re feeling — maybe down, irritable, unmotivated, fatigued, feeling as if life might not be worth living, and, yes, maybe there are some issues “down there” – requires a leap most men seem hesitant to take.

“Men are stubborn. We don’t want to talk about our feelings. We are very leery and afraid of being labeled sissies, afraid of looking weak, and a lot of those things apply when you’re talking about mental health,” said Matt Vogl, deputy director of the University of Colorado Depression Center.

“There’s this perception that ‘I’m not as macho when I ask for help.’ The pervasive attitude is ‘bite your lip, suck it up, pull your chin up off the bar. We should take care of this stuff on our own.’ As a result it’s very hard to get men into treatment and keep them in treatment. A man goes to the doctor for high blood pressure, gets medication and gets better. Therapy is often a long process.”

Mental health professionals are frustrated that not enough men are walking through their doors to seek treatment. Vogl and his colleagues at the Depression Center are attempting to find ways to connect with this hard-to-reach group.

“Men aren’t going to watch a PBS show on depression but they might if they hear about it at an event that appeals to them in another way,” said Vogl. “Our job is to create that cheese and put the pill inside.”

An ad campaign launched this week uses humor to nudge men into seeking help.

Mantherapy.org and a 30-second public service announcement are the centerpieces of an effort that spans viral videos on social networks, billboards and a community outreach network in 26 Colorado counties. It includes coasters to be distributed to bars, restaurants and golf courses.

The campaign is produced by the office of suicide prevention at the Colorado Department of Public Health, Cactus Marketing Communications and the Carson J. Spencer Foundation. It was funded initially by a grant from the Anschutz Foundation.

The site features Denver actor Ron Arp as Dr. Rich Mahogany, a therapist whose office is a place “where men can be men” and whose pitch to men is a riff on myriad manly touchstones from “take a knee” and “form-tackling” to a love of chainsaws and disdain for shopping malls and Spandex.

Underlying the humor is straight talk about anger, stress, substance abuse, layoffs and suicidal thoughts as well as links to “Gentlemental Health,” mental health resources and testimonials from men who have dealt with depression and other issues.

“The site is an acknowledgment that men don’t access mental health services the way they should,” said Jarrod Hindman, director of Colorado’s office of suicide prevention. “Historically, suicide prevention marketing and education materials really promoted the notion that it’s OK for men to ask for help. Men are doers. We want to provide men with an opportunity to experiment with tools to allow them to try to help themselves.”

The other objective is to change the way men  view mental health.

“We want people to think, ‘I have high blood pressure, I go see my doctor, medicate it, I’m better.’ We want mental health to be the same thing,” said Hindman. “The reality is the treatment success rates for things like depression are very high.”

Use of humor questioned

Much deliberation and research was involved about the role of humor in the campaign.

“We had some concerns with how the suicide prevention community and mental health professional community would respond,” said Hindman.

“To address that, they assembled a group of advisors who are leaders in suicide prevention. Some of the feedback suggested that  humor resonates with men.

“We’re confident we’ve done good background work,” he said.

Jarrod Hindman

“We were somewhat apprehensive,” said Hindman, “but from Day One we really charged Cactus to push the envelope because we thought that’s what was required to target men.”

Depression Center not yet on board

CU’s Depression Center is a resource on mantherapy.org, but the center has not formally endorsed the site.

“I still have some concerns about how it’s going to be received,” said Vogl. “The target group, men who are going onto the Internet and seeking some help, are the ones we might be able to get into therapy, and we’re afraid we might scare them away with the message that all they need is self-help.

“I think it does fill a void to try a different approach to reach a really hard-to-reach audience so I applaud the effort. Ultimately I think it’s going to be a good thing,” he said.

Among the outreach targets for the Depression Center is the first-responder field, a group Vogl characterizes as predominantly male and particularly averse to talking about their feelings.

When a team from the Depression Center talks to first responders about how to recognize the signs of a potential suicide when they are called to the scene of an emergency, the hope is that the responders also will become attuned to signs of trouble among their colleagues.

“We’re teaching people how to ask others about their suicidal tendencies: ‘Are you OK? Is something going on?’ with the hope they’ll help one another,” said Vogl.

The sports connection

Sports is often a vehicle to reach men.

Bucky Dilts, whose ability to nestle punts out of bounds deep inside opponents’ territory helped the Denver Broncos win the 1977 AFC championship and earn a spot in Super Bowl XII, had successful prostate cancer surgery at CU and was looking around the CU complex when he ran into Vogl and told him he wanted to help spread the word about depression.

Bucky Dilts

Dilts, whose sister and mother-in-law both committed suicide, already had done some public speaking about prostate cancer awareness.

As one of only slightly more than 4,000 men in the world who have played in a Super Bowl and a member of that historic Broncos team, Dilts brings a guy-centric cachet to events.

“When you say Bucky Dilts the former Bronco is going to attend, all of a sudden people show up and listen,” said Vogl.

Dilts, who has lived in the Denver area since his career ended and works in commercial real estate, wants to remove the stigma of talking about depression among men.

“Men have this old-time feeling that ‘I can deal with it.’ They don’t want to seek help, it’s weakness. Well, all that crap has to stop. If we can go out and change or get rid of that stigma it’s going to be a very normal conversation. Everybody talks about cancer today, even prostate cancer.

“What I’ve found in most cases is that I’ll make a comment about why I’m interested in it. I tell people the statistics, about suicide prevention, things being done through the university and around the country but in most cases you don’t get anything back. They don’t want to talk about it even if it’s a problem. There are still a lot of people who look at you like those are off-limits.”

When former NFL star Junior Seau took his life, Vogl and Dilts made appearances on Denver sports talk radio stations.

“That’s our audience, those are our people,” said Vogl.

Dilts said the focus on concussions as a possible contributing factor in these deaths obscures the role of mental health.

“Ex-NFL players suffering from depression is a bigger deal than you know about,” he said.

After Denver Broncos wide receiver Kenny McKinley committed suicide in 2010, Denver Post sports columnist Woody Paige wrote of his own struggle with depression, including his plan to take his own life eight years earlier.

“Woody told me he got more response to that column than anything he’d ever written,” said Vogl.

Boys urged to be tough

Socialization from infancy plays a significant role in how men deal with mental health issues, said Dr. Neil Weiner, director of men’s studies and treatment programs for the Depression Center and a clinical instructor in the Department of Psychiatry.

“When you look at the research, up until six months of age in terms of facial expression and crying, boys tend to be more emotionally expressive than girls. Once socialization starts to kick in, the pattern starts to change. If boys aren’t competitive or if they cry, show sensitivity or vulnerability, they are often teased, taunted or bullied,” he said.

Many boys are told it’s not masculine to show emotions.  Often emotions are suppressed, especially in boys who were raised by fathers whose male gender role expectations were molded in the two decades after World War II.

As a result, many men require a different therapeutic approach than women.

“The expectation of some therapists is that from the first session, men should be encouraged to speak about their feelings.  However, men raised with stereotypic male gender role expectations may be put off or leave treatment as they have been led to believe it is  unmanly to discuss their feelings.  They also may not have learned to use language to express their vulnerable feelings or emotions.  Men may become defensive, angry or competitive with the therapist, fearing that they will appear weak, vulnerable or subject to shame or humiliation,” said Weiner.

“When questioned about what he is feeling, a man may be aware of feeling uncomfortable or anxious, but he may not be able to identify that he’s feeling sad, vulnerable or experiencing emotional pain,” he said. “As a therapist, you often have to spend time helping a man identify what he is feeling and teach him to put words to more vulnerable emotions.”

Weiner said that when dealing with men, he uses humor, coaching and business analogies and emphasizes how much strength it takes to come forward and seek help.

Data show that women have a higher incidence of depression, about a 21 percent lifetime prevalence compared to 12.7 percent for men, Weiner said. “But when you look at completed suicides it’s a 7-1 ratio men to women.”

Colorado’s suicide rate ranks sixth nationally according to the state’s suicide prevention office, and 44 percent of all Colorado suicides occur among men ages 25 to 54. Women attempt suicide more often, but men use more lethal methods.

Weiner said the literature shows that depressed men are more likely to present with symptoms of anger and irritability and are more likely to self-medicate.  They may also get involved in risk-seeking behaviors to quell feelings of depression: fast cars, high endorphin sports such as extreme skiing, rock climbing, distance runs; or increased sexual activity.

“Participating in these activities distracts them from their depression and the endorphin rush may transiently improve their mood,” he said.

Women play key roles

Men often won’t seek therapy until the women in their lives insist.

“Their wives or mothers will tell me, ‘He’s not who he used to be.  I’m scared for him.  He refused to call and seek help on his own, but once I put my foot down and arranged the appointment for him, he reluctantly agreed to come,’ ” said Weiner. “We see this happen all the time.

Dr. Neil Weiner

“A man needs to be assured by the therapist that, if treated, his job performance will improve, he will be a better husband to his wife and the best father that he can be for his children.”

Once men get into treatment, the challenge is to keep them there.

“As soon as they see things are slightly better they’re more likely to drop out of treatment rather than go the distance,” Weiner said.

College athletes at risk

“What do Division I college athletes have to be depressed about?” Sheila Ridley asks rhetorically.

As the director of student athlete wellness at the University of Colorado, Ridley, a licensed clinical social worker, counsels athletes who are at the top of their game and, the perception is, on top of the world.

“Most college athletes come in here as a big fish and they wind up s a guppy. That’s not what they expected it to be. Kids don’t know how to conceptualize that change and that’s a trigger for depression,” said Ridley, one of about 60 athlete wellness directors across the nation.

“That’s a trigger for depression. They don’t talk about it with each other. There’s this rule that you manage your own stuff. I wish they would talk about it with each other so they would hear, ‘Oh yeah. Me too.’ “

Ridley sees about as many male as female athletes, but the way they present is much different.

“Females will go, ‘OK, something’s wrong. This doesn’t feel like me’ and they seek out answers. For men it’s ‘I better study harder, get up earlier.’ Guys say, ‘I must be doing something wrong.’

“Sometimes you’ll see a change in their performance but often that’s the last thing to be affected. They can keep that together. That’s how we miss it.”

Many of the male athletes Ridley sees come in near the end of their college years when it has become apparent that they are not going to continue in their sport at the professional level.

“These kids’ families think they’re going to the NBA or the NFL and support their families, and there’s this pressure to be more than they are. It’s a hard thing to tell your mom you don’t have what it takes,” said Ridley.

That’s why outreach programs like mantherapy.org are getting more attention.

Joe Conrad, founder and CEO of Cactus, said mantherapy.org, like all good communication, is designed “to befriend the viewer, get them to lean in, to want to learn more, to care. After you’ve accomplished that they’re more open to receiving your message.”

Kroenke Sports, which owns the Denver Nuggets, Colorado Avalanche, Colorado Rapids and Colorado Mammoth as well as the Altitude Sports cable TV channel, is among the promotional partners.

“We’re hoping it continues to grow virally. We’re hoping other states implement it on the ground and hope the military comes to the table and helps us further extend the breadth and reach of it,” said Conrad. “We think we’ve created something that’s culturally interesting and entertaining. Who knows where it might go?”

By Katie Kerwin McCrimmon

Latinos, who are uninsured at disproportionately high rates in Colorado, could gain the most as health reform takes hold.

That’s what happened in Massachusetts, which in 2006 became the first state in the nation to require health coverage for all individuals and to implement a health insurance exchange.

Massachusetts’ health reform law became a model for the Affordable Care Act, which the U.S. Supreme Court last month upheld.

“A lot of Latinos have low-paying jobs and they don’t qualify for Medicaid,” said Maria Gonzalez, spokeswoman of Health Care for All Massachusetts, a consumer advocacy group that helps people find health insurance.

“Before health reform in Massachusetts, one in four Latinos didn’t have health insurance. By 2010, 96 percent of documented Latinos had health insurance,” Gonzalez said.

Latinos have had the largest gains in health insurance in Massachusetts, but people from all racial and ethnic groups have increased coverage.

In Colorado, about one-third of Hispanics are uninsured, according to the Colorado Health Access Survey’s (CHAS) latest results from 2011. The survey found that Hispanics were more likely to be uninsured than Anglos or African Americans.

The CHAS is the most extensive survey of health care coverage in Colorado. A program of The Colorado Trust and conducted every two years by the Colorado Health Institute, the results are based on detailed surveys of more than 10,000 Colorado households that represent the state’s more than five million residents.

About 21 percent of Colorado’s 5.1 million people are Latino, according to U.S. Census data.

Neither the national health law, nor the Massachusetts health measure, provided for coverage for immigrants who had not entered the U.S. legally.  (Related: click here to read Opinion:

In Massachusetts, hospitals worked with advocates to create a separate program to give health coverage to undocumented immigrants. In Colorado, undocumented immigrants often seek care at ERs or through community health systems.

This week, Gonzalez and other health navigators from Massachusetts came to Colorado to advise a newly-formed Colorado group called Adelante con la Salud: Latino Health Care Engagement Project. The group aims to improve health access among Colorado Latinos and to help people here understand the concept of a health exchange.

Colorado’s new exchange, an online health marketplace where consumers and business owners will be able to buy and compare health insurance plans, is slated to open in October, 2013 for plans that will start on New Year’s Day in 2014.

“Now that the (U.S. Supreme) Court has ruled, it’s time for everyone, including Latinos, to understand the benefits of the health care law,” Melanie Herrera Bortz, co-director for the new group, said in a statement. “Our organization believes the ACA will do for Colorado Latinos what the Massachusetts health care law did for Latinos there. We just need to educate our community. In Massachusetts, coverage for Latinos skyrocketed.”

Among those who got help there was Eugenio Hernandez, a legal immigrant from El Salvador who says health insurance saved his life. Hernandez had lived and worked in the U.S. for about twenty years and had paid taxes, but never had health insurance.

“One day, he was not feeling great and had to go to the ER, then was diagnosed with prostate cancer. He was really worried and didn’t know what to do,” said Maria Gonzalez of the Health Care for All program.

A hospital worker referred Hernandez to Health Care for All’s HelpLine.

“He was eligible for a subsidized program. He got high quality treatment and always says this program has saved his life. He’s a janitor. He doesn’t make much money. If it wasn’t for this reform, he never would have gotten health insurance.

“He pays a little premium and has access to some of the best hospitals in the country,” Gonzalez said.

While health costs have been soaring throughout the U.S. and Massachusetts has long had among the highest health costs in the country, Gonzales says health costs there have risen more slowly than elsewhere since Massachusetts mandated health coverage for all.

According to a study in the Forum for Health Economics and Policy, from 2006 to 2010, employer=sponsored health care premiums for a family rose about 19 percent in Massachusetts while they rose about 22 percent in the U.S. as a whole. Previously, from 2002 to 2006, family premiums in Massachusetts were rising at a faster clip than the rest of the country, increasing 40 percent in that period of time compared to nation increases of about 35 percent.

The study authors couldn’t prove that the cost savings were directly related to Massachusetts’ new health law.

But, a separate study has also found that more Latinos in Massachusetts now have a regular primary provider. That means that have a “medical home” where they seek most of their care, rather than relying on ultra-costly ER visits. Overall, that study found a 5 to 8 percent drop in ER use in Massachusetts.

Reaching out to people who needed health insurance proved to be one of the biggest challenges, Gonzalez said. People also need reassurance that they will get help finding the right insurance and that it will be a relatively quick process. Gonzalez said her navigators can finish the basic intake call with a person in less than 10 minutes.

“Once the exchange is actually running, they’ll see that it’s very easy,” she said.

One surprise was how much people wanted help from a live human being who could guide them through the process. She said her group expected to shut down their HelpLine a year or two after implementation of Massachusetts’ health law began. But, navigators there continue to get calls and have fielded more than 180,000.

“A barrier at the beginning is how to get the information across,” Gonzalez said.

Her group aggressively marketed to Latinos through ethnic media outlets and advertised their help center.

“If people just do a campaign right before (implementation) and expect everybody to jump in, that doesn’t work. It has to be ongoing.”

Today, Gonzalez said 98 percent of adults in Massachusetts are now covered while 99.8 percent of children have health insurance. About one percent of people pay a penalty for failing to get health insurance.

“Our first goal in Massachusetts was to get everybody covered. I think the country will be there too,” Gonzalez said. “People shouldn’t have to choose between putting food on the table and having health care.”

By Jim Garcia

As the executive director and one of the founders of Clinica Tepeyac, a community health clinic that sees more than its share of uninsured patients, I applaud the Supreme Court’s ruling to uphold the Patient Protection and Affordable Care Act, the President’s health care reform law that increases access to care for millions of Americans.

Since we opened our doors at Clinica Tepeyac nearly 20 years ago, we committed ourselves to caring for all patients who cross our threshold, the vast majority of whom have no access to health insurance and who are desperately in need of basic health care services.

It should be no surprise then that we do not focus on whether patients are citizens or undocumented immigrants when they enter our clinic. We believe that everyone in our community needs and deserves high quality health care services.

Unfortunately, the health care reform law leaves undocumented immigrants largely outside of the discussion. We understand the political reality of today, where Congress is gridlocked on the issue of immigration.  Despite this impasse, the recent Supreme Court decision advances the idea that we are a nation that cares for its sick, and that the time has come for us to expand our definition of “we” to fully reflect our neighbors and our communities.

The National Immigration Law Center outlines exactly how the law treats undocumented immigrants. It notes that our undocumented neighbors, the people who care for our grandparents, who prepare our food, who clean our hotel rooms, and whose children play side by side with ours at school, are considered:

• Ineligible to purchase private health insurance through the state insurance exchange;
• Ineligible to receive premium tax credits or cost-sharing reductions to reduce health care costs;
• Exempt from the individual mandate to purchase health insurance; and
• Ineligible for Medicare, non-emergency Medicaid and the Child Health Insurance Program (CHIP).

Although the Affordable Care Act expands health insurance coverage for many more people, the only way undocumented immigrants can access care is through emergency Medicaid services (only if the person is extremely low-income) or through emergency room visits — an extremely costly option for our community.

By leaving immigrants outside of the health care reform tent, our nation pursues the most expensive option and one that will yield dire health outcomes for some of the most vulnerable people in our society.

Like other historic civil rights issues, we understand the movement toward covering all people in the United States will happen in time. It’s very easy for those of us with coverage to understand this and be patient, but the reality for undocumented immigrants who are sick is urgent. They need care now, not when we as a country get around to it.

Although we celebrate the court upholding the health care reform law, we can’t take our work gloves off or close our laptops just yet. Now is the time to make this the kind of country we want it to be: a country that honors all people living in its borders and believes that we should care for all of our neighbors when they are sick.

Jim Garcia is executive director of  Clinica Tepeyac.