STATEWIDE IMPACT

Apples

The story of health reform in Colorado

Colorado has been in the midst of health care systems change for many years, and each community has developed its own local strategies. There are many opinions—from the extremely positive to the extremely negative—about the changes new state and federal health reforms are bringing, but what is consistent across the state is a belief that health truly is a local, community-level issue. Every Colorado community has a different set of resources and priorities, will face unique implementation challenges, and there are no one-size-fits-all solutions. Read about the impact of reform on Colorado Springs, Montrose County, Summit County, and Yuma County.

The various stakeholders who can make the difference are often local. The federal government has a role to play, of course…and states are important…but the stakeholders who can really put the pieces together—the local medical society, hospital governing boards, businesses that might actually care about quality of care—are local.

–Dr. Elliott S. Fisher, co-director of the Dartmouth Atlas, on changing the health care system (quote from On the Redwood Coast)

Background

In 2008, the bipartisan Blue Ribbon Commission for Health Care presented its final report to the Colorado Legislature recommending state reforms around health insurance coverage, cost reduction, and delivery system redesign. These recommendations served as the blueprint for Colorado’s various policy and organizational efforts for statewide systems change, including the expansion of Medicaid, which occurred with the passage of the Hospital Provider Fee legislation in 2009. The passage of the Patient Protection and Affordable Care Act in 2010 brought additional tools to the state to help fully implement many of the Commission’s recommendations.

While all of this has been occurring at the state level, Colorado communities have been planning, designing, and implementing their own reforms to drive change locally. Some have even formed alliances of health care, business, local government, and other leaders, and have been making strides for decades. From state agencies to local communities, Colorado’s leaders have been coming together and taking the initiative to improve the health care systems in exciting and innovative ways for many years.

Timeline

Winter 2013

Overview

Colorado has very distinct regional differences. What works in Colorado Springs is not the same thing that works in Grand Junction or Pueblo or Sterling. I think we need to get back to the thought that health care is local! The resources in every community are different. The relationships in those communities are different. The needs of the consumers in the community are different.

–Carol Bruce-Fritz, CEO of Community Health Partnership

With significant changes ahead as recent state and federal health reforms are implemented, each Colorado community is preparing to face unique opportunities and challenges. For some, these changes are welcomed as new tools in their local efforts; for others, they are cause for concern, with potential to destabilize their current health care system.

Over the past few years, Colorado has had a robust statewide conversation about coverage, and the need for all Coloradans to have health insurance. New coverage opportunities have recently been made available through state and federal laws and the state has been hard at work since 2009 to make Medicaid available for those below the poverty level. Access to care is a more complex conversation though, and one that has been more fragmented across the state. Challenges of rural health care, provider shortages, and health care costs have been important issues for the state’s health care leaders for some time.

As communities prepare for health reform, it is clear that those with well-established, highly collaborative health care systems in place are feeling more confident in the outcome of these changes than those who face resource deficits and have taken a more reactive approach. Strong leadership and healthy collaboration exists in all four Health is Local communities, but the organization of the health care infrastructure and formal partnerships vary greatly: these differences will likely play an important role in the coming months.

Coverage

Tree
In January 2014, Medicaid was expanded for 160,000 low-income Coloradans. Additional coverage was made available with the passage of a bipartisan state law in 2011, which created Connect for Health Colorado, our state’s marketplace for private insurance. Some areas of the state—such as Montrose County, with its pockets of poverty, expect to see a significant portion of their population eligible for and enrolling in Medicaid; other areas, such as Summit County and other communities with high median incomes, are expected to have more residents enrolling in private insurance through the exchange. Concerns about premium costs and subsidy eligibility are pervasive, but there is broad commitment to getting everyone enrolled in coverage.

I’m excited. I’ve seen in my work a lot of people with no health coverage and haven’t had health coverage for a long time. And so I’m excited to see this happening.

–Silvia, Yuma County Resident

Access

Baby
As new coverage opportunities become available with state and federal reform laws, communities are working to mitigate access issues. Most of Colorado’s communities, and especially those in rural areas of the state, already face shortages of primary and specialty care. Communities with the resources and resolve to expand capacity—either through recruiting additional providers, construction of new hospitals and clinics, or both—will be better prepared to provide access to care for the newly insured. Colorado Springs, Summit County, Yuma County, and others around the state have prioritized this work as part of their reform preparations.

The economic impact of the local health care provider is significant. Economic impact studies consistently show a multiplier effect ranging from two to four dollars generated for every dollar spent by a local hospital. Employers have healthier employees and lost work time because of easy access to care. As we see in Yuma, with a broad array of health services available locally, people remain in the community upon retirement.

–John Gardner, CEO of Yuma District Hospital & Clinics

Leadership & Collaboration

Stores
Promising local reforms and collaborative approaches to health care systems change can be found throughout Colorado. Eight Colorado communities were selected to implement projects that aim to deliver better care and drive down costs in Medicare, Medicaid, and CHP+ through the highly-competitive Health Care Innovation Challenge sponsored by the CMS Innovation Center. Countless other communities are using innovative, collaborative approaches to improve access to the system, increase coverage, and drive down health care costs.

Spring 2014

Overview

I think it’s a great idea in practice. Maybe it’s not working quite as well as it should, but I think the general idea is a good thing. I just think that the whole idea of bringing the costs down is probably the best part of it. If it’s actually going to take place—only time will tell.

–Steve, Summit County resident

In the past few months, Colorado—along with a handful of other states—has been watched carefully for signs of the success or failure of health reform. For local communities, health reform’s early impacts have been measured. There have been shifts in the coverage landscape, but many uninsured still remain. Some providers have seen changes in their payer mix and patient population, but others have not. Pent-up demand for care appears to have been less than predicted, perhaps because Coloradans are generally healthy.

Those who have gained coverage, which is around 6% of the total state population, have secured protection and peace of mind. For some, this new coverage has been life-altering. However, there remain concerns about some patients’ abilities to understand and use their new coverage, as well as some communities’ abilities to supply enough providers and locations to fulfill demand for health care.

If there is one unsurprising lesson from the first few months of health reform, it is that the health care system changes slowly. There have been long-standing efforts to improve Colorado’s system, and change has always been incremental. For some communities, recent health reform has added new energy to their ongoing work, and in others, it has created new opportunities altogether. In still other communities, the local reform efforts continue on independent of changes at the state or federal level. What is clear, however, is that health reform has affected every community differently, depending on their resources, priorities, and preparation.

Coverage

Houses
Some communities have exceeded expectations in enrolling residents in new coverage opportunities. In Montrose County, for example, leaders prioritized their preparation for open enrollment and their efforts paid off. Medicaid has been especially important to low-income Coloradans, and its impact on their individual lives has been one of the most dramatic impacts of health reform to date. However, leaders from all communities see gaps where there is more work to be done in connecting the remaining uninsured to coverage.

Enrollment Data Colorado Residents
Medicaid (as of 4/15/14) 178,508
Connect for Health Colorado (as of 4/26/14) 123,899
Total New Enrollments 302,407
Estimate of Total Uninsured (2012 ACS) 757,881

Note: Not all residents who are newly-enrolled were previously uninsured.

Medicaid expansion has been life-altering. It is a joy to be able to get people who are really suffering on to Medicaid. We see this impact almost daily.
–Sarah Vaine, CEO of Summit Community Care Clinic

Access

Patient
Many hospitals and clinics from around Colorado have begun to see shifts in their payer mix. For most, but not all, it has been a reduction in uninsured patients and an increase in Medicaid patients. Some care providers in Colorado Springs and elsewhere are evaluating new financial and business models to address these changes, while others are more focused on addressing provider shortages and workforce capacity issues. While each community charts its individual path forward to improve access to care, there is general agreement that Coloradans need help understanding their newly acquired coverage so they can better utilize care.

How has increasing coverage options changed access to care? Patsy Boyle, Chief Operating Officer at The Center for Mental Health in Montrose County, says it’s been surprising.

Leadership & Collaboration

Tractor
Community leaders adapting to the new realities of health reform share a desire for agreement on what to measure and how to measure it. While long-term population health goals are somewhat easily identified, short-term goals for coverage, access, cost, and quality are more challenging to define because no one really knows what to anticipate in the months ahead. Even the expected timeframe in which to expect these impacts is unclear.

Summer 2014

Overview

It is more important than ever to access prevention and other sustaining methods for health. Accessing community-based organizations that offer fitness, nutrition, health education, and overall well-being choices should be recognized as part of the continuum of care. Individuals need to take the role of self-manager and partner with their care providers to be proactive in their health care.

–Vonie Weaver, Director, Wray Senior Community Center

Although most communities have seen some changes due to health reform over the past few months, the statewide conversation has remained mostly unchanged. Coverage remains a common topic of discussion throughout the state, as there continue to be gaps to address. Some communities are uncertain how Medicaid specifically will affect their long-term future and impact private businesses. Now that more Coloradans are covered, though, a new element of the coverage conversation has emerged: health insurance literacy. This includes understanding how to use insurance products, what different payments are (such as co-payments and deductibles), and what certain services cost. For example, Colorado Springs leaders report that some new enrollees were unaware that they would owe co-pays when visiting a health care provider.

The other primary conversation taking place around the state is how access to care is affecting communities. In some areas, such as Montrose and Yuma counties, this has manifested as a proactive focus on preventive health care and promoting healthier lifestyles. In others, such as Colorado Springs, it has focused on an intentional reorganization of providers and access points to ensure all patients have a usual source of care.

Although health reform remains a persistent topic of conversation in Colorado communities, it seems that only a small percent of residents in any community have been substantially affected by the changes of the past several months.

Coverage

Storm
Over 400,000 Coloradans have gained health insurance since the new coverage options were made available in January. The second open enrollment period begins November 15, and many more Coloradans are expected to enroll through Connect for Health Colorado or Medicaid. Nationally, Colorado has been recognized as a leader in enrolling residents in coverage, but new issues with health insurance literacy have now surfaced. The need for tools to better inform residents about how to use their health insurance has been echoed by communities across the state.

Access

Bridge

For the most part, there has not yet been a statewide conversation around access to care in Colorado. However, as more Coloradans gain coverage, the resulting access issues are beginning to get more attention. The heart of the access issues are around whether the supply of health care services—the number and availability of providers and care locations—are sufficient to fulfill the increasing demand of patient needs. There are additional aspects of access to care, such as quality and cost, which are being discussed in some communities, but the capacity of the system to care for all patients is the primary focus of access conversations currently. Health care leaders recognize that addressing these issues will require collaboration and coordination on a large scale.

A couple new primary care providers have joined existing practices and have agreed to see some Medicaid patients. The main health plan in the region is contractually requiring doctors to take a minimum number of Medicaid patients, so hopefully we will have more providers accepting Medicaid.
–Lynn Borup, Executive Director, Tri-County Health Network

Leadership & Collaboration

Grain Bin
Achieving optimal access to health coverage and care in Colorado will take years or more, even with both federal and community-level reforms underway. However, health care leaders in all four communities have found varying levels of early success already, due to their commitment to the work, collaboration with local partners, and adaptation to frequently changing conditions. In the short-term, they hope to continue that success through the next open enrollment period and are currently focused on their preparations.

There will now be a reorganization of the regions, so we will be seeing lower premiums thanks to all the work by the Commissioners, partners, and residents of Summit.
–Amy Wineland, RN, Summit County Department of Public Health

Fall 2014

Overview

It’s been a lot [of change] in a short period of time, so I am hoping best practices reveal themselves, and there won’t be so many different things going on that people feel pulled in so many directions. That it all levels off and they say, ‘Okay, this is working.’

–Sarah Vaine, CEO at Summit Community Care Clinic

At the end of 2013, which marked the beginning of the Health is Local project, each of the four highlighted communities were in different places as far as their preparation for and perspective on health reform. One year later, it’s not surprising that this is still the case. Federal and state policies are implemented into local systems that each have their own resources, priorities, and capacities. For those communities that were committed to working collaboratively and taking advantage of the new tools that health reform introduced—like Colorado Springs—the experience has been generally positive and the future holds even more promise. For other communities—specifically those in rural areas who may have struggled to form close partnerships and were already facing significant challenges with their health system—the experience has been mixed, and the future is uncertain.

Of all the changes brought about by health reform, the increase in the Medicaid population has had the largest effect on our four Health is Local communities. However, while the communities that were able to expand capacity or already had enough capacity to increase their patient load have found the expansion of Medicaid to be good news for residents and providers, the story has not been the same in low-access communities. Montrose County faced a shortage of Medicaid-accepting providers prior to the expansion, and one year later the system is straining even harder to keep up with demand.

As these communities look to the future, they will all need to continue to increase coverage, improve access, and continue to collaborate with other leaders. However, while Summit County will largely be focused on coverage in the short term, Yuma County is placing a higher priority on identifying opportunities for collaboration. Furthermore, while Montrose County is determined to make progress on access, Colorado Springs is now looking to lead the state on major systems reforms.

We have appreciated the opportunity to watch the story of health reform play out in Colorado over the last year. The state’s health system has made important steps forward through the collective efforts of local communities and state leaders, but progress has been measured. It is critical as we continue to implement health reform that state leaders not only recognize that each community has different capacity and resources to carry out the laws that are passed, but also that each law or policy will affect each community in differently. The coming year is shaping up to be just as exciting as the last, as the story of health reform in Colorado continues to unfold.

Coverage

StormWith the second open enrollment period underway, Colorado hopes to identify and enroll many more of those who were still uninsured after the expansions of coverage in January 2014. It is estimated that over the past year, the state’s rate of uninsured residents dropped from 17% to 11%, which is the fifth largest drop across the country. For many communities, a new challenge is health insurance literacy, or helping residents understand what their benefits are and how to use them. The affordability of coverage also remains an issue, and one that will likely be a long-term issue until consumers adjust to including health insurance premiums in their monthly budget.

I think coming up this next year, it will be important for us to focus on enrollment. It’s a new group that is going to be looking at the different options, and they need to understand… I love how so many were able to get information last year, but I don’t think that lets us off the hook for this year as we start open enrollment.
–Pam McManus, President & CEO at Peak Vista Community Health Centers

Access

Bridge

Balancing the supply of primary care providers and specialists with the demand for health care services is challenging, long-term work. Some communities have an easier time recruiting and retaining providers than others, but shortages are widespread. As local leaders catch their breath from the heavy focus on coverage issues over the past year, many are preparing for more intensive access conversations. Larger, more stable health systems are able to look beyond workforce issues to begin tackling cost, quality, and other access to care issues, while smaller, more rural systems are just trying to keep clinic doors open.

Health reform, yes, has impacted the community…positively for those individuals that had not had coverage previously, but again, it’s created unintended consequences: increased demand for care without increasing the workforce.
–Lynn Borup, Executive Director, Tri-County Health Network

Leadership & Collaboration

Grain BinPerhaps the most accurate predictor of a community’s experience with health reform over the past year was their local commitment to collaboration. The two communities with the most established collaborative relationships—Colorado Springs and Summit County—were better prepared for both expected and unexpected changes, and were able to effectively leverage those partnerships to make health reform work locally. With many more years of health reform changes still to come, local leaders should place a high value on collaborative efforts focused on a shared vision for the health of their community.

I think things will continue to improve. …We all work together for the best of residents. So whatever happens in the future, we are going to figure it out together.
–Jenniffer Gonzalez, Patient Support Services Manager at the Summit Community Care Clinic

Hot Topics in Community Conversations

As the impacts of health reform are felt in each community, the conversation changes to reflect the current issues.

The Communities

Learn more about the four Health is Local communities: