By Katie Kerwin McCrimmon

The young lawyer and mother of two wheeled herself into the ER at Swedish Medical Center, suffering from severe pain after the amputation of her lower right leg earlier this year.

Jessica Peck, right, once met a client in the hospital. The conservative activists does civil rights law and has added disability rights to her specialties after getting an amputation earlier this year.

She was in no condition to be defending herself against a worker’s demand a short time later that she fork over a $400 “deposit” from her hospital bed.

Jessica Peck, the famed conservative activist, was diagnosed at age 5 with a condition known as vascular malformations. Then in 2013, she learned she had a rare neurological condition known as Reflexive Sympathetic Dystrophy. Together, the diseases trigger aggressive destruction of bone, muscle and tissue. She also suffers from tremors that come on without warning.

She’s had approximately 50 surgeries, including the amputation and the earlier implantation of a spinal stimulator that proved unsuccessful.

At times, she’s had to suffer indignities like having to let her 10 year-old daughter take over laundry duty or allowing both girls — the younger one is 7 — haul her 40-pound wheelchair in and out of the car.

“I’m like an 80-year-old, but I’m 36,” says Peck. “Some days I’m mobile and great, but it’s getting tougher with time.”

Despite all the physical challenges and the financial ruin of ongoing medical bills, Peck tries never to take a sick day. She has paid off tens of thousands of dollars in medical debt and is in court on behalf of clients multiple times a week. This week, she has been busy working on a case involving international child abduction.

Born in Virginia and raised in Colorado, Peck specializes in civil rights and family law, often defending young African American and Hispanic boys who she believes have faced disproportionate discipline in schools.

Jessica Peck pulls her wheel chair out of her car as she picks her girls up from school.

Along with her law degree from the University of Denver, she has a graduate degree from Johns Hopkins, where her dissertation focused on the role of race and gender in higher education.

“I have no intention of slowing down and will adapt to current and future limitations,” Peck says.

Last week, however, Peck was feeling lousy, so she went to Swedish where she’s been a patient for 25 years. She’s at high risk for blood clots and wanted to be sure her increased pain was not the result of a clot.

Soon after she arrived and was settled into a room receiving medication, a worker from the registration department came into the room and demanded that she pay a “deposit” for her care.

“I was groggy from meds in a dark room resting and this stranger came in and demanded $400,” Peck said.

It was money she didn’t owe.

Back in January, she had reached her out-of-pocket maximum for the year, then spent most of the month of February at Swedish when she had her lower right leg amputated.

“I met my co-pay obligations eight days into 2015,” Peck said.

The worker relented, but still insisted that unless patients have proof that they’ve met their deductible, the hospital requires a payment on the spot.

“I do not owe this and I will not pay this,” she said.

Peck wonders how the worker decided to charge her $400 and what happens to all the people who aren’t lawyers and might feel bullied into forking over cash they might not owe.

Jessica Peck, with her two daughters, ages 10 and 7. The divorced mom and lawyer has fought to keep working despite two severe illnesses that make her feel like an 80-year-old. During hospitalizations, friends step in to help with the girls. While it was tough to opt for an amputation of part of her right leg earlier this year, Peck said she’s now suffering less.

She said Swedish admissions staff should look at their own records before patients are ever billed, saying they should have known that she’d had extensive care in 2015.

“To arbitrarily demand payment of $400 is not acceptable,” Peck said.

Adam Fox, an advocate with the Colorado Consumer Health Initiative, said his group occasionally hears from consumers who are facing increasingly aggressive hospital billing agents.

Fox said it’s wrong for hospitals to hit up patients for cash when they are at their most vulnerable.
“When someone is in a hospital bed, that’s not what they should be thinking about. It’s not a fair practice. They’re trying to get money out of somebody when they’re at their most vulnerable, when they’re in a hospital and suffering what is potentially a major medical condition. That’s not the time for the hospital to be asking for payment,” said Fox, director of strategic engagement for the consumer advocacy group.
He said hospitals should be negotiating with insurance companies, who should then bill patients later. Under the Affordable Care Act, patients who need financial assistance are supposed to be getting more help from hospitals and Colorado also has a law requiring reasonable payment plans.
“It comes down to consumers being aware of what they are being charged and when,” Fox said.

Spokeswoman Nicole Williams said Swedish uses a computer program common in Colorado and around the U.S. called “Passport” that shows how much a patient will owe.

Williams said it’s standard practice for workers to collect payments in the hospital. Even as a hospital employee, she said she had to make a payment during a recent visit to Swedish after a minor car accident.
She said workers would not have made any exceptions for a patient in a wheelchair or someone with an amputation. If a patient is comatose, can’t breathe or is having a heart attack, hospital workers stabilize the patient first, then work on registering and billing them later.

“If we don’t standardize (the process), then it’s not fair,” Williams said. “It’s part of the process of coming into the ED (Emergency Department) anywhere in Colorado. At some point, you will hit admissions and be told what your deductible is. We don’t look at someone and say, ‘Oh, they’ve had a hard run.’ If someone says, ‘I can’t make a payment,’ we say, ‘OK.’ Everyone does have a different situation. We work very closely with our patients and obviously do a ton of charity care.”

Jessica Peck and her girls took a beach vacation soon after her amputation. She has head to learn to get around with canes and her new bright pink wheel chair.

In Peck’s case, she is insured through the ColoradoHealthOP. Her card does not list an ER co-pay and hospital officials say Passport doesn’t link with the HealthOP’s records.

When Peck asked the hospital worker if he had called the number on her card to find out what she owed, he said he didn’t. She wonders how he came up with the $400 figure and scoffed at a computer system that couldn’t detect any information about her, despite her long history as a patient at Swedish.

“I was there from Feb. 7 to March 3 (for the amputation),” Peck said. “Last summer, I was in for up to 18 days at a time. My body gets atrophied and I can’t move. Maybe their ‘Passport’ should show that I have 25 years of passport stamps at Swedish.”

Fox of the Consumer Health Initiative said it’s greatly concerning that hospitals are using a software system that could be wrong.

“Using a system other than going through the health insurer raises concerns about consumers being incorrectly charged, or, as in the case of this consumer, being charged when they shouldn’t be,” Fox said.
Furthermore, he worries that many patients will simply pay on the spot because they fear if they don’t, they’ll get poor care.

“If they’re feeling vulnerable and concerned about getting the health care they need, they’re probably going to pay whatever is asked of them.”
Williams said billing issues are never tied to care.

“A patient’s ability to pay a deposit or not at the time of service does not impact the care being given,” she said.
Peck said that for the most part, she has received great care from her doctors at Swedish.

But because her pain is extreme, her tremors are hard to diagnose and she needs surgeries twice or more a year, she must use powerful and somewhat experimental medications.

“I was in the ER a couple of years ago at my doctor’s insistence and a staffer said, ‘You’re a junkie.’”

Given that Peck is part of a federally monitored prescription drug program, she is required to provide urine and blood tests, often randomly and at least once or twice a month.

Even a single positive result for an improper medication would mean Peck would be booted from the program. After approximately 36 months of tests since she began the program, she says she has never tested positive for a single drug not prescribed to her.

When the hospital worker accused her of abusing pain meds, she went straight to the front desk attendant and said, “I want a refund. You didn’t provide care and you called me a junkie. That’s not care.”

The worker at the register told her she didn’t know how to give a refund. No one had ever asked for one before and Peck never got her money back.

She did, however, work with staff to create a standard of care whenever she arrives at Swedish.

Jessica Peck picks up her girls from school. Despite her illness, she’s trying to do it all, never taking a sick day and continuing to be the mom who takes her kids to soccer, dance and cotillion.

To navigate all the medical bills, Peck has had to hire a patient advocate to fight on her behalf.
Said Peck: “The billing is worse than anything else in the world.”

That’s saying a lot when Peck has to endure regular treatments during which one of her doctors shoots ethanol into her body to try to break up the malformations and preserve the bones. She jokes that she has had to get used to being a “one-legged rabble rouser.”

Amputation was always in the cards and part of the discussion with Peck’s parents and doctors when she was a child. This year, she felt she had no choice, but to part with her right leg from the knee down.

“The pain was so extreme that I had begged for the amputation after a 2014 that included three months in and out of the hospital I thought, ‘the only way I can get out of here (the hospital) is if I cut the leg off,’ ” Peck said.

“The amputation has saved my sanity. I spend less time in hospitals now.”

Despite her frustration over the recent demand for cash, Peck says she’s doing relatively well at the moment.

“Things are calm, but in a split second, it could get out of control. The malformations are in my hip and my tremors are progressive.”

At risk now is her pelvis and spinal cord. Peck could be in deep trouble if her diseases strike either part of her body.

“They used to give a prognosis. Now, they don’t any more. It’s a strange way to live. Am I going to die or live to be 100? I don’t think I’ve ever taken a day for granted.”

By Katie Kerwin McCrimmon

Child poverty rates and the percentage of children without health insurance continue to decline in Colorado, giving advocates hope that the economic recovery is finally beginning to reach the state’s lowest income families.

Emmanuel Arroniz, 4, gets a checkup at the Rocky Mountain Youth Clinics’ Kids Clinic at Crawford Elementary School in Aurora. The clinic provides care for children in one of the highest poverty areas in Colorado.

The percentage of children living in poverty has declined for the second year in a row and poverty rates for families with children finally reached pre-recession levels, according to new data from the U.S. Census Bureau’s 2014 American Community Survey.

The 2014 rate was 15.4 percent, down from 16.9 percent in 2013.

The decreases two years in a row mark the first time Colorado has seen continuously declining child poverty rates since the survey started in 2000.

“We’re pleased that things are heading in the right direction,” said Sarah Hughes, research director for the Colorado Children’s Campaign. “We are hoping this marks a turnaround.”

The recovery has not been even across the country or in Colorado. Colorado had the sixth-largest percentage decline in 2014 and was one of just 10 states to see a statistically significant drop in child poverty rates for 2014. Hughes said many rural areas of the state are still struggling with a less-than-stellar recovery. County level poverty data will come out later this year, but some parts of the state, like the San Luis Valley, have seen persistent, multi-generational poverty rates that can leave up to one-third of children living in impoverished families.

Even with the recent declines, about 190,000 children live in impoverished families, up from 104,000 in 2000. Poverty is defined as annual income below $23,850 for a family of four.

On the health insurance front, the new census data confirm newer information from the Colorado Health Access Survey, which came out earlier this month and is based on a 2015 Colorado survey conducted by the Colorado Health Institute.

The census numbers from 2014 show that just 5.6 percent of Colorado children lacked health insurance, down from 8.2 percent in 2013. The newer data from the 2015 Colorado Health Access Survey showed an even more dramatic decline in uninsured children, down to 2.5 percent.

Hughes said timing explains the difference in the survey results. Census officials gather data throughout 2014. Some of the early numbers would not have reflected full implementation of the Affordable Care Act. Colorado has seen some of the largest jumps in the country in its Medicaid enrollment and health experts have said that as adults got health coverage, so did their children.

“Kids in Colorado are among the biggest winners in health reform,” said Chris Watney, president and CEO of the Colorado Children’s Campaign. “Expanding Medicaid access for whole families and establishing our own, state-based Colorado (exchange)… are among the reasons that Colorado experienced the nation’s second-largest percentage point decline in the rate of kids without insurance.”

Hughes said health insurance for families allows children to get preventive care and immunizations. They also have a place to go if a child gets sick.

“We’re on the right track. We have more kids covered by health insurance in Colorado than ever before,” Hughes said.

Coverage does not guarantee a child will have a provider, but school based clinics and community health centers are helping provide access for newly covered children in some parts of the state.

Children from Latino families continue to struggle the most. While many more African American and Native American kids got health coverage, Hispanic kids still are most likely to be uninsured. The census data showed that 9.6 percent remained uninsured in 2014, down from 13.1 percent in 2013.

The 2015 Health Access Survey showed similar trends for Hispanics of all ages. Hispanics had the highest uninsured rates overall. About 11.8 percent of Hispanics remained uninsured in 2015, compared to 21.8 percent in 2013, according to the Colorado Health Access Survey.

Geographic and ethnic disparities remain a challenge for the state.

Said Hughes: “We still have work to do to make sure all kids can access high quality coverage.”

By Katie Kerwin McCrimmon

Colorado’s health exchange board unanimously voted on Monday to give its chief strategy and sales officer a contract that could pay up to $150,000 for six months of work.

On an annual basis, that’s a higher rate of pay than the interim CEO for the exchange who receives $199,200 a year and more than triple what the governor of Colorado receives: $90,000 a year.

Marcia Benshoof will get paid $120 an hour and up to $150,000 over six months at Colorado’s health exchange. Lawmakers are questioning her lucrative contract.

The lucrative contract comes after exchange managers earlier this year hiked costs for customers to fund a ballooning budget and vowed to operate more efficiently with fewer highly paid contractors and more salaried employees. The previous head of Colorado’s exchange, Patty Fontneau, incurred the wrath of some critics when she sought a raise and bonuses when the exchange was performing poorly.

The exchange board met in secret during an executive session on Monday, then voted in public on the contract for Marcia Benshoof. She will receive $120 per hour and up to $150,000 during the next six months. A spokesman called Benshoof’s work “invaluable.”

Altogether over the past three years, Benshoof has received $542,880 for consulting work and expenses. On top of that, she worked for seven months in 2014 and early this year as an exchange employee. During those seven months, she earned $165,000 a year or about $96,200 in additional pay.

She’s not alone in receiving a high-paying contract. Another high-level exchange manager, Adele Work, worked as a contractor from spring of 2012 to spring of this year and the exchange paid North Highland Consulting just over $1 million for Work’s services. Earlier this year, Work became an exchange employee — chief information officer — and now earns $165,000 a year.

Among other work, Benshoof has overseen the small business exchange. As of April of this year, the small business exchange had only attracted 329 employer and 2,589 individual customers. In a report to board members at that time, Benshoof conceded that the small business exchange was “underperforming” and was at a critical juncture. Managers promised to make the system easier to use, but have shelved any fixes until spring.

Benshoof also oversees brokers working with the exchange, does outreach and eligibility work, partners with insurance carriers and federal officials, and is the official “insurance license” holder for the exchange, according to interim CEO Kevin Patterson.

In presentations to the board about enrollment projections this year, Benshoof has said that the exchange will have to perform much better in 2016 than it has in previous years. She predicted individual sign-ups closer to 217,000 for 2016, compared to about 143,000 for 2015. And she is gambling that the small business exchange will cover nearly 7,000 people by the middle of next year, compared to over 2,500 this year.

So far, the health exchange has not managed to attract the majority of customers in the individual market. The Colorado Health Access Survey released earlier this month found that Colorado’s exchange so far has captured 42 percent of the individual market.

After the Monday vote, the exchange’s lawyer, Alan Schmitz, and spokesman Luke Clarke both tried to stop Benshoof and board members from commenting on the contract.

Benshoof declined to comment.

Board Chair Sharon O’Hara said that the contract amounted to “appropriate spending” and “is necessary.”

Adela Flores-Brennan, a board member and former Connect for Health employee who now represents consumers as head of the Colorado Consumer Health Initiative, declined to explain why she voted yes.

Patterson said he recommended that the board approve Benshoof’s contract.

“When you look at the amount of responsibility and work that Marcia has to do, I think it’s very justifiable,” Patterson said after the board meeting. “She has a unique set of skills and a history of knowing this insurance world extremely well.”

Why not then make Benshoof a salaried employee?

Patterson said it’s unlikely he could replace Benshoof with a single person. He said she has the expertise, knowledge and relationships that add value for the exchange.

“For what she is able to deliver to our organization, I think it’ is the right amount (of pay),” Patterson said.

Exchange critics, however, said that the contract for Benshoof is typical of out-of-control spending at the exchange.

“Unfortunately, I’m not surprised, but I’m deeply disappointed,” said Sen. Kevin Lundberg, R-Berthoud, who sits on the legislature’s exchange review committee. “I’m not surprised because I’ve found that they spend money like water. They’ve already burned through (as much as) $200 million setting this whole system up and it’s still not functioning as expected.”

Lawmakers have tried to more carefully scrutinize exchange managers and board decisions. But Lundberg said the committee has little power over decisions like contracts.

Lundberg is planning to introduce a bill next year that would require voter approval for consumer cost hikes at the exchange that he believes amount to illegal taxes. Unlike a typical fee, Lundberg said all Colorado customers who buy health insurance have to pay to fund the health exchange and he calls that an illegal tax.

He said high pay has been the rule, not the exception at the exchange.

“Everybody who had done anything (for the exchange) has been paid well beyond the scale for state workers,” Lundberg said. “This is part of the state of Colorado. The state seal is on all their letters. They are created by the state. Yet they operate with impunity.”

Connect for Health Colorado is a public entity, but operates independently of state government.

“I believe their entire system is a fantasy. It does not provide affordable insurance for the people of Colorado. It just adds a layer of bureaucracy. They have driven a lot of people into Medicaid, but fewer people can afford to pay their medical bills,” Lundberg said.

Sen. Beth McCann, D-Denver, who is vice-chair of the legislative oversight committee, said that exchange workers have “confronted an extremely heavy work load with many challenges. Overall, they have been successful in signing up large numbers of people both for Medicaid and private insurance.”

McCann said “much work remains to be done” particularly with respect to glitches in the enrollment system.

“Marcia appears to be highly qualified and committed to the success of Connect for Health. The potential of $300,000 a year, if that is in fact the case, is too high. I would hope the Board will monitor her hours so that her compensation remains within reasonable limits, certainly not more than the CFO or CEO are making.”

Benshoof joined Connect for Health Colorado in 2012. She initially worked as a contractor at a rate of $74 an hour, a rate that jumped to $85 an hour, then to $120 per hour this year. Altogether, Benshoof has received $542,880 for consulting fees and expenses over the last three years, according to exchange spokesman Luke Clarke.

For six months last year and one month this year, Benshoof, worked as an employee for the exchange at a compensation rate of $165,000 per year. At the end of January this year, Clarke said she asked to go back to being a contractor.

By Bethany Pray

The Colorado Health Institute’s Colorado Health Access Survey (CHAS) data released earlier this month shows encouraging evidence that health care policy changes are resulting in more Coloradans getting health insurance coverage. According to the report, the rate of Coloradans without insurance dropped to a historical low of 6.7 percent — or 353,000 people. Meanwhile, a mere 2.5 percent of children are going without coverage. Much of the coverage growth can be attributed to two changes brought by the Affordable Care Act: Medicaid expansion and the availability of subsidized coverage through Colorado’s health care exchange, Connect for Health Colorado.

Bethany Pray

Yet, despite improvements in coverage, many Coloradans are “underinsured” — meaning that they lack adequate protection against high health costs relative to their income. CHAS defined people as underinsured if they had spent a substantial share of their income on out-of-pocket medical expenses — with the share set at 5 percent or 10 percent depending on the level of income. For example, a family of four with an income of $50,000 would be underinsured if their out-of-pocket expenses exceeded $5,000. A young adult with an income of $22,000 would be underinsured with expenses of $1,110 or more. In 2015, CHAS categorized almost one-fourth of those covered through the individual market as underinsured and 16 percent of Coloradans overall. We would argue that the actual number of the underinsured is likely to be even larger than CHAS suggests, for reasons explained below.

Who is underinsured?
According to CHAS data, those most at risk of underinsurance have lower incomes, are young, have health problems or live in rural areas of Colorado. For those 19 to 29, more than 20 percent were underinsured. While data on African American and Latino populations is not yet available through CHAS, the lower median income for both groups makes it likely that underinsurance is higher for those groups as well.

Do the figures capture all those who are underinsured?
The numbers of underinsured may be significantly larger than CHAS data suggest. The CHAS data identify those people who actually spent over a certain amount for health care. The numbers failed to capture those who were either at risk of having to spend significant portions of their household income on health care, or those who had health care needs they could not afford to treat. Take the case of Holly Wilson, an employed Denver resident who declined to take blood pressure medication for three months because her $2,500 deductible made it unaffordable.

In an effort to capture that additional sector of the underinsured, studies from The Commonwealth Fund included a third group – people whose deductibles exceeded 5 percent of family income – in their definition of the underinsured. In 2014, half of those characterized as underinsured by The Commonwealth Fund fell into that category because of high deductibles alone. Use of this standard could mean that Colorado has twice as many underinsured as reported in CHAS, and that as many as half of low-income adults (under 200 percent of the federal poverty level [FPL]) are underinsured.

Deductibles tend to be higher in the West, and Colorado’s average is a formidable $3,476, according to a report from The Commonwealth Fund. Based on The Commonwealth Fund’s definition, a family with the average Colorado deductible would be underinsured if its annual earnings were less than $69,520. CHAS data on the percentage of people who skip care because of cost provides a window into this additional group of the underinsured. Although many Coloradans now have insurance, CHAS figures from 2015 regarding those who forgo care are close to 2013 levels: 9.8 percent failed to fill a prescription, 10.4 percent failed to see a doctor, 11 percent failed to see a specialist and 17.1 percent did not see a dentist.

Are large deductibles really so hard for people to afford?
What underinsurance points to may be a disconnect between financial realities for most Coloradans and the substantial deductibles that have increasingly become a component of most plans. A recent Kaiser Family Foundation study found that nationally, only 32 percent of lower-income households (defined as those between 100 and 250 percent of the FPL) had sufficient resources to pay a $1,200 individual deductible or $2,400 family deductible. Until he or she exhausts that deductible, an individual must pay full price for office visits, medical procedures and medications. With a higher deductible – such as Colorado’s average of $3,476 – even many of those with higher incomes will struggle to cover costs. Kaiser’s data indicate that only about 40 percent of households between 250 and 400 percent of the FPL could cover a deductible in the range of Colorado’s average. Among those who make more than 400 percent of the FPL, almost a third still lack sufficient on-hand resources.

Another Kaiser study quotes a Federal Reserve conclusion that “only 48 percent of Americans would be able to completely cover a hypothetical emergency expense costing $400 without selling something or borrowing money.” Anyone who encounters a brief hospitalization or has a child newly diagnosed with asthma is likely to have to come up much more than that — even before cost-sharing begins.

What are the effects of underinsurance?
Those who are underinsured may risk bankruptcy and debt, may have to cut back on other essentials, and may lack access to care. Although historically one of the worst outcomes of underinsurance was medical bankruptcy, the ACA’s cap on out-of-pocket expenses appears to have made inroads on this issue. CHAS data indicate that medical bankruptcy has declined by more than 50 percent in Colorado since 2013.

However, people continue to incur debt or suffer other financial consequences. For the 15.2 percent in Colorado who continued to have difficulty paying medical bills, about two-thirds saved less or took funds out of savings, and almost half took on credit card debt. A comprehensive 2009 analysis by CCLP on the affordability of health care found that when health care consumes more than 5 percent of family income, families had to cut back on other essential expenses such as food, transportation, housing, clothing and child care to pay for it. Those whose income was 200 percent of the federal poverty level or less had essentially no funds to devote to health care costs, so any medical expense was unaffordable.

Lack of access to care may be the greatest concern, if it results in worse health outcomes and potentially greater hospital or emergency-room costs. Had Cathy Wilson’s failure to treat her high blood pressure led to a stroke, the financial and personal consequences could have been devastating.

Where do we go from here?
If Colorado’s goal is to have people not just insured, but able to get the care they need without incurring debt, more work must be done. Purchasers of insurance need to know how high or even moderate deductibles might affect their access to care and their household budgets, so that monthly premium costs are not considered in a vacuum. And policymakers might consider the causes of rising deductibles, look into why the West in particular has outpaced other regions in terms of average deductibles, and make changes so that “access” is more than just theoretical.
Bethany Pray is health care attorney for the Colorado Center on Law and Policy.

By Katie Kerwin McCrimmon

Yanto, left, a student from Indonesia studying at the University of Colorado, signs up his pregnant wife, Nachiyati, for Medicaid. Their two daughters, born in the U.S., both receive Medicaid while the family is living in Colorado. Almas, 2 1/2, was born with a congenital heart condition, but is doing much better after surgery and soon will be off oxygen. (Photo by Katie Kerwin McCrimmon, Health News Colorado)

Colorado’s uninsured rate has plummeted from a recent high of 15.8 percent four years ago to 6.7 percent this year, and the success of the Affordable Care Act in Colorado is almost entirely the result of Medicaid expansion, according to a much anticipated survey from the Colorado Health Institute.

The survey found that nearly one in three of the state’s 5.3 million residents now get insurance through Medicaid or other public health insurance programs.

With nearly 1.3 million Coloradans now on Medicaid, the state has the fourth fastest-growing Medicaid program in the country behind Kentucky, Oregon and Nevada, according to an analysis earlier this year from the federal Centers for Medicare & Medicaid Services.

The surge of Medicaid recipients in Colorado shattered Gov. John Hickenlooper’s 2013 projection that the state would add about 160,000 new Medicaid clients over 10 years without costing the state budget “a single dollar.”

According to the Colorado Health Access Survey, the state has 450,000 more Medicaid recipients in 2015 than in 2013. In states that expand their Medicaid programs under the health law, nearly all low-income Americans with incomes up to 138 percent of poverty ($16,242 per year for an individual in 2015) would qualify. Pregnant women and children in families with higher incomes — up to 260 percent of the federal poverty level or $60,700 for a family of four — can qualify for the Child Health Plan Plus in Colorado.

State officials are highlighting Colorado’s success, saying the state is close to covering everyone. In particular, they cited a major drop in the number of children who remain uninsured, from about 7 percent to 2.5 percent.

“Colorado is a state that has done what it set out to do. We got more people insured,” said Michele Lueck, president and CEO of the Institute, a research group. Analysts conducted the survey of 10,146 randomly selected households, including landlines and cell phones. The poll was conducted after open enrollment ended, between March 2 and June 26.

Sue Birch, executive director of Colorado’s Medicaid programs, says she and Gov. John Hickenlooper stand by their promise that Colorado taxpayers will not have to spend extra money to pay for a major influx of new Medicaid patients. (Photo by Katie Kerwin McCrimmon, Health News Colorado)

Sue Birch, executive director of Colorado’s Medicaid programs, downplayed the governor’s much lower projections for Medicaid expansion.

“The most important thing is that people got covered,” Birch said.

She said she and the governor stand by the promise that over 10 years, Medicaid programs will save enough money to cover the cost of additional patients.

“Health care transformation is an investment in time and the right strategies. Colorado has made the right choices and they are starting to pay dividends,” Birch said.

She said preventive care among patients is up, total cost of care per person is down 9 percent since Medicaid expansion started, more providers are stepping up to care for Medicaid patients and people with chronic conditions are getting better primary care.

“This was an invisible population,” Birch said. “Colorado’s story is about all this movement toward health.”

Most states that have expanded Medicaid have found that they guessed far too low, said Matt Salo, executive director of the National Association of Medicaid Directors.

“It’s hard to forecast what actually happens when you change a lot of pieces in an interconnected health care system,” Salo said. “A lot of states are finding that they’re enrolling more people (who qualify for Medicaid) than they assumed lived in the state.”

Those states include Colorado, Washington, Oregon, Kentucky and Ohio, Salo said.

“When you’ve got a state like Colorado that really puts its shoulder behind Medicaid expansion and expansion in coverage is something you go all in on, you’re going to see significant impacts,” he said.

Thus far, 31 states including the District of Columbia have expanded Medicaid and even in a place like Ohio with a Republican governor running for president, there is no sign of backpedaling, Salo said.

“There have been very, very few examples where a big expansion has been followed by a big retraction,” he said. “Once you’ve actually given insurance to hundreds of thousands of people who didn’t have it before, taking it away is a very real thing.”

While many patients with new coverage welcome the chance to see doctors, skeptics say Colorado taxpayers will have to pay dearly for the ballooning Medicaid population starting in 2017 when the federal government no longer picks up the full tab for new clients. Federal assistance falls to 95 percent that year and gradually decreases until it reaches 90 percent in 2020.

“You didn’t have to be a brain surgeon to see this coming,” said Sen. Ellen Roberts, a Republican from Durango, Colo., who tried to persuade the governor in 2013 not to add so many people to the Medicaid rolls all at once. “We’re putting Medicaid expenditures on a collision course with every other state expenditure, from K-12 (education) to highways to higher education. Medicaid is just consuming our state budget.”

The survey, which the Institute conducts every other year, also found that Colorado’s health exchange for individuals buying private insurance failed to capture the majority of that market. Despite spending nearly $200 million in federal funds on start-up costs and IT systems that have thus far been full of glitches, Connect for Health Colorado accounts for just 42 percent of the individual market; the number of individuals signing up for private health insurance in the individual market has stayed roughly the same since before the Affordable Care Act launched — about 409,000.

Other trends emerging from the Colorado Health Access Survey parallel those around the country:

• California and Ohio data show dramatic drops in their uninsured rates. The Gallup survey found the sharpest declines in states that expanded Medicaid. Obama administration officials in August said the uninsured rate dropped nationally to 9.2 percent, from 14.4 percent in 2013.

• The percentage of people getting health insurance through their jobs has fallen from nearly 58 percent in Colorado in 2009 to 51 percent this year. More large employers in Colorado are providing health insurance, while small businesses are dropping coverage.

• Gaps in coverage include undocumented workers who don’t qualify and people living in ski resort regions and rural western Colorado, many of whom say health coverage costs too much.

• Nearly 12 percent of Hispanics in Colorado still don’t have insurance, compared to about 5 percent among others.

• In a surprise finding, Colorado hipsters in their 30s are skipping health insurance at even higher rates than those in their 20s. In both cases, about one-quarter of so-called young invincibles used to be uninsured. While many more now have coverage, 12.9 percent of twenty-somethings and 13.4 percent of thirty-somethings still are not buying health insurance.

• The high cost of health insurance is by far the biggest reason people cite for skipping coverage.

• While the ranks of the uninsured have dropped a lot in Colorado, those who are “underinsured”— meaning they don’t have enough coverage to pay for expensive health care problems — has continued to grow over the past four years. Low-income people have the highest rates of being underinsured as do those who buy their insurance on the individual market.

Sen. Roberts chairs a legislative oversight committee that will start considering legislation this month about whether to keep Colorado’s exchange or consider folding it into the federal exchange. The biggest complaint Roberts hears from residents in her area in southwestern Colorado is that people qualify for Medicaid, but don’t want it because they can’t find providers who will care for them.

On the other hand, in Jefferson County in the Denver metropolitan area, health professionals were ready for the surge of new Medicaid clients. In Wheat Ridge, patients are getting care in a polished new community health center where they receive integrated physical, mental health and dental services all in one place.

Jefferson County hugs the foothills west of Denver and is the state’s fourth most populous county. There, the uninsured rate dropped a stunning 75 percent in just two years from 11.6 percent to 2.8 percent. That was the largest decrease statewide, according to the survey; analysts found that about 50,000 fewer people are now uninsured in Jefferson County than in 2013.

New Medicaid recipient Marty Rieger of Lakewood, Colo. stands outside the new clinic where he gets care. In the Colorado county where Rieger lives, a record number of uninsured have received care over the last two years. (Photo by Katie Kerwin McCrimmon, Health News Colorado)

Many are new Medicaid recipients, including Michael Goffinett, 53, of Lakewood.

He used to have insurance with his job as a fire restoration worker. Then he lost his job and need back surgery. First he got Medicaid and started going to the Wheat Ridge clinic. Now his wife and son also get coverage through Medicaid.

“It’s been a great help for me and my family. They’re always there for me,” Goffinett said as he braved his fears of dental care and had a cavity filled recently at the nonprofit Metro Community Provider Network’s Wheat Ridge clinic.

“They’re good,” Goffinett said of his doctors. “If you have a job or you don’t have a job, they take care of you. No hassles.”

Goffinett’s dentist, Dr. Fatima Kazi, had a waiting list of more than 200 patients when she started working at the Jefferson Family Health Services Center in December.

She had previously worked at other public health clinics in Colorado and welcomed the chance to practice at the big new clinic full of large windows, natural light and state-of-the art equipment.

“It’s beautiful,” Kazi said. “It’s comprehensive care in one place. That’s what makes a lot of public health successful. Patients only have to come to one location and they can get most of their treatment in one location.

“Part of the reason I do public health is that I believe everybody should have access to health care,” Kazi added. “Dentistry is not cheap. You can choose not to take care of your teeth and end up in the emergency room.”

She said having easily accessible dental care side-by-side with primary care makes it much easier for patients like Goffinett to come. He hadn’t seen a dentist in several years, but started having pain and his doctors sent him to the dentists.

As Kazi worked on his teeth, Goffinett fidgeted and kept asking if she was done.

“It’s the first time I’ve really dealt with my teeth. I love my dentist, but I don’t like going,” he said.

In the mental health section of the clinic, children with severe problems have group sessions with therapists while adults get help from peer counselors who have struggle with schizophrenia and other challenges themselves.

John Reid, vice president of fund development for the Metro Community Provider Network, credits the clinic’s CEO with having the foresight to brace for the surge in patients in Jefferson County and the other suburbs that surround Denver. The network got federal and local grants of more than $13 million to buy the land and open the Jefferson Family Health Services Center in Wheat Ridge in 2013. As the network finds and hires providers, it can treat more people and expects to serve about 10,000 patients at the center when it’s full.

Altogether, the network boasts 23 safety-net clinics, 10 of which are in Jefferson County. Last year, the network served nearly 43,000 patients. Some of the clinics are in schools while others are partnerships with the Jefferson Center for Mental Health.

The bump in Medicaid patients has been huge, Reid said. Previously about one-third of network patients qualified for Medicaid. Most of the rest were uninsured. Now nearly two-thirds of patients have Medicaid.

Reid said all the networks clinics are seeing thousands of new patients. They serve them regardless of their insurance status. Many are undocumented immigrants who can’t qualify for Medicaid.

“We want to be fiscally and financially sound. At the same time, we’re a community partner. We want to do what’s in the best interest of each and every patient, every touch every time. That’s our motto and we really live by that credo,” Reid said.

With the rush of patients in Jefferson County, some are arriving with severe problems.

Jamie Vader, a physician’s assistant at the Wheat Ridge Clinic, cared for a 61-year-old woman who arrived last week with severe abdominal pain. Vader and a student working with her did an extensive history and suspected more than the first-brush diagnosis of a bladder infection. They feared possible cervical cancer.

Tests showed they were right. The woman came back two days later. She was devastated, but the clinic set her up with a specialist to treat the cancer along with mental health care and a care coordinator to help her navigate the many appointments she’ll now need.

“It’s been over 10 years since she had any well care. Had she gotten care then, she wouldn’t have cancer,” Vader said.

The woman’s prognosis is not good since her cancer is so advanced.

While it’s good that people are getting coverage now, Vader said she’s seeing many sad cases.

“You have to clean it up first,” she said “We’ve always had a lot of really sick people. There are just more of them.”