Health Policy Solutions

By Michael Elliott

Teen marijuana use is increasing nationwide.  Yet according to federal government data collected by the Centers for Disease Control and Prevention (CDC), Colorado is seeing a decrease in marijuana use among teens. Considering that Colorado is now home to state-licensed medical cannabis businesses, this news may be surprising to opponents who previously claimed with certainty that the regulation of these new businesses would lead to increases in teen marijuana use.

The data show that these opponents were wrong, and states may have more control over teen drug use if they strictly regulate the cultivation and sale of medical cannabis.  According to the federal government, from 2009 to 2011 teen marijuana use in Colorado dropped from 24.8 percent to 22 percent (an 11 percent net decrease). Fewer Colorado teens are using marijuana now than in 2005 when Colorado had no medical cannabis businesses.

The CDC’s survey leads to the conclusion that Colorado’s comprehensive medical cannabis regulations are working.

Colorado’s decrease in teen marijuana use can be attributed in large part to strict rules put in place during the last three years by the Colorado General Assembly, the Colorado Department of Revenue, and the Colorado Department of Public Health and Environment (CDPHE).

Colorado now has a full-time medical marijuana enforcement division and 200 pages of state regulations, which require businesses to be licensed at the local and state level, establish “good moral character” standards for ownership and employment, and mandate rules for security and surveillance aimed at eliminating illicit activity.

By licensing, taxing, and tracking all aspects of medical cannabis businesses, Colorado is taking control away from the black market and giving it back to school districts, local governments and communities.

Colorado’s Health Department reports that the average age of a medical cannabis patient is 42; over 900 Colorado doctors have recommended medical cannabis; and about 2 percent of Colorado citizens are registered card holders.

Most strikingly, the evidence that fewer Colorado teens are using marijuana is coming straight from a highly respected, impartial and heavily cited federal government survey.  Every two years, the Centers for Disease Control and Prevention (CDC) conducts the Youth Risk Behavior Surveillance System, a survey designed to monitor a wide range of priority health risk behaviors among representative samples of high school students at the national, state, and local levels.

The CDC data show that almost all of the 17 states that allow medical marijuana are bucking the national trend and seeing teen marijuana use flat-line or decrease.

And there is more good news: Colorado is also seeing a decrease in overall drug availability at schools.  From 2009 to 2011, the percentage of Colorado high school students who were offered, sold or given an illegal drug on school property fell from 22.7 percent to 17.2 percent (a net decrease of 24 percent).  In contrast, the percentage of high school students nationwide who were offered, sold or given an illegal drug actually increased from 22.7 percent to 25.6 percent. Drugs are now 33 percent less available in Colorado schools than in schools nationwide.

The medical marijuana debate is about whether Coloradans have the freedom to use an often safe and effective medicine recommended by their physician. Should the government interfere with your health decisions and override the recommendations of your doctor? Should Angeline Chilton who suffers from multiple sclerosis, be forced by the government to return to her ineffective prescription drug cocktail, which previously left her unable to function and nearly bankrupt? Should Mary McNeely, a disabled Iraq war veteran, be denied her government benefits and threatened with incarceration because medical cannabis has been more effective and affordable than prescription drugs at controlling her pain and trauma?

A small and entrenched group of special interests, motivated by economics, politics and bad science, continues to believe the government should prohibit our ability to access this natural medicine. Sound public policy should be based on hard data and positive results.

While the CDC statistics are welcome news for Coloradans, the medical cannabis community has a duty to push this progress even further. That is why the Medical Marijuana Industry Group (MMIG), and several other organizations, have partnered with the Colorado Department of Transportation to promote The Heat is On campaign, a public education effort aimed at discouraging and preventing drugged driving.

MMIG is also seeking partners who are willing to put politics aside and work with us to find ways to improve results and educational outcomes. Together we can further decrease teen drug use and make Colorado the standard bearer for reduced teen drug use in the United States.

It is becoming increasingly clear that states can effectively regulate medical cannabis and control teen marijuana use. The CDC’s survey further demonstrates that the government should not be denying Coloradans controlled access to medical cannabis in order to ostensibly “protect our kids.” After all, when it comes to medical cannabis, we must protect public safety and our freedom. Fortunately, we can do both.

Michael Elliott is the executive director of the Medical Marijuana Industry Group, a trade association of Colorado medical cannabis businesses.  

By Katie Kerwin McCrimmon

COLORADO SPRINGS — The relationship is on the rocks.

Long divided into opposing cultures, doctors, who focus on the body, are trying to work side-by-side with behavioral health experts who try to heal patients’ minds. In a grand Colorado experiment called Advancing Care Together, 11 pilot sites are participating in a $4 million four-year experiment to bring these disparate worlds together.

And some are pining for a divorce.

Or at least they want a proper wedding that includes electronic medical records that actually talk to each other.

“If we want it, we’ve got a put a ring on it,” said Dr. James Meyer, with Miramont Family Medicine’s Parker office.  Meyer drew loud laughter from a room full of ACT participants who gathered recently in Colorado Springs.

Their struggles after a year in the trenches show just how complex real health reform will be.

Among the lessons learned so far:

• Physical space matters. A relatively small clinic in remote Cortez that was designed for integrated care is making the most progress. In fact, the Cortez Integrated Healthcare Clinic is now struggling with too many patients. Read more.
• At various sites, integration works better when behavioral and physical health experts trip over each other and are forced to share work areas. The behavioral health experts can “stalk docs” to make sure they are tapping their skills. And doctors, who are perpetually short of time, can give quick patient updates on the fly.  Patients benefit when they receive seamless care. Said Dr. C.J. Peek, an expert from the University of Minnesota Medical School: “You can’t put the therapist in a nice unused office with a couch and a fern. That person has to be in the traffic pattern, in the most cluttered place so you are tripping over each other. Out of sight. Out of mind.”
• The biggest health systems are struggling the most. In one that is supposed to be a national model for integration, it took a behavioral health expert two years to get an office at a medical clinic where she had been assigned. The rest of the time, she was supposed to float. With limited personnel and pressure for each provider to be more productive in less time, the counselor is supposed to spend just 20 minutes with each patient, a marked departure from the typical 50-minute or hour-long counseling session.
• Low-tech can work well. At Salud Family Health Centers, which has long had behavioral health experts in its clinics, counselors use white boards in common areas with doctors and simply mark a BH next to patients they want to see. They don’t wait for doctors to come get them since providers often miss signs of mental distress. Behavioral health experts see all new mothers and anyone who complains of pain, such as a headache or a stomachache that might be associated with a mental illness. Read more about integration at Salud. 
• Another innovator, Westminster Medical Clinic, has already gone through two therapists in a year and is hunting for a third. But even with unemployment high, it can’t find a qualified behavioral health expert who wants the part-time job. The first was great, but was hired away. The second only wanted to do limited work, never meshed with the rest of the staff and could make significantly more money doing crisis care at a hospital emergency room. Now Westminster has created a detailed contract it is calling a health compact that will govern how a future relationship will work. Central to its success will be housing the behavioral health expert in a room full of desks where the behavioral health experts will work “shoulder-to-shoulder” with the medical staff. Read more about Westminster’s initial efforts. 
• None of the sites can figure out how to pay for integrated care over the long term. For now, some ACT innovators feel they must “be creative” with health insurance billing codes in order to make ends meet. Others fear they will be dependent on grants forever. A separate experiment that will soon begin in Grand Junction aims to determine if a nonprofit health insurance company, Rocky Mountain Health Plans, which is not an ACT participant, can cover behavioral health in primary care settings through monthly “per member” fees instead of typical fee-for-service models. Read more: Insurance company bets on benefits of integration.
• Distrust between behavioral health experts and doctors is rampant. Some counselors think doctors simply prescribe unproven medications, then send patients packing without considering the potential value of therapy. Meanwhile some medical experts think behavioral health experts are slow, unresponsive and never keep them posted about patient progress. What’s more, some doctors hate the way mentally ill patients who should be seen through Colorado’s network of mental health facilities “get fired” if they fail to show up for appointments and ricochet right back to overwhelmed doctors.
• Electronic health records for medical and behavioral health care don’t interface even when that care is located in the same clinic.
• Some providers said they have “change fatigue.” They’re exhausted from the perpetual reforms in medicine.
• A solo medical practitioner in Basalt in the Roaring Fork River Valley near Aspen, Dr. Glenn Kotz, is making great progress at integrating by creating partnerships with nonprofits in the area. But because he’s so busy seeing patients each day and financial pressures are paramount in private practice, Kotz pours his energy into creating partnerships and innovating his practice from 4 to 6 a.m., then sees patients as fast as he can the rest of the day.

At the conference that brought representatives from the 11 sites together with a high-powered advisory board full of national experts on integration, there were moments when it felt like a fistfight might break out. But, these are health experts with advanced degrees. They duked it out through impeccably-cited dueling PowerPoint presentations instead.

Sounds chaotic. Right?

Yes, and that’s just what the unflappable leader of ACT, Dr. Larry Green, was hoping would happen at this stage of the game.

“It’s going better than I expected,” said Green, with the imperturbable air of an elementary school principal serene amid a group of naughty knee-high charges.  “It’s important to recall what our aim is. Our aim is to change practice. It’s hard.”

Even if opposing experts sometimes wanted to smack each other at their annual gathering on the flanks of Pikes Peak, at least they were in the same room, sharing results from real-life on-the-ground experiments. At each of their sites, they were testing unique methods that Green and others hope will someday amount to the “secret formulas” providing a playbook for integration around the country.

“Our name says we’re advancing care together, not apart. The institutional impediments to taking proper care of people are now out in plain sight. Pretty much anything is now discussable,” said Green.

Dr. Mary Jane England, chair of the ACT steering committee, a professor at the Boston University School of Public Health and one of the top mental health experts in the country, was downright rosy in her assessment of how the Colorado pilots are doing.

“You are leading the nation. We in Massachusetts have now covered 98 percent of people. We have a cap on expenditures and bundled payments … But you’re doing the really important work out here.

“You really are grass roots. This isn’t easy. This is change. It’s very exciting. You are now very much in the national forefront,” said England who chaired a watershed 2005 report for the National Academies’ Institute of Medicine on improving care for people with mental health and substance abuse problems.

Forefront, shmorefront. On the ground, reform is exhausting as are challenges that cut right to the core of patients’ lives.

Dr. Kotz, the solo doctor at MidValley Family Practice in Basalt, says the mental health system in his area that is supposed to help his neediest patients isn’t working. He is dealing with one family that has experienced severe trauma, abuse and domestic violence. He believes that both the mother and children should be getting care from the mental health facility. But, Kotz said his patients are not getting adequate care, so they keep coming back to him.

“I don’t want to paint this just as a negative picture. I think they try to do their best, but they are overwhelmed,” Kotz said.

To provide behavioral health to his patients, Kotz has partnered with the Aspen Hope Center, which is funded by the Aspen Valley Medical Center.  He now has a therapist employed by the Hope Center who works in his office part ime. Together they see the patients who have the toughest behavioral health challenges.

“They are high-need both from the medical and mental health standpoint,” Kotz said.

Some are bipolar or suicidal. One patient has been hospitalized 15 times.  Another is just 21, suffers from schizophrenia and has been hospitalized for the third time in three months.

Kotz said some mental health providers have expectations that patients can’t achieve.

“If you don’t show up, you’re fired.”

Then they wind up back at his practice.

To fill the gap, Amy Gensch, the Hope Center therapist in Kotz’ office, has simply taken on the family that suffered trauma and abuse so they won’t fall through the cracks.

“It’s the worst trauma I’ve ever seen,” Gensch said. “They had two therapists within two months. It didn’t work for them.”

Gensch and Kotz work together seamlessly, flagging each other down casually when they need to consult.

“It works really well,” said Gensch.

Their primary desire would be to expand their capacity.

“The statistics showing the number of mental health patients that come to primary care seeking help proves to me that it’s an absolute need to have primary care and behavioral health integrated,” said Kotz.

So, the goal is worthy. The path to get there remains difficult to find.

“Nobody has this figured out yet,” said Green, director of ACT. “We are comfortable enough to show all the warts now. We’ve got miles to go before we sleep.”

By Katie Kerwin McCrimmon

The biggest obstacle to blending physical and mental health care is money.

Doctors can’t bill insurance companies for treating their patients’ mental health woes and psychologists can’t treat physical ailments. So the two health specialties remain separate, while confused patients get splintered care and often get sicker.

Most experts acknowledge that the system is ridiculous, but feel shackled to insurance company billing codes.

Enter an insurance company that wants to prove once and for all that integrated physical and behavioral health care is both better for patients and less expensive in the long run.

In a new experiment set to start next spring in western Colorado, the nonprofit health insurance company, Rocky Mountain Health Plans, will give hefty “umbrella payments” to three primary care practices that are already working to integrate behavioral health. Also known as “global payments,” the funding will replace traditional “fee-for-service” payments that reimburse doctors for each visit with a patient or each test they order. The insurance company will then encourage the health providers to give patients excellent integrated care. That will vary from site to site and will depend on patients’ needs. Care could include a traditional office visit with a doctor or a health coach, email exchanges, telephone counseling or a typical counseling session. Patients will get all the care in the familiar setting of their primary care office.

At the same time, Rocky Mountain will give the control groups — three other primary care practices that are also trying to integrate behavioral health  — reimbursements under the traditional “fee for service” model, where providers bill for appointments and procedures.

Actuaries and data experts will then compare costs and patient outcomes. (Click here to read more about the experiment.)

The aim is to prove quickly that patients do better when doctors are paid to keep patients well rather than worrying about seeing as many patients as fast as possible to keep the cash flowing. Rocky Mountain ultimately wants to change the way it pays providers throughout Colorado and spur change around the country.

“This is not an academic exercise,” said Patrick Gordon, director of government programs for Rocky Mountain and executive director the Colorado Beacon Consortium, a coalition of nonprofit health groups that is seeking to boost the quality and efficiency of health care in western Colorado. “This will be a transformative pilot that is being built with the goal of replicating success across the country.”

Throughout Colorado, Rocky Mountain insures about 220,000 people. Altogether the primary care practices that participate in the pilot will serve 30,000 to 50,000 patients including the full spectrum of privately and publicly-insured patients. The organizers have not yet picked the practices that will participate.

Rocky Mountain is fronting the cash for the reimbursements. A group called the Collaborative Family Healthcare Association will coordinate the project while the Colorado Health Foundation is paying for an evaluation to see how well the three-year program works.

Clinical psychologist Benjamin Miller  will evaluate the effort. He is director of the Office of Integrated Healthcare Research and Policy in the family medicine department at the University of Colorado Denver.

“This is a total game changer in every facet,” said Miller. “It’s disruptive innovation. We’re telling the system, ‘We’re not going to play by the old rules anymore. We’re going to play with new rules and we want you to operate as a team.’”

Miller said the experiment “takes off the handcuffs of payment reform” and should produce some useful results.

“Everyone wants to know the answer to sustainability,” he said.

Currently, doctors are stuck trying to string together grants, fudge billing codes or give free office space to counselors in hopes that they’ll provide help to patients while creating their own streams of revenue.

Under the new concept, worries about finances will be gone.

“We’re going to take that off the table. Here is the financial support to make this sustainable,” Gordon said.

Rocky Mountain is pumping millions into covering up-front costs for various efforts to strengthen primary care practices and thereby reduce much more costly health expenditures such as surgeries, ER visits and lengthy hospital stays. The effort to integrate behavioral and physical health is part of the larger vision to bolster primary care.

Gordon could not say exactly how much the integration experiment would cost. But, in the long run, he and others are confident that giving patients much better primary care will help achieve the elusive holy grail of health reform: “bending the cost curve,” or slashing the increasing costs of health care in the U.S.

“We know that behavioral health integration is absolutely essential,” Gordon said. “The cost and structure of the payment model will probably vary from site to site. This project will give us much deeper insights into what those factors are.”

Gordon said initial estimates show that if primary care practices give high quality integrated behavioral and physical health care to all patients in western Colorado who earn at or below 250 percent of the poverty level — or about $56,000 a year for a family of four — health providers could cut the rate of growth in health expenditures by 4 to 5 percent over three years.

“Even relatively modest impacts on (growth) trends can produce more than enough to pay for all of these interventions,” Gordon said. “It also puts us in a position to share gains with government payers and employers.”

The ultimate goal is to make behavioral health sustainable in primary care. That means giving people help with a much wider array of issues beyond traditional mental health concerns such as depression or schizophrenia.

For instance, Gordon cites the potential benefits of a technique called motivational interviewing in which health providers spend time asking patients how they want to change their lives. The technique can help change unhealthy behaviors such as smoking, poor diet or a sedentary lifestyle, all of which lead to poor health outcomes.

“When you engage a patient in what they want for themselves…they are much more likely to …change elements of their own behavior,” Gordon said. “This is very much in contrast with the traditional didactic approach of most conversations between physicians and patients.”

One of the most promising methods for inducing behavior change is to start group visits for people with diabetes, for pregnant moms or for obese people.

“They have proven to be very powerful,” Gordon said. “You get a peer dynamic. And it’s the group that drives the discussion more than an authoritarian physician.”

By Diane Carman

Ezekiel “Zeke” Emanuel told an audience Thursday morning that the United States will be “guaranteed a much better health care system by 2020 because of the Affordable Care Act,” while his debate opponent Linda Gorman countered that the objective of Emanuel and other architects of “Obamacare” was really “to limit our freedom.”

The debate, sponsored by the University of Denver and the Denver Post, revealed yet again how far apart Americans remain on the issue of health care reform two years after its passage.

Emanuel, a University of Pennsylvania professor who served as special advisor to the Office of Management and Budget in the White House during the development of the Affordable Care Act, said that the Obama Administration spent nine months in futile negotiations with Republican lawmakers trying to develop a bipartisan package.

Ezekiel “Zeke” Emanuel

“There was a lot of talk and no action,” he said.

Even when the administration included all of Sen. Olympia Snowe’s demands in the proposed legislation, he said, she still voted against it.

“What’s the Republican alternative?”

Gorman, an economist at the free-market think tank, the Independence Institute, called for less regulation, less government involvement in health care and more freedom for individuals to pay for their own health care without interference from insurance companies.

“Insurance is the most expensive way to pay for health care,” Gorman said. “Let people decide what care they need.”

Emanuel said the Affordable Care Act is designed to address three problems with health care in the U.S.: lack of access to the 50 million people who are uninsured, uneven quality across the system and runaway costs.

“In 2012, the United States will spend $2.8 trillion on health care,” said Emanuel. “Health care spending here is the fifth-largest economy in the world.”

Gorman called the act’s goals “shiny objects” that look nice but don’t work and actually create serious problems.

“The only way the government knows how to cut costs is to ration care or cut payments to providers for care,” said Gorman, who claimed that the Affordable Care Act would “bankrupt one in seven hospitals and nursing homes.”

Gorman cited the decline in the cost of laser eye surgery over recent years as an example of the free market working to control costs for a service not covered by Medicare or Medicaid and, therefore, not affected by government regulation.

Emanuel said the act will control costs by “changing the incentives.” The longstanding fee-for-service compensation system for health care providers encourages them to wait for patients to get sick and then order expensive tests and procedures, he said. The Affordable Care Act provides incentives for them to keep people well, manage their health care more efficiently and deal with conditions before they require complicated, invasive and expensive treatment.

“We don’t know how much health care anybody needs,” countered Gorman, “And we don’t know how to keep people healthy. Things like cancer, arthritis leading to joint replacement … just happen. We don’t know why.”

Gorman called for a system that provides safety net care for the indigent and lets the rest of the people decide what care they need on their own.

“That’s exactly what the (health insurance) exchange does,” said Emanuel. “The purpose of the exchange is to provide people who don’t have insurance and want to get it on the individual market four options, four levels of coverage that are affordable and subsidized for people who can’t afford it. That’s exactly what Linda is calling for.”

Not so, said Gorman.

“It’s much less expensive to let insurance companies price risk and then subsidize people who can’t afford it,” she said.

Emanuel said the Affordable Care Act will eliminate the cost-shifting that occurs when hospitals and other health care providers charge patients with health insurance for the unpaid bills of those who are uninsured and need treatment.

Gorman said the cost-shifting still will occur, except that under the Affordable Care Act the burden will fall on the taxpayers.

As for the health insurance mandate included in the act, Emanuel said he knows “a lot of people are upset by it. But most Americans don’t want insurance companies to deny insurance to people with pre-existing conditions. There’s no way economically we can require them to cover people with pre-existing conditions without the mandate.”

When asked about the relatively small penalty imposed on those who defy the mandate, Emanuel said the objective was to create a “social norm” around taking personal responsibility for insurance coverage rather than creating an onerous penalty.

Gorman called for the repeal of the Affordable Care Act and that the country “regularize the laws of economics” to let the free market – not the government – be the primary influence on cost, quality and access to health care.

The debate continues and it should continue,” said former Gov. Dick Lamm, co-director of the DU Institute for Public Policy Studies and a moderator of the panel. “These are passionate advocates for their viewpoints.”

The debate is part of a series of events http://debate2012.du.edu/ leading to the Presidential Debate to be held at DU on Oct. 3.

By Diane Carman

Hunter Doherty “Patch” Adams is a physician who has “never made a penny from medicine.” He treats patients with laughter and loving, and he rebels openly against the “tyranny of market capitalism.”

He said he is “ashamed” of the U.S. health care system. “It’s not about health. It’s not about care. And it’s not a system, it’s a business.”

Adams spoke at the Tivoli Student Union on the Auraria campus Wednesday, challenging his audience to join his revolution of joy for the sake of their own well-being and that of the planet.

“You can decide to never have another bad day,” said the mustachioed doctor wearing bright patterned clown clothes and a dangly earring.

In the volumes of medical journals and peer-reviewed studies, Adams said, “there’s no evidence that it’s good for you to be serious. There’s no value to apathy, indifference, meanness, unkindness. Selfishness is never good for you.”

In contrast, the literature is full of evidence of the health benefits of “joy, love, humor … thoughtfulness,” he said.

A self-described provocateur, Adams rejects traditional medicine’s view of mental illness.

“To me, depression is never an illness, ever,” he said. “It’s a pharmaceutical company diagnosis.”

Depression, he insists, “is a symptom of loneliness. All you have to do to get rid of depression is have an active friend dancing in your head.

“I’ve never disliked a patient enough to give them a psychiatric diagnosis or medicine.”

Instead, he said, he held one patient for 12 hours to calm him and treat him with compassion instead of drugs.

Adams, who was hospitalized in his late teens when he was suicidal, said it wasn’t until the third hospitalization that “lightning struck” and he realized, “Don’t kill yourself, dummy, make revolution.”

He completed medical school at the Medical College of Virginia in 1971 and founded the Gesundheit! Institute, which provides medical care for free. He most famously was the subject of the 1998 feature film, “Patch Adams.”

Adams challenges his audience to embrace happiness.

“For the last 5,000 years, we’ve celebrated pain and suffering. History is about wars and winners and how bad the winners treated the losers,” he said. “There’s no party chapter.”

In religious training “we’re taught there’s salvation in suffering. … We love pain and suffering.”

He considers it profoundly unhealthy.

Being happy “is not an ethical or a moral thing,” he said. “It’s a damned old choice. And it’s clearly really good for you to be happy.”

Adams advocates communal living to increase friendship and human interaction, and to reduce costs and the impact of 7 billion people on the environment. “The smartest thing I did was to start a commune in 1971,” he said. “It made all this possible.”

Despite his active decision to be happy, Adams said he experiences the full range of emotions, including sadness and anger.

“When I hold a child who is dying of starvation and has no muscle mass … is just a sack of bones and doesn’t have the energy to speak … it’s hell.

“I want to tax the rich 95 percent,” he said. “Maybe it’s more important to love everybody than to have a thing.”

To get stuck in the “pain paradigm of sad, sad, sad and angry, angry, angry is like masturbation,” he said. Emotions should provoke action. His activism is focused on market capitalism.

“If we don’t stop market capitalism, we will be extinct in this century,” he said to applause.

At 67, he said he’s in “the ice cream phase of life,” so preventing the destruction of the planet must fall to the young. But at this point in life, he’s not about to start withholding his opinions.

“Emotions are there to guide people. I trust them. When I hear someone heaping a pile of b—s—, I speak up.”

In response to a question from a medical student seeking advice on how to pursue a path of treating the poor outside of the for-profit health care system, Adams offered an audacious suggestion.

“If you owe $200,000 when you graduate, don’t pay it. Work in Africa. There’s no such thing as debtor’ prison.”

It’s what he did, he said. When he finished medical school, he wasn’t making any money, so he didn’t pay off his student loans. “Later, when I started making money from other things, I paid it all back.”

Joy, he said, “is a platform on which you launch your life.

“I dove into the ocean of gratitude and never found the shore.”

By Julie Poppen of Education News Colorado

Politicians descended on Denver’s Lowry Elementary Monday to eat fresh veggies grown at school as part of a healthy lunch, tour the school’s impressive gardens and even dance “to the left” with people half their size.

It was all part of the U.S. Department of Education’s third annual back-to-school bus tour, which featured the nation’s schools chief Arne Duncan joining forces with Secretary of Health and Human Services Kathleen Sebelius and other politicians to tout the importance of healthy school lunches and increased exercise during the school day.

“If kids are healthy, they can be better students. They can focus on learning because they’re not suffering from hunger pangs,” said Sebelius, adding “Kids who are obese often have health problems that keep them out of school.”

The Colorado stops are part of a series of events being held coast-to-coast by Duncan and his leadership team through Sept. 21.

At Lowry, Duncan checked out the school’s Garden to Cafeteria program, which supplies its cafeteria with produce grown at the school. At his side were Gov. John Hickenlooper, Democratic U.S. Sens. Mark Udall and Michael Bennet, Colorado Commissioner of Education Robert Hammond and Denver Public Schools Superintendent Tom Boasberg.

U.S. Secretary of Education Arne Duncan dances with children at Lowry Elementary School in Denver during a tour to promote healthy school lunches. Photo by Julie Poppen of www.EducationNewsColorado

After sampling lunch, the group went outside to shoot a few hoops and then lined up with students for a little “Cupid Shuffle,” the popular line dance used as a warm-up in Lowry gym classes.

The school of 480 students – 38 percent of whom qualify for federal lunch assistance – has a well-established and parent-led health and wellness committee, a serenity garden and a vegetable garden that is tied to the school curriculum. Food is cooked from scratch for lunch. Each class has the opportunity to start seeds in the classroom.

“These are kids I don’t worry about,” Duncan said after the tour. “These are kids who are going to exercise, they’re going to eat well and they’re going to do it for the next 60, 70 or 80 years.”

A curriculum in a garden

Second-graders learn to plan potatoes in a pot. Students care for the potato pots indoors until the end of May, then the pots are dumped out so the students can see how many potatoes grew. Curriculum includes botany and history of potatoes.

School families maintain the garden and harvest produce. The school also offers a summer garden club that meets every Friday. From August to October, the school hosts weekly youth farmers’ markets run by fourth- and fifth-graders. Students sold 460 pounds of produce at its first market this year. Third-graders learn how to compost with worms.

Tanahcey Montgomery, a fourth-grader, rehearsed for her role as the garden guide for Secretary Sebelius. First, she had to prove she knew her stuff as far as the school garden is concerned. Holding a carrot just ripped from the ground, Tanahcey explained how sugar in the stalk moves into the root when it gets cold.

“I like to garden and the teacher picked me,” she said of how she landed the guide job.

Parent Lisa Emerson helped create the school’s first garden in 2006. The landscape architect and mom of two said she puts in about five hours a week on the school gardens.

“I get really fired up seeing how excited the kids are in the garden,” she said.

Emerson said she hopes the publicity surrounding Monday’s high-profile visitors will result in more schools everywhere deciding to make their schools healthier.

“We’re teaching kids lifelong lessons,” she said. “It’s important to get them when they’re young. By the time they reach middle school, they’re too cool for it. At the elementary level, they’re still excited by bugs or seeing a tomato start to form.”

The school is especially proud of its “healthy cupcake program” and its backpack program for homeless families.

The Lowry cafeteria bakes and decorates sweet potato muffins on request from parents for classroom parties. The so-called “Soar Cupcakes” cost under $10 to serve an average classroom.

Hunger addressed through backpack program

In 2010, the school embraced the Food for Kids Backpack Program, inspired by a fourth-grader who was collecting food from his buddies in exchange for losing at tetherball.

Some 32 Lowry families are now served each week through the program. Each Friday, volunteers and students create six meals and two snacks from food available in the school’s pantry. Then the backpacks are packed and delivered to the students in their classrooms to take home. The empty backpacks are returned Monday mornings. The program is supported by several organizations.

At the end of the tour and hand-shaking, Duncan’s entourage, which included staffers and Secret Service agents, took off in an army green U.S. Department of Education bus with the slogan “Education drives America” painted on it. School children waved and yelled as the bus began the trip to Limon on Colorado’s eastern plains.

Before he left, Duncan got in some praise for Colorado and Denver’s school reform efforts.

“As Denver moves, as Colorado moves, so moves the country. The national spotlight has been here and will continue to be here,” he said. “The courage, tenacity and spirit of reform here has been remarkable.”

In Limon, Duncan was expected to address 400 K-12 students, parents, teachers and community members at the school’s Constitution Day celebration.

In addition to these engagements, Acting Assistant Secretary for Postsecondary Education David Bergeron planned Monday afternoon to host a roundtable discussion on Science, Technology, Engineering and Mathematics – STEM – education at the University of Colorado Boulder.

For up-to-the-minute updates from the road, follow the Education Drives America tour on Twitter using the hashtag #edtour12.

By Katie Kerwin McCrimmon

GREENWOOD VILLAGE — Infant formula should be tracked and locked at all hospitals just like other supplies and pharmaceuticals, experts said Tuesday during the first-ever Colorado Hospital Breastfeeding Summit.

Studies in Colorado have found that nine of 10 mothers want to breastfeed their babies, and unnecessary use of infant formula in the early hours and days of newborns’ lives can derail mothers’ plans, according to breastfeeding expert and parenting author, Dr. Marianne Neifert, also known as “Dr. Mom.”

In New York, Mayor Michael Bloomberg is fighting obesity by limiting soda serving sizes and calling for formula to be locked up at New York hospitals.

“I’m a little dumbfounded that this is even an issue. It’s standard operating procedure…not a punishment,” said Trish MacEnroe, executive director for Baby-Friendly USA. The national group is helping U.S. hospitals implement recommendations from the World Health Organization and the United Nations Children’s Fund to achieve the highest level of certification to support breastfeeding.

MacEnroe said hospitals routinely lock up supplies, and infant formula should be no different.

But, hospital representatives at the Colorado summit acknowledged that few hospitals here track formula since they don’t pay for it. Many Colorado hospitals still send new mothers home with “swag bags” full of formula samples, coupons and gifts. Doctors attending the conference said formula companies are also spending millions of dollars to market directly to mothers through social media and by sending large canisters of formula directly to new mothers’ homes.

Dr. Jennifer Hyer, an OBGYN doctor at Denver Health, received multiple shipments of infant formula at her home. She didn’t use it, but felt the marketing could disrupt breastfeeding for struggling new mothers.

Dr. Jennifer Hyer, an obstetrician who works in clinics and the hospital at Denver Health, said she received multiple shipments of formula at her home after delivering her daughter a year and a half ago.

“Breastfeeding wasn’t easy for me. I was so committed to nursing and not using formula, but then it would come in the mail. There’s a part of you that thinks, ‘I could give her this and then we could both take a long nap,’ ” Hyer said. “You’re home alone. You haven’t showered. The baby’s crying. And you get this can of magic powder.”

Hyer now counsels patients and friends about the importance of getting support immediately in the hospital. In the first week before her own milk fully came in, Hyer was able to supplement her daughter with donated human milk. Some hospitals are now purchasing human milk and when mothers are struggling with breastfeeding, they offer human milk before formula.

At Memorial Hospital in Colorado Springs, Dr. Mark Duster says formula still sits in storage areas and is not locked up.

“It’s not like trying to get aspirin or Tylenol. You don’t have to sign out for it,” said Duster, who is medical director at the Memorial Hospital for Children and a pediatric cardiologist.

Memorial will be changing that policy in the next several months. All hospitals certified as “Baby-Friendly” must sever all marketing ties with infant formula companies and purchase, lock, track and distribute formula only with a prescription from a physician.

Memorial Hospital is on a fast track to achieve full Baby-Friendly status thanks to a new grant from the Centers for Disease Control and Prevention. Memorial was the only Colorado hospital in the country picked for the program.  Duster said he believes Memorial was selected for the grant because it has a high percentage of low-income patients and have been doing a poor job of helping them get started with breastfeeding.

About 56 percent of mothers delivering babies at Memorial’s central hospital are mothers on Medicaid. African-American mothers have the lowest breastfeeding rates nationally. Latina mothers in Colorado initiate breastfeeding at high rates, but also frequently supplement with infant formula. Low-income mothers breastfeed at significantly lower rates that wealthier women.

Dr. Mark Duster, medical director for the Memorial Hospital for Children in Colorado Springs, says changing hospital policies to support breastfeeding is painful, but essential to support public health.

Duster said Memorial Hospital no longer sends mothers home with formula goody bags. As part of the “Baby-Friendly” CDC program, about 40 hospital leaders meet weekly to review and change their policies. They will eventually purchase and lock all formula. But truly promoting breastfeeding is much more complex, said Duster.

Formula companies used to supply measuring tapes, charts for recording infant growth and even all the little tags that say “It’s a boy” or “It’s a girl.” Memorial no longer has any of those items, but formula companies still supply all the bottle nipples.

“It’s been difficult for us to wean ourselves and to remove subtle commercial advertising from our institution,” Duster said. “We’ve removed from our hospital everything that has an identifier of a commercial interest with the exception of the nipples.”

Duster said the scientific evidence is clear that breastfeeding should be viewed as a public health issue and that hospitals should help their patients succeed.

“The key to successful breastfeeding is successful breastfeeding in the hospital and in the first few weeks when the child is at home,” Duster said.

Unfettered marketing of formula both in hospitals and directly to mothers can interfere with success for mothers who are able to breastfeed.

“The appearance of impropriety is just as problematic as actual impropriety. To the extent that hospitals are participating in the marketing of any pharmaceutical product, it presents a conflict of interest,” Duster said.

Change is extremely painful. Nurses and exhausted mothers want to be able to quiet crying babies with a quick bottle. And many colleagues view breastfeeding as a trend, not a public health issue, Duster said.

“It’s a tremendous culture change and we’re on a journey,” said Duster. The intensive effort should result in full certification for Memorial within two years.

In Colorado, so far only three hospitals have achieved the“Baby-Friendly” designation. The first was Exempla Good Samaritan Medical Center in Lafayette.  The other two are Medical Center of the Rockies in Loveland  and Poudre Valley Hospital in Fort Collins.

Dr. Marianne Neifert, also known as “Dr. Mom,” says hospital policies are critical to helping mothers succeed at breastfeeding. She says the effort to have hospitals fully certified as “Baby-Friendly” facilities is on the verge of becoming a “megatrend.”

About a half-dozen others are working on certification, while 33 Colorado hospitals now comply with Colorado’s “Can Do 5!” program. Viewed as a step on the way to achieving full “Baby-Friendly” status, the Can Do hospitals pledge to help mothers breastfeed in the first hour, give newborns only breast milk, keep babies with their mothers, eliminate pacifiers and give mothers follow-up contact information for outpatient breastfeeding support.

Colorado recently earned kudos for being No. 1 in the nation for the number of women who follow recommended guidelines and exclusively breastfeed their babies for six months. But, state health officials want even more babies to breastfeed.

Colorado’s chief medical officer says he puts in a plug for breastfeeding everywhere he goes.

“Breastfeeding is great,” said Dr. Chris Urbina, executive director of the Colorado Department of Public Health and Environment, as he opened the summit to help Colorado hospital providers learn the best practices for supporting breastfeeding mothers.

Urbina says that while Colorado is the leanest state for adults, we don’t have much to brag about.

“We’re getting tired of hearing that because we’re actually getting heavier as we move forward,” he said.

One in seven Colorado children and one in five adults are now obese and the outlook is grim.

Colorado now ranks 29^th in the country for child obesity and a new report released this week  from the Trust for America’s Health and the Robert Wood Johnson Foundation has found that nearly half of Colorado adults could be obese by 2030.

Urbina said breastfeeding benefits both infants and their mothers.

“We know breastfeeding can help prevent childhood obesity and reduce the risk of many childhood illnesses,” Urbina said. “The majority of new mothers want to breastfeed, and these hospitals play a vital role in giving babies a healthy start.”

Mandy succeeded at breastfeeding her son Colin, now 4 months. She struggled at first and wishes she had spent more time with a lactation consultant earlier at the hospital.

Colorado hospitals that received the Colorado Can Do 5! award at the Colorado Hospital Breastfeeding Summit.

Aurora

-The Medical Center of Aurora

-University of Colorado Hospital

Colorado Springs

-St. Francis Medical Center

Delta

-Delta Memorial Hospital

Denver

-Exempla Saint Joseph Hospital

-Presbyterian/St Luke’s Medical Center

Englewood

-Swedish Medical Center

Estes Park

-Estes Park Medical Center

Frisco

-St. Anthony Summit Medical Center

Littleton

-Littleton Adventist Hospital

Lone Tree

-Sky Ridge Medical Center

Longmont

-Longmont United Hospital

Louisville

-Avista Adventist Hospital

Loveland

-Medical Center of the Rockies

Parker

- Parker Adventist Hospital

Pueblo

-Parkview Medical Center

Sterling

-Sterling Regional Medical Center

Westminster

-St. Anthony North Hospital

Wheat Ridge

-Exempla Lutheran Medical Center

Yuma

-Yuma District Hospital

By Katie Kerwin McCrimmon

In the first case of its kind in Colorado, a former Jefferson County teacher has won an undisclosed cash settlement and concessions from the school where she said she lost her job for taking breaks to pump her breast milk.

Under the 2008 Colorado Nursing Mothers Act, breastfeeding mothers in Colorado are entitled to take time in a private location to express milk at work. Colorado is one of 24 states with laws that support breastfeeding mothers in the workplace.  The right to pump milk at work is also now guaranteed under the federal Affordable Care Act. 

Heather Burgbacher held her daughter, Dreya, who is now 2 and said the dark days she endured while fighting back are now worthwhile. The American Civil Liberties Union of Colorado and the national ACLU fought the case on Burgbacher’s behalf.

“It was a very difficult road. I felt like a failure. I felt like I had done something wrong. It was devastating to have my career taken away from me,” Burgbacher said. “I’m just proud that we’re taking steps forward, changing for the good. Now people will be aware of what we need. Ignorance of the law was a big part of this.”

A lauded technology teacher for five years at the Rocky Mountain Academy of Evergreen (RAME), Burgbacher had arranged for a fellow teacher to supervise her students while she took 20-minute breaks about three times each week to pump her milk for Dreya, the younger of her two daughters.

Burgbacher said she was told in February 2011 that her contract wouldn’t be renewed the following year. She said then that her supervisor cited disputes over her desire to pump milk as the cause for her dismissal.

“I was told, ‘Welcome to the school of hard knocks,’” Burgbacher said Tuesday as she and her lawyers announced the settlement. “I wasn’t willing to accept that. If you feel you have been wronged, then definitely explore it. Don’t be afraid to speak up to your HR person…if you’re facing issues that need to be investigated further.”

Officials at the RAME charter school claimed in 2011 that Burgbacher’s job was changing and that the decision not to renew her contract had nothing to do with the pumping breaks she had sought. The school and school district did not admit any fault in the settlement and agreed to give Burgbacher positive letters of reference. Burgbacher has since found another job.

On Tuesday, school officials released a statement saying that they “strongly disagree” with the ACLU’s claims and that they already were compliant with the law when Burgbacher’s job was eliminated due to organizational restructuring.

“It’s unfortunate that the ACLU chose to target the Rocky Mountain Academy of Evergreen to boast the ‘first public settlement of a lawsuit regarding the Nursing Mothers Act’. Especially in light of the fact that the plaintiff’s accusations were false, and that she was accommodated by the school in terms of time and space to express breast milk in accordance with the law and with RMAE’s policies and procedures around this issue,” said Dan Cohen, the school’s executive director.

“It appears that the ACLU may have been a bit over anxious to make a statement regarding this relatively new law, and our school was the unfortunate target,” Cohen added.

In the settlement with Burgbacher, however, the school has agreed to multiple concessions for future nursing mothers including:

• Full compliance with the Colorado Nursing Mothers Act,
• Written notice to employees regarding their rights under the law,
• A private location where mothers can express their milk, and
• Notice to future employees who have filed harassment claims about the outcomes of any investigations.

Burgbacher’s attorneys, Rebecca Wallace of the ACLU and Mari Newman of the law firm Killmer, Lane and Newman, both said Burgbacher’s case could help codify rights for other working mothers who want to pump at work in order to preserve their milk supply.

ACLU staff attorney, Rebecca Wallace, with Heather Burgbacher and her 2-year-old daughter at a press conference announcing a settlement with the Jefferson County charter school where she used to be a technology teacher.

“This case serves as a real model for employers in Colorado that they can accommodate working mothers. The law simply doesn’t allow for discrimination,” Newman said. “This case certainly isn’t unique. Discrimination against working mothers certainly persists. This is just one of many examples of that.

“What’s significant about this is the efforts that the school has now made to accommodate future nursing mothers,” Newman said.

Until now, Wallis, a staff attorney with the ACLU, said the 2008 Colorado law had not been tested.

“The primary reason for taking the case, both for the ACLU and for Heather was to do public education and to teach employers what their responsibilities are and to teach employees how to stand up for their rights,” Wallis said.

Along with the ACLU, Burgbacher said she received help from local leaders of the breastfeeding support group, La Leche League International, and experts on breastfeeding and public health at the Colorado Department of Public Health and Environment.

Burgbacher said she was pumping her milk in hopes of giving Dreya the healthiest start in life that she could.

“I wanted to get to a year. I try to be a hands-on mom,” Burgbacher said.

She said her older daughter who is now 4 has never had an ear infection.

“I saw the benefits (of breastfeeding). I wanted that to be the same for this one. I know it’s important, not only for them physically, but also for the bond you establish.”

Burgbacher said employers should support mothers who breastfeed their babies.

“Do what you can to retain your valued employees. Breastfeeding is a huge commitment,” she said. “It’s a selfless act that needs support from everyone, your family, your spouse and your employer.”

By Leia Larsen and Katharina Bucholz

CU News Corps for I-News

Colorado’s ballot initiative to legalize marijuana possession is billed by one leading local advocate as “a grassroots effort here on the ground,” but an examination of contributions to the campaign tell a different story.

Contribution records from the Colorado Secretary of State’s office show that the four registered committees supporting legalization collected more than $1.4 million through Sept. 12, with more than $1.2 million coming from outside Colorado.

“They have an incredible amount of money,” said Floyd Ciruli, analyst at the polling firm Ciruli Associates.  ”It primarily came from out of state.”

Ciruil said Colorado is among other Western states “that have a little more libertarian attitude,” making them “fertile ground for laws that would legalize various behaviors like drugs.”

The top campaign contributor to Colorado’s Amendment 64 is the Marijuana Policy Project, a Washington, D.C.,–based lobbying group that has donated more than $1.1 million. According to the group’s website, it has more than 124,000 members and supporters.

Other top donors supporting the proposition include the Drug Policy Action Alliance, a national lobbying group, ($90,000); the California-based company Dr. Bronner’s Magic Soaps ($50,000); and Lawrence Hess of San Diego ($30,000).

Mason Tvert, co-director of the Campaign to Regulate Marijuana Like Alcohol and a long-time marijuana advocate in the state, said most of the pro-initiative work is being done by Coloradans. “This is a grassroots effort here on the ground. We have individuals canvassing their neighborhoods all across the state. We’re confident we’ll continue to see support grow.”

Morgan Fox, a spokesman for the Marijuana Policy Project, said in an email that the big spending should help. “The financial backing that the campaign has gathered so far will ensure that it is able to get its message out to voters far more effectively than the opposition, which will certainly be a benefit.”

Polling indicates that support for the measure may be wavering, however.

A Rasmussen Pollsters survey conducted in June indicated that 61 percent of voters would vote in favor or marijuana legalization. A poll conducted by Public Policy Polling in late August and early September showed 47 percent in favor, 38 percent opposed and 15 percent uncertain.

“This latest survey is more sobering,” Ciruli said. “It suggests to me that while they have the advantage of money, and I do think they have an argument, there’s an uphill battle. There’s a tendency for the positive vote to have attrition due to attacks, second thoughts, a variety of things.”

Gov. John Hickenlooper issued a statement last week opposing Amendment 64. “Colorado is known for many great things – marijuana should not be one of them,”he said. “Amendment 64 has the potential to increase the number of children using drugs and would detract from efforts to make Colorado the healthiest state in the nation. It sends the wrong message to kids that drugs are OK.”

Only one group, Smart Colorado: Vote No on 64, is registered to campaign against the measure. Smart Colorado had raised $194,000 through Sept. 12, and most of its money also came from out of state.

Florida-based Save our Society from Drugs contributed $151,497 of the total. The group also funded opposition to a 2006 Colorado legalization attempt.  The organization did not respond to phone calls and emails for comment.

Tvert’s organization is the official campaign driving the initiative.

If approved by Colorado voters, Amendment 64 will make it legal for those 21 and older to possess up to one ounce of marijuana. It also would create a regulatory system for marijuana similar to that of alcohol.  And it would allow cultivation and sale of industrial hemp. Federal laws, however, still would outlaw marijuana possession and use.

Washington and Oregon have similar amendments on their November ballots. Another ballot measure failed in California in 2010, with 53.5 percent of Californians opposing legalization and taxation of marijuana.

Another pro-legalization advocacy group, Citizens for Responsible Legalization, collected $779,000 last fall, almost all of it from Peter Lewis, an Ohio man who founded Progressive Insurance. The group spent the money on television ads and research in the Colorado Springs area before disbanding at the start of this year. Tvert said the group isn’t affiliated with the current initiative

The I-News Network is a nonprofit newsroom collaborating with Colorado news organizations to cover important issues. Learn more at iNewsNetwork.org