Health Policy Solutions

By Michael Lott-Manier

Colorado’s 69^th General Assembly convened in January in the shadow of heartbreaking tragedies in Aurora and in Newtown, Conn. Gov. John Hickenlooper and legislators from both parties expressed the desire to respond to a perceived connection between these atrocious crimes and serious mental illness.

Mental Health America of Colorado (MHAC), as it has done for 60 years, met with legislators and lobbyists to educate them about mental health. We reminded them that the vast majority (96 percent) of violent crimes are not committed by individuals with mental health conditions, that connecting violence and mental health in public policy further stigmatizes an already marginalized group of people, and that the best way to prevent violence in all its forms is to focus on the fundamentals of health and education.

The political expediency of taking action in response to tragic violence could have resulted in policies that would have worsened the stigma around mental health, negatively affecting many of the 1.5 million Coloradans who have a behavioral health condition. Motivated as always by the knowledge that mental illnesses and addictions are diagnosable and treatable health conditions, and that recovery is possible, MHAC and our partners chose to seize the opportunity created by renewed public attention to the issue of mental health. Together we moved the conversation toward policy changes that could help individuals with serious behavioral health problems and their families get the help they need, when they need it.

Evan Silverman of Denver testified before lawmakers about mental health issues. Silverman described the fear and isolation of being placed on an involuntary hold. He’s doing well now and shook Gov. John Hickenlooper’s hand during the bill signing.

After 120 days of intense debates, emotional advocacy, and legal fine-tuning, we are proud to say that 2013 truly was the Year of Mental Health at the Colorado state capitol.

In addition to other health care reforms (Medicaid expansion, improved parity for behavioral health coverage) two historic pieces of behavioral health legislation moved forward this year. One deals with Colorado’s civil commitment laws — statutes long overdue for a 21^st century update. The other is a bill that includes over $20 million in funding to create a statewide behavioral health crisis response system. The governor signed both bills into law at the Jefferson Center for Mental Health on May 16.

Updating commitment laws

Colorado’s current laws governing how law enforcement and medical professionals can commit someone against his or her will for mental health or addiction treatment were passed in the 1970s. Back then a diagnosis-driven mindset led to three separate commitment statutes for alcohol, drug and mental health treatment.  We advocate for a person-centered approach that recognizes the widespread issue of co-occurring mental health and substance use disorders. Colorado House Bill 13-1296 establishes a task force comprised of experts from the worlds of medicine, law enforcement, behavioral health advocacy and individuals who have lived experience with involuntary commitment to integrate these statutes into one new and improved law.

The group created by HB 13-1296 will also need to approve a legal definition of “danger” as it is used in statutes as meaning “substantial risk” of harm to self or others. There is currently no statutory definition of dangerousness due to mental illness in Colorado. Many people have expressed concerns about defining a term that has been variously interpreted by medical professionals and lawyers for decades. This task force is charged with creating a system that respects and balances individual civil rights, the concerns of family members, and the needs of law enforcement and medical professionals. Part of that system will be a just and standardized definition of danger to self or others.

Historic funding for crisis response

One of MHAC’s founding goals is to reduce the need for involuntary treatment. That is why we fought hard for funds to create a statewide behavioral health crisis response system that will offer evidence-based alternatives to hospitalization. We are very grateful for the support of Gov. Hickenlooper and members of the legislature’s Joint Budget Committee in securing over $20 million for this historic effort. Senate Bill 13-266 lays out guiding principles, crafted by MHAC and our partners at Metro Crisis Services and the Colorado Behavioral Healthcare Council, for a crisis system that will improve overall public services in our state.

Hickenlooper and behavioral health leaders from across Colorado attend the signing of HB 13-1296 and SB 13-266 at the Jefferson Center for Mental Health on May 16.

Calling 911 and/or going to the emergency room has become the de facto behavioral health crisis system for most Coloradans. This situation drains costly public resources while failing to improve public health and safety. SB 13-266 sets up a competitive bidding process for funding to establish regional crisis treatment centers across the state, form mobile crisis response teams and create a 24-hour statewide behavioral health crisis hotline. MHAC and our partners made sure that innovative, state of the art ideas — expanded peer-to-peer services, trauma informed care, public stigma reduction efforts — were also included in this historic bill.

It goes without saying that our work is just beginning. This legislative session has empowered Colorado’s behavioral health community to take bold steps to transform how we deal with this vital and long-ignored area of health care. With profound gratitude to the governor and the legislature, we are thrilled to be a part of the historic changes set in motion this year.

Michael Lott-Manier is the public policy and advocacy coordinator at Mental Health America of Colorado.

By Debra Judy

The Colorado Consumer Health Initiative is celebrating the end of the Colorado legislature because the takeaway is “Colorado health care consumers win big this session!”

For all of us, getting the care we need, when we need it isn’t too much to ask. So we were delighted that Colorado’s legislators and Gov. John Hickenlooper really took this idea to heart this year as they helped move toward barrier-free access to quality and affordable health care for all Coloradans. 

Sponsored by Rep. Beth McCann and Sen. Irene Aguilar, the bill to modernize stop-loss health insurance is an important step toward stabilizing and protecting the small group insurance market.  This bill raises the attachment point for businesses purchasing stop-loss insurance and will ensure that small businesses are not inappropriately self-insuring, thereby protecting the small group market from employers who jump into the market only when they have unhealthy employees. In addition, the Division of Insurance will collect data about stop-loss policies in Colorado so that we can better understand the impacts on the market.

One of the biggest health care issues the Colorado General Assembly faced this year was the creation of the New Medicaid program. On election night, Speaker of the House Mark Ferrandino said he hoped Colorado would honor Obamacare’s provision to expand Medicaid eligibility to individuals making about $15,000 a year or $30,000 a year for a family of four. After Gov. Hickenlooper announced his support for the expansion in January, the bill passed at the end of April. Adult dental care was also added to Colorado’s Medicaid program. Thanks to these bills, thousands of Coloradans will have better access to the health care they need.

Colorado took another huge step forward in implementing Obamacare with the passage of the Health Insurance Alignment Federal Law. While Colorado is one of the leader states in implementing health care reform, many of Obamacare’s consumer protections were not in Colorado law. With the passage of this bill, in 2014, Colorado will ban discrimination based on pre-existing conditions and allow young adults to stay on their parents’ plans up to age 26, among many other popular benefits.

Moreover, Colorado is well on its way to establishing its new health care marketplace, Connect for Health Colorado. The General Assembly passed a funding bill to ensure Connect for Health Colorado is financially sustainable in 2015 and beyond. Open enrollment begins Oct. 1, when thousands of Coloradans will be able to easily compare health plans – and use tax credits to help afford their insurance premiums. Now it’s time to get Coloradans enrolled in Connect for Health Colorado!

These great accomplishments are just a few of the health care related bills that passed this year, thanks to our legislative allies and the thousands of health care advocates across the state. Colorado is moving full steam ahead in implementing Obamacare to help thousands Coloradans gain health care coverage. This session has shown that our voices matter when it comes to decisions about health care – cheers to a great 2013 session.

Debra Judy is the policy director at the Colorado Consumer Health Initiative.

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

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 Dr. Anthony Vigil

While New Mexico and other states are grappling with the question of whether to allow doctors to write prescriptions for drugs that terminally ill patients can take to commit suicide, countries such as Belgium and The Netherlands are pushing the envelope in distressing ways.

For those who claim there is no evidence of a slippery slope in abuse of physician-assisted suicide once implemented, I offer several  problems presented by the Belgium and Netherlands experiments. In these countries, it is legal for  physicians to directly euthanize patients.

For example, within the last 10 years, several patients who have opted for euthanasia have then agreed to donate their organs. This was eerily predicted by Wesley Smith in his 1993 Newsweek article, “Whispers of Strangers.”

For those who agree with doctor-assisted suicide, this is a no-brainer. Why not get the organs right away?  For those against doc-assisted suicide, this is one more opening of an ethical Pandora’s Box.

Does the desire to donate organs play a role in the patient’s suicide decision? Do the pharmaceutical suicide agents affect the donor’s organs? Ethically, what is the difference between the doctor who prescribes the suicide drug and the surgeon who takes the vital organs of someone still alive? Couldn’t we eliminate the middle-man, skip the pharmaceutical agent and harvest the vital organs of a live patient who was bent on suicide anyway?

In Belgium, twins who were going blind decided suicide was a better choice than to struggle with blindness; they ended their lives with physician-directed euthanasia. Belgium also is considering allowing minors to consent to euthanasia.

According to the Smith article, the Royal Dutch Medical Association (KNMG) has condemned doctors who refuse to euthanize legally qualified patients due to conscientious objections. KNMG also states that “if a physician cannot or does not wish to honor a patient’s request for euthanasia or assited suicide, he must give the patient a timely and clear explanation of why, and furthermore must then refer or transfer the patient to another physician in good time.” The same paper by KNMG, states that when patients don’t qualify for legal euthanasia, a doctor may refer them to how-to suicide literature.

Proponents of physician-assisted suicide in the U.S. will object, saying “physician-assisted suicide is not the same as physician-directed euthanasia as practiced in Europe.” I reply that Europeans are not naive; they realize there is no moral difference between a physician injecting the suicidal agent themselves vs.  having the patient do it (both euthanasia and physician-assisted suicide are legal in Belgium and The Netherlands).

Similarly, there is no difference between a physician sending a patient a loaded gun in the mail or hiring a hit man, and giving explicit instructions on hundreds of painless ways to commit suicide — assuming the patient consents.  In either case, the physician is providing what ethicists call “formal cooperation” to an act.  In the case of physician-assisted suicide, the intent is the same:  death of the patient to relieve suffering. Obviously, physicians have been relieving pain and suffering for thousands of years, and we can do it legally and compassionately up to and including the point of hastening death.

So we see that the Europeans have gone beyond the slippery slope and are falling headlong into the abyss of the Culture of Death. Perhaps the United States is meant to drag them out of this spin with intelligent, clear thinking and reason — or be dragged into a tailspin of suicide.

Dr. Anthony Vigil is a general surgeon practicing in New Mexico.

By Linda Gorman

Spending money makes some people feel better, especially when it is other people’s money. As a case in point, the Colorado legislature has voted to expand Medicaid eligibility.

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

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 Francis M. Miller

The script for the Colorado Health Benefits Exchange is beginning to read like the storyline of Gilligan’s Island. It all started as a “three-hour tour.”

From the outset the debate has centered on whether Colorado should set up its own exchange or have the feds do it for us. So far, 13 states, including Colorado, have opted to set up state-run exchanges. More than half the states, 26 of them, are refusing to participate and the feds will have to run it out of Washington, D.C. This has pretty much divided along party lines with Republican-led states resisting Obamacare whenever and wherever they can.

Colorado in the past two decades has become  a metropolitian oasis and its politics have been bleached from purple to blue. Once the Republicans lost control of the state, Gov. Bill Ritter’s 208 Commission became a blueprint for a socialist field of dreams. That includes mandates, exchanges and a cooperative.

The focus of attention has been on the exchange’s budget and its logo. That seems par for the course these days, whether it is higher education or health care branding. It is the means to demonstrate a customer orientation. Starting out as a modestly funded organization, the exchange is now chasing $125 million dollars in grants. When they get awarded, they can relax and not feel forced to seek a premium tax on insurance premiums to fund their organization. Their funding, when combined with several hundred million dollars to expand Medicaid and nearly $70 million dollars to launch the health cooperative, represent the lion’s share of economic development that has taken place in Colorado since the 2008 recession. Legislators can now declare victory and go home.

I would have been more comfortable if the Obamacare debate had centered on two other issues. One is how do we bend the cost curve?  No one has been able to show  how this will get done.  I suspect we will crash through the 20 percent of GDP ceiling soon. Keep it up and eventually half the population will be caring for the other half. The only question is which half will be paying taxes.

The other question that has been ignored is — tell me again — how does the exchange create a competitive marketplace?  The current hyper-inflation in health care is not symptomatic of a competitive marketplace. It’s more a team of health provider rivals governed by insurance company oligarchs. Increasingly we treat the health market as an extractives industry.

Let me confront this issue by way of analogy. Let’s say you are unhappy with the level of competition in the auto industry. If you believe prices are too high and quality too low, to whom do you turn? Do you switch from an American manufacturer to a Japanese or Korean car? Or do you set up an exchange and have Ford Credit compete with GMAC Acceptance? None of us would pay $50,000 for a car without cheap financing, just as none of us would pay the outrageous bills for the average hospital stay without tax-favored subsidies from government or our employer. But, is the crucible of the marketplace formed by the financial intermediaries or by the competition between providers? I would argue that insurance is the source of the dead-weight loss in the health care industry.

Is competition furthered by standardizing benefits designs, regulating medical loss ratios and forcing fee schedules down the throats of providers? Or is it created by empowering the consumer?

To many of you, I am arguing distinctions without differences. Most people believe that insurance companies are high profit organizations and that we can squeeze their lemon to lower costs. Forget that it is the intensity of care, excessive administrative overhead and myriad other reasons that explain high health care costs. Why do you think the 12 leading socialized democracies in Europe expend half the money we spend and get superior outcomes? Wouldn’t you think a competitive market-based system would spend even less, not more? In an ideal world we would spend half what they spend, not twice as much.

In the end, the exchange can justify its existence by serving other purposes. The CBMS has been so broken and dysfunctional that the exchange can play a major role in getting people enrolled in Medicaid. It will also shepherd the 800,000 uninsured in Colorado. Even if they manage to enroll 150,000 of them, the subsidies will be a steroidal injection into Colorado’s economy.

So, all in all, the exchange promises to contribute more to economic development than any other agency the state could conceive. The combined effects of Medicaid dollars and subsidies when doubled by the economic multiplier effect will have more of an effect than highway dollars or promoting snowboarding. Whether it was conscious forethought or accidental isn’t worth debating. The cascading, trickle-down effects are sure to ripple through the economy affecting us all. Well, maybe not us all.

What still must be answered is whether Coloradoans want to base their economic future on federal transfer payments. Or do we seek to encourage wealth creating export industries? Clearly the natural resource extractions economy is the past and the window of opportunity is closing. The in-migration of the past 20 years has changed Colorado politics permanently. The eastern Front Range is now more of a city-state. You have to drive 100 miles in any direction (Cheyenne, Limon, Pueblo, Grand Junction) to reach the great outback that stretches for 1,000 miles before you encounter another urban area of consequence. Without wealth-creating exports, Colorado will be an island economy exchanging dollars internally.

I would argue that the in-flow of federal transfer payments is unsustainable in the very long run given deficits and unfunded liabilities. Eventually the rhetoric of our debate will have to change.

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

By 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.”