Colorado has been active in health initiatives over the past handful of years, serving as a laboratory for public health policies the rest of the country is closely watching.
While other states certainly pursue public health initiatives, Colorado is tackling some of the least conventional, but big, issues. These include marijuana legalization, women's reproductive health and single payer healthcare. Larry Wolk, MD, executive director and CMO of the Colorado Department of Public Health and Environment, says part of this has to do with Colorado's status as a swing state. "We have a lot of influences being a diverse state, a purple state," Dr. Wolk says.
The state's governance often switches between red and blue hands. A 2014 New York Times report examining Colorado's political leanings says they have "tilted back and forth in surprising ways since it became a state in 1876, sometimes marching in lock step with Republican ranching and mining magnates, and other times bolting to support populists or so-called Silver Republicans who detested the once-dominant gold standard."
Ted Trimpa, principal and CEO of national political consulting firm Trimpa Group, told NYT in that article, "This is very much an independent state, and more and more reflects where people in the rest of the country are."
Here's what has been happening in Colorado in the past few years. Time will tell if other states build off of this work.
Legalizing marijuana
In 2000, Colorado was one of the first states to legalize medical marijuana, and in 2012 it was one of the first two states (alongside Washington) to legalize marijuana for recreational use. Currently, 24 states and the District of Columbia permit marijuana for medical purposes, and four states and D.C. allow recreational use.
Coloradans still have mixed opinions about the legalization of marijuana. Proponents underscore how regulation of the drug helps eliminate tainted strains, and they point to the $70 million in tax revenues the state collected in the fiscal year ending June 30, 2015, as a financial benefit. For reference, Colorado collected $42 million from alcohol taxes during that same time period, according to TIME.
Opponents are concerned legalization may increase access to and use of the drug, particularly by those under the age of 21. Additionally, people are concerned legalization may increase the risk of impaired driving. The Colorado State Patrol reported in 2014 approximately 12 percent of 5,500 citations issued for driving under the influence of drugs or alcohol involved suspected marijuana use, either alone or with other intoxicants, according to The Denver Post. Officials can't yet say if this is an increase from prior years, as 2014 was the first year the state started tracking marijuana DUIs.
Although the legalization of marijuana remains controversial, the issue is popping up on ballots nationwide and even finding its way to the 2016 presidential campaign as a hot topic. Dr. Wolk says Colorado is "writing the manual" for other states in terms of public education campaigns, lab testing and overall surveillance related to legalizing marijuana.
"Being first unfortunately, or fortunately, means we get to find all the issues and problems and try to develop appropriate regulations and policy so we have responsible programs that other states can potentially choose to follow," Dr. Wolk says.
Long-acting reversible contraceptives
In 2009, Colorado launched the Colorado Family Planning Initiative, a public health program providing free or low-cost long-acting reversible contraceptives — intrauterine devices and hormonal implants — to teenagers and poor women across the state. The program was privately funded by a $23 million donation from the Susan Thompson Buffett Foundation, and the state used the money to train healthcare professionals and provide contraceptive devices in 65 state- and federally subsidized health clinics for low-income women.
In the five years following the launch of this program, Colorado's teenage birth rate and the rate of abortions fell 48 percent. Additionally, women in the poorer areas of Colorado began having children later: In 2009, half of these women gave birth to their first child by age 21, but by 2014, half of these first births didn't occur until the women were 24. Researchers say those few years give women more time to complete their education.
Dr. Wolk says Colorado's increased access to birth control also significantly decreased government costs on public assistance programs like Medicaid and the Colorado Special Supplemental Nutrition Program for Women, Infants, and Children, which provides free nutrition and health support for qualifying families.
Now, however, the initial $23 million donation for the Colorado Family Planning Initiative has run out, and the state is trying to find additional funding to keep the project afloat. In March 2015, lawmakers rejected a $5 million allocation in the budget to continue funding the program, according to the Wall Street Journal. In August, more than a dozen organizations pledged $2 million in temporary funding for the program.
Dr. Wolk says the LARC program is an example of a public health program that should gain public funding, especially given the demonstrated return on investment and public program savings. "We no longer should rely on private money to fund LARC. [Funding] should come through public and private insurance or general fund dollars because the return on investment has been demonstrated by our work over the past five years," he says.
Whether that happens remain to be seen, but the success of the contraceptive program and the potential to save significant government funds presents a strong opportunity for other states. "It makes perfect sense to build off of that experience and see what's worked and where the gaps continue to be so other states can follow suit," Dr. Wolk says.
Universal healthcare
Universal healthcare will be on Colorado's ballot in 2016, making it the second state to seriously consider the idea of a single payer system. If passed, the rest of the country will have to wait to see if the state can develop and implement a health insurance infrastructure that survives longer than Vermont's, which never made it past the planning stages.
Vermont passed a bill in 2011 establishing a publicly financed, single payer system, but in December 2014, Gov. Peter Shumlin's (D) financial analysis of the proposed program showed it would cost $4.3 billion in its first year in 2017, which would essentially double the state's $4.9 billion budget for the fiscal year 2015, according to The Boston Globe.
Now it's Colorado's turn to see how the proposal, called ColoradoCare, plays out. Politico suggests the dynamics in Colorado are different enough than in Vermont. For example, residents are voting on ColoradoCare via ballot instead of lawmakers moving a bill through legislation.
The proposed single payer system would rely on a 10 percent payroll tax to raise $25 billion a year to cover costs. Of that 10 percent tax, employers would pay two-thirds of it and and employees would pay one-third, according to The Denver Post.
Dr. Wolk says state administrators do not support a single payer system "because it flies in the face of the free markets" and also works in opposition to other health policies Colorado has adopted, especially as a state that expanded Medicaid and set up exchanges under the ACA. The state's uninsured rate fell from 15.8 percent in 2011 ago to 6.7 percent in 2015. "Having Medicaid expansion in our own state and a specific health insurance exchange…have been very successful in reducing the amount of uninsured and providing expansion in both public and private insurance," Dr. Wolk says.
Proponents of a single payer system say it would create annual surpluses of approximately $2 billion from reducing administrative costs from payers and physician offices, reports The Associated Press. Opponents see it as an overextension of government and are concerned about its effects on the state budget, like what happened in Vermont.
ColoradoCare would rely on the State Innovation Waivers established in the ACA that permit states to develop their own healthcare reforms if they cover the same number of people with benefits comparable to those provided by the ACA and as long as the changes exercise fiscal constraints and do not add to the federal deficit. The five-year waiver requires approval from the federal government and wouldn't take effect until 2017. Supporters of ColoradoCare are hoping for a January 2019 start date, Politico reports.
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