Health Policy Solutions

By Diane Carman

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

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

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

“It gets really personal,” said Stalls.

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

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

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

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

Questions abound

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

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

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

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

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

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

Testing intense

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

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

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

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

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

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

Robert Stern

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

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

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

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

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

Concussions optional

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

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

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

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

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

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

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

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

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

Lee Roy Selmon

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

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

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

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

NFL supports research

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

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

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

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

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

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

Results eagerly anticipated

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

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

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

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

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

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

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

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

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

Living for the present

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

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

Dave Stalls launched the Street Fraternity in April.

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

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

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

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

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

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

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

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

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

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

By Francis M. Miller

In declaring American independence, our founders sought to eliminate two perverse forms of tyranny that had ruled private lives for centuries.  The monarchy and the church had become corrupt and were oppressive.

My great-great-grandfather immigrated from Poland. Peasants there were not even allowed to pick up dead tree limbs for firewood. As Walter McDougall, the historian, wrote in “Freedom Just Around the Corner,” these medieval systems were never reformed.  They were replaced when the peasants dropped their hoes, walked out of the fields and boarded ships to America.

The 18th century mindset of our founding fathers did not envision predatory global corporations or the massive apparatus of government that rules our lives today.  If we go back to 1776, the lands west of the Mississippi River were hunter-gatherer and the colonial economies were agrarian.  Adam Smith was just writing his “Wealth of Nations” and the steam engine had just been invented.  There was really no concept of a market economy. Health care was carried out by blood-letting and leeches.  Our country had neither an income tax or a federal reserve.  And, whether you disagree with all or part of what’s happened recently, we can all pretty much agree that if our founding fathers were alive today, they would share our anxiety about the future.

Take health care, where I work. It took 200 years for health care to become 4 percent of our economy.  Since the 1970s, our so-called “competitive” health care system has hyper-inflated to where it is now 18 percent of GDP, twice that of the socialized democracies of Europe.

Sadly, it produces inferior results.  Every new law passed speaks to affordability, but during implementation, it always seems that a cascade of unintended consequences conspires and results in higher insurance premiums.  High health care costs have made it all but impossible to provide health care for our population without mandates and subsidies from either government or employers.  A vicious cycle has been set up and we seemingly cannot escape.

The most recent law, the Affordable Care Act of 2010 promises to reshape the health care landscape on a scale not witnessed since Medicare’s passage in 1965.  Everyone will be required to purchase insurance.  Medicaid will be enlarged, and much of the regulation of insurance will be transferred to federal oversight. On the surface it all sounds good until you meet the devil in the details.

Consider the health exchanges that are being instituted at a cost of billions.  The idea was to create an Internet-based bazaar where insurance could be compared and purchased.  The application form that the exchanges recently published is 21 pages long. (It is 61 pages long if you get one with instructions.)  This will require prospective applicants to go through a forced-march enrollment process.

My review has concluded that buying insurance through the exchange will be far more complicated than filing income taxes.  Not only that, the process calls for constant monitoring of your income by the IRS to continue qualifying for subsidies and eligibility.

Once the form is filled out, it must be passed up the line for approval by  three federal agencies. You can bet this will take another two to three weeks to be approved under the best of circumstances.  You and I both know that if one ‘t’ is not crossed or an ‘i’ is not dotted, you will have to go through it all again.

In a world where we can buy a car using an iPhone, this process defies all common sense.  Tell me again.  Why can’t I just go buy insurance where I see fit and file for a credit on my tax forms.  Why submit everyone to the “tyranny-of-the-process” about to be imposed by the exchange?

There is a serious question whether all of this is going to work.  We all know what happened when Colorado implemented it’s $300 million dollar CBMS benefits management system:  it has been in a state of failure for years.  Now, the apparatchiks are going to layer the exchange on top of that house of cards.

The legislature has not yet talked about how to fund the exchange, but you can bet they will need to layer another 3 to 5 percent onto insurance premiums to fund it all.

I think I am a typical man on the street. I am a free-market capitalist when it comes to iPhones and a socialist when it comes to fire and police protection or water and sewer.  There are private goods and public services and we need different ways to deliver and finance each of them.

The recent election validated that the public wants access to health care as an entitlement.  Perhaps we should take a lesson from the Europeans. Margaret Thatcher steadfastly increased funding for the British Health Service, all the while privatizing vast tracts of their socialized economy.  It is time for us to stop,  rethink what we are about to do, and be prepared to pivot.

The problem in all of this, of course, is that there are huge insurance companies and hundreds of thousands of people employed to implement the federal government’s 20,000 pages of new rules. Like the church and the monarchy, these players will resist any changes not in their self-interest. Health care is bigger than education and national defense combined. This is not chump change.  We, mere peasants, now that the middle class has been devastated, simply cannot drop our hoes and board a ship to America.  Health care is our Alamo.

I am sanguine that the right thing will happen.  I do, however, have faith in Herbert Stein’s famous dictum that stated, “If something cannot go on forever, it will stop,” In saying this he meant that if a trend  cannot go on forever, there is no  need for action or a program to make it stop, much less to make it stop immediately; it will somehow stop of its own accord.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By Katie Kerwin McCrimmon

A bill that would expand Medicaid to about 200,000 more low-income Coloradans continues to move through the Colorado legislature without support from Republicans in the House.

Bill sponsor and House Speaker Mark Ferrandino, D-Denver, said Medicaid expansion would boost Colorado’s economy by $4.4 billion and add up to 22,000 jobs by 2026 while saving taxpayers money in the long run.

Ferrandino sold Medicaid expansion as a measure that is winning support from Republican governors around the country.

But in Colorado, members of the GOP are not biting. While no opponents spoke against the bill — just like an earlier Senate hearing — Republicans remained deeply opposed. They said Medicaid doesn’t pay doctors enough and that in future years the federal government could break its promise  to pay the bulk of the costs to add new patients.

The Medicaid expansion measure, SB 13-200, squeaked through a House health committee by a 7-to-6 party-line vote on Tuesday. With continuing Democratic support, the Appropriations Committee and the full House are likely to pass the measure and Gov. John Hickenlooper has pledged his support.

Advocates for business groups, needy patients, children, hospital groups and insurance industry representatives all spoke in support of Medicaid expansion.

Ferrandino pointed out that taxpayers are paying for health care for the poor now. We’re just doing it by forcing people to wait until they are extremely sick; then they seek care in the most costly place: hospital emergency rooms.

“These people are getting health care, but what they’re getting is the most expensive health care by waiting until it becomes a big issue and going to the emergency room,” Ferrandino said.

“By ensuring that they have insurance and coverage, two things will happen. (Providers) will get paid for that care and it will reduce uncompensated care. That’s why you see a broad range of support from providers, the hospital association and the business community,” Ferrandino said.

“It’s a fundamental issue that everyone does get health care,” he said.

The question is, “How do we get it at the lowest costs with the best outcomes?”

That didn’t convince Rep. Kathleen Conti, R-Littleton.

She said the federal government is failing to provide adequate health care to returning wounded warriors, and that reimbursement rates for Medicaid and Medicare have continued to fall, spurring providers to stop taking patients with government insurance.

“There’s the old adage: fool me once, shame on you; fool me twice, shame on me. Why is it we’re willing to now go down this road and have faith and confidence in that same federal government that time and time and time again has committed to care for so many populations only to renege on each and every one of them?” Conti asked.

Rep. Lois Landgraf, R-Fountain, also decried the growing costs of health care overall.

She said health costs continue to climb while Colorado is cutting education expenditures.

“So the math to me just doesn’t work out. We can’t keep spending more and more money on health care and less and less on education and have things balance out,” Landgraf said.

Ferrandino responded that education groups also support Medicaid expansion.

“In order to have good educated kids in school, they need to have health care,” Ferrandino said, adding that a significant percentage of people who will be added to the rolls will be children.

A new study from the Colorado Health Institute found that one in six Coloradans between the ages of 19 and 64 would become newly eligible for Medicaid if the expansion passes.  The study estimates that about half of newly eligible people would actually enroll.

“Working-age adults, who historically have not had access to Medicaid, would benefit most,” the study found.

New Medicaid recipients would be younger than the Colorado population in general, mostly white, less educated and generally in worse health than the average Coloradan.

“They are likely to be employed with nearly half of the adults without dependent children and nearly 70 percent of the parents indicating they have jobs,” the Colorado Health Institute report found.

Among those speaking in support of the measure was John Gardner, CEO of the Yuma District Hospital and Clinics, which serves about 14,000 people in rural Yuma and Washington counties.

Gardner said many of his system’s patients simply can’t afford to pay for health care and that his hospital system has wracked up over $800,000 in bad debt over the past year.

“Much of it is from uninsured patients,” he said. “We’re providing coverage to high risk populations…This bill will improve the health of the uninsured in my community.”

Dr. Jeff Sankoff, an emergency physician from an opposite urban health system, Denver Health, also predicted that Medicaid expansion would improve the health of his patients.

“We see patients in the emergency department every day. We make diagnoses knowing full well that they’re never going to see anyone in follow-up. If I had any regret, it’s that this bill doesn’t go far enough,” Sankoff said. “There are too many people without access to care.”

Editor’s note: An earlier version of this story said that Medicaid expansion was moving forward in the Colorado legislature without support from “a single Republican.” That was incorrect. Sen. Larry Crowder, R-Alamosa, supported the bill in the Senate. No Republicans in the House Public Health Care and Human Services Committee voted for the bill on Tuesday.

By Katie Kerwin McCrimmon

Sparring between Colorado’s Medicaid managers and those building the state’s new health exchange prompted an outside analyst to recommend a “third party to triage and manage the project.”

A mediator from the New Jersey-based Robert Wood Johnson Foundation now will come to Colorado to help managers get the giant multi-million dollar project off the ground on time by Oct. 1 when it’s slated to open to consumers.

Complicating tight launch deadlines is that Colorado lawmakers set up the state’s new online health insurance marketplace as an independent public entity, not a state agency.

According to a new report from outside analysts at First Data, squabbling between state and exchange managers over IT projects and other policy decisions has been slowing down 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, an 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.

Federal grants that Colorado received to launch its exchange require outside analysts to conduct independent reviews. The process is known as IV&V for “independent verification and validation.”

First Data conducted the second of five planned reviews during the month of March and found that Medicaid management “lacked the ability to dedicate resources to assist with the development effort, but has recently brought additional staff to assist with the effort.”

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.”

Exchange managers presented Pham’s findings on Thursday to four exchange board members during a meeting of the committee that handles IT and implementation.

Both exchange managers and Medicaid managers say they are working together well now and that they welcome outside help.

Patty Fontneau, executive director and CEO of the exchange, said that grants will cover the costs of assistance from Robert Wood Johnson. She said an outside facilitator “absolutely” will help Colorado.

“It’s another resource to move us along faster as we’re working on a really fast time frame,” Fontneau said. Still, she insisted that outside consultants “won’t be making decisions for Colorado.”

Added Adele Work, the exchange’s lead manager for implementation: “It’s more like a relationship counselor, a mediator, not that we need one, but it would be more like that than an escalation point (or someone who would take over decision-making).”

Rachel Reiter, communications director for the state’s Medicaid office, said, “we’re working collaboratively. Decisions will be made by both the exchange and HCPF collaboratively.”

The new First Data report found that exchange managers had corrected problems uncovered in the first IV&V report. Now there are new problems that could undermine the exchange’s ability to open on time, Pham wrote.

“There is time to remedy these situations with corrective actions but these issues should be addressed immediately,” she said.

Among the critical concerns she highlighted:

• The addition of new IT projects that have expanded the scope of work needed to be done. These include the recent decision that exchange managers, not state workers will build an IT “eligibility engine” to determine if consumers qualify for federal subsidies to help pay for health insurance. Previously, exchange managers expected state officials to build that portion of their technology.
• New work needed to finalize a call center.
• Limited “visibility” of work being done by IT sub-contractor, hCentive. IT experts at hCentive are designing the core products that will run Colorado’s health exchange. Pham recommended that exchange managers closely monitor hCentive’s work to ensure that it’s done properly and that any fixes can be made as early as possible.

Overall the First Data report found that exchange managers are “willing to compromise by making difficult decisions to ensure the project stays on schedule.”

Adele Work said many of the concerns unearthed in March have already been addressed and that the IV&V update represents “a point in time.”

“These are our issues. We embrace these and are really working hard to try to resolve them. We own them,” Work said.

She said scheduling problems have escalated because new policies have continued to come down from the federal government and board policies.

“We’ve continued to take one line tasks and turn them into thousand line tasks,” Work said.

Another challenge has been that the exchange’s primary IT contractor, CGI, has not taken on all the responsibilities that exchange managers expected it to handle.

“When we brought on CGI as our system integrator, we had the naïve assumption that we were going to have a system integrator that was going to be responsible to all of us,” Work said.

In fact, CGI has handled about 90 percent of anticipated tasks, leaving exchange managers with a hefty and difficult chunk of about 10 percent of the oversight work, Work said.

Despite the complications, Fontneau and Work say they are meeting regularly with multiple partners including officials at state Medicaid offices and the Office of Information Technology (OIT).

Executives at OIT earlier told Solutions that because the exchange is not a state agency they were not allowed to supervise work at the exchange.

Fontneau said they work closely together.

“We work constantly with OIT,’’ she said, but added that OIT does not supervise exchange IT.

“They are a completely separate organization. They wouldn’t supervise our technology. That’s like saying JC Penney would supervise Macy’s. We’re separate organizations, but our systems will have interoperability, so of course we need to talk to each other.”

By Katie Kerwin McCrimmon

Sen. Irene Aguilar, D-Denver, withdrew her universal health care bill but has no intention of giving up the fight.

“This is Step One,” Aguilar said. “This is going to be a long process.”

Aguilar introduced a different measure calling for a study of universal care. That measure, SJR 13-021, passed the Senate and now moves to the House.

Aguilar has twice introduced measures into the Colorado Legislature — both in 2010 and this year — seeking universal health care only to face a buzz saw of opposition from health insurance and business lobbyists.

This year, Aguilar hoped to win support from at least one Republican colleague so that she could put an amendment to the Constitution before Colorado voters seeking universal care.

Mark Reece, associate director of the Colorado Association of Health Plans, sat next to Sen. Irene Aguilar and praised her during a hearing on universal health coverage. Nonetheless his industry group and other business groups opposed Aguilar’s measure seeing universal health coverage in Colorado.

Under Aguilar’s plan, employers would have paid a 6 percent payroll tax for each worker while employees would have covered 3 percent of the cost. Self-employed people and investors would have paid a 9 percent tax on income and capital gains.

In exchange, all Coloradans would have received extensive health and dental coverage. They could have picked from networks of nonprofit health plans and providers.

“I faced a well-funded opposition,” Aguilar said.

Nonetheless, she plans to move forward in future years either in the legislature or through the ballot initiative process.

Aguilar believes that when consumers see the cost of health coverage under the Affordable Care Act, they will realize that the state could do better by removing the middle men — for-profit insurance companies — and paying for universal coverage instead.

She vowed to carefully watch and publicize health insurance rate increases so consumers know they could fare much better under universal care.

Businesses groups and Republican lawmakers contended that Aguilar’s proposal amounted to a government takeover of health care. They argued that Colorado is leading the way on implementation of the Affordable Care Act and should allow that process to work.

Augilar has been working with a group called Co-Operate Colorado that has advocated for an owner-run cooperative in the mold of REI.

A separate group is advocating for a public universal health system that would bring Medicare-style health coverage to people of all ages. That group, Health Care for All Colorado, is already moving forward with plans for an initiative on Colorado’s ballot in either 2013 or 2014.

Among the advocates for that group is Nathan Wilkes, who is vice president for advocacy for the group. Wilkes is also a member of Colorado’s health exchange board.

The group’s working title for its measure is “Right to Health Care.” Ultimately they will need to get approval for the language from the Secretary of State, then get as many as 100,000 signatures to get the measure on the ballot.

The measure would call for a public health insurance program for every resident of Colorado.

“We see this primarily as a human rights issue. Even with full implementation of the Affordable Care Act in Colorado, you are still going to have several hundred thousand people who won’t have health insurance. And there will be at least that many who are underinsured,” said Wilkes, who has been working with Health Care for All Colorado since 2007 and is a volunteer vice president for advocay.

A hearing at the Capitol on universal health coverage drew dozens of activists seeking better, more affordable health care coverage in Colorado.

Wilkes became an activist on health policy issues by necessity after his young son, Thomas, was born with severe hemophilia. The cost for Thomas’ care routinely exceeded caps that health insurance companies set.

Wilkes thinks universal coverage will do far more for people than the Affordable Care Act alone. And he says moving forward on two tracks makes sense.

“Reforming our health care system is going to take several years. We have to start somewhere. By tackling the human rights component, we will also serve a huge part of the financial component. Health care costs aren’t going down. We need to capture the waste that’s in the system and use it for health care,” Wilkes said.

The Colorado health exchange is spending tens of millions of dollars to set up a system so consumers can shop for and buy private health insurance.

Wilkes said if Colorado moves toward a public health insurance system, the exchange technology would not be wasted.

“Obviously the exchange is set up to be a marketplace for private health insurance plans. The system of universal public health insurance would make the private insurance players obsolete in Colorado,” he said.

That part of the exchange technology would be unnecessary.

“But certainly we could use or reuse the exchange technology, not so much in selecting plans, but in selecting doctors or looking up information about providers,” he said. “You want to use the technology investments where you can.”

By Katie Kerwin McCrimmon

Colorado is the only state in the country where three separate laws govern the actions of police, emergency doctors, mental health and substance abuse experts  when patients appear to be a danger to themselves or others and need to be held against their will for 72 hours.

A new law winding its way through the legislature, HB 13-1296,  for the first time defines key terms related to involuntary holds including “danger to self or others” and what it means to be “gravely disabled” because of a mental health crisis.

Originally intended to meld and clarify the three disparate involuntary commitment laws, the bill instead creates a task force of health and law enforcement experts who will spend the summer studying how best to streamline Colorado’s laws relating to emergency holds. The task force is expected to produce draft legislation for 2014.

To help prevent another tragedy like last July’s theater massacre in Aurora, Gov. John Hickenlooper in December announced an $18 million plan to improve Colorado’s mental health systems by creating better crisis systems and clarifying the state’s civil commitment laws.

Reggie Bicha, executive director of the Colorado Department of Human Services, says Colorado is the only state in the country with three statutes that govern involuntary commitment.

“We believe individuals who are struggling with mental health (challenges) should receive services on a voluntary basis whenever possible. We are absolutely committed to reducing the use of involuntary commitment,” Reggie Bicha, executive director of Colorado’s Department of Human Services testified before the House health committee that unanimously moved the bill forward on Tuesday.

“That said, there are times when we must use the system,” Bicha said.

Colorado’s current system of having three separate laws — one related to mental health, one to alcohol abuse and the third to drug use — is out of date and confusing for workers coping with emergencies on the ground, Bicha said.

Furthermore, behavioral health experts now know that people struggling with mental health challenges often self-medicate with alcohol and drugs.  Or the reverse can be true. Substance abuse can increase the chances of psychosis later in life. Since substance use disorders can be intimately tied to mental health disorders, experts say it makes sense to meld laws related to involuntary commitment.

During an earlier briefing for lawmakers on involuntary commitments, experts from Mental Health America of Colorado said that in the 2011 fiscal year, 28,700 individuals were placed on emergency mental health holds or were certified for commitment. Of those:

• 20,819 were placed on at least one 72-hour hold
• About 3,800 were certified for at least one short- or long-term commitment.
• 3,942 individuals committed themselves voluntarily
• Ages ranged from under 5 to over 60
• Two-thirds were Anglo while about half were female and half were male
• 58 percent of all holds and certifications were the result of danger to self while only 3.5 percent related to danger to others.
• About 16 percent related to grave disability. Data to categorize the remaining holds is missing.

Data about mental health and substance abuse challenges in jails and prisons is also startling.

Arapahoe County Sheriff Grayson Robinson says as many as one in four of the inmates in his jail on any given day are dealing with a mental health challenge.

Arapahoe County Sheriff Grayson Robinson told lawmakers what they already know. “The jails of our country have become the mental health institutions of our country because we no longer have the capacity to care for these people.”

Data from his facility has found that nearly one in four of about 2,000 people in the Arapahoe County jail on any given day is suffering from a significant mental health issue while 85 percent or more say they were under the influence of alcohol or drugs while engaged in the criminal behavior that led to incarceration.

Robinson said he strongly supports improving the state’s mental health systems and better clarifying involuntary holds.

“This is clearly an important bill to mental health. It’s also a public safety matter.”

Robinson said law enforcement officials are often the first to confront people struggling with mental health challenges and substance abuse.

“Sometimes it’s confusing about which option to take,” Robinson said of Colorado’s three disparate statutes.

Also testifying on behalf of the bill were patients and parents of children who have struggled with mental health crises.

Evan Silverman of Denver shared with lawmakers how two psychotic breaks in the 1990s led to involuntary commitments. Silverman also spoke last week during the session sponsored by Mental Health America of Colorado. (Read more: Attacks from left and right undermine gun bill on mental health.)

Evan Silverman of Denver said he experienced his first bout of severe depression and paranoia in college. Three psychotic breaks followed in the 1999s. Silverman, who received a diagnosis of schizophrenia, is now doing well and works at Tattered Cover Book Store. But he says that he fears he might not have asked for help if he knew his name could end up on a police list of potentially dangerous patients.

He began by describing his peers in kindergarten:

“There were five of us in the advanced reading group. Three of those children ended up at Harvard and one at the University of Texas, followed by medical school at Stanford. I was not one of them. I am the only one who has been involuntarily committed.”

The first time he was committed, Silverman recalled the torture of being unable to sleep and counting every second for two days and two nights. He described seeing flies trapped between two panes of glass. Some were alive and some were dead. He empathized with the ones that were alive but could not escape.

“My doctor said he had never seen anyone so depressed,” Silverman recalled.

He recovered, then had a second psychotic break during which his father had to take him to the hospital. During that commitment, because Silverman’s regular psychiatrist was out of town for an extended vacation, he was taken to a different hospital where he had to endure confinement in an isolation room for 13 days.

Ultimately, Silverman was diagnosed with schizophrenia. He believes the emergency holds may have saved his life. But, he said he could have been hospitalized for a much shorter period of time during his second commitment had he received better care.

Silverman is now doing well, working at the Tattered Cover Book Store and is advocating for people with mental illnesses as a board member for Mental Health America of Colorado.

Sometimes parents know that their children need help, but can’t get it.

“This is an important bill for our communities. This is an important bill for our families,” said Rep. Tracy Kraft-Tharp, a co-sponsor of the bill along with Rep. Beth McCann. “People in our society have worked with families who may have an adult or adolescent child who is having a mental health crisis. They are at a loss as to what to do and they need help.”

Among those who wished his family had gotten help before a tragedy was Ron Liggett.

“My son has been in the news for murdering his mother,” Liggett told lawmakers.

His son, Ari Liggett, 24, has been accused of poisoning his mother, Beverly Liggett, then dismembering her body.

“We spent 20 years with the mental health system and know all its strengths and failures,” Liggett said. “I am representing myself and perhaps other families dealing with violent children.”

Liggett said he gets numerous calls from other distraught parents.

“We have a lot of young men that are very frustrated and angry and will be expressing it,” he said.

Citing the Boston explosions this week, Liggett said our society must focus equally on the potential dangers of both terrorism and threats related to mental health.

“We need to think of resources differently,’’ he said. “The ripple effect of what one mentally ill person can do to a neighborhood and a family is huge. There’s no end to this.”

By Katie Kerwin McCrimmon

As Adam Lanza fired 154 shots from a rifle, mowing down 20 first graders and six educators at Sandy Hook Elementary School, a group of gun control advocates and law enforcement officers happened to be meeting in Colorado to craft legislation to curb gun violence here.

Rep. Rhonda Fields, D-Aurora, who lost her son to a 2005 shooting, and Rep. Beth McCann, D-Denver, a former prosecutor and Denver manager of safety, both attended the Dec. 15 meeting. The news from Newtown, Conn., was fresh and shocking. Heartbreaking updates came in spurts on phones. No one knew at first why Lanza had aimed his violence at first-graders or that he had also killed his mother with her own gun. But it was clear immediately that a massacre of defenseless young children would dramatically alter the debate about guns in Colorado and the U.S., just like the Aurora theater shootings months earlier.

After the November elections, Colorado Democrats knew they would control both houses of the legislature and the governor’s office. Still, they wanted at least one of their gun-control measures to garner bipartisan support. Republicans here were unlikely to support universal background checks or restrictions on high-capacity magazines. So, Democrats honed in on a measure to keep guns out of the hands of people suffering from mental illnesses, hoping to attract support from conservatives.

Rep. Beth McCann is trying to win bipartisan support for a gun bill tied to mental health. While she doesn’t want to stigmatize people suffering from mental illnesses, she wants to protect the public.

Even the NRA endorses a national database of people with mental illnesses. The group frequently touts its slogan: “Guns don’t kill people. People do.” The inaccurate implication is that gun violence stems almost entirely from people with mental illnesses. Days after Newtown, NRA leader Wayne LaPierre decried “an unknown number of genuine monsters, people that are so deranged, so evil, so possessed by voices and driven by demons, that no sane person can every possibly comprehend them.”

In Colorado, McCann planned to sponsor a measure that zeroed in on keeping guns out of the hands of people experiencing mental illness. (Click here to read more.) By requiring mental health workers to report potentially violent patients, she hopes to keep guns away from people like accused Aurora-theater shooter, James Holmes.

“I’m looking at how to make our communities safer,” McCann said.

For instance, in the Aurora case, court records show Holmes had confessed to his psychiatrist that he was having homicidal thoughts more than a month before his attack. The psychiatrist reported those concerns to campus police, but Holmes was still able to stockpile guns, ammunition and sophisticated bomb-making equipment in advance of his July rampage.

While McCann is concerned about protecting the rights of people with mental illnesses, she’s also trying to safeguard the public. She planned to introduce her bill last month. But as drafts circulated around the Capitol, McCann took heat from all sides. Now she says the bill probably will call for a study instead of requiring mental health workers to report concerns about potentially dangerous patients to police. She may introduce it by Friday.

“I’m working with Republicans to see if we can come up with some mutually agreeable language,” McCann said Wednesday.

As a bipartisan group of U.S. Senators is coming together this week to allow the first debate on a major gun control bill in Congress since 1993, McCann is leading her own challenging behind-the-scenes negotiations to introduce the last piece of Colorado’s package of gun reforms that advocates were discussing back in December. Gov. John Hickenlooper has already signed measures for universal background checks and limits on high-capacity ammunition clips.

Now only the mental health questions remain on the table.

“It’s very challenging. It’s hard to figure out who’s going to make the decision about when someone is so dangerous that they should not be able to buy a gun. How do you predict that?” McCann said.

Guns seizure laws in Connecticut, Indiana provide models

As McCann has fought for a bill on guns and mental health, it turns out that forces on both the left and right colluded to undermine the effort. Gun-rights advocates in Colorado disagreed sharply with the NRA and didn’t want any lists of gun owners whether they had suffered mental illnesses or not. Civil libertarians objected to a lack of due process that could allow seizures of guns from innocent people. And advocates for people experiencing mental illnesses worried that the proposed bill would further stigmatize people in need of care and could frighten them away from seeking treatment.

Ironically, one of the most promising models for how to thwart gun violence among people experiencing mental health crises has been on the books since 1999 in Adam Lanza’s home state of Connecticut. That law allows police to obtain a warrant and seize guns from people who might be a danger to themselves or others. Indiana also has a gun seizure law. Passed in 2005 after a fatal shooting of a police officer by a man experiencing paranoia, it allows police to seize firearms without a warrant if a person appears to be mentally unstable and potentially violent. People who have had guns seized are then entitled to a hearing to determine if they can have them back.

While the laws could provide models for Colorado, they have been used very little in Connecticut and Indiana. (Read more about the Indiana law. Read more about the Connecticut law.)

And rather than preventing mass shootings like Newtown, Aurora or Columbine, the laws have been most likely to prevent suicides and potential murder-suicides.

Small fraction of violence linked to mental illness

Dr. Paul Appelbaum of Columbia, says that only a small percentage of violence is linked to mental illness. Laws reducing access to guns in general may be more effective than targeting people with mental illnesses.

National experts on guns and mental illness say Colorado may be better off taking a slower approach on new legislation to prevent gun violence related to mental illness. In New York, mental health advocates believe that the legislation Gov. Andrew Cuomo rushed into law in January could harm people with mental illnesses without curbing violence.

“The amount of attention that’s been devoted to mental illness since the Newtown shootings seems to me to be vastly disproportionate to the actual impact of mental illness on gun violence,” said Dr. Paul Appelbaum, a professor of psychiatry, medicine and law at Columbia University.

“The best data we have suggests that in this country somewhere between 3 and 5 percent of violence is attributable to mental illness,” Appelbaum said. “You could spend a lot of time and effort trying to identify everybody with a mental illness who might be dangerous and restricting their access to weapons and you’d be left with 95 to 97 percent of the violence we have now.

“Preventing (dangerous people) from having access to guns is a good thing. But the focus in my view ought to be on reducing access to guns as opposed to focusing on people with mental illness.”

Appelbaum is one of many New York mental health professionals who worries that the portion of the new New York gun law that requires mandatory reporting of potentially dangerous patients will do much more harm than good.

“It’s highly unlikely to have much of an effect on rates of violence,” Appelbaum said. “And it’s likely to be counterproductive in the long run. This is truly an unprecedented intrusion on the confidentiality of the therapist-patient relationship. It’s likely to deter people from seeking treatment.”

Fears that government lists could stop people from seeking help

One such patient who says mandatory reporting could have deterred him from asking for help during a psychotic break is Evan Silverman of Denver.

Evan Silverman of Denver said he experienced his first bout of severe depression and paranoia in college. Three psychotic breaks followed in the 1999s. Silverman, who received a diagnosis of schizophrenia, is now doing well and works at Tattered Cover Book Store. But he says that he fears he might not have asked for help if he knew his name could end up on a police list of potentially dangerous patients.

Silverman was a top student as a child then experienced his first bout of severe depression and paranoid delusions in college.

“I thought my neighbor was going to kill me,” Silverman said. His dad flew to Oregon to help him and Silverman graduated from college and went to work at Tattered Cover. Then he experienced two psychotic breaks in the 1990s that culminated with a long-term hospitalization.

As the psychosis set a second time, Silverman knew something was wrong and called his dad to meet him at a restaurant. As his dad arrived, Silverman raced out the door, convinced that someone from the FBI was tracking him.

“I knew in the deepest part of my soul that my dad would act in my best interest and that I needed his help,” Silverman recalled during a session on mental illness with Colorado lawmakers.

Silverman’s father drove him to the ER, where Silverman recalls trying to escape. He was committed and endured 13 excruciating days in isolation, convinced that doctors were trying to poison him, unable to eat and suffering delusions.

“One of my delusions while in the hospital was that to be free all I had to do was go to Tijuana (Mexico). Tijuana is always a somewhat dangerous place and especially for someone experiencing a psychotic break,” Silverman said. “I have heard it stated that people with serious and persistent mental illness are 11 times more likely than the general population to be victims of violent crime.

“If I had thought that by going to the hospital my confidentiality would be breached or my name would be added to a database of people who are considered potentially dangerous, I might have made the choice to not call my dad at all and actually headed to Mexico. I could have died,” said Silverman, now 38.

Initially diagnosed with bipolar disorder, Silverman ultimately received a diagnosis of schizophrenia. He is doing much better now, considers his medications critical to his health and continues to work at Tattered Cover.

Appelbaum of Columbia believes patients with severe mental illness who are most likely to hurt themselves or others also would be most likely to fear that if they’re honest with their mental health provider, that person would then betray longstanding patient privacy and report them to police. Many could fear having their names on government lists where they could remain for years.

“This is truly a sea change in how we’ve dealt with the privacy of the treatment relationship. We’re now turning (therapists) into agents of the state, charged with trying to identify people who may create a serious risk of harm to themselves or to other people.

“Part of the answer is what many people don’t want to hear. Guns that can kill large numbers of people ought not to be as available as they are today.”

Appelbaum thinks focusing on people with mental illness is a diversion from the truly dangerous people.

“Only a small number are mentally ill. Most murders are committed by people who are angry, drunk or using violence in the commission of another crime,” he said. “Identifying those people and depriving them of access to weapons is much more likely to be effective than this dragnet approach that we’ve taken toward people with mental illness, the vast majority of whom won’t hurt themselves or other people.”

‘People become mentally ill. And they recover.’

Another complication of keeping guns away from people experiencing mental health problems is that crises come and go. Sometimes people have mental illnesses and gun access can be dangerous. Sometimes they get better.

Deborah Azreal is a research scientist at the Harvard School of Public Health’s Injury Control Research Center.

She says that people with mental illnesses are at low risk in general for violence, but the biggest threat is suicide.

“Limiting access to firearms among people who are at risk of suicide — when they are actually at risk of suicide — is a laudable goal and isn’t being addressed much in the wake of Newtown,” Azrael said.

Rather than focusing on the purchase of new weapons, changing behaviors around access to existing weapons could be also prove effective, she said.

For instance, the slogan “Friends don’t let friends drive drunk” has helped stigmatize drunk driving. Azrael says there could be great potential in mounting a similar campaign to routinely lock up guns and prevent access to them during periods of stress.

Azrael’s fellow researchers at Harvard often talk about the “11^th Commandment of gun safety”: if you or someone you know is going through hard times — loss of a job, struggle with alcohol or drugs, divorce or a legal problem — it’s critical to limit the person’s access to guns during that period of vulnerability.

Azrael said there are interesting models around the country where places like gun ranges, pawnshops or gun stores allow the temporary surrender of guns.

“Responsible gun owners and responsible people need to be aware of that risk and willing to intervene,” she said. “It’s important to acknowledge that there are hundreds of millions of guns out there and that is going to limit the impact (of new gun laws.)”

Azrael also thinks the Connecticut law —allowing for temporary gun seizure when a person appears to be dangerous — holds promise.

“It’s ironic. It could have been used had someone called in the case of the Lanzas. I’m not pointing fingers at anyone, but one issue with mental health and firearms is that mental health isn’t a stable condition. People become mentally ill and they recover.

“We know that suicidal crises don’t last,” Azrael said. “If you can interrupt a process of (suicidal thoughts) you have a real chance of saving a life.”

Access to guns during periods of instability can be dangerous.

“The real issue with people who are unstable and have guns is that they are much more likely (to become violent) when they’re in possession of a gun already,” Azrael said. “There are 300 million Americans and we all have real risks of going through periods of mental illness.’’

“By all means, fix the mental health systems. The benefits are likely to be enormous in all sorts of ways,” Azrael said.

Appelbaum of Columbia is also a supporter of gun seizure laws. In Indiana, a person who has had a gun seized gets a hearing within 14 days.

“But in that critical period when some guy is beating his wife and threatening to blow her head off or belligerent and threatening people in a bar, he doesn’t have a weapon,” Appelbaum said.

In essence, there’s a critical cooling-off period.

Why mental health gun bill concerned advocates on left and right

In Colorado, gun-rights advocates, civil libertarians and advocates for the mentally ill all had reservations about the proposed bill related to guns and mental health.

Dudley Brown, executive director of Rocky Mountain Gun Owners, thought NRA leaders were crazy to endorse databases of people with mental illnesses.

“What’s scary about this is that a lot of soldiers come home from Iraq and Afghanistan and they’re going to need to talk to a counselor,” Brown said.  “If all of a sudden, the threat of talking to a counselor means they may not have the ability to possess a firearm for hunting or self-defense or a job, they’re not going to talk to a counselor.

“It’s no surprise that many people in the military possess firearms,” Brown said. “They want to go duck hunting with their son every year or they’re police officers or want guns for self-defense or target shooting.”

Brown said some studies show nearly half of Americans will have some sort of mental health challenge in their lifetimes.

“So, in other words, you can strip half of America’s rights to keep and bear arms. This is not a little tiny change in the law. It’s massive and it’s rife for potential lawsuits,” Brown said.

Dave Kopel, a libertarian with the Independence Institute, wants dangerous people off the streets, but worries about taking guns away from innocent people.

Dave Kopel is research director at the libertarian think tank, the Independence Institute. He’s also a policy analyst with the Cato Institute and a constitutional law professor at the University of Denver. He applauds the idea of a study on how to better keep guns out of the hands of people who are mentally ill.

“Mental health is a complex issue. It’s important to get all the experts in the room. Rep. McCann, to her credit, did not just have this drafted in the (Democratic) caucus. It was circulated to some Republicans and they raised concerns,” Kopel said.

“We need to take one step back,” Kopel said. “The issue is less about somebody like James Holmes buying a gun — which we don’t want him to do — but that James Holmes is walking the streets.

“You want a guy like him civilly committed and off the streets period,” Kopel said. “We need to strengthen our civil commitment laws and provide substantial funding for that. That is something that’s expensive in the short run, but will save lives and pay for itself in reduced prison costs. If you can commit a guy for three years and cure him, that’s better than a life sentence for 50 years or going through a capital trial.”

Kopel believes the big problem with ordering mental health workers to report potentially dangerous patients, then banning them from buying guns is that it takes away due process rights.

“A social worker or nurse says this person shouldn’t have a gun. That immediately imposes a gun ban on the person and turns them into a felon,” Kopel said. From his libertarian approach, he says, “you don’t take anybody’s rights away just based on someone’s accusations.”

In the Holmes case, Kopel believes that when the psychiatrist warned police about her client’s suicidal fantasies, he should have been placed on a 72-hour hold.

“If the person is taking steps (toward violence) you definitely want to move fast,” Kopel said. “I’m just concerned about due process. I want the guns taken away from the people from whom they should be taken. And I want it done with a fair process so we don’t turn innocent people into criminals.”

Many advocates for people with mental illnesses want fewer guns in general, but worry that measures that specifically target people experience mental illness could be misguided.

Michael Lott-Manier is public policy and advocacy coordinator for Mental Health America of Colorado. The group helped advise McCann, but didn’t take a formal position on her bill.

“Our goal is to get people treatment when they need it and to encourage wellness,” Lott-Manier said.  “When someone commits an act of violence whether it’s suicide with a firearm or one of these rampage killings, we want to prevent these atrocities from happening. But we want to go about it in a way that doesn’t keep people from seeking treatment.

“We want to help them when they need it,’’ he said. “Recovery is always possible even from serious mental illness.”

When there’s a highly publicized case like Newtown or Aurora and there are allegations of serious mental illness, Lott-Manier points out that system failures are complex.

“We didn’t just fail on guns. The failure happened a long time before any of these people got guns. There was a failure to address a pretty serious mental illness.”

Lott-Manier said lack of treatment can lead to violent outbursts. And when it comes to gun deaths, many more Coloradans commit suicide than use a gun to kill someone else, especially in an extremely rare rampage-style killing.

“We don’t want to say that any new gun laws are bad,” he said. “But we should all help people get the treatment they need.”

Lott-Manier says evidence and data about violence are quite clear.

“The way to prevent gun violence is to prevent violence and trauma in early childhood,” he said. “Those are the things that really matter to our community.”

By Katie Kerwin McCrimmon

As Colorado’s health exchange managers sprint toward an October 1 launch, a top manager warned board members on Monday that a recent decision to build a new “eligibility” IT system poses the greatest risk of delay and could undermine the quality of the online health marketplace.

Adele Work, who is leading implementation for the exchange, made a presentation about “key implementation risks” during a technology update for the board.

No. 1 on that list of risks is the new decision to divide one planned IT system into two. The report to the board said that IT developers for the exchange are now having to contract with a “team of eligibility experts” to develop the new engine that will determine if customers of the exchange qualify for federal subsidies. State Medicaid managers are building their own separate system to determine if exchange customers are eligible for Medicaid. Previously, Medicaid and the health exchange were planning to operate one “shared eligibility service,” the report said.

“This decision was made about a risk to our ‘go-live’ date,” Work told board members.

In order to try to open the exchange on time, Work also told board members that IT developers will delay some functions to future years.

Exchange board member Eric Grossman, an expert on health care technology who works for TriZetto, a health care technology company, asked about planning in case IT systems don’t work.

“The best laid plans go awry,” Grossman said. “What’s plan B? We can’t just keep dumping stuff on the plan.”

Exchange Executive Director and CEO Patty Fontneau responded that she’s putting a halt to any new components.

“We can’t do anything else,” Fontneau said. “We’re done. At this stage, we’re drafting a letter to HHS (the U.S. Department of Health and Human Services) saying, ‘if you tell us something else, we can’t do it.’”

Fontneau also warned board members that the exchange would need to hire and absorb extra costs in the first year for more workers to do jobs by hand in the “back office.” She previously anticipated those functions would be automated through tech systems.

Overall, Work said that IT projects are on schedule, but that lack of time could be problematic.

“We’re on track with the plan,” Work said. But she added, “it’s a highly aggressive plan. It would be silly to tell you it’s easy.”

The other greatest risk, according to Work’s report, is that there could be “functionality gaps or coding errors” in the basic exchange IT systems. And there will be little time to fix them.

“We will not know the full impact until later testing phases,” the report said.

Solutions reported on March 27 on a variety of tech troubles that could hobble the health exchange. Fontneau and communications consultants declined repeated requests for interviews on the problems. Asked Monday if she wished to talk about how the exchange is handling technology challenges, Fontneau said: “No comment.”

Exchange managers also declined repeated interview requests on Monday and Tuesday to explain the new decision to shift technology plans at such a late date. The exchange board did not vote on this decision.

Despite the fact that the health exchange is a public entity that is spending tens of millions of taxpayer dollars and must be responsive to the public, exchange managers are now refusing to conduct interviews about exchange operations with Solutions and will only answer questions in writing.

In a written response from communications consultant George Merritt, managers said that: “COHBE (the Colorado exchange), HCPF (state Medicaid managers) and OIT (Colorado’s Office of Information Technology) collectively decided earlier this year for COHBE to build the portion of the eligibility system related to access to new federal financial assistance to reduce the cost of health insurance and for HCPF to build the system that determines eligibility for Medicaid and CHP+.

“This plan is on the back end, does not affect the customer experience and will not cost more. Customers will still apply (sic) be able to apply for coverage through COHBE or through PEAK (the state benefits system) and our systems will share information. This plan creates a path to a successful launch in October that best serves Colorado consumers,” Merritt wrote.

State Medicaid managers also said consumers should not be affected by the change.

“The engine decision will not impact clients as both the exchange and Medicaid will have a ‘no wrong door’ approach so that no matter which system a client chooses to use, they will be able to apply for benefits,” Rachel Reiter, communications manager for HCPF said in a written statement.

Among other technology updates, Work reported that:

• IT contractor CGI, which the exchange is paying $66.3 million for technology, is taking commercial, off-the-shelf products, making changes to them and delivering the software in six releases.
• So far, exchange managers say they have received the first four releases. “There is some method to the madness in terms of building a plan. We have a lot of work to do in a very short period of time,” Work said. But, “We and CGI have met all of our milestones to date.”
• While outside analysts say the federal data services hub — with which exchanges must communicate in real time to determine if customers are citizens and eligible for federal subsidies  — is only 40 percent complete, Work’s report said there’s been “significant improvement” on the hub. She expects to begin testing with the hub by May.
• Exchange workers and contractors have been working to fix problems uncovered through an outside analysis by First Data. Work said three of six problems uncovered in First Data’s initial analysis have been fixed. The compressed completion schedule will make it difficult to excel in all categories that the analysts monitor.

On other matters related to the exchange, the board voted to allow customers who call insurance companies directly or who are renewing insurance policies to purchase new exchange products directly through insurance companies.

Exchange staffers estimate that about 400,000 Coloradans currently buy health insurance through the individual market and about half of them or 195,000 people will probably be eligible for new tax credits and subsidies through the exchange.

George Lyford, a lawyer for the Colorado Center on Law and Policy, urged board members not to allow insurance companies to sell exchange products directly to consumers.

“That means they will never access this state-of-the-art marketplace,” Lyford said. He said consumers won’t have key information they need about subsidies and may not understand their options.

“How will they select a plan that is best for them?” Lyford asked.

Exchange staffers estimated that between 30 and 50 percent of individual health insurance polices sold in Colorado are the result of a consumer who contacts an insurance company directly. The board will require sales staffers at insurance companies to inform consumers about the health exchange and let them know they may qualify for public health insurance or federal subsidies.

Exchange managers are also planning to set up six “assistance networks” throughout the state. Under three different scenarios, the health exchange would spend between $12 million and $20 million a year offering in-person assistance to exchange clients. Managers expect clients to need as much as 90 minutes each to explore health plans and learn about options they might choose. One of the staffers who tried filling out the necessary forms said it took her nearly 40 minutes and she’s savvy about health insurance.

Board members also received an update on a new communications plan.

The exchange contracted with a group called Corona Insights in Denver to analyze who the potential customers might be.

The typical uninsured Coloradan will most likely be a young man ages 25 to 34 who is a cook or works in the construction or entertainment industry. He would earn about $25,000 to $49,000 a year.

The typical customer who purchases individual insurance in Colorado has a household income of about $100,000 or greater, is between 55 and 64, and is white. Both men and women fit into this group and are most likely to be managers or sales people in the restaurant or construction industries.

By Michele Lueck

In college basketball, being No. 1 means winning the Final Four. In cinema, it means taking home an Oscar. But when it comes to Colorado’s health, being No. 1 could improve hundreds of thousands of lives and greatly benefit the local economy and business environment.

Though Colorado already is No. 1 in certain measures (we have the leanest and most-active adult population of any state), the 2012 Colorado Health Report Card shows there’s plenty of room for improvements.

For example, we’re No. 31 among other states in prenatal care and No. 38 in children’s preventative dental care. And though our adult population is the leanest relative to other states, our obesity rate for adults and children has risen dramatically in recent years

For the most part, Colorado is pretty average when it comes to health, but these statistics reveal a level of mediocrity that belies our national reputation as a healthy, vibrant and innovative state.

In fact, Colorado’s grades haven’t changed much since the Colorado Health Foundation partnered with the Colorado Health Institute to produce the first Colorado Health Report Card seven years ago. While that’s frustrating in many respects, it also begs the question: “What if we were No. 1?”

For the first time ever, the 2012 Colorado Report Card looks at exactly what it would mean if Colorado were No. 1 in key health indicators.

For example: If Colorado were ranked No. 1 instead of No. 36 on the percentage of children without health insurance, an additional 78,593 children would have coverage.

Among the other possibilities if Colorado were No. 1:

• 2,100 more babies would be born at a healthy weight
• 123,400 more children would have access to a medical home
• 24,900 fewer children would be obese
• 32,600 fewer high school students would smoke cigarettes
• 92,600 fewer adults would report mental health difficulties
• 376,800 fewer adults would binge drink
• 16,200 more older adults would have all of their recommended immunizations

It’s worth noting that most of these numbers reflect “modifiable health risk factors” – in other words, actions we can take to improve our health. A recent article in Health Affairs magazine noted that 22 percent of what we spend on health care can be mitigated or modified — such as lifestyle, behavior, the things we eat and how much we exercise.

Frankly, given our state’s resources and collective brain power, being No. 1 in these indicators isn’t much of a stretch.

Being No. 1 would not only make a difference to hundreds of thousands of Colorado lives, it’s a goal that would boost business and the economy.

Tom Clark, CEO of the Metro Denver Economic Development Corp., once told me that health is a major factor that companies consider when they look to relocate or expand to Colorado. He said ranking in the “top three” of key health measures greatly improves the “win rate” of landing prospective employers.

For businesses that are already operating in the state, the supplement to the 2012 Colorado Health Report Card “Keeping Colorado Competitive: Roadmap to a Healthier, More Productive Workforce,”  shows how certain health indicators affect Colorado’s economic health and competitiveness in terms of dollars saved.

For instance, Colorado employers and employees could save an estimated $121 million annually in health care costs if the state had the lowest rate of depression. Likewise, employers and employees could save an estimated $229 annually in health costs if obesity rates returned to 1996 levels.

The supplement also highlights nonprofits that are working to make a difference in improving Colorado’s health. They include The Youth Foundation in Eagle County, which uses an evidence-based program to increase the level of physical activity among at-risk K-8 children. We also highlight Mental Health First Aid Colorado, which focuses on increasing literacy and awareness about mental illness, reducing social stigma and supporting the community with tools for coping with mental illness.

A vast majority of us aren’t destined to win the Final Four or an Academy Award, but striving for the goal of being No. 1 in these key measures of health is worth doing and within reach. And it can be achieved through the individual and team efforts of Coloradans if work together.

Michele Lueck is president and CEO of Colorado Health Institute.