These are all of the health care bills proposed in the 2021 session. Each bill has its own bill number, please use your browser search feature to find the bill you are interested in. Return to the Colorado home page to pick a different bill category.

None of the text is the opinion of Engage. Each bill's description, arguments for, and arguments against are our best effort at describing what each bill does, arguments for, and arguments against the bill. The long description is hidden by design, you can click on it to expand it if you want to read more detail about the bill. If you believe we are missing something, please contact us with your suggestion. Some of these bills have the notation that they have been sent to the chamber's "kill" committee. This means that the leadership has decided to send the bill to the State committee even though it does not belong there based on its subject matter. This committee, in both chambers, is stacked with members from "safe" districts and the idea is to kill the bill without forcing any less safe members to take a hard vote. It is possible for a bill to survive the kill committee, but it is very rare.

Prime sponsors are given after each bill, with Senate sponsors in () and House sponsors in []. They are color-coded by party.

Some bills will have text highlighted in pink or highlighted in orange or highlighted in yellow. Pink highlights mean House amendments to the original bill; orange mean Senate amendments; yellow highlights mean conference committee amendments. The bill will say under the header if it has been amended.

Each bill has been given a "magnitude" category: Mega, Major, Medium, Minor+, Minor, and Technical. This is a combination of the change the bill would create and the "controversy" level of the bill. Some minor bills that are extending current programs would be major changes if they were introducing something new, but the entire goal here is to allow you to better curate your time. Something uncontroversial likely to pass nearly unanimously that continues a past program may not be worth your time (and please remember, you can still read all of the minor bills!). Technical bills are here to round out the list. They are non-substantive changes.

House

Click on the House bill title to jump to its section:

MEGA

HB21-1068 Insurance Coverage Mental Health Wellness Exam PASSED SIGNIFICANTLY AMENDED
HB21-1191 Prohibit Discrimination COVID-19 Vaccine Status KILLED BY HOUSE COMMITTEE
HB21-1232 Standardized Health Benefit Plan Colorado Option SIGNED INTO LAW VERY SIGNIFICANTLY AMENDED

MAJOR

HB21-1017 Protect Human Life At Conception KILLED BY HOUSE COMMITTEE
HB21-1036 Local Control Of Health Orders KILLED BY HOUSE COMMITTEE
HB21-1172 Hospital Patient Long-term Care Resident Visit Rights KILLED BY HOUSE COMMITTEE
HB21-1183 Induced Termination Of Pregnancy State Registrar KILLED BY HOUSE COMMITTEE
HB21-1198 Health-care Billing Requirements For Indigent Patients PASSED AMENDED
HB21-1258 Rapid Mental Health Response For Colorado Youth (state stimulus bill) PASSED AMENDED
HB21-1307 Prescription Insulin Pricing And Access PASSED AMENDED

MEDIUM

HB21-1135 Health-care Cost-sharing Consumer Protections KILLED BY BILL SPONSORS
HB21-1184 Physician Assistant Collaboration And Reimbursement KILLED BY HOUSE COMMITTEE
HB21-1202 Off-label Use Of Approved Drugs To Treat COVID-19 KILLED BY HOUSE COMMITTEE
HB21-1237 Competitive Pharmacy Benefits Manager Marketplace SIGNED INTO LAW AMENDED
HB21-1275 Medicaid Reimbursement For Services By Pharmacists PASSED AMENDED
HB21-1276 Prevention Of Substance Use Disorders PASSED AMENDED
HB21-1279 Occupational Therapy Interstate Compact PASSED AMENDED
HB21-1297 Pharmacy Benefit Manager And Insurer Requirements PASSED AMENDED

MINOR+

HB21-1012 Expand Prescription Drug Monitoring Program PASSED VERY SIGNIFICANTLY AMENDED
HB21-1020 Proton Beam Therapy For Cancer Treatment KILLED BY BILL SPONSORS
HB21-1021 Peer Support Professionals Behavioral Health PASSED AMENDED
HB21-1035 Pregnancy-based Parking Placard KILLED BY BILL SPONSORS
HB210-1085 Secure Transportation Behavioral Health Crisis PASSED AMENDED
HB21-1097 Establish Behavioral Health Administration SIGNED INTO LAW AMENDED
HB21-1119 Suicide Prevention, Intervention, & Postvention SIGNED INTO LAW AMENDED
HB21-1140 Eliminate Donor Costs For Living Organ Donations PASSED
HB21-1165 Assistance For Victims Of Strangulation SIGNED INTO LAW
HB21-1281 Community Behavioral Health Disaster Program PASSED AMENDED

MINOR

HB21-1005 Health Care Services Reserve Corps Task Force PASSED AMENDED
HB21-1033 Add Health Maintenance Organizations Life And Health Insurance Protection Association KILLED BY BILL SPONSORS
HB21-1130 Expand Transition Specialist Program SIGNED INTO LAW
HB21-1171 Kidney Disease Task Force PASSED AMENDED
HB21-1190 Defining Telemedicine For Medical Practitioners SIGNED INTO LAW AMENDED
HB21-1206 Medicaid Transportation Services PASSED AMENDED
HB21-1256 Delivering Health-care Services Through Telemedicine SIGNED INTO LAW
HB21-1305 Mental Health Practice Act PASSED VERY SIGNIFICANTLY AMENDED (category change)

TECHNICAL

HB21-1146 Auricular Acudetox Professional Practice SIGNED INTO LAW

Senate

Click on the Senate bill title to jump to its section:

MEGA

SB21-005 Business Exempt From Public Health Order To Close KILLED BY SENATE COMMITTEE
SB21-137 Behavioral Health Recovery Act PASSED VERY SIGNIFICANTLY AMENDED
SB21-175 Prescription Drug Affordability Review Board SIGNED INTO LAW AMENDED

MAJOR

SB21-028 Promulgation Of Public Health Rules And Orders KILLED BY SENATE COMMITTEE
SB21-036 Additional Requirements Issue Emergency Public Health Order KILLED BY SENATE COMMITTEE
SB21-123 Expand Canadian Rx Import Program SIGNED INTO LAW
SB21-142 Health Care Access In Cases Of Rape Or Incest SIGNED INTO LAW
SB21-193 Protection Of Pregnant People In Perinatal Period PASSED AMENDED
SB21-194 Maternal Health Providers PASSED AMENDED
SB21-243 Colorado Department Of Public Health And Environment Appropriation Public Health Infrastructure PASSED AMENDED

MEDIUM

SB21-009 Reproductive Health Care Program PASSED AMENDED
SB21-016 Protecting Preventive Health Care Coverage PASSED VERY SIGNIFICANTLY AMENDED
SB21-021 Audiology And Speech-language Interstate Compact SIGNED INTO LAW AMENDED
SB21-063 Multiple Employer Welfare Arrangements Offer Insurance PASSED VERY SIGNIFICANTLY AMENDED
SB21-085 Actuarial Review Health Insurance Mandate Legislation KILLED BY BILL SPONSORS AMENDED
SB21-094 Sunset Continue State Board Of Pharmacy PASSED AMENDED
SB21-156 Nurse Intake Of 911 Calls Grant Program PASSED AMENDED
SB21-278 Reimbursement For Out-of-home Placement Services PASSED

MINOR+

SB21-025 Family Planning Service For Eligible Individuals PASSED AMENDED
SB21-038 Expansion of Complementary And Alternative Medicine PASSED
SB21-098 Sunset Prescription Drug Monitoring Program PASSED
SB21-126 Timely Credentialing Of Physicians By Insurers PASSED AMENDED
SB21-139 Coverage For Telehealth Dental Services SIGNED INTO LAW
SB21-154 988 Suicide Prevention Lifeline Network PASSED AMENDED
SB21-158 Increase Medical Providers For Senior Citizens PASSED SIGNIFICANTLY AMENDED
SB21-181 Equity Strategic Plan Address Health Disparities PASSED AMENDED
SB21-187 Dialysis Treatment Transportation Funding KILLED BY BILL SPONSORS
SB21-239 2-1-1 Statewide Human Services Referral System (state stimulus bill) PASSED AMENDED
SB21-255 Free Menstrual Hygiene Products To Students PASSED AMENDED

MINOR

SB21-003 Recreate Occupational Therapy Practice Act SIGNED INTO LAW
SB21-011 Pharmacist Prescribe Dispense Opiate Antagonist SIGNED INTO LAW AMENDED
SB21-022 Notification Requirements For Health Care Policy And Financing Audit SIGNED INTO LAW AMENDED
SB21-089 Cancer Screening Services Through Colorado Department Of Public Health And Environment KILLED BY BILL SPONSORS
SB21-090 Small Group Health Insurance Plan Renewal SIGNED INTO LAW
SB21-092 Sunset Surgical Assistants And Surgical Technologists SIGNED INTO LAW AMENDED
SB21-093 Sunset Continue Healthcare Infections Advisory Committee SIGNED INTO LAW
SB21-097 Sunset Continue Medical Transparency Act SIGNED INTO LAW
SB21-101 Sunset Direct-entry Midwives SIGNED INTO LAW AMENDED
SB21-102 Sunset Dental Hygienists Specialized Functions SIGNED INTO LAW
SB21-122 Opiate Antagonist Bulk Purchase And Standing Orders SIGNED INTO LAW
SB21-195 Notarization Of Certain Probate Documents SIGNED INTO LAW
SB21-214 State Payment Hospice Providers Residential Care SIGNED INTO LAW

TECHNICAL

HB21-1005 Health Care Services Reserve Corps Task Force (Garcia (D)) [Mullica (D), Caraveo (D)]

PASSED

AMENDED: Minor

Appropriation: $108,984
Fiscal Impact: About $170,000 a year

Goal:

  • Create a health care service reserve corps task force to study how to best create a health care services reserve corps program that could be deploy medical professionals in emergencies or disasters across the state and receive some sort of benefit in return, such as student loan relief

Description:

Report is due by December 2023. The task force must consider and make recommendations on:

  • Types of medical professionals who could be in the program
  • Types of emergencies the program could assist with and the skills that would be required, including floods, fires, extreme weather conditions that cut off access to communities, and infectious disease outbreaks
  • Any legal or regulatory barriers to the program concept, including licensing, liability, and scope of practice and what changes would be necessary for the program to function
  • How the program could be streamlined or integrated with existing programs
  • The name of the program and how to differentiate it from existing similar programs
  • Types of training and number of hours of cross-training that would be required and how that training would be provided
  • How to design cross-training to ensure they account for geographic location of participants and are accessible to rural professionals
  • Overall size of program and number of different types of professionals required
  • How to ensure program participants come from a variety of communities and settings such that deploying the corps would not lead to shortages in other places
  • How long professionals would serve in the program
  • How would deploying the corps work, under what circumstances could it be used and how would it be coordinated with other agencies and officials
  • Could the corps be deployed out-of-state
  • What would the record keeping and certification requirements be to run the corps
  • What would the costs of the program be, including training and compensation rates during deployments
  • Any considerations related to insurance coverage, including out-of-network issues
  • Liability protections for program participants and consumer protections for patient participants
  • Type and scope of student loan relief benefits that could be offered, including how it would be funded, whether some communities should be prioritized over others, and how to market the program

Additional Information:

Task force must start work by November 2021. It must meet at least once every two months until it submits its report. It must consult with medical and nursing schools when considering factors relating to cross-training. It can consult with additional stakeholders to examine any other questions. State must provide office space and staff services. Task force consists of 20 at least ten and no more than 11 voting members, six are designated by office: Executive director of department of public health and environment; director of office of emergency management; director of the division of professions and occupations; director of the Colorado resiliency office; executive director of department of health care policy and financing; and commissioner of insurance. 14 are appointed by the governor executive director of department of public health and environment who is also on the task force, one member each from statewide organizations representing:

  • Paramedics
  • Nurses
  • Doctors
  • Physician assistants
  • Hospitals
  • Health insurance industry
  • Local public health officials
  • Plaintiff attorneys

And one member each:

  • With experience teaching nurses, physicians, or paramedics
  • With experience managing a health care clinic
  • Currently works in rural health care
  • From a community advocacy organization
  • With experience administering student loan relief to medical professionals One additional member at the discretion of executive director
  • Representing an entity that provides medical malpractice insurance

At least one member must be from rural Colorado. Governor Executive director must make appointments by October December 2021 and must fill any vacancies that arise. There is no compensation for serving and members are not entitled to reimbursement for expenses. Members select their own chair and vice chair.


Auto-Repeal: September 2024

Arguments For:

Bottom Line:

  • Currently we have no way of activating medical professionals who don’t have the specific training required to step in during an emergency outside of their specialty
  • There will be disasters in our future that require immediate medical aid, so we can create a win-win situation for the state and for medical professionals looking to get some student loan debt relief
  • This is a very complicated situation that requires careful study before jumping in

In Further Detail: Unfortunately we’ve all just gotten a first-hand look at how important having trained reserves of medical professionals can be in an emergency. The problem is that we’ve got a lot of medical professionals across the state who do not have the specific types of training required to step in during a disaster that involves something outside of their specialty. We of course also know that medical professionals frequently have a lot of student loan debt. So this could be a win-win situation for the state and its residents in the future. This could save lives, money, and offer benefits that could include student loan debt relief. But we can’t just jump in, look at the long list of issues in the Description section that need to be solved. This requires careful study first.

Arguments Against:

Bottom Line:

  • If there are existing programs such that one of the jobs of the task force is how to pick a name that won’t confuse people, maybe we can leverage existing programs instead

In Further Detail: No one denies this is a problem, but if there are existing programs to the degree that the legislature has to specifically charge the task force with figuring out a name that won’t cause confusion, perhaps we can work within existing programs to achieve the same end goal.

How Should Your Representatives Vote on HB21-1005

HB21-1012 Expand Prescription Drug Monitoring Program (Pettersen (D), Coram (R)) [Rich (R), Mullica (D)]

PASSED

AMENDED: Very Significant

Appropriation: None
Fiscal Impact: None, increased fees cover cost of program

Goal:

  • Expand the state’s prescription monitoring program from just monitoring controlled substances to monitoring all prescriptions. Veterinarians are excluded from this expansion Give the prescription drug review board the ability to expand the program to track all prescription drugs in the state, not just controlled substances. If the board decides not to track a particular drug, it must publicly note the reason why during the rule making process.

Description:

Bill also extends expiration of the program by five years to 2028. Controlled substances are regulated at the federal level into five tiers, not all of which are actually even available by prescription. They are considered more dangerous for abuse and more likely to cause addiction. Other substances, non-controlled, do still require a prescription. These are frequently things like medication for infections or chronic (non-pain) conditions like high cholesterol or high blood pressure.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Non-controlled substances can still be dangerous and evidence shows abuse of varies categories of these drugs, including rises in emergency room visits due to non-medical use
  • Our battle against opioids and other dangerous controlled substances has led to use of some non-controlled substances that can also be abused
  • Without tracking any of this data we, and our pharmacists, are in the dark—we need to shine some light on the subject

In Further Detail: Non-controlled substances can still be dangerous. Case studies and emergency room data indicate misuse and abuse of anticonvulsants, antidepressants, muscle relaxers and second-generation antipsychotics among others. Some watchdog groups have noted sharp rises in emergency room visits tied to non-medical use of non-controlled substances, so this problem may be getting worse. This is also occurring as we are looking for alternatives to controlled substances but still selecting drugs that could be abused like gabapentin or loperamide instead of an opioid. But we aren’t tracking these drugs at all, in the manner that we watch controlled substances to look for patterns of abuse. So pharmacists may not even be aware this is a problem, much less that a person standing in front them has a pattern of abuse of a particular drug. As for the program itself, it is being extended by another bill. it is an invaluable tool to help reduce prescription drug abuse by helping doctors and pharmacists make informed prescribing decisions and to prevent doctor shopping for prescriptions. It also provides invaluable aggregated statistics for us to better understand how prescriptions are being dispensed in the state. Access to the database by other entities, including the government, can only occur via a court-ordered subpoena.

Arguments Against:

Bottom Line:

  • The entire monitoring program is an invasion of privacy, allowing the government to look at the medical information of citizens without their consent. It should be disbanded, not expanded

In Further Detail: This program forces us to share our prescription information with an entire network of doctors, pharmacists, and government officials. There are rules around accessing the network of course, but one of them is not asking us for permission first. The entire thing should be disbanded, not expanded to even more prescriptions.


Bottom Line:

  • This should not be left up to the board to decide, the legislature should be making this decision</span

How Should Your Representatives Vote on HB21-1012

HB21-1017 Protect Human Life At Conception [Neville (R)]

KILLED BY HOUSE COMMITTEE

Appropriation: None
Fiscal Impact: None

Goal:

  • Make abortion illegal in Colorado except for protecting the mother’s health and a few other limited circumstances.

Description:

Prohibits abortion except in cases of protecting the mother’s health, when the fetus is already dead in the mother’s womb, if a physical is performing chemotherapy and accidentally kills the fetus, or to remove an ectopic pregnancy. Makes it a class 1 felony for the doctor, no punishment for the mother. States that the sale, use, prescription, and administration of contraceptive measures, devices, drugs, or chemicals is still legal.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Anyone who does not want a child can put it up for adoption
  • Abortion kills an unborn fetus and should not be permitted unless we are protecting someone else’s life (the mother)

In Further Detail: No one is forcing anyone to keep a child. Any mother who does not want her child is free to put it up for adoption. But abortion is a nice way of saying killing an unborn fetus. Whether or not a fetus could live outside the womb is not really the issue, the issue is that the act kills it and ends a potential human life before it has even begun. In cases where the health of another human, the mother, is threatened, then of course the mother’s health must be protected. The constitutionality of abortion may change with the new composition of the Supreme Court, which is what decides what is or is not constitutional in our country. This law is an opportunity for the state to test whether the Supreme Court will strike down Roe v. Wade.

Arguments Against:

Bottom Line:

  • This is interference in a personal medical decision and women’s control over their own bodies
  • A fetus is not a baby, there is a reason why we have separate terms for the two
  • The bill is unconstitutional

In Further Detail: This is the most deeply personal medical choice for any woman, and to be clear, it is a personal medical choice. The right to choose abortion is essential to ensuring a woman can decide for herself if, when and with whom to start or grow a family. Women have the right to make their own decisions about their bodies. A fetus is not a baby, there is a reason why we have separate terms for the two. Abortion is legal in this country (another issue with this bill, it is unconstitutional, full-stop, which it recognizes by stating the courts of the federal government have no jurisdiction to interfere with Colorado law in this area, which is not true) because we recognize that until it is born, a fetus is not a baby. We also know, for a fact, from our history that criminalizing abortion doesn’t end the practice, it merely moves it into the shadows and alleys where it becomes less safe. And that the result is people with means find a way to still obtain an abortion in a mostly safe environment while people who do not have means find a way to obtain an abortion in a very dangerous one. The bill would also force women to carry non-viable fetuses (that will definitely die after being born) to full-term. Finally, this contains no exception for rape or incest, forcing a woman to carry her abuser’s baby to full term and delivery. This could jeopardize our federal Medicaid funding, because Medicaid requires any woman who is the victim of rape to be able to obtain an abortion through Medicaid. And this could result in investigations of women who have miscarriages or a stillbirth.

How Should Your Representatives Vote on HB21-1017

HB21-1020 Proton Beam Therapy For Cancer Treatment [McCormick (D), Soper (R)]

KILLED BY BILL SPONSORS

Appropriation: None
Fiscal Impact: None

Goal:

  • Require insurers to hold proton beam cancer treatment to the same standard of clinical evidence requirements for coverage as other cancer treatments. Does not require them to provide coverage

Description:

Proton are positively charged particles and proton beam treatment is the process of using those particles to destroy cancer cells. It is similar to radiation therapy.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Proton therapy offers the potential for safer treatment of cancers that is just as effective as radiation therapy.
  • It has been around for decades but is somewhat controversial because it is more expensive than traditional radiation therapy and so insurers have tried to claim it is unproven—multiple lawsuits around the country in recent years have found against insurance companies
  • Bill only forces insurers to use same standards for this therapy as for other therapies. One standard for all treatments

In Further Detail: This coverage offers the potential for safer treatment of cancers that is just as effective as radiation therapy. It has been around for a few years but is somewhat controversial because it is more expensive than traditional radiation therapy and so insurers have tried to claim it is unproven. But it was approved by the FDA in 1988 and is covered by Medicare. It is included in national cancer treatment standards. All the bill does is say that insurers have to use the same standards they apply for clinical evidence for proton therapy. Which means they will not be able to duck out of paying for claims by simply making vague evidentiary claims, as many have been successfully sued for doing so recently. As for clinical trials, it is rich for insurers to complain about a lack of clinical trial evidence when they are refusing to pay for the therapy which makes it nearly impossible for patients to enroll in trials. The bottom line remains simple: one standard for clinical evidence for any treatment.

Arguments Against:

Bottom Line:

  • This is vastly more expensive than radiation therapy and has the potential to be more lucrative for the medial industry
  • Insurers are not the only ones saying there is insufficient clinical evidence proving the treatment is more effective than radiation therapy

In Further Detail: This isn’t just a little more expensive, it is multiple times more expensive than radiation therapy to deliver and requires a lot of overhead in order to do properly, on the order of millions of dollars just for a single room. Multiroom facilities can cost hundreds of millions of dollars to construct. And insurers are not the only ways saying there is insufficient evidence. The Journal of Clinical Oncology has pointed to the need for more clinical trials, the gold standard of medicine. The National Institute of Health just last year noted the need for phase 3 clinical trials. This is important because it needs to be proven that the therapy is more effective than radiation therapy, not just that it works. Because it is a direct alternative and we only use more expensive options when they are better.

How Should Your Representatives Vote on HB21-1020

HB21-1021 Peer Support Professionals Behavioral Health (Zenzinger (D), Hisey (R)) [Pelton (R), Caraveo (D)]

PASSED

AMENDED: Minor

Appropriation: $28,654
Fiscal Impact: Negligible each year

Goal:

  • Allow organizations that use peer support professionals to bill Medicaid for their services so long as they have an official relationship with a licensed mental health care provider that can demonstrate training in supervising peer support professionals and any other requirements the state decides.

Description:

These are recovery service organizations, defined as organizations led and governed by representatives of local communities of recovery (see Additional Information for more detail). State must approve any entity prior to billing Medicaid and may charge a fee for approval. Peer support professionals are people who have themselves recovered from a behavioral health disorder or trauma and are trained to provide non-clinical support to those suffering from the same problems. There are federal guidelines for core competencies for peer support professionals.

Additional Information:

Fee for approval cannot exceed costs to administer program. State can also accept gifts, grants, and donations to fund program. Recovery support services organization can bill for work done in the following settings:

  • Justice-involved
  • Physical health
  • Emergency departments
  • Services delivered via telehealth
  • Communities with persons experiencing homelessness
  • Peer respite homes
  • School-based health centers
  • Home and community-based settings

Recover support services organization are defined as providing the following services:

  • Peer-delivered support services
  • Peer-run drop-in centers, recovery and wellness centers, and employment services
  • Prevention and early intervention activities
  • Peer mentoring for children and adolescents
  • Patient and family support groups
  • Warm lines
  • Advocacy services

Peer support professionals include: peer support specialist, recovery coach, peer and family recovery support specialist, peer mentor, family advocate, or family systems navigator. Must be at least 18. Services defined as: peer-to-peer relationships that support healing, personal growth, life skills development, self-care, and crisis-strategy development to help achieve recovery, wellness, and life goals.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Lived experience can make an enormous difference in helping others walk the same road to recovery—and the data agrees. Peer support professionals can lower costs and increase results
  • We have a crisis in behavioral health providers in the state and people are going untreated
  • Peer support professionals are frequently poorly paid, we need to provide a mechanism for to reimburse them for their services, which may also increase the number of settings for people to receive treatment—a win-win

In Further Detail: There is just nothing quite like having actual real experience living through and recovering from behavioral health disorders and trauma. Peer support professionals are a critical element in recovery and on-going wellness because they have quite literally walked the same road. They reduce hospitalizations, increase engagement in wellness and self-care, and decrease symptoms of people in treatment. Other states have found enormous cost-savings, an average of nearly $5,500 for people in treatment with peer support versus those in treatment without it. But peer support professionals are often poorly paid, in part because they cannot get Medicaid reimbursement. We also have a behavioral health crisis in the state, with the number of people who have needed but not received treatment nearly doubling in the past two years. Expanding the number of settings that can provide treatment and receive reimbursement will help everyone.

Arguments Against:

Bottom Line:

  • Life experiences are not all the same, and people may not be able to extend beyond their own experience to help those with different ones. Therefore the help received may be inferior to what a licensed and fully trained professional would provide

In Further Detail: Everyone’s experience is different, and while there are commonalities, there may also be differences that a peer support professional might not be able to bridge. Licensed professionals are trained to handle different experiences. So there is a chance of people getting inferior care to what a licensed professional might provide if the peer support professional does not have similar experience to the patient.

How Should Your Representatives Vote on HB21-1021

HB21-1033 Add Health Maintenance Organizations Life And Health Insurance Protection Association (Gardner (R)) [Ricks (D)]

KILLED BY BILL SPONSORS

Appropriation: None
Fiscal Impact: None

Goal:

  • Add health maintenance organizations (HMOs) to the state’s Life and Health Protection Association, which subjects them to membership dues
  • Requires the board to allocate assessment dues 50/50 between accident/health members and life/annuity members

Description:

This association exists to help pay out claims to Colorado residents whose insurers become insolvent or can no longer meet their obligations. It is in essence insurance for insurance. There are limits on what the association will cover. Assessments are made when the association has to pay residents due to a member insurer failure.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • HMOs are health insurance, they belong in this association
  • It is only fair to spread assessments across the various types of insurance equitably

Arguments Against: n/a

How Should Your Representatives Vote on HB21-1033

HB21-1035 Pregnancy-based Parking Placard [Lynch (R)]

KILLED BY BILL SPONSORS

Appropriation: None
Fiscal Impact: Not yet released

Goal:

  • Expand temporary disability placards, which allow holders to park in reserved disability parking spaces to include pregnancy for the last trimester or the first two months after giving birth. The placard expires on the last day of the month in which the 60th day after birth occurs.

Description: Nothing to add

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The end of pregnancy and dealing with a newborn child bring many difficulties in moving around easily, similar to a temporary disability. It makes sense to allow parking in spaces reserved for those with disabilities for these months to help these expectant and new mothers out. We can also just take people at their word on this—no need for a complicated system to ensure precise compliance down to the day

Arguments Against:

Bottom Line:

  • Pregnancy is not a disability. It is nice to want to help out pregnant women, but those parking spaces are reserved for people with actual disabilities. The bill is also vague on how this process would work: A written statement is required to qualify. How does the state determine the end-date? Do we need a due date? And a birth certificate to determine actual birthdate? What happens to a placard issued in the 3rd trimester, how does the state find out when the baby was born so as to know the expiration date of the placard?

How Should Your Representatives Vote on HB21-1035

HB21-1036 Local Control Of Health Orders [Pico (R)]

KILLED BY HOUSE COMMITTEE

Appropriation: None
Fiscal Impact: None

Goal:

  • Allows the governing body of a county or city to reject health orders issued by state or local agencies by majority vote of the body. Also allows governing bodies to modify health orders by majority vote

Description: Nothing to add

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Health orders can have huge negative impacts on a community, like the business-related closures due to COVID. The most representative body of any community is its elected representatives and they should be able to fulfill the people’s will
  • One size fits all health orders from the state may not apply to a particular community, it should be able to do what is best for it

In Further Detail: Health orders can have huge negative effects on a community, as we have seen with businesses forced to close due to COVID. Long-term disasters like the COVID pandemic affect different parts of the state in different ways. What might be necessary in one part of the state may not be in another, but one-size fits all health orders from the state treat everyplace nearly the same. This bill allows communities to use the representatives closest to them, local elected officials, to enact their wishes, as opposed to unelected officials, some of whom aren’t even in the local community.

Arguments Against:

Bottom Line:

  • Health agencies are experts and employ experts to create their health orders, local elected officials are not experts and neither is the public. In this case, safety must come first
  • For some disasters, like an infectious disease pandemic, the actions of people in one part of the state affect those in others, as people move around

In Further Detail: We have public health agencies because we recognize this is an area where expertise is really important. Local elected officials are not experts and neither is the public. When it comes to the basic safety of our citizens, expertise must come first. The idea that elected representatives are more accountable is less appealing when we are talking about something that might kill a lot of people before accountability is possible. Furthermore, the actions taken by people in one part of the state can affect all of the rest of us. The first discovery of the UK variant of the Coronavirus in the US was made in a rural part of the state in someone who didn’t live in that county. We also saw rural areas hit the hardest this winter, in terms of per capita infections, and that included Colorado. Right now the counties with the most cases per 100,000 people in the state are Bent, Crowley, Lake, Lincoln, Grand, Washington, Rio Blanco, Eagle, Summit, and Fremont. Bent County did not report more than 1 case on a single day until November. It now has reported 1,469, or 26,340 cases per 100,000 residents. That’s the 2nd highest rate in the entire state, second only to Crowley county, which also had a small spike in May. The virus took a little longer to spread into those communities, but as is typical with infectious disease patterns, it did not spare them.

How Should Your Representatives Vote on HB21-1036

HB21-1068 Insurance Coverage Mental Health Wellness Exam (Moreno (D)) [Michaelson Jenet (D), Titone (D)]

Appropriation: None
Fiscal Impact: Negligible each year

Goal:

  • Require an annual mental health wellness exam performed by a qualified mental health care provider of up to 60 minutes to be part of the mandatory health insurance coverage of preventive health care services at no charge to the insured. Coverage must be comparable to annual physical examinations and comply with federal mental health parity laws.

Description:

Examination includes services such as:

  • Age-appropriate screenings or observations to understand a person’s mental health history, personal history, and mental and cognitive state, and when appropriate, relevant adult input through screenings, interviews, and question
  • Behavioral health screening
  • Education and consultation on healthy lifestyle changes
  • Referrals to ongoing treatment
  • Mental health services and other supports
  • Discussion of potential options for medication

Additional Information:

Qualified mental health care providers include:

  • Licensed physician with specific board certification or training in psychiatry or other mental or behavioral health care areas
  • Licensed psychologist, licensed clinical social worker, licensed marriage and family therapist, licensed professional counselor, or licensed addiction counselor
  • Licensed physician assistant who has training in psychiatry or mental health
  • Advanced practice nurse with specific training in psychiatric nursing


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This is the same idea as annual physicals: prevention and early identification can lead to better outcomes
  • What we hear far too often in the aftermath of tragedy is that the survivors didn’t know their relative or child was struggling
  • Because we treat mental health on a crisis-by-crisis basis, we cannot uncover problems early
  • This would also attack the stigma associated with mental health by making visits to mental health professionals more routine

In Further Detail: Just as we have annual physicals for preventive medicine, so we should have annual mental health wellness exams for preventive mental health. It’s the same idea: prevention and early identification can lead to better outcomes. Not only for long-term mental health and wellness but also for suicide prevention. Colorado has one of the highest suicide rates in the nation. What we hear far too often from families in the aftermath of tragedy is that they didn’t know their relative or child was struggling or suffering. Because we currently treat mental health on a crisis-by-crisis basis, we cannot uncover problems early, before they become acute. Imagine if we treated physical care in this manner, where you only went to see a doctor if you felt that something was wrong. How much more expensive would treatment be? How many lives would be cut short? Another benefit of this law would be to chip away at the stigma around mental health and asking for help. We think nothing of going to the doctor, even when nothing seems wrong. Imagine a world where mental checkups are commonplace and no one blinks an eye at seeing a mental health professional.

Arguments Against:

Bottom Line:

  • There is no guidance on billing, just a mandate for coverage. There are so many potential services it will be hard for insurers to zero on costs the way they can with physicals—note the bill does not apply to Medicaid
  • These benefits will get passed on to us in the form of higher premiums, when we already have a crisis in premium costs in many parts of the state

In Further Detail: This bill contains no guidance on billing. Annual physical examinations are fairly well defined and so insurers know what the costs will be that they will be required to cover. Mental health examinations under this bill are so broad that a wide range of potential services costing a wide range of money would all be acceptable as an annual examination. This could lead to vast disparities in what individuals are banking to their insurance, and thus to the rest of us in the form of higher premiums. And we already have a crisis in premium costs in many parts of the state. We simply cannot afford to pile more onto that ledger. And note the bill does not apply to Medicaid, where the state would have to bear the brunt of the costs.


Bottom Line:

  • The increased costs of providing all of this mental health care will be borne by all of us, in a major way. There is no such thing as a free lunch, and a free mental health exam for every Coloradan (even if not everyone takes insurers) will result in higher premiums as insurers adjust. Let’s keep providing mental health care to those that need it and not allow everyone any sort of mental health exam every year.

Bottom Line:

  • By excluding Medicaid this leaves way too many people out, particularly people who might have the least ability to pay for mental health services on their own.

How Should Your Representatives Vote on HB21-1068

HB210-1085 Secure Transportation Behavioral Health Crisis (Bridges (D), Smallwood (R)) [McCluskie (D), Larson (R)]

PASSED

AMENDED: Minor

Appropriation: $93,290
Fiscal Impact: About $250,000 of state dollars at full implementation a year

Goal:

  • Bar private transport by entities of individuals in a behavioral health crisis after 2022 without a valid license created by this bill, except for ambulance services, transportation provided by state agencies, emergency service patrol, and law enforcement personnel. Transport initiated by individuals still allowed. License is on a county level, with fee determined by county. But state board of health is to set minimum requirements.

Description:

Minimum requirements must address:

  • Staffing requirements for vehicles
  • Staff training requirements, including verbal de-escalation and trauma-informed care, and helping people with physical or cognitive difficulties
  • Operating procedures, including when physical restraint is allowed
  • Quality improvement and process used to investigate complaints
  • Data collection and reporting
  • Clinical and medical standards and procedures
  • Circumstances under which an individual may be transported
  • Criteria for pickup

Counties are to review applications, the applicant’s record, equipment, and training and operating procedures. These must meet or exceed standards set by the state board. Counties can add additional requirements. Licenses are to be for three years. Vehicles must get separate permit for each one. These are annual and the vehicle must meet minimum standards set by state board. Licenses are not transferable. Requires Medicaid to cover these transports and create a payment structure. Program may accept gifts, grants, and donations. State must report to legislature on program.

Additional Information:

Transport is defined to include:

  • Transportation to or from facilities for voluntary or involuntary hospitalization evaluation
  • Transportation to an approved treatment facility for alcohol or substance abuse or a walk-in crisis center
  • Transportation either across levels or to higher levels of care to an emergency medical facility or any of the other facilities already described

Report to legislature must include: how crisis contractors are facilitating use of secure transportation or contracting with licensees and how state has supported and encouraged crisis contractors to include secure transportation in the behavioral health crisis response system.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This provides a viable and less expensive alternative to calling 911 and getting an ambulance or local sheriff
  • Requirement for Medicaid to fund it ensures people will pursue the licenses

In Further Detail: Transporting someone experiencing a mental health crisis is no easy task and right now we solve this by calling 911 and getting an ambulance or local sheriff. This is obviously expensive and potentially difficult to coordinate and we may able to create a better way through these licensed private transports. The bill not only covers training and minimum standards, but also realizes this won’t work without funding and so requires Medicaid to fund it. We can still get the individual where they need to go in a safe manner.

Arguments Against:

Bottom Line:

  • This should remain a task for ambulances and law enforcement, despite the cost and hassle. It is too risky to rely on private transportation, even if it is licensed.

Bottom Line:

  • Without private insurance on-board the task of getting licensees may be more difficult

HB21-1097 Establish Behavioral Health Administration (Fields (D), Gardner (R)) [Young (D), Pelton (R)]

SIGNED INTO LAW

AMENDED: Minor

Appropriation: None
Fiscal Impact: None yet, but may cause added expenses in future budgets

Goal:

  • Create the Behavioral Health Administration inside the Department of Human Services. Human Services must provide a plan by November 2021 that includes strategies for streamlining and improving efforts addressing behavioral health needs in the state through the new office. Office to start functioning by July 2022. By November 2024 Human Services must report to the legislature if the new office should stay in Human Services or be transferred to another department

Description:

Plan must include: recommendations for funding and legislation to implement the plan; list and description of state programs that should be moved to the new office; governance structure of the office; opportunities for collaboration with local governments; a plan for handling grievances, appeals, and ombudsperson services; data integration plan that leverages existing infrastructure; and a description of how the office will ensure availability of programs and establish a standard of care.

The bill also directs more specific plan elements: how Medicaid behavioral health benefits are integrated into the new structure; how private insurance behavioral health benefits are integrated; and how prevention and preventative services are integrated.

Additional Information:

Bill directs the new office to serve as the single state agency responsible for behavioral health programs that are moved into it. It must also receive, coordinate, and distribute money for its programs throughout the state; monitor, evaluate, and report on those programs; and promote a behavioral health system that supports a whole-person approach to ensure Coloradans have the best chance to achieve wellness. This last part includes: integrated approach to mental health and substance abuse; supporting integration of physical and behavioral care; promoting coordination of services outside the behavioral health system to connect people to supports such as housing, transportation, and employment; supporting overall well-being of individual or family; and promoting culturally responsive and equitable care.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Like many states we struggle to deliver the behavioral health care our citizens need, but the problem in Colorado is more acute: we rank in the top ten in the country in suicide rate
  • A behavioral health task force created to study this problem unanimously recommending creating this separate state agency
  • Currently behavioral health programs are splintered across various state agencies, which makes it difficult for people and community providers to navigate, makes it hard to have an overarching strategy, and leads to inefficiencies that make data sharing and accountability difficult
  • Having a single office not only addresses those problems but creates a single champion focused on just this issue in state government

In Further Detail: Our state ranks in the top ten in the country in suicide rate and estimates are that 20% of our citizens are experiences at least one mental health condition. We struggle with the number of providers in the state, getting proper reimbursement for the providers we have, and providing a full continuum of behavioral services in the right place at the right time. So we created a task force to do a deep dive into how to fix the issues with behavioral health care in the state. This is one of the recommendations of the task force, its step one in the process (approved unanimously). From their report: “It will lead and promote the state’s behavioral health priorities, ensuring that behavioral health services respond to the changing needs of communities. It will provide the infrastructure to ensure that the recommendations reflected in this document are completed.” The report found that there were at least 10 state agencies with over 75 programs for people with behavioral health needs: a maze that we should not force anyone to navigate. This also puts a huge burden on community agencies doing most of the work, leads to a lack of an overarching strategy, and build inefficiencies into the entire system. It also makes system-wide accountability extremely difficult. Having a single contact point addresses all of these issues and also makes a single champion in state government for behavioral health care rather than fragmenting that interest across the entire government. That can make a critical difference when it comes to budgeting decisions. If the Office of Behavioral Health could accomplish all of this, the task force that included a member from that office probably would have suggested it—our current situation indicates it cannot and a new structure is needed. The bill envisions, but does not require, spinning this off into an entire separate agency.

Arguments Against:

Bottom Line:

  • We have an existing office of behavioral health that already holds many of the state’s programs and regulates the state’s behavioral health providers, do we need to create a brand new organization or can we just build off of what we already have
  • Sometimes the particular expertise of an office lends itself to handling behavioral health issues—the division of housing may be better suited to run a program that provides housing to people with behavioral problems (it has three)

In Further Detail: The Office of Behavioral Health is an already existing office inside the Department of Human Services. Why not build on that structure, moving programs that need to be moved into it, etc? Instead we are going to build a brand new behavioral health administration. What that means for the office of behavioral health is unclear, the bill is silent about it. For moving programs around, obviously there will be careful consideration before anything is moved but sometimes is just make more sense for a program to reside is a different department that has the technical expertise to execute it. A housing program, for instance, is better suited to the division of housing and so it has three of them related to behavioral health. Otherwise you end up duplicating technical expertise across departments and creating new and different inefficiencies and coordination problems. So the promised benefits of a one-stop shop for behavioral health either may not alter our current arrangement much or may not deliver the results we are looking for.

How Should Your Representatives Vote on HB21-1097

HB21-1119 Suicide Prevention, Intervention, & Postvention (Donovan (D), Coram (R)) [Rich (R), Daugherty (D)]

SIGNED INTO LAW

AMENDED: Moderate

Appropriation: None
Fiscal Impact: None

Goal:

  • Add intervention and postvention to the focus of the state’s suicide prevention efforts. This includes creating a uniform statewide K-12 suicide postvention component to include in the state’s suicide prevention plan and train-the-trainer programs to help teachers create a behavioral and mental health training course. This is for grades 6-12 to help better identify, understand, and respond to signs of mental or behavioral stress among their peers (renamed by the bill to prevention, intervention, and postvension plan)
  • Provide comprehensive education and training on suicide prevention, intervention, and postvention for first and last responders, health care providers, and K-12 educators to be created by the suicide prevention commission which is renamed the suicide prevention, intervention, and postvention commission>. Commission must also develop a plan for follow-up care for suicide attempt survivors who were treated in an emergency department

Description:

Postvention is defined as actions that come after a suicide or suicide attempt to mitigate the after-effects and deal with the harmful after-effects in other people. The bill adds the definition of comprehensive suicide prevention as stategies or approaches to prevent onset of suicidal dispair; public health invervention supports, including community training, workforce development, quality improvement, and provision of technical assistance to best practices and policies; and postvention responses to and support for individuals and communities affected by the aftermath of a suicide attempt.

Expands the scope of the state’s resource bank for mental health education to include materials on the after-effects of suicide attempts and postvention training.

Expands the scope of the office of suicide prevention to include collaborating with entities on intervention and postvention services and renames the office the office of suicide prevention, intervention, and postvention services. Requires facilities that work with the office to provide, in addition to what they already do, oral and written information or educational materials to the individual being released, or in a minor’s case to their responsible party, on the after-effects of a suicide attempt.

Expands the scope of the state’s suicide prevention plan to include intervention and postvention. This plan is to work with the office of suicide prevention, intervention and postvention to include intervention and postvention in their work to identify gaps in programs and services in the state.

Expands the scope of the state’s suicide prevention commission to set intervention and postvention priorities in the state and explore postvention policy changes as well as the after effects of suicide and suicide attempts, expand local and national partnerships for intervention and postvention, promote cooperation among intervention and postvention providers, and encourage development of intervention and postvention plans at the local level.

Expands the scope of the state’s crisis and suicide prevention training grant program to include grants for intervention and postvention and renames it the crisis and suicide prevention, intervention, and postvention grant training program.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The after-effects of a suicide or suicide attempt can be deadly: they increase the chances of others attempting suicide and for those who attempted suicide, the first week after discharge is an incredibly dangerous period
  • It is therefore very appropriate to slightly reorient our approach by explicating putting intervention and postvention into all of our efforts to combat suicide to ensure we are focusing on stopping future attempts in the wake of a suicide or suicide attempt
  • Making education available to first and last responders to suicides and suicides attempts should also help mitigate these after effects

In Further Detail: The aftermath of suicides and suicide attempt can cause even more suicides. People who have known someone who died by suicide in the last year were 3.7 times more likely to attempt suicide themselves. Children are just as susceptible as adults when learning about the suicide of a classmate: adolescents are twice as likely to attempt suicide in the year after learning of classmate’s attempt. And in failed attempts, the survivor is at extreme risk in the week after discharge. Men are 102 times more likely and women are 246 times more likely to attempt suicide than the general population. We must therefore ensure that all of our efforts to combat suicide explicitly tackle intervention and postvention for people exposed to suicide to ensure we are doing all we can to stop future attempts. Part of this is education of our first and last responders, health care providers, and K-12 educators.

Arguments Against: n/a

How Should Your Representatives Vote on HB21-1119

HB21-1130 Expand Transition Specialist Program (Kolker (D), Gardner (R)) [Michaelson Jenet (D), Bradfield (R)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

  • Expand the state’s community transition program for at-risk individuals by including some people receiving voluntary behavioral services: minors needing hospitalization or people in alcohol treatment. Also expands the facilities the program can work with to include those providing acute treatment services, crisis stabilization services, or emergency departments

Description:

This program is for people with significant mental health or substance abuse disorder who are not currently engaged in consistent behavioral health treatment. The bill also modifies that last description to “community behavioral health treatment.” Other eligible individuals are those on emergency 72 hour holds, in short or long term treatment facilities, or in emergency or involuntary commitment. The program is to help these individuals transition back into the community, including helping with housing, accessing treatment, advocating with insurers, planning for follow-up services, assistance with advanced directives, obtaining a representative payee or guardian, family supportive services, or compliance with court mandated appearances.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This just fills in a bit of a gap in this program’s coverage, some of the previously covered categories were also voluntary treatment, so there isn’t any real distinction there. The idea is to help people transitioning out of in-patient care back into their community. The new categories easily fit

Arguments Against: n/a

How Should Your Representatives Vote on HB21-1130

HB21-1135 Health-care Cost-sharing Consumer Protections (Fields (D)) [Lontine (D)]

KILLED BY BILL SPONSORS

Appropriation: None
Fiscal Impact: Negligible each year

Goal:

  • Require health care cost-sharing programs to report information regarding its operations in the state to the state, including financial statements, membership, and actions taken on medical bills. It also requires disclosures about the limitations of these programs, including that people remain personally responsible for medical bills and that the program may exclude people based on pre-existing conditions, on its website and all marketing materials and to respond to payment requests from providers within a set period of time. Copy of disclosure must be signed by any plan members. The programs are also banned from kicking people out for developing or being diagnosed with a medical condition. The bill also establishes penalties for failing to abide by any of these rules and for misrepresenting health care cost-sharing plans to the public

Description:

Health care cost-sharing programs are similar to insurance companies in that they pool members in a national program and share the cost of medical care, while paying monthly fees and out of pocket for a certain amount before the program pays the rest.

Definition of health care cost-sharing programs includes health care sharing ministries.

Member identification card must state that the covered individual is a member of an arrangement that provides no assumption of risk or promise to pay for health-care services

Must send monthly written or electronic statements to members that shows what amount of the total submitted medical expenses were paid for by the program. Must send quarterly statements showing the percentage of the entire membership’s contributions that were used for medical expenses and used for administrative costs. Must send members within 30 days of joining a complete set of guidelines for paying for medical expenses, appealing decisions, and filing complaints with the program and the state.

Penalty of up to $500 for initial violations and up to $5,000 for any subsequent failure to comply with any requirements.

Additional Information:

Annual disclosures from programs must include (all is for Colorado residents only):

  • Annual audited financial statements for previous year
  • Detailed list of any commissions or other fees paid to third parties for marketing, promotion, or enrolling members in the program or for operating, managing, or administering a program
  • List and description of member benefits, limitations, and exclusions
  • List of providers with whom the program has an agreement, contract, or other arrangement
  • Total number of members and households in the program in the previous year and if applicable, the total number of employer groups in the program and employees in those groups
  • Number of applications or other requests to join the program that were submitted, accepted, and denied in previous year
  • Total number of bills or medical expenses submitted to the program by or on behalf of members and the total amounts submitted, paid, and denied
  • Retroactive membership denials
  • Appeals or grievances submitted to the program, including number of appeals approved and dollar amounts approved
  • Total amount paid into the health care cost-sharing arrangement by members in previous year
  • Contact information for an individual serving as contact point for the state. This will not be made public

Programs must prominently display on their websites and in all marketing materials the following information as well as provide written disclosure to anyone enrolling or renewing anyone in the program:

  • Participation or membership in program does not guarantee payment of bills or medical expenses
  • Member of a program remains personally responsible for payment of all bills or medical expenses
  • Member of a program may be subject to pre-existing condition exclusions or other limitations
  • Any other information required by commissioner of insurance

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We have to ensure people understand what they may be getting into with these programs: they are not insurance, they are not subject to state or federal rules around insurance, and they can do all of the bad practices insurers could before the Affordable Care Act (exclude pre-existing conditions, set lifetime limits)
  • There is little evidence that these types of programs are sustainable over the long-term if they actually have to cover people with varying degrees of health (like insurance), so if this bill discourages people from joining them and they instead get real health coverage, all the better
  • We need closer monitoring of these programs at the state level to protect Coloradans

In Further Detail: If something sounds too good to be true, it probably is. These programs can and do exclude people with pre-existing conditions, they can deny care for actions they deem irresponsible (tends to happen more with the ministry programs), and they can have lifetime limits. In essence, this is health care before many of the protections in the Affordable Care Act. And at their most basic level they have no obligation to pay for anything and consumers cannot sue if they feel they were denied payment unfairly. There is very little evidence for how sustainable these types of programs are over the long-term with larger numbers of members with varying degrees of health. Note that the bill does not ban these programs. We at a minimum have to make sure people understand what they are signing up for, that it is in fact not insurance. And we need much closer monitoring of these programs to ensure they are keeping the promises they do make to Coloradans.

Arguments Against:

Bottom Line:

  • These programs fill essential gaps in our communities, in particular for the young and healthy who don’t need the deluxe provisions the Affordable Care Act mandates and for businesses that may struggle to pay for traditional insurance
  • We have skyrocketing insurance premiums in some parts of the state and need viable alternatives
  • This gives too much power to a likely hostile state employee (commission of insurance) to attack this industry

In Further Detail: These programs fill multiple essential gaps in our communities. First, some healthy individuals do not want what the Affordable Care Act now mandates. They are young, they do not have much need of health care, and they cannot afford the hefty premiums associated with traditional insurance. Some businesses want to offer their employees a form of coverage but again, cannot afford traditional insurance. We also are facing multiple areas in the state with skyrocketing insurance coverage and only one available “choice” that is really no choice at all for those that cannot afford it. This is their only option and it is better than nothing. This bill is an attack on these plans, with provisions that essentially allow the commissioner of insurance (who is likely to be hostile) to require whatever they want in terms of annual disclosures and require the programs to provide written statements again saying whatever the commissioner wants.

How Should Your Representatives Vote on HB21-1135

HB21-1140 Eliminate Donor Costs For Living Organ Donations (Coram (R)) [Titone (D)]

PASSED

AMENDED: Technical

Appropriation: $13,353
Fiscal Impact: Negligible each year

Goal:

  • Require all health insurance in the state to provide coverage for services related to living organ donations
  • Prohibit hospitals, health facilities, or health benefit plans from charging a living donor any deductibles, copays, or coinsurance or enforcing any benefit maximums, waiting periods, or other limitations on coverage for services necessary for the donation

Description:

A bill passed in 2019 forbids life, disability, and long-term care insurers from discriminating against living donors.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • More than 100,000 people in the United States are waiting for an organ donation and some organs can be donated by living patients
  • These are extremely expensive procedures and while expenses are typically paid by the organ recipients’ health care coverage, but that is not always the case, a 2016 study of kidney donors found 27% paying some parts themselves with 6% spending more than $500
  • We must remove all barriers to living organ donations: lives literally depend on it. No one who is willing to undergo these procedures should have to pay a dime in medical expenses or suffer any negative impacts on their insurance

Arguments Against:

Bottom Line:

  • Bill is silent about Medicaid, which enforces $10 co-pays per day. The state should shoulder this burden in addition to private companies

How Should Your Representatives Vote on HB21-1140

HB21-1146 Auricular Acudetox Professional Practice (Zenzinger (D), Woodward (R)) [Pico (R), D. Valdez (D)]

TECHNICAL BILL

From the Statutory Revision Committee

SIGNED INTO LAW

Description: Fixes a discrepancy in law around auricular acudetox procedures, which no longer require a license to perform.

 

HB21-1165 Assistance For Victims Of Strangulation (Gardner (R), Lee (D)) [Carver (R), Duran (D)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

  • Clarify that under the Colorado Crime Victim Compensation Act victims of strangulation are deemed to have cooperated with law enforcement if they get a medical forensic examination

Description:

This program reimburses victims for eligible medical expenses up to $20,000 in total (the list of eligible expenses is long and requires going through insurance first), including up to 3 therapy sessions. It also will pay for lost wages, funeral or burial support, home repair (for damage done during the crime) and rekeying, and crime scene clean-up. You do have to cooperate with law enforcement to be eligible or the board in charge of the program has to deem there was good cause for your failure to cooperate.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • It is important for a trained forensic medical examiner to complete an examination of a strangulation victim. We don’t want this to not happen because of cost, so adding this into the program will ensure that anyone who gets a forensic medical examination is deemed cooperative with law enforcement. One of the reasons to single out strangulation in this manner is that it is one of the more common assaults in domestic abuse cases, which is of course the most likely crime where the victim will not cooperate with law enforcement, but the primary reason is danger to the individual involved. The victim may have internal injuries that can later cause complete airway obstruction, even up to 36 hours later

Arguments Against:

Bottom Line:

  • The “good cause” clause should take care of domestic abuse cases and with so many different crimes covered under this program, it is a bit odd to single out strangulation. Sexual assault is another crime where a thorough medical exam and gathering medical evidence is extremely important. Other forms of assault can leave dangerous and potentially fatal internal injuries. But none get any such exemption (strangulation would be the only crime exempted in this manner)

How Should Your Representatives Vote on HB21-1165

HB21-1171 Kidney Disease Task Force (Buckner (D), Hisey (R)) [Bradfield (R), Titone]

PASSED

AMENDED: Minor

Appropriation: $91,657
Fiscal Impact: About $200,000 over next two years

Goal:

  • Create a task force to develop plans to raise awareness about early detection of kidney disease, reduce the burden of kidney disease in the state, and study and propose solutions to address higher rates of affliction in minority populations. Task force to submit its initial report by December 2023, then follow-ups each year a follow-up in 2026. Set to expire with sunset review in 2030 2026

Description:

Task force is to also work directly with policy makers, public health entities, and educational institutions to create health education programs around kidney disease; and examine chronic disease, transplantation (both living and deceased). The sustainable plan to raise awareness must include: health education workshops and seminars, preventative screenings, social media campaigns, and television and radio commercials.

Task force is to have four two members of the legislature (one appointed by leaders leader of both chambers) and ten seven non-legislative members, nine of whom are appointed by the governor Four appointed by majority leaders of the two chambers and three by minority leaders. No compensation for task force members and no reimbursement for expenses. Task force must meet at least four times a year.

Additional Information:

Exact task force composition is:

  • One legislator each appointed by president of Senate, Senate minority leader,
    and speaker of House, and House minority leader
  • The secretary of state (or their designee)
  • Nine governor appointees Seven appointees from the leadership of the legislature: one representing department of public health and environment, one representing renal provider community, one representing a state medical center with a kidney disease program, one representing the nephrologist community, two from different one from a non-profit focused on kidney disease, one representing the patient community, and two discretionary members to represent public health clinics, community health centers, one representing health interests of minority population health organizations, or private health insurers


Auto-Repeal: September 2026 with sunset review

Arguments For:

Bottom Line:

  • According the centers for disease control, 96% of people with early kidney disease are unaware they have any problem, but if the disease is caught early, it is often possible to slow or stop its progress. When it is not, often a transplant is required but in 2019 only 25% of Coloradans waiting for a kidney transplant got one. 37 million Americans suffer from this disease and Black Americans are 4 times more likely and Hispanic Americans 1.6 times more likely than whites to suffer from kidney failure.
  • Given all of that information, it is clear that early intervention and attempts to address disproportionate minority community impacts are clear needs at the state level and convening a task force of both legislators and experts should provide the blueprint for what we need

Arguments Against:

Bottom Line:

  • There are multiple ways to do this more quickly than a taskforce with no power other than to write a report. First—change this into a grant program with the task force handing out grants to organizations doing the work we need. Second—empower existing state agencies to work with key stakeholders to just go out and do what we are asking the task force to explore. Instead, we will get an answer at the end of 2023 about what legislation we need to pass in 2024. This is too critical a need to move at this pace

How Should Your Representatives Vote on HB21-1171

HB21-1172 Hospital Patient Long-term Care Resident Visit Rights (Smallwood (R), Ginal (D)) [Geitner (R)]

KILLED BY HOUSE COMMITTEE

Appropriation: None
Fiscal Impact: Negligible each year

Goal:

  • Guarantee hospital, nursing care, and assisted living patients the right to at least one visitor of their choosing. Facilities may develop policies and procedures restricting this access for medical reasons, but it cannot do so for the sole purpose of reducing the risk of infectious disease transmission. Facilities may, during periods of heightened risk of transmission, where community spread is not high, set some restrictions on visitors (see Description) which increase as the risk of spread gets higher in the community (again see Description).

Description: These facilities may, during periods of heightened risk of transmission, where community spread is not high, require visitors to enter through a single entrance, deny entrance to a visitor with symptoms of the disease, require visitors to use personal protective equipment, and require visitors to sign a waiver. Facilities are not required to supply required personal protective equipment. During widespread community transmission, facilities may require screening of visitors for symptoms (and deny entrance to those who have them), deny entrance to any except essential caregivers and require those caregivers to wear personal protective equipment. If a visitor is visiting an isolated patient with a communicable disease, the facility may limit visitation to essential caregivers, may limit to one visitor at a time, may require visitor scheduling, may restrict the movements of visitors within the facility, and may prohibit visitors during aerosol-generating procedures or collection of respiratory specimens.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Isolation contributes to poor mental health and can lead to worse health care outcomes
  • No one should have to die alone and people should have the chance to say goodbye
  • Infectious diseases are not new and our facilities can handle common sense restrictions to prevent spread while continuing to allow visitors

In Further Detail: The complete isolation of patients during the pandemic has multiple problems: for families who want to be with their loved ones and for the recovery of those isolated. People have been forced to die alone and loved ones have not been able to say proper goodbyes. And the reason for hospitalization is frequently not anything to do with Coronavirus. Given that communicable diseases are nothing new and hospitals have developed policies and procedures to address transmission issues with other diseases, they should be able to do the same for Coronavirus or other infectious diseases in the future.

Arguments Against:

Bottom Line:

  • We’ve seen what can happen when something like Coronavirus gets into long-term care facilities and it is ugly
  • Coronavirus is simply not like other infectious diseases (which is why we have a pandemic) and other similar diseases must be treated in the same manner
  • Facilities put great care into their policies—no one wants anyone to be alone or to die alone. But we need to leave public health decisions to the experts, not the legislature

In Further Detail: We sort of had a dry run of what it looks like to not close off access to these facilities during a pandemic with something as infectious as Coronavirus and the results were catastrophic. As of March 4 residents of long-term care facilities accounted for 34% of the deaths due to COVID in the US, despite being less than 1% of the population. We need to leave public health decisions to the experts, not to the legislature. Coronavirus is not at all like any other infectious disease we have, which is why we have a pandemic. It also has an unacceptably high asymptomatic transmission risk, so the idea of screening visitors just isn’t enough. These facilities put their policies in place during the pandemic not with a shrug and a hand waive, but with deeply considered thought that encompassed state, federal, and international guidelines. Most hospitals do already allow for a visitor at births and at deaths. This bill could allow for super-spreader events of diseases like Coronavirus among populations least able to withstand it. We need to keep these decisions in the hands of the experts. Better alone than dead.

How Should Your Representatives Vote on HB21-1172

HB21-1183 Induced Termination Of Pregnancy State Registrar [Luck (R)]

KILLED BY HOUSE COMMITTEE

AMENDED: Minor

Appropriation: None
Fiscal Impact: None

Goal:

  • Require any health care provider that performs an abortion to collect detailed information from the woman on her age, race and ethnicity, marital status, educational status, number of previous abortions, number of children, reason for terminating the pregnancy (see Description for list of options), and any impediments to the abortion (distance, age of fetus, cost, or partner or family opposition). Provider must send this information along to the state registrar of vital statistics in the department of public health and environment, along with the gestational age of the fetus, cost of the procedure and source of funding, type of procedure performed, name and type of facility where it was performed, and any complications. The information must not identify, or be able to be used to identify, the woman. The registrar is to make a summary of the report but only that is available to the public. Registrar must not release any information that identifies the facility or provider that performed the procedure

Description:

The registrar can permit the use of the data for statistical or research purposes, subject to the registrar’s conditions. These must be in writing. Registrar may disclose the information to federal, state, or local agencies in the conduct of their official duties.

The provider must indicate if the reason for the abortion was any of the following: failure of family planning (must specify), interference with woman’s education, interference with woman’s career, financial insecurity, doesn’t want a larger family, not ready to be a parent, opposition of partner or family to pregnancy, maternal health conditions (must specify), fetal abnormality (must specify), incest or rape.

If the abortion occurs after 22 gestational weeks, the provider must also indicate the reason for the delay: ambivalence about procedure, late confirmation of pregnancy, time needed to raise money for the procedure, need for judicial bypass, lack of leave time from work, or lack of transportation.

Failure or falsification of data is grounds for discipline on professional licenses and unprofessional conduct.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We don’t have data at this level on abortion and it is possible if we did, we could convince other Coloradans that the procedure must be banned
  • In the interim, the requirement for additional data may make some women pause and take stock and change their minds
  • The data may also help us better understand why women choose to get an abortion so we can attack those causes before they ever enter a clinic

In Further Detail: We lack high-quality data about abortions in this state and it is possible that if we had these kind of details we could convince other Coloradans that abortion is not what they think it is and should be banned. In the meantime, having to think through these issues may make some women pause and take stock of what they are doing and change their minds. Adoption is always an option for an unwanted baby. Finally the data may actually help us decrease abortions simply by better understanding root causes and intervening earlier in the process.

Arguments Against:

Bottom Line:

  • Colorado already publishes general data on abortions with no personal information. We do not ask similar questions for other medical procedures
  • This is not about research, this is about trying to find other ways to prevent women from exercising their right to control their own health care and their own bodies—through incredibly intrusive questions that may cause some women to not have the procedure (undoubtedly a goal of the legislation) and cracking open information about the provider and their funding streams
  • The data gathered is also likely to be useless as a high number of women are likely, and understandably, going to lie

In Further Detail: The state already publishes general data on abortions with no personal information. There is no great value gained from this highly intrusive and mandatory questionnaire, which seems more likely to shame women into not getting an abortion (or lying about the reasons why) and less likely to provide insights that will allow us to improve medical care. Because that is the only reason to ask detailed questions about a medical procedure, if we feel there is some problem with some people able to access the procedure or being denied the procedure. Otherwise none of this is anyone’s business. Whether or not you are married? How many children you have? Why you are having the procedure? And most ominously of all, how the provider got funding. All of these are irrelevant and guess what, we don’t ask. Unless of course the object is to erect a barrier that some women will not want to cross. Or to target specific providers and try to destroy their funding streams. Because you don’t think the procedure should ever occur and want salacious statistics you can try to parade in front of people. Advocates for this bill are quite open about that being a big part of why they want this bill to pass. We don’t ask these sorts of highly intrusive questions for other medical procedures. That alone should tell you about their medical value. The extremely high likelihood of women simply, and understandably, lying about all of this also should put to bed any considerations of research to improve women’s health care.

How Should Your Representatives Vote on HB21-1183

HB21-1184 Physician Assistant Collaboration And Reimbursement (Winter (D)) [Lontine (D), Will (R)]

KILLED BY HOUSE COMMITTEE

AMENDED: Moderate

Appropriation: None
Fiscal Impact: None

Goal:

  • Changes the collaboration requirements for physician assistants with physicians by changing the amount of time when collaboration standards get looser from more than 160 hours-3 years to more than 160 hours-5,765 hours. Once a physician assistant reaches 5,765 hours, the bill no longer requires any formal collaboration at all (see Description), just informal collaboration. Informal is not specifically defined in the bill, although collaboration is defined as both the physician and the physician assistant jointly contributing to care
  • Requires insurance plans in the state to reimburse physician’s assistants for services provided within their scope of practice (things they are allowed to do under the terms of their license) if the provider would reimburse a physician for providing the same service. They do not have to reimburse at the same rate. Authorizes physician assistants to bill and receive direct payments

Description:

For collaboration in current law (unchanged by the bill), that first 160 hours requires close supervision at the same location by a physician. After 160 hours there is a performance evaluation and a collaborative plan must be developed (in writing). Then at 3 years, under current law, there is a practice agreement created on how the two will interact in decision making and consulting, and that either can terminate the agreement. This bill changes that to 5,765 hours and then adds another level, where no formal collaboration documents are needed at all and the physician assistant does not appear to need to prove to the state that they are working with a physician at all.

The bill also takes a similar approach to practicing in a new specialty. Under current law this requires a supervision process similar to new physician assistants, again with using months instead of days for milestones. The bill changes the required evaluations from six months and 12 months to 960 hours and 3,840 hours. Just like the change to new physician assistants, it also adds the 5,765 hour barrier beyond which formal collaboration is no longer needed.

Insurers must identify the physician assistant as the professional who rendered care in the billing and claims process and cannot impose any requirements that are either inconsistent with or more restrictive than the state’s licensure requirements. Insurers must consider the physician assistant the primary care provider when they practice in a medical specialty for which a physician is required to be a primary care provider.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The current supervisory requirements for physician assistants greatly limits our state flexibility, particularly in rural areas where only 13% of the state’s physician assistants are located. Loosening these requirements should allow for easier deployment around the state and does not in any way affect the scope of practice requirements for physician assistants
  • Physician assistants are trained experts with years of education and clinical work required just to become one, and then the bill still requires thousands of hours of supervision
  • If we are going to free physician assistants from practice agreements then they need to be able to bill on their own, which is what the other part of the bill does. Because physician assistants bill at lower rates than physicians, they are one of our best weapons for lowering health care costs

In Further Detail: The supervisory requirements for physician assistants were raised two years ago (after they had been drastically lowered) and we went a little too far by requiring continual supervision of physician assistants into perpetuity. This greatly reduces flexibility in our medical system to create health care teams and the bill does still require collaboration and operating within scope of practice. This is really important because the rules around scope of practice are strict and violating them can cost you your license. So it is not at all true that this change will allow physician assistants to run amok with no doctor looking over their shoulder. You need a Master’s degree and at least 2,000 hours of clinical rotation along with national certification to become a physician’s assistant. Per the bill you then need 5,765 hours of supervised work (that’s 240 days) and to keep your license current, continuing education with the state. These are highly trained professionals. And what do we have here in Colorado? A shortage of qualified medical personnel in rural areas, where only 13% of state physician assistants practice. Getting them into looser collaboration and allowing them to directly bill and be reimbursed can allow us to potentially greatly expand the use of them in rural areas, which brings more cost-effective coverage. Because physician assistant’s bill less than physicians (which the bill does not change) they are widely seen as one of our best weapons for lowering health care costs. And if an employer wants to require more supervision? They still can. No one is arguing that this does anything to solve our problem of having enough physicians in rural areas—we still need more help there too and we want physician assistants to stay within their scope of practice and collaborate responsibly. But physician assistants are an important part of the cost variable and we should not deny that to rural Colorado.

Arguments Against:

Bottom Line:

  • Physician assistants are not medical doctors, the training is not the same and their scope of practice is not the same so we should not at any point treat them in the same manner
  • The point of continuing to require a formal supervision agreement is to ensure public safety. Yes a physician assistant can lose their license for practicing outside their scope, but that may be too late for whatever individuals were harmed in the process
  • Part of the point of physician assistants is to offload work from a more expensive physician they don’t need to see themselves—how is that going to work if there are no physicians in the area?

In Further Detail: First, physician assistants are not medical doctors and we should not be pretending they are equivalent. They are highly trained professionals but they do not receive the same training as doctors and are not permitted to do many of the things doctors are. So the point of continuing to require them to have formal supervision with a physician is public safety. We want to catch mistakes or practice outside of scope as they are happening, not afterward when we revoke a license too late to help the people harmed. And if part of the point of physician assistants is to offload work from a more expensive physician, thus saving us all money, how is that going to work in areas of rural Colorado that don’t have enough physicians? You need both, which is why we have insurance regulations the way we do now: physician assistants bill through their physicians. Otherwise what you have is an inferior substitute to a physician who hopefully knows enough to know what they don’t know. That is not the sort of solution we should want to our problem of medical care access in rural Colorado.

How Should Your Representatives Vote on HB21-1184

HB21-1190 Defining Telemedicine For Medical Practitioners (Kirkmeyer (R), Fields (D)) [Rich (R), Esgar (D)]

SIGNED INTO LAW

AMENDED: Minor

Appropriation: None
Fiscal Impact: None

Goal:

  • Redefine telemedicine to require HIPAA compliant technology and provide more detailed examples of the different types of technology that can be used

Description:

The exact new definition is: “delivery of medical services through HIPPA compliant telecommunications systems, including information, electronic, and communication technologies , remote monitoring technologies, and store-and-forward transfers, to facilitate the assessment, diagnosis, consultation, or treatment of a patient while the patient is located at an originating site and the licensee is located at a distant site.”

That replaces: “delivery of medical services and any diagnosis, consultation, or treatment using interactive audio, interactive video, or interactive data communication.”

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The HIPAA compliance is extremely important of course, but beyond that this is simply a far more detailed and useful definition. The wording here is extremely important because whether or not something meets this definition determines if it can be billed as telehealth for insurance purposes. There are multiple laws (and perhaps more coming in this session) around insurers being required to cover telehealth. We know from hard experience in these matters that we better cover all the bases

Arguments Against: n/a

How Should Your Representatives Vote on HB21-1190

HB21-1191 Prohibit Discrimination COVID-19 Vaccine Status [Ransom (R), Van Beber (R)]

KILLED BY BILL SPONSORS

AMENDED: Moderate

Appropriation: None
Fiscal Impact: Negligible each year

Goal:

  • Prohibit employers from taking any adverse actions against an employee based on if the employee has received a COVID-19 vaccine. Bans the state from requiring a COVID-19 vaccine and from requiring children to obtain one. Prohibits the state or any business or service provider from discriminating against a client, patron, or customer based on if they have received a COVID-19 vaccine. Prohibits health insurers from using COVID-19 vaccination status in any decision making on coverage or premiums
  • Prohibits health facilities to require COVID-19 vaccination as a condition of employment or take any adverse action against an employee based on if they have received the vaccine. State is prohibited from requiring facilities to ensure their employees receive a vaccine.

Description:

Anyone who violates these provisions may be sued in civil court for injunctive relief, affirmative relief including back pay and lost benefits with interest up to 10%, and any other equitable relief that may be appropriate. Courts may also order payment of attorney fees and punitive damages if it is demonstrated by clear and convincing evidence that the employer acted with malice or willful or wanton misconduct or this is a second or subsequent violation by the employer.

Adverse action means: refusing to hire, firing, refusing to promote, demoting, harassing, or discriminating in terms of compensation, terms, conditions, or privileges of employment.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • No one disputes that there are risk to vaccines, including in some cases, although quite rare, death or severe disability
  • The federal program for tracking vaccine injuries has taken in 15,923 adverse case reports as of February 21st. This includes 923 deaths, although it is not possible to know at this time if the vaccine caused the death (we just know the person was recently vaccinated)
  • The COVID vaccine is brand new and relies on new vaccine technology so it is impossible to yet know potential long-term effects or different reactions to the vaccine based on race, pregnancy, or other medications
  • We have long held in Colorado that people have the right to make their own health care decisions and consent to treatment is a universal tenet of our health care system. Yet right now someone can be fired for refusing to get the COVID vaccine. This bill fixes this by ensuring all Coloradans can choose not to get the vaccine without fear of being punished by the state or by an employer. If the vaccine is in fact nearly completely effective at preventing death from the virus, then the non-vaccinated would not be endangering the lives of anyone but themselves

In Further Detail:  Even pro-vaccine people admit that there are risks to vaccines. There is no risk of getting autism from a vaccine but there are other risks including bad reactions to the vaccine and in some cases, although quite rare, death or severe disability. Doctors themselves admit they cannot with 100% accuracy predict who will be harmed by vaccination. There is no liability for medical professionals administering them and extremely limited liability for pharmaceutical companies. There is a federal vaccine injury compensation program which takes on the liability for vaccines from pharmaceutical companies and it awards hundreds of millions of dollars a year in vaccine-related injury claims and more than $4.2 billion in claims over its lifetime. There is also an associated reporting system, which got about 30,000 complaints annually from across the country before COVID. For COVID itself as of February 21st it had received 15,923 adverse reaction reports including 1,869 reports of hospitalization and 923 cases where the person who received the vaccine died shortly thereafter (it is not possible at this point to definitely link the hospitalization or the deaths to the vaccine itself). It is also possible that this represents under-reporting of more mild injuries from vaccines, as not everyone is aware of the program. We also know that the COVID vaccines are extremely new and rely on different methods than most vaccines. It would be impossible to know the long-term potential effects from a vaccine that is essentially a year-old. We don’t have cross-racial studies, or in-depth studies on children or studies on pregnant women or studies on interactions with other drugs. So we have a medical treatment we know is not always safe and we cannot predict who necessarily it will not be safe for and we it is brand new. We also know that the medical code of ethics for the American Medical Association accepts that some individuals have medical, religious, or philosophical reasons not to be vaccinated and it is a universal tenet that we must have informed consent to medical treatment. And yet right now in Colorado there is no protection for someone invoking these personal rights from being fired or not hired because they lack COVID vaccination. It would be perfectly legal for any employer to mandate that all employees get the vaccine or face termination. If it is true that the vaccine is nearly completely effective at eliminating the risk of dying due to COVID, then the non-vaccinated would not be putting the lives of the vaccinated at-risk—just their own which is their choice to make.

Arguments Against:

Bottom Line:

  • Vaccines are extremely safe—most reports made to the federal vaccine injury program are for minor claims like sore shoulders and even including those the injury rate is around 1 in 4.5 million, and very few reporters actually get any compensation whatsoever even though the program is a guilty until proven innocent model for vaccines
  • COVID-19 adverse reaction reporting seems to be following a similar path, with adverse reports occurring in 0.03% of shots administered. As with other deaths in the system, until they are investigated we actually have no idea how these people died. The CDC has noticed no adverse patterns in the data that indicates the shot is not safe
  • Over 530,000 Americans have died from COVID so far, putting us on track for COVID to be the deadliest event in American history—so the tiny risk from vaccines is dwarfed by the risk of COVID and because we don’t know how long immunity actually lasts (except that is not going to be lifetime) the only route to herd immunity is vaccination. The alternative is continuing as we are right now. The vaccines are extraordinarily effective and appear to nearly completely eliminate the danger of dying from COVID
  • Your right to make your own health care decisions stops when it actively harms other people. You have the right to not get vaccinated (even if it is a foolish decision) but you don’t have the right to endanger others at your job. The vaccine is effective so far against all known variants of COVID but if the virus keeps circulating through the population it will keep mutating and there is no guarantee the vaccine will continue to be effective

In Further Detail: First of all, vaccines are actually extremely safe. Adjuvants are safe, and excipients (which basically means preservatives and mercury) are also safe. Mercury is no longer used at all in children and the exposure from a vaccine is less dangerous than the type of mercury contained in many fish anyway. First, in 30 years just 520 death claims have been compensated by the federal reporting program referenced in Arguments For, and almost half of those involved an older whooping cough vaccine that hasn’t been used in 20 years. A chunk of these recent claims (half!) are for shoulder injuries from flu shots done improperly by the health care provider. On the other hand about 300 million vaccines are administered every year in the United States. About 1 in every million of these doses gets some sort of compensation for an injury (or 300 total). But of those payments, the compensation program itself says about 70% of them come from a negotiated settlement in which the government has not concluded the vaccine caused the injury. The head of the reporting program describes it as a “guilty until proven innocent” model. So the final math on the injury rate for vaccines is about 1 in 4.5 million. The nature of the reporting system for deaths also means there is no attempt to actually prove causation. We have no idea how the 929 people cited in the reporting system actually died. They quite literally could have died from falling off a roof (unlikely that this would be reported in this manner but it is possible). The CDC has evaluated all of the information coming in the system and concluded there is no patterns that indicate safety problems with the vaccine. The bill sponsors are touting data showing 15,923 adverse reports by February 21 to COVID vaccinations. By February 20th 17.9 million Americans were fully vaccinated and 25.5 million had received just one shot. Because at that point the Johnson & Johnson single vaccine was not in use, we can say that means 61.3 million Americans had received a vaccine shot at that point. That is an adverse reaction rate (which remember, includes lots of things like “sore shoulder” and “slight fever” of 0.03%. 1 in 3.8 million. The death rate for COVID is hard to pin down because there are so many people who are never officially tested. But let’s take that adverse reaction rate (which is of course not even a death rate) and give two COVID shots to every single American: you just gave 98,460 Americans an adverse reaction to the shot. About 530,000 Americans died from COVID in the last year and the number is still rising. That is more Americans than died in World War II, more than in every other war except the Civil War combined, and we squarely in the middle of the number of Americans who died from the 1918-19 flu. Before we are done with COVID it may be the deadliest event in American history. We also know that so far the vaccine is extraordinarily effective. Reports from all around the world indicate that being fully vaccinated puts the risk of hospitalization and death down to near 0 and of course from getting the virus at all around 10% when exposed. So yes, vaccines are not 100% safe. But they are much safer than many of the activities we undertake on a daily basis (like driving a car or walking down the street) and they prevent things much worse. And the very nature of how vaccines work, with herd immunity helping those who cannot have one, means they are a public health concern. Each year in the United States, immunizations save 33,000 lives, prevent 14 million disease cases, and save $9.9 billion in direct health care costs. And that’s in a normal year, with no COVID. We spent over $5 trillion dollars at the federal level just in COVID stimulus, the final medical bill for care is likely to be astronomical. Businesses failed because we had to social distance to avoid spreading the virus. And yes it is true this is the fastest vaccination process in history. It is absolutely impossible to know the long-term effects of the vaccine. But here’s something else we don’t know: how long does immunity to COVID last? The belief is that we’ll need booster shots for years to come, including for people who already got COVID and recovered. So there is no other alternative to mass vaccination except letting the virus continue to rampage through the entire world and seeing massive numbers of deaths and economic disruption. We do have a long history in this country of accommodating others sincerely held beliefs and in letting people make their own decisions for their health care. But that must stop at the point where it endangers the health and safety of others, and that is why employers have the right to ensure the safety of their workplace and why in particular health care facilities must ensure their employees are not passing COVID to some of the most vulnerable people in our society. This is akin to an employer being able to fire you for firing off racial slurs in the office. You of course have the first amendment right to free speech. But you have no right to avoid any actions as a result of your speech. You have the right to not get vaccinated. It’s a mistake (unless you have a valid health reason you cannot get the vaccine) but you can do it. You have no right to keep your job if you are endangering the health of your co-workers and your customers. If the vaccine keeps spreading through the population it will continue to mutate. So far the vaccine is effective against the variants but that might not last. As a side note, many employers are thinking about encouraging vaccine adoption not by firing people who don’t get vaccinated but by offering bonuses to people who do. That would be illegal under this bill.

How Should Your Representatives Vote on HB21-1191

HB21-1198 Health-care Billing Requirements For Indigent Patients (Buckner (D), Kolker (D)) [Jodeh (D)]

PASSED

AMENDED: Moderate

Appropriation: $219,295
Fiscal Impact: About $500,000 a year at full implementation

Goal:

  • Require all health care facilities to bill patients who are eligible for state medical insurance plans (like Medicaid), which is 250% of the federal poverty line, at no more than 80%a percentage determine by the state that is not less than 80% 100% of Medicare rate or if that rate is unavailable, 100% of theMedicare base rates if they are uninsured and the services do not qualify for the state’s indigent care program (CICP). Payments to be collected in monthly installments so that the patient is not paying more than 5% 4% of their household income on a bill from a facility and no more than 2% on a bill from an individual provider and are capped at 36 months. Any money owed after the 36 months are up must be written off by the facility as uncollectable
  • To determine if a person is eligible, the bill requires health care facilities to screen all uninsured patients for eligibility for state assisted medical program Patients can decline the screening
  • Requires health care facilities to offer patients in debt to the facility payments plans that do need exceed 5% 4% of the person’s household income before involving a collection agency and prohibits taking any debt collection actions that require a court order (like placing liens on property or garnishing wages) for 180 182 days after the first bill for the debt and completely bans causing someone’s arrest (including in civil cases), foreclosing on someone’s property, or garnishing income tax refunds

Description:

State must create a uniform application for health care facilities to use in the screening process and a written explanation of patient rights under this bill at the sixth-grade reading level and translated into all languages spoken by 10% or more of the population in each county in the state. Health care facilities must make this notice on their website, in patient waiting areas, on each billing statement, and to the patient before discharge from the facility.

Health care facilities are barred from denying discounted care on the basis that the qualified individual is not actually in any of the state assistance programs they are qualified for and from denying care because the patient lacks insurance, may qualify for discounted care, requires extended or long-term treatment, or has an unpaid medical bill. For calculating qualification, state must provide a methodology for all facilities to use and it cannot consider assets.

State must create a process where patients can appeal if the facility determines they are not eligible. Facility must provide notice of this appeals process. State must also create a process for collecting complaints related to this law from patients and must review all complaints within 30 days. State must periodically review facilities to ensure compliance. For any problems the state uncovers, the facility has 90 days to file a corrective action plan, which must include notification of patients and any financial corrections required in patient billing. Facilities can request a 30 day extension. If the non-compliance is willful or part of a pattern of non-compliance, the state may fine the facility a maximum of $5,000. If the facility does not undertake corrective action that fine becomes weekly.

All health care facilities must report whatever the state determines is required to ensure compliance with the law. This should be reported aggregated by race, ethnicity, and primary language spoken. If a health care facility cannot report aggregated data it must make changes so that it can and inform the state of an ETA.

Before assigning debt to a collection agency, facilities must also inform the patient in plain language of the services that are owed and of potential collection actions. Agencies and facilities must inform patients at least 30 days prior to taking any debt collection action that requires a court order. The notice must include information on the discounted payment policy created by the bill and how to apply, what collection actions will be taken and when.

If it is later determined that the patient should have been eligible for discounted payments, the collector must delete all negative reports to consumer credit agencies, dismiss any pending legal action and vacate any judgments already issued, remove any wage garnishment orders and refund any excess money collected (above the amount the patient would have paid under the discounted payment program) ask for a court order to fix the amount owed to the proper amount, and cease any other debt collection actions that require a court order.

Failing to comply with the requirements to participate in the discounted payment program opens facilities up to civil lawsuits. Victorious plaintiffs can be awarded actual damages, reasonable attorney fees, and up to $1,000 in additional damages for individual suits and $500,000 or 1% of the net worth of the facility (whichever is lower) in class action suits. If the court finds the suit was brought it bad faith it can award attorney fees to the defendant.

State has until April 2022 to create the requirements for this program and facilities must begin following the bill in June 2022.

Additional Information:

Any debt collector that buys medical debt must agree in writing to abide by the provisions of this bill and the legal rates of interest that can be applied to medical debt (already exists in law).

Public health assistance programs include Medicaid, Emergency Medicaid, and the Children’s Basic Health Plan (CHP+). The CICP is not health insurance and participation in it is voluntary for health care facilities (unlike this bill). It is designed for people who are not eligible for Medicaid or CHP+, but you can be on Medicare. Payments for CICP are determined by family income (so there is no flat max 80% of Medicare rate like in this bill).

For determining amount of damages in cases where the facility did not follow the law, courts must consider the frequency and persistence of non-compliance by the facility, the nature of the non-compliance, and the extent to which it was intentional.

Any violation of the bill by debt collectors is considered an unfair debt collection practice and subject to existing penalties.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Coloradans struggle to pay medical expenses, with the latest data (which is pre-pandemic), showing 18% of everyone in the state having trouble. Nearly ¼ of the group that is 201% to 300% of the federal poverty line (so a prime target of this bill) reporting skipping medical care due to cost
  • Medical care is not like other forms of purchases: we need it and have little choice in the matter, unlike buying a car or television, so we should not be treating medical debt like other debt
  • The discounted payment requirement is pretty narrow: uninsured, less than 250% of poverty line, so it should not be overly burdensome for hospitals (80% over Medicare rates is not exactly bottom of the barrel pricing)
  • Pushing people in debt spirals over health care is counterproductive for everyone involved: we are better off if people pay slowly over time and better off giving people more time to pay before we start extraordinary measures like liens on houses or garnishing wages. And no one should be kicked out of their house for failing to pay medical debt
  • Cost shifting worries are overblown: the hospital industry was incredibly profitable pre-pandemic and will likely return to huge per patient profits once the pandemic recedes

In Further Detail: The latest data we have puts the number of Coloradans struggling with medical care at unacceptably high levels. 361,000 remain uninsured (6.5%) but the uninsured rate among those at 201% to 300% of the federal poverty line has nearly doubled since 2015 and is now the highest in the state at 11.8%. That is because chunks of this group are not eligible for Medicaid. Nearly ¼ of this population reported skipping medical care due to cost and the percent of all Coloradans who report struggling to pay for medical care has risen for the first time since the implementation of the Affordable Care Act to 18% in 2019 (pre-pandemic!). Of that 18%, 54% report taking on credit card debt, 33% report being unable to pay for basic necessities like food, 19% took out a loan, and 4% declared bankruptcy. All of that is because medical care and medical debt is unlike just about any other kind of service or debt we have. Choice doesn’t factor in the way you can decide not to buy a car or a television. And yet we treat in much a similar matter as other bills and debts. There is a price, someone has to pay it, and if you are uninsured a single medical emergency can in essence ruin you financially, for repercussions that can last generations. So rather than force people into that deadly spiral of debt or force them to skip care which might result in premature death or chronic (and expensive) illness, we should provide realistic methods for the indigent who don’t have state assisted insurance or cannot use the state medical program for the indigent, a way to get the care they need without financial ruin. The discounted payment requirement only applies to this one group. If you don’t have insurance but don’t meet the poverty requirements, then you have to pay full freight and even the discount isn’t likely to be terrible: 80% over Medicare rates. The same arguments apply to debt collection here for requiring it to occur slowly for these vulnerable populations. For the time limits required before instituting extraordinary measures, we need to give people more time before we start putting liens on homes or garnishing wages, which has the potential to kick off debt spirals. The bill does not ban these practices, just provides more breathing space. As for the cost-shifting argument, while the pandemic definitely has hit hospitals hard, we need to remember that this was a hugely profitable industry before 2020 and will likely revert to profits once the pandemic recedes. Denver-area hospitals made a record $2 billion in profit (yes profit, not revenue) and prices overall in the state grew 70% between 2009 and 2018. In the state, hospitals are now profiting (again, profiting) at $1,518 per patient in 2018. That number was $538 in 2009. A 280% increase in pure profit. We have the second highest hospital profits in the entire country, the fourth-highest administrative expenses (non-medical care—you don’t profit on salaries but you can compensate your executives highly, like over $5 million a year for the CEO for instance), and the second-most hospital construction in the country, despite the fact that we are one of the healthiest states in the nation. So it is not at all a given that facilities cannot handle the lower revenues from this sliver of patients without passing on financial pain to the rest of us.

Arguments Against:

Bottom Line:

  • Big chunks of money are likely going to be unrecoverable under this bill with the 36 month deadline combined with the 5% limitation on income. That will not vanish into thin air but likely be recouped by facilities in some other way: higher costs and premiums for the rest of us
  • There are ways to address the problem of uninsured who qualify for state medical assistance programs, like signing them up for the programs
  • The ban on asset consideration for eligibility is too broad a brush—there are a lot of things beyond primary residences and retirement savings that someone could have as an asset
  • Hospital profits are more complex than may first appear, since they include profits from investments. Patient profit margins are in fact frequently lower

In Further Detail: The biggest provision of the bill is the requirement to cease collecting payments after 36 months while being limited to 5% of a person’s income. That is going to results in big chunks of costs being unrecoverable. While it always sad when someone falls into such steep debt that they cannot pay the money they owe, the fact is that the money is owed and the creditor has to be able to get it back. Excluded medical costs will not just vanish into thin air, it will come out of the pocket of everyone who is paying their medical bills in the form of increased costs and potentially increased premiums. There are other ways to address people who are eligible for state assistance programs but aren’t participating. Screening for them and then helping them enroll would be one way. And the ban on consideration of assets is too much of a broad brush for qualification. Clearly someone’s primary residence is something they cannot just sell to pay a bill without severe repercussions and retirement savings carry tax penalties for early withdrawal (and will be needed in retirement), but someone with plenty of money in the bank or in the stock market or living off of a health amount of non-wage income is a different matter. For hospital profitability, the profit numbers include profits from investment income (reserve funds, which no one denies a hospital should have, don’t just sit in a bank account), and the profits due to just patient care drop the profit margin from 10% to 4%. And of course we need new construction, we are one of the fastest growing states in the country. So it seems more likely than not that these facilities, including hospitals, aren’t going to shrug and accept getting drastically less money from these patients as a cost of doing business. They will try to find ways to recoup those losses elsewhere.

How Should Your Representatives Vote on HB21-1198

HB21-1202 Off-label Use Of Approved Drugs To Treat COVID-19 [Luck (R)]

KILLED BY HOUSE COMMITTEE

Appropriation: None
Fiscal Impact: None

Goal:

  • Allows prescribers to prescribe, and pharmacists to dispense, FDA approved therapeutic drugs for off-label use (not using them as intended or approved for by FDA) for people to treat COVID-19. This can be for treatment in any setting and does not require suspected exposure to the virus or a positive test. Includes hydroxychloroquine sulfate and ivermectin

Description:

Clarifies that doing this does not constitute unprofessional conduct by the prescriber and cannot subject them to discipline or investigation by their licensing board.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The super scare study last summer that found series harm from hydroxychloroquine in COVID patients had to be retracted due to problems with its data and subsequent studies have not found greater harms than placebo treatments

Arguments Against:

Bottom Line:

  • The use of these drugs to treat COVID has long since been debunked by multiple studies that showed they had no effect at best. The single greatest piece of proof that these treatments won’t help is that their greatest booster, President Trump, did not receive them when he got COVID
  • We actually now have a pretty decent suite of treatments for COVID, including the regeneron cocktail and the bamlanivimab cocktail. So this isn’t just a matter of giving what at best amounts to a placebo: we have other treatments that can work
  • These medicines are actually needed by people for the actual intended use. People with lupus need hydroxychloroquine to treat it and faced shortages last year, particularly last summer, and suffered negative health results

In Further Detail: These drugs have long since been debunked as effective COVID treatments by multiple studies. The National Institute of Health does not recommend it. When President Trump got COVID last year, despite the fact that he was perhaps the most prominent public supporter of hydroxychloroquine he did not take it at all and the strong belief is that he never did, despite saying he took a two week course last May. So what’s the problem, if it doesn’t cause harm (which does appear to be the case, although some research indicated some possible serious side effects which later had to be retracted)? First, we actually have better treatment options for COVID now, including two antibody cocktails (regeneron and bamlanivimab), one of which President Trump took. Those should be what people are taking. Second, people actually need these other drugs, for their intended use. Hydroxychloroquine is taken by people with lupus and rheumatoid arthritis and last year many were unable to access the drug due to shortages. This had serious negative impacts on their health. At this point the FDA has had plenty of time to approve these drugs for COVID use if they actually worked. They don’t, so the FDA hasn’t. We need to listen to the experts.

How Should Your Representatives Vote on HB21-1202

HB21-1206 Medicaid Transportation Services (Moreno (D), Coram (R)) [Larson (R), A. Valdez (D)]

PASSED

Appropriation: None
Fiscal Impact: None

Goal:

  • Move the oversight of Medicaid non-medical and non-emergency medical transportation services from the public utilities commission to the department of health care policy and financing

Description:

Bill also requires the department to collaborate with stakeholders to set rules and processes for the safety and oversight of these transportation services. This includes driver and vehicle requirements that minimize financial and administrative burdens for providers and other organizations and contractors providing these services. To the extent possible the department is to use existing regulations.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This is just common sense: these transports don’t belong with cabs and busses in the purview of the public utilities commission, they belong with the state division that oversees Medicaid

Arguments Against: n/a

How Should Your Representatives Vote on HB21-1206

HB21-1232 Standardized Health Benefit Plan Colorado Option (Donovan (D)) [Roberts (D), Jodeh (D)]

SIGNED INTO LAW

AMENDED: Very Significant

Appropriation: $1,619,637
Fiscal Impact: About $2 million a year

Goal:

  • Requires commissioner of insurance to develop a standardized health benefit plan for insurers called the Colorado Option. Plans must be at least ACA bronze, silver, and gold levels of coverage, include the essential benefits package required under the ACA, have designed benefit and cost sharing, and provide first-dollar, predeductible coverage for certain high-value services that reduce racial disparity in health outcomes such as primary care and behavioral health care as appropriate. Commissioner must work with stakeholders (see Description) to create the plan and it must be designed to improve racial health equity through variety of means including perinatal coverage. It must be actuarially sound
  • Carriers only have to offer the Colorado Option if by January 2023 they have not reduced their premiums by 10% compared to 2021 (county by county comparison) and by January 2024 if they have not reduced their premiums by 20% compared to 2022. Insurers must set a goal of offering the standardized plans at 10% less in 2023 and 20% less in 2024 than 2021 rates. All of this is for both the individual and the small group markets. Beginning in 2025 insurers are encourage to reduce their price increases by no more than inflation plus 1% must offer the plan on the individual and small group markets beginning in 2023. The commissioner cannot force insurers to offer the plan in any county where the insurer doesn't offer insurance. The premium rate for the plan must be at least six percent less than the premium rate plans offered by the provider in the same county in 2021, adjusted for medical inflation. This will be calculated by the commissioner of insurance. If the insurer didn't offer coverage in that county in 2021, then the rate must be 6% 5% less than the average of all rates in the county in 2021 in that market (so individual for individual plans, small group for small group). In 2024 this rate reduction must be 12% 10% as compared to 2021. In 2025, 18%15% compared to 2021. Thereafter premiums can only increase by medical inflation.
  • Commissioner to create fee schedule for the Colorado Option to pay providers. Commissioner may take into account circumstances of critical access hospitals (only hospital serving area), rural and independent health care providers (not part of any larger system), and providers that serve a higher than average number of uninsured and/or Medicaid patients. May also consider cost of adequate wages, benefits, staffing, and training for providers’ employees to provide adequate care. By 2025 these reimbursement rates must achieve the 20% reduction in premiums goal and the inflation+1% goal thereafter.
  • If insurers cannot meet these rate requirements and keep network adequecy (see Description), the commissioner can, after a public hearing, modify provider reimbursement rates. Base reimbursement for hospitals must not be less than 155% of the hospital's Medicare or equivalent reimbursement rate. Essential access hospitals or hospitals that are not part of any network (so unaffiliated with other hospitals) get a 20% increase and if a hospital is both (essential and unaffiliated), 40%. Hospitals that exceed statewide average of Medicare or Medicaid patients get up to a 30% increase, actual amount based on their actual number of such patients. For hospitals that prove efficiency in managing care based on margins, operating costs, and net patient revenue, up to a 40% increase. For pediatric hospitals with a level one trauma center, a 55% increase and no other increases (so doesn't matter if they qualify for any of these other increases). For providers, rates must be a minimum of 135% of the Medicare rate for the same service in the same area. But the commissioner cannot decrease rates for any hospital by more than 20% in one year. The commissioner can also force providers hospitals to accept these rates (in other words force them into accepting the Colorado Option) in order to ensure network adequacy but it cannot force providers (except for hospitals that provide a majority of services through a single contracted medical group for a non-profit HMO) to work with specific insurers. Commissioner must contract with a third-party organization to determine how to best phase-in these new rates using a quality metric adjustment and an acuity adjustment as measured by the hosptial's case-mix. Evaluation must be complete by end of 2022
  • Providers are banned from balance billing consumers in the Colorado Option, which means they cannot charge consumer more than the Option reimburses for services
  • Every health care provider in the state must accept the Colorado Option, except the commission may exclude providers from the fee schedule or change it if the provider can demonstrate it will reduce its ability to accept or provide coverage to the uninsured and Medicaid/CHP+ patients
  • Creates the Colorado Option Authority, which is to operate as an insurer in Colorado only if all insurance carriers fail to meet the 10% or 20% rate reduction goals. Board is a quasi-public entity (it operates independently from any branch of government but is not a private corporation) governed by a board. Board must also appoint an advisory committee to help it carry out its work. Authority requires a waiver from the federal government to capture savings in Medicaid to use to fund the Authority. Commissioner must consult with an advisory board created by the bill to adminster this bill. Committe must also consider recommendations to streamline prior authorization and utilization management for the plan, ways to keep health care services in the communities where patients live, and consider alternate payment models for particular services, keeping in mind the impacts of such models on people of color. Bill also creates an insurance ombudsman to advocate for consumers in any public hearings on rates or access required by the bill. Ombudsman also to evaluate the Colorado Option for network access and affordability and interact with consumers regarding any issues with the plan</span.

Description:

The network requirement for the plan is one that is culturally responsive and to the greatest extent possible reflects the diversity of its enrollees and is no more narrow than the most restrictive network the carrier is offering for other plans in the area. When carriers develop networks for the Colorado Option, they must include as part of the network a description of the carrier's efforts to construct diverse, culturally responsive networks that are well-positioned to address health equity and reduce health disparities and include a majority of the essential community providers in the service area. Carriers must file action plans with the commissioner if they cannot construct an adequate network

Premium rate reductions must account for policy adjustments deemed necessary to prevent people with low and moderate income from experiencing net increases in premium costs (lots of people get subsidies for their insurance from the federal government). Commissions paid to insurers for plans must be comparable to the average commissions for other plans in the market.

The reimbursement rate structure set by the commissioner is available to other health care plans, including co-operatives, if the commissioner approves.

Commissioner must consult with employee membership organizations representing health care providers’ employees in the state and with hospital-based health care providers in setting reimbursement rate formulas.

Stakeholder process for creating standardized plans must include physicians, individuals who represent health care workers or work in health care, health care industry and consumer representatives and individuals working in or representing diverse communities. Diversity is defined as race, ethnicity, immigration status, age, ability, sexual orientation, gender identity, and geographic regions of the state affected by higher rates of health disparities and inequities. Commission can update the plans annually by rule. If insurers are offering them, Standardized plans must be offered in a way that allows consumers to easily compare them.

Requires the commissioner to contract with an independent third party to analyze the impact of this bill on health plan enrollment, health insurance affordability, and health equity. This must be disaggregated by race, ethnicity, immigration status, sexual orientation, gender identity, age, and ability to the extent possible. It also must include information on total out-of-pocket spending. Report due by January 2026. Commissioner must also contract with an independent third party organization to analyze the effect of this bill on staffing, wages, benefits, training, and working conditions of hospital workers and as it relates to provider workload. This must produce three different reports, one in July 2023, then July 2024, and then July 2025. State must report to the legislature on the implementation and effects of this bill every year.

Carriers can take reimbursement rate disputes with providers to non-binding arbitration. At any public hearing regarding rates, alll affected parties must be allowed to testify (insurers, hosptials, providers, consumer advocacy organizations, individuals, and the ombudsman). The hearing must be limited to the reasons why the insurer cannot meet either the premium reductions or network requirements. All rulings by the commisioner are appealable in district court.

If an insurer working with a co-op has previously achieved 18% reductions in premiums, regardless of first year benefit plans were offered, that plan is deemed to comply with the requirements of this bill (so no Colorado Option needed).

When considering premium amounts and if they meet the reduction requirement, the commissioner must take into account actuarial differences between the Colorado Option and health plans offered in 2021, any changes to the Colorado Option, and any federal or state law changes after 2021 that would affect premiums. For the purposes of reimbursement rate setting for an insurer who failed to meet the reduction requirements, the insurer must provide reasonable information to identify which hospitals or providers were responsible for the failure (or for failing to meet network requirements).

Commissioner is barred from using failure of insurers to meet Colorado Option rate reduction or network requirements in consideration of approval of other plans from the insurer (all insurance plans must already be approved by the commisioner in this state)

Bill bans cost shifting between the Colorado Option and other insurer plans (jacking up rates on the plans they control to cover lost or less money coming in on the Colorado Option). Failing to comply with the terms of the law subjects license holders to discipline from the state, including unprofessional conduct charges. hospitals to discipline on their license, including having it revoked suspended. Hospitals can be fined up to $10,000 per day for the first 30 days it fails to comply and up to $40,000 a day for each day after. Providers can be fined up to $5,000 (just a flat fine) and are not subject to any other discipline.

If the federal government creates a federal public option for insurance that is as good or better than the Colorado Option, then the entire Colorado Option and Authority are repealed. State is to ask federal government for an innovation waiver so as to capture all applicable savings to the federal government from this bill for the state. If approved, the state is to give that money to the already existing Colorado health insurance affordability enterprise to increase the value, affordability, quality, and equity of health care coverage for Coloradans historically and systematically disadvantaged by health and economic systems.

Board members are appointed by governor, require Senate confirmation, and serve four-year terms. They receive a per diem and reimbursement for expenses. Board is subject to state open meetings laws. It must hire an executive director to run the Authority. It may contract with other state agencies to implement the Colorado Option., board is composed of 11 members and the governor must strive for a diverse board and try to ensure at least a third of the board members are people of color and that rural areas of the state are represented.

Additional Information:

For counties where insurers did not participate in 2021, the goal should be 20% rate reduction compared to the average premium rate in that county in 2021.

State to survey Colorado Option consumers on their purchasing experience and whether the plan addresses health equity and health disparity concerns. Survey must be completed by January 2026.

Board is composed of nine members and each member must have expertise or experience in at least two of the following areas: must to extent practicable include people who:

  • Individual health insurance coverage Have faced barriers to access, including people of color, immigrants, and those with low-incomes
  • Value-based purchasing and plan design Have experience using the Colorado Option
  • Health care consumer navigation and assistance in accessing health care Represent consumer advocacy organizations
  • Health care finance Have experience in health equity
  • Provision of health care services in rural areas Have expertise in health benefits for small business
  • Provision of health care services to uninsured and low-income populations Represent insurers or who have experience designing health plans and setting rates
  • Health care actuarial analysis Represent hospitals or have experience in hospital/insurer contracts
  • As a member of an employee organization that represents employees in the health care industry Represent providers or have experience in provider/insurer contracts
  • Health care delivery systems Represent an organization that represents health care employees
  • Representing consumers in the development of health care policy Licensed or retired physicians who practice or practiced in Colorado
  • Hospital administration
  • Insurance brokerage
  • Improving health equity for communities of color and decreasing racial disparities in health care

Board as a whole must cover most of these areas. At least five members of the board must be consumers, representatives of consumers, and small business owners. One member must be a representative of hospitals and one must be a representative of providers. No members can be employed by an insurer or managed care organization. Members must publicly disclose any conflicts of interest. The board should reflect geographic, ethnic, racial, immigration status, income, wealth, and ability of the state as much as possible. Must attempt to appoint members from both rural and urban areas.

The advisory committee is left open to the board in terms of appointment requirements. Board must give special consideration to Coloradans with low-income and to communities of color. Must include members who intend to enroll in Colorado Option and must reflect diversity of the state.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Multiple regions in the state still struggle to obtain affordable and useful insurance—10 counties had access to only one insurer through the state exchange
  • Health care is different than any other thing we purchase: we don’t price out our options, we don’t understand our costs and options, we don’t have choice of insurers in most cases, and we can’t just not get care
  • Insurance companies remain extremely profitable with net profit margins higher than before the introduction of the Affordable Care Act in 2010 and hospitals in this state are wildly profitable (pre-COVID), 2nd highest profitability rate in the nation. Both can afford the 10% and 20% 18% 15% reductions the bill calls for and still provide service (and yes, make a profit)
  • By providing rate flexibility to various providers that are actually struggling right now that serve Medicaid patients or are critical access hospitals or any of the other automatic increases on the list, the bill could actually help them more than the status quo
  • The bill gives the entire industry a final chance to put their money where their mouth is and bring down costs—only if they fail does the heavy hand of government come in

In Further Detail: Multiple regions in Colorado still struggle to obtain affordable, useful insurance. The useful clause there is important, low-cost mostly useless insurance doesn’t do anymore much good and is the system we had before the Affordable Care Act when bankruptcy from health care costs was considered a normal thing in this country. 10 counties had access to only one insurer through the state’s exchange in 2020. The federal government doesn’t seem like it is going to do anything to address this, so it is up to us. Free markets have utterly failed in this industry for several very good reasons. First, consumers do not “price” their health care options. It is nearly impossible to do so even if you wanted to shop around at various providers. Second, consumers mostly do not have the choice over their insurance to begin with, since the vast majority get it through their employer. And most importantly, we cannot choose to not get health care. We all need it and we cannot choose when we need it. And so we have two choices: offer insurance through the government where the government is in essence the insurance company and pays out all claims (similar to the Canadian system) or create and manage an insurance option. In essence, attack head-on the problems we all see in the health care marketplace through an insurance plan that must be offered throughout the state. We passed a bill two years ago to explore this issue and the committee it created recommended this solution. A Canadian type system just does not fit with state finances (multiple other states including Vermont and California have explored this and come to the same conclusion). So what are these problem areas? First, insurance companies themselves, who remain an extremely profitable industry, with net profit margin higher than before the introduction of the ACA (3.4% in 2018 and rising) on vastly increased revenues (thanks in part to all of those new ACA customers). Second and most importantly, a big part of this is hospitals. Denver-area hospitals made a record $2 billion in profit (yes profit, not revenue) and prices overall in the state grew 70% between 2009 and 2018. In the state, hospitals are now profiting (again, profiting) at $1,518 per patient in 2018. That number was $538 in 2009. A 280% increase in pure profit. Coloradans have lost billions of dollars just so these hospitals can make more money, mainly through charging non-Medicare and Medicaid patients far more than they need to offset any potential losses. We have the second highest hospital profits in the entire country, the fourth-highest administrative expenses (non-medical care—you don’t profit on salaries but you can compensate your executives highly, like over $5 million a year for the CEO for instance), and the second-most hospital construction in the country, despite the fact that we are one of the healthiest states in the nation. And this is an industry dominated by “non-profits” (over ¾ of the hospitals in the state) who aren’t supposed to care about making a profit at all. These non-profits have cut spending on charity care by 2% according to the latest tax data available while instead money is plowed into unnecessary construction (our occupancy rate is below average for the country and dropping) and stockpiling of “reserves”. All of that extra cost gets passed on to us through insurance premiums. And yes, this is all pre-pandemic numbers. The industry has been hit hard by the pandemic but we should absolutely not make public policy based on once in a generation problems that are right now starting to fade (and will fade more rapidly with more vaccinations). Probably the most controversial part of this bill will be the rate setting, providers of course face similar issues with Medicaid and Medicare but have more flexibility to opt-out of providing some of that care. The break-even point for most hospitals is believed to be at about 143% of Medicare rates. In 2019 hospitals were charging an average of 280%. Between just that and insurance profits, it is easy to see all of the money being drained out of our pockets in this industry. Then of course we want to not have a one size-fits all rate but target hospitals in specific circumstances (including having more of those low fee Medicare and Medicaid patients) for higher reimbursement rates. No one wants to run hospitals out of business or put added stress on hospitals that are already struggling (thus the ability to also have a complete exemption from these rates). We just want to reign in one of the worst systems in the entire country when it comes to cost. So yes, the state sets reimbursement rates and those rates may in fact drive other insurance plans offered in the state to negotiate their own rates from a place of power, rather than their current place of weakness in the face of the monopolistic structure of our hospital system (where there has also been a lot of consolidation of ownership). That is in fact the entire point. We do not need the most profitable hospital industry in the nation. The design of the bill may actually also raise reimbursement for some hospitals who are not part of a big system, critical care locations, and efficiently serving high numbers of Medicare and Medicaid patients (for last year’s bill, the media found found at least 10 hospitals, all rural, that they believe will actually see rate increases, since this year’s does not have specified rates in the bill, it is impossible to know for sure if the number will be similar and the numbers in this bill are exactly the same, so the same analysis holds). And those are precisely the hospitals that are currently struggling and the ones we want to reward. The bill also protects against two main areas of concern with a state-backed plan: that insurers will simply shift costs to non-Colorado Option plans and that those on subsidies will be negatively affected. For the first, the commissioner of insurance can deny any rate change that is a cost shift (all plans must be approved by the commissioner to appear on the marketplace right now). As for the alternative total cost of care model proposed in arguments against, this is a model that fails to acknowledge that our current spending is wildly out-of-control and instead locks that spending level in and just tries to “limit” future growth. Massachusetts may believe they have saved money by using this plan compared to nothing at all, but insurance premiums and out-of-pocket expenses have grown there by more than their targeted maximum growth figure (which was 3.8%, well above inflation). So it may be somewhat helping but it by no means gets a full handle on the problem. The final point is the concern over insurers fleeing the state entirely. This gets parts of the equation here wrong. Insurers are going to love the reimbursement rates set on hospitals, if it even occurs, and if it doesn't, they'll love the lower reimbursements that allow them to get premium costs down (who also aren’t going anywhere) and are going to love the bargaining power this option gives them when it comes to their own plans. Which brings us to the final, and most important part of this bill. The medical industry has been telling us for years that they can handle bringing down skyrocketing costs without the heavy hand of the government. Well, here’s their chance to prove it. All of the heavy government intervention only occurs if the private sector fails. And if it does fail, then yes, insurers will face competition for an in-essence non-profit government operation that every single provider in the state must accept.the state will step in and start setting rates. Because we are doing waiting on false promises and ready to see some action.

Arguments Against:

Bottom Line:

  • More free market innovation is the way to bring down costs, get the government out of the way and let insurers provide plans with more flexibility in terms of what they cover
  • The market is also improving right now, it was 14 single-serve counties in 2019 and insurance premiums in these areas are dropping
  • The bill sets out an impossible task for the industry and then when it inevitably fails introduces government intervention on steroids: commissioner of insurance setting rates for the entire state (so price controls) and the ability to require all some providers to participate
  • Hospital profitability is more complex, it includes profits from investment income and we need new construction as one of the fastest growing states in the country
  • Health care is also just plain expensive, due to the really high cost of research and development of new drugs, new procedures, and new technology
  • Instead of a government smackdown, we should go with the collaborative model used in Oregon and Massachusetts (hardly conservative bastions) whereby the state works with the industry to set cost growth goals and works with individual providers who fail to meet them. Massachusetts believes it has saved billions of dollars with such a program

In Further Detail: Getting costs down by getting more free market innovation into the space is the right way to go, not more government involvement. There is a reason why there are few insurers who want to provide coverage in these counties and that is because of the high cost of delivering health care in these areas. Thanks to the Affordable Care Act, these insurers cannot offer lower cost plans that do not cover as much, so everyone is stuck with high priced plans. We need to get government out of the way, not more deeply involved as this bill envisions. It is also important to note that the number of single-serve counties is dropping (it was 14 in 2019) and insurance premiums on the exchanges in these areas are also dropping (thanks in part to a reinsurance bill passed by the state in 2019). In essence, this bill gives an enormous amount of power to unelected government officials to basically set the health care market for the entire state. The commissioner of insurance gets to create this plan and its requirements and tell providers exactly what they are allowed to charge for services. It is government price controls, plain and simple. This is government intervention on steroids. Oh yes, it only happens if the industry fails the test the state sets out for it, which is a basically impossible goal with two or three years to achieve. The bill wants the industry to fail. For hospitals, there is a lot to unpack here. First, the profit numbers include profits from investment income (reserve funds, which no one denies a hospital should have, don’t just sit in a bank account), and the profits due to just patient care drop the profit margin from 10% to 4%. And of course we need new construction, we are one of the fastest growing states in the country. We might be somewhat under-capacity right now, but we know more people are coming. And when it comes to cost, the fact that no one like to talk about is that health care innovation is incredibly expensive. All of the work that goes into creating new drugs and new equipment and new procedures that benefit us all must be paid for. And hospitals frequently have to make significant capital investments in that new equipment just to keep up. But yes, there probably is extra cost here that could be addressed. But instead of government pricing controls, we should look to the model used in Massachusetts and Oregon (hardly bastions of conservative thought). This is a total cost of care model that sets a desired target for how much health care spending can grow and then work with hospitals that do not meet the target (including public hearings and a formal improvement plan). Massachusetts believes it has saved billions with this program and we can do the same here in Colorado by working with the hospital industry, not in conflict with it. And that truly is the bottom line here, a collaborative approach with all elements of this industry to foster innovation and competition by removing government oversight. Then consumers can pick options that work best for them, which in a free market drives money to the best operators in the industry, including those with the best costs. Because this plan runs the risk of insurers and hospital providers deciding they don’t want to participate in Colorado at all. The commissioner of insurance or state government cannot force them. So instead of creating more options and lower costs, we could end up with fewer options as these companies flee the state entirely and we are left with a single government insurance plan with lower quality providers that don’t adequately cover the state’s needs.


Bottom Line:

  • One too many threads have been pulled out of this, but allowing everyone except hospitals to refuse to accept the Colorado Option, it may be doomed to failure. Because what provider is going to want to take the potential mandatory haircut on their profits when they can just ignore the plan? If the plan has poor network coverage in the state, then it becomes useless. It is very important that this succeeds out the gate, because the folks that want it to fail aren't going to let us take multiple whacks at getting it right

How Should Your Representatives Vote on HB21-1232

HB21-1237 Competitive Pharmacy Benefits Manager Marketplace (Kirkmeyer (R), Moreno (D)) [Lontine (D), Rich (R)]

SIGNED INTO LAW

AMENDED: Moderate

Appropriation: None
Fiscal Impact: None with potential savings on the contract

Goal:

Use a reverse auction bidding process (where companies compete against themselves to provide the lowest bid) for the state’s prescription drug benefit manager for state employees. The winning company is to pay the costs of the process and the same technology used to conduct the reverse auction is also to be used to ensure compliance with the contract terms.

Description:

Requires the state to use a reverse auction bidding process to pick a prescription benefit manager (PBM) for the state’s medical plan. PBMs serve as intermediaries between insurers, pharmacies, and drug companies by negotiating prices including rebates that are supposed to passed on to consumers from drug manufacturers, providing drug utilization reviews, and sometimes requiring certain preferred drugs to treat conditions. A reverse auction is where companies dynamically bid against each other (anonymously, though they can of course see the bids) to obtain a contract, with the lowest bid that provides all required services winning. In this case, the bill requires all companies to agree to the same contract terms and negotiate based upon price. The auction goes through “rounds” where each PBM submits their amount, which is then number-crunched within an hour (see below). Then a PBM can see what all the bids are (again anonymously) and decide if they want to make a lower bid. The bill lets the state determine the number of rounds to allow. The state can back out of the auction if the winning bid is higher than the projected cost trend for the current contract.

This auction is to be conducted using software that has the capability to do them (other states have this system in place, so the technology already exists). The platform must normalize the PBM data and automatically reprice proposals to ensure direct comparison among them is possible (PBMs have different methods, for instance for the same drug one might have negotiated a cost of $10 with no rebate while another has $15 with a $10 rebate—that is a very simplified version of what can get very complicated). The platform is to use the state’s drug claims data to determine total estimated costs for each proposal and produce an automated report and analysis of each bid which also includes qualitative aspects. The winning PBM is to pay for all costs of the system.

The system is then to be used during the contract to as an automated pharmacy claims adjudicator by instantly comparing invoiced PBM drug claims to the contract and finding any deviations. State is to reconcile this monthly or quarterly to ensure the correct amounts are paid. If the PBM feels it is being underpaid, it may seek resolution through a mutually agreed-upon dispute process that must be included in the contract.

Bill allows any self-funded private sector health plan to participate in a joint purchasing pool with state employees for these auctions (jump in essentially) and notes that any other self-funded public sector health plan may use the procedures set forth by the bill. Any private plan must agree to accept whatever PBM the state choses (so no backing out after). But they retain full control over their own prescription drug formularies and plan designs.

First auction to be done in 2022 for contract to take effect in 2023.

Additional Information:

Auctions must occur no later than three months prior to the expiration of the previous contract. For any eligible groups that have Medicare Part D enrollees, the time frame extends to six months prior to expiration. The state is currently in a five-year contract with its PBM but has annual opt-out clauses which it would have to invoke this year so as to have a clean slate heading into 2022.

State can perform market checks during the contract to compare the state’s PBM contract to other PBM reverse auctions conducted in the country during the previous year. This is to be done with the same technology platform.

State cannot award technology contract to any company that is a PBM itself or a subsidiary or affiliate of a PBM. Vendor is prohibited from outsourcing any of the work.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • You get a better deal through a multi-round bidding process than simply asking for proposals and picking one
  • New Jersey implemented a similar system in 2017 and has seen enormous savings: $2.5 billion over five years which includes $45.9 million saved in just 18 months through compliance checks similar to this bill. The preliminary guess is that we will save $6.7 to $8.9 million a year through just the bidding process alone
  • Bill also lays out a framework for the rest of the state to potentially participate in the process

In Further Detail: At its core this is pretty simple: a multi-round competitive bidding process is going to get you a better deal than simply asking for proposals and picking one. Two other states have already implemented this process and we have the clear and convincing results already from one of them: New Jersey. It implemented a similar system in 2017 and saved $2.5 billion for its employees on its five year contract without reducing any drug benefits. That’s an average of $625 per employee, per year. Part of those savings were the oversight compliance this bill also builds into the system. In New Jersey, $45.9 million saved in just 18 months by ensuring contract compliance by the PBM. We don’t know exactly how much Colorado will save of course, until we have the auction. The preliminary guess is in the range of $6.7 to $8.9 million a year, which represents a 15-20% range of savings (we’re a smaller state with fewer employees than New Jersey). That is from the contract savings alone, not considering potential overcharge savings. Even better, the bill lays out a framework for the rest of the state to participate in this, with the potential for enormous savings simply by doing what all of the pro-market folks keep saying is necessary in the health care space: forcing competition through free market forces to drive down prices. Given that the PBM pays for all of it too, it’s pretty much a no-brainer. We’ve had several years to see that New Jersey has not in fact run into problems due to corners cut or any of the other traditional concerns with accepting the lowest possible bid.

Arguments Against:

Bottom Line:

  • You get what you pay for—there is a risk inherent in choosing the lowest bidder that can multiply when you are forcing people to bid against each other in a competitive situation that the result will be corners cut elsewhere in order to make up the difference. PBMs are for-profit companies that make money being middlemen, they are likely to try to find other ways to keep at least some of their profits through decreasing their costs which could affect service
  • We also should be realistic here about this market—it is dominated by three major players and the extent to which more and more states adopt reverse auction strategies you might begin to see tacit collusion in the bidding process

Bottom Line:

  • This is another example of us strengthening all that is wrong with the for-profit health care industry rather than taking a hammer to it and taking the profit out of health care

How Should Your Representatives Vote on HB21-1237

HB21-1256 Delivering Health-care Services Through Telemedicine (Winter (D), Simpson (R)) [Lontine (D)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

Require the state to create rules for entities that deliver health care primarily or exclusively through telemedicine. This has to do with reimbursement for care from Medicaid.

Description:

Requires the state to create rules for entities that deliver health care primarily or exclusively through telemedicine.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We aren’t set-up to reimburse these types of providers under standard rules (we are using emergency rules right now due to COVID), which means we aren’t rewarding best practices, ensuring services are streamlined, ensuring continuity of care, and ensuring care is accessible to all

Arguments Against:

Bottom Line:

  • We need a broader process for something like this, including input from key stakeholders, to ensure people have access to in-person care when they want it

How Should Your Representatives Vote on HB21-1256

HB21-1258 Rapid Mental Health Response For Colorado Youth (Buckner (D), Woodward (R)) [Michaelson Jenet (D), Van Winkle (R)]

*State stimulus bill, 1% of total stimulus spending is in this bill*

PASSED

Appropriation: $9 million
Fiscal Impact: None beyond appropriation

Goal:

Spend $9 million to provide 3 mental health sessions to youth in the state with a licensed mental health professional. State is to use a web-based portal to facilitate connecting youth with providers and conduct a public awareness campaign.

Description:

Creates a temporary program that will reimburse up to 3 mental health sessions with a licensed psychiatrist, psychologist, social worker, marriage and family therapist, professional counselor, or addiction counselor for people 18 or younger, or someone 18-21 receiving special education services. Appropriates $9 million to the program. Subject to available money, youth can receive more than 3 sessions.

State must enter into a contract with a third-party vendor to create or use an existing web-based portal to serve as a platform for initial screenings to see if a youth would benefit from mental health support, allow providers to register and share schedule availability, and connect youth with providers. If the youth’s insurance will pay for treatment, the portal is supposed to help connect with providers that accept that insurance.

State is also to implement a public awareness campaign and is encourage to involve schools, neighborhood youth organizations, health care providers, faith-based organizations, and any other community organizations that interact with youth.

State must create a process for providers to apply to be a part of this program and determine a reasonable rate of reimbursement. Providers must maintain patient confidentiality and the state may create rules to ensure privacy. Program repeals in July 2022

Additional Information: n/a

Auto-Repeal: July 2022

Arguments For:

Bottom Line:

  • We already have one of the highest youth suicide rates in the nation, pre-pandemic, and as is widely known, the pandemic has worsened mental health for everyone in the state, including our kids
  • Our crisis hotline has seen a 30% spike in activity and Children’s Hospital has seen a 10% increase in psychiatric emergencies
  • This program allows us to provide free mental health care to any child in the state that needs it in a triage like three sessions. That could also build relationships that last beyond the three sessions and help break down stigma around mental health care
  • The bill will also provide stimulus to our mental health professionals and may help us expand the capacity of care in the state, which is desperately needed

In Further Detail: Colorado has one of the highest youth (and overall) suicide rates in the nation, and that was before the pandemic. Since the pandemic began the state’s crisis services hotline has seen a 30% increase in contacts and Children’s Hospital has seen a 10% increase in psychiatric emergency visits. It has been an extraordinarily difficult year and our children have suffered along with the rest of us. This program is a way to not only potentially provide some needed triage work to help kids who are near that dangerous edge, but also a way to reduce the stigma around mental health care and build some real relationships with youth and providers that could continue past these three sessions, in particular if insurance is covering the bill. This is particularly true in traditionally underserved communities where access to mental health care can be difficult to come by. As a final bonus, this bill will provide our mental health professionals with some stimulus of their own and may help some professionals open or expand practices, which is something we desperately need in the state. We have $800 million to spend in state stimulus money, thanks to better than expected tax returns last year. This is a great way to spend some of it.

Arguments Against:

Bottom Line:

  • The program is too vaguely defined and does not have any prioritization. $9 million is nowhere near enough to cover our youth population so even if insurance covers some of it we could run out easily
  • We should not offer 4th sessions unless we have excess money, as that encourages even more of a disparity in service, with traditionally underserved communities likely to be slower to take advantage of the program
  • What about Medicaid? Not all providers accept it, but we absolutely should take advantage of those that do to stretch our money further, since the federal government picks up the vast majority of the tab

In Further Detail: This program is very vague and even with $9 million that could lead to trouble. There is no prioritization here, and with an eligible population of somewhere around 900,000 youth, we simply are not going to be able to serve all Colorado kids even if insurance does cover some of it. So we need to build some choices into this program, which only lasts for one year, in terms of trying to ensure we reach traditionally underserved populations and children who have already been identified as struggling. Schools are a great place to start on that front, and of course the bill already requires outreach to schools. We also absolutely should not be offering 4th sessions unless there is still money left when we hit next June, because that just encourages even more of a disparity of response, with traditionally underserved communities even less likely to be able to take advantage of this program due to a probable slower response out of the gate. The program is also silent about Medicaid, the single largest payer of mental health care in the country. Obviously not all providers accept Medicaid, but just as the bill tries to match up insurance, it should try to match up Medicaid. That would stretch our dollars much further, as we would not have to use much of the $9 million to pay the tab: the federal government covers the vast majority of it.


Bottom Line:

  • With $800 million to spend we can do a lot better than $9 million considering the scope of the problem. $30 million probably still wouldn’t cover everyone but we’d get a lot closer

How Should Your Representatives Vote on HB21-1258

HB21-1275 Medicaid Reimbursement For Services By Pharmacists (Ginal (D), Kirkmeyer (R)) [Lontine (D), Will (R)]

PASSED

AMENDED: Minor

Appropriation: $372,554
Fiscal Impact: $3.5 million a year in state funds at full implementation, possibly offset some or all through long-term cost savings

Goal:

Allow pharmacists to be reimbursed by Medicaid for primary care services (that they are already authorized to do, so no new authorizations) and for administering extended-released injectable medication for treatment of mental health or substance use disorders.

Description:

Allow pharmacists to be reimbursed by Medicaid at the same rates as doctors or advanced practice nurses for the same primary care services. This does not change the scope of practice allowed to pharmacists (so they will not be legally allowed to provide services they cannot already). In a similar vein, the bill also allows pharmacists to be reimbursed by Medicaid for extended-release injectable medication for treatment of mental health or substance use disorders. Pharmacist must be authorized to administer the medication.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • In both cases here we are talking about services pharmacists already provide or are already authorized to provide by state law. Things like blood pressure checks, diabetes follow-ups, and long-term chronic disease medication management are all well within the purview of pharmacists, who it is worth remembering are required to obtain a doctorate with 1,500 hours of experience as an intern and passage of a national examination. 90% of Americans live within 5 miles of a pharmacy, so this can also help us with areas that have shortages of primary care physicians (particularly those that accept Medicaid). It also helps pharmacists in integrated medical homes. For the extended-release medication, this has been proven to have multiple benefits over oral medications and again, we are talking about something a pharmacist is already authorized to dispense (the bill adds no new authorizations). We are just making sure the pharmacist can actually get paid for doing so. This may also help people get a better handle on chronic conditions and so actually lower overall health care costs in the long run

Arguments Against:

Bottom Line:

  • Pharmacists are not physicians. They may have years of training and we trust them to do a potentially dangerous job but we should not allow them to start taking over primary care responsibilities we entrust to physicians. We don’t want to solve problems of primary care provider shortages through inferior substitutes. The notion of lower overall costs over time is also speculative, we may end up cost-shifting more than anything else

How Should Your Representatives Vote on HB21-1275

HB21-1276 Prevention Of Substance Use Disorders (Pettersen (D), Priola (R)) [Kennedy (D), Herod (D)]

PASSED

AMENDED: Moderate

Appropriation: $241,207
Fiscal Impact: About $410,000 a year

Goal:

Extend several existing limitations on opioids to prevent over-prescribing, modify access and rules around the state’s prescription drug database, and promote alternatives to opioid treatment, including non-pharmaceutical options, with requirements for insurance coverage.

Description:

  • Requires insurers to cover at least 6 physical therapy and at least 6 occupational therapy visits per year for alternatives to opioids for pain. And at least 6 acupuncture visits must be covered a year with maximum of one copayment. These must all be at the insurer's lowest cost-sharing tier. Any other non-pharmacological treatments the commissioner approves must also be covered. State must get a ruling from the federal government that these benefits would not require defrayal from the state. If the state gets the thumbs-up, then large group plans must have this coverage by 2022 and small group and invididual plans by 2023
  • Insurers are prohibited from banning or punishing these therapists from telling clients the amount of their financial responsibility for care and also prohibited from requiring therapists to collect copays higher than what is owed.
  • Prohibits insurers from limiting coverage of any atypical opioid or alternative pain treatment that is approved by the FDA through step-treatment (must try other less expensive options first) or prior authorization requirements. Prescription still needed from doctor. Insurer must make drug available at lowest level cost-sharing tier applied to an opioid that would have been used in the same situation. Atypical includes opioid agonists with documented safer side-effects and less risk of addiction than older opium-based medications
  • Permanently extends the ban on opioids being prescribed no more often than one 7-day supply in a year, with a few exceptions. Permanently extends the requirement that providers must check the state’s prescription drug monitoring program before prescribing a second fill for an opioid and before any fill of benzodiazepine, with a few exceptions.
  • Requires state licesning boards to consult with center for research into substance use disorder prevention, treatment, and recovery support strategies and the state medical board to create ensure continuing education requirements for prescribers on best practices for opioids include potential harm of inappropriately limiting prescriptoins to chronic pain patients and best practices for prescribing benzodiazepines
  • Expands access to the drug monitoring program to medical examiners and coroners from their previously autopsy-only access to include death investigations as well. Changes the requirements for adding information to the program slightly and adds the name of the person paying for the prescription as required information, and allows the department of health care policy and financing and the health information organization access to it. Requires the state to enable utillization of federal RxCheck program, whicih allows for checking prescription records across state lines.
  • Appropriates $250,000 of marijuana cash funds a year for the next five years to the center for research into substance use disorder prevention, treatment, and recovery support strategies to continue to develop and implement continuing education to prescribers. Adds requirement to specifically address benzodiazepines.
  • Creates a prevention collaborative consisting of institutions of higher education, non-profits, and state agencies to gather feedback from local public health agencies and groups represented in the collaborative on evidence-based prevention practices. Directs marijuana tax funding for operations but does not specify an amount.

State must conduct an actuarial study to determine impact of bill's health insurance requirements on premiums.
Additional Information:

Atypical opioids and other non-opioid pain relievers must be FDA approved for pain relief to be covered as alternatives. Those entering information into the state tracking database must do so daily. Clarifies that there can be no fee charged for pharmacists and prescribers for accessing the database. Exceptions for benzodiazepine query requirement are: epilespy, spasticity, hospice care, seizure treatment, alcohol withdrawal, or neurological or psychological emergency. Rules must allow for a tapering off of benzodiazepines and must not require an abrupt discontinuation or withdrawal.

Exact mission of the collaborative is:

  • Coordinate and assist state agencies and communities to strengthen prevention infrastructure and implement a statewide strategic plan for primary prevention of substance use disorders
  • Advance the use of tested and effective prevention programs and practices through education, outreach, advocacy, and technical assistance, with emphasis on underserved communities and populations
  • Raise public awareness of cost savings of preventative measures
  • Provide direct training and technical assistance to communities regarding selection, implementation, and sustainment of tested and effective primary prevention programs
  • Pursue local and state policy changes and advise state agencies and communities to enhance use of these programs
  • Support funding efforts to align funding and services and help communities with funding strategies
  • Establish a minimum prevention standard for the state
  • Expand state’s prevention workforce

Office of behavioral health to work with collaborative to establish community coalitions, implement primary prevention programs, coordinate with state agencies and other organizations, and report back to legislature.


Auto-Repeal: Collaborative, September 2025

Arguments For:

Bottom Line:

  • Stopping people from getting hooked on opioids in the first place is our best strategy for fighting opioid addiction and we know the prime driver is legally prescribed opioid prescriptions for pain
  • The bill attacks these legal prescriptions in multiple areas but perhaps most importantly in ensuring that we provide viable alternatives that do not cost more, because we don’t make things equal people will reach for the cheaper, opioid, option
  • In the long run we will likely save money through less need for treatment for addiction, and that may even be true of insurance companies

In Further Detail: One of the most important areas in tackling substance abuse is stopping people from getting hooked in the first place. We know that the prime driver of the opioid crisis is legally prescribed opioid prescriptions for pain. This bill attacks this cause head-on in multiple areas, by extending already existing limitations on prescribing opioids to better educating prescribers to providing viable alternatives that cost the same to the member of the public. Because if we do not make all things equal in that sense, people will reach for the less expensive, opioid, option. This may cost insurers more but the automatic assumption that they won’t save any money on addiction treatment is misguided. Not to mention these costs are far less expensive than the massive costs of substance abuse on our society. As for the Polis veto, last year the governor said he would not sign into law any legislation that raised insurance premiums during the pandemic. Well the end of the pandemic is in sight as vaccination efforts continue to ramp up throughout the state. Nearly the entire medical community expressed their displeasure with the governor after the veto. And perhaps the governor will be more open to the idea that in the long run, this bill will save us money by preventing more opioid addiction.

Arguments Against:

Bottom Line:

  • This adds too much red tape to the state’s bureaucracy
  • This may increase health insurance premiums in the state, the estimate last year was $22 to $38 million worth across the entire state, which is why the governor vetoed a nearly identical bill (at least in the area that counts for why he vetoed it) last year

In Further Detail: This bill adds a lot of unnecessary red tape to the state’s bureaucracy: prescribers that barely interact with people getting opioids and wasting medical examiner’s time by playing detective instead of using the body they have in front of them. Finally, almost this exact same bill was vetoed by Governor Polis last year, and the part that drew the veto has not changed at all. The new insurance requirements were estimated last year to require $22 to $38 million extra, which of course they will just pass along to the rest of us in increased premiums. That is the exact opposite of what we need from our premium costs, especially in the more rural parts of the state.

How Should Your Representatives Vote on HB21-1276

HB21-1305 Mental Health Practice Act (Winter (D)) [Michaelson Jenet (D), Pelton (R)]

PASSED

AMENDED: Very Significant (category change)

Appropriation: None
Fiscal Impact: None

Goal:

Require sealing of certain non-violent felony convictions from open records laws for mental health providers if they were at least seven years in the past, occurred before first application for licensure, and were known to the board at time of application. Also allow sealing of letters of admonition at the licensing board’s discretion if enough time has passed (varies based on offense) and the letter is the only past such action from the same licensing board. Also do some housekeeping on clinical hour requirements for some addiction licenses and some general minor housekeeping on mental health licensure laws.

Description:

Requires conviction records of mental health providers to be sealed from open records laws (pertaining to their license or registration) if the most recent conviction was at least 7 years ago, the convictions were for non-violent, non-fraud related felonies, they occurred prior to initial application for licensure or registration and were disclosed to the licensing board, and the individual has completed all sentencing requirements (including parole and probation).

Letters of admonition can be sealed in a similar matter by request if the letter was for either a minor or administrative violation, or at least three years have passed, or in the case of major violations, at least seven years have passed. In all cases the individual is not eligible if they have been subject to two or more public disciplinary actions (including the letter) from the same board and placed on probation or subject to conditions on their license. In the future the board must notify people in any letter when it would be eligible for sealing. The board has final say in the matter and must consider: amount of time lapsed, any information provided by the licensee regarding rehabilitation, evidence of lack of subsequent professional misconduct, severity of misconduct that caused the letter, severity of harm to client that caused the letter, if fraud was involved, if there was a pattern of conduct involved, and any other relevant factors. Board must include a reason if they deny the request and requests can be made only once per letter. Boards can unsell letters if new letters of admonition or disciplinary actions are undertaken. Sealed letters may be shared with other regulators upon request and are still subject to open records law. If a letter is sealed, the individual does not have to report it if asked about past disciplinary actions.

Decreases the number of hours required for a licensed addiction counselor from 3,000 to 2,000 but keeps requirement that 2,000 hours be direct clinical hours so in effect keeps same clinical hour requirement. Increases the number of clinical hours required for a certified addiction specialist from 2,000 to 3,000 clinic work hours over 18 (instead of 12) months.

Clarifies that anyone with a valid and unsuspended license as a certified addiction specialist can supervise people working toward addiction technician or addiction specialist licenses and anyone with a valid and unsuspended license as an addiction counselor can supervise people working toward addiction counselor, addiction specialist, or addiction technician licenses.

Additional Information:

Clarifies that in the scope of practice for licensed addiction counselor, “co-occurring disorders” means “co-occurring mental health disorders”.

Clarifies that the titles “certified addiction specialist” or “CAS”,  “certified addiction technician” or “CAT” and “addiction counselor candidate” are all protected titles and cannot be used to market to the public if the individual claiming it doesn’t have the licensure to back it up. Removes “certified addiction counselor” or “CAC” from the list.

Removes the statutory requirements for education for licensure as an addiction counselor and instead directs the state to set the requirements by rule.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The arguments for sealing/not disclosing records are similar to the arguments for similar such actions when it comes to the criminal justice system. Namely, at some point we have to be willing to decide that someone has paid their debt, shown they can stay on the straight path, and is not a threat to repeat their past bad behavior. Because without that we might as well just make the punishments permanent, because that’s what they are. We all know how people will react finding this stuff out, even if it is ancient history and does not bear on the individual as they are today. And so the bill, with appropriate safeguards, gives mechanisms to keep these things quiet unless circumstances change. The rest of the bill is mostly housekeeping.

Arguments Against:

Bottom Line:

  • Patients have the right to know this information and make the best choice for themselves, not find out after the fact that this knowledge was hidden. No one should be the case that caused all of this stuff to be unsealed or findable again because 10 years after the last incident, a practitioner again abused the public trust. Note that victim’s rights crimes are not excluded from the bill (they are not all non-violent crimes) The bill has been gutted, the idea of sealing of records under certain circumstances was a good one and should have moved forward

How Should Your Representatives Vote on HB21-1305

HB21-1279 Occupational Therapy Interstate Compact (Fields (D)) [Young (D), Holtorf (R)]

PASSED

AMENDED: Minor

Appropriation: None
Fiscal Impact: None

Goal:

Join Colorado to the proposed occupational therapy interstate compact which requires 10 states to start functioning (right now there are two others, with legislation pending in other states). This allows Colorado licensed occupational therapists access to the other member states through their Colorado license (with an added fee to join the compact), including through telehealth. It also subjects them to investigation for license violations in those states, but Colorado retains the sole ability to punish licensees.

Description:

Joins Colorado to the occupational therapy interstate compact which requires 10 states to start functioning (right now there are two others, with legislation pending in other states). For Colorado, this requires participating in the compact’s data system and notify the compact’s governing commission of any adverse action against a Colorado licensee. Other requirements are things the state already does (require continuing education, require passing of an exam from a nationally recognized body, investigate licensees, and do criminal background checks on them).

For licensees, the state may charge a fee to join the compact (on top of the licensing fee), but if a licensee joins they get automatic reciprocal licenses in compact states and can practice in them (this includes telehealth), but any occupational therapy assistant must be supervised by a licensed occupational therapist with compact privileges or a license in that state. Laws of the remote state are the ones that apply to practice, as are any investigations against the licensee. But only the home state has the power to impose adverse actions against a license. Home states must treat investigations in other states like their own and accept any investigatory results without further investigation of their own. Investigators in remote states can compel people to come to the state and testify via subpoena, but the state must pay all associated travel costs. If permitted by their state law, the remote state can recover investigation costs from the licensee if adverse action is taken. States can participate in joint investigations.

No one is forced to join the compact, they can just get a regular license in Colorado like they do now. The compact does require either a social security number or valid national practitioner identification number, you must have had at least two years since any adverse actions against your license, and you must report any adverse actions taken against your license by a non-compact state within 30 days (compact states will report these actions as part of their requirements).

If a licensee has their license encumbered in any way they lose compact privileges until two years after the license is cleared.

The compact is governed by a commission. Each member state gets one delegate to the commission, who must be either a current member of the state’s licensing board and a occupational therapist or occupational therapy assistant or public member or they must be an administrator of the licensing board. Commission meets at least once a year and is to create the governing structure of the compact (based on this standardized law). Commission can hire staff, sue and be sued, borrow money, accept donations and gifts, hold property, and is in charge of the compact’s budget. The commission sets the fee on each member state, which must be enough to cover its operating activities.

Commission must develop the data system for the compact, which must have a uniform structure for each member state for identifying information for licensees, licensure data, adverse actions, non-confidential information related to alternative program participation (instead of adverse actions), denial of applications for licensure, current significant investigative information, and any other information the commission deems necessary.

A majority of the legislatures in the member states can veto any rule created by the commission by passing a law or resolution. Any amendment to the state compact law (this bill) requires the approval of all member states (by passing another law in each one).

States can be kicked out of the compact for non-compliance that is not fixed (the compact must first notify the state of its non-compliance and offer training and technical assistance to fix it). This requires a majority vote of the member states. This can be appealed in federal court. Majority can also vote to initiate legal action against a non-compliant state for both injunctive relief and damages. States can voluntarily withdraw from the compact at any time by passing a law (like this one but in reverse). For disputes between states, the bill requires the commission to create a rule for both mediation and binding arbitration.

Additional Information:

If you move between compact states, you must get a new home state license in your new state of residence and your former home state license gets converted into a compact privilege. Military personnel and their spouses can designate a home state.

There is to be an executive committee of the commission which consists of seven voting members from the commission (elected by their peers) and two ex-officio non-voting members, one from a recognized national occupational therapy professional association and one from a recognized national occupational therapy certification organization. These are appointed by their organizations.

All commission meetings are open to the public except that the executive committee can meet in closed session to discuss: noncompliance of a member state, employment issues for staff, litigation, negotiation for purchase or sale of goods or services or real estate, anything to do with criminal activity or censure, trade secrets, confidential personal information, investigative records for law enforcement, and matters exempt from disclosure by member states. Minutes of closed meetings must be kept under seal, subject to release by a majority vote of the commission or a court order.

Bill sets out rulemaking process for the commission, which includes at least 30 days notice of the meeting for the proposed rule, including time, date, and location, text of the proposed rule, and ability for people to submit comments in addition to commenting at the meeting.

If at least 25 people or a government agency or an association or organization with at least 25 members request a public hearing on the proposed rule, then the commission must hold one. Anyone wishing to be heard at the hearing must notify the executive director of the commission at least 5 days prior to the date of the hearing. All hearings must be recorded.

Commission may adopt emergency rules to meet an imminent threat to public health, safety or welfare; prevent a loss of commission or member state funds; meet a deadline for a rule that is required by state or federal law; or to protect public health and safety. Regular rules must be created within 90 days of the emergency.

Bill has state specific provisions directing the state to appoint a delegate to the commission and to adhere to the rules of the compact.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Interstate compacts are good for everyone: consumers get access to a much wider range of professionals, professionals get access to a much wider range of consumers, and mountains of red tape get vastly reduced
  • This compact is well-structured so as to allow home states to continue their own regulatory scheme but also protect consumers in their state from harm done by licensees from other states
  • Getting Colorado in on the ground floor means we will have a say in the exact construction of the compact’s rules and bylaws

In Further Detail: This is a win-win. Consumers in Colorado get immediate access to a vast network of licensed professionals all over the country—of course this access is likely to be via telehealth but if we didn’t know it already, we’ve learned over the past year that there is a lot that be accomplished via telehealth and that is definitely true of this field. In exchange Colorado practitioners get access to all of those consumers in other states, without having to apply for and maintain individual licenses in these states, to the extent it is even possible to do so. And there is nothing mandatory about licensees joining the compact. If they don’t want to pay whatever fees are associated with it or they don’t want to deal with clients in other states or they don’t want to worry about differences in laws in other states, they are free to keep practicing just in Colorado on their Colorado license. The structure of this compact also ensures that Colorado consumers are protected. The state is free to investigate and punish license holders in other states for malfeasance and know that this punishment will stick. Yes, Colorado license holders will be subject to the jurisdiction of other states, but they will have entered into such an arrangement willingly. They know they have to follow the laws of other states and we can trust other states to faithfully uphold their own laws. This compact was just created at the end of last year and two other states are already in, it is likely to become a reality fairly soon. If we don’t join, we are likely soon to be shutout of an agreement comprising a big chunk of the country with more and more likely to be added soon. It could be a competitive disadvantage for our practitioners. Getting in on the ground floor also allows Colorado to help shape the crucial founding of the organization, when its structure is going to be built from scratch.

Arguments Against:

Bottom Line:

  • This surrenders our ability to set our own laws and police our own licensees
  • The degree of influence we have over the creation of the compact is likely to be small

In Further Detail: The plain fact is that the compact forces Colorado to abide by the judgment of regulators in other states, relating to laws in other states. This means it is completely unaccountable to Colorado voters. Yes, licensees should know in advance what they are getting in to and that other state laws will govern their behavior, but there is no process for appealing a decision our state feels is unjust. And losing such a judgment brings consequences not only for the licensee’s ability to participate in the compact, which is essentially ended for at least two years, but also their ability to practice in Colorado. Because the state is forced to take whatever adverse action against the license as would happen if such a violation occurred in Colorado. It is also harder for the state to police activity occurring in other states. If a Colorado consumer is harmed, the state must undertake an investigation of a practitioner that could be in Hawaii. We have plenty of licensed professionals in Colorado: they can continue to treat Coloradans. As for the ground-floor argument, with so many states set to join this compact, the initial work of building its structure likely won’t happen until half the country is involved anyway, so the actual degree to which Colorado can influence events is likely to be small.

How Should Your Representatives Vote on HB21-1279

HB21-1281 Community Behavioral Health Disaster Program (Pettersen (D)) [Cutter (D), Will (R)]

PASSED

AMENDED: Minor

Appropriation: $529,801
Fiscal Impact: About $560,000 a year

Goal:

Create a community behavioral health disaster preparedness and response program that is intended to support community behavioral health organizations in creating and implementing, when necessary, their own disaster preparedness, response, and recovery activities. The bill lists a series of potential activities for the state to reimburse these organizations for and directs the state to setup the nuts and bolts of the program in consultation with these organizations. No money is appropriated to the program.

Description:

Create a community behavioral health disaster preparedness and response program that is intended to support community behavioral health organizations in creating and implementing, when necessary, their own disaster preparedness, response, and recovery activities. Any participating organization must have a designated response coordinator.

Preparedness activities can include: risk assessment, hazard vulnerability, and disaster planning; development of policies and procedures for disaster preparedness and response; implementing disaster communication plans; training on and practicing existing disaster plans; and engaging with local and state partners for preparedness and surge planning.

Response activities can include: coordination and response with state and local partners; supporting emergency functions such as resource requests for behavioral health services; triaging psychological or psychosocial care; providing immediate and ongoing support and care for individuals in crisis affected by the disaster, including professionals who responded to the scene; and providing ongoing follow-up, referrals, and services.

Recovery activities can include: providing ongoing debriefing opportunities for people and communities and maintaining connections to ongoing care for affected individuals.

Bill directs the state to setup the structure of the program, including allowable uses of money, expected duties of the coordinator, and measures for preparedness capability and reporting methodology, all in conjunction with community behavioral health organizations. For eligibility, state must consider capabilities and capacity in: service, planning, response strike team availability, training, and culturally and linguistically appropriate services.

Bill creates a cash fund to support this program but does not appropriate any money to it.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This came out of a behavioral task force convened by the governor last year to development recommendations for mitigating future crises that involve behavioral health (as most do). The conclusion was that the state lacked a formal and coordinated behavioral health emergency response plan, in particular at the level where so much service is provided: community organizations. These organizations already respond to disasters and have for decades but there is no dedicated funding stream to help them prepare and respond and so the entire effort is more ad hoc at this point. This bill dedicates an entire program to this effort so we can support these organizations and help them get adequately reimbursed for their efforts

Arguments Against:

Bottom Line:

  • This is all a bit too vague. It’s all well and good to leave some details up to the people charged with actually implementing the program, but constructing the entire thing (in concert with the very organizations that will benefit financially) is too much. We need more concrete guidance on grant award prioritization, reporting, and most critically, reimbursement for services during a disaster when demand will spike

Bottom Line:

  • This all sounds very nice but with no money in the program (especially in a year where the state is flush with cash like it never has been before and may never be again) it is nothing more than a gesture at this point

How Should Your Representatives Vote on HB21-1281

HB21-1297 Pharmacy Benefit Manager And Insurer Requirements (Sonnenberg (R), Buckner (D)) [Hooton (D)]

PASSED

AMENDED: Moderate

Appropriation: None
Fiscal Impact: None

Goal:

Require Pharmacy Benefit Managers (PBMs) to allow people covered by insurance to access their drug benefits at any in-network pharmacy with very limited exceptions, set a limit on PBM fees for claim adjudication, ban different accreditation standards for similar pharmacies, and require PBMs to designate pharmacies in counties of less than 20,000 people as preferred, which unlocks co-pay savings for customers. Also require PBMs to provide detailed cost information about any drug, including all clinically appropriate alternatives, on request. Finally, if a PBM decides to remove a drug from its plan or increase its pricing tier, it must keep providing the drug on the same pricing tier until the end of the consumer’s plan year.

Description:

Prohibits Pharmacy Benefit Managers (PBMs) from precluding people covered by insurance from accessing their prescription drug benefits at an in-network pharmacy unless the FDA has restricted access to the drug or the drug requires special handling that cannot be done at a retail pharmacy. PBMs are allowed to charge different cost sharing amounts but this must count toward annual insurance plan caps for cost-sharing.

Prohibits PBMs from charging pharmacies or pharmacists fees related to adjudication of claims other than one-time reasonable fee not to exceed 25% of the dispensing fee or $0.25, whichever is less. PBMs cannot require different pharmacy accreditation standards from similar pharmacies in their network or fail or refuse to designate a preferred pharmacy if the pharmacy is located in a county with a population of less than 20,000 people (preferred pharmacy designated is supposed to be used for pharmacies that give larger discounts and lower copays, but this does not always occur in practice).

A PBM administering a drug assistance program operated by the state is exempt from these requirements but for that program only.

PBMs must provide upon request to individuals, insurers, providers (doctors etc.), or third-parties acting on their behalf: the individual’s eligibility for the drug, a list of any clinically appropriate alternatives that are covered by the person’s insurance plan, cost-sharing information for the drug and for all those alternatives including any variance based upon pharmacy, and any applicable restrictions on the drug and those alternatives including prior authorization (insurer must approve), step therapy (must try other lower cost drugs first), quantity limits, and site-of-service restrictions. Data must be kept current (maximum of one business day to change information), be provided in real-time, and provided in the same format as the request (e-mail, etc.). Faxes, proprietary payer or patient portals, or other electronic form is not an acceptable electronic format. PBMs must not inhibit the ability of providers to communicate this information to their patients in any way nor the ability to provide additional information on low-cost alternatives even if they are not covered by the patient’s plan nor other payment or cost-sharing programs that may reduce out-of-pocket costs. This includes charging fees, failing to respond to requests, implementing technology in non-standard ways or instituting requirements likely to lead to delays, or any penalties to providers.

If a PBM removes coverage of a drug or moves it to a higher price tier, either the insurer or the PBM must notify any patients using the drug at least 30 days prior to the change and allow the patient to keep using the same drug at the same price through the end of the plan year. If a PBM has to remove a drug based on FDA rulings or actions by the manufacturer (shortages, discontinuing production) then it must notify the patients as soon as possible.

Prohibits multiple audits of pharmacies by a PBM or insurer within a 12 month span unless there is indication of fraud or willful misrepresentation of data.

All insurers to submit to the state a list of all PBMs they contract with or use. This information is proprietary and not subject to open records laws.

Additional Information:

Notice to patients for drug tier changes or removals can be done electronically unless the patient has requested written notification.

Responses to requests for drug coverage information must be provided using established industry content and transport standards published by either a standards developing organization accredited by the American National Standards Institute or its successor entity or a relevant federal or state governing body. PBMs must respond to requests whether they are made using the drug’s unique billing code or a descriptive term like the drug name.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • PBMs are a highly consolidated industry with many of them owning their own pharmacies (like CVS) and we want to prevent any discriminatory steering of customers. All things roughly equal, people should be able to pick the pharmacy of their choice and the reason for not being able to do so should never be because the PBM owns the pharmacy
  • We have severe access problems in rural parts of the state and people who live there deserve the same access to cost-savings at preferred pharmacies as everyone else. Since multiple studies have demonstrated that preferred pharmacies aren’t always cheaper than non-preferred, it isn’t like we are disrupting some cost-savings machine here
  • Patients and providers should have full and transparent access to all drug information in order to make the best choice for that patient and never be denied information about alternatives because of manufacturer pressure
  • PBMs and insurers need to honor their contract: if a drug was available at a certain price when the plan was agreed to then it needs to stay that way until the plan year is over. Then it is fair to require either a different drug or more out-of-pocket if the consumer still agrees

In Further Detail: This is mostly about basic fairness. PBMs have become a consolidated industry with many of them also owning pharmacies themselves (CVS is perhaps the most prominent example of this) and we want to prevent any sort of discriminatory steering of customers. When PBMs work correctly they provide a valuable service for consumers (and yes, profit off this service) but when consumers cannot use the pharmacy of their choice for no other reason than the PBM doesn’t own, that crosses the line. In a similar vein, we have severe access problems in rural areas of the state and in places where there is only one pharmacy or maybe two, consumers should have the same ability to unlock the cost-savings people in more populated areas can enjoy by going to “preferred’ pharmacies. The fact that numerous investigations around the country have found that at times preferred pharmacies are just as expensive if not more so than other pharmacies for certain drugs is an obvious rejoinder to the argument that we are somehow wrecking a savings network. For providing information to patients and providers, this is again about fairness and transparency. Patients (and providers) should be free to make an informed choice about which drugs to use based on all available information, not kept in the dark about alternatives because of manufacturer pressure on PBMs. Finally, when it comes to pricing tiers, this is again about fairness. The PBM in this case is changing the rules in the middle of the game: when the insurance policy was agreed to the drug cost a certain amount (and was covered). If the PBM and insurer decide that no longer works for them, fine, but you have to give people the services they contracted for. In this case that means the same drug at the same price. Once a new plan year rolls around, it is fair to move to the new price (or not cover the drug at all) if the patient or their employer decides to continue with the same plan.

Arguments Against:

Bottom Line:

  • PBMs serve an essential role in our health care system as pharmacies lack the negotiating power to deal with the drug companies. Pretty much all the prescription rebates in Medicare, for instance, are thanks to PBMs
  • PBMs operating their own pharmacies allows for greater efficiency, forcing them to allow essentially all pharmacies regardless of efficiency my be detrimental not only to PBMs bottom line, but also their ability to save consumers money at certain pharmacies
  • Forcing preferential status without the requisite savings from the pharmacy does much the same thing
  • The information requests are unreasonable in their time frame (1 business day to make changes) and their form (no patient or provider portals allowed)
  • Large price increases on a popular drug from a manufacturer could cost a PBMs millions of dollars if they forced to stick with old pricing for extended periods of time

In Further Detail: PBMs are the boogeyman right now but they serve an essential role in our health care system. Pharmacies simply do not have the negotiating power to drive down prices from prescription drug companies on their own and potentially save billions on drug costs. Pretty much all prescription rebates in Medicare, for instance, are thanks to PBMs. And of course nothing comes for free, they profit off the service they provide that administer programs for more than 270 million Americans, but you must compare the profit of the industry against the money it is saving. And yes, PBMs operate their own pharmacies, but this allows them to more efficiently serve the market. Forcing PBMs to allow essentially all pharmacies, regardless of how efficient the pharmacy is or what other relationships PBMs have, may be detrimental not only to PBMs bottom line, but also their ability to save consumers money at certain pharmacies. Note that state medical assistance programs are exempt from this particular requirement. It also makes the preferential term basically meaningless if PBMs are forced to bestow it on pharmacies because of simple population density. Remember, this isn’t about ensuring that people can use those pharmacies, it is about forcing the same rewards for doing so on PBMs who aren’t going to recover any of the economic benefit they get from preferred pharmacies. The information requests are also unreasonable, not the information itself, but the draconian time limits (1 day to make any changes as they occur) and ban on using patient or provider portals to provide the information. These portals are a highly efficient way to deliver confidential information (they have to be HIPAA compliant). Finally when it comes to pricing, many times this is in reaction to the manufacturers themselves, something a PBM has no control over. A large price increase from a manufacturer on a popular drug could be a mutli-million dollar loss for the PBM if it is forced to keep the old pricing for extended periods of time.

How Should Your Representatives Vote on HB21-1297

HB21-1307 Prescription Insulin Pricing And Access (Donovan (D), Liston (R)) [Roberts (D)]

PASSED

AMENDED: Minor

Appropriation: None
Fiscal Impact: Negligible this year

Goal:

Create a program for Coloradans not already covered by the state’s $100 cap on a 30 day supply of insulin law, so that Coloradans do not have to pay more than $50 for a 30 day supply and can get an emergency supply at $35 once in year in some circumstances. Pharmacies would require reimbursement for their losses from the manufacturer. Also closes a loophole in the existing $100 cap law by making the cap apply to the entire monthly supply, not just one prescription.

Description:

Creates the Insulin Affordability Program for Colorado residents who are not eligible for Medicaid or Medicare, have a valid insulin prescription, and are not enrolled in a prescription drug plan that limits the amount of cost-sharing enrollees are required to pay for a 30-day supply of insulin to $100. Applications for this program are done at the pharmacy level when getting insulin and must also include proof of state residency. Pharmacies can collect a $50 copayment for each 30-day supply and send an electronic claim to the manufacturer. The manufacturer (or their designated representative) must reimburse the pharmacy so as to cover the difference between what the pharmacy paid for the drug and the amount the individual paid the pharmacy. For instance, if the pharmacy charged $50 but paid $100, the manufacturer owes the pharmacy $50. Or the manufacturer can simply replace the insulin (in this case it would be $50 worth of insulin). Pharmacies are limited to claims for wholesale costs of more than $8 per milliliter. This amount is tied to inflation. State is required to promote the availability of this plan.

Second, allows some individuals access to one emergency prescription insulin supply of 30 days not to exceed a cost of $35 each year. To be eligible for the emergency supply, individuals must have a valid prescription, have less than 7 days of insulin left, be required to pay more than $100 for each month of their prescription, and be a resident of the state. Again the pharmacy sends a claim to the manufacturer who must make up the difference between the wholesale cost and the $35 or replace the insulin and again no pharmacy can submit a claim for insulin obtained at $8 or less per milliliter.

Failure by a manufacturer to comply with this bill's requirements is subject to a $10,000 monthly fine.

Also makes a clarification to current law that regulates insulin pricing by clarifying that the $100 cap on a 30-day supply is for the individual’s entire supply, regardless of how many prescriptions they have. Currently the law is being treated as $100 cap per prescription.

Additional Information:

State is to develop application form for the affordability program and the emergency program and make them available on its website and to providers and pharmacies. Pharmacies must keep applications submitted to them for at least two years.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Nearly 300,000 Colorado adults are diagnosed diabetics and it is estimated that another 110,000 are undiagnosed but live with the disease. Insulin prices rose by 45% between 2014 and 2017 and a 2020 study found that 40% of Coloradans reported rationing their insulin at least once a year
  • This is despite our 2019 bill that capped insulin at $100 for a 30 day supply because that bill only affected insurers regulated by the state, which leaves a lot of Coloradans out
  • This bill fills that gap by in essence passing on any losses to manufacturers (the 2019 bill forced insurers to eat losses). Remember that insulin is a life-saving drug that is not at all new. It has been around for a long-time and the time for drug companies to grossly profit at our expense on it needs to be over

In Further Detail: In 2019 we passed landmark legislation capping the price of insulin at $100 for a 30 day supply (part of this bill closes a loophole in that bill). Nearly 300,000 Colorado adults are diagnosed diabetics and it is estimated that another 110,000 are undiagnosed but live with the disease. The annual medical cost related to diabetes that year in Colorado was $4 billion, 18% of which is prescription drugs. Insulin prices rose by 45% between 2014 and 2017. Part of the 2019 legislation was a deep study of this issue and it found that more than 40% of Coloradans reported rationing their insulin at least once a year. This is a life-saving (and not at all new) drug, it should be impossible in the richest nation on Earth that it is out-of-reach for some Coloradans. That 2019 only covered insurance plans regulated by the state which leaves a large part of the state out. This bill fills in some of that gap by extending caps on out-of-pocket spending at $50 and creating an emergency $35 option for once a year use. This is accomplished by in essence passing on any “losses” to the manufacturers, so the pharmacies won’t be hurt (although they too won’t profit from this as only their wholesale cost will be covered). Will that hurt drug company profits? Yes, it will, but again, we are talking about insulin here. This is not some new miracle drug, it has been around for a long time and the time for drug companies to grossly profit at our expense on it is over. We also need to be skeptical about the claims of needing exorbitant profits on successful drugs to cover failures. That claim is dubious because we already know that pharma companies inflate the average cost of producing a drug at around $2.6 billion, while other private studies have been unable to find many drugs where the total development price was over $1 billion. And most failures happen early, when costs are lower. 40% fail in phase I, typical sticker cost: $25 million. For the group that’s left, 70% fail in phase II, typical cost: $60 million. Let’s also remember that drug companies may be one the most profitable industries in the entire country, with profit margins in excess of 20% in a particular year not unusual for the largest companies. The 35 largest pharma companies brought in $1.9 trillion in net income from 2000-2018 with profit margin of 14%. Is the program really easy to access with a low burden of proof? Again, yes, that’s the point. No one should be paying this much for insulin, period.

Arguments Against:

Bottom Line:

  • This is price-fixing, which is not how the market operates in America
  • Drug companies have to spend enormous sums in research and most of those projects fail, so the successful 10% has to support the entire operation (and profit, which isn’t a four-letter word in this country)
  • It’s easy to make drug companies out to be the bad guys but that same report Arguments For cited also noted that distributors and insurers accounting for the cost of insulin nearly doubling off the manufacturer’s cost. Yet the manufacturers are the ones bearing the burden of this program

In Further Detail: This is price-fixing, which is something we should not do in America. Drug companies have to spend enormous sums on medical research, much of which doesn’t end up going anywhere, and thus need to be able to set the price of their medications where they see fit. Time and time again these companies have to write-up costly failures. In all, when you consider the entire industry, you are looking at something on the order of $100 billion spent each year on research and development. And since 90% of drugs fail, pharmaceuticals must fund their entire operation on the remaining 10%. And yes, earn a profit. Because this is American and profit is not a four letter word. The profit motive is what helps bring talented people into this field in order to push the frontiers of science to bring us cures. Nowhere was this more evident than the miracle that is the multiple COVID-19 vaccines that were produced in record time and have proven to be extraordinarily effective. Let’s also be clear here: it is easy to point the finger at drug companies and try to make them the bad guys, but distributors, pharmacies, and insurers are also responsible for the cost. That same report Arguments For cited also noted that distributers and insurers are responsible for nearly doubling the manufacturer’s cost. Yet the entire burden of this program is falling on manufacturers (and somewhat on pharmacies). The program also has very few barriers, you must prove state residence and demonstrate in some unnamed way that you meet the other eligibility requirements but no one is checking up on this apparently. At least there is no mechanism in the bill to do so.

How Should Your Representatives Vote on HB21-1307

SB21-003 Recreate Occupational Therapy Practice Act (Fields (D), Holbert (R)) [Ortiz (D), Larson (R)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: No different than last year’s bill

Goal:

  • Fix a mistake in last year’s session that resulted in occupational therapy regulation disappearing entirely, instead of being extended (and slightly altered) through September 2030 as the bill intended.

Description: n/a

Additional Information: n/a

Auto-Repeal: September 2030

Arguments For:

This is pretty simple, there was an inadvertent error that had to with a petition clause in last year’s bill. This bill fixes it.

Arguments Against: n/a

How Should Your Representatives Vote on SB21-003

SB21-005 Business Exempt From Public Health Order To Close (Woodward (R)) [Larson (R)]

KILLED BY SENATE COMMITTEE

Appropriation: None
Fiscal Impact: None

Goal:

  • Allow businesses to avoid public health related orders to close if they can comply with any safety precautions required of businesses allowed to remain open and they sell products or services that are available at a business that was allowed to remain open. Currently such activity is a misdemeanor offense.

Description:

This applies to either orders issued by a state agency or the governor. The exact health related closures that apply are those due to: a declared emergency, an epidemic, a threatened epidemic, or the unusual prevalence of a dangerous communicable disease. The open business must operate at a physical location in the same geographic area.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This is about fairness—big chains get to be “essential businesses” (which also gets warped beyond definition) and stay open while smaller businesses are forced to just shut down even if they can provide an environment that is just as safe as the big chain
  • The result of our current system has a lot to do with politics and political pressure, which small businesses cannot exert to any large degree on their own

In Further Detail: It is not fair to a small business that can provide the same level of safety as a big chain that sells the same stuff if the small business is forced to close under the penalty of criminal charges while the big chain gets to stay open. Small businesses are the backbone of our economy and also generally less positioned to weather extreme economic damage—like being forced to close for several months. So if a business can provide the same level of safety as one that is allowed to stay open and sells the same stuff, we should not be forcing it to close. And that doesn’t even get into what the definition of “essential” is—since when are liquor stores and marijuana shops essential? It all becomes political and smaller businesses simply cannot lobby the governor or the mayor. This is supposed to be about safety: if a Walmart can stay open safely, then another retailer who does the same safety practices can too. If a Walmart can’t stay open safely, then it shouldn’t be open.

Arguments Against:

Bottom Line:

  • This is essence makes closure orders useless for the vast majority of businesses that sell products—because Walmart sells just about everything and they are allowed to remain open as an essential service because they sell groceries
  • The wording is vague enough to allow businesses to stock just one item that you can find at an essential business allowed to stay open to evade the ban

In Further Detail: This entirely guts the premise of closure orders, at least for product-related businesses (it might be a bit harder for service businesses but they can probably find a way as we’ll discuss). The reason is simple: Walmart gets to stay open as an essential business because they sell medicine, groceries, and other essential items like diapers. But Walmart also sells just about everything under the sun. So if you have a business that doesn’t sell any essential items like Walmart does but does sell jewelry, which you can buy at Walmart, then presto: you get to stay open even though your business is entirely different. Businesses that are primarily service-oriented can get in on this too: Walmart sells hair products. So does a hair salon. Going a bit further, let’s say you want to reopen but someone don’t manage to sell something you can buy at Walmart. Just stock up on one item that they also sell and you are set, even if it has nothing to do with your business. Perhaps you are a business that operates escape rooms—something would be a terrible thing to open during a pandemic. Maybe start selling candy at your counter? They sell that at Walmart. Movie theaters already sell candy. That’s one of the worst places to go during an airborne pandemic. Now the “out” here is supposed to be that the business must be able to comply with safety precautions. But the reality is that we know for sure that it is a risk going to a store, even if you wear a mask and try to stay 6 feet away from others. Places like Walmart have mask requirements and ask customers to socially distance. They have safety measures in place for their employees as well. But that is really the extent of it. Extending those same safety measures to a salon or an escape room won’t cut it. We accept that even when things get really bad people need food and medicine and basic supplies. So we allow the risk. That doesn’t mean we should create giant loopholes to greatly multiply the risk. No one wants to harm businesses. But keeping people alive and healthy takes priority.

How Should Your Representatives Vote on SB21-005

SB21-009 Reproductive Health Care Program (Jaquez Lewis (D)) [Caraveo (D)]

PASSED

AMENDED: Minor

Appropriation: $4,399,139
Fiscal Impact: About $3 million a year

Goal:

  • Create a reproductive health care program that provides counseling services and a free one-year supply of the requested contraceptive (or equivalent) for undocumented individuals who would be eligible for Medicaid if they had citizenship.

Description:

Pharmacists in collaborative pharmacy practice agreements with physicians to prescribe and dispense hormonal contraceptive patches and oral hormonal contraceptives and all physicians who accept Medicaid patients must comply with this bill by prescribing the requested FDA approved contraceptive, or an alternate if the pharmacist or physician deems the requested contraceptive to be medically inadvisable. No prior authorization, step therapy (trying less costly or invasive methods first) or other utilization control techniques may be used to avoid prescribing FDA approved drugs, devices, or products. The one-year supply can be lessened upon request of the individual getting the prescription. The state is to pay for the costs of these prescriptions and any associated counseling (as it already partially does for Medicaid, the federal government picks up the rest of that tab). Program must be running at start of 2022. State must report to the legislature on this program every year beginning in 2023.

Additional Information:

Bill requires the state to adopt rules about how people will be notified about this program and how they will be enrolled. Counseling includes any information helping people use the device correctly and continuously and any other counseling required by federal law for that drug, device, or product. The report to the legislature must include: estimated total number of eligible people for the program; number actually in the program, disaggregated by race, ethnicity, gender, and income; cost of providing contraception and services; preferred contraception methods by participants; and cost savings realized due to avoiding unintended pregnancies.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The basic services provided by this bill are already available to anyone with private insurance or on Medicaid, thanks to the Affordable Care Act, because we recognize that unintended pregnancies are much more expensive than paying for people to use birth control, so this will save us money
  • Undocumented people are much less likely to have employer-based insurance, so they are much less likely to have access to free birth control
  • For those who are opposed to undocumented people being in Colorado—the constitution of the United States says that anyone who is born in the United States is automatically a US citizen, this bill will actually prevent that from happening as often as it does now

In Further Detail: Pregnancy is an expensive proposition, both to the mother and to the state in terms of health care costs. Unintended pregnancies can actually be even more expensive, because they are likelier to happen to people with lower income levels and thus hit our social safety net harder. In 2010 it was estimated that unintended pregnancies cost the federal government $21 billion. Contraceptives, on the other hand, are pretty cheap—they are only 0.03% of overall Medicaid expenditures right now, when Medicaid must provide them for free. Beyond that, unintended pregnancies increase the risk of poor maternal and fetal outcomes and result in more abortions. Undocumented individuals are of course not eligible for Medicaid and are much less likely to have access to employer-based insurance coverage. 38% of Latinas are uninsured, double the next closest group, and 25% live in poverty. Here in Colorado, Latinos have the highest uninsured rate of any group at 27%. Latina youth experience pregnancy at roughly double the rate of their white counterparts. So there is clear evidence that the lack of access to free birth control takes its toll on the undocumented population in Colorado, which is overwhelmingly Latino. The one-year supply requirement is pretty simple: it’s much more effective. Studies have shown women who receive a one-year supply are 30% less likely to experience an unintended pregnancy than those who receive just a month or three-month supply. As for the religious argument, we don’t live in a theocracy and it is simply not how tax dollars work that you get to dictate where they go based on your religious beliefs. And the vast, vast, majority of American support the use of birth control. And in a final twist of logic, those who tend to oppose undocumented individuals should take note that any child born to an undocumented individual in the United States is an American citizen, thanks to the US Constitution. In other words, this should be a bill that everyone should be able to get behind.

Arguments Against:

Bottom Line:

  • Medicaid is mostly paid for by the federal government, the costs here will be borne entirely by Colorado so the cost-savings might not be as clear to the state government
  • The bill is quite vague on implementation, how are people supposed to prove qualification for this program?
  • Some religious organizations, like the Catholic Church, oppose any form of birth control as interference in the procreative act, so the government should not be providing it for free
  • Any services provided to undocumented individuals in Colorado but not necessarily elsewhere in the US may make Colorado more attractive to undocumented individuals

In Further Detail: This will be different than Medicaid, which is cost sharing arrangement between Colorado and the federal government. For Medicaid, when you factor in the enormous amount the federal government covers of the 2010 expansion due to the Affordable Care Act, the federal government is picking up more of the tab. This program would be entirely funded by Colorado, while some of the cost savings will actually be federal in nature. So it may not be so clear cut to the state’s bottom line. On implementation, the bill is very vague. The state must determine how to register people for the program, so presumably some sort of card, like an insurance card, would be how people would prove to providers that they qualify. But how does the state determine qualification? Given that this would in essence a state registry of undocumented individuals, it may be difficult to get people to sign up, and we have to prove they would be eligible for Medicaid. Some religious organizations, like the Catholic Church, oppose contraception as interfering in the procreative act. Members of these organizations should not see their tax dollars going to something that violates their beliefs. It is also noteworthy that Catholicism is the dominant religion among those without documentation, so some of the increased unintended pregnancy rate may be due to religious belief. And as with other bills, anything offered to undocumented individuals that they cannot get in other states may make Colorado more attractive for those without documentation, increasing their numbers here and the government services they consume.

How Should Your Representatives Vote on SB21-009

SB21-011 Pharmacist Prescribe Dispense Opiate Antagonist (Fields (D)) [Mullica (D), Pelton (R)]

SIGNED INTO LAW

AMENDED: Moderate

Appropriation: None
Fiscal Impact: About $124,000 a year at full implementation

Goal:

  • Expand the notification requirements on availability of free antagonists (stops overdoses) for pharmacists distributing opioids to include required notification if the individual has a history of prior overdose or substance use disorder; has simultaneous prescriptions of a benzodiazepine, a sedative hypnotic drug, carisoprodol, tramadol, or gabapentin; or if the opioid prescription is at or in excess of 90 morphine milligram equivalent

Description:

Current law only requires this notification if the person would benefit from it in the pharmacist’s professional judgement (that is kept in this bill as another reason for notification). The bill also makes the notification more explicit. Instead of just notifying about the availability of a free antagonist, the pharmacist must inform the individual of the danger of high doses of opioids, as described by federal health agencies, and offer to prescribe and dispense an antagonist annually. If the person accepts, the bill also requires the pharmacist to counsel the individual on how to use the antagonist. The simultaneous prescription requirement does not apply to patients with cancer, sickle cell, or in hospice or palliative care.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This is about savings lives. Antagonists are our best weapon against overdoses and if the tiny bit of extra effort required by this bill saves just one life it will be worth it
  • Current law is just too vague and leaves too much up to the pharmacist’s judgment

In Further Detail: Antagonists are widely used by medical personnel to attempt to stop overdoses on opioids. Unfortunately that personnel may not arrive in time, so we’ve come to recognize that having this prescription drug on hand can be a life saver. Studies have suggested that high rates of antagonist distribution among both regular people and emergency responders could avoid 21% of opioid overdose deaths. So yes, the pharmacist has to do a little extra work and the customer has to listen to a spiel. It is well-worth it to save even one life. The current law is unfortunately just too vague. We know someone with a history of overdose or is consuming certain drugs or has a super high prescription amount is more likely to overdose. In these cases we need to take it out of the hands of the pharmacist. We also need to provide a little more structure: the pharmacist needs to make sure the person knows how dangerous opioids are and how to use the antagonist.

Arguments Against:

Bottom Line:

  • Current law with the pharmacist’s judgment is fine

In Further Detail: Leaving it to the judgment of the pharmacist is fine, they know about the warning signs first-hand and are able to distinguish who does and doesn’t need this information.

How Should Your Representatives Vote on SB21-011

SB21-016 Protecting Preventive Health Care Coverage (Pettersen (D), Moreno (D)) [Esgar (D), Mullica (D)]

PASSED

AMENDED: Very Significant

Appropriation: $103,900
Fiscal Impact: Negligible state funds each year

Goal:

  • Enshrine the preventive health care services required to be covered at no cost by insurers by the federal Affordable Care Act into Colorado law while Adds a couple of additional services to preventative health care services required to be covered at no cost by insurers and allowing providers to administer preventative treatment of sexually transmitted infections to minors without parental consent. Only takes effect if the federal government signs-off that it will not require state defrayal of the benefit (added state costs)

Description:

Codifies the preventive health care services required to be covered at no cost by insurers by the federal Affordable Care Act into Colorado law. Adds osteoporosis screening, urinary incontinence screening, and screening and treatment of sexually transmitted infections to the list of preventive health care services required to be covered at no cost by insurers by the federal Affordable Care Act into Colorado law.

Allows providers to administer preventative treatment for sexually transmitted infections without parental consent to a minor (previously just screening and treatment of an infection was allowed without consent). Allows staffing by medical professionals to be accomplished through telemedicine. Bill also defines family planning services as any health or counseling service focused on preventing, delaying, or planning for a pregnancy, which must include medically necessary evaluation or preventative services and supplies. Defines family planning related services as medically necessary health care or counseling services provided pursuant to family planning visit. This may include treatment of conditions diagnosed during the visit and treatment of complications resulting from the visit.

State must ask federal government if these added benefits would be subject to defrayal by the state. If the government agrees they are not or does not respond for 365 days, then the benefits must be implemented by January for large group contracts and January 2023 for all other insurance.

Additional Information:

The complete list of covered preventative health care includes:

  • Abdominal aortic aneurysm one-time screening
  • Aspirin-prevention medication
  • Blood pressure screening
  • Type 2 diabetes screening for adults and gestational mellitus screening
  • Healthy diet and physical activity counseling to prevent cardiovascular disease
  • Fall prevention for adults over 65 who live in a community setting
  • Hepatitis B and C screening
  • HIV screening
  • Lung cancer screening
  • Obesity screening and counseling
  • Counseling, prevention, screening, and treatment of a sexually transmitted infection
  • Statin preventative medication for adults
  • Tuberculosis screening
  • Anemia screening on a routine basis
  • Comprehensive breastfeeding support and counseling from trained providers and access to breastfeeding supplies for pregnant and nursing individuals
  • Folic acid supplements for people who may become pregnant
  • Preeclampsia prevention and screening for pregnant people with high blood pressure
  • RH incompatibility screening for all pregnant people and follow-up testing for individuals at a higher risk of RH incompatibility
  • Urinary tract, yeast, or other infection screening
  • Domestic and interpersonal violence screening and counseling
  • Osteoporosis screening for all over 65
  • Yearly urinary incontinence screening
  • All contraception
  • Family planning services and family planning related services
  • Any other preventative services included in the A or B recommendation of the task force for the particular preventive health care service or federal law


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Preventative medicine saves money in the long-run and we need to ensure it continues to be available for free in Colorado no matter what happens at the Supreme Court to the Affordable Care Act
  • It is too early to make sweeping judgments about the effectiveness of the ACA’s provisions on preventative medicine for long-term cost questions: we are taking about a decades-long timeframe
  • We all have the right to control our own bodies, including minors and part of that right is treating sexually transmitted infections

In Further Detail: Preventive medicine not only can save lives by allowing faster intervention for health care problems, it also can save us a boatload of money. Chronic diseases that are avoidable through preventive care account for nearly ¾ of our health care spending and lower economic output in the US by $260 billion a year. If we can get more people access to preventive care we can lower overall health care spending. It is far too early at this point to make any “calls” on how greatly increasing coverage of preventive medicine has affected overall costs, many of these are long-term effects and we just haven’t been doing this for very long. We also of course can greatly improve the quality and length of people’s lives, the overriding goal of any health care system. The old way, before the Affordable Care Act, was awful and we all knew it. Part of that awfulness was a lack of preventive care coverage that led to people not getting the services at all. Cheap insurance that doesn’t cover anything is about as useful as having no insurance at all. This bill doesn’t actually change much in current law, but the ACA remains under assault at the federal level, including a court case that is at the Supreme Court right now which would throw out the entire act (yes, this did already happen a few years ago, this is a different case). If that happens, we must be prepared to keep the protections for preventive care enshrined by the ACA so as to not jeopardize the health of Coloradans. The changes around sexually transmitted infections flow around our recognition that we all have the right to control over our own bodies, including minors, and part of that right is prevention of sexually transmitted infections.

Arguments Against:

Bottom Line:

  • Requiring these services to be free increases premium costs, we need the flexibility for cheaper plans—which means getting rid of the ACA, not copying it into our laws
  • Data on saving costs through preventative care via the ACA is mixed right now, you also may get more people in the health care system for longer periods of time, which costs money

In Further Detail: Requiring coverage of all of these items increases insurance premiums, because of course insurers will pass along all of these costs (and the services still cost money, just not to the patient) along to us in our premium payments. We need the flexibility for cheaper plans that do not cover all of this so some folks can get affordable insurance for catastrophic situations. If we can get rid of the ACA, then good riddance and we’ll try to build something better. We should not copy its provisions into our law. The data on saving costs through preventive health care is mixed, now that the ACA has been with us for several years. This is not surprising given that many of these effects would be long-term, but we shouldn’t expect to save large amounts of money through providing more preventive care in Colorado for free. We may also get more people into the system for longer periods of time, which also costs money. We should not be allowing children to get this sort of treatment without parental consent.


Bottom Line:

  • This bill has been gutted and will no longer protect Coloradans if the Affordable Care Act is struck down

    How Should Your Representatives Vote on SB21-016

SB21-021 Audiology And Speech-language Interstate Compact (Buckner (D), Hisey (R)) [Young (D), Carver (R)]

Appropriation: None
Fiscal Impact: Negligible each year

Goal:

  • Enter Colorado in the Audiology and Speech-Language Pathology Interstate Compact, which will allow licensed practitioners in Colorado to practice in other member states, including via telehealth. Of course also allows the reverse: licensed practitioners in other states can operate in Colorado without obtaining a license from Colorado
  • Pact becomes operational when 10 states join (looks likely to happen very soon, 7 have joined already). Each member state gets two voting members of the Compact’s governing commission
  • There are specific requirements each member state must meet for its own licenses
  • Member states can investigate and take adverse action against licensees in other member states

Description:

The core of this interstate compact is the ability for any licensed member to practice in any state inside the compact, without the need for any further licensure or registration. This can be done via telehealth. A licensee must maintain a license in their state of residence, so if they move to another state within the compact, they have to obtain a license in that state and the old license is defunct. People who do not live in a compact state can continue to apply for a single-state license as necessary. Member states can charge whatever fees they deem appropriate for granting compact practice privileges. That privilege is granted by the compact commission itself, so it is not automatic upon getting state licensure. In addition to a valid license in a compact state, it requires no encumbrances on any state licenses, meeting the compact’s requirements for licensure (see below), and no adverse actions on any license within the past two years.

The compact’s requirement for licensure for audiologists is:

  • If the degree is before 2008, at least a Masters and if after 2008, a Doctorate, in audiology from an accredited institution or graduation from an audiology program from an institution outside the US if accredited in the home country and verified by independent review agency to be functionally similar to US programs
  • Meet supervised clinical practical work requirements determined by compact commission and pass a national exam approved by the compact commission
  • No criminal record in the field
  • Valid social security number or national practitioner identification number

Speech language pathologists is basically the same, except the education requirement is just a Master’s degree. Both must pass a fingerprint background check from the FBI and state agency.

Licensees must comply with the laws of whatever state they are practicing in, so if a Colorado licensee is doing remote work in Nebraska, the laws of Nebraska apply. The regulatory authority from that state also applies, so that same licensee is subject to investigation and discipline from Nebraska for any actions taken while practicing in Nebraska. Home states must take whatever action is required by their laws for any discipline made in other states. Again, if that licensee is disciplined by Nebraska, then whatever Colorado law requires be done to their Colorado license if the discipline had been done by Colorado must occur. If any encumbrance happens to the home state license, the licensee loses the privilege to practice in compact states until two years pass and the license is no longer encumbered.

The commission that governs this pact consists of two delegates from each member state, one has to be an audiologist and one must be speech-language pathologist. Majority vote determines action. Commission must meet at least once per year and remote participation is allowed. This is structured so that the commission in essence sets up the rules and bylaws of the compact. They are not pre-ordained, except that the commission is given certain duties (see Additional Information). The commission also elects its own executive committee, which includes some commission members and some ex-officios (non-voting members, again see Additional Information). Most meetings are open but there are some exceptions. There is nothing in the law about payment for serving on the commission or the executive committee, it is not expressly forbidden but also not expressly allowed. The commission may create fees on member states and also accept gifts, grants, and donations in order to operate. It must maintain a database for all the member states.

Rules set by the commission can be vetoed by a majority of the state legislatures of the compact states (majority determine by state, not by population size or legislature size) within four years of the rule adoption. Commission has to give notice prior to rulemaking or voting on adoption of rules. It must also allow for public hearings in certain circumstances. It can make emergency rules under some circumstances, but ordinary procedures must be followed within 90 days to make the rules stick. The commission is also empowered to attempt to resolve disputes between states, including between member and non-member states, and can initiate legal action. States can withdraw from the compact via legislation.

Additional Information:

Licensees must report to the commission any adverse action taken against them by a non-member state within 30 days. If a licensee moves to a non-member state, they lose compact privileges and their previous home state license converts to a single state license. Active duty members and their spouses can retain their home state license if they wish even if they are transferred to another state.

Member states can issue subpoenas that require attendance of witnesses and their testimony, in person. Home states must enforce these subpoenas if issued. Any travel expenses or other associated fees with appearing in person must be paid by the state issuing the subpoenas but states can recover these costs and other costs associated with the investigation if adverse action is taken against the licensee (and if permitted by their state laws). If a licensee moves during an investigation, the home state must complete it. Member states can do joint investigations. All member states must share the results of an investigation with the compact and promptly notify the compact of any adverse action taken against a licensee.

The venue for actions taken by the commission itself is the District of Columbia and the state where it is headquartered (where exactly that is or how that is to be determined is not specified). In addition to the member delegates from the states, the commission will also have five delegates chosen by executive committee from a pool of nominees provided by the commission. These are to be public administrators or board administrators from member states. The member state delegates must also be current members of their licensing boards. Delegates can be removed or suspended by the states themselves, vacancies to be filled within 90 days.

The exact powers of the commission are:

  • Establish fiscal year, bylaws, and a code of ethics
  • Maintain financial records, establish a budget, and borrow money as necessary
  • Make rules to facilitate operation of the compact
  • Bring legal proceedings where necessary
  • Purchase and maintain insurance and bonds
  • Hire employees, elect or appoint officials and set compensation and duties for these employees
  • Borrow, accept, or contract for services personnel that are already employees of member states
  • Accept gifts, grants, and donations so long as they do not present a conflict of interest
  • Hold and dispose of property as necessary, including by gift, grant, or donation, again avoiding conflicts of interest
  • Appoint committees, including electing the executive committee
  • Work with law enforcement as necessary

The executive committee is composed of 10 members. Seven are commission members and are the voting members. Three are non-voting. One of these is to be from a nationally recognized audiology professional association, one from a nationally recognized speech-language pathology association, and one from the audiology and speech pathology membership organization licensing board. The three non-voting members are selected by their own organizations. Duties include:

  • Recommend bylaw and rule changes to the commission, including fees and fee changes
  • Ensure administration of the compact is working
  • Prepare and recommend the annual budget
  • Maintain financial records
  • Monitor states for compact compliance

Closed non-public meetings of the commission or the executive committee are only allowed if they are going to discuss non-compliance of a member state; employment matters relating to a specific individual; litigation; negotiation of contracts for purchase or lease or sale of goods, services, or real estate; formal censure or criminal activity discussion; disclosure of trade secrets, confidential financial information, personal information, or investigative records intended for law enforcement or for committee action; anything exempted from disclosure by federal or member state law. Minutes are kept for all meetings, for closed meetings these are keep sealed unless the committee votes to release them or a court orders it.

Credit of individual member states may not be pledged by the commission without the state’s consent. All members of the commission are granted qualified immunity and indemnification from actions taken in the course of their duties so long as there is no intentional or willfull or wanton misconduct.

Commission must provide at least 30 days advance notice of rulemaking voting. This includes notices on the commission website and the websites of each member state. Notice must include exact date, time and location of hearing, text of the proposed rule or amendment and the reason for it, a request for comment and how these comments may be submitted, and how someone can attend the hearing. Any submitted comments must be made public. A public hearing must be granted by the commission if at least 25 people ask for one, or if a state or federal agency asks for one, or if an association with at least 25 members asks for one. If there is to be a public hearing, the commission must publish notice of the date, time, and place, and if it is to be electronic, how to access it. Anyone who wishes to speak at the hearing must notify the commission at least 5 days prior to the hearing. All hearings must be recorded and copies must be made available upon request.

Emergency rules can be adopted by the commission if the commission determines it is necessary to meet an imminent threat to public health, safety or welfare; stop a loss of commission or member state funds; or meet a deadline established by federal or state law.

Non-substantive grammatical, format, typography, or consistency error corrections do not have to go through the public notice process. They must be publicly posted and can be challenged within 30 days as being actually substantive.

The commission is charged with creating rules providing for both mediation and binding dispute resolution between member states and between member and non-member states.

Compact rules supersede member state laws, except for constitutional provisions. States may enter into agreements with non-member states so long as that agreement doesn’t violate compact rules.

If a state withdraws from the compact, that withdrawal will not take place until six months after the new legislation is enacted into law.

The compact may be amended by the member states, but it takes approval of all of the member states to approve any changes.

The bill also contains appropriate instruction to Colorado agencies to designate commission members and work with the compact if the compact becomes operational.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Interstate compacts are good for everyone: consumers get access to a much wider range of professionals, professionals get access to a much wider range of consumers, and mountains of red tape get vastly reduced
  • This compact is well-structured so as to allow home states to continue their own regulatory scheme but also protect consumers in their state from harm done by licensees from other states
  • Getting Colorado in on the ground floor means we will have a say in the exact construction of the compact’s rules and bylaws

In Further Detail: This is a win-win. Consumers in Colorado get immediate access to a vast network of licensed professionals all over the country—of course this access is likely to be via telehealth but if we didn’t know it already, we’ve learned over the past year that there is a lot that be accomplished via telehealth and that is definitely true of this field. In exchange Colorado practitioners get access to all of those consumers in other states, without having to apply for and maintain individual licenses in these states, to the extent it is even possible to do so. And there is nothing mandatory about licensees joining the compact. If they don’t want to pay whatever fees are associated with it or they don’t want to deal with clients in other states or they don’t want to worry about differences in laws in other states, they are free to keep practicing just in Colorado on their Colorado license. The structure of this compact also ensures that Colorado consumers are protected. The state is free to investigate and punish license holders in other states for malfeasance and know that this punishment will stick. Yes, Colorado license holders will be subject to the jurisdiction of other states, but they will have entered into such an arrangement willingly. They know they have to follow the laws of other states and we can trust other states to faithfully uphold their own laws. Finally, this compact has been approved already by 7 other states. It is pending in 16 others, with more surely to come. If we don’t join, we are likely soon to be shutout of an agreement comprising half of the country with more and more likely to be added soon. It could be a competitive disadvantage for our practitioners. Getting in on the ground floor also allows Colorado to help shape the crucial founding of the organization, when its structure is going to be built from scratch.

Arguments Against:

Bottom Line:

  • This surrenders our ability to set our own laws and police our own licensees
  • The degree of influence we have over the creation of the compact is likely to be small

In Further Detail: The plain fact is that the compact forces Colorado to abide by the judgment of regulators in other states, relating to laws in other states. This means it is completely unaccountable to Colorado voters. Yes, licensees should know in advance what they are getting in to and that other state laws will govern their behavior, but there is no process for appealing a decision our state feels is unjust. And losing such a judgment brings consequences not only for the licensee’s ability to participate in the compact, which is essentially ended for at least two years, but also their ability to practice in Colorado. Because the state is forced to take whatever adverse action against the license as would happen if such a violation occurred in Colorado. It is also harder for the state to police activity occurring in other states. If a Colorado consumer is harmed, the state must undertake an investigation of a practitioner that could be in Hawaii. We have plenty of licensed professionals in Colorado: they can continue to treat Coloradans. As for the ground-floor argument, with so many states set to join this compact, the initial work of building its structure likely won’t happen until half the country is involved anyway, so the actual degree to which Colorado can influence events is likely to be small.

How Should Your Representatives Vote on SB21-021

SB21-022 Notification Requirements For Health Care Policy And Financing Audit (Bridges (D), Smallwood (R)) [Snyder (D), McKean (R)]

SIGNED INTO LAW

AMENDED: Moderate

Appropriation: None
Fiscal Impact: $2.1 milllion a year (assumption people dodging audits)

Goal:

  • Require auditors or reviewers of Medicaid providers to confirm receipt of the written request to commence the review or audit by the provider.

Description:

If the auditor cannot make contact after three different notifications using different communication methods, it may commence the audit.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • These requests are too often not being received by the end party due to e-mail spam filters. Then the providers are unaware of what is happening and can miss key deadlines and not have the correct records prepared

In Further Detail: This is a simple 2021 story: the government’s emails are being caught by spam filters. The providers then fail to see them, and these notices contain crucial information required by law, such as detail on the exact records request, offering the option of providing a copy or originals of these records or an actual on-site inspection. The notice has to define clear milestone dates, possible extensions, and really critically, possible appeals. It is obvious to see what a mess might occur if the provider never gets the e-mail. Our auditors and reviewers have to confirm receipt, we have telephones to fall back on if necessary.

Arguments Against:

  • This could allow people to evade audits by simply ignoring the notification

How Should Your Representatives Vote on SB21-022

SB21-025 Family Planning Service For Eligible Individuals (Pettersen (D), Coram (R)) [Tipper (D), Will (R)]

PASSED

AMENDED: Moderate

Appropriation: $818,731
Fiscal Impact: $1 million in state funds, $4 million federal annually

Goal:

  • Ask for federal authorization to expand Medicaid coverage for family planning services up to the 250% of federal poverty level line. This will grant access to services focused on preventing, delaying, or planning for pregnancy, including ensuring access to free prescription contraception. If granted the federal government would pay 90% of costs, Colorado the other 10%

Description:

Services must include: medically necessary evaluations or preventive services such as tobacco utilization screening, counseling, testing, and cessation services; follow-up visits if any problems occur; sterilization services; cervical cancer screening and prevention; infertility assessments; and diagnosis and treatment of sexually transmitted infections or other conditions of the urogenital system, all contraception, health care and counseling services focused on preventing, delaying, or planning for a pregnancy, follow-up visits to manage contraception, sterlization services, and basic fertility services.

If approved the state must not impose age, sex, or gender limitations on eligible individuals and create a process by which eligible individuals can be presumed to be eligible for the program. Prescription contraception must include up to a year’s supply at one time. State program must also educate eligible individuals about other health care insurance options, including Medicaid, the Children’s Basic Health Plan, public benefit corporations, and the state insurance marketplace.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The basic services provided by this bill are already available to anyone with private insurance or on Medicaid, thanks to the Affordable Care Act, because we recognize that unintended pregnancies are much more expensive than paying for people to use birth control, so this will save us money
  • State data from 2019 showed that roughly 58,000 women in Colorado were without coverage for these basic services and of that group, 21,000 would fall into the income levels covered by this bill
  • 28 other states have already received similar federal authorizations, the federal government will pay the vast majority of the cost, and the bill provides mechanisms to encourage people to move off of it and onto full insurance

In Further Detail: Pregnancy is an expensive proposition, both to the mother and to the state in terms of health care costs. Unintended pregnancies can actually be even more expensive, because they are likelier to happen to people with lower income levels and thus hit our social safety net harder. In 2010 it was estimated that unintended pregnancies cost the federal government $21 billion. Contraceptives, on the other hand, are pretty cheap—they are only 0.03% of overall Medicaid expenditures right now, when Medicaid must provide them for free. Beyond that, unintended pregnancies increase the risk of poor maternal and fetal outcomes and result in more abortions. We also know from survey data that access to contraception is a worry among a significant number of women: 27% were worried about being able to afford it in a recent study on the impacts of COVID-19 on reproduction. We don’t need study data to know that the economic downturn we are still in also pushes more people out of private insurance as employers look for ways to spend less money. This sort of waiver is already in use in over half the country and the federal government is going to bear the vast majority of the fairly small (in the grand scheme of things) cost. The one-year supply requirement is pretty simple: it’s much more effective. Studies have shown women who receive a one-year supply are 30% less likely to experience an unintended pregnancy than those who receive just a month or three-month supply. As for the religious argument, we don’t live in a theocracy and it is simply not how tax dollars work that you get to dictate where they go based on your religious beliefs.

Arguments Against:

Bottom Line:

  • Some religious organizations, like the Catholic Church, oppose any form of birth control as interference in the procreative act, so the government should not be providing it for free

How Should Your Representatives Vote on SB21-025

SB21-028 Promulgation Of Public Health Rules And Orders (Kirkmeyer (R))

KILLED BY SENATE COMMITTEE

Appropriation: None
Fiscal Impact: Increased, during a pandemic possibly hundreds of thousands of dollars, normal times negligible each year

Goal:

  • Requires the state to comply with the state administrative procedure act whenever the state board of health or department of public health and environment create a rule or an order that has the general applicability of a rule

Description:

The procedure act requires that emergency rules may be adopted without a hearing and with no notice. These expire within 120 days. Prior to adopting a permanent rule, the state must file notice and make the proposed rule available for a minimum of 20 days prior to a public hearing.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • If state agencies are going to make rules (or basically things that are rules) they need to follow our laws, which include the ability for public comment
  • This will not take away any ability to do emergency health orders, it just requires public notice and comment for anything beyond 120 days

In Further Detail: We have laws around creating rules because we want a clear process that includes public comment and the ability for anyone who is the target of a specific health violation to appeal. The emergency rule process would still allow state health agencies to issue immediate rules and they would be in place for 120 days, plenty of time to set up public hearings and if the rules need to change because circumstances change, that can be done too. Rules also have the effect of law and can be easier to enforce than public health orders.

Arguments Against:

Bottom Line:

  • This ties up the flexibility of our public agencies in a health emergency where a crisis can be evolving

In Further Detail: The biggest problem with this is that public health emergencies evolve and can evolve rapidly. To force agencies to continually go through a rule making process will force them to spend a lot of energy on rewriting rules and then having to bring in even more public comment, rather than doing their jobs. There were somewhere around 60 public health orders issued by the state during the COVID pandemic (so far). Imagine having to continually revise the rule, then prepare to bring in another round of public comment. Then bring in all the appeals from people all over the state to health orders. We also cannot assume that future public health emergencies will be any easier than COVID. They could even be worse.

How Should Your Representatives Vote on SB21-028

SB21-036 Additional Requirements Issue Emergency Public Health Order (Gardner (R))

KILLED BY SENATE COMMITTEE

Appropriation: None
Fiscal Impact: Negligible in an emergency, otherwise none

Goal:

  • Limit the ability for any agencies to issue emergency public health orders beyond their 120 day limit by requiring the agency to go through the regular rule making process to continue beyond that point

Description:

Basically we allow agencies to issue emergency orders because the rule making process takes time, as required by state law, so in an emergency we sometimes just have to act. These emergency rules have 120 lives, but right now they can be extended. This of course happened around COVID-19 related orders.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • You can’t keep claiming an emergency to avoid the regular rule process. 120 days is enough time to go through the process if necessary. Allowing extensions nullifies the purpose of the rule making process and shuts out interested parties.

In Further Detail: We saw, and continue to see, a lot of this because of COVID. Health agencies issue emergency rules that impinge on the ability for businesses to operate, then the rules keep getting extended and tweaked, all without the regular rule making process required by Colorado law. Avoiding the process means avoiding public input. Of course we must be able to react to an emergency, but 120 days is a long time, plenty long enough to do the correct process for whatever is required going forward. The bill does not prevent emergency rules like those made for COVID from being made regular rules, it just forces state agencies to go through the proper process.

Arguments Against:

Bottom Line:

  • As we all know far too well right now, emergencies are not static. They change, and not according to any deadlines, so agencies must be able to adapt to that change as required. If the people or the legislature is not happy they have recourse: through laws and elections

In Further Detail: The problem with this bill’s approach is that it assumes that after 120 days we have a static situation that will not require future emergency changes. We all know from experience this past year that this is not the case. We have to allow our agencies the tools to adapt to the crisis as the crisis unfolds, not tie them down in red tape. And if we are unhappy with their actions, there are remedies at hand. State law trumps state rules. Agencies report to elected officials who can be voted out. We also know that this is not a system run amok because prior to the pandemic the state health agencies issued very few public health emergency orders.

How Should Your Representatives Vote on SB21-036

SB21-038 Expansion of Complementary And Alternative Medicine (Zenzinger (D), Smallwood (R)) [Kennedy (D), Van Winkle (R)]

PASSED

Appropriation: Net of $1 due to federal funds
Fiscal Impact: Small savings in Medicaid program

Goal:

  • Expand conditions eligible for the state’s complimentary or alternative medicine pilot program to genetic diseases and brain injuries and expand the program to the entire state.

Description:

Adds multiple sclerosis, brain injuries, spina bifida, muscular dystrophy, or cerebral palsy, all with total inability for independent ambulation due to the condition, to list of conditions eligible to participate in the state’s complimentary or alternative medicine pilot program. Opens the program to anyone in Colorado.

Additional Information: n/a

Auto-Repeal: Program still repeals in 2025

Arguments For:

Bottom Line:

  • This is proven to be an effective program at both keeping costs down and keeping people away from opioids, so it makes sense to expand it to those with genetic disorders and the entire state.

In Further Detail: This program allows people with spinal cord injuries to receive complimentary (not free, but additional) or alternative medicine for their injuries. These treatments provide additional benefits to the injured and help keep our Medicaid costs down, as well as preventing people from searching for alternative methods to manage pain, like opioids or other drugs. People in the program have reported higher quality of life from these treatments. But the program currently is only for injuries and does not allow those with genetic disorders to qualify. This bill fixes this, as well as open the program up for all Coloradans.

Arguments Against: n/a

How Should Your Representatives Vote on SB21-038

SB21-063 Multiple Employer Welfare Arrangements Offer Insurance (Sonnenberg (R), Fields (D)) [Hooton (D), Pelton (R)]

PASSED

AMENDED: Very Significant

Appropriation: $13,352
Fiscal Impact: None beyond appropriation

Goal:

  • Under current law, a Multiple Employer Welfare Arrangement (MEWA) must have been in existence continuously since 1983 to operate in Colorado. This bill changes that date to 2010 instead allows MEWAs to petition the health insurance commissioner to operate in Colorado and must meet the following criteria: have at least $2 million plus 3 times the MEWAs authorized control level of risk capital in unallocated reserve, be managed by a company in good standing all states the MEWA operates in, be managed by a 3rd party administrator that has a fidelity bond of at least $200,000, maintain a complaint system compliant with state law, provide all documentation the commissioner requires and quarterly financial statements, and meet all coverage requirements of the Affordable Care Act. The MEWA must also not condition membership or charge different rates or offer different benefit levels based on health-status related factors. It cannot offer insurance through any mechanism other than the MEWA
  • The choice is still up to the commissioner, who must decide if allowing the MEWA will lower premiums in the area, impact on the fully insured market, consumer experience with the MEWA and potential for consumer harm, the financial soundness of the MEWA, and any other relevant factors. Waivers last for two years, then MEWAs must reapply. If they are approved five straight times, they are permanently approved

Description:

MEWAs are groups of employers in a similar industry that have joined together to offer health insurance to their employees. In most cases the employers create the plan, fund it through premiums on their employees, and the MEWA pays out the claims (so the employer doesn’t have to deal with the administrative burden). In some they contract with a health insurance company, but get to act like a big employer when it comes to rates but this is much less common.

MEWAs must submit in their application: all of their operating documents (articles of incorporation, bylaws, etc); their membership criteria and benefits of membership; names, addresses, and official capacities of all individuals responsible for running the MEWA including officers and directors; any potential conflicts of interest those individuals have; proof of plan benefits and rate tables for the plan; copy of stop-loss insurance or excess insurance policy, if applicable; audited financial statements from the last five years prepared by a certified public accountant; and a copy of every contract between the MEWA and its administrative or service company. All the individuals named in the application must do a fingerprint-based background check and if that check turns up any arrests without final disposition, a name-based check as well.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Options in rural areas for health care are limited so we need think beyond basic insurance. MEWAs can be a good tool in these circumstances but current law basically makes it nearly impossible for a MEWA to operate in Colorado
  • MEWAs allow multiple employers to band together, which allows them to get better rates, while creating plans for themselves that fit their needs
  • The bill contains robust requirements for MEWAs to ensure they are offering true insurance on-par with the benefits of ACA compliant plans
  • State law already requires adequate reserve funding, prohibits refusing to pay claims for specific individuals, and MEWAs must follow HIPAA to protect privacy

In Further Detail: It is not news that insurance coverage is hard to get in many parts of Colorado. In too many places there is only one or maybe two insurance options with potentially limited, high-cost plans to choose. MEWAs can be a good tool in these circumstances: allowing multiple employers to band together to get better rates. They are free from the profit motivation of insurance companies and can create plans that best suit the needs of their employees. But current state law in essence makes this impossible, with the 1983 existence requirement that in essence bans MEWAs in the state. This bill would open us back to this alternative. Some of the concerns around MEWAs are alleviated by existing state law which requires MEWAs to have unallocated reserves of 5% of the first $2 million in contributions. State law already prohibits “lasering” by insurers (refusing to pay claims for specific individuals on the plan, obviously usually high-cost individuals) so businesses in this state are already protected from one of the common pitfalls of self-funding. Businesses must also follow state HIPAA laws to protect health care information privacy and of course must follow federal laws when it comes to their coverage decisions. And the bill contains robust provisions to ensure the MEWA is financially sound and offers true insurance that is compliant with the provisions of the Affordable Care Act.

Arguments Against:

Bottom Line:

  • This type of health coverage is not adequate. All of the bad things we got rid of in 2010 in the health insurance industry: no lifetime limits, no guaranteed benefits, and denial of coverage for pre-existing conditions. Bad insurance gives people the false sense that they are covered if something happens to them
  • The dead giveaway that we are trying to get around Affordable Care Act protections is the 2010 date. Plans that were in effect prior to 2010 were grandfathered in, so they do not have to be compliant with the Act
  • Most MEWA plans are also self-funded, which means the employer is change of insurance decisions, which is bad for employees

In Further Detail: MEWAs are usually, in essence, more complex self-funded insurance, where the employer is actually the insurer (except in this case it is multiple employers). Self-funded plans are bad and we should be taking steps to eliminate them, not to make it easier for businesses to operate them. They put the employer into the seat of determining benefits and makes the insurance not beholden to our state laws or regulation from the state commissioner of insurance. For instance, we just passed a law in Colorado two years ago that protected people from surprise out-of-network billing (where you go to an in-network facility but get treated by an out-of-network physician and get charged the out-of-network rate). There is no federal law with this protection, so a self-funded plan would not have it unless the employer specifically chose it. And instead of the insurance company making final decisions on payment for medical claims your employer does, through a third-party but what should really be considered an affiliated company. This is not an insurer, it is an arrangement that solely exists to serve the affiliated companies. This not only opens up your entire medical history to your employer, it puts them in the position as insurance companies: their bottom line is directly affected by their ability to not pay out claims. This also means any disputes are solved by the Department of Labor and people are only eligible to recover their actual lost costs, no other damages. And the real kicker is the new date: 2010 instead of 1983. Why 2010? Because that is the year the Affordable Care Act passed and any plan that existed at the time of its passage was grandfathered in. So a MEWA that existed prior to 2010 is free to ignore all of the requirements of the ACA when it comes to caps on lifetime spending limits, guaranteed coverage for basic benefits, and no discrimination against pre-existing conditions. MEWAs allowed under this bill would be able to do all of those things. A huge part of the ACA was our knowledge that bad insurance was nearly useless in any sort of moderate medical situation and could be catastrophically unhelpful in major situations where people faced going without care or bankruptcy. So having bad insurance in the market can be actively damaging, in particular when people don’t realize that’s what they have. We should not expand this type of insurance in Colorado and look for other solutions to our problems.

How Should Your Representatives Vote on SB21-063

SB21-085 Actuarial Review Health Insurance Mandate Legislation (Ginal (D), Smallwood (R)) [Lontine (D)]

KILLED BY BILL SPONSORS

AMENDED: Moderate

Appropriation: None
Fiscal Impact: $120,000 a year

Goal:

  • Allow actuarial analysis of proposed legislation that may impose a new benefit or mandate on health insurance plans. Maximum of five bills per session. This to be done by a third-party with experience in health care policy and actuarial review that the state contracts with.

Description:

Request for analysis must be submitted before September 1 of the year before the legislative session.

If there are more than five bills meeting the requirements of this bill the chairs of the house and senate health committees will select which five get the analysis. Analysis must predict the effects of the legislation during the five years after implantation, including:

  • Number of Coloradans directly affected
  • Potential change in rates of utilization of specific health care services that may result from the legislation
  • Potential changes in consumer cost-sharing, broken down by race, ethnicity, gender, sex, and age
  • Potential increases in insurance premiums across all markets
  • Potential increases in cost of coverage of state employees
  • Potential increase in spending in state Medicaid
  • Potential increase in cost of coverage for employers, broken up by those with under 100 employees, those with 100-500 employees, and those with 500 or more employees
  • Potential long-term cost savings associated with any new benefit or service
  • Potential health benefits associated with any new benefit or service, again broken down by race, ethnicity, gender, sex, and age
  • Information on any disproportionate impacts, again broken down by race, ethnicity, gender, sex, and age
  • Estimate of potential out-of-pocket savings, if any, due to the bill, including information broken down by race, ethnicity, gender, sex, and age

All of this data must be in dollar amounts, where applicable, and insurance premium must be in per-member, monthly form.

Contractor has access to the state’s all claims database. Insurers and providers are encouraged to cooperate but not required to do so. Information gathered is to be included on the bill’s fiscal note.

Bill also repeals a section of law that currently requires anyone seeking legislative action which would mandate any form of health coverage to submit broadly similar information to the committee considering the legislation but that does not require specific dollar estimates.

Bill repeals in November 2024

Additional Information: n/a

Auto-Repeal: November 2024

Arguments For:

Bottom Line:

  • We need more data when making these big changes to insurance and Medicaid—right now we just get potentially biased reports from advocacy groups (on both sides of any issue)
  • Allowing this to be done by a third-party and actuarially will guarantee strict standards and expertise are used to get the best predictions possible

In Further Detail: We are constantly making sweeping changes to insurance without complete understanding of what these changes will mean for people’s premiums and coverage in concrete terms. We need to know if bill XYZ is actually going to raise premiums by 10% and not actually increase coverage much or if it will have little impact on premiums and make a big difference in access to services. But right now we just get a fiscal note that says the bill may have unknown impacts on these things and potentially biased reports from advocacy groups and that is it. That is not the fault of the legislative staff preparing these fiscal notes, it is not their job at all. So this bill creates a situation where it will be someone’s job and requires us to know these impacts for any bill affecting insurance in the state. Importantly, actuarial analysis is also a quasi-legal term: there are strict standards for doing it so we can also be more assured that we are getting the most accurate prediction possible, not one tainted by ulterior motives. The bill provides plenty of time for such analysis to occur.

Arguments Against:

Bottom Line:

  • This may be unworkable, with tight deadlines and rapidly changing bills, how is the contractor going to be able to keep up with the pace of the legislature amendments and provide accurate and detailed analysis? This also requires legislators to essentially freeze their bills the September before the session, which is not realistic especially for big bills. Lots of back and forth negotiating occurs before a bill is introduced

In Further Detail: This may be unworkable. Real detailed actuarial analysis takes time. To come up with the total impacts of legislation on such tight windows (before a committee vote) may prove extremely difficult, especially with multiple bills coming out at the same time or late in the session. And what of amendments that totally change the character of bills? The September deadline may also prove a problem because it would require legislators to freeze their bills at that point, which seems unrealistic given the amount of back and forth negotiating that usually occurs right up until a bill's introduction (and after that too), especially for the bigger bills we are probably envisioning getting this analysis.

How Should Your Representatives Vote on SB21-085

SB21-089 Cancer Screening Services Through Colorado Department Of Public Health And Environment (Buckner (D))

KILLED BY BILL SPONSORS

Appropriation: None
Fiscal Impact: None

Goal:

  • Expand an existing cancer screening fund that solely funds breast and cervical cancer screenings to include additional cancer screenings. The fund gets $5 million annually from tobacco tax fund, the bill directs a minimum allocation of $2.5 million to breast and cervical cancer screenings, $1 million for colorectal cancer screenings, and if feasible, money for other cancer screenings

Description:

Fund is designed to provide screenings when they are not otherwise readily available for cost or distance reasons. It is targeted at people at or below 250% of the federal poverty line. It can purchase vehicles to reach people, provide evaluations and referrals. Bill alters definition of screening so as to broaden it to fit other cancer tests.

Bill also changes the composition of the advisory board for this fund from people interested in health care and promotion of breast cancer screening to those interested promotion of health care and cancer screening. Bill adds that members serve without compensation except for necessary expenses reimbursement.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We should not lose track of critical screenings for cancers other than breast or cervical that can save lives. This is about fighting all forms of cancer

In Further Detail: While breast and cervical cancer screenings are extremely important, we should not lose track of other critical screenings that can save lives when done regularly. Colorectal is an obvious one and so the bill mentions it specifically, but in general the idea is to provide screening support for those that need it for cancer, period.

Arguments Against:

Bottom Line:

  • This reduces a funding stream for breast and cervical cancer screenings by diverting part of it. If we want to screen for other things, then either boost the funds in this program or create another one

In Further Detail: Right now there is $5 million for breast and cervical cancer screening support. If the bill passes, that number drops to at most $4 million. If we want to screen for other cancers (and we should!) then boost the funding of this program so breast and cervical still get $5 million or create a new fund.

How Should Your Representatives Vote on SB21-089

SB21-090 Small Group Health Insurance Plan Renewal (Smallwood (R)) [Hooton (D)]

SIGNED INTO LAW

AMENDED: Technical

Appropriation: None
Fiscal Impact: None

Goal:

  • Require insurers to continue to let employers keep a small-group insurance plan even if they now are in the large group category, so long as the employer keeps the same plan. If the insurer no longer offers the plan, the employer must be able to keep a similar plan.

Description:

Small-group insurance in Colorado is under 100 employees. Once an employer has 100 employees, they must go into a large group plan, unless this law passes. The rules and regulations are different for the different sizes. Small groups rates cannot be based upon anything but location of business, age of enrollees, and in some cases, tobacco usage. Large group plans can consider other factors. Small group plans also have flat pricing with no negotiation. Large group plans can be negotiated.

Bill also requires insurers to notify employers if they are no longer going to be eligible for small-group plans within 60 days of becoming aware of the change and no later than the anniversary date of the plan, and that all state laws governing small group benefits will cease to apply if the employer doesn’t renew their plan.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The big differences between the groups mean we should allow companies that are used to small business plan rules and their current health care plan to stay there. It could mean the difference between an employer keeping or dropping employee insurance coverage

In Further Detail: It can make a big difference to a business to go from the small to the large group bucket. And while of course we have to draw the line somewhere, jumping from 99 to 100 employees shouldn’t necessarily come with such drastic changes. So as long as the company keeps its old plan, we should allow it to continue to operate like a small business insurer. That we don’t right now may lead some companies to drop employer-based coverage completely, which is exactly what we don’t want to happen.

Arguments Against:

Bottom Line:

  • This isn’t fair to a business that is in the large group already
  • There are no thresholds in the bill—a company that jumps from 99 to 100 would be treated the same as one that jumped from 99 to 1,000 employees

In Further Detail: We have to draw the line somewhere and it isn’t fair to a business that is in the large group to have others businesses of the same size get treated differently. Also, while the story of adding just one employee to go from 99 to 100 may give some pause, the bill would treat a company that went from 99 to 1000 employees the exact same. We have these categories for a reason, we need to stick to them.

How Should Your Representatives Vote on SB21-090

SB21-092 Sunset Surgical Assistants And Surgical Technologists (Kolker (D), Simpson (R)) [Jodeh (D), Soper (R)]

SIGNED INTO LAW

AMENDED: Minor

Appropriation: None
Fiscal Impact: None

Goal:

  • Continue registration of surgical assistants and surgical technologists through 2028
  • Require a surgical assistant or surgical technologist whose registration is revoked to wait two years before reapplying for registration. Allow the state to issue letters of admonition and confidential letters of concern to surgical assistants and surgical technologists
  • Allow the state to discipline surgical assistants and surgical technologists for failing to notify the state of or failing to act within the limitations created by any physical condition, mental condition, substance use disorder, or intellectual or developmental disability that would prevent them from performing their job. Can also discipline for acting outside the scope of their profession or failing to satisfy generally accepted standards of their profession
  • Allows the state to enter into confidentiality agreements to limit the scope of practice for surgical assistants or surgical technologists based upon an illness or other health condition that affects their ability to practice safely

Description:

Bill also requires surgical assistants and surgical technologists to notify the state of any disciplinary action against their license (previously was suspension, revocation or denial only) and to notify of all actions against license within 30 days. Requires them to respond in a timely and materially responsive manner to any complaint also within 30 days.

Surgical assistants and surgical technologists are healthcare professionals who most commonly work in hospitals, ambulatory surgery centers or physicians’ offices where procedures are performed. These professionals perform distinct job duties during and after a surgical procedure. Surgical assistants and surgical technologists work under the direction of a surgeon. Surgical assistants typically perform duties associated with hands-on work with the patient, and surgical technologists are more involved with preparing materials and equipment.

Additional Information: n/a

Auto-Repeal: September 2028

Arguments For:

Bottom Line:

  • These are all recommendations of the department of regulatory agencies’ sunset review report. No higher levels of regulation were recommended (licensing)
  • All of the other changes simply match other medical professional licensing and registration requirements

In Further Detail: From the sunset review report: “Surgery is inherently risky. It involves sharp instruments, powerful medications, and sophisticated equipment that requires expertise to operate. Patients undergoing surgery are at risk for infection and complications; when they enter the operating room, most are under anesthesia and unable to advocate for themselves. The registration program ensures that surgical assistants and surgical technologists are safe to practice from a criminal history perspective…the Director rarely imposed formal discipline on surgical assistants or surgical technologists. As such, additional regulatory requirements are not necessary.” Everything else simply matches the way we regulate other medical professionals.

Arguments Against: n/a

How Should Your Representatives Vote on SB21-092

SB21-093 Sunset Continue Healthcare Infections Advisory Committee (Bridges (D)) [Lontine (D)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

  • Continue the Healthcare-Associated Infections and Antimicrobial Resistance Advisory Committee indefinitely by removing its sunset review. It was scheduled to repeal in September.

Description:

This committee is responsible for assisting in implementing the data collection requirement for infections during specific clinical procedures and developing the methodology for releasing and disseminating the data.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • The department of regulatory agencies recommended continuing the committee in its sunset review report. Given that identifying new procedures that need to be tracked will always be needed, we will always need this committee. No need to waste state resources on future sunset reviews

In Further Detail: From the sunset review report: “The Committee is instrumental in helping CDPHE identify infections that should be monitored and collaborates with stakeholders to cultivate and implement best practices for infection control. The Committee fulfills its statutory mission at no cost to the state.”

Arguments Against: n/a

How Should Your Representatives Vote on SB21-093

SB21-094 Sunset Continue State Board Of Pharmacy (Ginal (D), Winter (D)) [Roberts (D), Ortiz (D)]

PASSED

AMENDED: Moderate

Appropriation: $1,024,330
Fiscal Impact: $1.2 million a year in new impacts from changes

Goal:

  • Continue the pharmacy board until 2030 and consolidate all aspects of the board within one sunset review
  • Align the state’s pharmacy laws with federal drug laws
  • Allow pharmacists to prescribe opiate antagonists (drugs that stop opioid overdoses)
  • Allow the state to inspect out-of-state pharmacies and wholesalers
  • Make it easier for pharmacists to make minor alterations to prescriptions, including substituting drugs approved by the FDA as being of similar bioquality under certain circumstances, changing doses if it achieves the intent of the prescriber, changing quantities if the prescribed quantity is unavailable in that package size or to extend the quantity for a limited time to synchronize refills with other medication, and completing missing information on the prescription if there is sufficient evidence to support it. Physicians can overrule any ability to adapt an order on the prescription
  • Allow community mental health clinics and licensed substance use disorder treatment programs to register as pharmacies
  • Increase the amount of medication that can be dispensed to an emergency room patient from a 24 hour supply to a 72 hour supply
  • Numerous other changes described in Description and Additional Information

Description:

  • Adds functions to the scope of practice of a pharmacist (what they are allowed to do under their license without getting into trouble): providing care to patients under a collaborative pharmacy practice agreement; exercising independent prescriptive authority under the provisions of this law; ordering and evaluating lab tests as related to medication therapy; and performing limited physical assessments commensurate with education and training. Also adds functions to the scope of practice of pharmacy technicians: gathering, documenting, and maintaining proper clinical and non-clinical information from patients; and replenishing automated dispensing devices without the need for pharmacist verification so long as bar code technology is being used and a second pharmacy technician verifies it
  • Requires pharmacists, pharmacies, and insurance companies to report malpractice settlements and judgments to the board
  • Allows pharmacists technicians to designate up to six people to access the state’s drug monitoring program database under their own accounts, acting on behalf of the pharmacist
  • Specifies tasks a pharmacist may delegate to ancillary personnel: delivery and proper safe storage of drugs or devices, cashier transactions, medication shipping and handling, medication transportation, record keeping, telephone or communication triage, inventory management, and other administrative duties
  • Requires the state to create rules for the electronic storage of records required to be maintained by pharmacies
  • Requires pharmacists to provide patient counseling for any new prescription, and allows pharmacists to provide counseling for any other prescription based on their judgment. Alternatives to in-person counseling may be used. Patients can decline counseling
  • Allows prescription of 24 72 hour supply of drugs for patients on temporary leave from a hospital if it is not a new prescription and administered by an authorized person
  • For substituting different medications, this can only be done to replace a drug that is on back order, to ensure compliance with the patient’s health insurance plan, or for uninsured patients, to lower their cost
  • And more in Additional Information

Additional Information:

  • Clarifies that an out-of-state pharmacy does not need to register with the board when distributing drugs to in-state pharmacies if they have common ownership (like CVS) and the drugs remain in the original manufacturer’s packaging, are not compounded, and the transfer is done due to an inventory shortage
  • Excluded from definition of compounding activities like repackaging, tablet splitting, or adding standard flavoring to oral liquid drugs
  • Alters standards for pharmacy board membership by designating that of the pharmacist members, one must be practicing in a hospital, one must be practicing in a chain pharmacy, and one must be practicing in an independent pharmacy
  • Repeals requirement that board justify its decisions from deviating from the recommendations of the veterinary pharmaceutical advisory committee
  • Repeals requirement that the label on anabolic steroids prescriptions indicate the purpose of the prescription
  • Specify that discipline may be done for excessive use or abuse of alcohol, habit-forming drugs, or controlled substances but not for just having a substance use disorder
  • Eliminates requirement that admonitions be sent by certified mail


Auto-Repeal: September 2030 with sunset review

Arguments For:

Bottom Line:

  • These are almost all recommendations from the department of regulatory agencies’ sunset review report
  • We want pharmacists to be able act more quickly in multiple areas: dispensing opiate antagonists, substituting similar drugs for good reason (the substitution must be FDA approved), and fixing minor errors or smoothing over minor prescription issues. All of this right now requires going back to the prescribing doctor.
  • Right now the state is powerless to stop bad actors in other states if that other home state won’t intervene. Coloradans have died because of this
  • The 24 hour medicine rule is difficult for rural Coloradans, who may struggle to get what they need from a pharmacy in that time
  • The rest is mostly common-sense

In Further Detail: The vast, vast majority of these recommendations come from the sunset review report. The need for regulation is obvious: pharmacists can kill people if they don’t do their job correctly. For the multiple provisions that allow for more independence: we want pharmacists to be able to prescribe antagonists on the spot to potentially prevent overdoses. And pharmacists are required to obtain a doctorate with 1,500 hours of experience as an intern and passage of a national examination. They are up to the minor alterations the bill envisions without needing to call back to the prescriber, which obviously wastes time and effort for everyone involved. Doctors can still ensure no alterations occur without their consent if they want. For the out-of-state provision, currently the state can identify a problem coming from out-of-state products but cannot do anything about it. Several Coloradans died from one such incident in 2011 when a Massachusetts-based pharmacy was acting as a wholesaler and shipping contaminated drugs into Colorado (they were discovered in an inspection of a Colorado pharmacy). Massachusetts did not act and the company defied a cease and desist order in Colorado. For the 24-hour moving to 72-hour rule, 24 hours is a tight window for some rural Coloradans to get their prescription filled.

Arguments Against:

Bottom Line:

  • Pharmacists may have large amounts of training but they are not physicians and we should not treat them like physicians in any way
  • It is not clear that the inspection would have made a difference in that case cited in arguments for. There was a court order that was violated

In Further Detail: Pharmacists are not physicians. They may have years of training and we trust them to do a potentially dangerous job but we should not allow them to start fiddling with prescriptions on their own. Even if the changes seem minor and time-saving, these are things we trust our physicians to manage and the extra day or two of delay is worth lowering the risk. For inspecting out-of-state facilities, first this may prove quite difficult and costly in practice (we have to pay to send our inspectors out-of-state) and other states may prove uncooperative. Second, it isn’t clear this would have done anything to save the lives of the Coloradans mentioned in the specific case in arguments for. We knew about the bad drugs already, so inspection wasn’t going to help. And we had a court order in place that was violated, so it isn’t clear what other actions taken by the board would have done. The bill gives them no authority to do anything other than inspect.

How Should Your Representatives Vote on SB21-094

SB21-097 Sunset Continue Medical Transparency Act (Garcia (D), Smallwood (R)) [Caraveo (D), Williams (R)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

  • Continue the Michael Skolnik Medical Transparency Act until 2028

Description:

This act requires all medical professionals to create and maintain their professional profiles, including information on disciplinary actions imposed on their license, malpractice insurance settlements, criminal convictions, any awards or recognitions received, and any investments that might cause a conflict of interest.

Additional Information: n/a

Auto-Repeal: September 2028 with sunset review

Arguments For:

Bottom Line:

  • This is the recommendation of the department of regulatory agencies sunset review report

In Further Detail: From the sunset review report: “the HPPP is an important program to assist in consumer protection by ensuring the public is able to access information regarding their health care providers. Therefore, the General Assembly should continue the HPPP for seven years, until 2028. Doing so will ensure that the HPPP continues to provide transparency to the public regarding information about their health-care providers, including information related to disciplinary actions, which provides consumers information related to a health-care practitioners’ competency and ability to practice safely.”

Arguments Against:

Bottom Line:

  • The report also recommending implementing a process to ensure profiles are up-to-date. A survey done by the agency found 34% of respondents unaware they were required to maintain their profile and 27% indicated their profile was not up-to-date. Only 11% indicated receiving some sort of outreach from the state about their requirements to keep their profile up-to-date

How Should Your Representatives Vote on SB21-097

SB21-098 Sunset Prescription Drug Monitoring Program (Jaquez Lewis (D), Pettersen (D)) [Mullica (D), Rich (R)]

PASSED

Appropriation: None
Fiscal Impact: None

Goal:

  • Continue the state prescription drug monitoring program through 2028
  • Allow the program to identify prescription drugs and other substances that are not controlled substances but have substantial potential for abuse and should be added to the program
  • Create a data retention schedule for the information in the program and the process for preservation of de-identified data for a period of time

Description:

Allow coroners to authorize a deputy to access the program if the coroner takes reasonable steps to ensure the deputy can use the program and ensures access to the program is limited to what is allowed for coroners. The coroner is responsible for all actions of the deputy in the program, including negligent data breaches. Bill also requires the state to submit to the legislature as part of its annual report updates on attempts to fund the program with gifts, grants, and donations.

The program is a database that tracks controlled substance prescriptions after they are dispensed. All pharmacists must register with the program and enter prescriptions into it. They are also required to look for suspicious behavior, as are prescribers. Controlled substances are considered dangerous by the federal government, not all are even available by prescription.

Additional Information: n/a

Auto-Repeal: September 2028 with sunset review

Arguments For:

Bottom Line:

  • These were the recommendation of the department of regulatory agencies sunset review
  • 27 other states authorize similar boards to look at non-controlled substances and there is other legislation pending to do that in this session as well.

In Further Detail: From the sunset review report: “One study found a 30 percent reduction in prescribing Schedule II opioid analgesics following the implementation of statewide PDMPs and it also determined that this reduction was sustained over a three-year period. Prescribers also report that having controlled substance histories for their patients is useful to clinical practice and for uncovering illicit drug use.” On non-controlled substances, “Authorizing the Board to define other drugs of concern by rule, using evidence-based practices, would allow regulators the flexibility to respond to problems in the state as soon as possible and to remove them from the list when they are obsolete.” This is also why it is best to allow the program to determine these drugs and not have to pass a law each time we want to add something. For coroners, large counties have heavier workloads and it is unreasonable to restrict access to just the coroner. For data, right now the law doesn’t say anything about how long data must be stored or how it should be retained.

Arguments Against: n/a

How Should Your Representatives Vote on SB21-098

SB21-101 Sunset Direct-entry Midwives (Fields (D), Story (D)) [Caraveo (D), Williams (R)]

SIGNED INTO LAW

AMENDED: Minor

Appropriation: None
Fiscal Impact: None

Goal:

  • Continue the registration of direct-entry midwives through 2028
  • Allows direct-entry midwives to administer group b streptococcus (GBS) prophylaxis. Those who were registered prior to the year 2000 must apply to add this ability to their practice and pay any applicable fees. Qualifications must be verified before granting request
  • Adds licensed birth centers to places where a direct-entry midwife can practice
  • Requires the state to develop policies and protocols for direct-entry midwives in training that reflect requirements of the North American Registry of Midwives

Description:

Direct-entry midwives attend and assist with home births. To be registered in Colorado they are required to pass the national North American Registry of Midwives examination. These are different than certified nurse midwives (who are registered nurses), certified midwives (although the degree is similar), lay midwives (not regulated at all), and doulas (provide emotional and physical support but aren’t there to provide medical care). Direct-entry midwives are expressly forbidden from assisting with high-risk pregnancies and births.

Licensed birth centers are defined as freestanding facilities that are not a hospital or located in or attached to a hospital; provide prenatal, labor, delivery and postpartum care to low-risk pregnancies; and provide care during delivery and immediately after that is generally less than 24 hours.

Group B strep bacteria is incredibly dangerous to babies. Two to three of every 50 babies who contract it die, and those that survive may have long-term problems such as deafness or developmental disabilities. Part of the current North American Registry of Midwives examination requires training in administering the prophylaxis but it was not part of the training prior to 2000.

Requires hospitals to report for all live births if the mother was transfered to the hospital by a direct entry midwife.

Bill allows the state to order a mental or physical examination of a direct entry midwife if it has reason to believe the midwife is subject to a physical or mental disability that renders them unable to treat patients with reasonable skill or that might endanger a patient's safety.

Additional Information: n/a

Auto-Repeal: September 2028 with sunset review

Arguments For:

Bottom Line:

  • These are all recommendations of the department of regulatory agencies’ sunset review report
  • Most direct-entry midwives already possess the training to deal with strep in pregnancies, and the condition is incredibly dangerous
  • The distinction between birth centers and home birth is not enough to warrant keeping direct-entry midwives out of birth centers. If they are qualified to do a low-risk pregnancy home birth than they are qualified to do one in a birth center

In Further Detail: From the sunset review report: “The abilities to sanction registrants and ensure best practices provide necessary consumer protections. Regulation also ensures that birth attendants are qualified to help in such a unique situation. The program is essential to protecting life and wellbeing and is necessary.” The other two large changes are easy: strep is incredibly dangerous and part of the standard of care for pregnant women is testing for it and giving antibiotics. Most direct-entry midwives already posses the training to do this, and we can check the qualifications of those that weren’t explicitly trained. Current law only allows nurse midwives to work in birth centers, but direct-entry midwives are more than qualified to do so. The distinction about home birth versus a birth center is not meaningful enough. And as for the idea we should do away with midwives altogether as a profession with official approval: midwives have existed for thousands of years and requiring professional standards ensures people who want to have a home birth can do so safely. Of course there is still danger: women still die in the hospital giving birth. Giving birth is just a dangerous activity. But a trained midwife in an appropriate setting for the risk level of the pregnancy can provide the safety required. All direct-entry midwives must have emergency plans and there are specific circumstances that trigger that plan. Allowing the state to order a physical or mental examination is common in professional medical licensing, it appears in almost all other licensed medical professional guidelines in Colorado.

Arguments Against:

Bottom Line:

  • Few doctors in mainstream American medicine recommend home birth, even for low-risk pregnancies. If something goes wrong, it is better to be at a hospital
  • Because people want to engage in behavior we think is dangerous is not a reason to give a stamp of approval to a less-dangerous variant

In Further Detail: Many complications that arise in delivery occur fast and require prompt treatment. And while many of them are knowable in advance, some are not. Any home birth is by definition not in the range of rapid treatment from a doctor, and so very few doctors in mainstream American medicine recommend home births. Even if the vast majority of the time they work out fine for low-risk pregnancies, that is not good enough. And the idea that people want to do this is not a good enough reason to put our official stamp of approval on it. Yes, the registration program requires training but this is just a less dangerous version of home birth. We should move in the opposite direction and crack down on the practice entirely.

How Should Your Representatives Vote on SB21-101

SB21-102 Sunset Dental Hygienists Specialized Functions (Buckner (D), Simpson (R)) [Duran (D), Will (R)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

  • Continue the ability of dental hygienists to apply interim therapeutic restorations and silver diamine fluoride (both require permits) through 2025 (short extension to align with sunset review of state dental board)
  • Specify requirements of a plan for supervision by a dentist for administering these treatments (required by law). Must include any protocols, restrictions, or limitations, follow-up and referral mechanisms, and notification and disclosure requirements
  • Specifies education format required to gain permit to administer silver diamine fluoride: post-secondary or continuing education that meets board requirements that include live and interactive course presentation or an on-demand webinar with a completion quiz component or any other format approved by board
  • Allows the board to grant waivers to dentists in order to supervise more than 5 dental hygienists at one time performing these procedures
  • More in Description section

Description:

  • Removes specific supervision hours requirements for hygienists to perform these procedures
  • Adds requirement for supervising telehealth dentist (this is already allowed) to have an active license in good standing in Colorado but does allow them to be out-of-state if they are within reasonable proximity of the location where the procedure is done
  • Other technical changes

ITR is a technique in which a dental hygienist may use hand instruments to remove portions of tooth decay, and a glass ionomer sealant is applied to adhere to the enamel of the tooth structure to prevent additional decay. SDF is an FDA-approved, topical treatment which halts the progression of decay and may prevent further decay in the affected tooth following application. ITR can permanently damage tooth structure and SDF can cause permanent staining. The ability for hygienists to do these procedures stems from a 2015 bill.

Additional Information: n/a

Auto-Repeal: September 2025 with sunset review

Arguments For:

Bottom Line:

  • These changes were recommended by the department of regulatory agencies’ sunset review report
  • Removing the hours requirement in law lets the board set the requirement themselves. There is some belief in the dental communities that the requirements are too high right now

In Further Detail: “The ITR procedure may have the possibility to create additional harm to patients if not performed properly… The incorporation of ITR into the variety of available treatment options enables Coloradans to receive critical interventions that may protect them from further deterioration of their oral health, and these treatment options strengthen community access to important dental care treatment for Coloradans. Therefore, the General Assembly should continue the regulation of ITR performed by dental hygienists.”

Arguments Against: n/a

How Should Your Representatives Vote on SB21-102

SB21-122 Opiate Antagonist Bulk Purchase And Standing Orders (Ginal (D)) [Froelich (D)]

SIGNED INTO LAW

AMENDED: Minor

Appropriation: None
Fiscal Impact: None

Goal:

  • Allow local governments to purchase opioid antagonists through prescribers and allow harm reduction organizations, law enforcement agencies, or first responders who have access to antagonists through prescriptions to purchase from the state’s bulk purchase fund

Description:

In current law local governments may purchase from the bulk purchase fund. All access to prescriptions is handled through standing orders and protocols, which allow non-prescribers to administer medicine. One of the reasons to do this is in the case of an emergency, like an opioid overdose.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This just aligns our state antagonist programs so various actors who need lots of antagonists can get them from multiple, already approved, sources

Arguments Against: n/a

How Should Your Representatives Vote on SB21-122

SB21-123 Expand Canadian Rx Import Program (Ginal (D), Coram (R)) [McCormick (D), Lynch (R)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

  • Allows the state to expand its plan to import prescription drugs from Canada (which just received federal approval) to other countries that meet the same requirements laid out for drugs coming from Canada and have been approved by the federal government. This is only if Congress passes legislation allowing this activity. Prior to asking for approval, state must submit evidence to the legislature that the country's regulatory system is at least as stringent as the FDA or otherwise ensures the safety, purity, and potency of its prescription drugs. This must include comparing regulatory system on the supply chain, manufacturing, labeling, and drug tracking and tracing.

Description:

The Canadian requirements include:

  • Human medicine only
  • Must sample imported products for purity, chemical composition, and potency, including statistically valid sample of each batch for first importation and statistically valid sample of shipment for subsequent ones
  • Must ensure that all imported products are significantly less costly than their U.S. equivalents.
  • Must ensure that no drugs are distributed, dispensed, or sold outside Colorado
  • Must ensure that carriers are both paying the proper amounts for the drugs and charging the proper copays to consumers
  • Must exclude generic products if their importation would violate US patent law
  • Must determine a method to cover administrative costs which may include a fee on each product sold
  • No infused, intravenously injected, or drugs that are inhaled during surgery
  • Importers must track date received, quantity, point of origin and destination, and price paid. Canadian exporter must track original source of drug (including manufacturer), date manufactured, location of manufacture, date shipped, quantity shipped, and lot and batch numbers. Vendors must have a surety bond of at least $25,000.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • US customers may some of the highest prescription drug costs in the world, but there are other countries besides Canada that have robust regulatory environments and lower prices, like much of Europe
  • Canadian drug importation has been approved and that process is beginning, so it is possible the federal government will extend the program to other countries
  • The concern over demand spikes for Canadian drugs is valid, so it makes sense to cast as wide a net as possible and the increased competition may force the prices for drugs manufactured in the United States down

In Further Detail: U.S. consumers pay some of the highest prescription drug costs in the world, as high as twice as Canadians for patented drugs and 20% more for generics. They also in some cases are skyrocketing. There are other countries in the world besides Canada that have robust regulatory environments, such as much of Europe, and we could benefit from widening the importation net. The federal government just finalized rules last November allowing the importation of prescription drugs from Canada and Colorado has begun to ramp up its plan. The arguments against importation from Canada alone regarding price, that the surge in demand will increase prices of Canadian drugs, has some merit so widening our potential sources of supply does make sense. It may also act to bring the prices of drugs produced in the United States down due to the competition. The bill allowing importation from Canada includes sufficient protections to make sure that the drugs are safe and effective and that no new cottage industry is created to grossly profit from the situation. This bill follows those same rules.

Arguments Against:

Bottom Line:

  • The FDA opposed this for a long time for safety concerns—other governments do not inspect or take responsibility for the legitimacy of prescription medicine shipped to the US
  • The risk of counterfeit drugs will rise with this program, especially when we bring even more countries in
  • The state may lose money on this: constructing a monitoring system may be expensive and the state just discovered it won’t save much of any money on drugs for Medicaid

In Further Detail: The FDA previously opposed this for safety concerns. Canada and other European countries may have their own versions but it is not the same as our FDA and other governments do not inspect or take responsibility for the legitimacy of prescription medicines shipped to the U.S. We should not rely on a vague sampling process to keep our citizens safe. Importation also greatly increases the risk of counterfeiting, particularly with Internet pharmacies, and the burden of investigating this will fall on ill-prepared state governments. The state’s ability to construct some sort of monitoring system to ensure safety may either not exist or be extremely expensive. And the state just learned earlier this year that it already pays similar prices for prescription drugs for Medicaid, so prescription drug importation likely won’t save the government much money at all. This bill will also damage American pharmaceutical companies which employ thousands of American workers.


Bottom Line:

  • Drugs from Canada may be fine, the US and Canada have a memorandum of understanding on pharmaceutical regulation cooperation since 1973, but it is a step too far to extend this to other countries (especially if we aren’t even going to list them).

How Should Your Representatives Vote on SB21-123

SB21-126 Timely Credentialing Of Physicians By Insurers (Fields (D)) [Michaelson Jenet (D)]

PASSED

AMENDED: Minor

Appropriation: $52,505
Fiscal Impact: None

Goal:

  • Increase the timeliness of accepting physicians in insurance plans by requiring the insurer to complete its decision process on credentialing the physician for their network within 60 days of receipt of application. The insurer then has 10 days to notify the physician. Insurers must also provide a written or electronic receipt for the application within 7 days of receiving it
  • Bars insurers from denying in-network claims for covered benefits that are provided by a physician who has concluded the credentialing process
  • Insurers can require recredentialling but it cannot require an application or a contracting process to do so. Insurers cannot kick a physician out unless they discover information indicating the physician no longer meets the insurer’s guidelines

Description:

Insurers must promptly determine if applications are complete. They have 10 days to notify the applicant of any missing material. If the insurer fails to provide receipt of application to the physician, the insurer must accept the physician, effective no later than 53 days following receipt of application. If the applicant requests non-proprietary information regarding the insurer’s decision, it must provide it.

Insurers must post on its website its credentialing policies and procedures, information required in an application, a checklist for the application process, designated contact information including a phone number and e-mail address and individual name, and the requirements of this bill in the first bullet point in the Goals section.

Insurers that have agreements with either health care facilities or carrier credentialing alliances that impose equivalent or higher standards than this bill don’t have to follow the bill’s requirements.

Violations of this bill are subject to civil penalties as determined by the commissioner of insurance.

Additional Information:

Insurers must fix errors in their network directory within 30 days after receiving a report from a physician. Physicians must notify insurers of any change in name, address, phone number, business structure, or tax ID within 15 business days.

Recredentialling can only be required if it is required by law or in the insurer’s contract with the physician. Nothing in the bill affects contract termination rights of either party.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Doctors cannot properly bill insurance companies until they are credentialed, and you’ll never guess, but they sometimes drag their feet to keep the doctors out-of-network, like 6 months to a year
  • Recredentialling is yet another potential dragged out mess with hoops to jump through: if nothing has fundamentally changed we don’t need all of this

In Further Detail: A doctor cannot properly bill for in-network services to an insurer until they are credentialed and like everything in insurance, insurers sometimes use that to their advantage by drawing out the process. We know this can be done in 60 days. And of course there’s the old application incomplete issue, which can bring further delays. All the bill does is force insurers onto a known and acceptable time frame, including acknowledging they got the application and prompt notice of incomplete applications. And then we get recredentialling, with a whole bunch more hoops to jump through. That is not necessary: unless the insurer believes something has changed, there is no reason to have yet another application and go through the whole process again.

Arguments Against:

Bottom Line:

  • These time frames may be too tight for every single application and may increase overhead at insurance companies because they have to hire more people to keep up
  • Recredentialling is like renewing a license—we may not need everything we did the first time but we do need to ensure some basics are still being met

In Further Detail: The 10 and 60 day timeframes for determining an application is incomplete and finishing review may not be realistic for every application and insurers may therefore have to hire more people to review applications. On the recredential side, this is similar to licensure. Of course you don’t need the same application, but the point is to do a recheck to make sure fundamental standards are still being met. Otherwise what’s the point? If it is just a rubber stamp regardless than the entire process would be unnecessary.

How Should Your Representatives Vote on SB21-126

SB21-137 Behavioral Health Recovery Act (Pettersen (D), Winter (D)) [Michaelson Jenet (D), Kennedy (D)]

PASSED

AMENDED: Very Significant

Appropriation: $8,057,614 in general fund money, $550 million in federal stimulus funds, $5.7 million in marijuana funds
Fiscal Impact: Beyond appropriation, $14.3 million next year and $6.5 million in annual spending

Goal:

Creates a cash fund to hold federal stimulus money and puts $550 million into the fund, then spends $99.3 million in the bill. For the rest of the money, the leadership from both parties of both legislative chamber is to create a task force to meet during the 2021 interim (after end of 2021 session and before start of 2022 session) to create a report with recommendations on how to spend the money to create transformational change in behavioral health care.

  • Create a temporary financial housing assistance program to people with a substance use disorder who have no supportive housing options and are either in treatment for their disorder or transitioning out of residential treatment into recovery. State is to set rules on maximum amount of assistance a person can get and maximum amount of time they can get it. The time rules must be clinically based. Funding must be prioritized for people entering into a recovery residence. State must report to legislature each year on the amount of assistance provided, number of people and entities that received the assistance, and duration of assistance for each person or entity. $4 million appropriated every year in perpetuity for the program
  • Requires state to develop statewide care coordination infrastructure for uninsured and people on Medicaid without available care coordination services. This must include a website and mobile application that serves as the centralized gateway for information for patients, providers, and care coordinators and that promotes access and navigation of services and supports. State must use a working group to help create this infrastructure which must include people with lived and professional experience. State must undertake a robust marketing campaign to drive awareness of the program. $26 million of federal stimulus money appropriated to program
  • Creates a workforce development program to increase the ability of the state to treat people with severe behavioral health disorders. This must include: an online training system and curriculum that will support a high-quality, trained, culturally responsive, and diverse behavioral health care workforce; fiscal incentives for low income individuals to obtain a degree in the field, with funding specifically targeted for rural areas of the state; training to certify for federal reimbursement for services; capacity-building grants; and attrition prevention grants. $18 million in federal stimulus money appropriated to program
  • Creates a county behavioral health grant program to provide matching grants to counties for expansion or improvement of local or regional behavioral health programs. Money can be used for: peer training, augmentation of direct therapy, acute treatment units, in-patient treatment programs, outreach and education, navigation or care coordination, capital investments in behavioral health center infrastructure, services for non-English speakers, culturally responsive and attuned services, suicide prevention and intervention, crisis response, withdrawal management, workforce development, supporting regional service delivery, or other purposes identified by state. No more than $1 million per grant unless two or more counties are involved in a regional effort. Direct service providers limited to 10% spending of money on adminstrative costs, and any entity that oversees a provider to 5%. Any money used on capital projects must demonstrate commitment to continued spending on project for at least five years beyond grant cycle. Grantees can use federal stimulus money as their matching funds. State is to prioritze applications with innovation or collaboration, rural and frontier counties, demonstrated needs showing community input, and ability to rapidly distribute grant money into community. $9 million in federal stimulus money appropriated to program. Program expires in July 2023
  • Appropriates $5 million in federal stimulus funds to the state to use for emergency resources to licensed providers to help remove barriers they face in treating kids in residential programs. State can set rules around the funding, including quality assurance monitoring, admissions, discharge planning, length of stay, appeals process for kids determined ineligible, and compliance with federal law (including family first law). Providers must agree to admit any child that is eligible and not discharge any child for being too severe a case (but the state must work with providers to transfer kids as needed). State must pay for direct costs of care for the child and coordinate with Medicaid for any kids covered by Medicaid. Any child referred to the program (and any provider can refer) must be screened for Medicaid eligiblity within 7 days. Providers must report to the state and the state to the legislature. Program expires in July 2025 but by September 2024 the state must recommend to the legislature how to provide necessary care on an ongoing basis (without all of this federal money)
  • Expands the AgrAbility project by providing funding to rural rehabilitation services to provide information, services, and research-based, stress-assistance information, education, suicide prevention training, and referrals to behavioral health care services to farmers, ranchers, agricultural workers, and their families. This program is run by Colorado State University and is currently set up to help people with disabilities or other physical challenges in agriculture. $900,000 appropriated per year in perpetuity to fund expansion
  • Appropriate $2 million in perpetuity to the State Department to address behavioral health disorders through public health prevention and intervention and to work with community partners, including local governments, to address behavioral health, mental health, and substance use disorder throughout the state. Money can be used for data collection, analysis, and dissemination activities related to behavioral health disorders, including community health assessments and improvement planning. $500,000 of the money may be used for administrative costs
  • Create a recovery support services grant program to provide grants to recovery community organizations to provide recovery-oriented services to people with a substance use disorder and a co-occurring mental health disorder (See Description for more detail). Grants to go through the designated managed services organization for the area, which also awards grants based on state created criteria. Must prioritize programs outlining a capacity to deliver services to meet the needs of diverse racial, cultural, income, ability, and other underserved groups. Each managed services organization must report to the state each year and the state must report to the legislature. $1.6 million appropriated annually in perpetuity for the program
  • Creates a regional health connector workforce program to be run by the University of Colorado. Program is to educate providers on evidence-based and evidence-informed therapies and techniques to enable providers to incorporate them into their practices, provide support and assistance to primary care providers and serve as a link between them and behavioral health services, including substance abuse treatment, educate providers about preventative medicine, health promotion, chronic disease management, and behavioral health services; and provide clear information to providers and the community on COVID prevention, treatment, and vaccines. $1 million in federal stimulus money appropriated to program
  • More in Description

Description:

Appropriates money to various behavioral health programs for the 2021-22 fiscal year:

  • $5 million in federal stimulus funds for jail-based behavioral health services
  • $5 million for a pilot program for residential placement of kids with high acuity physical, mental, or behavioral health needs
  • $3.8 $10 million for co-responder programs, Colorado crisis system services, housing assistance, and treatment for rural communities
  • $3.5 $10 million in federal stimulus funds to managed service organizations (same ones as mentioned earlier, that treat substance use disorder) and $3.25 million in federal stimulus funds to community mental health centers for unexpected expenses related to COVID-19
  • $2.5 million of marijuana cash funds to the K-5 social and emotional health pilot program
  • $2 million in federal stimulus funds for services provided to school-aged children and parents by community mental health center school-based clinicians and prevention specialists
  • $2 million in federal stimulus funds for behavioral health and substance use disorder treatment for children, youth, and their families
  • $2.7 million, of which $1.7 million is federal stimulus money and $1 million is marijuana tax money, to existing program in the health service corps fund to provide loan repayment and scholarships to behavioral health providers
  • $1.15 $2.2 million in federal stimulus funds million for the opiate antagonist bulk purchase fund and school-based health centers
  • $1 million for a mental health awareness campaign
  • $500,000 to the behavioral health professional matching grant program
  • $500,000 $250,000 in federal stimulus funds to managed service organizations for substance use screening, brief intervention services, referral to treatment, training, and supports
  • $500,000 in federal stimulus funds for community transition services for guardianship services for people transitioning out of mental health institutes
  • $500,000 $2 million in federal funds for the HIV and AIDS prevention grant program
  • $500,000 in federal stimulus funds for the early childhood mental health consultation program
  • $250,000 $200,000 for treatment and detox programs
  • $250,000 to mental health first aid for in-person and virtual trainings
  • $120,000 for the safe2tell program

Recovery support services grants can be used to

  • Offer engagement in activities focused on mental or physical wellness or community service
  • Provide guidance to these people and their families on navigating treatment, social service, and recovery support systems
  • Help connect with resources needed to initiate and maintain recovery along the four dimensions of recovery: health, home, community, and purpose
  • Assist in establishing and sustaining a social and physical environment supportive of recovery
  • Provide local and state recovery resources
  • Provide recovery support services to caregivers and family

For the recovery support services grant program, to be eligible a community organization must be a non-profit led and governed by representatives of local communities of recovery that organize recovery-focused policy advocacy activities, carry out recovery-focused community education and outreach programs, or provide peer-run recovery support services. Grantees must annually report: number of community members in the organization, detailed description of the organization’s advocacy efforts, any collaborative projects the organization has with other recovery organizations across the state, and any other information required by state.

Extend the medication-assisted treatment expansion pilot program through 2023 2024 and restores its funding from $500,000 a year to $2 $3 million. This is a program that provides grants to enable training of nurse practitioners and physician assistants to provide medication-assisted substance abuse treatment. Funding was cut last year from $2 million to $500,000. Was set to expire in 2022.

Requires managed care organizations designated by the state to provide treatment services for drug and alcohol abuse in a designated geographic area to notify a covered individual’s health care provider of approval of services for residential and in-patient substance use disorder treatment within 24 hours of submission request. Intensive residential treatment authorizations must be for at least 7 days and transitional residential must be for at least 14 days, unless the organization does not have sufficient documentation from the provider. If the provider and managed care organization disagree on the continuation of treatment, the organization must defer to the provider. It may request additional information from the provider on the rationale for continuation. Organizations must provide specific justification for each denial of continued authorizations for all six dimensions in the most recent edition of the ASAM Criteria. Requires the state to consult with managed care organizations to develop standardized utilization management processes to determine medical necessity for residential and in-patient substance use disorder treatment. This must incoprorate most recent ASAM criteria standards and align with federal Medicaid requirements. New processes must be in place by next year. Beginning this fall and then every quarter thereafter, organizations must provide to state average length of initial authorization and average length of continued authorizations for services, denials of initial authorizations and reasons why, and average response times to requests, including how many needed extensions due to documentation issues. By July 2022 state is audit 33% of all denials and report to legislature, including on any needed legislative changes. State is to contract with at least one third-party entity by July 2023 to serve as arbiter for external medical reviews requested by a Medicaid provider when there is a denial or reduction in for residential or in-patient treatment and all appeals have been exhausted.

Requires state to develop a statewide data collection and information system to analyze implementation data and selected outcomes in the early childhood mental health consultation program, designed to improve social, emotional, and behavioral outcomes of young children and not required to come online until July 2022. System is to identify areas for improvement, promote accountability, and provide insights to continually improve child and program outcomes. State must report to legislature in 2023 and then every two years on this program, including gap analysis of mental health consultant availability across the state and adjustments to better meet mental health consultant caseload. State must contract with a third-party consultant by August 2026 to conduct an evaluation of the program, with a report due to the legislature in January 2027.

Appropriates $750,000 from the marijuana tax cash fund in perpetuity for the center for research into substance use disorder prevention, treatment, and recovery support strategies (previously was $250,000 a year through 2024). Removes the 2024 sunset review expiration of the center. Requires the center to engage in community engagement activities to address substance use prevention, harm reduction, criminal justice system response, treatment, and recovery. The center must also utilize data from Medicaid, the state’s prescription drug monitoring program, the state’s TRAILS system for tracking abuse, the state’s immunization information system, the office of behavioral health, and birth and death records for its ongoing research into how to improve outcomes for families impacted by substance use during pregnancy. Previously the center “could” use state administered data sources. Bill also allows the center to use other state or non-state data sources. $75,000 appropriated in 2021-22 funds to this data program. Another $600,000 in 2021-22 funds to the center for education for health-care professionals, grant writing assistance, and PPE and telehealth supplies for the medication assisted treatment expansion pilot program.

Requires the University of Colorado to provide practice consultation services to health care providers who are eligible to provide medication for opioid use disorder, including staff training and workflow enhancement to encourage better patient screening, supporting communication strategies to patients and referral sources, and providing access to marketing materials. The program is also to provide stipends to providers who can prove they've adopted the services and provided medication to at least ten patients in the last year. $630,000 in federal stimulus money appropriated for the program, which expires July 2023.

Allows existing high-risk families cash fund to spend money on services for families with behaviorial health needs (previously was limited to kids with needs or parents with needs but not the entire family). Appropriates $3 million in federal stimulus funds to the fund.

Requires the state to use a competitive bidding process to select a recovery residence certifying body to certify recovery residences. State is already required by law to certify recovery residences which must meet certain standards (again already established). The certifying body must also educate and train recovery residence owners and staff on industry best practices. $200,000 appropriated annually to achieve this.

Requires state to contract with a non-profit primarily focused on serving agricultural and rural communities to provide vouchers for people living in rural and frontier communities in need of behavioral health services. Only licensed behavioral health providers with training on cultural competencies specific to the state’s agricultural and rural community lifestyle can be used. At least 60% of the money in the contract must be used for direct care. The non-profit can use the rest to develop materials and train behavioral health care providers on the cultural competencies needed to work with these groups. Contract is for $50,000 a year and is appropriated in perpetuity.

Require the department of corrections, subject to available funds, to offer at least two doses of an opioid reversal medication (must be FDA approved) to those who were treated while in custody for an opioid substance use disorder when they are released.

More in Additional Information.

Additional Information:

Requires mother of every perinatal child (immediately before and after birth) in Medicaid to be able to get screening for perinatal mood and anxiety disorders. Must apply so long as the child is in Medicaid (mother’s status does not matter).

Sunset review expiration removed from the program to increase public awareness concerning the safe use, storage, and disposal of opioids and the availability of naloxone and other drugs to combat overdoses. Was scheduled to expire in September 2024. Removes repeal of the building substance use disorder treatment capacity in underserved communities grant program, was set to repeal in July 2024. Harm reduction grant program cash fund changed so it can keep its money after September 2024 and continued indefinitely. Maternal and child health pilot program funding continued.

Continues requirement that podiatrists adhere to limitations on prescribing opioids.

The statewide data collection for the early childhood mental health consultation program must place the least burden possible on the mental health consultants in the program. State must incorporate the variability across diverse settings and populations in selecting data.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We are currently dealing with a double whammy of cut-backs from last year’s budget due to fears that COVID would decimate what was available to spend and massive increases in need due to COVID
  • Fortunately we have the money to spend thanks to better than expected tax revenues. Instead of a massive budget crisis we have a surplus (because we planned for a massive crisis) and we have massive amounts of federal stimulus money
  • Like all crises, places that were already struggling were hit the hardest, so it is appropriate to focus more attention on substance use disorder needs and rural areas
  • We of course also already had a crisis of behavioral health care, so it is very appropriate to spend the large amounts of federal stimulus money on attempts to build capacity into our system, both in terms of people (providers) and infrastructure
  • The two new programs attempt to halt the negative cycle of homelessness and substance use disorder and provide people getting out of treatment a better shot at staying clean and sober

In Further Detail: This a smorgasbord bill so we won’t go point-by-point but in general we know two things right now about behavioral health in the state: we had to cut funding from some programs last year to make our budget work and COVID-19 greatly increased the need for behavioral health services. All sorts of needs went untreated and people developed new needs due to the events of the last year. So we have a hole to dig out of and fortunately, we have the money thanks to better than expected recovery of tax revenue from COVID. Like all crises, the places that were already struggling were hit the hardest. A big part of that is capacity in the entire behavioral health system, so it is appropriate to put huge chunks of federal stimulus funds into capacity building (both in terms of people and infrastucture) and money into emergency funding to tide us over to better solutions. It is also appropriate to put quite a bit of attention on substance use disorder needs, particularly in rural areas. On that front, the two new programs in this bill dealing with housing and supportive services for those getting treatment for substance use disorder are actually altered versions of programs that were in a bill last year that, like so many others, died in the shortened COVID-affected session. The idea here is pretty simple: homelessness and behavioral health issues are a self-reinforcing cycle. People with mental health needs have trouble, lose housing, and then their mental health needs become worse as they are forced to fend for themselves on the street. If they get treatment, once they are back out. They have trouble getting housing and end up on the street again, and the cycle continues. This costs communities tremendous amounts of money and contributes to recovery failure and involvement in the criminal justice system. Supportive services are a way to step in and stabilize housing for this population in an attempt to break the cycle. Unfortunately there are many communities that simply don’t have the infrastructure to access funding that is available for this exact purpose and different communities have different needs, so we need a broad scope of how to assist them. Much of the rest of the bill is either clarifying existing programs, providing supports to existing programs that need firming up (like certifying residential facilities), permanently extending programs, and yes, spending money in a bunch of different areas.

Arguments Against:

Bottom Line:

  • The two new programs are rather vague in scope (the bill last year had much more clearly defined rules) and the grant program appears to be too focused on advocacy
  • We have a massive housing problem in the state and limited state resources—we should be attacking housing supply
  • A lot of the programs whose expiration were removed were set for sunset review. That doesn’t mean that they weren’t worthy, it just meant we wanted them examined in detail to ensure that they were doing their intended purpose

In Further Detail: The two new programs in the bill are pretty vague. The state is to provide housing assistance but the actual amounts and time of assistance are left for the state to decide. The services grants are pretty undefined, in particular the section on helping on the four dimensions of recovery. And the reporting requirements of that grant program are a bit troubling: they focus on what advocacy efforts these community organizations are doing instead of what supportive services they have provided. That bill last year that was in a similar vein focused more on the criminal justice system and was designed to help those with behavioral and mental health disorders and those who were experiencing or at risk of experiencing homeless avoid getting tangled or retangled with the justice system. On the concept in general, we have limited state resources and a massive housing problem. Putting resources not toward housing but to create programs to help access housing is not the best way to spend our funds to attack homelessness. For the many programs that were permanently extended, several had sunset review clauses. We use sunset review not because we are doubtful that a program should exist, but because this provides an x-ray into the program. Yes to see if it should continue, but also to see what needs to be improved. We use sunset review for a host of things, including stuff that is obviously going to be continued like licensing doctors. Taking it away here means no one will be forced to examine these programs to see how they are doing.

  • The programs using federal stimulus money also suffer from the same lack of definition. That is a lot of money to spend with very few guiderails in place.

    How Should Your Representatives Vote on SB21-137

SB21-139 Coverage For Telehealth Dental Services (Fields (D), Simpson (R)) [Lontine (D), Soper (R)]

SIGNED INTO LAW

AMENDED: Technical

Appropriation: None
Fiscal Impact: None

Goal:

  • Extend the already existing telehealth insurance requirements for medical insurance to dental insurance

Description:

This includes the requirement to cover telehealth services and not require documentation of barriers to in-person treatment in order to approve telehealth. It requires payments for telehealth services to be the same as for in-person treatment. It requires insurers to keep the exact same copay, coinsurance, deductible and out-of-pocket maximum treatment structures for the plan for telehealth. Insurers are not required to cover consultations that are not provided through HIPAA compliant communications.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • There is no good reason to treat dental insurance differently than medical insurance when it comes to telehealth. On the contrary, we want to encourage telehealth for dental care in situations where we can avoid trips to see the dentist in-person, just as with medical insurance

Arguments Against:

Bottom Line:

  • It was wrong to force insurers to treat telehealth consultations the same as in-person consultations for medical insurance and it remains wrong to extend it to dental coverage. The resources consumed are just different and should be treated that way

How Should Your Representatives Vote on SB21-139

SB21-142 Health Care Access In Cases Of Rape Or Incest (Pettersen (D), Donovan (D)) [Caraveo (D), McCluskie (D)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

  • Remove a restriction in state law that requires anyone who is getting an abortion using Medicaid funds (which is allowed for cases where the women’s life is in danger or in cases of rape or incest) do so at licensed health care facility (essentially a hospital)

Description:

The procedure must already be performed by a licensed medical professional of course. Current law allows for an exception for the licensed health care facility requirement if the woman’s life would be endangered by transfer to such a facility and there is no such facility within 30 miles.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This does not change any of the provisions about when Medicaid funds can be used for abortions. All it does is lift restrictions on where those abortions can be performed to match where anyone else can get an abortion in this state legally
  • Every person has a right to personal health care decisions made free from government coercion and the right to accessible care. No one should be required to navigate a maze of rules (the state couldn’t even tell a local news outlet how many facilities are allowed to perform abortions on Medicaid coverage in the state) or travel long distances to receive care
  • Most abortions are performed in the first trimester and are extremely safe, they don’t need to be performed in a hospital. For any procedure that does, like with anything else, we can trust our licensed doctors to make the right judgment

In Further Detail: First, it is important to say that this bill does not change how state taxpayer money can be spent. It is already legal to spend Medicaid dollars on abortions in cases where the mother’s life is in danger or rape or incest. That is federal law. But Colorado has this extra restriction on this procedure which doesn’t do much other than make it harder for many women to get the medical care they deserve. Everyone has the right to medical care without having to navigate a maze of rules on exactly where they can get it. It is very telling that the state couldn’t tell a local news outlet just how many hospitals in the state there are where women can use Medicaid to get an abortion. Not all hospitals offer this procedure and the sense of bill advocates is that the total number is very low, but they don’t know either. It is a bad sign when a basic question like this cannot be easily answered. How is a patient supposed to answer it? And if they can, forcing someone to drive across the state to undertake one of the most deeply personal medical procedures is yet another barrier to in essence to try discourage people from doing it at all. As for the safety angle, abortions are one of the most safe medical procedures we have. Most can be performed on an out-patient basis and do not require a hospital. For any procedure that does require a hospital, we can treat abortions like all other legal medical procedures and simply leave that to the judgment of our medical professionals.

Arguments Against:

Bottom Line:

  • Current law is designed to ensure that if we are performing an abortion to save the life of the mother (one of the three conditions where this is permissible with Medicaid dollars), we do so in the safest setting possible
  • No one is prevented from using Medicaid to get an abortion under current law, there are just specified places they can do so

In Further Detail: One of the three conditions under which you can use Medicaid to get an abortion is if the mother’s life is in danger. It would seem logical that in those circumstances we need more robust medical care and therefore the need for a hospital. But in all three allowable circumstances no one is prevented from using Medicaid to get their health care. They may have to drive a little farther or do a little more research, but they can still get their legally allowed care.


Bottom Line:

  • We should ban all abortions, not pay for them with taxpayer money and certainly not make it easier for women to get them

How Should Your Representatives Vote on SB21-142

SB21-154 988 Suicide Prevention Lifeline Network (Kolker (D), Simpson (R)) [Cutter (D), Soper (R)]

PASSED

AMENDED: Moderate

Appropriation: $74,566
Fiscal Impact: Net impact in future years appears slightly positive but the revenue is intended to fund this program

Goal:

  • Implement 988 in Colorado as a suicide hotline (was created by federal law last year) as an enterprise program that is exempt from TABOR. Requires the state to contract with a non-profit organization to create the 988 crisis hotline center to provide intervention services and crisis care coordination to people calling 988 24-7. Creates a surcharge on phone users (landline and cell phone) who call 988 to go to funding 988. Charge set by public utilities commission but not to exceed $0.50 $0.30 per month per 988 call. Does not apply to prepaid wireless phones, which instead are charged an amount determined by the commission at sale not to exceed $0.30 per transaction

Description:

988 crisis hotline must have an active agreement with the administrator of the national suicide prevention lifeline for participation in the network, meet that lifeline’s standards for operations, clinical work, and requirements for serving high-risk and specialized populations. It must deploy mobile response units and co-responder programs (behavioral health experts trained to respond to these situations along with first responders like police), and coordinate access to walk-in centers. It must also provide follow-up services to individuals who call the hotline. It must also coordinate with the veterans crisis line .

State must consider how this hotline interacts with the existing 24/7 crisis line.

For prepaid wireless, initially the surcharge is set at 1.4% of the sales transaction price. That expires at the end of the year, at which point the commission takes over. Commission must set the rate by October, which then takes affect the next January (every year). Must be reasonably calculated to meet the needs of the program. Money collected by department of revenue.

Phone companies can keep 1% of the surcharge to cover their administrative costs. Public utilities commission can keep up to 4% of what it collects to cover its administrative costs. Sellers of prepaid wireless phones can keep 3.3% of the fee collected. State can keep up to 3% of what is receives to cover its costs.

State must report to the legislature each year on the hotline.

Additional Information:

Service providers must keep 988 surcharge records for three years. Charges must be clearly identifiable on bill. If a provider fails to timely file its 988 surcharge report and money, the commission is to estimate the amount owed and issue a penalty of 15% and interest on the owed amount of 1% a month. Commission can conduct audits of providers.


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Suicide is a huge problem in Colorado, it is the 7th leading cause of death in the state and we have the 5th highest suicide rate in the nation according to the CDC
  • The federal passage of 988 provides an opportunity for us to allow 24-7 access with a number that everyone can easily remember (our current 24-7 crisis line is a bit more broadly focused and of course is a full telephone number) and align ourselves with federal law
  • We fund 911 calls in part through a similar surcharge on use—the amount is tiny and not going to deter anyone from using it

In Further Detail: Suicide is the 7th leading cause of death in Colorado and we have the 5th highest suicide rate in the nation (deaths due to suicide per size of population). This is not a new phenomenon and not related to COVID (although that has not helped). We consistently rank near the bottom in suicide prevention and although there are unique factors that appear to contribute to this beyond our control (altitude), we certainly can do more to try to prevent suicides. The federal passage of 988 provides us with such an opportunity. First, by implementing 988 in the state we are aligning ourselves with federal law and regulations. But more importantly, just like 911 it is an easy to remember number in a crisis that requires no research to uncover. Our current 24-7 crisis line is a bit more broadly focused (it is marketed as a place to call if you need to talk) and of course is a full telephone number you need to find. As for the funding part of this, 911 calls in the state are funded in part through an almost identical surcharge on use, so this is not novel. And the amount is tiny, no more than $0.50 a month, which should not deter anyone from using the service.

Arguments Against:

Bottom Line:

  • There is going to need to be an enormous marketing campaign to drive awareness of 988, we cannot rely on the federal government to do this for us—the bill does nothing in this area
  • Program should not be funded by use, the 24/7 crisis line is not. Even if the charge is minimal, when you have to pay to call someone in 2021 there is a natural hesitancy because it is so novel. A surcharge on all phone users would fund this program with just a tiny amount collected from everyone

In Further Detail: It’s nice to have an easy three digit number but that is meaningless if no one knows about. We all know about 911, it is drilled into us from an early age. It will take a lot of work (and money) to raise awareness about 988. Yes the federal government will likely do some of this but we can’t simply count on them. We need to have our own public awareness campaign and the bill does not do this. And on the funding: just because we have a poor model of funding 911 calls in this manner doesn’t mean we need to extend it. The 24/7 crisis hotline the state already operates is free to call. Even if the charge is minimal, we are simply not used to paying to call someone in 2021. If people know the call is not free, they may balk, and the very last thing we want to do is put any barriers in front of using 988. Just as with the prepaid wireless phones, fund this by a broad surcharge on everyone. The amount required will undoubtedly be tiny and barely noticeable in a monthly phone bill.

How Should Your Representatives Vote on SB21-154

SB21-156 Nurse Intake Of 911 Calls Grant Program (Garcia (D)) [Mullica (D)]

PASSED

AMENDED: Moderate

Appropriation: $856,583
Fiscal Impact: Beyond appropriation, negligible next year only

Goal:

  • Create a pilot program to provide nurses to help 911 dispatchers determine which incoming calls can be diverted to a type of medical care that does not require ambulance service or treatment in an emergency room. State is to provide grants to four 911 dispatch centers in the state with the money to be used to pay for the costs associated with nurse intake of 911 calls. State must also provide technical support. Pilot must begin by January 2022 and ends in September 2023 2024

Description:

For the four locations, one must be located within a county that has 60,000 or more residents and three must be in counties with less than 60,000 residents. To be in the program, the 911 facility must agree that it will enter into a contract with an entity that employs or contracts with nurses who are trained and equipped to provide nurse intake of 911 calls. Must also supply anticipated financial savings in its grant application.

Prior to entering into a contract, dispatch centers must get direction from the medical director and chief of the fire department of the jurisdiction. Must also seek input from community stakeholders including police, EMS services employers, and community and medical providers that might be used as part of the program.

Grantees must report to the state on the number of calls nurses were used on and the outcome of those calls. Report must include individual satisfaction scores from people who used the program and savings to the state's health care system. State must publicly publish this information online and report it to legislature.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We waste a lot of money in our health care sector in unnecessary emergency room visits and ambulance use—we could potentially save $800 million by treating non-emergency issues through alternative health care venues
  • Diverting calls that don’t need emergency services can also free up our first responders
  • You test new concepts through pilot programs to see if they can work on a small scale—and this is not a totally new concept in health care, multiple other cities use a version of this program and it is widely used in the UK and Australia

In Further Detail: It is estimated that around 40% of emergency visits in Colorado are for non-emergencies. This is critical because our most expensive health care is the emergency room, which when in used in conjunction with an ambulance for transportation, represents a huge waste of everyone’s money: patients, insurers, and the government. It is estimated we could save $800 million a year in Colorado by treating non-emergency issues in more appropriate venues like a doctor’s office or urgent care clinic. But right now when someone dials 911, it is up to the dispatcher to tell that person what to do. If we instead could have a trained medical professional use their judgment to divert non-emergencies we could open a vast vista of savings and free up our first responders (and emergency rooms) to handle true emergencies. Because this is a new concept it is appropriate to pilot test it in a few locations first. But we shouldn’t act like this is some mysterious thing that has never been done before. Multiple cities in the US, including the District of Columbia, have similar programs. This will absolutely not eliminate the problem of people using the emergency room when they do not have to, people will still walk-in without dialing 911 at all. But it should help quite a bit.

Arguments Against:

Bottom Line:

  • We may want to require more information out of grant applicants to ensure that they are doing a thorough job of attempting this difficult integration—we want a true test here
  • A huge problem other locations have run into is coordinating with medical providers—the bill does not address this
  • Attempting triage over the phone with no medical history is also difficult

In Further Detail: No one should kid themselves, this is a highly complicated integration challenge. Other locations that have run similar programs have run into difficulties because they have trouble having actual alternative places to send patients. It is all well and good to discuss doctor’s offices, but the city of Richmond had to abandon its program because they couldn’t get enough doctor’s offices, clinics, and urgent care facilities onboard with receiving patients in this manner. In Louisville, Kentucky, they spent an entire year recruiting medical professionals to participate in the program before launching it. Then there is the matter of transportation: if the patient cannot transport themselves, then what? Can we authorize use of taxis or Uber or Lyft? Then we have the issue of attempting diagnosis over the phone with no access to patient history. Dallas actually created a program like this back in the 1980s but had to quickly pull the plug when a woman died after a nurse determined an ambulance was not necessary. Fort Worth has actually created a mobile paramedic option that involved sending a nurse to the home if necessary. That also brings up the question of liability, are nurses who participate liable if they make the wrong decision? All of this is to say that if we want to have true pilot programs with the greatest amount of success we need to do a lot more work up-front to ensure the programs can work.

How Should Your Representatives Vote on SB21-156

SB21-158 Increase Medical Providers For Senior Citizens (Danielson (D), Pettersen (D)) [Titone (D), Duran (D)]

PASSED

AMENDED: Significant

Appropriation: $400,000
Fiscal Impact: Negligible beyond appropriation

Goal:

  • Modify the existing Colorado Health Corps Service program, which includes a loan repayment component, to include advanced practice nurses and physician assistants who agree to spend at least 50% of their time providing geriatric care in shortage areas in the state for at least two years in geriatrics. Adds a geriatric care provider as a member to the Health Corps Service Advisory Council, and appropriates $1,925,000 over the next five years to specifically cover geriatric care provider loan repayments $400,000 to the program.

Description:

To be eligible, an individual must be an advanced practice nurse or physician assistant that meets at least one of the following criteria:

  • Completed formal postgraduate geriatrics training program with at least six months of education in geriatric care and clinical experience with primary care of older adults with no more than 25% of that care in inpatient or hospice settings
  • Completed formal geriatrics training within an advanced practice provider training program with at least 12 months of postgraduate clinical experience (at least 50% of time spent in geriatrics) or at least 24 months of postgraduate clinical experience (less than 50% of time spent in geriatrics) or an emphasis on geriatric care, or completed geriatric track clinical experience during their training program with at least 50% of clinical training spent in geriatrics.

Geriatrics does not include hospice-only care.

Council must give priority to applicants that are providing care in a rural setting, practicing with a non-profit entity, and willing to serve as a clinical preceptor for others seeking training in geriatrics.

Additional Information:

Funding is broken down as follows:

Year 1: $225,000

Year 2: $400,000

Year 3: $575,000

Year 4: $450,000

Year 5: $275,000


Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We already have a shortage of geriatric providers in the state, particularly in the rural areas where half of the over age 75 population lives. This is only going to get worse as our elderly population increases over the next decade
  • Geriatric care is as much as specialty as pediatrics: there are complexities of care that can arise with old age and medical conditions that almost always only appear in old age
  • We already have a program designed to help fill shortages across the state so it makes sense to add geriatrics to it and the bill adds funding for the expansion, so no existing fields will be hurt

In Further Detail: We have a shortage of these providers in many areas of the state. A 2016 estimate had the state short 176 geriatricians and at the time, only 5 of the 148 geriatrics practices listed in an online database were outside the Front Range and Grand Junction. Nearly 50% of our of Coloradans aged 75 and older live in rural areas, but only 10% of geriatric specialists reside or practice there. Those trained in geriatrics are experts in the complexities of care that accompany old age, much as pediatricians are experts in the complexities of care of children. Meanwhile the number of Coloradans over the age of 65 is expected to grow by 43% to 1.2 million. We have an acute need here and a program that already exists to fill such needs, with a long list of eligible providers across the entire medical spectrum: from dental hygienists to doctors, including geriatric doctors. So adding advanced practice nurses and physician assistants who will specialize in geriatrics is not a stretch at all. And the bill adds funding for its expansion of the program, so no existing fields will be hurt.

Arguments Against:

Bottom Line:

  • We have lots of shortages in many areas of medicine in this state, particularly in rural areas, but the only specialization currently in the program is substance use disorders
  • We may be better served by beefing up these professional in general, the way the program is currently set, then focusing solely on geriatrics with these extra funds

In Further Detail: This program already includes advanced practice nurses and physician assistants, who must agree to work for three years, not two, in the state. The only other type of advanced practice nurse and physician assistant specialization that is separated is substance use disorders. No one denies we have a geriatrics shortage, but we have lots of other shortages in rural areas of the state and we may be better served by beefing up advanced practice nurses and physician assistants in general with these extra funds, rather than focusing solely on geriatrics.


Bottom Line:

  • This bill does nothing to prevent an individual from getting their loan repayment and then either leaving the state entirely or moving to a non-shortage area to practice. It now no longer even requires that the graduate practice in shortage areas in the state

How Should Your Representatives Vote on SB21-158

SB21-175 Prescription Drug Affordability Review Board (Jaquez Lewis (D), Gonzales (D),) [Caraveo (D), Kennedy (D)]

SIGNED INTO LAW

AMENDED: Moderate

Appropriation: $730,711
Fiscal Impact: About $800,000 in year one, $480,000 a year after that

Goal:

  • Create an independent review board that can establish upper payment limits for prescription drugs the board deems are unaffordable for Colorado consumers. Maximum of 12 drugs per year in 2022, 2023, and 2024. Any upper payment limits take effect six months after announcement. State must gather pricing information for the board each year, which involves insurers reporting to the state its top 15 prescription drugs in numerous categories in terms of end-user payments under its benefit plans (see Description) and its wholesale prices to pharmacies (again see Description). This pricing information is to be posted publicly (except for redacted proprietary information)
  • To be deemed unaffordable, brand name drugs must either have an initial wholesale cost of $30,000 or more or an increase in wholesale cost of $3,000 10% or more during the last year. Both figures are for a year’s supply or a course of treatment that is less than a year. Biosimilar drugs (similar to generics but created slightly differently) must have a wholesale cost that is not at least 15% lower than the corresponding brand name drug. Generics must have a wholesale cost of $100 or more for a full supply as recommended by FDA (either 30 days, less than 30 days, or just one dose if the FDA does not recommend a finite dosage) and a wholesale acquisition cost increased by 200% or more during the past year. All pricing is inflation adjusted
  • For unaffordable drugs, the board first decides if a full affordability review is required (see Description for this full process). If the board decides to set a maximum price, it must follow a methodology set by rule that considers: cost of administering or dispensing the drug, cost of distributing the drug to consumers, impact on safety net providers if the drug is available under federal Medicaid program 340B for hospitals, the status of the drug on the FDA shortage list, and other relevant costs. Board must consider impact on older adults and not value their lives less than others. Self-funded health benefit plans (where the employer is in essence the insurer) are exempt from maximum costs but can opt-in fi they wish. Decisions are appealable to the board and if the appeal is denied, can be appealed in court. If manufacturers decide to stop selling their drug in Colorado because of this decision, they must give the state and each entity in the state the manufacturer has a contract with at least 180 days notice
  • If a manufacturer refuses to make a drug available, individuals can request expidited judicial reviews to gain access to the drug at the old price. If the court agrees, the manufacturer can sell the drug to that person at the old price
  • The bill also creates the Colorado Prescription Drug Affordability Advisory Council to help the board make these decisions
  • Any savings created by setting a maximum limit to an insurer must be used to lower premium costs. They must verify this with detailed annual reporting to the state
  • Cannabis-based prescription drugs are excluded

Description:

For drugs purchased by consumers under their plans, insurers must report: most expensive drugs in the previous year by unit price and by total plan spending, the top 15 that increased the most over the previous year as a total of plan spending, the top 15 that caused the greatest increases in insurer premiums, the top 15 most used drugs that had a rebate from manufacturers, the top 15 with the highest rebates from manufactures (by percentage of total cost), and the top 15 with the largest rebates from manufacturers (by dollar amount).

For wholesale pricing to pharmacies, insurers and pharmacy benefit managers must report the average wholesale price paid, broken down by insurance group size category (individual, small biz, large biz): brand name drugs purchased from retail pharmacies, generic drugs purchased from retail pharmacies, brand name drugs purchased from mail order pharmacies, generic drugs purchased from mail order pharmacies, and prescription drugs administered by a practitioner, administered in an in-patient hospital setting, and administered in an out-patient hospital setting.

To decide if a drug needs an affordability review, the board must evaluate the class of drug and whether there are other therapeutically equivalent drugs for sale, evaluate aggregated data, seek input from the advisory council, seek input from affected patients and caregivers, experts with scientific or medical training relating to the drug in question, and consider the average patient’s out-of-pocket cost for the drug.

In an affordability review, the board must consider:

  • Wholesale cost of the drug
  • Cost and availability of therapeutically equivalent alternatives
  • Effect of the price of the drug on access for Coloradans, including the relative financial effects on health, medical, or social service costs compared to baseline effects of existing therapeutically equivalent alternatives
  • Typical patient co-pays or cost shares for the drug
  • Any other information the manufacturer, carrier, pharmacy benefit firm, or other entity chooses to provide. This can include life-cycle management, the average cost of the drug in the state, market competition and context, projected revenue, cost-effectiveness of the drug, and off-label usage of the drug. Board cannot use any methodologies that discount the value of someone's life due to their age or disability

The board can also consider pricing in other states and countries to the extent it can acquire the information. It can request this information from manufacturers as well. There is no mechanism to require the manufacturers to divulge the information.

In general board meetings are public meetings and the bill requires all decisions made on doing an affordability review, votes on establishing upper payment limits, and final decision to be made in public without exception. The board can meet privately in executive session only to consider information that is proprietary. Recordings of these sessions are not permitted if doing so would divulge the information and minutes from the sessions cannot include the proprietary information.

Proprietary information is subject to non-disclosure agreements. Carriers and pharmacy benefit managers can also ask for redaction of information they claim is proprietary in their annual reporting requirements. The commissioner of insurance can only disclose redacted information as is required by Colorado open records law and to employees of the division as necessary.

The board consists of five members appointed by the governor and confirmed by the Senate. They must collectively each have experience and expertise in health-care economics and clinical medicine. Members serve for three year terms. Individuals under consideration for the board must disclose any conflict of interest (see Additional Information for full conflict of interest definition) and cannot be an employee, board member, or consultant of: a manufacturer or trade association of manufacturers, an insurer or association of insurers, or a pharmacy benefit manager or trade association of pharmacy benefit managers. All conflicts of interest for board members must be publicly posted online.

The board can contract with a third-party to help carry out its duties and hire staff. Third-party must agree not to release any information it obtains through its work with the board and must disclose any conflicts of interest to the board. Staff members are not permitted to see proprietary information gathered during affordability reviews. Attorney general also to assign an assistant attorney general to provide legal counsel to the board. They must also disclose conflicts of interest. Everyone associated with the board, including staff and contractors, must recuse themselves from situations in which they have a conflict of interest.

The board can accept gifts, grants, and donations to carry out its work (goes to state treasurer to place in board’s operational fund) but it cannot accept any that would create a conflict of interest or appearance of one. All board members, staff members, contractors and their immediate families are barred from accepting financial benefits or gifts, bequests, or donations of services or property that suggest a conflict of interest or have the appearance of creating bias in the board’s work.

Council members must also disclose conflicts of interest (which are also posted publicly) and must also meet in public except for meetings of three or fewer members to gather and understand data or to establish, organize, and plan for the business of the council. Council members are not required to recuse themselves when they do have a conflict of interest. Except for the executive director of the department of health care policy, council members are appointed by the board.

Bill is silent about if board members or council members can receive compensation or reimbursement for expenses for their work.

Violating the upper payment limit established by the board carries a fine of $1,000 per violation. Failure by manufacturers to provide proper notification before exiting the state carries a fine of no more than $5,000.

Board must report annually to the governor and the legislature, including number of drugs subjected to an affordability review and the outcome of the review (including the maximum payment set by the board), as well as other information.

Entire program is set for sunset review repeal five years after the first upper payment limit is established.

Additional Information:

Conflict of interest is defined as an association, including a financial or personal association, that has the potential to bias or appear to bias an individual’s decisions in matters related to the board or the advisory council or the conduct of the activities of the board or the advisory council. Includes any instance where the individual could receive a financial benefit from a board action, or a financial benefit from an item being studied by the board. This includes increases to stock values held by the individual.

Board must meet every six weeks and is exempt from the state procurement code. It is also exempt from requirement to complete thorough reporting to state on any grants it receives.

Parties have 60 days to appeal the board’s decision. Board has 60 days to come to a ruling after an appeal. Judicial review can come 60 days after board’s decision if there is no appeal.

The appointed members of the council are to the extent possible, reflect the diversity of the state including race, ethnicity, immigration status, income, wealth, and geography. At least one council member must reside on the eastern plains and one must reside on the western slope. To the extent possible, each congressional district should have a council member.

13 14 members are appointed as follows:

  • Two who are health care consumers or represent health care consumers
  • One representing a state-wide health care consumer advocacy organization
  • One representing consumers with chronic diseases
  • One representing a labor union
  • One representing employers
  • One representing carriers
  • One representing pharmacy benefit management firms
  • One representing health care professionals
  • One employed by an organization that performs research on prescription drug pricing
  • One representing brand name drug manufacturers
  • One representing generic drug manufacturers
  • One representing pharmacists
  • One representing wholesalers

Every member of the council must have knowledge at least one of the following subject matter areas:

  • Pharmaceutical business model
  • Supply chain business models
  • Practice of medicine or clinical training
  • Health-care consumer or patient perspectives
  • Health-care cost trends and drivers
  • Clinical and health services research
  • Colorado’s health care marketplace

Counsel to meet at least once every three months.

Board report to the state must also include: publicly available data on price trends, number and dispositions of any appeals or judicial reviews of board decisions, summary of all appeals made to board, description of each conflict of interest disclosed to the board during the previous year, description of any violations of the bill’s provisions and any enforcement actions taken, impact of upper payment limits on providers and pharmacies, and patients' ability to access drugs and any recommendations for policy changes to increase affordability of prescription drugs in the state.


Auto-Repeal: Five years after first upper payment limit, with sunset review

Arguments For:

Bottom Line:

  • This is life and death for many people and yet increasing numbers of Coloradans cannot afford their prescription medication without making cuts in places like food and housing. As many as 1 in 3 struggle to fill their prescriptions
  • We pay vastly more for prescription drugs than most other similar nations
  • The negative impacts from these high-priced drugs are enormous, from health problems not being treated to financial difficulties to money bleeding out of the state’s coffers
  • This is not a normal industry and should not be treated like one: people do not have the normal purchasing decision power to simply forgo expensive options
  • The board created by this bill is independent, discloses conflicts of interest, only acts in egregious cases, and only acts after due deliberation. Its decisions are appealable in court
  • The pharmaceutical industry is one of the most profitable industries in the world, raking in $1.9 trillion in net income from 2000 to 2018 (that’s $105 billion a year on average). They’ll be just fine

In Further Detail:

Many prescription drugs are life or death for the people who need them. And yet increasing numbers of Americans are forgoing these medications because they cannot afford them. According to a state report about 11% of state residents did not fill a prescription because of cost in 2019 and that was before the pandemic. Estimates are now that as many as 1 in 3 Coloradans struggle to afford their prescription drug medication by skipping doses, cutting pills, or leaving prescriptions unfilled. State Medicaid spending grew by a whopping $435 million from 2014 to 2019 and is now over $1 billion per year. And there is another part of this story that we all already now: we pay vastly more for prescription drugs in the United States than people do in other similar nations. The Colorado Consumer Health Initiative has found that difference can be as high as 65% to 80% more money coming out of our pockets for the exact same drug. All of this has enormous detrimental impacts to our state. Health problems are not treated properly, which leads to increased costs down the line and increased adverse results including premature death. Money drains out of every corner of our state, including the state government, to pay for higher prices when the drugs are used. Families are faced with decisions about which basic necessities to forgo in order to pay for their prescriptions. This industry is not a normal one. We cannot simply decide to not buy a drug if we decide it is too expensive or drop down to some other less pricey model like a television. It should therefore not be treated like a normal industry. This bill sets up an independent final arbiter of excessive drug pricing. The board is to operate with complete disclosure of potential conflicts and look out for the best interest of Coloradans. It only examines egregious cases of price increases and then only acts after due deliberation and almost entirely in public. Its decisions can be appealed in court. Any cost savings from board decisions come to consumers, not insurers. Pharmaceutical companies will still be able to make profits, as they do all over the world. They will not be stopped from researching new lifesaving drugs. They may not be one of the most profitable industries in the entire country, as numerous studies have determined they are right now, with profit margins in excess of 20% in a particular year not unusual for the largest companies. The 35 largest pharma companies brought in $1.9 trillion in net income from 2000-2018 with profit margin of 14%. They’ll survive just fine. We are done being the profit center for these companies while they charge the rest of the world fairer prices. On the concern about future research, studies have demonstrated that the revenue generated by drugs in the rest of the world (at non-exorbitant prices) cover pharma research and development costs easily. In 2015 the top 15 drug companies spent $76 billion on research and development. The revenue they brought in simply from the difference in US pricing and the rest of the world (the difference not the total), was $116 billion. That’s about $40 billion in pure profit and that implies a best case scenario for the pharmaceutical manufacturers: that pricing at the level of the rest of the world simply doesn’t cover the cost of producing a drug. That claim is dubious because we already know that pharma companies inflate the average cost of producing a drug at around $2.6 billion, while other private studies have been unable to find many drugs where the total development price was over $1 billion. And most failures happen early, when costs are lower. 40% fail in phase I, typical sticker cost: $25 million. For the group that’s left, 70% fail in phase II, typical cost: $60 million. So the more likely tale is simply that the US is a profit center for these manufacturers, not a necessary sector to cover their R&D costs. Poor pharma may just have be solidly profitable rather than spectacularly profitable.

Arguments Against:

Bottom Line:

  • The pharmaceutical business relies on a heavy amount of research and development spending to develop drugs with the knowledge that around 90% of them will fail (and thus bring in no revenue) so they must fund their entire business on the other 10% including earning a profit—because this is American and profit is not a four letter word
  • There may be other factors at play in prescription drug costs in this country, insurance companies and if they are properly passing on rebates to consumers
  • We need pharmaceutical companies to continue to fund all of their research efforts and that may be hampered if they see threats to their bottom line
  • Pharmaceutical companies may simply refuse to sell drugs with price limits on them in Colorado—what then? Colorado can’t move the entire US market on its own
  • The board created to run this process is unelected, has little to no accountability to the public or the legislature, and has a very vague financing structure that is not spelled out in the bill, nor is the amount of funds that can be spent on administration and salaries

In Further Detail: The pharmaceutical business model is rather unique in that enormous amounts of money are required to fund research and development of a drug without any guarantee it will actually work. Time and time again these companies have to write-up costly failures. In all, when you consider the entire industry, you are looking at something on the order of $100 billion spent each year on research and development. And since 90% of drugs fail, pharmaceuticals must fund their entire operation on the remaining 10%. And yes, earn a profit. Because this is American and profit is not a four letter word. The profit motive is what helps bring talented people into this field in order to push the frontiers of science to bring us cures. Nowhere was this more evident than the miracle that is the multiple COVID-19 vaccines that were produced in record time and have proven to be extraordinarily effective. The reason prices are lower in other countries is not some nefarious scheme but simply that they have price controls in the manner that this bill is suggesting. It also may have something to do with insurance companies, who drug companies claim do not pass along all of the rebates they receive to consumers (note the bill requires some disclosure around these rebates). The idea that these publicly traded companies are simply going to swallow enormous reductions in their profits without doing anything to try to cut expenses is simply not believable. So closing off one of the last remaining free markets for these companies may very well result in some decisions on drug research we don’t like. In particular this has the potential to harm research into drugs that will likely not be very profitable (even under our current market condition). It may cause these companies to layoff employees and reduce salaries. And the really important thing it may cause is something bill does pay a passing mention to. Colorado acting alone simply cannot influence the prescription drug market in the United States. Faced with having to dramatically lower its pricing for just Colorado, a drug manufacturer may just decide it doesn’t want to sell into the state. The bill brings up just this very thing with a requirement that any manufacturer notify the state it will pull out with a paltry fine for non-compliance that no manufacturer is going to take seriously as well as a potentially completely unworkable plan for individuals to appeal to gain access to their drugs at the old prices. Perhaps the thought is that no drug company would dare refuse to sell its medication, but since the bill has a negative viewpoint of drug companies to being with, that may or may not be the case. What happens if drug manufacturers decide to play hardball is not clear. The final thing worth discussing is the structure of this plan. An unelected board of just five members is given the power to set prices on products in the state. Sure you can appeal (to the same board!) or you can try to go to court. But the breadth of unchecked power given to this board is vast. And it all flows from the governor, the only person with the power to remove someone from the board. The legislature, the voice of the people, is mostly left behind. The legislature is not required to approve any decisions on maximum prices. There is no mechanism for disapproval either if you want the board to be able to move faster when the legislature is out of session. The legislature has little oversight over the board. Conflicts of interest are to be disclosed but there is no investigation done of these five board members to ensure they are being honest and thorough with their disclosures. And we have no idea how this board is to be funded. The bill says it is explicitly not through gifts, grants, and donations, but if not that, then what? Compensation for board members is also absent. There is no limit placed on administrative and salary costs that the board may use for whatever funds it does receive. Too much power concentrated in too few hands with too little oversight and regulation.

How Should Your Representatives Vote on SB21-175

SB21-181 Equity Strategic Plan Address Health Disparities (Fields (D), Coram (R)) [Herod (D), Caraveo (D)]

PASSED

AMENDED: Minor

Appropriation: $4,924,607
Fiscal Impact: Negligible each year

Goal:

  • Expand existing health disparities grant program by renaming it health disparities and community grant program and allowing it to award grants to positively affect social determinants of health to reduce the risk of future disease and exacerbating health disparities in underrepresented populations. Appropriate $4.7 million to fund grants
  • Grant criteria for community organizations can include how the organization plan to use strategic planning, building capacity of staff and volunteers, technical training and assistance, and impact on the community
  • Requires the state to facilitate a work group to develop an equity strategic plan health equity commission to convene witihin six months after the first required report is published (see Description) in 2022 to develop an equity strategic plan, repsond to the report and to ensure coordination in equity-related work across state agencies to address social determinants of health

Description:

Grants can already go to financial support for statewide initiatives that address prevention, early detection, and treatment of cancer and cardiovascular and pulmonary diseases in underrepresented populations.

Adds five seven members to the existing health equity commission (currently has 15 members): executive directors of departments of labor, local affairs, transportation, public safety, corrections, higher education, and commission of education.

Beginning in 2022 state must report every two years to the legislature on health disparities in Colorado by race and ethnicity that includes the impact of social determinants of health and health disparities and strategies to address them.

Social determinants of health are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life risks and outcomes.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • It is well-established and proven that better quality of life leads to better health outcomes. Social determinants of health are a Centers for Disease Control identified framework to attack specific quality of life issues that play a large role in the nearly across the board poorer health outcomes for people of color in this country
  • This grant program should not be excluded from providing grants that help attack this problem, in whatever way. Excluding this ability because we cannot solve the entire problem is counterproductive and can prevent positive change

In Further Detail: The Centers for Disease Control outlines five key areas of social determinants of health: healthcare quality and access, education quality and access, social and community context, economic stability, and neighborhood and built environment. Quality of life can have a significant impact on health outcomes. Housing, education access, public safety, availability of healthy foods, local emergency/health services, and environments free of toxins all contribute to better health. These impacts can be multi-generational in affect. So when we look at statistics that say 16% of Hispanics and 11% of Blacks lack insurance compared with 6% of non-Hispanic whites or 42% of Black adults suffer from hypertension versus 29% of non-Hispanic whites or Blacks have the highest mortality rate from cancer or the highest infant death rate (twice the national average) we have to do more than just examine the medical system (and those stats are just a small taste of the massive health disparities by race in America). To be clear, there are problems in the medical system that are in part the cause of these statistics: poor testing of medication and equipment on minorities, lack of understanding of ways in which some more dominant traits in minorities can complicate care (sickle cell in Blacks for instance), and doctors who refuse to believe minority patients’ self-reported symptoms. But there are also deep systemic problems at work and unless we address those problems health care disparities aren’t going anywhere. Of course this grant program is not going to solve centuries of structural racial problems. But these problems are directly related to the goal of this grant program and we should not exclude the possibility of funding grants that make positive change simply because it won’t solve the entire problem.

Arguments Against:

Bottom Line:

  • These are massive systemic issues that cannot be solved by a small grant program
  • The grant program exists to attack other problems, namely prevention and early detection of the three main killer diseases and this focus should not be shunted aside

In Further Detail: A little grant program is not going to do much to solve systematic racial problems in housing, education, employment, and community. This is quite literally a list of some of the biggest structural problems in our country. So we may be better off using this grant program to attack the medical side of the problem and continuing to try to attack all of these other large problems at the scale that is required. Focus is always important for grant programs and we want to ensure that the prime purpose of this program: to drive prevention and early detection of the three main killer diseases, is not shunted aside.

How Should Your Representatives Vote on SB21-181

SB21-187 Dialysis Treatment Transportation Funding (Danielson (D)) [Jackson (D)]

KILLED BY BILL SPONSORS

Appropriation: None
Fiscal Impact: Net loss of $1.1 million a year at full implementation

Goal:

  • Create a dialysis treatment transportation provider reimbursement program to provide mileage reimbursement to a provider that transports a patient over 50 years old that is not eligible for Medicaid to or from a treatment clinic. State to determine reimbursement rate, which must equal or exceed the Medicaid rate
  • Money for reimbursement is to come from a fee on each for-profit dialysis clinic in the state. Fee to be set by state and is not to exceed 15% of the per-treatment Medicaid reimbursement rate in the previous year. State is to examine fee balance each year and if it is not sufficient to cover reimbursements, then it can raise the rate above 15% to reach the amount required (can be done retroactively)

Description:

Any non-medical transport is eligible for the reimbursement, including family and friends. Non family and friends providers must submit a monthly mileage report to the state.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Many dialysis patients need treatment three days a week, which presents an enormous burden on getting to and from the clinic and transport must be booked in advance, so if it fills up, patients are left with few good, easy options
  • Missing an appointment is life threatening, so the bill provides a way to get the sort of reimbursement Medicaid patients can access for non-Medicaid patients to bridge this transportation gap

Arguments Against:

Bottom Line:

  • The bill is a little unclear, it appears to on the one hand provide reimbursement to family and friends (which we should not be doing) but on the other hand not provide a mechanism for them to get reimbursed and only want to reimburse other non-medical transports
  • The bill provides for a mechanism to increase fees if there is not enough money coming in but no mechanism to lower fees if too much is coming in

How Should Your Representatives Vote on SB21-187

SB21-193 Protection Of Pregnant People In Perinatal Period (Buckner (D)) [Herod (D)]

PASSED

AMENDED: Minor

Appropriation: $198,998
Fiscal Impact: About $240,000 a year

Goal:

  • Require all correctional facilities to be prepared to offer care to women who are pregnant, including training staff to ensure the pregnant person receives safe and respectful treatment, that the facility’s policies are trauma-informed and integrated with current best practices, that each woman is provided access to necessary providers, supplies, food, and education, and that efforts are made to help women transitioning out of corrections during pregnancy or post-partum. Must also keep the newborn with the woman unless the parent or legal guardian consents to a medical treatment or the newborn is released to a legal guardian
  • Require all health care facilities that provide childbirth services to allow every woman to have a companion or doula along with their partner or spouse in the birthing room, to allow newborns to remain with their families, to allow physiologic birth (essentially natural birth with no interventions) and not interrupt that process without consent, and to accept transfers from home births or birthing centers without discrimination.
  • Allow the state civil rights division to receive and investigate (and punish) allegations of mistreatment during maternity care, birth, or post-partum care that is not culturally congruent; does not maintain the person’s dignity, privacy, and confidentiality; does not ensure freedom from harm and mistreatment; or does not enable informed choices and continuous support
  • Bill also repeals a law that invalidates a pregnant woman’s advance directives so long as they are carrying a viable fetus.

Description:

Bill also extends the civil statute of limitations on allegations of lack of informed consent related to pregnancy regarding health care providers or facilities from two to three years, and requires medical malpractice insurers to cover providers for care during the entire course of a person’s vaginal birth after a previous caesarian birth. In other words, if a woman needs a caesarian and then in a subsequent pregnancy has a vaginal birth, the doctor is covered by malpractice insurance (vaginal births after a previous caesarian can be more risky under certain circumstances, under others they are actually safer than a repeat caesarian).

Bill requires annual reporting to the legislature from prisons on: use of restraints against pregnant women and women giving birth (already required to be documented) and number of births by women in custody of the facility in the previous year.

The precise things prisons must provide to pregnant women, to expand on what was stated in the Goals section, are: perinatal health care providers with perinatal experience, healthy foods and nutritional counseling, menstrual products, breast pumps, counseling and treatment for women with a diagnosed behavioral or mental health disorder, trauma or violence in their past including sexual abuse, HIV, loss of a previous pregnancy or infant, or chronic conditions, and pregnancy and childbirth education, parenting support, and other relevant health literacy. Must also provide educational materials for pregnant women who have suffered from trauma or violence, sexual abuse, or loss of a child or pregnancy. Postpartum the facilities must offer opportunities for maintaining contact with the newborn for the mother including enhanced visitation policies, access to facility nursing programs, and breastfeeding support. For women transitioning out of corrections, must transfer health records to community providers, connect the woman to community-based resources, including health care providers, substance use disorder treatment (as necessary), and social services that address social determinants of maternal health. To help facilitate that, prisons must establish partnerships with local public entities, private community entities, community-based organizations, and Native American tribes and tribal organizations.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We have a clear problem with pregnant women in our prisons, pre-COVID we went three years in a row with at least one horrible incident involving a birth in a prison. Women in prison are also at higher risk than the general population. All the bill does is lay out basic standards of care that any woman should receive and address potential coordination of care concerns post-release
  • Restraints are bad for pregnant women and we need to have a clearer understanding of how often they are being used
  • Doulas can be a critical aspect of a successful birth and we must ensure that any woman who wants one doesn’t have to choose between a spouse and a doula (as some facility’s current COVID restrictions require)
  • We continue to have issues with birth interventions being done contrary to women’s planned wishes, as doctors steamroll them for reasons not related to health or safety. And any birth planned outside the hospital needs the hospital as a backup in case of complications
  • The violations listed in the bill for the civil rights division to investigate are certainly violations of civil rights. Plus, we have serious racial disparities in maternal and infant care centered around Black women and infants
  • Advanced medical directives are someone’s wishes if they are in a certain medical states. They are not entered into lightly and are about our basic control over our own bodies and lives when we can no longer make decisions for ourselves. The presence of a fetus should not change that equation. Women’s bodies are not incubators

In Further Detail: The need for stronger legislative requirements for prisons is clear. In 2019 a woman in jail in La Plata County for missing court in a traffic violation case (she couldn’t pay the bond to get out while awaiting her hearing) ended up losing her baby, internal reproductive organs, and having multiple emergency surgeries due to improper medical care at the jail. In 2018 a woman gave birth alone her in her cell in prison in Denver. In 2017 a woman gave birth in a toilet in prison in El Paso County. Women in prison are also more vulnerable than the general population to complications arising from substance use, poor nutrition, and sexually-transmitted infections. All the bill does is require correctional facilities to provide the basic care any pregnant woman should receive and address potential coordination of care problems after release. The use of restraints on pregnant women has serious health impacts: increased pain, inhibited diagnosis of complications, and limited movement. Our current requirement for detailed documentation whenever such a restraint occurs is good, but without the reporting this bill requires it is hard to see the bigger picture. For the wider part of the bill dealing with health care facilities, during COVID many facilities have limited the number of people who can be in the room to just one, depriving women of a doula and their spouse. And we have an on-going problem with interventions in the birth process that are not necessary for health or safety. The bill simply requires consent, as we do more all medical procedures. For women who chose to do a home or birthing center birth, part of that choice is the knowledge that if something goes wrong, they have the hospital as a backup. For the civil rights angle of this, unfortunately we still have racial disparities in maternal and infant mortality. In Colorado, Black children infant mortality is roughly twice that of all other races (which are mostly similar): 8.1 per 1,000 births vs. 4.4 for whites (who are the lowest, next highest after Blacks is 4.8). For the United States as a whole (and there is no reason to think Colorado is any different), Black women maternal mortality rates are between three and four times higher than non-Hispanic whites (40 per 100,000 or 0.4 per 1,000 births vs. 12.4 or .124). This is of course part of a larger pattern across medicine, but it is absolutely a civil rights violation to not be treated properly during your pregnancy, birth, or post-partum period, regardless of race. The bill’s directives here are clear and simple and the civil rights division is more than capable of handling frivolous complaints. An advanced medical directive is a legal document that is about our basic control over our own bodies when we lose the ability to make those decisions ourselves. They are not entered into lightly and the basic facts do not change because of the presence of a fetus. Women are not incubators for babies. Remember that advanced medical directives are not set in stone, they can be changed at any time, including by a pregnant woman.

Arguments Against:

Bottom Line:

  • This goes too far in tying the hands of hospitals, who may not be equipped to fully provide a physiologic birth and may disagree with the mother about the health and safety of the evolving birth. If people want the full physiologic experience, there are options for that outside of hospitals. If that is not possible because of risk, then the physiologic experience cannot happen. Birth remains incredibly dangerous but modern medicine has made it much less so
  • The civil rights division is not the appropriate venue for problems with medical care—that is the department of regulatory agencies which oversees the practitioner or facility’s license and civil courts in cases of damages. The bill also provides wide language subject to different interpretation
  • A viable fetus greatly changes the equation of advanced medical directives because it can be possible to save the life of that fetus by prolonging the life of the mother, who may not have thought to change her advanced medical directives when she became pregnant

In Further Detail: The exclusion against interference with physiologic birth without consent leaves out health and safety concerns and requires hospitals to allow birth in non-supine positions which it may not be equipped to do. People don’t get to have it both ways, if you want the aid of modern medicine and a doctor in a hospital setting then you get the hospital policies (which of course include consent). If you want a true physiologic birth then you do a home birth or go to a birthing center. If you were at one of those and had to be transferred to a hospital, then unfortunately physiologic birth is out the window. Giving birth remains an incredibly dangerous activity, even with modern medicine, but in cases where medical interventions are needed, we need to do them. The civil rights division is not the appropriate venue for problems with the medical treatment someone has received. That is the purview of the division of regulatory agencies and the provider’s license and civil courts in cases with damages. If we are talking about an unlicensed individual, then we have to bring in consumer choice here rather than let anyone who is dissatisfied with the care they received bring a civil rights complaint. There can be a lot of indignity and lack of privacy in the process of giving birth just through normal procedures. Some cultural practices may in fact be more dangerous for the health of the mother or the baby. Leave the civil rights division out of it. For the advanced medical directives, a viable fetus most certainly changes the equation. This is a life that could be saved if the mother is kept alive longer, not permanently just long enough to save the fetus. And not all women will think to change their advanced medical directives once they become pregnant, so the directive may not even still reflect the wishes of the woman. We should keep that law as it is.

How Should Your Representatives Vote on SB21-193

SB21-194 Maternal Health Providers (Buckner (D)) [Herod (D)]

PASSED

AMENDED: Minor

Appropriation: None
Fiscal Impact: About $9 million in state funds per year at full implementation

Goal:

  • Require all insurance companies that cover maternal care and labor, as well as Medicaid, to not discriminate against providers based on the type of provider or facility so long as they promote high-quality, cost-effective care and prevent risk in subsequent pregnancies. In effect, this forces insurers to cover out-of-hospital births unless the insurer can prove it is unsafe or overly expensive
  • Require the state to ask the federal government for a waiver for Medicaid to extend post-partum coverage of eligible women and infants from 60 days to 1 year

Description:

Requires existing maternal mortality review board to specifically consult with multi-disciplinary non-profit and community-based organizations that serve pregnancy/post-partum population with specific emphasis on people from racial and ethnic minority backgrounds. In addition to its already existing tasks, the bill also requires the board to make recommendations on improving collection and public reporting of maternal health data from hospitals, health systems, midwifery practices, and birthing centers, including data on race/ethnicity and disability, uptake of training on bias and discrimination, and incidents of disrespect of pregnant women. This should include collecting stories from women, again with a focus on racial and ethnic minority groups.

Also requires the existing health equity commission maternal mortality review commission to study the use of research evidence in polices related to the perinatal period and report to the legislature on that topic by September 2023.

Finally, the bill requires that the state registrar’s birth certificate worksheet include a place to report where the pregnant person intended to give birth when labor started.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Our hospitals are overly fond of medical intervention during birth even when it is not required for health or safety, so some would rather give birth outside a hospital naturally—of course with the proper safety measures in place and transport to a hospital if required
  • The data may be mixed but the biggest study of home births even done showed they were just as safe as hospital births
  • Racial disparities in maternal and infant death are likely in part due to doctors and nurses refusing to fully credit self-reported symptoms from Black women, making home birth or birthing centers an attractive alternative (again when safe)
  • But since these are not covered by insurance they are prohibitively expensive for all but the wealthiest Americans
  • For expanding Medicaid, 60 days just does not cover the actual post-partum time so some women and their infant lose health coverage while they still need it. 1/3 of maternal deaths occur post-partum and in particular, research indicates that a chunk of this is due to medical conditions that disproportionately affect women of color. Increasing Medicaid post-partum coverage may help reduce the maternal mortality gap
  • Birth certificates right now don’t list the start point for labor, which means it is much harder to track home births and those in birth centers

In Further Detail: We still are overly fond of medical intervention in birth, even when unnecessary, in U.S. hospitals. Our c-section rate of 30%, for instance, is twice as high as the recommended rate from the World Health Organization, while home births only result in c-section about 5% of the time. Birth is a physiological process and the more at ease the woman is, the better things are likely to go. That is much easier outside a hospital. Now, of course we must require certain safeguards and we already do under Colorado law. Women must be transported to a hospital if the medical need arises and only low-risk pregnancies can use birthing centers (or be attended by licensed midwives, if we are talking about unlicensed behavior that no insurance company would cover it anyway). The data on this, as Arguments Against will go into detail on, is mixed but a massive survey of nearly 17,000 home births from 2004 to 2009 published in 2014 showed home births were just as safe as hospital births. Part of this bill fixes the problem with birth certificates not recording where the birth began, which skews hospital statistics against home birth. And this choice is absolutely not for everyone, but it should be an actual choice. Right now, unless you are wealthy, it isn’t. Most insurers will not cover care in a birthing center and certainly will not pay for a licensed midwife to do a home birth. So a woman wanting to go that route must pay all of it, thousands of dollars, out of her own pocket. You can see this in the data: 99% of births (pre-COVID) still occurred in hospitals. That means births outside hospitals are truly only available to those with means, and because of the structure of our society, means communities of color mostly are left out. And this is where it is important to bring in the Black experience. In Colorado, Black children infant mortality is roughly twice that of all other races (which are mostly similar): 8.1 per 1,000 births vs. 4.4 for whites (who are the lowest, next highest after Blacks is 4.8). For the United States as a whole (and there is no reason to think Colorado is any different), Black women maternal mortality rates are between three and four times higher than non-Hispanic whites (40 per 100,000 or 0.4 per 1,000 births vs. 12.4 or .124). For Black women, doctors and nurses who don’t believe their self-reported symptoms may in fact not be an improvement over a birthing center or a home birth. So this barrier is not just about women wanting to feel more comfortable or not use a hospital (and many hospitals have birth settings that are decidedly unhospital-like), it is about having the person delivering your baby be someone you can trust will believe you and help you. And let’s also be clear: this is frequently going to be less expensive for the insurance company than a hospital birth, due to the lower number of medical interventions. On expanding Medicaid, this is part of a nationwide push that understands that two months does not begin to adequately describe the true postpartum period. Even in Colorado, where we have expanded Medicaid coverage thanks to the Affordable Care Act, there are still gaps where our current law means that a women and her infant lose medical insurance at 60 days. One third of maternal deaths occur post-partum and research has indicated that a disproportionate number of these are women of color, specifically due to medical conditions that are more likely to occur among women of color. That may account for some of the higher maternal mortality statistics. Mental health and post-partum depression may of course occur long after 60 days. Multiple other states are seeking this same waiver, we should do the same.

Arguments Against:

Bottom Line:

  • Birth is dangerous and modern medicine at hospitals makes it less so. The data on home births/birthing centers is conflicting and there is no good unbiased data on safety versus hospitals. So we need to fall back on common sense: it can be hard to know in advance when complications are going to occur and having immediate access to emergency care can save lives
  • We therefore should not be encouraging births outside of the hospital setting by forcing insurers to cover it
  • The solution to the racial problems in our health care system is not to push people outside the health care system

In Further Detail: In many walks of life we forget how things used to be before modern technology. Medicine is no different, and giving birth in particular has become prone to over-romanticization of a past that never really existed. In 1900, when almost all childbirth took place at home, the infant mortality rate was 100 in every 1,000. Today it is 5.9. This is of course not to say that every birth needs a hospital, but the problem is that we are assuming too much knowledge that we may not have in every case, so that if something surprising does occur, instead of being in a hospital surrounded by trained medical professionals you are at best minutes away and worst tens of minutes away (or even longer) from emergency care. The American College of Obstetricians and Gynecologists recommends all births be done in a hospital and they believe the data shows home births result in higher infant mortality. The American Academy of Pediatrics just released a guide for COVID home birth (since there was a surge of understandable interest) which stated their belief that home birth raised the risk of infant mortality by 1 or 2 deaths per 1,000 births. There quite honestly is no good unbiased data on this subject (one thing this bill is trying to remedy)—home birth advocates say that data is only based on hospital birth certificates, so it is only pulling in the home births that resulted in a trip to the hospital. Those advocates say their data show home birth is just as safe as hospital birth. Remember that in most cases hospitals will have all of the known high-risk pregnancies to begin with. So when we have conflicting or uncertain data like this (both parties are biased and both have flaws in their data), it is sometimes best to fall back on common sense. Child birth is extremely dangerous and many things can go wrong, and sometimes unexpectedly. We still, in modern America, at best lose 12 women out of every 100,000 who give birth and 4 infants out of every 100 (the white women statistics, obviously we have racial disparities the bill attempts to help address). That is with 99% of births occurring in hospitals. Under the best circumstances, births outside hospitals are fine, but the same is true of births in hospitals. It’s the bad cases that are worrying and it is for that reason that we should not be extending insurance coverage to these practices to make them more accessible. The solution to our race problem in health care is not in pushing people out of modern medicine. It is solving the race problem in our health care system.

How Should Your Representatives Vote on SB21-194

SB21-195 Notarization Of Certain Probate Documents (Story (D)) [Snyder (D), Soper (R)]

SIGNED INTO LAW

Appropriation: None
Fiscal Impact: None

Goal:

  • Currently any advanced medical directives must be signed in front of two witnesses. The bill adds that a notary public or any other individual authorized by law is also acceptable. Bill extends the same notary or other authorized individual to the requirement for witnesses the signature of someone signing on behalf of a person physically unable to sign a donor card for organ donation

Description:

Bill extends the prohibition on the witnesses being an attending physician or employee of the facility in which the individual is a patient or anyone who has a claim or believes they will on the estate of the individual to notary public or other authorized individuals.

Additional Information: n/a

Auto-Renew: n/a

Arguments For:

Bottom Line:

  • These are really serious medical and life decisions and that is why we require extra scrutiny on such documents but a notary public is a perfect witness and trusted by the state to attest to documents all the time. The bill ensures this person will not benefit from the individual’s death

Arguments Against:

Bottom Line:

  • Having two people insures no one person is exerting undue influence on an individual, which can happen even absent direct financial gain. Parts of this law require a disinterested witness, perhaps we should require a disinterested notary

How Should Your Representatives Vote on SB21-195

SB21-214 State Payment Hospice Providers Residential Care (Hansen (D)) [McCluskie (D)]

Note: This bill is part of the overall budget package

From the Joint Budget Committee

SIGNED INTO LAW

Appropriation: $684,000
Fiscal Impact: None beyond appropriation

Goal:

Allow nursing facility providers who cannot provide a bed for hospice care for their patients and instead must use other facilities that don’t ordinarily get Medicaid reimbursement to get some reimbursement from the state for the next year.

Description:

Allows nursing facility providers to get some state reimbursement for Medicaid patients who have a hospice diagnosis but cannot secure a nursing facility bed due to COVID impacts, complexity of medical care, behavioral health issues, or other issues as determined by state and are instead provided services in some other place, like hospice residential beds. Payment limited to 28 days per patient and is ½ of the statewide per diem average for nursing facilities. Bill provides $684,000 for these payments.

In this situation providers can still get federal reimbursement through Medicare.

Additional Information: n/a

Auto-Repeal: July 2022

Arguments For:

Bottom Line:

  • It has been understandably difficult to get nursing care facility beds during COVID, so some hospice patients have been shifted to locations where the nursing facility can’t get reimbursed for room and board expenses and have had to eat them instead. This bill allows for some reimbursement while the crisis lasts.

Arguments Against: n/a

How Should Your Representatives Vote on SB21-214

SB21-239 2-1-1 Statewide Human Services Referral System (Kolker (D), Zenzinger (D)) [Amabile (D), Van Beber (R)]

*State stimulus bill, less than 1% of overall stimulus funds spent in this bill*

PASSED

AMENDED: Minor

Appropriation: $1 million
Fiscal Impact: None beyond appropriation

Goal:

Expand the 2-1-1 information program to include behavioral health referrals. Market this expansion to people in the state, particularly those in underrepresented communities, and market the 2-1-1 program to the unemployed. Give the program $1 million in state stimulus money to do all of this.

Description:

Expand the existing state 211 program to include referrals for behavioral health services and assistance for other referrals (the bill specifically mentions housing and food). This involves the office of behavioral health contracting with 211 to ensure specialized personnel are hired, trained, and can assist people who call the number to access necessary referrals. This must include bilingual or multilingual speakers to ensure traditionally underrepresented communities can use the service.

Bill appropriates $1 million to achieve this program and to a marketing program the bill requires the office of behavioral health to collaborate with the 211 program on targeted outreach to communities, particularly traditionally underserved communities such as immigrant communities, low-income communities, and communities of color. State to also run targeted digital ads as part of this program. State must report to legislature by January 30, 2023 2022, on this entire program.

211 program also to work with department of labor and employment to target, conduct outreach and market to people who are unemployed. This is to be in the form of an e-mail and text campaign and updated website materials.

2-1-1 is an existing program that allows access via text, chat, and e-mail as well as phone and it has a website that displays its database of resources. It has trained individuals to respond and claims statewide coverage.

Program extension repeals July 2023 2022

Additional Information: n/a

Auto-Repeal: July 2022

Arguments For:

Bottom Line:

  • 2-1-1 is a very successful program run by non-profits throughout the state. It has a database of more than 8,000 services supported by more than 2,800 agencies. But one of these services is not behavioral health care (there are a lot of other health care resources already available). It makes sense to extend 2-1-1’s capabilities in this manner, in particular with the increased behavioral health needs of the state due to the pandemic. Of course if you are going to create a new center of information like this you need to make sure people are aware of it, thus the marketing money. And it needs to be funded to work, thus the appropriation. 2-1-1 is a treasure-trove of resources for the state and should be supported

Arguments Against:

Bottom Line:

  • 2-1-1 is great but it is not funded adequately at the moment (it has a big donate button on the website). It is not officially in state law and has no state funding streams. There was an attempt last year to provide more permanent funding that did not succeed. It should be revisited

How Should Your Representatives Vote on SB21-239

SB21-243 Colorado Department Of Public Health And Environment Appropriation Public Health Infrastructure (Moreno (D)) [McCluskie (D)]

PASSED

Appropriation: $63.3 million over the next three years, $21.1 of which is federal stimulus money
Fiscal Impact: None beyond appropriation

Goal:

Spend $21.1 million each year for the next three years on local public health agencies and the state’s disease control division. This year's appopriation is federal stimulus money ($21.1 million).

Description:

Appropriates $10 million for this year, next year and the year after to distribute to local public health agencies and $11 million in all of those years for use by the division of disease control and public health response. So $63.3 million in all.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • This is pretty simple: COVID is going to be with us for some time. We don’t know exactly what the situation is going to be with booster shots of the vaccine but we are pretty sure they are going to be necessary. We still have large swaths of the population to vaccinate. We are going to have people who refuse to get vaccinated and then get COVID and need treatment. We are then going to have to do it all over again, and then probably again. So we will need all of this money.

Arguments Against:

Bottom Line:

  • It’s a bit technical but the issue here isn’t necessarily the money, it’s that we aren’t in essence using our stimulus windfall this year to pay for it. The money in this year’s budget, maybe depending on how you add it all up. But the money spent next year and the year after will come from the budgets of those two years, which means they are not coming from our one-time stimulus this year. The bill could have been structured instead to use all money from this year but prevent parts of it from being spent until next year and then the year after

How Should Your Representatives Vote on SB21-243

SB21-255 Free Menstrual Hygiene Products To Students (Winter (D)) [Herod (D), Titone (D)]

PASSED

AMENDED: Minor

Appropriation: $100,000
Fiscal Impact: None beyond appropriation

Goal:

Create a grant program to help schools provide menstrual hygiene products at no expense to students, with only schools with a majority of students eligible for free or reduced lunch eligible.

Description:

Creates the Menstrual Hygiene Products Accessibility Grant Program to provide menstrual hygiene products at no expense to students. Grantees can use funds for acquisition and distribution of menstrual hygiene products or installation and maintenance of a dispensing machine or disposal receptacle. To be eligible for the program, a school must have 50% or more of its students eligible for reduced or free lunch or be the school for the deaf and blind. Applicants must include the total number of restrooms, including gender-neutral restrooms, on its property. Grants are to be awarded proportionately based on number of students and restrooms at a school. Grantees must report to the state how they used the money and the state must report to the legislature. Program is not appropriated any money.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • Menstrual products are a fundamental health need and poor hygiene can lead to multiple serious negative health outcomes but many schools do not provide these products to students free of charge
  • The extent to which schools do have these in the nurse’s office it is not always easily accessible and students are sometimes embarrassed to ask. A recent survey found nearly one in five girls have either left school early or missed school entirely because they did not have access to menstrual products
  • We provide toilet paper for students, menstrual hygiene products fall into the same category

In Further Detail: Menstrual products are a fundamental health right and need for many students in our schools. Poor menstrual hygiene can lead to negative health outcomes, including serious infections, toxic shock syndrome, and other abnormalities. And yet many of our schools do not provide these products free of charge to students. And while it is true that all schools do have menstrual products in the nurse’s office, they are not always easily accessible and sometimes students are too embarrassed to ask for them. And frankly, some students come from extreme poverty and struggle to afford these products. A recent survey found that nearly one in five girls have either left school early or missed school entirely because they did not have access to menstrual products. We provide toilet paper, apparently that doesn’t rise to the level of personal responsibility for those who think that this burden should fall entirely on the parents and students. As for the gender-neutral restroom part of the application, this is pretty simple. Students who identify as male but still have female sexual organs and thus need menstrual hygiene products should not be forced to use a girls’ restroom in order to access the products. That would not only force these students to use the wrong bathroom, it would potentially invite ridicule from other students. So a school that does not provide appropriate restrooms to all of its students is failing a portion of them. And this is no state mandate. It is simply a grant program for those who want it. Those who don’t are free not to apply.

Arguments Against:

Bottom Line:

  • No one disputes that menstrual products are a fundamental health need. But it is not the responsibility of our schools to provide all fundamental needs to our kids. Providing menstrual products is the responsibility of the parents, and in cases of an emergency, we have the nurses as a back-up. If individual schools or districts feel differently, it is of course their prerogative, but we shouldn’t spend any state resources on this

Bottom Line:

  • The friendliness of schools to transgender students should not be a prioritization for factor for schools that want to provide these products. It conflates one issue, providing more access to menstrual products in schools, with another, bathroom policies for students

Bottom Line:

  • This bill doesn’t provide any funding for the program, it is left to the devices of the appropriations process. Four states also have laws requiring schools provide menstrual hygiene products. We should too

How Should Your Representatives Vote on SB21-255

SB21-278 Reimbursement For Out-of-home Placement Services (Moreno (D)) [Herod (D)]

From the Joint Budget Committee

PASSED

AMENDED: Minor

Appropriation: $250,000
Fiscal Impact: Likely will increase provider rates, which will cost the state more money, but that is not certain

Goal:

Analyze the number of placements needed in the state for behavioral health care at all levels outside the home and the costs required to provide it. Then develop and implement a plan to increase capacity to meet the need and change rates to fit the costs. Requires rate analysis every three years. Also provides help to providers to transition to compliance with federal family first law.

Description:

Requires the state, in conjunction with all the counties, to analyze the number of placements in out-of-home facilities for kids at each level of care. This must be done by the end of the year. Then before July 2022 the state must develop and implement a plan to increase capacity and develop appropriate and necessary out-of-home placement options for each level of care so that all kids who require care can get it in-state.

For funding, first requires the state to contract with an independent vendor to update its actuarial analysis of the costs necessary to provide services in out-of-home placements (this includes division of youth services). This must be done by September. Then the state must implement adjusted rates so as to comply with federal law (family first act) and the revised analysis. Then in 2022-23 the state must again contract with a vendor to update cost analysis, and then again every three years into the future. State must submit a report to the legislature on these updates each year after it is done. The bill also authorizes counties to negotiate higher rates with providers who serve kids with higher service needs. The counties would have to pay this extra amount themselves.

The bill also requires the state, for the next two years, to assist residential treatment providers to transition to a business model that qualifies them for reimbursement under federal law (this is needed to comply with the family first law, which made a lot of changes). Assistance comes from at least 15% of the funding the state was given by the federal government to support this transition. Grants must be available by September and can be awarded until January 2023.

The bill also makes some changes to conform with the family first law.

Requires the state to convene a working group of diverse partners and stakeholders to analyze the collection of fees for residential care of kids in out-of-home placements who are not there due to a finding of dependence or neglect. Group must ensure any recommendations comply with federal law. Must submit to the state by April 2022.

Additional Information: n/a

Auto-Repeal: n/a

Arguments For:

Bottom Line:

  • We simply don’t pay our providers enough right now to care for kids. Recent reporting by 9News and the Colorado Sun found disturbing instances occurring in these facilities and a common theme was that they simply lacked the money to do everything they needed to (including pay employees enough). Many facilities resort to large-scale charitable fundraising just to make ends meet
  • So the bill provides us a chance to get serious about funding these facilities at the right amounts
  • The rest is about conforming to the federal family first law, which is a tough transition for many facilities to make, so much so that the federal government has provided money to help. The bill spends some of that money

In Further Detail: This is another case of the state not being able to provide adequate behavioral health care for kids right now. Because we don’t have enough capacity in residential treatment facilities, kids get shipped out-of-state. Because we don’t pay the treatment facility providers we do have enough money, kids’ care suffer and they are actually in more danger. A recent report by 9News and the Colorado Sun found disturbing instances occurring in just about all the major treatment facilities in the state the common theme was pretty simple: lack of resources leads to lack of ability for these facilities to provide the care we expect, including paying good enough wages to keep staff. Many of them have to raise significant amounts of money via charity in order to just stay open. Things like adequate fencing are beyond the capability of some of the large facilities to build because of the cost involved. So we need to get serious about actually funding the care of these kids. The rest of the bill is simply about conforming to federal law, which is critical in order to continue to receive federal funding. The family first transition is not an easy one for many providers, as the requirements are tougher to meet. So the federal government provided the states with money to help providers make the transition. The bill spends part of that money

Arguments Against:

Bottom Line:

  • It is not at all clear the bill is committing to making the large scale reimbursement changes necessary to make the changes we need in the system. If we want to demand changes in rates that meet actual need, we need to be a lot more specific
  • We also are going to need long-term sources of revenue to fund any larger changes, stimulus money will be gone in a few years and we have to make the budget work. An enterprise (which would be exempt from TABOR limits) with a fee collected off hospitals (who would benefit from fewer kids needing emergency care) seems tailor-made to solve this and other behavioral health problems in the state

In Further Detail: There is no guarantee we are going to get much out of this analysis because it is given almost no required parameters other than “cost” which can be defined to mean a lot of different things. So the actuarial analysis is vague, the muscle behind increasing capacity is undefined, and the result may be some tinkering around the edges. Real changes will require being a lot more specific: how competitive do we need wages to be? What sort of money needs to be available for capital improvements like fencing? We are also going to need long-term sources of revenue to fund any larger changes. We have tons of money right now thanks to state and federal stimulus but that will be gone in a few years. Then we have to balance the budget with regular revenues, which were insufficient to the task in the past. An enterprise (which would exempt from TABOR and thus not trigger taxpayer refunds) funded by a fee on hospitals (who benefit from fewer emergency cases) seems like the perfect solution to many of our behavioral health care problems which nearly all boil down to not enough money.