By Aubrey Hill
Supreme Court Justice Louis Brandeis first articulated the oft-quoted philosophy that states are the laboratories of democracy, in which “novel social and economic experiments” can be tested. We at the Colorado Coalition for the Medically Underserved assert that while our state has made some innovative policy decisions regarding health care, our local communities are the true laboratories for change.
The proof is in our project, Health Is Local, which was established to monitor and understand the impact of health reform and is set in four strategically chosen communities in the state: Yuma County, Montrose County, Summit County, and the city of Colorado Springs. We initially interviewed residents and leaders of these communities last November and then again this spring, once the majority of the policy changes associated with health reform had been implemented.
We can now confidently say that health reform has begun to tangibly impact most communities, and while every community is experiencing it a little differently, there are shared themes across the state. One of these was the high level of effort centered on educating and enrolling qualified residents in Medicaid and Connect for Health Colorado plans. Overall, the whole state enrolled over 300,000 residents into new coverage options. Though we cannot yet assess how many of those were previously uninsured, community leaders expressed sincere enthusiasm for the positive individual impacts that having insurance will make for these new enrollees.
These enrollment efforts have been met with some barriers, however, and concerns about affordability of private plans rose to the top. We heard through all communities that even with the sliding-scale tax credits for some Connect for Health Colorado plans, coverage was still out of reach for some residents, especially those whose incomes were close to four times the poverty level. Additionally, for those who had purchased plans, concerns about the high premiums and deductibles meant that residents were uncertain for how long they could maintain their coverage.
With the first hurdle that communities faced—ensuring residents could take advantage of expanding coverage opportunities—partially cleared, many communities are now moving on to issues of access to care. In some communities, such as Montrose, there are real concerns about the capacity of the system to care for the newly enrolled, especially around a perceived shortage of providers that accept Medicaid. In other communities though, such as Colorado Springs or Yuma County, the systems were prepared for the growth in patients and thus have not faced the same issues.
While the coverage and access landscape have begun to shift, public perception of health reform and a desire for local control have predominantly stayed the same. Community leaders report that for individuals, local opinions of health reform mostly remain a mix of frustration and confusion. For leaders, the opinions are generally more positive, but still remain focused on and committed to implementing health reform in a way that is aligned with local priorities. In Yuma County, there is widespread interest in leveraging the strong collaboration between hospitals, clinics, and providers to address patient engagement and personal responsibility for health. In Summit County, leaders are more focused on developing new models of care and addressing cost issues.
This project was founded on the ardent belief that health is local, and that we cannot understand the impact of health reform without understanding its local impacts. We have found that national and state narratives do not do justice to the complex and diverse experiences of health reform the way that local narratives can. Every community has its own health care system shaped by its priorities and resources, and nearly every community has been working to improve their health care system since long before the Affordable Care Act (ACA) even passed. Now, these communities are adapting and adopting tools provided by the ACA and state law, and the results are understandably varied. We will continue to give voice to these experiences from our local laboratories of change and hope you’ll join the conversation.