Health Policy Solutions

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 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

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 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.”

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.