Health Policy Solutions

By Katie Kerwin McCrimmon

Health insurance companies in Colorado can no longer discriminate against people who are gay, lesbian, bisexual or transgender.

Colorado is the third state to prohibit discrimination in health coverage. California and Oregon have barred the practice along with the District of Columbia. The federal Affordable Care Act calls for equity in LGBT health care, but very few states have taken action thus far to codify these rights.

Colorado’s Division of Insurance issued a bulletin last week that outlines the new rules.

It states that health plans in Colorado can no longer:

• Charge LGBT people higher rates for health plans;
• Use a patient’s sexual orientation as a pre-existing condition to limit or deny coverage;
• Deny or limit coverage for procedures that patients and their doctors determine are medically necessary if the patient’s health plan covers those services and they would be provided to other individuals without regard to their sexual orientation.

“This is a huge victory to ensure that everybody gets the care they need when they need it. Nobody should be denied services based on who they are,” said Dede de Percin, executive director for the Colorado Consumer Health Initiative.

Nicole Garcia is a transgender patient in Colorado. She could benefit from the new prohibition on discrimination against LGBT patients in Colorado. Photo courtesy of One Colorado.

The group worked with LGBT activists at One Colorado and policymakers at Colorado’s Division of Insurance to negotiate the new guidelines.

“Colorado is leading the way on sensible health reform,” de Percin said.

She expects the new policy to immediately invalidate insurance plans that contain discriminatory language. For instance, she said a transgender person in Colorado was denied coverage for a broken arm because that person was taking hormones. The patient’s insurance company determined that the hormones weaken bones and claimed that treatment of the broken arm would therefore not be covered.

“Many insurers — including our own plan (at CCHI) — have broad exclusions that say anything related to being transgender can be used to exclude coverage,” de Percin said.

She also had to intervene for a patient who identifies as male, but still needs annual pap smears and gynecological exams. The patient was afraid to change the gender marker at his provider’s office from female to male for fear that the insurance company would no longer cover annual gynecological exams. De Percin went directly to the insurance company to get permission for the patient, but said there was “still a kerfuffle on the billing.”

From now on, patients should not have to fight for coverage or procedures that their plans cover for other patients.

LGBT advocates started talking with Colorado regulators last summer, making the argument that discrimination is illegal under both state and federal law. In a timely coincidence, the new ruling emerged this week as the U.S. is marking LGBT Health Awareness Week.

U.S. Health and Human Services Secretary Kathleen Sebelius released a statement today saying that HHS has been fighting to ensure that LGBT people get the same rights and protections as other Americans.

“For example, we have released rules requiring Medicare- and Medicaid-participating hospitals to allow visitation rights for same-sex partners. This means LGBT Americans now have the same opportunities as other Americans to be with their families and loved ones when they are sick,” Sebelius said.

She said LGBT people continue to experience disparities in health coverage and are more likely to be uninsured and underinsured. (Click here to read a story about how older LGBT patients struggle to get health care in Colorado.)

De Percin said the timing of the new policies in Colorado is also vital because health insurance companies are now in the process of finalizing plans they wish to sell on Colorado’s health exchange. The companies must submit products for inclusion on the exchange by April 30.

“It’s serendipitous timing,” de Percin said. “It’s really about basic fairness and getting the care you need.”

By Katie Kerwin McCrimmon

Colorado is flunking when it comes to children’s health and it’s time to mount an aggressive turnaround campaign.

That was one of the key lessons from the release last week of the annual Colorado Health Report Card.

“We’re not growing our own healthy children. Our child obesity rate remains in the middle of the pack,” said Anne Warhover, president and CEO of the Colorado Health Foundation, which releases the report card each spring. “That’s where the foundation is really going to emphasize more and more of our work in trying to prevent childhood obesity. It leads to so much cost in our system.”

Ellen Robinson is Colorado’s new health and wellness director.

Warhover also announced that the foundation is funding a new position in Gov. John Hickenlooper’s office: a state director of health and wellness. In an era when Mayor Michael Bloomberg of New York has become the de facto U.S. Surgeon General by combating everything from smoking to sugar-laden drinks and assault weapons, leadership from politicians can be vital in driving improvements in health. Hickenlooper often repeats the mantra that he wants Colorado to be the healthiest state in the nation. Now Ellen Robinson, whose family started Denver’s Robinson Dairy in 1885, will become the state’s new health and wellness director.

Her work will be challenging.

For years, Coloradans have been congratulating themselves because the state is the leanest in the nation. But, in fact, Colorado’s adult obesity rate has doubled in fewer than 20 years while child obesity rates continue to climb at one of the fastest clips in the nation.

Source: 2012 Colorado Health Report Card. (Click on image to enlarge.)

Overall, when it comes to nurturing healthy children, the state declined from a C- in 2011 down to a D+ in 2012, where the state had hovered the previous two years.  Pregnant moms and newborns fare only slightly better with consistently poor C grades, while adolescents, adults and seniors get Bs.

For this year’s report, study authors posed the question “What if Colorado were number 1?” Analysts at the Colorado Health Institute teamed with the Colorado Health Foundation and found that being No. 1 in 38 key health indicators would not only boost the physical and mental health of Coloradans, but would also save taxpayers and businesses hundreds of millions of dollars annually while helping to revive the economy.

Kelly Brough, president and CEO of the Denver Metro Chamber of Commerce, said people in the business community now understand that improving health in Colorado is central to hiking profits.

“The first step toward fixing a problem is acknowledging you have one,” said Brough. “To not be No. 1 in all of these indicators is shocking. The economic imperative for us to do this is critical.”

Brough said the Chamber recently identified three pillars upon which business success will rest: dramatic improvements in health, education and infrastructure.

Brough said that prospective employers have long lists they’re checking and that Colorado’s health status is as vital as the state’s tax policies.

“We’re the leanest. We exercise the most and we’re the smartest,” Brough said. “I sell this all day long.

“But these aren’t stupid people. They see our growth rate (in child and adult obesity). While the South may be staying ahead of us, we’re coming on fast. These CEOs are smart enough to look at the generation we’re raising and those numbers are not at all encouraging,” Brough said.

She highlighted some of the potential savings identified in this year’s Health Report Card if Colorado could climb to No. 1:

• $230 million a year if Colorado could cut its obesity rate in half, back to 1996 levels. (Currently, Colorado ranks No. 1 in its low rate of adult obesity, but one in five Colorado adults is obese. The state ranks 23^rd in the nation for child obesity with 14.2 percent of children now obese. The percentages swell much more when analysts include adults and children who are overweight, but not yet considered obese.)
• $184 million a year if Colorado ranked 1^st, not 27^th on teen pregnancy and 3,000 fewer teens got pregnant each year.
• $121 million a year if the state did a better job of treating depression.

Brough said Colorado must tap its popularity with fit, young people and work much harder to give children who grow up in Colorado better opportunities.

“Colorado is the top attraction for 25- to 34-year-olds. Why care? They also come very well educated to our state. We have jobs and our quality of life really matters to them: our sunshine, our mountains, our outdoor lifestyles. We’re hardworking and smart and we get up earlier on weekends than weekdays.”

Employers look for fit, smart employees who cost less because they stay well, fill fewer prescriptions and have much lower rates of heart disease, cancer and diabetes, three of the most expensive illnesses.

“They want a workforce that is healthy,” she said. “But it’s not enough to be among states with good health. We need to lead the world.”

If Colorado continues to rear unhealthy children, the state will soon become unattractive to both prospective employers and bright young people who want to move here.

“We are losing our competitive position,” she said. “Why do we care (about health)? Because it costs so damn much not to care.”

Source: 2012 Colorado Health Report Card. (Click on image to enlarge.)

Warhover challenged health advocates and business leaders to each tackle a single indicator and fight for first place in the nation.

“What if we were No. 1 instead of 36^th (on children who have insurance)? An additional 78,000 kids would need to be insured. That’s not a lot of kids. We can do that. We could get to be No. 1 in normal weight (newborns) if 2,100 babies were born in a given year at a healthy weight,” Warhover said.

“It’s not that aspirational,” added Michele Lueck, president and CEO of the Colorado Health Institute, whose researchers analyzed the health data for the report card.

Lueck cited some examples. Currently only 77 percent of Colorado kids get preventive dental visits. Hawaii does much better with nearly 87 percent of kids getting dental care.

To beat Hawaii, Colorado would need to get dental visits for 116,000 more kids a year.

“It seems like we can get to this,” Lueck said and joked that perhaps the business or health groups that sponsor and succeed on that indicator should score a trip to Hawaii.

“It seems doable. We can be No. 1 in things other than football,” Lueck said.

In addition to capturing bragging rights, the cost savings would be substantial.

“Mental health is one of the most striking,” said Lueck. “The cost savings would be over $120 million annually if we did a better job with mental health, not eliminating it, just getting the No. 1 ranking.”

While the 2012 Colorado Health Report Card posts bleak grades overall, Shepard Nevel, vice president for policy and evaluation for the Colorado Health Foundation, sees the cup (of water, not soda) very much half full.

“These are goals that we as a state can achieve,” he said.

It’s very doable to make sure that 2,100 additional babies each year are born at healthy birth weights or that an additional 23,400 children have access to regular health care at a “medical home.”

Reversing the child obesity epidemic will be the first order of business as the Health Foundation moves forward.

“Child obesity has such a significant and enduring impact on health, the economy, our health care systems and education,” Nevel said.

“These are significant, but very achievable goals.”

By Gretchen Hammer

In 2012, Colorado welcomed roughly 1,800 refugees as new residents of our state. Mirroring national trends, in recent years the majority of refugees who settle in Colorado are Bhutanese, Burmese, from Iraq and Iran, and from African countries including Somalia, the Democratic Republic of Congo, Eritrea, Sudan and Ethiopia.

The path to Colorado is not smooth for many of these individuals and families. Many have spent years living in camps or moving from place to place to escape danger and suffering. By definition, refugees are persons who have fled their home country due to a well-founded fear of persecution because of race, religion, nationality, political opinion or membership in a social group. Each year the United States government determines how many refugees the country will accept for resettlement — for 2013, 70,000 admissions were allocated. Globally, only about 1 percent of all refugees ultimately are resettled in another country, but of those that are, the United States welcomes more than all other countries combined.

Source: Colorado Coalition for the Medically Underserved. (Click on image to enlarge.)

Resettling to a country with an entirely new language, culture, food, weather, education and health care system can be daunting. To support individuals and families as they go through this transition, many local agencies are dedicated to supporting refugees as they adjust to their new lives. This includes everything from finding them housing to teaching them how to go grocery shopping. It means getting their children enrolled in school and helping them write a resume so they can seek employment.

Managing immediate and chronic health care needs of refugees and helping them learn to navigate our very complex delivery system is another important early issue. Each refugee admitted to the United States has an overseas medical examination and an initial public health screening once he arrives. In Colorado, the Colorado Department of Public Health and Environment manages the Colorado Refugee Health Program.

However, simply identifying health care needs is not enough for providers who aim to provide high quality care to refugee patients. Understanding the cultural traditions about health and health care is equally critical. Many refugees are used to relying on home remedies and traditional healers, and only seek health care as a response to a serious problem, as opposed to also seeking preventive care. There are also family structures and gender roles that can affect who and how refugees seek health care. To help providers better understand these customs and practices, the Refugee Health Program has a series of presentations designed for providers about the major refugee communities in Colorado. These presentations provide important insight into the cultural traditions about common health care issues for refugees including mental health, violence, childbirth, diet, chronic disease management and infections.

Another issue significantly affecting the health of refugees is the language barrier. Through a new collaboration between the Colorado Coalition for the Medically Underserved and Mercy Housing, I recently had the opportunity to sit down and listen to a number of refugees share about their health care experiences, and heard repeatedly about the importance of high quality language interpretation. Communicating about health can be hard even if the patient and provider speak the same language. For patients and providers who speak different languages, trusted and trained interpreters are an absolute must if both parties are to feel confident that critical health information is being shared accurately.

Beyond the issues of language and cultural competence, refugees mostly face challenges similar to those faced by other medically underserved Coloradans. These challenges include timely access to primary care services for children and adults, very limited access to oral health and vision services, difficulties with transportation to and from health care appointments, difficulties navigating complex and at times competing health care systems, and barriers related to cost. These issues are challenging enough on their own, so for refugees, differences in cultural norms and languages add an extra degree of difficulty.

Colorado’s recently resettled refugees have traveled a very long way to get here, and still have a long journey ahead of them to feel at home in our society. As we work to improve the health care system for all Coloradans, we must also account for the unique needs of our newest neighbors. This means that when we are working to improve patient and provider communications, we include translation services in our conversation. It means increasing access to primary health, oral health and vision care, and doing it in a way that is culturally sensitive. We must create smooth transitions of care that consider a patient’s unique situation and ability to navigate the system. It is the right thing to do for our communities, and it is the right thing to do for our state.

Access the full CCMU infographic on Colorado’s refugees at www.ccmu.org/refugees
Gretchen Hammer is executive director of the Colorado Coalition for the Medically Underserved.

By Michael Lott Manier

In the wake of the heartbreaking tragedies in Aurora and Newtown, the debate over gun control has taken center stage in Colorado. The legislature is now set to consider an expansion of the ways in which individuals who have received treatment for mental health conditions or substance use disorders (collectively known as behavioral health) can be prohibited from purchasing or possessing firearms.

The rampage killings that reignited the gun control debate have been inextricably linked in the public consciousness with the issue of mental health. Politicians and gun-rights advocates have focused on the message that the way to keep our communities safe is to keep guns out of the hands of “the mentally ill” or “the wrong people.” Certainly there are commonsense ways to protect our communities from gun violence that focus on behavioral health. In fact, limiting access to guns among individuals who have been committed to a facility for mental health treatment is already part of Colorado law.

Source: Colorado Department of Public Health and Environment. (Click on image to enlarge.)

What the gun control debate in Colorado and across the U.S. has ignored, however, is that the most significant intersection of behavioral health and gun violence is not mass shootings nor violence against others. It is suicide.

Suicide, whether or not it is committed with a firearm, is an urgent public health issue in Colorado. In 2011 at least 910 Coloradans died from suicide, making it the seventh leading cause of death. Among Coloradans ages 10 to 34, suicide was the second leading cause of death — more than homicide, influenza and pneumonia, diabetes, leukemia, lymphoma and heart disease combined. Only motor vehicle crashes kill more young people than suicide in Colorado.

One of the reasons for the consistently high suicide rate in Colorado is the use of firearms. Homicides by firearm have been trending downward in the United States thanks in large part to advances in emergency medicine. If someone is shot by another person during the commission of a crime in the U.S. and receives emergency care in time, he or she has about an 80 percent chance of survival. The chances are reversed when it comes to suicide. If someone uses a gun to kill him or herself, the fatality rate is 85 percent.

Nationally, two-thirds of all firearms deaths each year are suicides. In Colorado, the numbers are more acute. From 2004 to 2011, 4,362 people died as a result of firearm wounds in Colorado. More than three quarters of those deaths — 3,315 — were suicides. At least half of all suicides in Colorado are committed with a firearm. As is the case everywhere, the overwhelming majority of those killed are male. More white non-Hispanic men commit suicide with a firearm in Colorado than almost any other state.

Source: Colorado Department of Public Health and Environment. (Click on image to enlarge.)

These grim statistics stand in sharp contrast to the numbers associated with violence against others. People with a mental health diagnosis who do not have a co-occurring substance use disorder are no more likely than the general population to commit an act of violence against another person.  Only 4 percent of violent crimes against others are committed by someone with a diagnosis of serious mental illness.  The same risk factors that make someone without a diagnosable mental illness more likely to commit a violent crime also affect people with a mental health diagnosis — and at almost exactly the same rates. The strongest predictors of violence against others are substance abuse, a history of trauma and low socioeconomic status. There is overwhelming evidence that managing those three risk factors greatly reduces violent crime. In contrast, there is no evidence showing that a lower rate of mental illness in a population is associated with a lower rate of violent crimes against others. 

While the focus of politicians and gun-rights advocates may be on the danger posed to the public by people with mental illness, the most common intersection of violent crimes against others and behavioral health is actually the victimization of people with an untreated condition. Men and women with a serious mental illness who may or may not have a substance use problem are 11 times more likely to be the victim of a violent crime than the general population. 

Source: Colorado Department of Public Health and Environment. (Click on image to enlarge.)

Just as with other health conditions, social determinants of health — employment, income, education — strongly affect an individual’s chances of having a serious behavioral health condition. People with an untreated behavioral health condition who are low-income and whose social supports are weak, are far more likely to be the victims of sexual assault, domestic violence and homicide than people who do not have an untreated condition. The trauma of those crimes also increases the victim’s risk of suicide.

As Coloradans continue to debate firearms, violence and behavioral health in our society, we need to remind everyone of the essential facts. We need commonsense gun violence prevention laws, but we also need to address the behavioral health needs of our most vulnerable citizens. Colorado is moving in the right direction as it restores some of the funding for behavioral health services that were cut dramatically during the recession, and we must advocate vigorously for each and every additional dollar.

Funding, however, is not enough. It is time to bring suicide in general, and especially the role of firearms in suicide, out of the closet and into the light of day. More than three-quarters of all firearm deaths in Colorado are suicides. These violent deaths are almost always the fatal symptom of an untreated behavioral health condition. When that is the case, they are 100 percent preventable. If saving the most lives is our top priority, if we want to rescue the most families from the tragedy of losing a loved one to gun violence, then our focus must include preventing suicide.

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

By Katie Kerwin McCrimmon

The percentage of Colorado children whose families live in poverty nearly doubled over the last decade from 10 to 18 percent, marking the steepest increase in the country except for Nevada, according to the 2013 KIDS COUNT report.

That meant that an additional 6,000 children sunk into poverty between 2010 and 2011, on top of 113,000 children already subjected to poverty since 2000.

“We are not where we should be. We are not even close to where we want to be,” Gov. John Hickenlooper said Monday when the Colorado Children’s Campaign unveiled the new data at the Capitol.

The governor said he’s hopeful the poverty rate increases appear to be slowing. And, as the economy improves, he also hopes fewer parents will be jobless and that their children will then fare better.

“The rate of increases has gone down significantly. That’s always important to make sure the trend is not accelerating,” Hickenlooper said. “(Poverty) is still growing. That has been a function of in-migration: kids coming in (to Colorado) whose parents weren’t earning enough.”

Chris Watney, president and CEO of the Colorado Children’s Campaign, noted that the poverty data come from 2011, when economic woes were still severe in Colorado.

“We aren’t sure yet where this is headed,” Watney said. “We had a really hard time recovering from the recession.”

The many costs of poverty can be devastating for children especially with respect to health and education.

For instance, child obesity rates are significantly higher in Colorado than adult rates and they are much higher among the poor.

“We are the only country on earth where obesity is connected to poverty. This is a unique issue that we face,” Hickenlooper said.

“The lifestyle conditions that have created this epidemic of obesity around the country start at very early ages. There’s no better place to address this than with 3- and 4-year-olds coming into daycare and high quality early childhood education programs,” he said.

Gov. John Hickenlooper with Nancy Almond, director of the Estes Valley Investment in Childhood Success program. Hickenlooper said Colorado must “grow healthy children” before the state will ever meet his goal of being the healthiest state in the nation.

Hickenlooper cited numerous programs that the Colorado Health Foundation is leading to “aggressively make sure every kids gets a healthy breakfast.”

Along with healthier foods, the governor is hoping that better access to health care will help kids succeed.

Indeed, the percentage of children who now have health insurance has increased dramatically over the last decade. In 2010, the most recent year for which data are available, 9 percent of all Colorado children under age 18 were uninsured, the lowest percentage since 1992. Between 2009 and 2010, the number of uninsured Colorado children dropped from 117,000 to 113,000 according to U.S. Census data.

Hickenlooper is banking on Colorado’s health exchange — slated to open on Oct. 1 — to help more families get health insurance.

“We lead the nation in one sense in developing the state-based insurance exchange which, if used properly, should help expand the number of kids that are covered,” Hickenlooper said.

Among other findings from the KIDS COUNT report:

• The number of children in the state has consistently increased since 1990 to about 1.2 million now. These children are more diverse than in the past with a higher percentage of Latino kids – now 31 percent, up from 24 percent in 2000. The proportion of Anglo children has dropped 9 percentage points since 2000 to 57 percent of the state’s children in 2011.
• About 21 percent of children are living in immigrant families, slightly less than the national average of about 24 percent.
• The vast majority of Colorado kids in immigrant families — 88 percent— are U.S. citizens, and 97 percent have parents who have lived in the U.S. for at least five years.
• Poverty rates vary widely from county to county. The highest poverty rate for families with children is in Pueblo with 27 percent. Denver ranks second-highest at 26 percent while Douglas County has just 5 percent of families living in poverty.
• For the second year, the report includes a “child well-being index” that assesses health, education, and family and community support. Douglas County topped the list of Colorado’s counties for the highest outcomes while Denver ranked at the bottom of the 25 largest counties in the state.
• The other counties among the top 10 were Elbert, Broomfield, Boulder, Larimer, Jefferson, Routt, Teller, Eagle and La Plata Counties.

Children in Douglas County have the highest rates on the “well-being index” while children in Denver fare the worst among the most populated 25 counties in Colorado. Source: Colorado Children’s Campaign. (Click on image to enlarge.)

“There continue to be significant and growing gaps between children who are doing well and those who are struggling that are influenced by family income, as well as factors like race, gender, community and neighborhood,” Watney said.

Still, Colorado has a long way to go both on health and education matters if it’s going to live up to his goal of making Colorado the healthiest state in the nation.

“We are never going to do that if we don’t address in a very focused way how healthy our kids are.”
While disparities among children are especially marked on education, Watney said the good news of the 2013 report centered on child health. Along with an increased number of children who have health insurance, more expectant mothers are getting prenatal care and Colorado’s teen birth rate is also declining.

Policy changes are the key to improving how children fare in Colorado, Watney said.

“Ensuring our state has the kind of funding mechanism to support a world-class education system; ensuring that our most vulnerable families have access to health care and streamlining our early childhood programs so that parents and families have the best access to those services are among the Children’s Campaigns’ highest priorities as we look at the data about where we are and ensuring that we are headed in the right direction.”

As Colorado seeks to improve its outlook for children, Hickenlooper said it’s key to entice businesses so the economy will be healthy and parents will have better job opportunities.

“Businesses want to be in places with healthy schools and healthy children,” Hickenlooper said. “The great dividends are going to be in years to come, having healthy, well-educated kids who are going to lead the state.”

The governor also frequently cites his goal of making Colorado the healthiest state in the nation.

“We are never going to do that if we don’t address in a very focused way how healthy our kids are.”

By Dr. Tom Gottlieb

The recent Time Magazine Special Report by Stephen Brill “Why Medical bills Are Killing Us” demonstrates a series of narratives that describe problems in our health care system. The article focuses on the cost of health care services. Brill blames cost problems on insurance companies, medical equipment manufacturers, hospitals (both for-profit and nonprofit) and pharmaceutical companies. He says that excess costs by and large are not related to physician and patient behaviors.

Brill suggests that real solutions might be related to lowering the age for Medicare eligibility and implementing a single-payer system. He further states that these solutions are not feasible. Brill then offers incremental solutions including tightening anti-trust laws, taxing profits up to 75 percent, imposing surcharges on all non-doctor hospital salaries, outlawing chargemasters, amending patent laws, reforming medical malpractice laws and capping insurance payments for imaging.

So there is little good news on health care reform except that the situation is overwhelming. It appears that tinkering around the edges of America’s dysfunctional system for funding health care with private insurance companies and pharmaceutical companies is over. No small reform such as those suggested by Brill will begin to adequately control the legalized theft of the health care dollars.

Universal health care coverage financed by a public single-payer system provides a solution to the health care crisis. We could achieve this through a system known as “Improved Medicare for All.” Whereas some politicians want to increase the age for Medicare participation, Brill argues that we should allow younger people to participate in Medicare.

Brill states: “. . . those numbers would seem to argue for lowering the Medicare age, not raising it . . . That’s not a liberal argument for protecting entitlements while the deficit balloons. It’s just a matter of hardheaded arithmetic.” He further says: “That kind of systemic overhaul not only seems unrealistic but is also packed with all kinds of risk related to the microproblems of execution and the macro issue of giving government all that power.”

Do citizens want a single-payer health care system? YES! Pollsters have repeatedly asked Americans a key question: “Do you favor or oppose having a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for-All?” Responses in a recent Kaiser Health tracking poll show that 58 percent of those surveyed favored a government plan.

Further, Brill does not document the risks of creating universal care or giving “all that power” to government. In fact, surveys suggest that citizens trust the government more than private insurance companies. A movement is underway. We can beat private insurance companies.

As an attorney and universal care proponent, Diane Archer pointed out on the Health Affairs blog, “Congress has three options to rein in runaway prices: It can use Medicare-style techniques to set rates or rate ceilings in the commercial marketplace, including in the new health insurance exchanges, just as every other developed nation does. It can give people under 65 the choice of a public health insurance plan that works like Medicare, competes against the private health plans and brings down costs. Or it can do both.”

Universal health care financed by a public single-payer system seems to be the only solution for our health care crisis. This is best done as a national Medicare-style plan, but may instead be a movement that builds state by state.

Tom Gottlieb, M.D., trained as a biochemist at the University of Colorado Boulder and as a physician at the CU School of Medicine. He worked for the Indian Health Service, the CU Division of Clinical Pharmacology, as medical director for the Denver Neighborhood Health Center and in private practice. Gottlieb is now retired and advocating for a single-payer system to fund universal health care. He is a board member of Health Care for All Colorado Foundation. 

By Katie Kerwin McCrimmon

Sen. Irene Aguilar, D-Denver, plans to introduce a bill on Friday seeking universal health care in Colorado.

Under her plan, employers would pay a 6 percent payroll tax for each worker while employees would pay a 3 percent share. Self-employed people and investors would pay a 9 percent tax on income and capital gains.

In exchange for those costs, all Coloradans who have lived in the state for at least one year by the beginning of 2016 would become part of a statewide health care “co-op” and would get “platinum-level” health plans, the most generous package of essential benefits under the Affordable Care Act.

Those plans would include primary and specialty care, hospitalizations, emergency visits, prescription coverage, mental health care, substance abuse treatment and some limited dental, vision and hearing benefits. In most cases, patients would not have co-payments or deductibles.

Patients would pick a network of providers and see any doctors who participate in their plan. Aguilar hopes the large providers would serve as “accountable care organizations,” competing against each other to provide patients with the best care. (Click here to read about how accountable care plans work for Medicaid patients in Colorado.)

Sen. Irene Aguilar is a primary care doctor who used to practice at Denver Health.

“We would move from fee-for-service to fees for keeping people healthy,” Aguilar said.

Nonprofit insurance companies like Kaiser Permanente and Rocky Mountain Health Plans would likely continue as service providers under the new system. For-profit insurance companies would either start managing health care networks or would no longer exist, meaning Aguilar faces a massive battle from lobbyists. Groups representing businesses in Colorado have been waiting to see Aguilar’s final bill before deciding whether to support or oppose it.

Aguilar designed her measure as an amendment to the Colorado Constitution. That means she needs to get support from two-thirds of members in the state Senate and House along with the governor’s signature. Then, at the soonest, Coloradans would weigh in on the referendum in November.

“I believe that access to health care is a basic human right,” said Aguilar. “And eventually we pay for it.”

She said she often hears from people who are frustrated with the U.S. health care system.

“I agree we have a dysfunctional health system. Here’s my idea of how to fix it. This is my idea of ColoradoCare.

“Any time you fix something, there are going to be winners and losers. The winners will be the people of Colorado and businesses.

“The losers, probably at some level, will be pharmaceutical and medical device companies with whom we’ll bargain. The Affordable Care Act has already put the reins on the insurance industry, but they are not a small force.”

A new economic study from University of Massachusetts Amherst economist Gerald Friedman estimates Colorado would spend about $5 billion less on health care in 2016 than if the state proceeded with changes under the Affordable Care Act. The savings would increase over time with an estimated $10 billion in savings in 2020 and $16.8 billion in 2024. A group supporting Aguilar’s bill, the Colorado Foundation for Universal Care, commissioned Friedman’s study with support from the Caring for Colorado Foundation.

Projected health spending in Colorado. Source: Economic analysis of the Colorado Health Care Cooperative. (Click on image to enlarge.)

Friedman’s study found that health care costs have tripled in Colorado and have grown from under 10 percent of the state’s economy in 1997 to over 13 percent in 2012. The rising cost of health care has prompted more employers to drop coverage as they’ve seen premiums rise, on average by about 8 percent each year over the last decade.

Freidman estimates that health care costs will continue to climb under the Affordable Care Act or under Aguilar’s plan because in both cases, more people will be covered. His models also found that costs would have kept climbing without any health reform. But creating one giant risk pool composed of all Coloradans would dramatically cut administrative costs and allow Coloradans to cut better deals for care, prescriptions and medical devices. Overall, in 2016, Friedman predicts a statewide health co-op would drive down costs by 10 percent or $900 per person.

He predicts that universal care in Colorado would hold health costs down to about 13 to 14 percent of Colorado’s economy through 2024. Under full implementation of the Affordable Care Act or no health reform, he found that costs would continue to rise to between 17 and 19 percent of Colorado’s total spending.

To critics who say Friedman’s economic prediction is too rosy, he says, look at the numbers.

“If we reduce what we’re wasting on administration, then there’s plenty of room to cover everybody,” Friedman said. “And if you keep people healthier, that’s cheaper than fixing them when they’re broken.”

A new study predicts that universal care in Colorado would hold health costs down to about 13 to14 percent of Colorado’s economy through 2024. Under full implementation of the Affordable Care Act or no health reform, he found that costs would continue to rise to between 17 and 19 percent of Colorado’s total spending. Source: Economic Analysis of Colorado Health Care Cooperative. (Click on image to enlarge.)

Furthermore, he thinks that Colorado and other states including Vermont, California and Oregon that are considering similar universal care systems, will become more attractive to employers.

“Colorado businesses will be able to spend less money on health insurance so Colorado will be able to underprice other states,” he said. “The largest cost in making a car in the U.S. is not steel or plastic or any of those things. It’s health insurance,” Friedman said.

Aguilar says businesses across the country are spending on average about 11.8 percent of expenses on health insurance and would welcome the chance to cut those costs to 6 percent.

That appeals to Terri Monley, owner of Gate City Moving, a family business in Denver. Monley has become a fan of universal care and is now talking to fellow business owners about the benefits it could provide them. She said she has about 15 to 20 employees and offers health insurance, but it’s so expensive for both Monley and her employees that not everyone takes it.

“It’s the most onerous expense we have. You can’t budget for it. You can’t predict it,” she said. “The cooperative would cut the costs for all of us. I could have bought six new trucks for the money I’ve thrown away on health insurance. It’s a terrible expense.”

While bringing more stable health care costs to business owners, universal health care would cause some upheaval in Colorado’s job market according to Friedman’s study. He estimated that 15,000 people would lose jobs in the first year. At the same time, he predicted that expansion of health care would create about 45,000 new jobs in 2016 and about 50,000 new jobs in 2024.

In terms of economic benefits to the state, Aguilar said it would be like “Medicaid expansion on steroids.”

Projected savings on health care in Colorado. Source: Economic Analysis of the Colorado Health Care Collaborative. (Click on image to enlarge.)

A study that the Colorado Health Foundation released last week found that expanding Medicaid to 275,000 Coloradans would create jobs, boost GDP and bring hundreds of millions of federal dollars to Colorado.

Aguilar said her plan would magnify that economic growth while also covering almost everyone in the state.

Currently, according to the Colorado Health Access Survey, about 830,000 Coloradans have no health insurance. The Colorado Trust funds the survey and the Colorado Health Institute conducts it.

Aguilar said universal care does not mean a government-run system.

“I absolutely do not want the government running health care. We are still going to have a market between the health provider and the patient,” said Aguilar, who is herself a primary care doctor.

“The provider will need to do a great job at taking care of the patient so they don’t switch. They will need to be innovative and take better care of people for less money.”

By Donna Smith

It isn’t often that I learn a new word in the health care system discussion, but this week I did. Churning. I was at a meeting here in Colorado where I have taken on a new role in advocating and administering for a publicly financed, universal, single-payer system with Health Care for All Colorado. And the definition of churning I learned is a sad commentary on a system that still allows access to care based on inequality of coverage that leaves so many people suffering and tens of thousands dying in America every year.

Churning is the policy wonk term for those who qualify and are covered by a public program, like Medicaid, and then have access to a private insurance plan through a new job that offers it or through a family member’s coverage, but then lose that coverage and end up back on the public insurance for which they qualify. They churn. And they suffer.

Churning doesn’t happen in an orderly or smooth way. There is a person with health care needs churning. There may be weeks or even months during which that person has no coverage and therefore only the access that money can buy them, and we all know how far that will go. Sometimes there are children involved who churn with their parents. Kids with illness for which they need care can suffer during delays of approvals for both public and private plans. How do we explain churning to a child up in the middle of night with asthma symptoms or other problems? “Sorry, sweetheart, mommy is churning this week, and we do not have the money to buy that inhaler. Maybe the insurance will come through next week.”

Those who have tried to transition from one private plan to another due to a loss or change of jobs will understand. It is stressful to make these changes even under the best of circumstances. Imagine that policy wonks discuss ways to reduce churning from public to private and back to public plans again when there is a clear and equitable way to end it for good. Adopting a sensible, equitable, universal, publicly financed, single-payer – Medicare for all for life – system would end all of this awful churning and the need for policy wonks to study and find ways to reduce it.

So, I do not like the word for which I just learned a new connotation. Churning. Let’s end it. And while we’re at it, take a look at the most recent study results that reconfirm that this system of ours is among the worst, not the best, in the world. Those engaged in our public policy and budgetary decisions consider what broader sorts of economic churning does to our system.

From the article linked above: “Policymakers must recognize the potential implications of current decisions that have to be made about public health and social programs that are currently in jeopardy because of fiscal concerns,” Woolf says.

“Understanding how cuts to those programs might help balance budgets will probably exacerbate the country’s current health disadvantage – and make greater demands on the system later on. We need to help them understand the larger economic implications, if not the human toll.”

People are suffering while we have the capacity to stop the suffering. Our community values would have us end that suffering if it was at all possible, and it is definitely possible.  We need the will to do so. Let’s get on with that work.

Donna Smith is executive director of the Health Care for All Colorado Foundation. A former award-winning journalist, Smith has co-chaired the Progressive Democrats of America’s national “Healthcare Not Warfare” campaign since 2007. Smith also was featured in Michael Moore’s 2007 documentary, SiCKO, after she and her husband both became ill, lost their home to bankruptcy and had to move in with one of their six children even though Smith had health insurance at the time. Moore took Smith to Cuba to receive free care through the country’s universal health system.

By Dr. Jay Want

I do a fair amount of work in payment and delivery system reform in various communities around the country.  I have been speaking to physicians about change coming for over a decade. If you have done any of this work, you may have had this common experience: that change is hard and people have to have a really good reason to change the status quo. I admit it sometimes seemed to me that change would never come.

But lately I have noticed some of the conversations are different.  I have been in a couple of meetings recently where audience physicians were answering the doubts and objections of other audience physicians.

“Aren’t all these quality measures arbitrary, and unhelpful in real patient care?” one might pose.

“No, in my organization, knowing our real performance has helped us improve things for patients. We’re thankful for this information and we’re proud of doing better,” another would answer.

“Isn’t this just a race to the lowest price?  Isn’t this just a way to penalize me for investing more in the care I give?”

“No, in fact quality and value rankings have helped weed out the bad performers in my procedure.The guys looking to make a quick buck are gone and should be gone. And, my designation as a center of excellence has brought me new business.”

Say what?  Where did this second group of docs come from?

I’m not sure of the answer, but here are some guesses:

• From integrated delivery systems.  Many of the docs in this new category come from places that have been able to generate their own internal quality and value reports.  Because these systems often have advanced IT shops and analytics, they are able to generate useful information based on both financial and clinical data.  This definitely is an advantage in the era of Big Data, and is one reason why we have seen and will see more provider consolidation.
• From specialties that are competing for business nationally.  If your particular niche is a rare and expensive one, you’ve already experienced something many of your peers have not—buyers shopping actively and aggressively for value, holding up your services to the light.  They don’t come to you because you’re down the street, or even in the same state.  They come to you because you are able to offer something predictable, affordable and professionally excellent. And what buyers are shopping for is expanding.  They are looking at more services and conditions every day, and shopping for them regionally and nationally.
• From those who have grieved the loss of unaccountability and moved on.  If no one can measure whether you’re doing a better or worse job than the next person, it’s hard to penalize anyone for bad performance.  (It’s also hard to reward anyone for good performance.)  This is a real loss for us docs, as we took the lack of shopping by buyers as a tacit endorsement of our judgment and competence.  But truthfully, it probably represented as much an inability to judge quality by any meaningful criteria.  That’s hard to swallow, but those who are succeeding in quality-driven markets have gotten over that loss.

This second group of docs is by no means a majority.  But a decade ago, they were almost nonexistent.  I think we are following the typical innovation diffusion curve: experimenters, followed by early majority, followed by late majority.  I think what I have been seeing recently is the move from experimenters to early majority.  And that, as those familiar with that S-shaped curve know, is the steepest part of the curve.  Here’s hoping.

Jay Want, MD, is the chief medical officer for the Center for Improving Value in Health Care, CIVHC. He is also the owner and principal of Want Healthcare, LLC. This opinion piece originally appeared on www.wanthealthcarellc.com. Contact Dr. Want at jwant@civhc.org.  

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

By Katie Kerwin McCrimmon

Expanding Medicaid to an estimated 275,000 additional people will cost Colorado less than the price of not adding them.

That’s the bold prediction from a new study of Medicaid expansion commissioned by the Colorado Health Foundation, which supports expansion, and conducted by seasoned legislative budget analyst Charlie Brown and a team of economists.

Brown and his team found that expanding Medicaid would essentially be a stimulus program for Colorado because so many millions of federal dollars would flow into the state to pay for the new patients’ care. Federal taxes will pay 100 percent of the costs of Medicaid expansion from 2014 to 2016, then taper to 90 percent by 2020. The team analyzed costs and benefits of expansion all the way through the fiscal year, 2025-26. For the full 13-year period, the total cost of Medicaid expansion would be $20.1 billion with the federal government paying $18.2 billion. Over that same time period, the study authors found that economic activity, or GDP, in Colorado would grow by .75 percent or $4.4 billion dollars.

In addition to economic growth, the authors also estimated that Medicaid expansion would create 22,400 jobs. Job creation would begin almost immediately, the study authors predicted, with 14,500 of the total jobs coming in the first 18 months of Medicaid expansion in 2014 and the first half of 2015. That’s a 20 percent jump over the number of jobs that the economists estimate Colorado would create without Medicaid expansion.

“It’s a no-brainer,” said Warren Olson, an independent economic consultant who worked on the study. “The biggest part of this is that the federal government is financing the vast majority of (expansion). We’re showing that the economic impact is good.”

On top of the positive economic drivers, “ultimately it comes down to hundreds of thousands of people getting care,” Olson said.

“It seems to be a fairly straightforward decision,” said Brown, who conducted the study through his consulting firm, Charles Brown Consulting. Brown also is launching a new public policy institute at Colorado State University called the Colorado Futures Center. http://coloradofutures.colostate.edu/

“You get a stronger economy and it’s less costly to the state,” Brown said. “At the end of the day, over the course of our forecast, the general fund projections are better off with the expansion than without it.”

Gov. John Hickenlooper announced last month that he supports Medicaid expansion and lawmakers expect to introduce a bill in the coming weeks to move forward with it. The new Colorado Health Foundation study follows a similar economic impact study that the Colorado Trust and the Colorado Health Institute released last week. That study found that expanding Medicaid would cost Colorado about $1 billion over 10 years, but would get health coverage for about 240,000 additional people and save at least 629 lives a year.

An earlier study from the Kaiser Commission on Medicaid and the Uninsured found that Colorado would foot the bill for $858 million for new Medicaid enrollees plus $639 million for people already expected to qualify. That brought total state costs for Colorado to $1.5 billion with the feds picking up $11.6 billion for a total of $13.1 billion.

Each study has set out to answer slightly different questions and the newest Colorado Health Foundation report found that Colorado could save millions of dollars by enrolling people in Medicaid whose health care costs the state is now fully funding. This population includes prisoners and indigent people. Currently, Colorado’s Department of Corrections must foot the bill if prisoners have to be hospitalized. If some prisoners become eligible for Medicaid, then federal taxes would pay for any hospital stays, the Brown study found.

Between 2013 and 2026, the study authors found nearly a billion dollars in savings to Colorado’s coffers from four major programs: prisoner hospitalizations, the Department of Human Service’s community mental health, alcohol and drug treatment programs, and an old age pension program.

In the first year alone, the economists estimate $32 million in savings from those programs. That number jumps to $94 million a year by 2025-26 and altogether saves the state about $975 million over the 13-year period.

The bottom line is that Colorado can get the benefit of shifting costs to the federal government or it will end up helping to fund other states that do, the study found.

“If Colorado does not expand Medicaid coverage, Colorado residents will still be subsidizing Medicaid expansion in those states that do expand without the state receiving the benefit of additional federal funding,” the report notes.

The study authors also found a strong “multiplier effect.” Health dollars spent in Colorado tend to have a powerful impact locally because health jobs usually pay well and most people don’t go out of state or out of the country to get medical care.

An infusion of dollars comes into an economy,” said Phyllis Resnick, an economic forecaster who was part of the team. “We start to treat people for their medical needs. We need more nurses, doctors, everyone at the hospital. There’s a direct infusion into the medical system. That creates jobs. Then we need more supplies, etc….and that has a secondary effect.”

Overall, the study found both positive and negative multiplier effects. New health spending would increase expenditures directly in health care and related fields. Some of the cost savings, such as cuts to state spending on drug treatment programs, would put a drag on the economy. Overall, the study authors estimated a .75 percent hike in GDP by 2026.

“We believe that the larger economy plus the savings elsewhere in the general fund are sufficient to protect (Colorado) from an adverse impact of the expansion decision,” Resnick said.

Among other findings of the report:

• Average annual household earnings will be $608 more if the state expands Medicaid.
• Including the costs of expansion, Colorado’s general fund will save about $134 million through 2025-26 if Colorado expands Medicaid.
• Of the 275,000 Coloradans expected to be added to Medicaid rolls, about 209,000 would be adults without children, about 44,000 newly eligible parents and an additional 22,000 eligible, but not yet enrolled children and parents.
• The average of care per person varies by age and health status. On average, covering children costs about $1,500 a year while the most expensive adults without children cost about $5,800 a year.
• Medicaid expansion will reduce the number of uninsured non-elderly Coloradans by 189,000, thus cutting the percentage of uninsured among non-elderly adults from 11.1 percent to 7.7 percent.

While the study did not explore possible increased productivity if more people have health insurance, Shepard Nevel, vice president for policy and evaluation at the Colorado Health Foundation, said there’s a strong correlation between higher rates of health coverage and healthier people.

“Our mission is to make Colorado the healthiest state in the nation and we know that expanding coverage correlates with healthier people,” Nevel said. “We support Medicaid expansion as an important part of achieving our mission.”

Colorado Health Foundation President and CEO Anne Warhover said expansion makes sense both in terms of economics and health.

“Expanding public health insurance to greater numbers of vulnerable Coloradans — in many cases, hard-working families — will bring more jobs, strengthen the state’s economy and generate higher household earnings, which benefit all Coloradans,” Warhover said.

(Editor’s note: www.HealthPolicySolutions.org receives funding from the Colorado Health Foundation and other foundations.)