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

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

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

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

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

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

Updating commitment laws

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

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

Historic funding for crisis response

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

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

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

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

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

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

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

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

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

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

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

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

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

I-News Network

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Poverty, drugs and guns

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

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

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

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

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

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

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

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

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

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

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

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

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

Multifaceted solutions

Against that backdrop, thoughts on addressing gun deaths vary.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pricing will be a gamble for all the companies.

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

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

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

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

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

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

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

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

For those of us who have been in health care for a while, Medicare’s recent release of hospital data identifying substantial variation between prices charged and actual payments isn’t news. Nor is the fact that charges for similar services by one hospital can be vastly different from those of the one down the road. Health insiders have known for years that the amounts charged by hospitals have little or no relationship to what is actually paid. Making the data public for the first time, however, does give us an opportunity to review Medicare payments alongside amounts being paid by other health insurers to start making sense of it all.

Colorado’s All Payer Claims Database (APCD) puts Colorado ahead of most states in truly understanding and identifying health care payment variation across all insurance plans for both hospital services and those performed outside the hospital. These payments to hospitals and clinical providers are the amounts shown on Explanations of Benefits (EOB’s) that are used to calculate the copays and deductibles that consumers end up paying. Thus, the Colorado APCD will provide actionable information to consumers on what services will actually cost them.

Some have been outraged by the seemingly pointless variation in charges the Medicare data show. However, some variation in the base charges for hospital services does make sense. Facilities and providers alike need to charge differently depending on how sick and complicated their patients are, whether they have additional overhead costs because they are a teaching facility, number of patients receiving charity care, etc. The more important task, though, is to figure out where variation is not adding value and to identify opportunities to get health care spending under control.

While the Medicare data focus on the wide variation on charges and paid amounts, the more interesting question is why there is so much variation on how much is being paid for a similar service.

A new report on the Colorado APCD website shows a $44,000 difference in average payments for knee replacements being made to the highest volume facilities in Colorado. The report is based on commercial insurance and Medicaid payments, and some of the discrepancies are likely due to the health status of the patients and the fact that Medicaid may be the dominant payer at some facilities. By December, reports like this will be adjusted for patient health status, will identify facility names, and will be searchable by insurance type so that consumers can evaluate how much they might pay for a procedure or service across different facilities and provider groups. Medicare data, and small group and self-insured commercial data are slated to be included in the Colorado APCD in 2014 allowing for even more shopping comparisons.

A common patient misconception when seeing big price tags associated with health care services is “you get what you pay for.” There are no data to support that you’ll get a better result if you pay more. In fact, there is typically no correlation between cost and quality. For this reason, we’re aiming to include not only a price tag but also a quality score on the Colorado APCD consumer-focused website to enable patients to make a value-based decision.

Colorado is also ahead of the curve in that our medical community is in favor of price transparency. Colorado hospitals have long supported transparent price information. Colorado lawmakers passed a law last year to ensure that uninsured patients would have the same discounted prices at hospitals that insurance companies do. In addition, CIVHC has been working collaboratively with hospitals and physicians to identify appropriate and meaningful quality measures to accompany provider prices that will be displayed on the Colorado APCD later this year.

Medicare should be applauded for taking a step in the right direction and supporting essential health care price transparency. It often takes time and repetition for important information like this to take root, and now we’re on the road to getting enough meaningful data that we’ll be able to capture patients’ and purchasers’ attention. As Medicare indicated, the next critical step is to support data centers in each state to make the information valuable to consumers and allow providers and hospitals to compare themselves on a level playing field. Colorado has a significant head start in making sense of price variation with the APCD and our state’s efforts will only be strengthened by this additional national push for transparency.

Phil Kalin is president and CEO for the Center for Improving Value in Health Care, a nonprofit organization dedicated to improving health care by increasing quality, containing costs and enhancing the population’s health.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

May is a notable month in Asian American history.

On May 7, 1843 — 170 years ago — Nakanohama Manjiro became the first Japanese immigrant to the United States. Twenty-six years later, Chinese laborers completed the trans-continental railroad on May 10, 1869. To mark these historic events and celebrate Asian American and Pacific Islander heritage, each May we celebrate Asian Pacific American Heritage Month. It is a time to reflect on the struggles, contributions, and rich histories of the ethnic and racial groups that make up the Asian American and Pacific Islander (AAPI) community. It is also an apt time to reflect on the unique health experiences of Colorado’s AAPI community.

Over 185,000 Asian American and Pacific Islanders call Colorado home. Arguably the most diverse of any racial and ethnic group, the AAPI community in Colorado includes descendants of and immigrants from 30 Asian and 25 Pacific Island nations. The AAPI population, both in Colorado and across the country, is growing faster than all other racial and ethnic groups. Immigration has much to do with this growth. In fact, Asian Americans recently passed Latinos as the largest group of new immigrants to the United States.

Taken as a whole, Colorado’s AAPI population is one of the healthiest and most well-off in the state. Members of this group have a higher median income, graduate high school and college at a higher rate, and are more likely to be insured compared to the average Coloradan. Perhaps most tellingly, the life expectancy of an average Asian American or Pacific Islander is 12 years longer than most Coloradans. However, looking at this group in total doesn’t capture the considerable variance in health experiences between different groups in this community. The diverse backgrounds and cultures of the AAPI community make data collection and analysis difficult, but the limited information we do have suggests that these differences are worth exploring. When looked at by country of origin and gender, it becomes clear that there are significant economic and health disparities within the Colorado Asian American and Pacific Islander population.

Nationally, some AAPI ethnic subgroups face major health challenges. While only 6.6 percent of Japanese Americans are uninsured, 19.8 percent of Vietnamese Americans and 25.5 percent of Korean Americans are uninsured.  Cervical cancer rates are particularly high for Laotian Americans, Samoan Americans, Vietnamese Americans and Cambodian Americans. Native Hawaiians are three times more likely than non-Hispanic whites to be diagnosed with heart disease and also have the highest rates of lung cancer death.

In Colorado, Asian American and Pacific Islander men lag far behind women in key health indicators. Approximately twice as many AAPI men are obese, smoke, have diabetes and are in fair or poor health compared to AAPI women. Nearly 30 percent of Colorado’s AAPI men do not have a medical home — a doctor’s office or clinic where they go for basic health care services — compared to only 16 percent of AAPI women.

Even though the AAPI population generally does well as a whole in key health and economic indicators, they fare poorly in important preventive health figures. Nationally, AAPIs are less likely to undergo mammograms, Pap smears, and colorectal cancer screenings than whites. And AAPI children and adults are more likely to have had no health care visit to an office or clinic in the past year when compared to their white counterparts.

Another obstacle to optimal health for Colorado’s AAPI population is limited access to culturally-appropriate care. Creating more culturally appropriate health care homes — like the Asian Pacific Development Center is working to do — will help improve access to health care, including preventive visits and services, and hopefully also improve overall health.

Given the growth in Colorado’s AAPI population, it is important that we work to increase our understanding of these disparities and any others that may exist among  Colorado’s AAPI populations. A true celebration for Asian Pacific American Heritage month would be to ensure that we are adequately providing for their unique health needs.

Access the full CCMU infographic on Colorado’s AAPI population at www.ccmu.org/AAPI.

Joe Sammen is the director of community initiatives at the Colorado Coalition for the Medically Underserved.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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