Health Policy Solutions

Cathy Alderman is vice president of public affairs for Planned Parenthood Votes Colorado.

By Katie Kerwin McCrimmon

Despite a sea of pink draping Colorado in October, fundraising for Komen breast cancer affiliates is down by as much as 30 percent, a drop that will hit local nonprofits across the state.

Employees at Komen affiliates in Colorado risked their jobs in February when they publicly opposed the national move of Susan G. Komen for the Cure to cut funding to Planned Parenthood. The political spat between the two women’s health groups erupted after Komen officials withdrew $680,000 from Planned Parenthood, which along with abortions and contraceptives, provides breast cancer screening to the poor. The flap resulted in such outrage nationally that Komen ultimately reversed its decision. Resignations, recriminations and a tell-all book have since followed.

While the politics of women’s health play out nationally in the presidential race and beyond, reverberations from the Komen controversy are hitting local groups in Colorado now and will filter down to nonprofits in coming months.

At Komen of Southeastern Colorado, which serves El Paso, Teller and Pueblo Counties, Race for the Cure participation and proceeds were both down. The race took place on Sept. 9 at Garden of the Gods in Colorado Springs. It drew 5,400 participants who raised about $280,000, a 30 percent decline from the 2011 race. The race is by far the largest fund-raiser of the year for the southeastern Colorado affiliate. There was one silver lining in that individuals who participated in the race each raised 6 percent more funds this year than individuals have in the past. But anger over the Planned Parenthood fight combined with the poor economy mean that the Colorado Komen group will give out fewer dollars next year.

“Komen made a dumb mistake and hopefully that mistake won’t ever be made again,” said Paul Montville, executive director of the southeastern Colorado Komen affiliate. “That being said, you can be mad at us, but don’t be mad at the women we serve. We do good work. Don’t withhold support from the women who need our help. In my wildest dreams, we couldn’t grant enough money for all the women who need it.”

The largest Komen affiliate in the state and one of the top-grossing affiliates in the nation, the Denver metropolitan group also saw its Race for the Cure proceeds and participation decline about 20 percent this year. This year’s Race for the Cure, the largest fundraiser of the year for the Denver affiliate, took place on Oct. 7, attracted more than 40,000 people and brought in about $2.4 million in revenues. Attendance has been declining throughout the recession since its peak in 2006 when more than 60,000 people participated.

The Denver Metropolitan Komen affiliate serves a far larger area than its name implies, including 19 counties that stretch into the mountains and across the eastern plains.

“We know that our grant funds will go down this year,” said Michele Ostrander, executive director for the Denver affiliate. “Because of that, our board has had to make some strategic decisions.”

Ostrander said Komen Denver will fund basic needs including breast cancer screening and community health navigators who can help women find care. For 2013, she said her group will not be able to fund excellent support programs including groups that provide non-medical services such as meals, transportation and housing support for low-income people with breast cancer.

Women gather in Colorado Springs at the Race for the Cure in September. Fund-raising for Komen affiliates across the country is down as local groups try to rebound from the national organization’s flap with Planned Parenthood.

Ostrander and her board released a letter in February decrying the Planned Parenthood decision and have always maintained local funding for Planned Parenthood clinics. Nonetheless, the Denver group finds itself having to beg for forgiveness and renewed support here in Colorado.

“You’re helping your friends, your neighbors who don’t have access to care,” Ostrander said. “Komen Denver saves lives in our community. We can’t do that without the support of the community. We hope that if folks are still angry about the flap between national and Planned Parenthood that they will forgive us because lives are depending on it.”

Ostrander thinks that message may be reaching some of the biggest donors. Both attendance and revenues were up at the Denver group’s Pink Tie Affair, which took place on Oct. 27 in Denver. The event grew about 9 percent to 960 people, up from 840 last year and generated revenues of about $420,000. The Pink Tie Affair attracts a more well-heeled crowd, while Race for the Cure reaches the masses. Better results at the fancy affair may mean that the economy is improving for upper income people while middle- and low-income people may still be struggling. Many of the donations to Race for the Cure can be as small as $10 or $25.

“If a family is struggling, then that is more likely to be affected by the ongoing problems with the economy,” Ostrander said.

Representatives from Colorado’s Komen affiliate in Aspen declined to comment, but in an August letter to the Aspen Times, Komen board member Nancy Pickard said donations were down 20 percent and pleaded with community members to support the local group.

“We live here. We save lives here,” Pickard wrote, saying she was addressing those who were not participating in Komen events to retaliate against the national group’s actions against Planned Parenthood.

“I support your feelings and was very upset as well that Komen took such a politically motivated step that only served to hurt the women we serve. Please remember, however, that Komen Aspen not only had nothing to do with the decision, but the moment we heard about it, we immediately (opposed it).”

The Colorado affiliates have always maintained their ties with Planned Parenthood. But they are not alone in feeling repercussions from the controversy.

Ostrander said she’s heard from fellow affiliate directors across the country that revenues are down 15 to 30 percent.

Funds raised in Colorado do not support administrative costs at the national Komen office in Texas. Rather, 25 percent of funds go to research while the rest stay in the local community to fund early detection of breast cancer.

Paul Montville of the southeastern affiliate said it’s a shame that the group that perfected marketing for a cause is now suffering because of poor decisions at the top.

“We had 5,400 people show up (at our race) in what is arguably the toughest year we’ve ever had. It will be a tough grant year,” he said.

But, he is trying to move forward, tapping the enthusiasm of dedicated people on the ground in Colorado.

“The race is about more than paying your $30, getting a T-shirt and having a fun morning in Garden of the Gods.  People are showing solidarity and we’re trying to ask them to ask 10 friends for $10 each. That money goes right to our bottom line. We give it away for mammograms and treatment support,” Montville said.

“There’s nothing even in second place for us,” he said of the Race for the Cure. “The race is us and we are the race.”

By Rebecca Jones of Education News Colorado

The Colorado Department of Public Health and Environment has launched a campaign to get young people, parents, schools, policy makers and community groups to start talking about something likely to make many of them squirm.

The state health department has released a 64-page document exploring strategies for improving youth sexual health.

Dubbed Youth Sexual Health in Colorado: A Call to Action, the campaign hopes to encourage young people to delay sexual activity and to use condoms and contraception consistently and correctly if they are engaged in sexual activity.

But beyond that, organizers hope it ultimately results in giving more Colorado teens access to supportive relationships that will allow them to finish their educations and achieve their economic and career goals.

“Youth. Sex. This topic can turn off a lot of people,” said Anne-Marie Braga, director of adolescent health initiatives for CDPHE. “I can’t say enough about our department really taking leadership on this. It’s time to normalize this issue and do something about it.”

The Call to Action summarizes the state of youth sexual health in Colorado and provides specific strategies for young people, their families, their communities and state policy makers to follow to have a positive impact on the issue.

Developing the Call to Action involved convening informal focus groups of parents and of young people around the state. The youth were asked to share their experiences about what they want regarding their sexual health, what works and what doesn’t. Parents and adult mentors were asked for their perspectives. In addition, more than 700 people responded to a statewide survey.

The interviews also underscored the need for young people to have trusted adults to whom they can turn – parents, yes, but other adult mentors as well. Failure to provide that can have devastating long-term consequences.

“Teen pregnancy and sexual health is dear to my heart,” said Sen. Irene Aguilar, a Denver Democrat and a physician practicing at Denver Health’s Westside Family Health Center, who spoke at the Oct. 27 kickoff for the Call to Action, held at the Denver Museum of Science and Nature.

“I know firsthand what a difference it can make to be educated about sexuality and to be able to take control of that. Teens don’t want adults telling them what to do, but they need information to make their own decisions,” she said.

“If someone has uncomfortable situations happening around sexuality, it can lead to depression or suicide,” Aguilar said. “An unwanted pregnancy can change the trajectory of your whole life. Teens who get pregnant are more likely than others not to finish high school and to live in poverty, as are their children. So this impacts not only you now, but future generations.”

“Thank you for this groundbreaking work,” she told organizers, “and thank you for pushing those lazy adults into talking about things they don’t want to talk about,” she told the young people gathered at the kickoff.

Rep. Cindy Acree, an Aurora Republican considered one of the legislature’s experts in health care policy, was unable to attend the kickoff on Saturday, but she sent greetings and shared her own experience with teen pregnancy. Her daughter is a single, teenage mother who lives with Acree. “She works two jobs, has little social life and no money to do extra things,” Acree said in her prepared remarks. “Suddenly she is grown up and dealing with all these issues.”

Youth sexual health involves more than simply avoiding pregnancy or catching a sexually-transmitted disease, say organizers. A sexually healthy person is able to decide for himself or herself when to engage in a sexual relationship, free from oppression, exploitation and abuse. A sexually healthy person knows how to access information and can talk comfortably with health care providers, as well as family and friends.

Scarlett Jimenez, a student at Aurora’s Hinkley High School, is one of the youth leaders advising the state on youth sexual health.

In Colorado, teen birth rates have fallen steadily over the past decade, down nearly 37 percent since 1992. This mirrors what has happened nationwide. In addition, sexual activity among young people is slightly less than the national average. According to the Healthy Kids Colorado Survey, nearly 40 percent of all Colorado high schoolers report having had sex at some point.

But not all the news is good. Condom use is spotty, rates of chlamydia are increasing and sexual violence is on the rise.

“On average, 17 babies are born to teenagers in Colorado every day – about one baby every 84 minutes,” said Scarlett Jimenez, a senior at Aurora’s Hinkley High School, and one of the young people serving as advisors to the Call to Action campaign. Jimenez said she’s also witnessed hate and bullying around sexuality, and she called on schools to provide more comprehensive sex education, which she said would decrease bullying.

Elaine Gantz Berman, a member of the state Board of Education, said that lawmakers can pass enlightened, well-meaning policies, but unless those policies are implemented, little will change.

“We have a comprehensive sex education policy in this state,” she said. “Is it being implemented in every district? Absolutely not. We need to hold districts’ feet to the fire to make sure they’re implementing these standards.”

Berman suggested that it might be possible to tie youth sexual health to initiatives related to childhood obesity, an issue around which there is tremendous interest and funding. “Maybe there are ways we can combine the importance of nutrition, physical activity and health into comprehensive sex education. We need to be creative as policy makers,” she said.

By Katie Kerwin McCrimmon

More Coloradans are using ERs, but people with Medicaid and Medicare use them the most, not the uninsured, according to a new analysis of the Colorado Health Access Survey (CHAS).

That finding surprised policymakers from The Colorado Trust and the Colorado Health Institute, who today released a new study on ER use in Colorado. High ER use among Medicaid patients will also become a focus of debate about whether Colorado should expand Medicaid under the Affordable Care Act.

Analysts think the uninsured may seek less ER care in part because many of them are young and relatively healthy.

“There’s a myth that’s been perpetuated that the uninsured rely on emergency departments for unnecessary services and that that’s the main place where they get care,” said Jeff Bontrager, director of research on coverage and access for the Colorado Health Institute.

“One of the key surprises was that the uninsured tended to have ED (emergency department) use rates that were much more comparable to people who have private insurance. That flies in the face of conventional wisdom,” Bontrager said.

In 2011, nearly 1.2 million Coloradans, or 22 percent of the population, visited a hospital emergency department at least once in the previous year, up from 1 million, or 20 percent of the population, three years earlier.

Nearly half of those who sought emergency care — 44 percent —  said their visit was for a condition that could have been treated in a doctor’s office or clinic had one been available when they needed help.

People with Medicaid — the poor, disabled, children and pregnant women — had the highest ED use rates (40 percent), followed by elderly patients on Medicare (30 percent). Uninsured people used the ED at a rate of 21 percent, a similar rate to those with private health insurance (19 percent).

Dr. Ned Calonge, president and CEO of The Colorado Trust, which funds the health survey, said there are no simple answers for why ED use has climbed. But he noted that patients say they have a difficult time finding doctors who will accept Medicaid. Waiting lists are long at safety net clinics and low-income patients say they often can’t get appointments quickly when they need care.

Why people seek emergency care. (Click on image to enlarge.) Source: Colorado Health Access Survey.

Other people who used ERs reported that they needed care after their doctor’s office was closed and that the ER was more convenient. Hospitals have been aggressively marketing short ER wait times with real-time web updates, mobile apps, texts and billboards.

“People make choices and they may be picking convenience over continuity of care,” Calonge said. “If I’m insulated from cost, I may just not worry about that.”

Calonge said one of the toughest health care dilemmas is figuring out a co-payment that makes people think carefully about using emergency services, but not one so high that people will avoid care when they need it.

“We’ve wrestled with this for a long time in health care. You can increase out-of-pocket costs. At the same time, we don’t want to raise them so high that…people make the wrong decisions. It’s a complex issue,” he said.

The increase in ED use rose as Colorado’s economy soured. Colorado’s Medicaid caseload is projected to climb to about 740,000 in fiscal year 2013-14, up 32 percent since 2010-11.

States across the country are pondering whether to expand Medicaid to even more people as the Affordable Care Act (ACA) goes into effect. The U.S. Supreme Court ruling that upheld the ACA also gave states the power to decide whether to expand Medicaid.  Many Republican governors have said they will not do so. Colorado Gov. John Hickenlooper has not made a decision yet. High costs for Medicaid patients seeking care in EDs and elsewhere will be a key factor as Colorado policymakers decide how to proceed after the Nov. 6 election.

Calonge noted that ED use rose in Massachusetts after the state required everyone to buy health insurance.

“But, it started adjusting over time. A population that hasn’t been using the system might have pent up needs,” Calonge said.

Ideally, more patients will have regular medical homes in clinics and at doctors’ offices where they can seek less expensive, non-emergency care.

“Regardless of what happens with the election, regardless of what happens with the Affordable Care Act, all of these issues are the same. Ultimately, we’re going to have to figure out how we address them. (ED) use isn’t going to go away by itself,” Calonge said.

Among other key findings:

• The highest users of EDs are young children, adults ages 65 and older, people with disabilities or in poor health, African Americans and people with the lowest incomes.
• High users are also many of the same people who are covered by Medicaid.
• Underinsured Coloradans, those with health insurance, but who still spend more than 10 percent of their income on medical expenses, used EDs at a rate of 30 percent — more often than people who were uninsured.
• ED visits were lowest (12 percent) in the mountain resort counties of Eagle, Garfield, Grand, Pitkin and Summit.
• Mesa County in western Colorado had the highest rates of ED usage (32 percent). The Grand Junction area is often cited as a national leader for low-cost health coverage. Analysts were uncertain why the survey found such high ED usage rates there.
• Nearly 200,000 Coloradans are frequent ED visitors, meaning they sought emergency care three or more times in one year. People with Medicare and Medicaid used EDs most frequently. Those with disabilities and in poor health use EDs more frequently.

When people explained why they sought emergency care, 79 percent said they needed help after hours, 63 percent said they couldn’t get an appointment when they needed it, 45 percent said the ED was more convenient and 28 percent said doctors would not accept their health insurance.

Rates at which people seek emergency care throughout Colorado. (Click on image to enlarge.) Source: Colorado Health Access Survey.

“We tend to see higher use of the ED among vulnerable populations in Colorado. That can mean lots of different things: low-income, poor health status or some minority groups who may be disenfranchised from the health care system,” Bontrager said.

Seniors and children also frequently need ED care.

“The question really becomes are the resources available to handle additional Coloradans covered by Medicaid? How are their health care needs going to be met and are there providers that are available (to serve them)?” Bontrager said.

He said EDs and people who seek care in them have both been demonized for ratcheting up health care costs. Some ED use is absolutely appropriate, for instance for accidents and heart attacks.

For those who don’t need emergency care, policymakers need to find ways to cut wait times, improve care coordination, offer lower-cost after-hours options and support patients as they try to navigate confusing health systems.

“If you have access to primary care and a relationship with a medical home or a doctor, you are less likely to report to an ED to try to get treatment for something that may not be an emergency,” Bontrager said.

The CHAS is based on in-depth surveys of more than 10,000 Colorado households. Pollsters collected the most recent data in 2011. The Trust has committed $4.5 million to conducting the survey every other year until at least 2017.

By Dr. Amanda Dempsey

After lunch on a typical clinic day, I review my schedule for the afternoon and see that Danny S. is scheduled for his 4-month well child check-up.  His name rings an alarm bell in my head.  Looking through the chart I see why. Danny’s parents have been adamantly against vaccines at past visits.  At Danny’s 2-month visit, they declined getting any of the recommended vaccines, despite my strong suggestions otherwise.

“OK,” I think. “Maybe today will be the day,” and I resolve to try again to change their minds.  However, the moment I bring up vaccines during his visit, Danny’s dad produces a notarized document written in legalese indicating that because of their “religious beliefs,” the parents plan to continue to refuse all vaccines, and by the way, PLEASE stop asking them to sign the “vaccine refusal” waiver at every one of Danny’s visits!

The document goes on to state a long list of reasons why vaccines are “harmful.” One of the most interesting includes the notion that giving Danny the Hepatitis B vaccine will cause him to be sexually promiscuous. I guess they’re talking about 12 to 18 years from now when he might actually be thinking of sex?  I’ll keep trying to get Danny vaccinated at every visit, but I already know that I’m most likely not going to make any headway with his family.

Danny’s parents’ views provide an example at the extreme end of the vaccine hesitancy spectrum, and show the lengths that some parents will go to keep their child from getting vaccinated.

Vaccine hesitancy can be broadly defined as having “concerns about the safety and/or necessity of vaccines.” These concerns often give parents significant pause when deciding whether to have their child vaccinated, and can lead to vaccine refusal or delay.

Vaccine hesitancy has been rising steadily over the last several years, with the proportion of parents with concerns about vaccines increasing from 19 percent to 50 percent between 2000 and 2010.  Similarly, the number of non-medical vaccination exemptions (i.e. those for religious or philosophical reasons) for school-required vaccines has also increase steadily during this time, while medically based exemptions have remained stable.

When looking at vaccine hesitancy across the U.S., one piece of good news is that the proportion of parents who refuse ALL vaccines for their child has been consistently low at 1 to 2 percent for the last several years.  Far more commonly, vaccine hesitancy manifests as one of two scenarios: 1) parents have a vague sense of unease about vaccines in general (Are they safe?  Does my child REALLY need them?  Aren’t we going to “overwhelm” my child’s immune system?), or 2) parents agree to vaccination in general, but with strong hesitations for one or more specific vaccines (for example, those who say, “Sure, I’ll get all the vaccines – except the flu”).

Among the nearly 50 percent of U.S. parents with some degree of vaccine hesitancy, it is the “fence-sitters” (i.e. those who DO follow the recommended vaccination schedule, but with reservations), that may be the most significant group when it comes to how their action (or inaction) affects public health.

A recent study showed that among fence-sitting parents, about one in four do not believe that the recommended vaccine schedule is either the safest or best schedule to use.  This indicates to me that the problem of vaccine hesitancy and subsequent vaccine refusal and delay is likely to get worse with time.

I think we can all agree that all parents strive to do what is best for their children. From my standpoint as a parent AND a doctor, vaccines are a “no brainer” – tons of benefit and little to no risk.  So why the vaccine hesitancy problem?

A primary reason is that most people make decisions via heuristics (i.e. their “gut feeling”) rather than rationalization.

This is problematic because heuristic decisions are particularly sensitive to recall bias and personal experience. For example, the “representativeness heuristic” means that when people are faced with an unknown risk they look for similarities in their surroundings to estimate that risk.

Using this heuristic, a parent who feels unsure about whether it is “worth it” to get the flu vaccine for her daughter may note that a friend’s daughter became sick after her flu vaccine.  Because the mother and daughter share many similarities with the friend and her daughter, the mother concludes that her daughter will also get sick after getting the flu vaccine, so she refuses.

The “availability heuristic” describes how a person judges the probability that an event will occur based on the ease with which examples of that event come to mind. This helps to explain why parents who are inundated with the media’s scare stories about how vaccines “cause” autism, seizures and a variety of other health problems easily conclude that these problems are a common side effect to vaccination.

When faced with these heuristic biases, facts, figures and rational arguments may do little to make vaccine hesitant parents feel at ease.

So what can we do then?

We are increasingly seeing the public health impacts of this steady rise in vaccine hesitancy.  Widespread outbreaks of several diseases like measles, hemophilus meningitis, and pertussis are occurring more and more frequently, fueled in large part by those who are unimmunized or under-immunized.

However, because no vaccine is 100 percent effective, even those fully vaccinated are at risk during these outbreaks.

Though I would never wish anyone sickness, a small part of me wonders what would happen if one of these outbreaks affected someone famous.  Ideally, it would be someone with enough “street cred” to meaningfully connect with today’s parents, and also willing to step up to the plate and speak out nationally about the experience and why childhood vaccination is so important.

Given the way things are going, it seems like only matter of time before something like this happens.

Until then, we all need to be immunization champions in our own way. This means getting ourselves and our own kids vaccinated, promoting the benefits of vaccination to others, cracking down on media that promulgate stories that unnecessarily scare the public, enforcing compliance with school-mandated vaccines, and looking for opportunities to push the policy agenda to minimize the ease with which a religious or philosophical exemptions can be obtained.

For me, the issue has  become deeply personal. I just found out my best friend’s daughter has leukemia. Her treatment will wipe out all the prior benefit she received from her childhood vaccines and her weakened immune system will put her at very high risk for getting infected with vaccine preventable diseases.

I am already trying to plant the seed with her parents to make sure that ALL of her visitors and caretakers are fully vaccinated.   However, that will only go so far.

I can only hope and pray that she doesn’t encounter Danny, or someone like him, when she leaves the house.

Dr. Amanda Dempsey is an associate professor of pediatrics at the University of Colorado School of Medicine. She graduated from the  University of Rochester in 1991 and earned her doctorate at Vanderbilt University in 2000. Dempsey’s areas of interest include immunization delivery, vaccine refusal, human papillomavirus and mathematical modeling.

By Katie Kerwin McCrimmon

Colorado’s whooping cough epidemic has now triggered 1,090 cases of the highly contagious disease, making 2012 the worst year for the disease since 2005 when the state recorded 1,383 cases.

Other states that have declared epidemics are Washington and Wisconsin. In 2010, 10 babies died in California from an outbreak there.

So far, no one has died from the illness this year in Colorado, but Dr. Rachel Herlihy of the Colorado Department of Public Health and Environment, said there have been several close calls with infants who often get the most severe cases of the disease.

“We’ve had a large number of cases with infants and some close calls with infants who have had to be on respirators,” said Herlihy, director of the state health department’s immunization section.

Herlihy urged parents and people who work around children to get vaccinated and to make sure both young children and adolescents are up to date on their immunizations for the disease, which is also called pertussis.

“It’s especially important for those who have contact with young children who are more vulnerable to whooping cough. Child care workers, health care workers, parents, grandparents and siblings of young children should all make sure they are up to date on their whooping cough vaccinations,” Herlihy said.

All adults should receive the whooping cough booster vaccine, which is called Tdap, but few have received it, or even know they should get it, Herlihy said. There is no lifetime protection against whooping cough. People can get it more than once and the vaccine wanes over time.

Some families in Colorado choose not to vaccinate their babies. Boulder and Broomfield counties have the highest rates of pertussis right now and Boulder is frequently cited as one of the national hotspots for people who refuse vaccines.

While some unvaccinated children are spreading the disease, it also seems to be striking some older children whose vaccinations may be wearing off early.

Herlihy said infected children also may be returning to day care or school too soon and also could be continuing to spread whooping cough.

“You are supposed to isolate yourself for a full five days of antibiotics. Unfortunately, we’re seeing kids who are going back to school too soon and they are continuing to spread the infection,” Herlihy said.

The telltale sign of the disease is a persistent cough that won’t go away. Herlihy said that in China, the disease is called the “100-day illness.” Anyone who has a family member who is experiencing a long-lasting illness with a cough should call or visit a doctor.

Infants under six months are too young to have received all the vaccine doses necessary to protect them from pertussis. So, it’s critical for people who live and work around them to be immunized.

The Tdap vaccine is recommended for the following groups:

• Pregnant women in the third or late-second trimester
• Parents of infants under 12 months of age.
• Caregivers of infants, including grandparents, babysitters and child care workers.
• Health care workers
• Others who plan on having close contact with an infant
• All adults need a tetanus booster if they have previously not received Tdap

Pertussis is a bacterial infection of the respiratory tract that can easily spread through the air when an infected person coughs or sneezes. The illness often starts with cold-like symptoms, including sneezing, a runny nose and a mild cough. Often there is no fever or just a low-grade fever. The cough becomes more severe during the first week or two and people who are ill can have coughing fits, followed by a high-pitched “whoop” or a coughing fit so severe that the person vomits. The cough may last for a couple of months and is more frequent at night.

Since symptoms in adults and adolescents can be relatively mild, individuals may not realize they have pertussis and can easily spread it to others. Young infants with pertussis often do not have a cough but gasp or struggle to breathe.

For more information on pertussis, click here. 

For more information on immunizations, click here.

By Michele Lueck

As the Colorado Health Institute observes its 10^th anniversary this year, we are spending a bit of time looking back but much more time thinking about the future of health care in our state.

CHI was founded in 2002 to address a gap in sound health policy data and analysis, particularly independent and impartial information. Today, the need for reliable data and research has never been greater as leaders in the public, private and nonprofit sectors work to transform Colorado’s health care system – an increasingly costly system that isn’t working as well as it should for nearly anybody.

This is a time of extraordinary change in health care. Most people are familiar with the revisions in the Affordable Care Act. But many may not realize the level of innovation that is underway in Colorado regardless of changes in the law, particularly collaborative efforts that would have been unthinkable even a decade ago.

Most of these projects are working toward three common goals – improving how patients experience the health care system, increasing the health of all Coloradans, and reducing the per-capita cost of health care by making it more efficient and effective. Meanwhile, there’s widespread recognition that stronger preventive health for individuals and better overall health for our communities will be important components of successful change.

With that in mind, here are CHI’s top five Colorado health care trends heading into 2013 – and CHI’s second decade:

1.    More public-private partnerships

Dozens of health care collaborations are being tested in Colorado, with private insurance payers, health care organizations and clinicians, among others, joining with public programs such as Medicare and Medicaid to try new ideas. It’s tough work that calls for fundamentally rethinking how health care is delivered, how it’s paid for and how to make it more transparent, especially for patients. The bottom line of these collaborations is a sharing of the risks and the rewards. One unique initiative to keep an eye on: The Colorado Comprehensive Primary Care Initiative is bringing public and private insurers together to expand comprehensive primary care and the medical home model in 73 primary care practices across Colorado.

2.    Integrating all aspects of patient care

Moving from a scattered, fragmented system to one that integrates every part of a patient’s care, including primary care, specialty care, oral health and behavioral health, is a top priority.  The Colorado Department of Health Care Policy and Financing is conducting a pilot program that has the potential to be a transformative model.  The Accountable Care Collaborative divides the state into seven regions and challenges regional coordinators to enroll Medicaid clients in “medical homes” that oversee and integrate their care. Nearly 150,000 Coloradans are in the ACC project, with an anticipated 200,000 set to be signed up soon. Early results looking at whether the program can lower expensive emergency room visits and hospital stays are encouraging. Meanwhile, Colorado tapped leaders across the state to help draft an application for a competitive State Innovation Models grant that would further support these ground-breaking efforts.

3.    A Colorado flavor of payment reform

State lawmakers approved a bill in the 2012 session that sets the stage to experiment with different payment models in the Medicaid pilot program, allowing for a move away from the traditional fee-for-service payment system to variations of a global payment system that would reward caregivers for providing more efficient, integrated care. This was a bipartisan effort that continues the creative and forward-looking work by Colorado’s legislators related to health reform. Stay tuned.

4.    Big questions for small employers

Colorado employers with the largest part-time work forces face important questions in 2013 as they prepare to comply with health insurance requirements. Beginning in 2014, most large employers must provide coverage for employees working 30 hours or more each week or face penalties.  In Colorado, most of these businesses are in the retail and hospitality industry. Looking at significant new expenses, CHI anticipates that many of these businesses will consider curtailing worker hours.

5.    A steep learning curve: purchasing insurance

We’re heading into a brave new health insurance world. There will be many options for purchasing coverage – the Small-Employer (SHOP) Exchange, the Individual Exchange, private exchanges, the broker market. There will be myriad choices as well – basic health plans, gold plans, silver plans, bronze plans. The good news is that there should be more transparency, making comparisons easier. But it will be a new frontier, and CHI expects that there will be confusion and anxiety as change kicks in.

CHI also recognizes that policies and decisions made in Colorado affect real people, about 5 million of our fellow Coloradans. With that in mind, CHI is marking its anniversary with the publication of a photo book titled “Colorado: A Picture of Health.”

The book shows Coloradans on the front lines of health care – providers, patients, educators, students, volunteers and community health advocates. It covers the state from Montrose to Las Animas, from inner city Denver to the San Luis Valley. And it depicts all ages, from a minutes-old baby to seniors working to stay healthy and vibrant.

This book is a gift back to the community for its support of CHI over the past 10 years.

Today, CHI is a trusted source of health care data, information, evidence and analysis for a wide range of Coloradans, including policymakers on the local, county, regional and state levels, policy and advocacy groups, businesses and organizations providing health care, public and private health care payers, educators, journalists and interested citizens.

Our mission is to help make Colorado – and all Coloradans – healthier.

Contact Brian Clark at clarkb@coloradohealthinsitute.org for a copy of the book. Or view it online at http://www.coloradohealthinstitute.org/blog/detail/chi-releases-photo-book-to-mark-10-years.

Michele Lueck is president and CEO of the Colorado Health Institute. She joined the organization in November 2010, bringing nearly 20 years of health and health care experience. Her work ranges from consulting with leading academic organizations to serving rural health care providers.  Her expertise in strategic communications informs the current work and direction of CHI.

By Katie Kerwin McCrimmon

Doctors from Children’s Hospital Colorado and the Colorado chapter of the American Academy of Pediatrics have warned about dangers of marijuana, saying it can be laced with other drugs, is tied to crime and that the increasing popularity of edible marijuana has led to poisonings among infants and children.

“We’re hearing youth say it’s medicine and there’s nothing wrong with it. The message we want to give is that marijuana has risks to health and to our youth and our children,” said Dr. Kathryn Wells, a pediatrician specializing in child abuse and president of the Colorado chapter of the American Academy of Pediatrics.

Proponents of an initiative to legalize marijuana have garnered support from other doctors who cite the dangers of continuing a war on drugs that has many casualties as well.

“We are not making any kind of argument to suggest that marijuana is without harm,” said Betty Aldworth, advocacy director for the Campaign to Regulate Marijuana Like Alcohol. “What the physicians who have joined us in support of Amendment 64 agree with is that the war on marijuana…is much more harmful to our families and our communities than marijuana itself.”

Early voting has begun and Amendment 64, which would legalize marijuana for adults in Colorado, is among the most hotly contested measures on the Nov. 6 ballot.

At Children’s Hospital, spokeswoman Elizabeth Whitehead said the hospital’s chronic pain clinic has seen a spike in the number of inquiries from families regarding use of marijuana for pain in children.

Pain experts at Children’s last year prepared a handout titled “Marijuana and Chronic Pain.”  It warned that while marijuana is billed as natural, it can be laced with “crack cocaine, PCP and embalming fluid,” can cause depression, can be addictive and is tied to crime with “40 percent of adult males arrested test(ing) positive for marijuana usage.”

The fact sheet warns patients to level with their doctors about all substances they are using and says parents who give their children marijuana can face criminal prosecution.

“It is illegal to give one’s medical marijuana to another person, even if it is a parent giving it to their own child,” the document said. “Giving your child marijuana could be considered a reportable offense to Child Protective Services.”

While the document that Solutions obtained says it was approved by the hospital’s Patient Family Education Committee in 2011, Whitehead says it was a draft and that the document has not been posted externally or shared with patients.

“Children’s Hospital Colorado does not have a position on the legalization of marijuana or whether medical marijuana should be available, as prescribing is a clinical decision made between the physician and the patient,” Whitehead said in a written statement.

Other health professionals have been sparring this month over the potential hazards of marijuana, especially as use relates to children and teens. Marijuana use by minors would remain illegal, regardless of the outcome in the voting on Amendment 64.

An investigation earlier this year by Solutions, Education News Colorado and the I-News Network found that drug violations in Colorado’s K-12 schools have increased 45 percent in the past four years. School officials said they are under siege as medical marijuana shops have proliferated throughout Colorado and students now have easy access to high quality, cheaper, more potent marijuana. Industry officials say students can’t get marijuana from medical marijuana facilities and that use among Colorado teens has declined rather than increased.

A group of physicians from the Colorado Chapter of the American Academy of Pediatrics released a letter earlier this month outlining the dangers of marijuana use. Their concerns included:

• Accidental marijuana ingestion.  Between October 2009 and December 2011, 14 children between the ages of 8 months and 12 years were seen for accidental ingestion at Children’s Colorado. Of these children, nine had to be hospitalized and two were admitted to the intensive care unit. In contrast from 2005 to 2009, Children’s did not have any patients who had ingested marijuana.
• Impacts of marijuana on the teen brain. Studies have found that chronic use of marijuana before age 15 leads to worse neurocognitive functioning, or the ability to think and reason, later in life.
• Increased risk for use of other illegal drugs.

Because marijuana has been sold as “medicine,” children and teens in Colorado wrongly believe that it is safe and healthy, said Dr. Wells of the American Academy of Pediatrics.

She said that the AAP nationally has a statement related to the dangers of using marijuana, but that local doctors wanted to weigh in because they’ve seen an increase in hazards in Colorado, including accidental ingestion.

“The medical risks of (marijuana) ingestion can range from being sleepy all the way to potentially have to be on a respirator,” Wells said.

Aldworth, the spokeswoman for the proponents of 64, said parents are the problem when children ingest marijuana.

“Just like any other product that we don’t want youth to get their hands on, parents need to be responsible for ensuring that they are storing marijuana products in a  safe manner and keeping it out of the hands of kids,” Aldworth said.

In addition to the dangers of edibles, Wells and her colleagues warned of the risks of children being exposed to smoke and harming their brains. As a specialist on abuse, Wells also said potential harm to children increases when parents are under the influence of alcohol and drugs, including marijuana.

“Child abuse pediatricians are concerned about someone who is under the influence trying to parent. It’s actually quite common that a child becomes injured because a parent is neglecting them while under the influence of drugs or alcohol,” said Wells.

On the other side, proponents of Amendment 64 held a press conference this month and touted support from 300 Colorado physicians including Dr. Larry Bedard, former president of the American College of Emergency Physicians; Dr. Bruce Madison, former associated medical director of the faculty at the University of Colorado School of Medicine; and Dr. Christopher Unrein, past president of the Colorado Medical Society.

Bedard said alcohol causes significantly more harm than marijuana and it’s time to decriminalize use of the drug.

“In my 35-plus years as an emergency physician, I saw hundreds of injuries, accidents, and deaths due to alcohol, but virtually none associated with marijuana. It is time to embrace a more commonsense policy, and stop criminalizing adults for using a substance less harmful than alcohol,” he said in a written statement.

Madison said the war on drugs has failed. 


“As physicians we have a professional obligation to do no harm. But the truth is that the Colorado marijuana laws do just that, by wasting hundreds of millions of dollars in a failed War on Marijuana, by ruining thousands of lives by unnecessary arrest and incarceration, and by causing the deaths of hundreds of people killed in black-market criminal activities.”

By Courtney Law

After 2 1/2 years as the law of the land, Obamacare has benefited millions of Americans and will benefit millions more as the law becomes fully implemented.

The idea behind the Patient Protection and Affordable Care Act, also known as Obamacare, is that no Americans should have to go into debt because they need health care.  President Obama’s health care law expands access to the care Americans need and lowers its cost.

The heart of the law is to hold insurance companies accountable by prohibiting them from cutting off coverage for people with pre-existing conditions.

For years, insurance companies could drop your coverage if you were diagnosed with cancer or diabetes, if your toddler developed asthma or if your husband hurt his back.  But now, parents of children who have pre-existing conditions can rest assured that their children won’t lose their ability to see their doctor or to fill a prescription when they need it.  In 2014, that rule will apply to everybody.

This provision alone represents a dramatic shift in how citizens access health care.But there’s more.

In this economy, young people are struggling to find work that offers health benefits, or in some cases they struggle to find work at all.  Under the Affordable Care Act, Americans under age 26 can remain on their parents’ insurance plans.  Over 3 million young people across the country have taken advantage of this provision.  In Colorado, 50,000 young people have coverage now that was not available to them before Obamacare.

Under the health care law, Colorado seniors on Medicare have saved an average of nearly $700 on their prescription drugs, and almost 400,000 Colorado seniors have received a free preventive care service, such as a mammogram, flu shot, wellness exam, cancer screening, bone density measurement or other service.

Obamacare gives power back to consumers.

The law requires insurance companies to justify rate increases, gives you the right to repeal a denied claim, phases out annual and lifetime limits on your coverage, and forces insurance companies to spend at least 80 percent of your premiums on providing care — not on marketing or bonuses.

When health insurance exchanges are implemented in states by 2014, all of us will have the same insurance options as members of Congress.  These marketplaces will allow individuals and small businesses to compare rates and find plans that work for them or their employees.

By providing small businesses the same purchasing power as large corporations and increasing competition among providers, Americans will have greater control over their health care and will see overall costs driven down.

Gov. Romney has stated on multiple occasions that his health care law in Massachusetts is a model for the nation.  In fact, it was a model for Obamacare.

Regardless, he has vowed to repeal Obamacare on Day One of a Romney presidency, yet can’t give a clear answer on what he’ll to do address the issue of 50 million to 122 million Americans with pre-existing conditions who once again would be at the mercy of insurance companies.

On a visit to Colorado he even stated that it could take up to 10 years to figure out a way to address that issue.  He and his running mate U.S. Rep. Paul Ryan also have proposed a plan to privatize Medicare, which would cost seniors thousands more in out-of-pocket expenses.

Their health care promises would hurt Americans.

President Obama’s health care law gives Americans more choice, more protections and more access to the care they need.  It has given millions of Americans greater peace of mind and has fundamentally changed our health care system for the better.

Courtney Law is spokeswoman for Protect Your Care.

Opinions communicated in Solutions represent the view of individual authors, and may not reflect the position of the University of Colorado Denver or the University of Colorado system.

By Linda Gorman

The Obama Administration’s health law assumes that U.S. health care system problems occur because patients and providers have too much freedom. In contrast, Gov. Romney’s proposed reforms recognize that 70 years of regulatory accretion has compromised the ability of the system to adjust to dramatic demographic, economic and technological change.

In short, the problem is too much of the wrong kind of regulation rather than too little.

Gov. Romney says that he would increase choice and competition, reduce wasteful spending by equalizing the tax treatment of individually-purchased and employer-provided health plans, and rescue Medicare by replacing the Obama Administration’s Medicare cuts with premium support. He would also cure Medicaid’s dysfunctional spending incentives by using block grants that would better serve the poor and sick by freeing states to design innovative programs that fit their populations.

A major flaw of the President’s reforms is that they require virtually everyone to join a coverage plan that purchases health care for them with other people’s money. Current estimates suggest that President Obama’s emphasis on third-party payments will increase federal health spending by a minimum of $1.7 trillion in the next decade, will raise taxes by more than $1.2 trillion, and will increase the cost of individual insurance in Colorado by 19 percent in 4 years.

Most of the new revenues will be taken from individuals and businesses that currently use them to fund new jobs and innovation.

People who buy medical care with their own money spend more wisely than those who buy medical care with other people’s money. They often negotiate prices that are up to a third lower than those paid by either Medicare or private insurance networks.

One reason Americans spend so much on health care is that less than 12 percent of U.S. health spending is in cash, the third-lowest fraction in among the industrialized countries. Requiring everyone to use health coverage to pay for routine expenses is the most expensive possible way to purchase health care. If, for example, one buys eyeglasses using health insurance, one must pay both the price of the eyeglasses and the cost of the insurer’s overhead.

Gov. Romney would encourage people to purchase a larger share of their health care with their own money. One way to do this to end the preferential tax treatment of employer provided health plans.

A result of World War II price controls that exempted medical expenses paid for by employer coverage plans from taxation, the employer insurance tax preference is unfair to those who use after-tax money to purchase their own health insurance.

The tax preference fosters a “use it or lose it” mentality and encourages the provision of “free” services for everything from major medical events to routine doctor visits in employer health plans.By making individual coverage relatively expensive, it sets people up to lose their coverage if they lose their jobs, leave their jobs or become too sick to work.

Existing evidence suggests that eliminating the preference may result in a more rapid spread of individually owned policies that promote cash payment, reduce system overhead, provide better health security and lower costs.

For Medicare reform, the choice is between an orderly change or a traumatic one.

In 2011, total income from Medicare payroll taxes, premiums and other dedicated revenues was $530 billion, about 3.7 percent of GDP. Total Medicare expenditures were $549 billion. Although the Medicare balance sheet reports $344 billion in assets that can be used to make up the difference, the “assets” are simply claims on the remaining tax revenues in the U.S. Treasury general fund.

President Obama has opted for traumatic change. His plan cuts physician reimbursement rates by 31 percent in 2013. The Medicare Trustees say that along with other reimbursement cuts, this will bankrupt 15 percent of hospitals and nursing homes by 2019.

Though Medicare benefits theoretically remain the same, no reasonable person believes that access and quality can be preserved with cuts of this magnitude. Against a backdrop of hidden rationing and price controls, Obama’s reforms also make government the judge of who lives and who dies because it controls the purse strings and defines acceptable medical treatment.

Gov. Romney proposes orderly Medicare reform that would transition the program to premium support. The goal is to reduce costs and expenditures by rewarding Medicare recipients for finding ways to reduce their health spending, by encouraging innovation and by eliminating the need for large swathes of the Medicare bureaucracy.

Applied only to those at least a decade away from retirement, the government would invite insurers to bid on the provision of a package of Medicare benefits. It would pick one of the bids as the amount that will be given to every Medicare beneficiary to purchase health insurance from approved plans. People who wish to purchase more expensive plans are free to do so. People who wish to spend less may keep the difference.

Medicare Part D was a trial run for premium support financing. It is the only major government health program for which real spending has been lower than initially projected.

Gov. Romney models his Medicaid reform proposal after the successful TAANF reform for federal welfare programs. With block grants, states would no longer be paid to maximize their Medicaid spending. Instead, they would receive a fixed sum of money and be encouraged to design innovative programs to care for those who are in need.

President Obama’s law leaves Medicaid’s dysfunctional spending incentives in place. He had planned to expand Medicaid by an estimated 17 to 20 million people, paying for it by commanding states to expand the program or lose all of their Medicaid funding. Going forward, he has not so far advanced any coherent plan for Medicaid reform.

Linda Gorman is the director of the Health Care Policy Center for the Independence Institute in Denver.