Health Policy Solutions

By Kevin Vaughan

I-News Network

Tragedies like those at Columbine and Aurora drive the public debate about guns, but the truth in Colorado is that the state experienced an unremitting loss of life involving firearms – 6,258 deaths – over the 12 years between those mass shootings.

That’s 10 gun deaths a week – every week – during that span.

And the area that experienced the most gun deaths from 2000 through 2011 was not a gang-weary section of Denver or Aurora but a southeast Colorado Springs neighborhood of 1960s tract homes, apartments and schools where postcard-perfect views of Pikes Peak frame the skyline, an I-News analysis of health and census data found.

The area is designated by the federal government as Census Tract 54.00, one of 1,249 geographically distinct districts in the state. And from 2000 through 2011, 24 of its residents died of gunshot wounds.

The next deadliest census tract, with 20 deaths, was located in Grand Junction, and another in Denver had 19, I-News found. Five of the top six neighborhoods for gun homicides were in the Denver or Aurora, while the top four neighborhoods for gun suicides were in Grand Junction, Montrose or Mesa County.

Over that span, 76 percent of the state’s gun deaths were suicides, 20 percent homicides.

“It is a public health issue,” said state Rep. Rhonda Fields, D-Aurora, and the mother of a son taken by gunfire. “We pay for it in the end. Society – we pay for the medical treatment, the loss of productivity. It’s a ripple effect. When someone gets murdered or harmed by gun violence, it affects the family, it affects the community – not just that one person.”

The death toll for residents of Census Tract 54.00, part of the Colorado Springs neighborhood known as Pikes Peak Park, included 12 homicides and 12 suicides. That made it an anomaly among the deadliest neighborhoods in that it had as many homicides as suicides.

The second deadliest tract, in Grand Junction, had 17 suicides and three homicides. The tract in Denver’s Platte Park area that experienced 19 deaths had 10 suicides, eight homicides and one classified as “other” – a police shooting, accident or undetermined fatality.

Four other tracts had 17 gun deaths during the 12-year span – three in Grand Junction, Montrose and Teller County driven by suicides and one in Denver’s Montbello neighborhood driven by homicides.

The I-News investigation of Colorado’s shooting deaths found a strong relationship between poverty and firearms homicides – and no discernible link between being poor and gun suicides.

For example, the average poverty rate in 656 census tracts with no gun homicides was 10 percent. It jumped to 16 percent in neighborhoods with at least one gun homicide, to 22 percent in tracts with at least three, and to 24 percent in areas with at least four.

It was vastly different with suicides: The average poverty rate fluctuated around 12.7 percent in neighborhoods with no gun suicides and up to and including those with four or more.

In that way, Census Tract 54.00 fell in line with homicide statistics and bucked suicide statistics.

The area, developed in the 1960s, includes ranch and multi-level suburban homes, apartment complexes, a commercial district and four schools. And its 5,615 residents face serious socio-economic challenges. The median family income was $29,313 in 2010, according to the U.S. Census Bureau – down significantly from 1980, when median family income was the equivalent of $40,010 in today’s dollars. More than 20 percent of families – and nearly 44 percent of children – live in poverty.

The Colorado Department of Public Health and Environment data included the census tract where each victim lived but, because death certificates are not public, not the identities of those who died. I-News was able to identify many using police, court and coroner’s records and other public documents.

The loss of life in Census Tract 54.00 was a mosaic: A father who shot his teenage son while trying to teach him gun safety. A gangland slaying. Solitary suicides. A jealous former boyfriend who fired blindly through a door. Four domestic violence murder-suicides. And an utterly random shooting carried out by a Fort Carson-based U.S. Army soldier.

“Some of them, they are domestic related and they are very personal, to the very random or motivated through drugs or through property crimes or through any number of things,” said Colorado Springs police Cmdr. Kirk Wilson, whose division includes Census Tract 54.00. “There is no pattern, if you will, for why some of these homicides take place.”

Poverty, drugs and guns

Joy Kelly-Blackwell, whose sister, Leslie Brown, was murdered in 2004 by a former boyfriend, grew up in south Colorado Springs and has a sober view of life there.

“Where there’s poverty, there’s drugs – drugs and alcohol,” she said. “Where there’s drugs and alcohol, there will be guns. Therefore there will be crime.”

Poverty and guns are definitely a part of life in Pikes Peak Park – and it is nothing new.

“These children were at war,” said Rich Caruth, who managed an apartment complex in the neighborhood for years and initiated an anti-gang program. “When they’d go outside their house, they had to worry about a drive-by shooting. They had to worry about being robbed and losing their tennis shoes.”

But the neighborhood’s problems aren’t only economic. Transience is a way of life – an I-News examination of property records found that nearly 30 percent of the 1,181 single-family homes are rentals, and the neighborhood includes 772 apartment units and 131 townhome and condominium units.

People come and go often, tearing at the sense of “community” – the perception of belonging to a place and caring about it.

Katherine Giuffre, chair of the sociology department at Colorado College in Colorado Springs, knows transience – she lives next to a rental home, where tenants have come and gone every three months or four months for 17 years.

“I don’t even bother to know who they are because they’ll be out soon,” Giuffre said. “I’m not baking a banana bread and going over there.”

Poverty, transience and neighborhood violence confront the teachers and administrators at the four public schools in the tract – Centennial, Monterey and Pikes Peak elementary schools and Carmel Middle. There, the percentage of students eligible for free or reduced lunch is high – 81.5 at Carmel, 87.1 at Monterey, 90.5 at Centennial, 90.6 at Pikes Peak. The vast majority qualify for free lunches, meaning family income in the 2011-12 school year totaled $29,055 or less for a family of four.

Wendy Birhanzel, Centennial’s principal, and other educators in the area’s schools have a simple goal: Remove the obstacles between students and success. That means making sure they have backpacks and jackets, or even taking up a collection to help a family pay its utility bill.

It also means monthly events – like “Science Night” or “Movie Night” – aimed at building relationship with families.

And while data shos that the schools are safe places, they can’t escape the neighborhood around them. This spring, a student’s father was shot to death.

“That is reality,” Birhanzel said. “Homicides and shootings are not just happening to people we don’t know.”

Multifaceted solutions

Against that backdrop, thoughts on addressing gun deaths vary.

“We have all these laws and proposals and whatever to try and handle what’s happening,” said Dr. Manish Sethi, an orthopedic trauma surgeon at Vanderbilt University Medical Center in Tennessee who frequently operates on gunshot victims. “And I just feel like we need community solutions.”

So he and a colleague won a small grant for a pilot program that teaches conflict resolution strategies in schools. The initial results were encouraging, and now they are seeking money to extend the program to 10 schools.

“Some of these children, once these things happen to them, their lives are over,” said Sethi, who has lectured on gun violence. “They’re done, and the world that they knew is gone.”

Rep. Fields applauded that kind of work. But she also touted new laws – she sponsored a measure extending background checks to private gun sales.

“I would agree that legislation is not the sole avenue … but I do think that legislation is one tool to help us address those that use guns when they’re committing crimes, and how they go about purchasing their guns, and how we regulate guns,” Fields said.

I-News senior reporter Burt Hubbard contributed data analysis and additional reporting. To read the narrative version of this story and to see additional components please go to inewsnetwork.org. Contact Kevin Vaughan at 303-446-4936 or kvaughan@inewsnetwork.org.

By Katie Kerwin McCrimmon

Coloradans hunting for health insurance will have 19 companies competing for their business with up to 1,000 different plans that could be offered through the state’s new health exchange and on the open market.

Starting in 2014, for the first time, insurance companies selling to individuals won’t be able to exclude people with pre-existing health conditions. That’s one of the reasons consumers and competitors are eagerly awaiting plan details and costs, which Colorado authorities plan to unveil Wednesday.

For now, Colorados Commissioner of Insurance Jim Riesberg says he’s pleasantly surprised that 19 health insurance companies want to vie for business here.

“It’s a rather significant number, which should mean we’re going to have good competition in Colorado,” Riesberg said on Thursday.

Commissioner of Insurance Jim Riesberg said he’s pleasantly surprised that 19 companies want to offer about 1,000 new health insurance plans in Colorado.

Riesberg said he had expected about a dozen companies to offer plans in Colorado.

The deadline for health insurance companies to notify regulators that they wanted to sell plans in Colorado was midnight Wednesday. Riesberg and a beefed-up staff of rate reviewers are now analyzing the proposals and plan to make the proposals public on May 22. He declined to name the companies until next week.

The plans won’t be approved or rejected until July 31. Then, potential customers will be able to start shopping for them on October 1 when Colorado’s new health exchange, an online marketplace called Connect for Health Colorado, is slated to open.

Riesberg did not yet have a sense of whether there will be “rate shock” over the prices for the new plans. He urged caution about reading too much into the numbers when they become public next week.

In part that’s because the plans feature a “base rate.” Many lower-income people will qualify for tax subsidies that will bring their rates down from that base price. Other customers may have to pay more than the base rate since insurance companies are allowed to charge higher rates to smokers, older people, those living in certain geographic areas and based on family size.

“The base rates are not what the ending prices are going to be,” Riesberg said.

Consumers will also be able to select from plans that offer varying levels of coverage for a package of “essential benefits” that all companies must provide.

“There may be rate shock or may not be rate shock,” Riesberg said. Regardless, “the essential health benefits (package) is a fairly rich package. It’s a very good policy. You get what you pay for.

“Putting too much emphasis on prices early on is going to muddle the decision-making. People can’t even begin to purchase plans until October. And they can’t find out what their subsidies are going to be until then,” Riesberg said.

Analysts with the Division of Insurance will review all the proposed plans to ensure that the prices are not too high or too low (which could mean that a company cannot fulfill its obligations) and that insurers are not discriminating against anyone.

Pricing will be a gamble for all the companies.

“We’re in a brand new marketplace,” Riesberg said. “Within the individual market, no one has ever had to do this before (accept all those with pre-existing conditions),” Riesberg said.

It’s unclear how many people will want to buy insurance, and how many will have gone without health care for years and may have pent-up needs.

“They may want every (medical) test under the sun,” Riesberg said. “It’s just a guess as to what the trend is going to be.”

Or, there could be less demand than anticipated if some of the estimated half-million uninsured people expected to buy through the exchange decide not to buy health insurance and pay federal fines instead.

Learning about the new proposed plans and their pricing is one of many puzzle pieces that must fall into place as the Affordable Care Act begins to be full implemented in 2014.

“This is a first step in a process of crafting a whole new marketplace,” Riesberg said. “In the individual marketplace, it’s a whole way of doing business not only for the consumers, but also for the (insurance companies.)”

Riesberg said he previously had concerns that the federal data HUB would not be ready by this fall. States like Colorado that are building their own health exchanges must be able to connect with the HUB in real time to determine if consumers qualify for tax subsidies. Recently, Riesberg said he’s become more confident that all the pieces of the puzzle will fall into place.

“Any time you have something brand new, there could be a hiccup,” he said. “But I think we’re setting the stage for some very exciting times for people to begin to take more personal responsibility for their health care decisions and as a result of that, building a healthier society.”

By Katie Kerwin McCrimmon

Hovering at just over 4 feet 5 inches, the Broomfield second-grader is a smidge short for the NBA.

But that’s not stopping Caleb Nolan from planning his career as a basketball star and neither is his cystic fibrosis (CF).

Diagnosed at birth with the rare disease, Caleb receives regular care at Children’s Hospital Colorado and happily plays basketball, soccer, baseball and football. Aside from licking salt on the sidelines to thwart dehydration, he’s like any of the other boys on his team.

And thanks to a new medication called Kalydeco that has been fast-tracked to market, Caleb’s lungs are in excellent shape and his future is very bright.

Just decades ago, children born with CF had a bleak outlook and could hope to live only into their teens. Doctors could do little to help them except to treat the frequent infections that attacked and damaged their lungs. Now the official life expectancy for Caleb and kids like him is 37 and Caleb’s doctor expects that number to keep going up.

On Friday, Caleb got the chance to meet Sen. Michael Bennet, the Colorado Democrat who supported the legislation in Congress that is helping drugs like Kalydeco get to patients faster.

Kalydeco received approval last year and has now been designated as a “breakthrough therapy.” This faster pathway for drugs to make it to market is based on a provision that Bennet wrote and that Congress approved last July as part of the FDA Safety and Innovation Act.

“It’s been making a big difference. It’s been helping me a lot by clearing out my lungs,” Caleb said of Kalydeco, one of about 25 pills he takes each day. “I get sick less with Kalydeco. I sometimes don’t even notice I have CF.”

Nolan chatted and joked with Bennet, giving the Senator a hard time when he said that he believes kids should have to go to summer school “all summer long.”

“But I can’t get anybody else to agree with me,” Bennet confided.

“Yeah, I don’t agree with you either,” Nolan said.

“Neither do my daughters,” said Bennet, the former superintendent of the Denver Public Schools.

Charmed by Nolan’s candor, Bennet said the trip to Children’s Hospital Colorado was a refreshing change from the gridlock on Capitol Hill. Seeing the results of the new legislation and meeting Nolan marked one of his favorite days since joining the Senate in 2009.

“This is easily one of the highlights of the last four years,” Bennet said as the 7-year-old schooled him on CF treatments, hoops and his dislike for spelling and vocabulary tests.

Bennet said that speeding safe and successful drugs to market makes sense for both patients and drug developers.

“Essentially what this legislation did was say that if you are finding drugs and they show exceptional results for patients, for heaven’s sake, we should get them to market (faster). There ought to be a priority for those kinds of drugs,” Bennet said.

He said Colorado is home to about 600 bioscience firms and that he’s trying to do all he can to speed the approval of promising drugs. He said it’s getting harder and harder for bioscience firms to attract venture capital since drug approval can take as long as 15 years. In the case of drugs that receive breakthrough designation, approval can come in as few as three to five years.

“Most importantly, it makes a huge difference for patients,” Bennet said. “The rollout has been faster than I expected.”

Kalydeco has been shown to be effective for a small percentage of CF patients who, like Caleb, have a specific gene mutation. But there’s great hope that in the future, the drug can be paired with other new drugs to help a much higher percentage of people with CF.

Children’s Hospital Colorado houses the largest CF clinical care center in the U.S., with more than 500 young patients. Caleb was originally diagnosed with CF as a newborn because Dr. Frank Accurso, Caleb’s doctor, spearheaded legislation to make CF screenings standard at birth. That’s now the case across the country.

CF affects about 70,000 people worldwide and about 30,000 in the U.S. Known as an “orphan disease” because it’s so rare, advocates for people with CF have had to create an entirely new system for drug development known as “venture philanthropy.” (Read more: Venture philanthropy new cure for deadly diseases.)

In essence, they’ve had to raise money and drive the drug development process themselves.

“Even though the number of patients is small, the impact is significant,” said Accurso who helped lead the clinical trials for Kalydeco.

“We all believe it is life-extending and in some cases life-saving. It certainly improves the quality of life,” Accurso said.

Caleb’s dad is a UPS driver and he personally delivered his son’s first treatments of Kalydeco.

Now Caleb’s mom has given herself permission to imagine her son years from now.

“We’ve always held on to hope and faith,” Melissa Nolan said. “Now we can see the future.”

By Katie Kerwin McCrimmon

Colorado’s health exchange board approved a new federal grant request of $125 million on Friday that will include about $13 million to provide in-person assistance to the uninsured.

Some board members tried but failed to boost the grant request even higher — to between $133 and $135 million — to ensure that Colorado will have enough money to reach out to people who may never have had health insurance and could need extensive help signing up for federal subsidies starting this fall.

Now dubbed Connect for Health Colorado, the new exchange is slated to start signing up customers on Oct. 1.

After a contentious hearing Tuesday with lawmakers on an oversight committee, other board members opposed the $125 million request, saying it was already too costly. (Read more about Tuesday’s meeting: Despite outrage, health exchange wants additional $125 million.)

Steve ErkenBrack, president of Rocky Mountain Health Plans, said that both the high-dollar figure of the grant request and a rushed process that left some Republicans lawmakers angry threatened to undermine a history of bipartisan cooperation on health reform in Colorado.

“I am very troubled by how this has played out,” ErkenBrack said during a Friday morning board meeting.

He praised exchange staff members for working on tight deadlines and said it’s not their fault that the grant application deadline in mid-May coincided with the end of the legislative session. But, ErkenBrack said managers and board members could have done a much better job of briefing and winning support from lawmakers on both sides of the aisle.

That’s why he ultimately voted against the $125 million request and vigorously opposed asking for even more money.

“To come back and say we’re going to increase it even more is extremely problematic,” ErkenBrack said.

Board member Arnold Salazar, who is executive of Colorado Health Partnerships, had pushed exchange managers to ask for more federal cash in case Colorado needs help promoting the exchange and signing up new customers, many of whom don’t have a clue what the health exchange is or how it may help them get insurance.

Salazar said the exchange will only get one chance to launch and needs to do it right.

“If we fail…we’re going to pay in other ways,” Salazar said. “Let’s see if we can get the money in. If it needs to go back to the feds, that’s fine. I don’t want to undercapitalize this venture at a time when I think it’s going to be critical.”

Sue Birch, executive director of Colorado’s Medicaid programs, is a non-voting member of the board. She joined Salazar and board member Nathan Wilkes in their unsuccessful bid to convince fellow board members to spend at least $18-to-$20 million on an assistance network and heed states like California where foundations and exchange managers will be spending hundreds of millions to promote outreach and assistance.

Birch said the exchange’s success hinges on signing people up.

“If we miss on this round, we will forever have tainted our work going forward,” Birch said.

In the end, five board members voted in support of the $125 million grant while two opposed it. Voting in favor were Gretchen Hammer, Richard Betts, Nathan Wilkes, Arnold Salazar and Robert Ruiz-Moss. Opposing the grant request were ErkenBrack and Mike Fallon.

The chair and vice-chair of Colorado’s legislative review committee have already indicated that they will sign off on the grant and staff members are expected to submit it to the federal government by next Wednesday.

By Katie Kerwin McCrimmon

In an ambitious new health agenda, Gov. John Hickenlooper is pledging to cut the number of uninsured people in Colorado by 520,000, prevent 150,000 Coloradans from becoming obese and reduce Medicaid costs by $280 million.

Hickenlooper this week released a report called The State of Health as part of his commitment to make Colorado the healthiest state in the nation.

“We want to make sure that from the Eastern Plains to the San Juans, from rural communities to urban communities, that at any income, age, gender or ethnicity that everybody has the chance to live the healthiest life they possibly can,” Hickenlooper said Monday when he unveiled the new report.

To emphasize his health theme, the governor and some of his top aides pedaled over from the Capitol on B-cycle bikes. The governor’s bike fittingly was sponsored by LiveWell Colorado, a statewide nonprofit committed to reducing obesity and promoting healthier communities in Colorado.

The report centers on four key areas of focus: wellness and prevention, expanding health access and coverage, improving health systems and boosting value while cutting costs.

“We need to make sure that all Coloradans have the access to care at the right time and the right place.

Among the specific goals, Hickenlooper plans to:

• Prevent 92,000 people from misusing prescription drugs
• Improve oral health by ensuring that 7,500 children visit a dentist before age 1.
• Integrate physical and behavioral health systems
• Engage at least half of state employees in health risk assessments and encourage prevention and wellness programs

With respect to covering more of the uninsured, Hickenlooper said he plans to focus intently on cutting costs while expanding care.

“We’re going to expand coverage and I guarantee you we’re going to improve quality, but we also have to focus now on controlling costs,” Hickenlooper said.

“If we’re going to do this, it’s going to require all hands on deck.”

By Katie Kerwin McCrimmon

Colorado’s governor has added his deputy chief of staff to the state’s health exchange board and says he wants the project to come in on time and on budget.

Kevin Patterson, Gov. John Hickenlooper’s deputy chief of staff and chief administrative officer, joined the board following news that Colorado needed a mediator to help settle differences between the state’s Medicaid managers and those building the state’s new health exchange. (Read more: Mediator to triage health exchange problems)

“Kevin is one of the most talented people we have in the administration,” Hickenlooper said this week. “When there’s something really important, I usually try to get him involved. That’s a reflection of how important we take it.

“Doing something on this scale is very, very challenging,” Hickenlooper said. “I want to make sure we give them every opportunity to succeed and that they come in on time and on budget if humanly possible.”

Patterson becomes the third ex-officio or non-voting member of the 12-member oversight board along with Susan Birch, executive director of Colorado’s Medicaid programs, and Jim Riesberg, the state’s Commissioner of Insurance. He replaces Ken Lund, executive director of Colorado’s Office of Economic Development and International Trade.

Health exchange managers declined to comment on Hickenlooper’s decision to add Patterson to the board.

Colorado’s exchange managers have come under increasing criticism as the deadline to go live with the new system on October 1 approaches.

On Tuesday, Republican lawmakers scolded exchange managers for asking for an additional $125 million in federal funds to launch and run the exchange. (Read more: Despite outrage, health exchange wants additional $125 million.)

And last month, an outside analyst monitoring IT for the exchange recommended a “third party to triage and manage the project.”

A mediator from the New Jersey-based Robert Wood Johnson Foundation has come to Colorado to help settle differences between the exchange, an independent public entity, and state Medicaid managers.

A spokeswoman for the Robert Wood Johnson Foundation did not reply to requests for an interview about the mediator. After an intense weekend of working through some technology challenges last month, exchange managers said it was helpful to have an outsider move decisions forward. But the exchange’s CEO and executive director, Patty Fontneau, said then that the mediator would not be making decisions for Colorado.

The state’s health exchange is slated to be an online marketplace that helps people find health insurance. Under the Affordable Care Act, if a person qualifies for a public program, like Medicaid, the exchange is supposed to seamlessly connect that applicant with state computer systems to sign them up in real time.

The outside analyst from First Data found in a March report  that squabbling between state and exchange managers over IT projects and other policy decisions has been slowing progress on the exchange.

“A number of policy decisions need to be resolved by both COHBE (the Colorado Health Benefit Exchange) and HCPF (Medicaid managers at the Department of Health Care Policy and Financing); they include the approach to accommodate referrals, eligibility mixed households and life change events,” wrote Yen Pham, the analyst from First Data.

“These open policy decisions have an impact on each organization and are affecting the development progress. COHBE and HCPF have a peer relationship. This adds a layer of complexity as neither has the authority to direct and manage the activities of the other organization,” Pham wrote.

Pham wrote that “COHBE and HCPF are working collaboratively in resolving the challenges.” Yet, she warned that “there is limited time remaining to design, build and test (exchange technology) prior to the Oct. 2013 Go-Live date.”

First Data is scheduled to be doing its third of five assessments during a three-week period this month. Read the initial First Data analysis from January and the second review from March.

By Katie Kerwin McCrimmon

Despite outrage from some lawmakers who called review of Colorado’s health exchange a “mockery,” a bid for an additional $125 million in federal dollars is likely to move forward by next week.

“I would anticipate that we will sign off on this,” said Sen. Irene Aguilar, D-Denver. This (federal) money exists. If we don’t take it, we’re going to have citizens picking up the costs for their premiums. Our goal is to have the most successful exchange in the country and this is part of that.”

Aguilar anticipated “sticker shock” over such high costs, but as chair for the legislature’s exchange review committee, she and vice-chair, Rep. Beth McCann, D-Denver, can authorize the grant request.

The 10-member oversight committee did not take a vote and has no plans to do so before the legislative session ends Wednesday.

Members of Colorado’s health exchange board plan to meet again to finalize the grant application before exchange managers must submit it next week.

Republican members of the committee scolded exchange managers for dramatically boosting the estimated costs to run the online health insurance market, which is supposed to make it easier for uninsured people to find and buy private health insurance.

“I am stunned, shocked and horrified at this proposal at this time,” Sen. Ellen Roberts, R-Durango, said early Tuesday when exchange managers came to the legislature to ask for approval for a new federal grant request. The new $125 million grant request is far larger than two previous federal implementation grants of $18 million and $43 million respectively. In earlier cost estimates, exchange managers have predicted that the exchange would cost $22 to $26 million a year to run.

Roberts said she had only seen the drafts seeking $125 million more in federal cash for the first time on Tuesday morning and could not possibly live up to her obligation to properly oversee Colorado’s health exchange. She called the review process a “mockery.”

In part because some states are refusing to build their own health exchanges, there is more federal money available to states like Colorado that are building exchanges. And the U.S. Department of Health and Human Services is now allowing states to request “implementation” funds for costs that stretch well into 2016. Colorado’s health exchange is supposed to open for business on October 1 of this year for plans that will cover people starting on Jan. 1 of 2014. Previously exchange managers planned to ask for funds to build the exchange and run it during 2014.

Lawmakers on Tuesday scolded sxchange board members and managers. Testifying were Rob Ruiz-Moss, an exchange board member who works for Anthem Blue Cross and Blue Shield, exchange CEO and executive director, Patty Fontneau and board president, Gretchen Hammer, who is also executive director for the Colorado Coalition for the Medically Underserved.

Now, with looser federal rules, they are asking for additional funds. For instance, managers are considering using $3 million in federal funds to buy a building in Colorado Springs that will house the exchange’s call center. Previously, managers planned to rent the space and cover those costs as an ongoing expense.

Among other major costs included in the $125 million application:

• $52 million for technology costs
• $10 million for customer service center infrastructure
• $13 million for customer service staffing
• $8 million for “back office” staff to handle manual processing that IT programs can’t yet do
• $10.5 million for a customer assistance network
• $15 million for marketing and outreach campaigns and consultants

Sen. Kevin Lundberg, R-Berthoud, joined Roberts in his frustration with the exchange managers saying that he was “disgusted” and “flabbergasted.”

Just last week in a health committee meeting, Lundberg said he asked about costs for the exchange and recalls managers telling him they’d be $48 million in 2013 then $22 to $26 million thereafter.

“This adds an extra $60 million over the next three years,” Lundberg said. “Last week I’m told one number. Somehow it’s magically changed.”

Exchange CEO and executive director Patty Fontneau told lawmakers that Colorado is applying for federal grants to save Colorado taxpayers money.

“Our main and primary goal is ‘how do we do this while keeping costs to individuals in Colorado as low as possible?’”

She said Colorado is right in line with other states including Washington that requested a similar grant for $127 million and Maryland that applied for one for $123 million.

Sen. Jessie Ulibarri, D-Commerce City, defended the $125 million request.

“If we don’t receive (the grant) these funds will go to another state,” Ulibarri said. “We as Colorado taxpayers are paying into this fund.”

He said Colorado should reduce health costs for its citizens by applying for the funds.

On Monday, during an exchange board meeting, a similar schism erupted between board members. Dr. Mike Fallon, who owns urgent care clinics, said the exchange should be run like a lean business operation.

“What I’m a little bit aghast at is that we are now an entity closing in on $200 million to sell insurance,” Fallon said. “I don’t think we need $125 million.”

“We are supposed to be a market savvy business operation, not a government entity. Just because other people are doing it (asking for additional federal dollars) doesn’t mean we should.”

On the opposite side, Arnold Salazar, executive director of Colorado Health Partnerships, LLC, said Colorado should be applying for as generous a grant as possible.

“We are implementing an exchange that we know nothing about. It’s never been done,” Salazar said.

He added that it’s impossible to accurately estimate how much it’s really going to cost and that it will be difficult to go back to the federal government and “backfill” with new grant requests later.

Telluride businessman and board member Richard Betts seconded Salazar’s opinion.

“The No. 1 reason businesses fail is a lack of proper capitalization,” Betts said. “We need to make sure we ask for enough money. We made certain promises of accomplishments in the first 18 months.”

Several board members wanted additional funds for navigator programs. In previous board meetings, exchange managers estimated that they would need at least $20 million to successfully help people sign up for health insurance. People who have never before had insurance could need at least 90 minutes in a face-to-face session with someone who could help them through the complicated process.

The federal grant request so far includes a specific request of about $10 million for an assistance network. But Fontneau has said other sources of cash could bring the funding for navigators to about $14 to $16 million.

Fontneau told both the board members on Monday and lawmakers on Tuesday that she and her colleagues are building “a sophisticated web-based marketplace.”

She said the grant application includes funds for a “creative and celebratory” public outreach campaign and that the exchange supports options for small businesses and the opportunity to connect the public and private sectors, although she emphasized that there will be only minimal “interoperability” between public systems like Medicaid and the health exchange.

As for the increased cost estimates and the much larger than expected $125 million grant request, Fontneau said that exchange managers had a new understanding of federal rules.

“We had understood that when they said we had to be self-sustaining by December 31, 2014, that meant no federal funds could be used after that,” she said. “When we pulled the grant request up, it says that the grant can be used for three years.”

By Katie Kerwin McCrimmon

I’m blaming Francis Underwood.

The soulless snake responsible for all evil in the nation’s Capitol on the Netflix hit, “House of Cards,” turned me into a couch potato this winter.

Oh, and those Crawley sisters on Downton Abbey also messed up my metabolism. I was late to that party, so my daughter and I binged on three seasons of love, war and class intrigue, galloping from the sinking of the Titanic through World War I to the Roaring Twenties in a matter of weeks.

I’m a health writer so I try to monitor my wellness in part by wearing a pedometer. As my TV watching spiked, my steps plunged.

No surprise there. It turns out that that more than 10,000 people now being tracked on the National Weight Control Registry who have successfully lost at least 30 pounds and kept it off for a year or more can’t be couch potatoes and move a lot more than average Americans.

Of those who have succeeded in losing weight and keeping it off:

• 62 percent watch fewer than 10 hours of TV per week
• 98 percent modified their food intake in some way to lose weight
• 94 percent increased their physical activity, most frequently by walking
• 78 percent eat breakfast every day
• 75 percent weigh themselves at least once a week
• 90 percent exercise, on average, about one hour a day

This week, I’ve been getting a crash course on the obesity epidemic during a conference sponsored by the National Press Foundation at the University of Colorado’s gleaming new Anschutz Health and Wellness Center.

I’ll be sharing a series of stories from all that I’ve learned in the coming months. So, stay tuned for research that may depress us all. The numbers are bleak. Solutions seem to be elusive. And long-term success is rare. Our bodies seem to be hard-wired to pack on the pounds unless we move a lot more than we do now.

Forget the Caveman diet. Rather than focusing on eating Paleo, we may need to start moving like some prehistoric creatures are chasing us.

For now, here are some tidbits gleaned from experts and fellow journalists to whet your appetite:

• “Our chairs are killing us.” That’s the bottom line message from Dr. James Levine, a professor of medicine at the Mayo Clinic and inventor of the famous “fidget pants” that track movement. Levine is convinced that non-exercise movement — all the energy we expend living our daily lives — could save us if we move more. I watched Levine refuse to sit during a panel on obesity solutions. Perhaps we all need to take a cue from him and start working at stand-up treadmill desks. Levine also consults with schools. And guess what? Kids who move more score better on tests. Rather than focusing on P.E., maybe it’s time to re-engineer schools so kids can move all day.
• We think of obesity as a problem of the uneducated poor. Indeed, minority groups have the highest rates of obesity, “but we’re seeing increases in every group. This is a problem that affects the rich and the poor,” said James O. Hill, executive director of the Health and Wellness Center.
• If you think obesity is an easy problem to solve, check out anti-obesity activist, Morgan Downey’s list of 83 potential causes that have popped up in scientific research. They range from air conditioning and suburbanization to early antibiotic use and maternal employment. Go figure.
• If you’re biased against surgical solutions to obesity, step for a moment into the shoes of journalist Michael S. Miller, editor in chief and a columnist for the Toledo Free Press.  Miller started at 380 pounds and has lost more than 160 pounds since September. He shared his story with us including the double wake-up call one day when he saw how he looked on a super-sized Costco TV (from a pre-taped appearance). That same day, his 6-year-old cried and confessed that other kids were making fun of him because his dad was so fat. Miller now walks as much as 90 minutes a day and said that for the first time in years, he didn’t have to endure the humiliation of asking for a seat-expander when he flew to Denver.
• Want to be grossed out? Liz Neprorent, of ABC News (follow her on Twitter – @Lizzyfit) has written about a new gadget that lets people eat like pigs, then dump the calories. The pump allows patients to eat, wait 20 minutes, then pump 30 percent of their stomach contents into the toilet through a tube. The inventors call this a solution. I call it sanctioned bulimia. Click here to read more.
• Fighting obesity by focusing on the built environment has become a hot topic. But researcher Janne Boone-Heinonen of the Oregon Health and Science University has found that there’s not much evidence that food deserts are as common as we think. And while fast food outlets may be more common in neighborhoods where more people are obese, she’s not convinced that proximity influences what a person eats. Click here to read more.
• And while Mayor Michael Bloomberg, whom I think of as the de facto U.S. Surgeon General of the U.S., has been targeting super-sized sugary drinks, the soda marketing geniuses have been boosting the market share of diet sodas. For men who are attracted to the macho black cans of Coke Zero and women who are hooked on Diet Coke, it might be time to take a closer look. It turns out that fake sweeteners may actually be making us fatter. Listen here to a report by Pauline Dakin of the CBC.

James Hill, the head of the Health and Wellness Center, thinks our obesity epidemic began after World War II when work gradually changed and we became so sedentary that our bodies couldn’t keep up with our food intake.

In the 1980s, restaurants started serving much larger portions of food to entice people to spend money on restaurant meals after declines in the economy spurred them to eat more at home.

“Food is everywhere. Portions are large. It tastes great. This certainly has influenced our choices,” Hill says.

How do we fix it? We have to get what Hill calls the “energy balance system” back in balance.

But, he has some colleagues who are convinced that Americans — and increasingly the Chinese and Europeans who are fast adopting KFC, McDonalds and our other fatty habits — may simply decide to accept obesity.

Hill is not ready to succumb to the pessimists. He thinks we can succeed by making lots of little changes that would help us expend more energy or reduce calorie intake by as little as 100 calories a day.

Let’s hope that’s possible. Otherwise, I keep thinking of the images from Wall-E. Once upon a time, back in 2008, the Pixar flick seemed more sci-fi than reality. As Daniel Engber wrote in a great piece in Slate called Fat-E, “Wall-E tells us that if we don’t change the way we live, we’ll all get really fat and destroy the world.”

In the movie, humans get so big they can no longer walk and “are too lazy to think.”

That’s a bleak portrayal, but if obesity rates keep climbing, we all may be headed toward a life of perma-Barcaloungers with pumps that dump our stomachs.

By Diane Carman

It was at the funeral of former teammate Lee Roy Selmon that Dave Stalls confronted his own mortality.

Selmon, who played alongside Stalls on the defensive line of the Tampa Bay Buccaneers in the 1980s, died of a massive stroke on Sept. 4, 2011. He was 56, the same age as Stalls.

As Stalls looked around at the mourners at the service, something struck him. None of the other members of that Tampa Bay starting defensive line was there. Many of them – including the defensive line coach – were dead.

“It gets really personal,” said Stalls.

Dave Stalls in the Sigma Chi music room at the Street Fraternity.

When he realized he was among only a few members of that defensive line left, “I started to think, ‘Do I have six months? A year? Thirty years?’”

Stalls came home and started making some life-changing decisions. He resigned from his position as director of Big Brothers Big Sisters of Colorado and set out to create Street Fraternity, a nonprofit program to help young men overcome their violent past. He hiked the Camino de Santiago in Spain with his son.

And he enrolled in a research project with 99 other former NFL players and 50 other elite athletes at Boston University. The goal: to identify the indicators that could enable doctors to diagnose chronic traumatic encephalopathy, or CTE, in living patients and find ways to treat it.

Questions abound

Before the condition was called CTE, it had many other names, but was most commonly known as “dementia pugilistica” or being “punch drunk.” When it was identified back in 1928, it was thought to occur only in boxers who suffered repeated blows to the head, and since that population was relatively small, little research was done on it for decades.

Over the last 10 years, however, post-mortem studies on the brains of deceased boxers, football players and other athletes in contact sports have found striking evidence of a very specific kind of brain damage.

Dr. Ann McKee, a professor of neurology and pathology at Boston University School of Medicine, has found tau protein and other signs of damage in their brains and, suddenly, concerns about the long-term impacts of concussions and sub-concussive blows to the head have reverberated across our sports-obsessed culture.

Still, there has been no way to diagnose the condition in living patients, guys like Dave Stalls.

Finally, in 2011 the National Institutes of Health awarded its first grant for the study of biomarkers for CTE in living patients. Robert Stern, professor of neurology and neurosurgery at Boston University School of Medicine and a colleague of McKee’s at the Center for the Study of Traumatic Encephalopathy, is leading that study, which is dubbed DETECT (Diagnosing and Evaluating Traumatic Encephalopathy using Clinical Tests).

Stalls said he volunteered to join the study (Stern would not confirm his participation due to strict confidentiality rules), and he spent two days in Boston in January undergoing a battery of tests.

Testing intense

For many years, Stern’s role in CTE research included interviewing family members and friends after a death linked to head trauma. As a result, he became the leading expert on the clinical presentation – the symptoms – of CTE.

For this study, he gets to talk to people who suspect that they might be living with the condition and could help him piece together evidence of possible early signs.

“What we know of CTE is that it has three primary areas of impairment,” Stern said. Those are: cognitive impairment, including memory problems and executive function or planning; behavioral changes, including impulse control, an explosive temperament and being verbally or physically violent; and mood disturbances, such as depression, hopelessness or suicidal tendencies.

So a big part of the testing involves interviewing the participants, administering tests of their ability to remember things and organize information, evaluating them for signs of psychiatric or behavioral problems, and requiring them to report on their own impressions of their condition.

Other tests are designed to evaluate the neurobiology of the participants. They include analyses of blood and spinal fluid, neuroimaging using advanced MRI (magnetic resonance imaging) and MRS (magnetic resonance spectroscopy) technology to perform a virtual biopsy of the brain, and a specialized form of EEG to measure electrophysiological changes in the brain.

“It’s been such an incredible joy and honor to work with these guys,” Stern said of the former players. “These wonderful heroes have been eager to participate, giving of themselves and courageous in all ways.

Robert Stern

“Our mutual goal in all of this is not to ruin or destroy the game of football, but to protect it.”

Stalls said his two days in Boston – ironically the week before the Super Bowl – were packed with examinations of all kinds.

“There were all these tests,” Stalls said. “They’d tell you a story and you had to repeat it. They’d give you a list of words and you’d have to remember as many as you could.”

But the one that Stalls, still an imposing figure with broad shoulders and an athlete’s powerful physique, shivers as he recalls it was when a clinician stuck a needle into his back to draw spinal fluid.

“They all hate that one,” said Stern, who insists that it doesn’t hurt … much.

Concussions optional

The 100 former football players who are participating in the study were selected because they played positions that required them to use their heads – literally — for brute force.

Kickers and quarterbacks are not included, Stern said, because while they sometimes get big hits in the game, “they’re not getting hit over and over again.”

A lineman, in contrast, “hits his head against his opponent almost every play in every game and every practice.”

Stern estimated the impact at 15-20 g-force. “It’s the equivalent of driving a car at 35 mph into a brick wall 1,000 to 1,300 times a season.”

The test results of this group will be compared to those of 50 other elite athletes who don’t slam their heads into virtual brick walls as part of their sport – former baseball players, rowers, swimmers.

“These are people who played at the highest level of their sports, had similar lifestyles and similar bodies, but never hit their heads,” Stern explained. “If we know the one variable that is the necessary ingredient – hitting your head over and over again – that’s the one thing we want to control for.”

Other factors that may play a part in the development of CTE include genetics and the age at which the head trauma first occurred.

When the researchers asked Stalls how many times he experienced a concussion in his football career, he said he honestly had no idea.

“I remember one play where I got my bell rung really hard.”

Lee Roy Selmon

He was playing with the Cowboys in 1978 or ’79, and was opposite Earl Campbell. “With a guy his size with legs so huge, there was no good option. I went in low with my head toward his legs and got a knee into my head.

“I lay on the ground for a while and I was in another world,” Stalls said. “Then I got up and got back in the huddle.”

Most of the time, though, the head traumas were so familiar they weren’t even memorable.

“How do you even define a concussion? When they told me their definition, I said it was hundreds. It happened almost every day,” Stalls said. “When they asked me for a number, I said, ‘Let’s just say 200.’”

NFL supports research

In the early days of CTE research, Stern said the NFL leaders “had their heads in the sand.” Officials from the organization issued statements denying the relationship between the repeated head trauma involved in football and brain disease.

Now, with the evidence mounting, the NFL has provided financial support to Stern’s project with an unrestricted $1 million grant. “They really understand that this is a big issue.”

Players’ organizations are watching the research closely as well and with good reason. Several lawsuits against the NFL have been filed, and former players have begun looking to the organization for support.

Stalls is not a part of any lawsuits at this point, but he doesn’t rule out that possibility.

“I made a lot of money for the NFL over the years,” he said. “Can the NFL make sure my kids won’t be bankrupt from taking care of me if I end up with Alzheimer’s or Lou Gehrig’s disease or Parkinson’s?

“Dying is a lot less stressful than losing your mind. To not know your family or even recognize people. To be unable to take care of yourself.”

Results eagerly anticipated

Stern anticipates completing the DETECT study in about 18 months, but further research on CTE will continue.

“We’re always submitting new grants for similar types of studies and offshoots from our research,” he said.

The hope is that real understanding of the disease will be achieved and lead to effective means of prevention and treatment.

“It’s why this research is so critical,” Stern said.

Evidence of CTE was found in the brains of 34 of 35 professional football players who died and left their brains to the Boston University scientists, he said, “so it’s probably very common. But we have no idea how common.”

Brain at left is from a healthy control subject. Brown stains on two brains indicate the presence of tau protein. (Images from Boston University)

Stern said they want to know what other risk factors beyond trauma play a role in developing CTE, how to prevent it and, ultimately, how to treat it effectively.

Once they have answers to these questions, clinical trials can begin on potential drug therapies. “Many scientists and pharmaceutical companies are interested in developing drugs to treat CTE,” Stern said. Among them are concepts for “anti-tau” treatments focused on eradicating the protein that seems to play a critical role in developing the disease.

“If we had adequate funding, we would be able to diagnose CTE in living patients within five years,” Stern said. “But financial support for research is at an all-time low right now, and with sequestration, it’s even worse.”

Living for the present

Stalls has no idea what impact those thousands of hits had on his brain, his memory or his life expectancy.

His memory is “terrible,” he said. In a test a year ago, he was asked to name as many words beginning with the letter “f” as possible in 30 seconds. “I could literally do four. I was embarrassed.”

Dave Stalls launched the Street Fraternity in April.

Despite the fact that playing in three Super Bowls ranks among the most exciting experiences in his life, Stalls said he “can’t remember a single play. I can’t tell you the scores. Is that really normal aging?”

Back when he was playing football, players didn’t know what they were doing to themselves. “Sure, we knew we were giving up our knees, our backs, really every joint in our bodies. But nobody thought he was giving up his cognitive ability. Losing your mind is a whole different deal.”

For now, he wants to live life to the fullest.

He offers a tour of the facility he’s assembling for the Street Fraternity, excitedly describing the various rooms, one designed for the young men to vent their frustration and pent-up physical energy, one for contemplation, one for producing music, another for working on computers.

“I haven’t seen anybody do this, helping people acknowledge their violent selves and learn about the aggressive self that is inside each of us,” he said. “During your teen years and your 20s, for a guy that’s a strong piece of who you are.”

Stalls said that’s apparent in combat veterans, in law enforcement professionals and in athletes, particularly those who play violent sports, like football.

“I know I can do this,” he said of the Street Fraternity project. “It’s important work and nobody else is doing it.”

He looks around at the warren of rooms, all painted vivid colors, and imagines them filled with young men with their whole lives ahead of them, men who need help with something he understands instinctively.

“I know I’m going to die. When is the question,” he said. “I don’t feel morose about it at all. It’s just a reality.

“So I’ve decided to use the time I have left as significantly as I possibly can.”

By Katie Kerwin McCrimmon

The horror of 20 children being shot to death at Sandy Hook Elementary School shocked the nation and the world.

But Colorado researchers — who initially set out to study playground accidents — found that gun violence is harming children every day. Very few people know about these gun injuries because federal law has prohibited funding for research on gun accidents and fatalities.

The Colorado researchers combed through every single injury over an eight-year period at Denver’s two primary trauma hospitals that serve children, Denver Health and Children’s Hospital Colorado. They expected to find information about playground injuries and were surprised to learn that violence was harming a significant number of children every year.

On average, at least 14 children between the ages of 4 and 17 were suffering gun injuries every year between 2000 and 2008 in the Denver area alone. That doesn’t include the number of children who died of gunshot wounds or those who didn’t seek emergency care for their injuries.

Dr. Angele Sauaia is an associate professor at the Colorado School of Public Health. She and a team of researchers found that gun injuries among children are common.

“We realized that there was this horrible pattern of violence in the injuries,” said Dr. Angela Sauaia, a trauma researcher and associate professor of public health and surgery at the Colorado School of Public Health. “A large percent were due to knives, pieces of glass and guns.”

Sauaia and her three research partners found that over one-third of the trauma cases related to violence stemmed from gun injuries. The number of gun-related trauma cases has stayed relatively steady, and Sauaia said she expected that the number would have remained consistent from 2008 to the present.

The findings were published Tuesday in the Journal of the American Medical Association.  (To read a JAMA Q & A with Sauaia, click here.)

“With New Town and the Aurora tragedy happening, we decided it was important for people to know that kids are being injured by guns on a routine basis,” Sauaia said.

The researchers also found that a stunning 14 percent of the gun injuries were self-inflicted. Either the children accidentally shot themselves or some were trying to commit suicide. Self-inflicted gun wounds were more common in children ages 10 to 17.

“We don’t know if they were intentional or by accident,” Sauaia said. “Regardless of intention, these kids managed to get ahold of an unlocked, loaded gun. Nobody would think that children should have unsupervised access to unlocked, loaded guns.

“So, regardless of where you stand, that’s good common ground for all of us to work on,” Sauaia said.

The researchers conducted their work without any federal funding. Sauaia said there are major gaps in knowledge about gun injuries and deaths because funding has been so difficult to attain. She said the number of children and adults who die from guns is small compared to those who suffer injuries. So there’s a great need for new research on gun injuries.

Regardless of how much researchers know about the causes of gun injuries, the consequences are clear and ominous, Sauaia said.

“If your child is hurt and the wound is due to a firearm, they are 10 times more likely to die than any other injury,” she said. “Most victims of trauma don’t die, but they suffer consequences for the rest of their lives.

“People tend to only pay attention to gun safety issues after these mass killings but this is happening all the time to our children and it’s totally preventable,” Sauaia said. “Are we as a society willing to accept that 14 or more children shot each year is an acceptable number?”

Conducting the research with Sauaia were Joshua Miller, a former student at the Colorado School of Public Health; Dr. David Partrick, a pediatric trauma surgeon at Children’s Hospital Colorado; and Dr. Ernest “Gene” Moore, head of surgery at Denver Health.