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 Dr. Larry Wolk

Since 2001, Aug. 31 has marked International Overdose Awareness Day. In 2013, thanks to Gov. John Hickenlooper, Aug. 31 also is Colorado Overdose Awareness Day. On this day, we take time to raise awareness of overdoses, reduce the stigma of drug-related deaths, educate the public on prevention and acknowledge the grief felt by families and friends of those who died prematurely because of a drug overdose.

Dr. Larry Wolk

 An overdose occurs when a person’s body is unable to process the amount of a drug or drugs in his system. When the drug is an opioid pain reliever or heroin, a person will experience respiratory depression, depriving the brain of oxygen, and eventually a loss of consciousness. Without oxygen, the heart stops beating and the person dies. Timely recognition of overdose signs and symptoms is essential to keeping people alive.

 Drug overdose death rates in the U.S. have more than tripled since 1990 and continue to rise in Colorado. Colorado Department of Public Health and Environment data show 9,672 Coloradans died from drug overdoses between 2000 and 2014. Opioids were the main factor in at least 3,213 of these deaths. While some of these deaths involve illegal drugs, many more involve prescription painkillers — drugs many of us have in our medicine cabinets.

In 2013, Gov. Hickenlooper’s office, state agencies, prescribers, universities, pharmacists and others developed the Colorado Plan to Reduce Prescription Drug Abuse. Since 2012, the Colorado Legislature has passed three new laws aimed at reducing the harm associated with overdose in Colorado.

• The 911 Good Samaritan Law gives immunity to people who suffer from, and report, an emergency drug- or alcohol-related overdose. Without threat of prosecution, people who otherwise would be reluctant to report such an event can rest assured they won’t be prosecuted by the legal system. This is a lifesaver for many people.
• Most overdoses are unintentional and witnessed. In most cases, lives could be saved by the timely administration of Naloxone, a prescription drug that reverses the effects of opioids. In Colorado, Naloxone now is available to third parties, including family members, friends, law enforcement officers and any person in a position to assist someone with an increased risk of overdose. Licensed prescribers, dispensers of Naloxone and anyone else who administers Naloxone in good faith to someone who they believe is experiencing a drug overdose are immune from criminal prosecution.
• During the 2015 legislative session, Colorado passed a law providing standing orders for larger access to Naloxone around our state. As chief medical officer at the state public health department, I will issue standing orders for Naloxone to be dispensed by pharmacies and harm reduction organizations to expand statewide Naloxone access to those who need it most. Today, you can walk into six pharmacies across the state to get this lifesaving drug. We expect many more will participate in this opportunity to save lives.

Overdose Awareness Day and Colorado’s efforts send a strong message to current and former drug users: You are valued. To those who have ever loved a drug user, let us remember those who have died by educating our communities and helping prevent others from losing loved ones to overdose. We can do this together.

Dr. Larry Wolk is executive director and chief medical officer at the Colorado Department of Public Health and Environment.

Before this fiasco is over we could have rebuilt every hospital along the Front Range.

Francis M. Miller

Francis M. Miller is the past president of the Colorado Business Coalition for Health and the vice chairman of the Colorado Health Data Commission. He founded the first consumer cooperative for health care called the Alliance and is the current president of Health Smart Co-op. He blogs on www.thethoughtczar.com.

By Sharon Adams

There is nothing simple about the state of health care in Colorado. It’s filled with activities and initiatives around delivery system redesign, payment reform, quality improvement and practice transformation.

All of this work and innovation is designed for better care delivered at a lower cost with greater patient satisfaction. Colorado’s Community Safety Net Clinics know a thing or two about innovation, transformation, cost effectiveness and serving patients and families, and doing so on extremely tight budgets.

Sharon Adams

Safety Net Clinics have and will continue to make life-changing differences every day in their communities. They remain a vital part of the health care delivery system during times of change, including  health care reform.

While the number of uninsured individuals and families in Colorado has decreased, having insurance coverage does not always translate into easy access to health care services. There are also other unintended consequences of health care reform, but as with anything new, there are going to be bumps in the road.

Health insurance coverage can be very confusing, and the newly insured often struggle to understand their coverage. Some providers in our communities don’t accept certain insurance, and for some newly insured patients, the deductibles, copays and coinsurance are still too expensive, so they delay getting care despite having coverage. Safety Net Clinics are skilled at being adaptable and flexible in the face of change, and they are continuing to find ways to provide health care to those in need.

Colorado’s Community Safety Net Clinics include approximately 40 sites serving Coloradans who are lower income and uninsured, underinsured, and/or insured through public programs like Medicaid, CHP+ and Medicare. These clinics do not turn away an individual or family based on an inability to pay.

In addition, they provide care on modest budgets with limited paid staff. Safety Net Clinics do not receive supplemental federal funding to provide services to people in need. Instead, they fund their operations through philanthropic donations and grants, modest patient revenue and in-kind donations. In addition,  some staffing models rely heavily on volunteer providers and administrators.

Last year, Community Safety Net Clinics provided an estimated 495,000 visits to approximately 150,000 underserved Coloradans.

Finding a health care professional who provides patient-centered, culturally competent care can be a challenge for low-income, at-risk individuals and families. These clinics seek to meet patient needs by providing one or more health care services including primary care, behavioral health, oral health treatment, optical and/or specialty care.

In addition, these clinics help address other factors such as transportation, child care, and food and housing challenges that can create barriers to their patients achieving the best possible health outcomes. Access to specialty care remains a challenge for many patients, and Safety Net Clinics work hard to try to  enable specialty care access for patients.

The patients served at these clinics are men, women, families, children and seniors. Many adults work full time, some are stay-at-home parents and some are retired after decades of work. Some are children who live with families caught in the margins.

In many cases, patients are uninsured because they are not eligible for any coverage, and many others are unemployed or simply find that the newer coverages are still unaffordable. In all cases, these people are members of our communities who need access to health care.

During Safety Net Clinic Week, Aug. 17-21, 2015, we recognize clinics that continue to meet the needs of the communities across our state. We celebrate doctors, nurses, other health care professionals, and the countless volunteers who work selflessly to ensure that all people have access to health care.

Sharon Adams is the executive director of ClinicNET, the centralized voice for Colorado’s Community Safety Net Clinics, committed to strengthening Colorado’s safety net for people in need by advancing health equity, health care access and innovative care delivery.

By Bethany Pray

Programs of All-inclusive Care for the Elderly (PACE) provide a range of services to people over the age of 55 who qualify for nursing-home level care but wish to retain their independence.

PACE programs are responsible for providing enrollees, many of whom have chronic illnesses or are in fragile health, with all aspects of medical care: doctor’s visits, medications, day programs, behavioral services, hospital care, and long-term services and supports. Most PACE participants are enrolled in both Medicare and Medicaid.

Bethany Pray

The philosophy and structure of PACE programs came from an innovative program in the early 1970s that brought together adult day centers, in-home care, home-delivered meals, etc., to residents of the Chinatown-North Beach community of San Francisco. That program’s success led to pilot programs in the 1980s and 1990s, and culminated in 1997 legislation to establish such programs nationally.

Final regulations published in 2006 permitted only nonprofit or public entities to operate PACE programs, though the original legislation also allowed a handful of programs to apply for participation in a for-profit demonstration project. The goal of the demonstration project was to evaluate whether for-profit programs could achieve similar outcomes to the nonprofit or government entities.

In May 2015, the Centers for Medicare and Medicaid Services presented a report to Congress showing that the for-profit demonstration PACE programs did, in fact, meet the required criteria. The findings triggered a provision in the original PACE legislation that required CMS to accommodate for-profit PACE providers.

Until this year, Colorado law mirrored federal law by requiring PACE providers to operate as nonprofits. Colorado legislation anticipating the change was enacted this past spring and paved the way for nonprofit PACE providers to convert to for-profit status. InnovAge, Colorado’s largest PACE provider, worked on Senate Bill15-137, which passed.

Why would such a conversion matter to Coloradans? Conversions from nonprofit to for-profit status raise some important concerns: What happens to the value accrued by the nonprofit? How does the public know what that value is? Who should benefit from those dollars? What happens to those already using PACE services during the transition from nonprofit to for-profit? And how will we ensure that the for-profit entity continues to provide the same or better care to this vulnerable population?

A general principle regarding nonprofit entities is that their value is derived from charitable, tax-exempt funds and must remain dedicated to public benefit. Whatever the original source of those funds, a nonprofit truly belongs to the public.

The assets of PACE programs derive from the savings realized through beneficial tax status, and from grants given by charitable organizations (not to mention, substantial Medicare and Medicaid dollars). Public citizens might be seen, therefore, as the nonprofit’s owners. The public paid for it – so in a sense, the public “owns” it.

Recognizing the likely impact that these conversions would have on the public, the Colorado Center on Law and Policy worked with supporters of the Colorado legislation to amend SB 137, helping to ensure that there is a public process associated with any conversion through which stakeholders can weigh in.

The amendments require nonprofit PACE providers to submit a conversion plan to Colorado’s Attorney General at least 60 days before a conversion is to occur. That plan must include a valuation of the fair market value of the business, a detailed explanation of how the value of the nonprofit will be distributed upon conversion, a description of the nonprofit entity that will receive the proceeds and the composition of its board of directors, information regarding any bonuses that officers or directors of the converting entity will receive as a result of the conversion, and audited financial statements for the three most recent years.

The AG will then post the conversion plan and ensure that stakeholders have at least 30 days to comment on any aspect of that plan, from the valuation to the type of charitable foundation that will receive the funds. Under common law principles, and as embodied by Colorado conversion law specific to hospitals and insurance companies, the purpose of foundation dollars resulting from a conversion should remain as close as possible to the original purpose of the funds.

In the case of a PACE program, the value would be expected to continue to benefit older and disabled people who wish to maintain their independence. Health care for this group should be of paramount concern to the public, especially when one notes that Colorado’s population of those 65 and over is expected to more than double by 2030, according to a report from the Bell Policy Center.

PACE conversions are on the horizon. Current or future recipients of services, family members, caregivers, providers and advocates will have a vital role in ensuring that the full value of PACE programs’ public dollars continues to benefit older and disabled Coloradans to the greatest extent possible.

Bethany Pray is health care attorney for the Colorado Center on Law and Policy.