Amendment 35 and Health Care Reform

Looking both ways:

The past and future for Amendment 35 for disease prevention in Colorado.

 Tim Byers, MD, MPH

Associate Dean for Public Health Practice,

Colorado School of Public Health

  Why this paper?

On September 16, 2010, about 120 people met at a Denver hotel for a day-long look at how Amendment 35 investments might work in synergy with health care reform activities.  The notes and presentations from that meeting, “The Amendment 35 and Health Care Symposium”, are available.  Use this link to view symposium notes [pdf] and this link to view the National Conference of State Legislatures presentation [pdf]. 

This is more of an op-ed than an academic white paper.  Building on ideas that emerged from the symposium, I am writing to elicit ideas and opinions from others on questions about the future use of Amendment 35 funds for chronic disease prevention in Colorado. 

This paper is posted here as a forum topic so that readers can post their own thoughts in response.  It is my hope that this exchange will be useful for prompting ideas and creating consensus on future opportunities for the uses of Amendment 35 funds once they are fully restored.

A brief history of Amendment 35.

There had been several unsuccessful attempts in the past to increase the Colorado excise tax on tobacco.  In 2004, a broad coalition was formed to try to increase tobacco taxes via a constitutional amendment process. That coalition succeeded in pre-specifying the uses for revenues from a new tax for uses that had broad public support (see Amendment 35 report [pdf]).  Briefly, 46% of the tax was to go to CHIP, 19% for funding community clinics, 16% for tobacco control, and 16% for a chronic disease prevention grants program.  The new tax (Constitutional Amendment 35) passed by a wide margin in all parts of Colorado.  Public support was especially strong due to the pre-specification of the uses of the new funds.

In its authorization legislation, the Colorado Legislature then designated the distribution of the funds pretty much as Amendment 35 had prescribed, with some minor modifications, including the designation of funding for the Office of Health Disparities at CDPHE and funding to expand the CDC-funded breast and cervical cancer screening program (in Colorado, called the Womens Wellness Connection, WWC). 

Between 2005 and 2008,  chronic disease prevention efforts in Colorado substantially ramped-up, with the State Tobacco Education and Prevention Partnership (STEPP) program expanding under the direction of an oversight board, and the Cancer, Cardiovascular disease and Pulmonary Disease (CCPD) program being created and managed by a Review Committee charged to disperse funds via a competitive grants program. 

Then the recession hit, and the “escape clause” provision of Amendment 35 was triggered, with the Colorado Legislature designating a fiscal emergency, enabling them to re-direct Amendment 35 funds for other purposes.  In the past 2 years, both the STEPP and CCPD programs have been operating with only about a third of the funding they had previously received. 

So that is where we are now – in a low point of Amendment 35 funding for chronic disease prevention in Colorado, and with uncertainty as to when the fiscal emergency will end.  The symposium was not intended to collectively mourn the loss of Amendment 35 funds, nor was it to critique past decisions by the STEPP or CCPD review committees.  Rather, it was to look forward to a future when Amendment 35 funding will be restored (not likely in 2011, but perhaps in 2012 or 2013) and imagine what new opportunities for synergy with health care reform we might anticipate at that time. 

Amendment 35 funds and health care reform.

Health care reform will be more than just making insurance more widely available.  Reform will also include much more emphasis on quality improvement of outcomes in populations. This will open-up many new opportunities for better linkages between public health systems and clinical systems in areas such as community needs assessment, chronic disease navigation and management, and in shared roles in assurance of better outcomes for chronic disease risk factor reduction (eg, in control of tobacco, hypertension, and obesity).  Following are seven specific recommendations I offer to stimulate thought and discussion:

• Better publicize the Amendment 35 success stories now.

There is a continuing threat to Amendment 35 funds with the deepening recession in Colorado.  There is therefore concern that more cuts will come next year.  What we now need to do is to be more public about the important successes of Amendment 35 programs for preventing disease.  Concern about future health care costs with expanded access can be used as justification for prevention programs now.  We will be more successful in the legislative committee hearing rooms this winter if we more widely communicate the successes of Amendment 35 programs in tobacco control and chronic disease prevention this fall. 

•  Plan to reauthorize Amendment 35 funding when the fiscal emergency ends.  

When Amendment 35 funds are restored (at the end of the fiscal emergency period in Colorado, perhaps in 2011, but more likely in 2012 or 2013), one of the strategic decisions will be whether there should be a new legislative authorization process.   In its 2004 authorization legislation, the Colorado Legislature designated the distribution of the funds pretty much as Amendment 35 had prescribed, with some minor modifications.  There are pros and cons to opening-up legislative re-authorization, of course, but since Amendment 35 is pretty clear in its intent for distribution and management of funds, and since there will have been a period of about 8 years passed, a re-authorization process after the fiscal emergency passes seems to me to be the best choice. 

• Ask the STEPP and CCPD review committees to strategically plan for re-expansion when the fiscal emergency ends so that new investments can be planned in synergy with health care reform.

There was little wrong with the ways in which these two programs were developed and folded-out in 2005, but with the opportunities in health care reform,  as these programs are again unfurled in 2012 or 2013, the two oversight committees should be very strategic about how spending can be most effectively restored.  Now is the best time to develop those strategies, allowing time for broad public input.

• Create an evidence based public health workgroup in Colorado.

Both the STEPP and the CCPD programs are “evidence-based”, meaning they decide on how resources are used based on their interpretation of the evidence for effectiveness.  Both of those oversight boards have been very diligent about that and have done an excellent job in the past. There is a need, though, as we move forward, to make the process of judging the evidence become more inclusive and more transparent.   In the clinical realm, the Colorado Clinical Guidelines Collaborative was useful for creating a broad consensus on the evidence base for clinical guidelines.  We could benefit from a similar transparent and open process in Colorado to judge the evidence on effectiveness of public health preventive interventions and approaches.

• Ask the current cancer screening programs funded by Amendment 35 to prepare to evolve those programs to new purposes.

In the future, as the provision of clinical preventive services such as cancer screenings becomes more universally accessed by everyone, some of the stand-alone screening programs such as the WWC and the Colorado Colorectal Screening Program will no longer be needed in their current forms or current sizes.  Those programs should now begin to plan for their evolution to efforts more purposed for education, advocacy, navigation, and quality assurance than for the provision of direct services. 

• Prepare to foster the development of new chronic disease risk factor management systems designed to become self-sufficient with health care funding.

With increasing emphasis placed on chronic disease risk factor management in clinical settings as a part of health care reform, how should the CCPD Review Committee regard these areas as priorities for funding?  One way might be to invest in programs that are community-based but also firmly linked to clinical systems that could develop evidence-based programs locally for chronic disease risk factor management.  This pertains to tobacco cessation services funded by STEPP as well.  Those efforts should be strategically designed to prime the pump for clinical resources to then be used to sustain those programs.  Many of the current efforts funded by the CCPD (eg, the WISEWOMAN – type screening and referral programs) and STEPP (eg, cessation services) could evolve in that way.  As this is done, there will need to be clear policies and definitions about preventive services and treatment services. Amendment 35 specifies that no more than 10% of all funding in the CCPD program can be spent oAlthough there are no particular strings to the core funding to community health clinics in the Amendment 35 intent, now would be a good time for both the CCPD and STEPP programs to develop plans in concert with community clinics for increased cooperation in disease prevention when the fiscal emergency ends.  This will be especially important as both Amendment 35 and the Affordable Care Act will both be supporting community clinic expansion and programs such as patient navigation and chronic disease management that are also natural activities for public health-clinical care cooperation.n clinical care.  In chronic disease management, however, there are many gray areas overlapping prevention and clinical care.  For example, in cardiovascular disease prevention, the process of supporting patients in the important but sometimes complex process of managing hypertension or lipid levels, or tobacco cessation, or weight control could all be regarded as either prevention or treatment.  The CCPD review committee needs to give careful thought to how “treatment” of risk factors for disease differs (or not) from prevention.

• Create firmer partnerships in prevention with community clinics.

Although there are no particular strings to the core funding to community health clinics in the Amendment 35 intent, now would be a good time for both the CCPD and STEPP programs to develop plans in concert with community clinics for increased cooperation in disease prevention when the fiscal emergency ends.  This will be especially important as both Amendment 35 and the Affordable Care Act will both be supporting community clinic expansion and programs such as patient navigation and chronic disease management that are also natural activities for public health-clinical care cooperation.