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The Briefing Book

an introduction to the health issues facing Colorado
Table of Contents

A Note from the Executive Director 3

Healthcare Access 4
Medicaid 5
Mental and Behavioral Health Care 10
Immunizations 15

School Health 18

Physical Education 19
Nutrition 24
Wellness 27

Community Health 1
Physical Activity 33
Food Access
39
Infrastructure 45
Oral Health 51
A Note from the Executive Director
Health might not be what you think it is. It is scientific and social. It is personal and systemic. It
is far more than what happens in the doctor’s office.

Though our political debate usually centers on health care, the reality is that health care is just
one (albeit important) piece of the health puzzle. Research indicates that access to health care
only has a 10% impact on the risk of premature death in America. Meanwhile, social and
environmental factors (20%), genetics (30%) and individual behavior (40%) have a much greater
impact. These influences do not exist in isolation from one another. Notably, individuals’ ability
to engage in healthy behavior is impacted by social, economic and environmental factors.i

Public policy has a profound impact on health. Recent studies have shown that disparities in life
expectancy within the United States are linked to public expenditures and the availability of
public health resources. As a policymaker in Colorado, you will be in a position to improve and
lengthen the lives of our state’s residents.

We at Healthier Colorado use a principle to guide our way through the complexity of advancing
health: everybody deserves a fair shot at living a healthy life. We hope that this briefing book
helps you navigate our state toward a healthier future for our state. Please consider us as an
ongoing resource in your journey.

Jake Williams

i. https://www.healthsystemtracker.org/indicator/health-well-being/life-expectancy/
i. http://www.cnn.com/2017/12/21/health/us-life-expectancy-study/index.html
i. http://www.nejm.org/doi/full/10.1056/NEJMsa073350#t=article

The Briefing Book -- 3
Healthcare Access
Medicaid
• Medicaid is an important economic driver across the state. It helps pay for services, creates
jobs, and increases household earnings.

• Medicaid covers 1.3 million people in Colorado and specifically serves those with disabilities,
low income individuals, and some seniors. It provides a range of services, from physical and
behavioral health care to long term care services for adults and children with disabilities, as well
as to some low-income seniors.

• Medicaid is a financial partnership between the federal government and the state.

Mental and Behavioral Health Care
• Despite the appearance of increased access to mental health services, the situation on the
ground is not so optimistic, especially in rural Colorado.

• Many factors contribute to a lack of mental health care acccess. They include cost of
treatment, lack of transportation to services (or services being located too far to travel to easily),
and individuals feeling uncomfortable seeking out services because of stigma.

• To improve access to services, investments could be made in workforce development --
especially in rural Colorado -- to create better behavioral health infrastructure and raise
awareness to reduce related stigma.

Immunizations
• Vaccination against disease is a valuable tool in keeping both individuals and whole
populations healthy.

• Those who are immunocompromised or have a weak immune system may not have the option
of being vaccinated. In order protect these individuals, the community must maintain a high level
of overal immunization, called "herd immunity" or "community immunity."

• Establishing herd immunity is a simple way of stopping a disease outbreak before it starts. It
saves time, money, and other resources.

The Briefing Book -- 4
Healthcare Access: Medicaid

Medicaid
C olorado’s Medicaid program serves low-income people,
people with disabilities, and some seniors. It provides a
range of services from physical and behavioral health care to
long term care for people with disabilities and seniors who
cannot afford to pay for them out of pocket (because
Medicare doesn’t cover them). Medicaid currently covers
roughly 1.3 million Coloradans. More than 400,000 of those
are covered because of the state’s decision to expand
Medicaid under the Affordable Care Act.1 In addition to
providing care and vital services for some of our state’s most
under resourced and vulnerable, Medicaid also acts as an
important economic driver for many communities around the
state. Nationwide, 1 out of every 6 health care dollars is
spent by Medicaid. 2

Colorado at a Glance
System of Service Delivery

The Department of Health Care Policy and Financing (HCPF) oversees Health First Colorado.
HCPF contracts with a wide range of providers across the state, including primary care
providers, hospitals, nursing homes, rehab facilities, behavioral health specialists, other
specialty care providers, and many more.

Primary care is mostly delivered through the department’s Accountable Care Collaborative. The
state is divided into seven primary care regions, each of which is managed by a Regional Care
Collaborative Organization.3

Behavioral health care is overseen by Colorado’s Department of Human Services (CDHS)
through their Office of Behavioral Health. Much like primary care, the state is divided into five
behavioral health regions and HCPF and CDHS contract with five behavioral health
organizations which manage behavioral health care through contracts with behavioral health
organizations which provide the direct care.4 The Briefing Book -- 5
Healthcare Access: Medicaid

Colorado currently offers 11 Medicaid waivers

Medicaid waivers allow the state to offer specialized benefits to seniors and those with
disabilities. These are people who may qualify for supports and services that provide long term
care, including home- and community-based services, which allow waiver clients to live as
independently as possible.

Waivers are designed for those who might otherwise be relegated to permanent institutional
care if they don't have additional support. Services offered through waivers include attendant
care to help with dressing and bathing, food preparation and cooking, specialized therapies,
and homemaking services.

All of these help to keep people with disabilities living in the community, allow seniors age to in
place, and patients to live as independently as possible. Waivers must adhere to federal
regulation and be approved by the Center for Medicaid and Medicare Services (CMS). In
Colorado, new waivers must be created legislatively and must also be approved by CMS. After
the legislature creates or drastically changes a waiver, the HCPF is responsible for submitting a
waiver application to Medicaid.

Five of the current Medicaid waivers are open to children and the remaining six are open to
adults. The list of waivers includes:5

• Children’s Home and Community Based Services (HCBS) Waiver
• Children’s Extensive Support Services Waiver
• Children with Autism Waiver
• Children with Life Limiting Illness Waiver
• Children’s Habitation and Residential Waiver
• Brain Injury Waiver
• Community Mental Health Supports Waiver
• Elderly, Blind and Disabled Waiver
• Spinal Cord Injury Waiver
• Supported Living Services Waiver
• Developmental Disability Waiver

The Briefing Book -- 6
Healthcare Access: Medicaid

While the waiver system is complicated, Colorado’s Medicaid program is an efficient and
effective way to deliver health care. Medicaid also provides Colorado with a significant amount
of flexibility to find efficiencies and cost savings. The Accountable Care Collaborative and the
State Innovation Model (designed to help integrate behavioral and physical health and
discussed more in the mental health chapter) are two recent examples of pilot programs that
have allowed the state to explore additional innovations and cost savings.

Financing

Medicaid is a financial partnership between the state and federal government. Colorado’s
regular Federal Match Assistance Percentage (FMAP) is 50.02, which means that the federal
government matches roughly every dollar the state invests in the program.6 There are a few
exceptions and some programs offered by Colorado’s Medicaid program receive a higher match.
The most notable example of this is the Medicaid expansion for adults without dependent
children under the Affordable Care Act (ACA). This is almost solely funded by the federal
government. If no changes to the financing mechanism of the expansion happen before 2020,
the state will be expected to pay for 10% of the expansion while the federal government pays for
the other 90%. 7

Medicaid accounts for a substantial portion of Colorado’s state budget with annual spending
in FY 15-16 reaching $8.2 billion. More than 60% of the program’s funding comes from the
federal government, 29% is general fund money, 7% from the hospital provider fee, and 4% from
cash funds.8

The Briefing Book -- 7
Healthcare Access: Medicaid

HCPF ensures that Medicaid providers are reimbursed for the Medicaid services they provide.
While reimbursement rates vary by service and type of provider, they are generally not high
enough and providers are practicing under constant threat of reduced rates. Inadequate
reimbursement for providers affects access to care and is particularly acute in the behavioral
health sector.

Medicaid as an Economic Driver
Because Medicaid acts as a payer for so many entities in the
health care system, it is an important economic driver for the
state as a whole. Medicaid funds pay for services provided The newly created
at hospitals, by doctors and individual medical practices, to Medicaid expansion for
durable medical equipment providers, nursing homes, home
adults without dependent
health agencies, and home care workers to name a few. A
report by the Colorado Health Foundation analyzed the children under the ACA
Medicaid expansion for adults without dependent children has created 31,074 jobs
under the ACA. It found that this expansion has created and increased household
31,074 jobs and increased household earnings by an earnings by an average of
average of $643.9 The Hospital Provider Fee, which is a fee $643.
assessed on hospitals that draws down a federal match, is
used to help hospitals cover uncompensated care and is
particularly important for rural hospitals.

The Future of Medicaid
Medicaid is a vital part of Colorado’s economy that provides essential coverage and long-term
supports and services for more than 1,000,000 people in Colorado. Both the state’s health and
economy depend on a robust, innovative, and efficient Medicaid program. It is
critical for the state to maintain its commitment to a strong program that prioritizes quality
health coverage and community based long-term supports and services for seniors and people
with disabilities. Access to services, especially in rural areas and in the provision of behavioral
health care, could be improved partially through an increase in provider reimbursement rates.
Care delivery choices for people with disabilities and seniors needing long-term care could be
improved through a more-streamlined process of care delivery across all of the state’s eleven
Medicaid waivers. Colorado has been a leader in pilot programs like the Accountable Care
Collaborative and the State Innovation Model and should continue to engage in opportunities to
improve the program.

The Briefing Book -- 8
Healthcare Access: Medicaid

Endnotes

1. “Putting Colorado’s Health First: 2015-2016 Annual Report.” The Department of Financing and Health Care Policy.
Accessed July 25, 2017. https://www.colorado.gov/hcpf/hcpf-2015-2016-annual-report.

2. Rudowitz, Robin. “Medicaid Financing: The Basics.” The Kaiser Commission on Medicaid and the Uninsured.
December 2016. http://files.kff.org/attachment/Issue-Brief-Medicaid-Financing-The-Basics.

3.. “Regional Care Collaborative Map.” Colorado Department of Health Care Policy & Financing. Accessed July 25,
2017. https://www.colorado.gov/pacific/hcpf/regional-care-collaborative-organization-map.

4. “Behavioral Health Care Organization Map.” Colorado Department of Health Care Policy & Financing. Accessed July
25, 2017. https://www.colorado.gov/pacific/hcpf/behavioral-health-organization-map.

5. “List of Medicaid Programs, HCPF.” Colorado Deaportment of Health Care & Financing. Accessed July 27, 2017.
https://www.colorado.gov/pacific/hcpf/program-list.

6. “FY 2017 Federal Medical Assistance Percentages.” Office of the Assistant Secretary for Planning and Evaluation,
U.S. Department of Health and Human Services. December 29, 2015. https://aspe.hhs.gov/basic-report/fy2017-federal-
medical-assistance-percentages

7. “Affordable Care Act Financing.” Mediciad.gov. Accessed July 27, 2017. https://www.medicaid.gov/affordable-
care-act/financing/index.html.

8. “Putting Colorado’s Health First: 2015-2016 Annual Report.” The Department of Financing and Health Care Policy.
Accessed July 25, 2017. https://www.colorado.gov/hcpf/hcpf-2015-2016-annual-report.

9. “Analysis Reveals that Medicaid Expansion Sparks Economic Activity in Colorado.” The Colorado Health
Foundation. June 2, 2016. http://www.coloradohealth.org/news/analysis-reveals-medicaid-expansion-sparks
economic-activity-colorado.

The Briefing Book -- 9
Healthcare Access: Mental and Behavioral Health Care

Mental and Behavioral Health Care

W ith the passage of the Affordable Care Act, access to mental and behavioral health services
was expanded to all Americans, both through the Medicaid expansion and through the
marketplace, where plans had to be compliant with the law’s Essential Health Benefits
provision.1 Despite the appearance of increased access to mental health services, the situation on
the ground is less encouraging, especially in rural Colorado. In 2015,
442,278 Coloradans 5 years of age and older weren’t able to
receive counseling or mental health services when they needed it.2
Access to mental and behavioral health may be expanding, but
progress remains slow.

In 2015, according to the Colorado Health Access Survey, 9.9% of
Coloradans reported experiencing poor mental health in the previous
year. This rate was markedly higher for Coloradans without a high
school degree (22.0%), and for lower-income Coloradans (17.0% for
those living between 0% and 100% the Federal Poverty Level [FPL],
and 12.2% for those living between 100% and 200% FPL).

Reports of poor mental health are stratified by region as well; 15.4%
of individuals in Health Statistics Region 7 (Pueblo County) report experiencing poor mental
health -- the highest rate in the state. In comparison, Health Statistics Region 12 (Garfield,
Eagle, Grand, Summit, and Pitkin counties) finds only 5.2% of residents reporting poor mental
health -- the lowest rate in the state.3 This disparity at the income level and becomes even more
stark when the type of health insurance is considered. Medicaid enrollees report poor mental
health at a rate significantly higher than those covered by a private insurer: Medicaid at 18.3%
vs. private insurance at 6.6%.

Colorado at a Glance
Identifying individuals experiencing poor mental health is only the first step in addressing
Colorado’s mental and behavioral health limitations. Patients' ability to receive treatment
The Briefing Book -- 10
Healthcare Access: Mental and Behavioral Health Care

is a critical factor as well. In some areas, physical
distance can impose barriers to care. As of 2016, Colorado Case Studies
there were 12 counties in the state without a
licensed psychologist or social worker serving Colorado has been a leader in finding innovative
solutions to address the state’s high rate of suicide.
their residents.4 Even when patients are able to
travel to a healthcare provider, they may become Modeled off a similar innovative
discouraged when it comes time to pay. 57.3% of Colorado Gun program in New Hampshire, the Gun
Shop Project Shop Project works with gun and
Coloradans who were unable to receive mental or pawn shop owners, firing range
operators, and gun clubs to raise
behavioral health care cited perceived cost of care suicide awareness.
as a barrier.5 Cost of care concerns were most
prevalent for those who were privately insured. Man Therapy is a project of the
Coloradans who are publicly insured, through Colorado Office of Suicide Prevention
Medicaid, CHP+, or Medicare, still show a Man Therapy and is an innovative public awareness
campaign aimed at helping
concern with cost, but also face other barriers to destigmatize behavioral health care
for men, who make up a majority of
accessing effective mental or behavioral health completed suicides in Colorado.
services.6

For those served by public insurance, specifically Medicaid, mental and behavioral health
services are administered by multiple departments and offices of the state. The intersections of
these offices can manifest in intimidating and confusing ways -- for insiders and outsiders alike.
Medicaid is primarily administered through the Department of Health Care Policy and Financing
(HCPF), but Medicaid-funded behavioral and mental health services are managed by the Office
of Behavioral Health (OBH) in the Department of Human Services. Medicaid-funded mental
health care is provided through Behavioral Health Organizations (BHOs).

Behavioral Health Organizations (BHOs) in Colorado
Organization Area(s) Served

Access Behavioral Health Denver and Northeast plains

Behavioral Healthcare Inc. Outer metro area
Boulder, Gilpin, Clear Creek,
Foothills Behavioral Health Partners
Broomfield, and Jefferson counties

Colorado Health Partnerships Rest of the state

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Healthcare Access: Mental and Behavioral Health Care

A recent interdepartmental review by the Department of Public Health and Environment, the HCPF,
and the OBH examined the splits in integrating patients' mental and physical health care.
Integrated care can foster a more efficient health care environment that treats the whole person,
which is preferable to disparate treatments of different conditions.7 The review found that the
separation between the provision of mental and physical health services was not especially present
in rules or statutes, but quite present in agency culture and day-to-day practice. The distinction in
payment types -- levied for mental and behavioral health, and fee-for-service for physical health --
was seen to be the primary source of the differences in agency culture that cause confusion and
add to patients' difficultly navigating the system, thus making it more difficult to integrate mental
and physical health care.8

This push for integrated care in the state is possible in part
because of Colorado’s State Innovation Model (SIM) grant.9
The primary aim of the SIM program is to expand access to
integrated physical and mental health care to 80% of
Coloradans who access care through value-based plans.
Methods required to accomplish SIM's goals:
• Convene payer-stakeholders to find best methods to
move away from fee-for-service payment and toward a
value-based structure
• Expand information technology capabilities, especially
for telehealth, a boon for remote communities
• Support practices, through capital grants and health information technology integration, at
the individual clinic level, during their moves toward integrated health services
• Define a final state plan to improve broad, population-level health.10

Fully integrating mental and behavioral health services in the state of Colorado is no easy task.
In the state, all but 6 counties are designated as Mental Health Professional Shortage Areas
(HSPAs). Those counties are Adams, Arapahoe, Boulder, Broomfield, Douglas, and Larimer.11

Weld and Denver counties received their HSPA designation due to a lack of mental health
providers for low-income Coloradans. The remaining counties are geographic HSPAs, meaning
they lack the appropriate number of mental health care providers for their size. These HSPAs
represent 1,941,571 Coloradans who lack care.12

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Healthcare Access: Mental and Behavioral Health Care

Colorado faces a lack of available mental and behavioral health services and also lacks the physical
infrastructure through which to provide treatment. It will likely take multiple policy changes to
adequately address Coloradans' overall lack of mental and behavioral health care access.
Bolstering the state’s rural mental and behavioral health care workforce is necessary as well, as is
addressing inadequate reimbursements for both individual facilities and institutional care
providers. Moreover, Colorado needs more physical infrastructure, including mental health centers,
to provide both inpatient and outpatient treatment. The state should look for innovative ways to
partner with, and possibly support, counties and local communities who are working to bring
comprehensive mental and behavioral health services to their residents. The state should also
continue to support ongoing efforts to destigmatize mental health treatment, especially among men
and in rural areas. As the opioid epidemic grows and Colorado's rates of suicide, alcohol, and other
substance use continue to be high, the need for a robust mental and behavioral health system will
only continue to grow.

Endnotes

1. “What Marketplace insurance plans cover.” Healthcaregov.gov. Accessed May 6, 2017. https://www.healthcare.gov/
coverage/what-marketplace-plans-cover/.

2. “Colorado Health Access Survey.” Colorado Health Institute. September 16, 2015. http://www.coloradohealthinstitute.
org/data-repository/detail/2015-chas-state-and-regional-workbook.

3. Keeney, Tamara. “Mapping Data A to Z: Mental Health Status.” Colorado Health Institute. June 21, 2016. http://www.
coloradohealthinstitute.org/research/mapping-data-z-mental-health-status.

4. “The State of Health in Rural Colorado: 2016 Edition.” Colorado Rural Health Center. Accessed May 6, 2017. https://
www.colorado.gov/pacific/sites/default/files/11%20-%20Colorado%20Rural%20Health%20Center%20%20-%20
2016%20Snapshot.pdf.

5. “Colorado Health Access Survey.” Colorado Health Institute. September 16, 2015. http://www.coloradohealthinstitute.
org/data-repository/detail/2015-chas-state-and-regional-workbook.

7. Keeney, Tamara. “Why aren’t Coloradans getting the Mental Health Care they need?” Colorado Health Institute. June
2, 2016. http://www.coloradohealthinstitute.org/insights/insight/why-arent-coloradans-getting-the-mental-health-care-
they-need.

6. “Tri Agency Regulatory Alighnment Initiative to Support Integral Care.” Colorado Departments of Services-Office of
Behavioral Health, Health Care Policy and Financing, and Public Health and Environment. Accessed June 1, 2017. https://
drive.google.com/file/d/0B6eUVZvBBTHjekVCRzJBN3lpZFk/view.

8. D. Allen, Gillen E., and L. Rixon. “The Effectiveness of Integrated Care Pathways for Adults and Children in
Health Care Settings: A Systematic Review.” PubMed.gov. no. 3 (2009): 80-129. https://www.ncbi.nlm.nih.gov/
pubmed/27820426.
9. “Colorado State Innovation Model (SIM) Frequently Asked Questions.” Colorado.gov. Accessed May 5, 2017. https://
drive.google.com/file/d/0BxUiTIOwSbPUZllKdzdDYi05UVU/view.

The Briefing Book -- 13
10. “What is SIM?” Practice Innovation Program Colorado. Accessed May 5, 2017. http://www.practiceinnovationco.org/
sim/about/what-is-sim/.

11. “Mental Health: Health Proffessional Shortage Areas (HPSAs).” Colorado Department of Public Health and
Environment GIS. October 1, 2015. https://www.colorado.gov/pacific/sites/default/files/PCO_HPSA-mental-health-map.
pdf.

12. “HRSA Data Warehouse: Shortage Areas.” HRSA.gov. Accessed May 15, 2017. https://datawarehouse.hrsa.gov/
topics/shortageAreas.aspx.

The Briefing Book -- 14
Healthcare Access: Immunizations

Immunizations

V accinations are about protecting us all. Everyone
benefits when vaccination rates are high.
While individuals can make decisions regarding their own
health, vaccines have benefits far beyond helping any one
person stay well. For instance, the immunocompromised --
those with weak or absent immune systems -- cannot be
vaccinated in many cases, because even the controlled
exposure in a vaccine may still overwhelm their immune
system.
In order to protect our most-vulnerable -- who tend to be our youngest children and seniors --
our community needs to maintain a level of “herd immunity.”2

Colorado at a Glance
In 2016, Colorado ranked 14th in the nation for child
immunization rates. This relatively high ranking is despite the
fact that 24.6% of children 3 years old and younger are behind
on the Colorado Board of Health recommended vaccine
schedule.1 Part of maintaining a strong public health
infrastructure is encouraging and engaging in proactive
behaviors. Vaccination is a valuable, but sometimes
misunderstood, tool that can be a strong support in efforts to
keep the public healthy. This support for the health of
immunologically vulnerable populations, such as children and
their still-developing immune systems.

Schools, are therefore, a hotspot for public health concerns and interventions, especially in
regard to infectious and communicable diseases.

The rate of a community’s population who are vaccinated against a disease needs to be
relatively high in order to offer the full scope of protection. A disease such as measles has a
herd immunity threshold of 90 -95% of the population.3

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Healthcare Access: Immunizations

Widespread immunity can slow, mitigate, or even prevent the spread of infectious disease due
to a lower number of vulnerable people. Community immunity means stopping a disease
outbreak before it starts, saving time, money, and innumerable resources.

Schools and childcare facilities are required by Colorado law to track and keep up-to-date
records of the immunizations of their students.4 Required immunizations include common
diseases like measles, chicken pox, and tetanus.5 Students who do not have complete records
may be suspended or expelled from their school or childcare facility after a period of non-
compliance. However, this is not to say that students are solely required to receive
immunizations to attend school; there are numerous possible medical and nonmedical
exemptions available to Colorado students.6
While the state currently collects immunization data, reports
on general immunization rates are sometimes difficult to come
by. However, immunization rates are available, by request,
at the school level. Data sets have been compiled by media
sources7, but can be hard to come by for the average parent.
The availability of this information is critical for parents and
caregivers to make the correct health decisions for their
families.

Of the top 15 schools with the highest immunization exemption rates in Colorado, over half are
in the Boulder Valley School District.8 Even outside the individual school level, Boulder Valley
School District stands out as the district with the highest immunization exemption rates in the
state. Other high exemption rate districts include Weld County RE-1, LewisPalmer School
District 38, and Academy School District 20. 9

The Future of Immunizations
Colorado would benefit from having a more centralized way to collect immunization records.
This would increase the ease with which parents can access vaccinations rates for the schools
they are considering for their children. It would also streamline the process for both submitting
records and opting out of vaccination. It is concerning that some areas of the state are well
below the level of immunization that is required for herd immunity. This presents a troubling
public health threat in the event of an outbreak. Particular attention should be paid to continued
awareness of the safety of vaccines as well, as a tightening of Colorado’s current exemption law,
which is notably more lax than many other states in the country by allowing a philosophical
exemption.10
The Briefing Book -- 16
Healthcare Access: Immunizations

Endnotes
1. “New Report Shows High Cost of Vaccine-Preventable Disease, Increased Risk for Colorado Children and Commu-
nities.” Children’s Hospital Colorado and Colorado Children’s Immunization Coalition. February, 24, 2017. https://www.
childrensimmunization.org/uploads/2016-Vaccine-Preventable-Diseases-in-CO-Children-Report-_Press-Release.pdf.

2. “Community Immunity (“Herd Immunity”).”Vaccines.gov. October 11, 2006. https://www.vaccines.gov/basics/
protection/.

3. “Immunization and Infectious Diseases.” HealthyPeople.gov. Accessed April 27, 2017. https://www.healthypeople.
gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives.

4. The Infant Immunization Program and Immunization of Students Attending: 6 CCR 1009-2.” Code of Colorado
Regulations, Secretary of State Colorado. Accessed April 28, 2017. http://www.sos.state.co.us/CCR/6%20CCR%201009-
2.pdf?ruleVersionId=6808&fileName=6.

5. “School-required vaccines.” Colorado.gov. Accessed April 27, 2017. https://www.colorado.gov/pacific/cdphe/
schoolrequiredvaccines/.

6. “Vaccine exemptions.” Colorado.gov. Accessed April 27, 2017. https://www.colorado.gov/pacific/cdphe/vaccine-
exemptions.

7. Schimke, Ann. “Colorado, find your school’s immunization compliance and exemption rates.” Chalkbeat. February 9,
2015.http://www.chalkbeat.org/posts/co/2015/02/09/immunization-database/.

8. Glen, Sarah, and Ann Schimke. “Six charts that explain who’s getting vaccinated in Colorado - and who’s not.”
Chalkbeat. June 29, 2016. http://www.chalkbeat.org/posts/co/2016/06/29/six-charts-that-explain-whos-getting-
vaccinated-in-colorado-and-whos-not/.

9.Kamidani, Satoshi MD, Jessica Cataldi MD, Elizabeth Abbott, MPH, Carl Armon PhD, Sean O’Leary MD, Daniel
Olson MD, James Gaensbauer MD, Suchitra Rao MD, Stephanie Wasserman MPH,
James K. Todd MD, and Edwin J. Asturias MD. “The Vaccine-preventable Diseases Report, 2016: The risk and
cost of not fully protecting our children .” Children’s Hospital Colorado. Volume XIII no. 1 (2017); 1-10. https://www.
childrensimmunization.org/uploads/Vaccine-preventable-disease-report-2016-FINAL-rev-5-19jkt.pdf.

10. “Vaccines Exemption Laws by State.” FindLaw. Accessed April 28, 2017. http://healthcare.findlaw.com/patient-
rights/vaccine-exemption-laws-by-state.html.

The Briefing Book -- 17
School Health
Physical Education
• Children spend nearly half of their waking hours at school. Ensuring children are physically
active throughout the school day may lower the rate of obesity and also improve a child’s
cognitive function throughout the school day.

• In Colorado, more than 1 in 4 children are overweight or obese. However, less than a third of
high school aged children receive the doctor-recommended 60 minutes of physical activity a day.

• By eliminating the barriers associated with children being active during the school day and
finding innovative ways to ensure all students participate in physical education classes, Colorado
can help set our children up for future success.

School Nutrition
• Now that nearly a third of Colorado children are getting their meals from school lunchrooms,
cafeterias are well-positioned to help guarantee children have access to healthy foods.

• Studies find that when students have access to healthy foods, especially fruits and vegetables,
they perform better in school and have better academic outcomes.

• Investing in programs to get fresh and nutritious foods into schools not only has a positive
impact on students, but can also help boost Colorado’s agricultural economy.

School-Based Wellness
• Children who have adequate access to health care are more likely to graduate from high
school. On top of that, creating a culture of wellness in schools helps foster a successful
learning environment.

• School Based Health Centers (SBHCs) can provide children with a number of services --
including primary care, mental health services, immunizations and oral healthcare -- all in a
setting they are familiar with.

• When wellness policies are implemented collaboratively among students, teachers, parents,
and school administrators, they can promote healthy eating and physical activity and lead to
better educational outcomes.

18- The Briefing Book
School Health: Physical Education

Physical Education
C olorado’s children aren’t as active as they should be. More
than 1 in 4 children in Colorado are overweight or obese,1
and only 27.8% of high schoolers in the state get an hour of
Did you know...?
physical activity or more daily.2 Research is increasingly showing
the benefits of physical activity and physical education for Only 27.8% of high
children and adolescents, which includes improved cognitive schoolers in the state
function.3 Correcting shortcomings regarding physical education get an hour of
and the availability of physical activity, specifically in schools, is physical activity or
an intervention that can help ensure that all children in our state more daily
are able to choose healthy and active lifestyles.

Colorado at a Glance
The rates at which children and adolescents engage in physical activity vary widely throughout the
state. Health Statistics Region 5 (Cheyenne, Elbert, Kit Carson, and Lincoln counties) has the
highest rate of average child physical activity, with 75.4% of students engaging in 60 minutes of
physical activity five days or more per week. In contrast, HSR 15 (Arapahoe County) has the lowest
rate of average physical activity, with only 43.1% of students engaging in 60 minutes of physical
activity at least 5 days a week.4

The form that physical activity takes varies per region as well. Participation on a sports team is
one such way to get active. In the past 12 months, 60.1% of high school students in Colorado
participated in one or more sports teams. HSR 5 had the highest rate of sport participation at 82.75,
while HSR 14 (Adams County) had the lowest rate at 54.7%.6 Other than competitive activities,
active transportation to school, like walking or riding a bike, is another avenue to active living.
Across the state, 18.6% of high school students use active transportation to get to school at least
one day a week.7 That rate is highest in HSR 20 (Denver County), at 27.3%, and lowest in HSR 19
(Mesa County) at 13.1%. Sports participation was higher in non-urban areas, while active
transportation was more prevalent in dense urban areas.8

The Briefing Book -- 19
School Health: Physical Education

Access to safe and fun physical activities outside of schools can be limited for some children,
especially those from low-income households or those living in sparsely-populated rural areas.
Low-income parents often have a difficult time finding and utilizing resources to ensure that their
children can be as active as they should. The cost of extracurricular sports -- which can include
registration and equipment costs, restrictive parental work schedules, and familial obligations for
children and adolescents can all constrain opportunities for physical activity.9

One way that Colorado can combat these limitations in a child’s home life is to ensure access
to physical education while in school. Currently, the state
sets standards for physical education through the Colorado
Policymakers Department of Education (CDE), whose most recent standards
should continue to were established in 2009. At that time, the Board of Education
created a shared set of standards for physical education and
explore innovative comprehensive health, meant to further the understanding that
ways to bring health is not limited strictly to the mechanics of the body, but
additional mental rather to a more comprehensive definition of physical,
health screening emotional, and social wellness. These standards also include
and treatment movement competence and understanding, as well as
prevention and risk management.10
opportunities to
SBHCS.
These standards encompass grade levels from kindergarten through high school and form the
floor for curricula in Colorado. As such, individual districts' curriculum standards must meet or
exceed the state's.11

Physical education is only one effort to improve the amount and quality of kids' physical activity in
Colorado. Elementary schools and districts are required to incorporate a minimum amount of time
for physical activity during the school day as well. This physical activity differs from physical
education in that it offers students a chance to practice skills that they may have learned in PE
class, while creating a less-structured environment where they can turn those skills into lifelong
habits. For schools in session five days a week, full time students are required to have 600 minutes
of physical activity a month, while those in session for four days or fewer are required to have 30
minutes of physical activity per day. There are similar requirements for children who are in school
half-time. These physical activity minutes may include recess, physical activity field trips, or
physical education classes. Non-instructional physical activity under this statute cannot take the
place of a standards-based physical activity curriculum.12

The Briefing Book -- 20
School Health: Physical Education

In the schoolhouse, students’ schedules can be constructed to allow for the full integration of
physical activity and wellness. Red Hawk Elementary, part of St. Vrain Valley Schools, does just
this, allotting 40 minutes of each day to physical activity, not counting physical education
classes.13 These physical activity periods include activities such as dancing, walking special
routes within the school, and outdoor activities like tag and jump rope. Students at Red Hawk are
proficient and advanced in reading, writing, and mathematics at a higher rate than the state
average, indicating that their focus on movement is possible in every school, even in one that
performs in the 83rd percentile in reading and 81st percentile in mathematics on the state TCAP
exam (school year 2014-15); 14

Gains in physical activity time are not shared by all students, however. A recent review by Denver
Public Schools saw that schools with a higher percentage of English Language Learners -- 48% or
more -- had dedicated less time to physical education than schools with fewer ELL students.15
Though the cause of this disparity is undetermined, the difference in access limits ELL students’
ability to practice healthy habits and engage in a culture of wellness in their school. Additionally,
even schools with lower proportions of ELL students fail to dedicate adequate time to physical
education. On average, DPS schools dedicate between 61 minutes and 120 minutes per week to
physical education in elementary schools.16 SHAPE America recommends 150 minutes of physical
education per week for elementary students and 225 minutes per week for middle and high school
students.17

The Future of Physical Education
Colorado needs to support local districts to ensure they have the capacity necessary to offer
comprehensive PE to all students. Additionally, resources need to be provided to schools to build
gyms and obtain the equipment necessary for all children to be active and stay fit. Finally, schools
should require students to take PE classes at the recommended amount per week, and make after-
school activities and sports programs affordable to all. In order to do this, Colorado needs to
incentivize schools to require physical education and/or make physical education a mandatory
requirement.

The Briefing Book -- 21
School Health: Physical Education

Endnotes
1. “Overweight and Obesity in Colorado: Fact Sheet.” Colorado.gov. March 2015. https://www.colorado.gov/pacific/
sites/default/files/DC_fact-sheet_Childhood-Obesity_Aug_2015_1.pdf.

2. “Healthy Kids Colorado Survey 2015.” Colorado.gov. Accessed May 10, 2017. https://www.colorado.gov/pacific/sites/
default/files/PF_Youth_HKCS-Exec-Summary-2015.pdf.

3. Donnelly, Joseph E., Charles H. Hillman, Darla Castelli, Jennifer L. Etnier, Sarah Lee, Phillip Tomporowski, Kate
Lambourne, and Amanda N. Szabo-Reed. “Physical Activity, Fitness, Cognitive Function, and Academic Achievement
in Children.” Medicine & Science in Sports & Exercise 48, no. 6 (June 2016): 1223-224. https://www.ncbi.nlm.nih.gov/
pubmed/27182986.

4. “Healthy Kids: Physical Activity.” Colorado Health Institute. January 31, 2017. http://www.coloradohealthinstitute.org/
research/healthy-kids-physical-activity.

5. “Regional snapshot - Region 5: Cheyene, Elbert, Kit Carson, and Lincoln Counties.” Colorado.gov. Accessed May 9,
2017. https://www.colorado.gov/pacific/sites/default/files/PF_Youth_HKCS-Snapshot-region-5.pdf.

6. “Regional Snapshot- Region 14: Adams County. 2015 Healthy Kids Coorado Survey.” Colorado.gov. Accessed May
10, 2017. https://www.colorado.gov/pacific/sites/default/files/PF_Youth_HKCS-Snapshot-region-14.pdf.

7.“Healthy Kids: Physical Activity.” Colorado Health Institute. January 31, 2017. http://www.coloradohealthinstitute.org/
research/healthy-kids-physical-activity.

8. Ibid.

9. Finkelstien, Daniel, Dana Petersen, Lisa Schottenfeld, Lauren Hula, and Molly McGlone. “Promoting Physical Activity
among Low-Income Children in Colorado: Family Perspectives on Barriers and Opportunities.” The Colorado Health
Foundation. August 30, 2016. http://www.coloradohealth.org/sites/default/files/documents/2017-01/Mathematica_
physicalactivitystudyTCHF102016.pdf.

10. “Colorado Academic Standards: Comprehensive Health and Physical Education.” Colorado Department of Education.
December 10, 2009. https://www.cde.state.co.us/sites/default/files/documents/cohealthpe/documents/health_pe_
standards_adopted_12.10.09.pdf.

11. “Rules for Administration of a statewide system to evaluate the effetiveness of licensed personnel employed by
school districts and Boards of Cooperative Services.” Code of Colorado Regulations Secretary of State of Colorado.
Accessed May 11, 2017. http://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=5568

12. “22-32-136.5 Chilrens Wellness- Physical Activity Requirement- Legislative Declaration.” Lpdirect.net. Accessed May
11, 2017. http://www.lpdirect.net/casb/crs/22-32-136_5.html

13. “Movement.: Red Hawk Elementary School.” SCCSD.net. Accessed May 17, 2017. http://rhes.svvsd.org/node/15797/
movement.

14. “Colorado›s Unified Improvement Plan for Schools for 2014-15: Red Hawk Elementary.” CDE. June 17, 2014. https://
cedar2.cde.state.co.us/documents/UIP2015/0470-5181.pdf.

15. Schimke, Ann. “Denver schools with large numbers of English learners get less physical education.” Chalkbeat.
November 28, 2016. http://www.chalkbeat.org/posts/co/2016/11/28/denver-schools-with-large
numbers-of-english-learners-get-less-physical-education/.

The Briefing Book -- 22
School Health: Physical Education

16. “DPS Physical Education Presentation.” Denver Public Schools. PPT. November 17, 2016. http://www.boarddocs.
com/co/dpsk12/Board.nsf/files/AFQT2F753E47/$file/Arts%20%20PE%20Board%20Deck%20-%20FINAL%2011%20
15%2016.pdf

17. “Physical Education Guidelines.” SHAPE America. Accessed May 18, 2017. http:/
portal.shapeamerica.org/standards/guidelines/peguidelines.aspx.

The Briefing Book -- 23
School Health: Nutrition

Nutrition
Colorado at A Glance Did you know...?

W hile Colorado is known for our active and healthy culture,
1 in 4 Colorado children are overweight or obese, a trend that
continues to worsen.1 In the 2016-­2017 school year, 905,019 students
1 in 4 Colorado
children are
overweight or
were served by public schools in the state of Colorado,2 making the obese.
school a prime location to lay a healthy foundation. These habits start
with healthy food consumption. With 33% of Colorado students getting
their daily meals from the school cafeteria, the lunchroom is the frontline in the effort to make
Colorado kids healthy.3

The United States Department of Agriculture (USDA) is the primary federal player funding and
overseeing school nutrition programs. The USDA administers the National School Lunch Program,
School Breakfast Program, Fresh Fruit and Vegetable Program, and Summer Food Service Program,
all of which provide funding to ensure low income students have access to breakfast and lunch
all year long. The department works with states to reimburse districts for all or part of the cost of
the meals they serve to kids who qualify for participation in the program. In addition to the federal
funding, Colorado has allocated a small pot of funding to help school districts cover select costs for
the reduced price meals the district provides.4 At the state level, Colorado’s Department of
Education works with school districts to ensure they are reimbursed for the meals they serve.

Eligibility for these programs is determined either through a household income analysis or through
categorical eligibility, whereby eligibility for programs like SNAP and Medicaid can be used to
determine eligibility. In the 2016-17 school year, 42.11% of students in the state were eligible for
free or reduced price lunch (FRL), 381,103 students in total. Eligibility rates vary widely across the
state. Colorado’s highest rate of eligibility for FRL programs is found in Sauguache County’s
Center 26 JT district where 93.39% of the district’s students are eligible for FRL. Inversely, Pitkin
County’s Aspen 1 district serves only 4.71% of students who are eligible for FRL.

The Briefing Book -- 24
School Health: Nutrition

Colorado’s legislature has enacted policies to offer additional funding to schools who provide
breakfast and lunch to students who qualify for the free and
reduced lunch program.
This includes the Smart Start Nutrition Program5 and the
Child Nutrition School Lunch Protection Program.6 Both bills
Farm-to-school and school
created line-item appropriations to cover the student payment garden programs offer a
for reduced price breakfasts and lunches. These efforts all means to ensure that the
work toward improving the nutritional quality of the food fruits and vegetables
children receive while pursuing their education. Improved necessary for growing
student diet quality is associated with better academic children come from fresh
outcomes,7 especially when student diets include substantial sources and, as an added
amounts of fruits and vegetables. bonus, can contribute to
the economic growth of
Farm-to-school and school garden programs offer a chance to
ensure that the fruits and vegetables necessary for growing
the community.
children come from fresh sources and, as an added bonus,
can contribute to the economic growth of the community. Individual farmers can see increases in
income up to 5% when participating in a farm-to-school program. Additionally, for each $1 spent in
a farm-to-school program, $2.16 in economic activity is generated. As such, the creation of a single
farm-to-school job results in the generation of 1.67 additional jobs within the economy.8

Other food access programs, such as Denver Public Schools’ Breakfast In The Classroom, have
shown to be effective in improving student outcomes. A large majority, 82.9%, of DPS faculty had
a positive impression about the program9, while 54.3% reported that the program helped to give
students access to the amount of food they needed in a day “to a great extent.” Most notably,
faculty surveyed about the program noted that it made positive contributions to student behavior
(83.8%), student academic outcomes (81.5%), student physical health (74.4%), as well as student
mental health (76%). More than half (56.6%) of faculty surveyed felt that the program ought be
expanded to other schools. Universally offered programs, like Breakfast In The Classroom, can
also decrease the stigma surrounding school meals, which can be erroneously labeled as “just for
poor kids.”10

The Future of Nutrition
School nutrition is an area where the state and local school districts work in close partnership to
administer vital programs. The state provides the organizational infrastructure that allows local
communities to utilize the federal dollars that make up a large portion of the program’s funding.
The Briefing Book -- 25
School Health: Nutrition

Because the state is such an important player in the administration of these programs, more
streamlining and funding is necessary in order to more seamlessly administer the farm-to-school
program, which will help get more Colorado-grown produce into school lunches. Additionally,
some schools still struggle to pay for their portion of their reduced price meal programs. If drastic
changes or cuts happen at the federal level, the state will most likely have to revisit the program’s
structure and potentially make some difficult decisions -- with results likely to be to the detriment
of parents, students and schools alike.

Endnotes

1. “Overweight and Obesity in Colorado: Data Infographic.” Colorado Department of Public Health and Environment.
Accessed May 10, 2017. http://www.chd.dphe.state.co.us/Weight/obesity-in-Colorado-infographic.html.

2. “News Release: Colorado preschool through 12th-grade student enrollment grows slightly.”Colorado Department of
Education. January 12, 2017. http://www.cde.state.co.us/communications/20170112enrollment.

3. Colorado Department of Public Health and Environment. Healthy Eating and Active Living Among Youth in Colora-
do, Healthy Kids Colorado Survey 2015. PDF. Denver, March 2017.

4. Colorado Department of Education Fact Sheet: State Funding for Reduced Price Meals https://www.cde.state.co.us/
nutrition/osnstatefundingreducedpricemealsfactsheet accessed 8/9/17

5. C.R.S. 22-82.7-104

6. C.R.S. 22-82.9-105

7. Florence, Michelle D., Mark Asbridge, and Paul J. Veugelers. “Diet Quality and Academic Performance.” Journal of
School Health 78, no. 4 (2008): 209-15. doi:10.1111/j.1746-1561.2008.00288.x.

8. National Farm to School Network. The Benefits of Farm to School. PDF. 2017.

9. Gallagher, Kaia, Ph.D. Impacts of the Denver Public Schools Breakfast in the Classroom Program: Survey of Nurses,
Counselors, Psychologists and Social Workers. PDF. Denver, February 2015.

10. Leos-Urbel, Jacob, Amy Ellen Schwartz, Meryle Weinstein, and Sean Corcoran. “Not just for poor kids: The impact
of universal free school breakfast on meal participation and student outcomes.” Economics of Education Review 36
(2013): 88-107. Accessed May 1, 2017. doi:10.1016/j.econedurev.2013.06.007.

The Briefing Book -- 26
School Health: Wellness

Wellness
W hen children have access to health care, they are more likely to graduate from high
school.1 Healthy kids focus more in class and are positioned to achieve better educational
outcomes. Access to health care, a school culture of wellness, and appropriate mental health
supports for students all foster a learning environment where every child has the chance to
succeed.

Colorado at a Glance
School Based Health Centers

Schools have become a new frontier for providing health care
services to their students. School based health centers can
provide students with a range of services -- including primary
care, mental health, immunizations, and oral health care, all
within the familiar context of their own school. By placing
themselves in a setting that already sees students, SBHCs offer
an accessible measure to improve the health (and thus the
education) of their student populations -- especially for students
who do not have a consistent medical home or regular access to
care.

SBHCs are also often the product of a school culture that invests
in the success of its students, resulting in higher rates of college
preparedness and positive student/school relationships.2 This is not to say that an SBHC is
capable of achieving all these results by itself, but the school
culture that successfullyutilizes an SBHC will be more likely
to achieve these positive outcomes.

For the 2013-14 school year, 35,286 students were served by
an SBHC. These serve populations that are more likely to
receive health insurance coverage through Medicaid,
compared to like populations in the state of Colorado.
The Briefing Book -- 27
School Health: Wellness

In fact, 57.3% of patients under 19 at SBHCs are covered by Medicaid.3 The largest sources of
revenue for SBHCs are patient-related revenue (41.4%), Medicaid (35.7%), state funding (23.6%),
and federal funding (20.5%). SBHCs depend on public funding to serve their communities. The
state makes contributions to SBHCs through grants created through the Department of Public
Health and Environment’s Prevention Services Division.4 For FY 2016-17, roughly $5 million
was appropriated for the grant program.5

Colorado SBHCs are located primarily in 40.0% of high schools and 25.5% of middle schools.
Seventy percent of all SBHCs in Colorado are located in urban and suburban areas. Colorado’s
highest health care need schools -- schools that would benefit greatly from an SBHC -- are
located primarily in Denver and Adams counties. For rural schools, high-need districts are
concentrated in Moffat, Garfield, Monte Vista, and Alamosa counties.6

The availability of health centers within schools allows
students to address and access care for medical issues
that for which may otherwise be difficult to find care.
SBHCs, due to their cross-jurisdictional purpose as a
The availability of
health centers within
medical center within an educational environment, must
schools allows for
simultaneously consider Health Insurance Portability and
students to address
Accountability Act (HIPAA) and Family Educational
and access care for
Rights and Privacy Act (FERPA) requirements for the
medical issues that
privacy of those they serve. 7 may otherwise be
Both of these federal laws must be considered when difficult in addressing.
addressing the capabilities and limitations of SBHCs.

While a full health center within a school requires collaboration between the individual school,
district, and care providers, school wellness policies are a first step to create cultures of health for
students and staff. Though wellness policies may be created at the school or district level, strong
district support is a best practice for creating effective policy. 9

Wellness Policies
Wellness policies started to satisfy a rule change in the federal School Lunch Program. These
policies should be created collaboratively with students, teachers, parents, and school
administrators.

The Briefing Book -- 28
School Health: Wellness

The plans should also be accountable through self-evaluation means, promote healthy eating,
and promote physical activity that takes place before, during, and after school.10

Different districts approach their wellness programs in different manners, to best fit the needs of
their students. Both Adams 12 Five Star Schools11 and Garfield 1612 have districtwide wellness
policies, though their approaches to implementation vary.

Adams 12’s policy approaches wellness goals broadly, giving room to schools to find the
implementation strategy that works best for them. This broad approach is made effective by
outlining what is disallowed by schools, rather than defining affirmative metrics that may be
easy to accomplish for some schools but difficult for others. The breadth of the policy allows it to
emphasize the importance of a wide scope and comprehensive culture when improving school
wellness.

Garfield 16’s district wellness policy approaches the goal of school wellness by establishing
specific measures that can be accomplished by its schools. The policy names achievable goals
for and is more detailed in its approach to what constitutes a comprehensive wellness strategy.
In defining actionable goals and opportunities for schools to implement a comprehensive
wellness strategy, the policy can serve as a provisional roadmap to help guide administrators to
implement the best methods to create a healthy school.13

Mental Health Services

Mental health access and supports in schools can provide a quality environment for Colorado
students to succeed, but there need to be professionals available to administer that assistance.
Colorado ranks quite low, 39th14 in the nation, when it comes to its nurse-to-student ratio. Even
within schools, confusion is common around responsibility for directing at-risk children to
appropriate mental health care. The confusion often delays or inhibits appropriate interventions.

In 2016, the state legislature created a Behavioral Health Care Professional Matching Grant
Program, administered by the Department of Education. This program is meant to improve
student access to substance abuse and mental health care, and is not intended to replace
funding already allocated to those areas. The grant program is set up to provide matching funds
to state education providers, in hopes of increasing the number of substance abuse and mental
health care professionals in schools.15 While this does not directly address Colorado’s nurse-to-
student ratio in schools, it is a step in the right direction.

The Briefing Book -- 29
School Health: Wellness

The Future of Wellness in Schools
Colorado’s SBHCs serve an important role in the lives of our state’s young people. Medicaid’s
continued financial support of these clinics is crucial for their survival and potential expansion.
More can also be done to address the mental and emotional well being of Colorado residents under
the age of 18. Additional funding for SBHCs would help to decrease the state’s student-to-nurse
ratio, which would provide better access to care, as well as better access to a range of services.
While the Behavioral Health Care Professional Matching Grant Program is an important step
toward increased behavioral health services in schools, it is only a small investment in our
students’ mental health and well being. Policy makers should continue to explore innovative ways
to bring additional mental health screening and treatment opportunities to SBHCs.

Wellness policies are a critical step that local district leadership can take to demonstrate a
commitment to a healthy school environment. A comprehensive wellness policy should include
all aspects of children’s health. This includes physical activity, nutrition, food marketing and
provisions meant to safeguard a student’s mental health and well-being. Many model wellness
policies include an anti-bullying clause and the school’s commitment to fostering an emotionally
supportive environment. Wellness policies and SBHCs are not necessarily linked. Many schools
that have voluntarily adopted wellness policies do not have school based health centers.

Endnotes

1. McIntyre, Adrianna. “Kids who ge health insurance are more likely to finish high school and college.” Vox. June 04,
2014. http://www.vox.com/2014/6/4/5776050/kids-who-get-health-insurance-are-more-likel-to-finish-high-school.

2. Bersamin, M., S. Garbers, J. Gaarde, and J. Santelli. “Assessing the Impact of School-Based Health Centers on
Academic Achievement and College Preparation Efforts: Using Propensity Score Matching to Assess School-Level
Data in California.” The Journal of School Nursing 32, no. 4 (August 23, 2016): 241-45.https://www.ncbi.nlm.nih.gov/
pubmed/27009589

3. “The Changing Face of Colorado’s School-Based Health Centers.” The Colorado Health Institute. August 2016. http://
www.coloradohealthinstitute.org/sites/default/files/file_attachments/SBHC_August_2016.pdf

4. “Colorado Revised Statutes Title 25 Health § 25-205-503 School-based health center grant program--creation-
-funding-- grants.” FindLaw. Accessed April 28, 2017. http://codes.findlaw.com/co/title-25-health/co-rev-st-
sect-25-20-5-503.html.

5. “FY 2015-16 Supplemental Request - Public Health and Environment.” CDPHE. Accessed April 27, 2017. https://
drive.google.com/file/d/0B0TNL0CtD9wXWmZ0Q3ZYRnYteEE/view?usp=sharing.

6. Triedman, Natalie, Jeff Bontrager, Rebecca Crepin, Cliff Foster, Deb Goekin, and Joe Hanel. “Assessing the Need for
School-Based Health Center Services in Colorado, 2015.” The Colorado Health Institute. April 10, 2015. https://www.
colorado.gov/pacific/sites/default/files/SBHC2_Assessing-the-Need_report-April-2015.pdf.
The Briefing Book -- 30
School Health: Wellness

7. “Your Rights Under HIPAA.” HHS.gov. Accessed April 27, 2017. https://www.hhs.gov/hipaa/for-individuals/
guidance-materials-for-consumers/index.html.

8. “Family Educational Rights and Privacy Act (FERPA).” U.S. Department of Education. Accessed April 27, 2017.
https://ed.gov/policy/gen/guid/fpco/ferpa/index.html

9. Colorado Legacy Foundation. “Best Practices Guide for Healthy Schools.” Colorado Education Initiative. Accessed
April 27, 2017. http://www.coloradoedinitiative.org/wp-content/uploads/2013/04/BestPracticesGuideUpdatedPages.pdf.

10. “Local School Wellness Policy.” United States Department of Agriculture Food and Nutrition Service. April 20, 2017.
https://www.fns.usda.gov/tn/local-school-wellness-policy.

11. Adams 12 Five Star Schools. Superintendent Policy - Wellness Policy. PDF. Thornton, CO.

12. Garfield County School District No. 16. School Wellness. Parachute, CO, June 13, 2006.

13 “Welcome to the WellSAT 2.0.” WellSAT: Rudd Center. Accessed April 27, 2017. http://www.wellsat.org/default.
aspx.

14. Healthy Children Learn Better! School Nurses Make a Difference. PDF. Silver Spring, MD: National Association of
School Nurses.

15. Anderson, Meg, and Kavitha Cardoza. “Mental Health In Schools: A Hidden Crisis Affecting Millions Of
Students.” NPR. August 31, 2016. Accessed April 26, 2017. http://www.npr.org/sections/ed/2016/08/31/464727159/
mental-health-in-schools-a-hidden-crisis-affecting-millions-of-students.

The Briefing Book -- 31
Community Health
Physical Activity
• Obesity levels and leisure physical activity vary widely across the state.

• Investing in public spaces and the related infrastructure, so that individuals can choose to be
active, is one important way to impact public health within a community.

Food Access
• Access to healthy, fresh food is a major determinant of health for thousands of Coloradans.
Both accessibility and affordability are top reasons why many of these types of foods are not
available to all individuals.

• Food insecurity raises the risk of obesity and affects women and people of color at a higher
rate than their white, male counterparts.

• Colorado should focus on investing in programs to increase the accessibility and
affordability of food. One successful example is the Double Up Food Bucks Program.

Community Infrastructure
• Poverty, unemployment, and underemployment are major factors in determining health. Poor
health can further exacerbate the effects of poverty.

• Lack of affordable housing, a major factor in poverty, can be traced to regulatory issues such
as construction defect litigation, density limits and supply issues.

• Creating spaces for people to be active in their community is one way to improve health,
regardless of income level or residential area. Investing in complete streets, to include bike
lanes and sidewalks, can improve people’s ability to move in their community. Additionally, this
investment can create jobs, increase home values, and improve public safety.

Oral Health
• Ensuring that Coloradans have excellent oral health will lead to broad benefits to our state's
overall health.

• Although Coloradans have access to Colorado's dental Medicaid program, they still face
barriers in seeking treatment and preventative dental services with this type of insurance.

• Community water flurodiation is an evidence-based, cost effective, public health benefit that
means just simply adjusting fluoride to an optimal level that protects teeth from decay.
32- The Briefing Book
Community Health: Physical Activity

Physical Activity
Colorado at a Glance

T hough Colorado does rank among the states with the
lowest prevalence of obesity, the obesity rate in Colorado
has doubled in the past twenty years.1 The availability of
accessible and safe locations for physical activity in
communities is an area of opportunity for the state to improve
health outcomes on a large scale. Even small changes have the
capability to create larger population scale ripples.2

Amounts of leisure time physical activity vary wildly among
different regions of the state. The quantity of the population
which is overweight or obese also shows substantial regional
variation.3

Different ethnic and racial populations see disparities in their
P.A. rates as well. More than 64% of Black Coloradans and
66.4% of Hispanic Coloradans are overweight or obese, with
21.4% and 27.1% of those populations, respectively,
reporting that they do not engage in leisure time P.A.

These rates stand in stark contrast to the state average of 56.6% of the population who are
overweight or obese, and 16.4% of the population who do not engage in leisure time P.A. Some
populations do show better-than-average health indicators: 54.4% of American Indian
Coloradans and 54.6% of white Coloradans are overweight or obese, with only 13.2% of white
Coloradans reporting that they do not engage in leisure time P.A. 4

Coloradans of differing levels of educational attainment also experience differences in their
quantity of leisure time P.A. Coloradans with higher levels of educational attainment are more
likely to engage in it. 34.7% of Coloradans with less than high school diploma or G.E.D. and
22.6% of Coloradans with a H.S. diploma or G.E.D. reported no leisure time P.A.

The Briefing Book -- 33
Community Health: Physical Activity

Populations Reporting No Leisure Physical Activity

White Coloradans 13.20%

Hispanic Coloradans 27.10%

Black Coloradans 21.40%

State Average 16.40%

In comparison, 14.9% of Coloradans with some post high school education and 7.4% of college
graduates.

Higher levels of income were also associated with greater leisure time P.A.: 32.5% of Coloradans
earning $15,000 or less and 25.4% of those earning between $15,000 and $24,999 reported that
they did not engage in leisure time P.A. Only 12.6% of Coloradans earning between $50,000 and
$74,000 and a mere 7.8% of those earning more than $75,000 did not engage in leisure time
P.A.5

Creating Active Public Spaces
Physical activity can be encouraged and enabled through smart
policy. Both real and perceived ease of access to natural physical
activity are important to the ability to impact public health
within a community,6 and creating publicly accessible options
can help to combat current lack of current physical activity
trends.

The Briefing Book -- 34
Community Health: Physical Activity

The concept of active transportation can be integrated into zoning laws, neighborhood plans, and
business development programs.7 Active transportation programs, can be broadly utilized to
change a community’s capacity and willingness to engage in P.A. Greater proximity to methods
for active transportation have been shown to be related to greater prevalence of active
transportation.8 Steps toward this goal will vary depending on the location of the community. The
processes that work for rural communities may not look the same as those for urban areas.

Case Study 1: Lamar

Community members in the city of Lamar (population 7,800),9 in conjunction with the Urban
Land Institute, were able to identify challenges and create a set of active transportation solutions
for their community10. These challenges and solutions were all tailored to the character and
unique capabilities of the city. The importance of this locality of solutions cannot be overstated --
neighborhoods know best what they need, but those needs may require the support of larger
governments and/or organizations to be fully implemented.

The majority of transportation in Lamar, as described by residents, was accomplished by
cars. Due to this reliance on vehicles, much of the infrastructure for active transportation (safe
sidewalks and/or bike paths) were either in disrepair or nonexistent. This vehicular focus extends
even to Main Street, where fast-moving trucks make the street unwelcome to pedestrians and
bikers. Additionally, many existing parks were underused and lacking in modern facilities,
making them unappealing destinations. Despite Lamar's strong city center, the dispersed nature
of the surrounding community and irregular nature of transit in the area create barriers to
utilizing active transportation as a method for daily commutes.

Active transportation, for Lamar, needs to be an attraction in its own right. People need to want to
actively move for the enjoyment of it. The community-centered solutions to these issues were
primarily infrastructure improvements, including better lighting for sidewalks and parks, clearer
signage for trails and paths, and the development of parks as community gathering places to
better attract individuals and families. These are local projects, but state-level encouragement and
supports are certainly possible and often a boon to the communities undertaking them.

The Briefing Book -- 35
Community Health: Physical Activity

Case Study 2: Westwood in Denver

The Denver neighborhood of Westwood stands as a useful counterpoint to show the unique
challenges in an urban environment to encourage physical activity through public policy.
Westwood is home to roughly 16,900 Coloradans11 and is in the process of implementing a
neighborhood plan that aims to solidify the character of the area, with a complementary goal of
improving public health.12 Westwood’s neighborhood plan included a Health Impact Assessment,
which found that Westwood had higher rates of both children and adults who are overweight or
obese, compared to the rest of the city of Denver.13

The neighborhood plan was created with the input of Westwood residents, with the intent that
their vision be translated into the community they wanted. Prior to the implementation of the
plan, residents expressed that the transportation network in the area benefited cars over
pedestrians, with Morrison Road -- a main thoroughfare -- lacking speed control measures. This
vehicular-centric outlook similarly makes it difficult for children to walk to school. This had a
substantial impact for the community, which has the largest population of children in the city and
where most elementary students live within one mile of their school. Residents also saw that the
area was under-served when it came to availability of public parks and recreation.

To combat these challenges, the neighborhood plan includes: increased traffic-calming measures
on heavily traveled roads (such as traffic circles or clearly defined pedestrian crossings), better
transit connectivity (which is a useful backup for when folks plan to engage in active
transportation for their day-to-day activities), safety improvements to routes often used by
children to get to school, and improvements such as safer bike infrastructure and further
integration of Westwood bikeways into existing city plans to facilitate greater daily bike usage. 14

The Future of Physical Activity in Colorado
While most of the policy aimed at creating widespread active communities is happening at the
local level, state-level interventions and supports can help bring about positive outcomes by
complementing local efforts. Active transit can be supported at the state level through budgeting
and grant programs for communities across the state to use for active transportation and
complete streets infrastructure. That could include sidewalks, bike lanes, and features to keep
non-car users safer. The state also plays a significant role in designating and maintaining
outdoor recreation spaces and providing funding and legal and oversight infrastructure support
for the Safe Routes to Schools program.

The Briefing Book -- 36
Community Health: Physical Activity
The state should work in close partnership with local governments across Colorado to support
efforts to create communities where active lifestyles are not only possible, but the norm.

Endnotes
1. “Overweight and Obesity in Colorado: data infographic.” Colorado Department of Public Health and Environment.
Accessed April 29, 2017. http://www.chd.dphe.state.co.us/Weight/obesity-in-Colorado-infographic.html.

2. Lytvyak, Ellina, Dana Lee Olstad, Donald P. Schopflocher, Ronald C. Plotnikoff, Kate E. Storey, Candace I. J.
Nykiforuk, and Kim D. Raine. “Impact of a 3-year multi-centre community-based intervention on risk factors for
chronic disease and obesity among free-living adults: the Healthy Alberta Communities study.” BMC Public Health
16, no. 1 (2016). https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3021-1.

3. “Behavioral Risk Factors.” Colorado Health Information Dataset (CoHID). Accessed April 28, 2017. http://www.chd.
dphe.state.co.us/cohid/topics.aspx?q=Behavioral_Risk_Factors.

4. “Chronic Disease and Health Promotion Data & Indicators: Table of Overweight and Obesity (BMI).” Centers
for Disease Control and Prevention. Accessed April 28, 2017. https://chronicdata.cdc.gov/Behavioral-Risk-Factors/
BRFSS-Table-of-Overweight-and-Obesity-BMI-/fqb7-mgjf/data.

5. “Chronic Disease and Health Promotion Data & Indicators: Nutrition, Physical Activity, and Obesity- Behavioral
Risk Factor Surveillance System.” Centers for Disease Control and Prevention. Accessed April 28, 2017. https://
chronicdata.cdc.gov/Nutrition-Physical-Activity-and-Obesity/Nutrition-Physical-Activity-and-Obesity-Behavioral/
hn4x-zwk7.

6. Carlon, Jordan A., M.A., James F. Sallis, Ph.D., Terry L. Conway, Ph.D., Brian E. Saelens, Ph.D., Lawrence D.
Frank, Ph.D., Kelli L. Cain, M.A., and Abby C. King, Ph.D. “Interactions between Psychosocial and Built Environment
Factors in Explaining Older Adults’ Physical Activity.” Preventative Medicine 54, no. 1 (January 01, 2012): 68-73.
doi:10.1016/j.ypmed.2011.10.004.

7. “Transportation Health Impact Assessment Toolkit.” Centers for Disease Control and Prevention. October 19, 2011.
https://www.cdc.gov/healthyplaces/transportation/promote_strategy.htm.

8. Goodman, Anna, Shannon Sahlqvist, and David Ogilvie. “New Walking and Cycling Routes and Increased
Physical Activity: One- and 2-Year Findings From the UK iConnect Study.” American Journal of Public Health 104, no.
9 (September 2014): 38-46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151955/.

9. “American FactFinder - Community Facts.” United States Census Bureau. Accessed April 28, 2017. https://
factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF.

10. Urban Land Institute. Lamar Colorado Healthy Places: Designing a Healthy Colorado. Accessed April 28, 2017.
http://www.coloradohealth.org/sites/default/files/documents/2017-01/Lamar_revised_ULI%20Panel%20Report.pdf

11. “Community Facts: Westwood.” DenverMetroData.org. Accessed April 28, 2017. http://denvermetrodata.org/
neighborhood/westwood.

12. “The Westwood Neighborhood Plan.” Denver City Council. July 18, 2016. https://www.denvergov.org/content/
dam/denvergov/Portals/646/documents/planning/Plans/Westwood_Neighborhood_Plan.pdf.

The Briefing Book -- 37
13. “Health Impact Assessment for the Westwood Neighborhood Plan.” Denver Department of Environmental Health.
July 2016. https://www.denvergov.org/content/dam/denvergov/Portals/771/documents/CH/Westwood%20HIA/
Westwood%20HIA%20-%20compressed.pdf.

14. Ibid.

The Briefing Book -- 38
Community Health: Food Access

Food Access

A ccessibility of healthy, fresh food is a major determinant of health
for thousands of Coloradans. It’s estimated that nearly 700,000
people are food-insecure in Colorado1, of whom more than 226,000
Food Insecurity:
An economic and
social condition
are children. Of Colorado’s nearly 1.3 million children, 18.1% were of limited or
food insecure in 2014.2 These numbers have serious impacts on uncertain access
wider health outcomes in the communities where they live. to adequate food.
Healthy food might not be available due to a variety of factors, chief
among them being accessibility and affordability. Federal assistance
is available through programs like the Supplemental Nutrition Assistance Program (SNAP)
and the Women, Infant, and Children (WIC) Food and Nutrition Service, and roughly 59% of
Americans who report being food insecure are enrolled in at least one of these programs.3

The Briefing Book -- 39
Community Health: Food Access

Conforming to USDA healthy eating
guidelines could increase the average
food budget by 10%.4 Despite this,
the average Coloradan enrolled in
SNAP is allotted only $129.92 per
person per month, and households of
two people, receive around $275.96.5
These low figures mean that healthy
eating is even more difficult to afford.

Food insecurity raises the risk of
obesity by 32%. The effects are felt by
women first, particularly mothers. They
are more-likely to be obese than women
without children and fathers, even
when accounting for the metabolic
changes of pregnancy.6 People of color in Colorado are also more likely to be obese than their
white counterparts. Twenty-nine percent of African American Coloradans and 28.3% of Hispanic
Coloradans are obese, compared to 19.1% of white Coloradans.7

Colorado at a Glance
The accessibility of food is a huge determinant of health for Coloradans, especially Coloradans
of color. Studies have shown that Hispanic neighborhoods like Sun Valley or Westwood have
only 32% as many chain supermarkets as white neighborhoods such as Cherry Creek or
Congress Park. African American neighborhoods such as Five Points and Montbello have only
52% as many. This difficulty is compounded in areas dependent on cars. For the more than a
quarter of Americans earning below $20,000 a year having no access to a car, grocery shopping
becomes very difficult. People living in these communities often rely on fast food and smaller
corner shops that frequently do not have the capacity to offer healthy options.8

One solution from Detroit has been the Double Up Food Bucks (DUFB) program9, which matches
SNAP benefits when they're used at farmers markets and grocery stores. Eighty-three percent of
farmers at participating farmers markets said they made more money with the DUFB program in
place. As a response to the increased sales, 35% of farmers said they would put more land into
production, and 43% said they would start using hoop houses to increase the growing season.

The Briefing Book -- 40
Community Health: Food Access

On the consumer side, 70% said that the food they purchased through the program was cheaper
than at their neighborhood store. Moreover, 85% said the quality of the food was better than
what they could buy at the neighborhood store, and 95% said the market was easy to get to.
Most important of all, 93% of the SNAP DUFB shoppers reported eating more fruits and
vegetables.10 The model expanded into Colorado, where previously there had been local efforts,
such as the Harvest Bucks Program at the Boulder County Farmers Market, but no statewide
program.11

In Philadelphia, the Healthy Corner Store Initiative targets the existing infrastructure of corner
stores and incentivizes them to sell more healthy, nutritious options through a series of easy to
follow steps and cash bonuses. The program proved so popular that the population of stores
participating grew sixteen times its pilot size in two years, demonstrating that some store owners
want to provide healthier options and residents of their communities want to purchase those
options. Outcomes of the program included increased sales, decreased food waste, and increased
property values in the surrounding communities.12 A similar program began operating in Denver
in 2016.13

The Briefing Book -- 41
Community Health: Food Access

Part of the reason that the Healthy Corner Store Initiative in Philadelphia was so successful was
that it remained culturally relevant to participants throughout the process. A majority of the store
owners who participated in the program were most comfortable speaking Spanish, so
consultations were held in that language.14 Besides linguistic barriers, cultural barriers also
exist to health.

There are organizations working to eliminate those barriers. Oldways, a nonprofit food an
nutrition education organization that focuses on culturally traditional diets, has created new food
pyramids specific to the African diaspora, the Latino community, and the Asian community, each
of which seek to recreate diets that were common before the advent of many food-related
diseases like diabetes and heart disease.15 These programs show that where Eurocentric
approaches to health can fail to appeal to people who may not trust these institutions, there are
alternative methods available, ones that will inspire trust and understanding.16

Changing diets is only one way to improve health outcomes in our
communities. Increasing outdoor activity is another critical step.
Changing diets is only One way to do both is by encouraging gardening. The Gardens for
one way to improve Growing Healthy Communities research initiative, a partnership of
Denver Urban Gardens and the Colorado School of Public Health,
health outcomes in our
reports numerous health benefits that gardeners experience,
communities. More including an increased intake of fresh produce, better mental and
outdoor activity is physical health, and increased community involvement, all while
giving produce to friends and neighbors. Benefits extend even
another critical step.
beyond gardeners: 88% of people surveyed who didn’t garden said
they would want a garden in their neighborhood.17

The Future of Colorado Food Access
Colorado must continue to engage innovative solutions to solve the
state's lack of access to healthy food. We can look towards
successes in Philadelphia, Detroit, and even Denver, but we also
must develop our own innovative community-centered solutions. In
Colorado must
addition to creating incentives for local use of SNAP dollars at
continue to engage
farmers markets and for corner stores to offer fresh produce, we
innovative solutions
must explore ways for the private sector to work with local
to solve the lack of
communities to bring grocery stores and increased healthy food
access to the healthy
options to residents.
food problem

The Briefing Book -- 42
Community Health: Food Access

Ensuring that everyone across Colorado, whether they are living in a rural or urban area, has
access to affordable and nutritious food will require new ideas and new collaborations. Along
with exploring policy change that improves access to nutritious food, the state’s leaders must
also work closely with the private sector to encourage the development of new grocery and
market infrastructure and increasing nutritious prepared food options.

Bibliography

1. “Food Insecurity in Colorado.” Feeding America. Accessed April 27, 2017. http://map.feedingamerica.org/
county/2014/overall/colorado.

2. “Child Food Insecurity in Colorado.” Feeding America. Accessed April 27, 2017. http://map.feedingamerica.org/
county/2014/child/colorado.

3. Coleman-Jensen, Alisha, Matthew P. Rabbit, Christian A. Gregory, and Anita Singh. “Household Food Security in
the United States in 2015.” Department Of Agriculture. Economic Research Service. September 2016. https://www.ers.
usda.gov/webdocs/publications/79761/err-215.pdf?v=42636.

4. Moyer, Dustin C. “Denver Food Deserts and the Impact on Public Health.” University of Denver. Accessed April 27,
2017. https://www.du.edu/korbel/ipps/media/documents/moyer_policymemo.pdf.

5. “Supplemental Nutrition Assitance Program: ‘Tate Activity Report Fiscal Year 2015.” The Program Accountability
and Administration Division. August 2016. https://www.fns.usda.gov/sites/default/files/snap/2015-State-Activity-
Report.pdf.

6. “Understanding the Connections: Food Insecurity and Obesity, Washington, DC.” Food Research and Action Center.
October 2015. http://frac.org/wp-content/uploads/frac_brief_understanding_the_connections.pdf.

7. “State of Obesity in Colorado.” Trust for America’s Health and the Robert Wood Johnson Foundation. Accessed April
27, 2017. http://stateofobesity.org/states/co/.

8. Moyer, Dustin C. “Denver Food Deserts and the Impact on Public Health.” University of Denver. Accessed April 27,
2017. https://www.du.edu/korbel/ipps/media/documents/moyer_policymemo.pdf.

9. “How It Works.” Double Up Food Bucks. Accessed April 27, 2017. https://www.doubleupfoodbucks.org/how-it-
works/.

10. “Connecting Farmers and Low Income Consumers.“ Fitzgeral and Canepa. October 21, 2014. http://www.
farmlandinfo.org/sites/default/files/Connecting%20Farmers%20and%20Nutrition%20Program%20Particpants_
AFTNationalConference2014.pdf.

11. “Double Up Food Bucks: A win for Colorado familites, farmers and communities.” Double Up Colorado. Accessed
April 27, 2017. https://doubleupcolorado.org/about-2/.

12. “Healthy Corner Store Initiative Overview.” Tbe Food Trust. Accessed April 29, 2017.
http://thefoodtrust.org/uploads/media_items/healthy-corner-store-overview.original.pdf

13. “Healthy Corner Stores.” Denvergov.org. Accessed April 27, 2017. https://www.denvergov.org/content/denvergov/
en/environmental-health/community-health/healthy-corner-stores.html.

The Briefing Book -- 43
Community Health: Food Access

14. “Healthy Corner Store Initiative Overview, Philadelphia.” The Food Trust. Accessed April 29, 2017.
http://thefoodtrust.org/uploads/media_items/healthy-corner-store-overview.original.pdf

15. “Inspiring Good Health Through Cultural Food Traditions.” Oldways. Accessed April 27, 2017. https://www.
oldwayspt.org/.

16. Taylor, Kevin. “Eating indigenously changes diets and lives of Native Americans.” Al Jazeera America. October 24,
2013. http://america.aljazeera.com/articles/2013/10/24/eating-indigenouslychangesdietsandlivesofnativeamericans.
html.

17. “Gardens for Growing Healthy Communities.” Denver Urban Gardens. Accessed April 27, 2017. https://dug.org/
gghc/.

The Briefing Book -- 44
Community Health: Infrastructure

Infrastructure
W hile health may be seen as confined to a doctor’s office or hospital, there are many factors
outside of access to traditional care that shape a person’s health. These things include social
determinants of health such as housing and jobs, as well as community infrastructure.

Colorado at a Glance
Housing

Too many Coloradans don’t have access to quality, affordable
housing. Fair market rent for a two bedroom apartment in the state
is $916, meaning that a wage to afford that living space would be
$17.61 per hour, or $36,623 per year1, assuming the renter is An analysis of
paying around 30%of their income, a common standard2 for the
amount of income that should be spent on housing. Based on
health in any
average wages, a fifth of working Coloradans don’t make above community is
$36,623 per year.3 Poverty4, unemployment5, and not complete
underemployment6 are huge factors in determining health without
outcomes. Poor health can, in turn, exacerbate the effects of
poverty, making the process cyclical. For these reasons, an
understanding
analysis of health in any community is not complete without what effects
understanding the effects of poverty there.7 Twelve percent of poverty might
Coloradans were living in poverty in 2014, and even more were
have.
hovering near that threshold. The Colorado Center on Law and
Policy estimates that nearly one-in-three Coloradans are living at
or near the poverty level.8

Often, the true cost of housing in Colorado is much higher than $916 a month. It’s estimated that
47% of the state's renting population is experiencing financial stress.9

The Briefing Book -- 45
Community Health: Infrastructure

Complete Streets

In addition to being expensive to maintain, single transit-mode neighborhoods are dangerous due
to the often-injurious interactions that they force pedestrians and bicyclists to have with
automobiles.10 One way to address this issue of inequality, where streets serve only cars and not
pedestrians or bicyclists, is to focus more investment dollars on complete streets11, which
generally promote safety for all street users.

Studies have shown that improving pedestrian mobility through the development of complete
streets also incentivizes private investment and raises property values. WalkScore, an
organization that rates cities on their walkability12, found that in seventeen major US real estate
markets, a one point increase on their WalkScore metric translated into between a $700 and
$300013 increase in home value.

Active transportation also has the potential to create more jobs. Labor-intensive projects like a
new bike lane or trail require more planning and less materials than an automotive-oriented
project like a street resurfacing, where the majority of the money spent on the project will go
towards materials over workers' wages.14

Active transportation in Colorado is on the rise. In 2016, 43% of Coloradans rode a bike at some
point15 and 85% took a walk15. These activities generated $4.8 billion between their respective
economic and health benefits. Forty-five percent of Coloradans report walking as a means of
transportation, usually either to work or school, at some point in the past year. An increase of
10% in the number of Coloradans who walk or bike could prevent 30 to 40 deaths per year16 and
generate $258 to $387 million in health benefits.17

The downtown neighborhoods in Denver and Boulder are very walkable, but that is feature which
does not extend far into the rest of the state, or even beyond the central neighborhoods of those
cities. But smaller, older towns, of which there are many in Colorado, have tremendous potential
to be walkable and bikeable communities18 that could attract new residents and generate
economic activity that has been sorely missed in rural Colorado. These towns' surrounding
natural beauty can attract investment and they can become models for a healthier standard of
living. Many of Colorado’s towns are already incorporated into a statewide biking infrastructure19
that could be a boon to both economic and public health.

The Briefing Book -- 46
Community Health: Infrastructure

Another job-creator in the state is transit, which has the added potential to alleviate congestion
on many of Colorado’s roads and highways. Public transportation currently exists in only 38
of Colorado’s 64 counties20, but there are benefits to expanding it to residents throughout the
state. By expanding public transit, it’s possible to improve the economic health of lower income
Coloradans and increase the mobility of seniors, young people, and people with disabilities who
don’t drive. One in ten Coloradans of driving age doesn’t have a driver’s license21, and
improving their transportation options improves their health outcomes -- especially when
considering the added benefit of their ability to get to a hospital, grocery store, behavioral care
clinic, or even a park.

Current barriers to improved service primarily stem from a
lack of funding streams. Funding for transit in Colorado
comesPRVWO\ from local and federal sources 6tate IXQGLQJ
LVFRPSDUDWLYHO\VFDQW 2perating dollars from local
sources in 2013 were $34,581,000, where $6,959,000 were
from federal sources, and $635,000 from state money.22
Senate %ill 13048, enacted in 201323, directs some highway
dollars to municipal transit projects, but CDOT remains
unable to help fund operating costs for local transit
authorities in any meaningful way. Because of this, there
are significant gaps in service, particularly in rural areas.23

The improvement of transit networks can spur the development of transit oriented developments,
or TODs.24 These developments are located close to a transit center, such as a park-n-ride or train
station, typically within a mile radius, and are denser, mixed use zoned developments that
encourage active transportation over vehicle use.25 These developments attract younger adults
and retired seniors alike, who are more interested in environments that are walkable and feature
more public space.26

Public Safety

The structure of the community environment can also have an impact on crime, which is a major
concern to many Coloradans. Statewide, rape and motor vehicle theft are on the rise27, and the
Interstate 25 corridor remains a major route for human trafficking, with 443 cases reported in
Colorado since 2007, roughly 45 cases per year for the last decade.28

The Briefing Book -- 47
Community Health: Infrastructure

These kinds of statistics are more than numbers. The underlying events deeply affect people’s
ability to engage in a healthy community. Parents may feel that they can’t let their children play
outside or people may be concerned to go out at night. Streets and sidewalks play a huge role in
determining how people feel about their neighborhoods.

Jane Jacob’s theory of 'Eyes Of The Street' details this issue. If
people don’t perceive their streets to be safe, they will
correspondingly think of their city as a dangerous place to live
overall. They'll thus be much less likely to spend time outside
and engage in their community in an active manner.

When we make streets more conducive to and safe for active use,
people will feel more comfortable spending time in their own
community. When that happens, the community serves to make
itself increasingly safer and more secure.29

The Future of Colorado Infrastructure
Health extends far beyond the scope of doctors’ offices and hospitals. Communities shape their
resident’s lives and health on a daily basis. Because of this, we should strive to not just ensure
that people have access to medical care, but that our communities are built in a way that
optimizes healthy opportunities.

In order to have an impact on Coloradans' overall health, both government and private entities
must address issues that have traditionally been considered outside of the scope of health. A
community’s built environment and infrastructure, the crime rate, availability of affordable
housing, and employment rates all have a tremendous impact on residents' health. While these
are big problems, Colorado has a long history of innovation in both the public and private sector
and the proven ability to recognize that each of the state’s communities has its own unique needs.

The Briefing Book -- 48
Community Health: Infrastructure

Endnotes

1. “Colorado.” Housingcolorado.org. Accessed April 25, 2017. http://c.ymcdn.com/sites/www.housingcolorado.org/
resource/resmgr/Advocacy/2014-OOR-CO_Profile.pdf.

2. Matthews, Chris. “The 30 percent rule: Why is this the benchmark for affordable housing?” Fortune.com. August
04, 2015. Accessed April 25, 2017. http://fortune.com/2015/08/04/housing-30-percent-rule/.

3. United States. Colorado Department of Labor and Employment. Office of Labor Market Information. Wage Rates
and Job Openings Table. Denver, CO: CDLE, 2017. Accessed April 26, 2017. https://www.colmigateway.com/vosnet/
analyzer/results.aspx?session=wagerates.

4. Conway, Claire. “Poor Health: When Poverty Becomes Disease.” Ucsf.edu. January 06, 2016. Accessed April 25,
2017. https://www.ucsf.edu/news/2016/01/401251/poor-health.
5. Linn, M. W., R. Sandifer, and S. Stein. “Effects of unemployment on mental and physical health.” American Journal
of Public Health 75, no. 5 (May 1, 1985): 502-506. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1646287/.

6. Alberti, Mike. “The hidden toll of underemployment.” Remapping Debate. November 9, 2011. Accessed April 26,
2017. http://www.remappingdebate.org/article/hidden-toll-underemployment.

7. Paul-Sen Gupta, Rita, MSc, Margaret L. De Wit, PhD, and David McKeown, MDCM MHSc FRCPC. “The impact of
poverty on the current and future health status of children.” Pediatric Child Health 12, no. 8 (October 1, 2007): 667-72.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528796/.

8. Webster, Michelle and S. Casey O’Donell. “State of Working Colorado 2015-16.” Colorado Center on Law and Policy.
November 1, 2015. http://cclponline.org/wp-content/uploads/2015/11/SOWC_2015_FULL_FINAL.pdf.

9. “Affordable Housing in Colorado.” Housing Colorado. Accessed April 26, 2017. http://www.housingcolorado. org/?
page=affordablehousingco.

10. Cook, Lindsey. “The Inequality of Who Gets Hit by Cars.” U.S. News. October 19, 2015. https://www.usnews.com/
news/blogs/data-mine/2015/10/19/the-inequality-of-who-gets-hit-by-cars.

11. “What are Complete Streets?” Smart Growth America. Accessed April 26, 2017. https://smartgrowthamerica.org/
program/national-complete-streets-coalition/what-are-complete-streets/.

12. “Cities in Colorado.” Walk Score. Accessed April 26, 2017. https://www.walkscore.com/CO/.

13. “Benefits of Complete Streets.” Smart Growth America. Accessed April 26, 2017. https://smartgrowthamerica.org/
app/uploads/2016/08/cs-economic.pdf, Washington, DC.

14. Garrett-Peltier, Heidi. “Pedestrian and Bicycle Infrastructure: A National Study of Employment Impacts, Political
Economy Research Institute.” Bike League. June 1, 2011. http://bikeleague.org/sites/default/files/PERI_Natl_Study_
June2011.pdf.

The Briefing Book -- 49
Community Health: Infrastructure

15. “Economic and Health Benefits of Walking and Bicycling - State of Colorado, Colorado Office of Economic
Development and International Trade.” BBC Research and Consulting. October 6, 2016. https://choosecolorado.com/
wp-content/uploads/2016/06/Economic-and-Health-Benefits-of-Bicycling-and-Walking-in-Colorado-4.pdf.

16. Ibid.

17. Ibid.

18. Ibid.

19. Mader, Christiaan. “Putting smart growth to work on Main Street.” Smart Growth America. March 15, 2017.
Accessed April 26, 2017. https://smartgrowthamerica.org/putting-smart-growth-work-main-street/.

20. Mattson, Jeremy. “Rural Transit Fact Book 2015.” Small Urban and Rural Transit Center. June 1, 2015. http://
www. surtc.org/transitfactbook/downloads/2015-rural-transit-fact-book.pdf.

21. Katz, Danny, Will Toor, Mike Salisbury, and Jill Lacantore. “Colorado Transit, Biking & Walking Needs Over the
Next 25 Years.” COPIRG. August 1, 2016. http://www.swenergy.org/data/sites/1/media/documents/publications/
documents/COPIRG-Transit-Report.pdf.

22.Ibid.

23. S. 13-048, 69th Assembly. (2013) (enacted).

24. CODOT. March 1, 2015. Statewide Transit Plan, https://www.codot.gov/programs/transitandrail/
statewidetransitplan/statewide-transit-plan/view, Denver.

25. “What is TOD?” Reconnecting America. Accessed April 26, 2017. http://reconnectingamerica.org/what-we-do/
what-is-tod/.

26. Noland, Robert B., PhD, Kaan Ozbay, PhD, Stephanie DiPetrillo, and Shri Iyer. Mineta National Transit Research
Consortium. October 1, 2014. Measuring Benefits of Transit Oriented Development, San Jose State College College
of Business, San Jose.

27. Lewis, Roger K. “Expect to see more transit-oriented housing in the future.” The Washington Post, May 6, 2015.
Accessed April 26, 2017. https://www.washingtonpost.com/news/where-we-live/wp/2015/05/06/expect-to-see-more-
transit-oriented-housing-in-the-future/?utm_term=.26d32b603a57.

28. USA. Colorado Bureau of Investigation. Crime Information Management Unit. Crime in Colorado 2015. Denver,
CO: CBI.

29. United States. Department of Health & Human Services . Office on Trafficking in Persons. Colorado.
Administration for Children and Families.

30. Paul, Jesse. “Why Pueblo has the highest per-capita homicide rate in Colorado.” Denver Post, March 12, 2016.
Accessed April 26, 2017. http://www.denverpost.com/2016/03/12/why-pueblo-has-the-highest-per-capita-homicide-
rate-in-colorado/.

31. Gehl, Jan. “Jan Gehl on Making Cities Safe for People.” Streets Blog NYC (web log), June 14, 2011. Accessed
April 26, 2017. http://nyc.streetsblog.org/2011/06/14/jan-gehl-on-making-cities-safe-for-people/.

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Community Health: Oral Health

Oral Health

O
ral health is a proven factor in overall health and well-being. From difficulty eating healthy
foods to tooth decay over time, studies have found that unhealthy teeth and gums regularly
correlate to heart disease and other life-threatening conditions.1 Ensuring that Coloradans have
excellent oral health will lead to broad benefits to our state’s overall health. According to the
2017 Colorado Health Access Survey, nearly 90% of Coloradans in good physical health reported
having good oral health, while only half of those with poor physical health reported good oral
health.2

Oral health must be examined as an intrinsic factor to overall health of Coloradans. Over time,
more Coloradans have gained dental insurance, which can help them achieve better oral health.
Seven out of ten Coloradans now have dental insurance, up 63% from 2009.2 Despite this, the
percentage of Coloradans who actually visited the dentist has held steady around 66%.3 Even
though access to dental insurance has increased, several factors still contribute to disparities
in the oral health of Coloradans. Those include socioeconomic status, number of dentists in a
geographic region, and differences between private and public insurance options.

Crucial factors such as community water fluoridation and children’s oral health should be
paid special attention. Community water fluoridation is an important public health benefit
and a necessary contributing factor to all Coloradans’ oral health. As oral health has lifelong
implications, paying special attention to the oral health of children leads to overall healthier
adults.

Colorado at a Glance
Access to dental insurance is an important factor when it comes to seeking oral health care.
According to the 2017 Colorado Health Access Survey, disparities still exist between those who
may have private and public insurance. Of those enrolled in private dental insurance options,
73.8% reported visiting a dentist or dental hygienist in the past 12 months, and 90.5% reported
having excellent or very good oral health. Comparatively, of those who are ensured in public
dental insurance, 60.2% reported visiting a dentist or dental hygienist in the past 12 months,
and 76.2% reported having excellent or very good oral health.2 Of those who are completely
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Community Health: Oral Health

uninsured, 34.9% reported fair or poor oral health.2

Colorado’s dental Medicaid program is called, “Health First Colorado.” Many Coloradans take
advantage of this public form of dental insurance – roughly 1 in 5 Coloradans are enrolled in
Medicaid.4 In 2014, an adult dental benefit in Medicaid provided greater access to care for low-
income families.3 The data show that Medicaid enrollees are taking advantage of the adult
dental benefit, with a tenfold increase between 2013 and 2016 in enrollees receiving dental care.3
There was also progress in terms of dental providers who provided services for Medicaid
enrollees, as it grew by 78% from 2013 to 2016.3

Although Coloradans have access to Colorado’s dental Medicaid program, they still face barriers
in seeking treatment and preventative dental services with this type of insurance. For example,
the statewide average of dentists accepting Medicaid sits at 48%.5 Four counties do not accept
any Medicaid dental insurance, Washington, Park, Pitkin, and Saguache counties.5 Even with
access to Medicaid dental insurance, Coloradans are often left with few dentists who accept this
insurance in their area.

It doesn’t matter if a Coloradan’s dental insurance is private or public, accessibility to a
dentist is a huge impeding factor to receiving dental care. Of Colorado’s 64 counties, 57 are
designated as a ‘Dental Health Professional Shortage Area’ by the U.S. Health Resources
& Services Administration.18 This shortage designation is defined by the number of dental
health professionals relative to the population for dental care in particular this means that
the population to provider ratio must at least be 5,000 to 1.6 Nine Colorado Counties have
no practicing dentist at all.5 These shortages greatly impede a person’s ability to seek dental
services.

In three regions, northeast Colorado, Weld County, and the San Luis Valley, less than 60% of
residents visited a dentist or hygienist in 2016.7 More than 40% of residents living in these
particular areas did not receive cleaning, screening, or other preventive dental services. Like
many issues in our state, there is a great disparity between Front Range counties and the rest of
the state. The highest rate of regular care is found in Douglas County, with 80% of its population
regularly seeing a dentist.7

Community Water Fluoridation
Community water fluoridation is recognized by the Centers for Disease Control and Prevention
as one of the ten greatest health achievements of the 20th century.8 Water fluoridation has been
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Community Health: Oral Health
shown to be safe and effective, and one of the least costly ways to provide the benefits of fluoride
to all residents of a community. Scientific research has shown that drinking optimally fluoridated
water prevents approximately 25% of cavities.9

Fluoride is derived from fluorine, one of the most common elements on Earth. Fluoride’s benefits
were first discovered right here in the early 1900s, in Colorado Springs.10 Fluoride is a naturally
occurring element and can be found in most water supplies, plants, and animals. Many water
systems in Colorado already have enough natural fluoride to prevent tooth decay. Among
communities whose supplies don’t, many choose to adjust their fluoride levels by taking part in
Community Water Fluoridation program.

Community water fluoridation is an evidence-based, cost-effective public health benefit that
means just simply adjusting fluoride to an optimal level that protects teeth from decay.
Approximately 74% of Coloradans whose homes are connected to a public water system benefit
from fluoridated water.11 As a state, Colorado ranks 28th among all the states for the percentage
of population receiving fluoridated water.12

The benefits of community water fluoridation run for citizens’ full lives. For young children,
fluoride helps strengthen adult teeth that are developing. For adults, fluoride supports tooth
enamel, which helps teeth stay healthy and strong. Further health benefits include: less-severe
cavities, fewer cavities overall, less pain due to tooth decay, and less need for fillings or removal
of teeth.13

Community water fluoridation also makes sense from an economic perspective, as it has been
shown to save money for the health care system and families. According to the CDC, “The return
of investment for community water fluoridation ranged from $4 in small communities of 5,000
people or less, to $27 in large communities of 200,000 people or more.”14

Community water fluoridation is an essential program for the state of Colorado to protect and
expand. Especially amid statewide concerns about access to dentists and affordability of care,
prevention programs, community water fluoridation included, must be a priority.

Children’s Oral Health
It’s also critical to understand and address barriers to oral health care among children as they
become adults because poor oral health can escalate into more serious problems later in life.
Good oral health has wide-ranging impacts on a child’s life, from school readiness to school

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Community Health: Oral Health

performance. Cavities and dental decay can affect children’s ability to sleep, learn, and thrive.
Yet they remain the number one chronic disease of childhood, both in Colorado and nationally.15
As such, it’s important that children receive regular dental care, especially preventative services
like sealants and fluoride, that can set them up for a lifetime of good health.

Over the past fifteen years, the oral health of Colorado’s children has improved significantly, but
disparities still remain. Colorado’s Oral Health Basic Screening Survey shows that fewer than
31% of Colorado kindergartners had tooth decay, missing teeth, or fillings in 2017, down from
the 46% in from the 2004 survey.3 In the same period, fewer students had untreated decay or an
urgent need for dental care. Another positive trend the survey found was that third graders were
much more likely to have dental sealants, which will protect teeth from cavities and decay.
Despite a positive trend, we still have room for improvement, as dental decay still remains a
significant problem for children. Almost 43% of third grade children still do not have sealants
on adult teeth and would benefit from this preventative treatment method.15

The same study also found that socioeconomic status still has a huge impact on oral health of
children, with as lower-income children are more likely to have tooth decay, missing teeth, or
fillings than higher income children.15 Additionally, students at the lowest socioeconomic status
schools were more likely to have tooth decay, more likely to have untreated decay, and less likely
to have preventive sealants than students at the state’s most-affluent schools.15 The survey also
found that students of color had a significantly higher burden of cavities and untreated decay, as
well as a lower prevalence of sealants compared to white students.15

In terms of dental coverage, Colorado’s children are more likely to have dental insurance than
adults: 85.3% of children are insured, compared to 65.2% of adults.16 Despite this, many young
children still lack access to a dentist or dental home. Also, children receiving Medicaid coverage
are less likely to see a dentist than those with private or commercial insurance. In 2017, 73.3%
of Medicaid enrollees younger than age 19 saw a dentist, compared to the 80.4% of those with
private coverage who saw dentists.17

It is crucially important to keep tabs on disparities and barriers Colorado’s children face to
accessing preventative dental care as these issues will only cause further problems to their oral
health and overall health as they grow into adults.

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Community Health: Oral Health

Endnotes
1. “Oral and Overall Health - Get the Connection.” Delta Dental. Accessed May 15, 2018. https://www.deltadentalins.
com/oral_health/overall_health.html

2. “2017 Colorado Health Access Survey: Oral Health” Colorado Health Institute. Accessed May 15, 2018. https://www.
coloradohealthinstitute.org/data/

3. “Promising Trends in Children’s Oral Health.” Colorado Health Institute. Accessed May 15, 2018. https://www.
coloradohealthinstitute.org/research/snac-labs/Food-for-Thought-Nov-2-2017

4. Daley, John. “One in Five Coloradans Now Enrolled in Medicaid.” Colorado Public Radio. Accessed May 21, 2018.
http://www.cpr.org/news/story/one-five-coloradans-now-enrolled-medicaid

5.“Percentage of Dentists Accepting Medicaid 2015-2016.” Colorado Health Institute. Accessed May 15, 2018. https://
www.coloradohealthinstitute.org/sites/default/files/download_files/MK%20Dental%20Map.png

6.“Dental Care Health Professional Shortage Areas “HPSAs.” Henry J Kaiser Family Foundation. Accessed May 15,
2018. https://www.kff.org/other/state-indicator/dental-care-health-professional-shortage-areas-hpsas/?currentTimefram
e=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

7.“Mapping Data A to Z: Oral Health Visits.” Colorado Health Institute. Accessed May 15, 2018. https://www.
coloradohealthinstitute.org/research/mapping-data-z-oral-health-visits

8.“Ten Great Public Health Achievements -- United States, 1900-1999.” Center For Disease Control and Prevention.
Accessed May 15, 2018. https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

9. “Health Indicator Report of Water - Fluoridated Drinking Water (HA2020 Leading Health Indicator: 20).” Alaska
Department of Health and Social Services. Accessed May 15, 2018. http://ibis.dhss.alaska.gov/indicator/view/
DriWatFlu.Potential.html

10. “The Story of Fluoridation.” National Institute of Dental and Craniofacial Research. Accessed May 21, 2018. https://
www.nidcr.nih.gov/health-info/fluoride/the-story-of-fluoridation

11.“Know the Facts about Fluoridated Drinking Water.” Colorado Fluoride Facts. Accessed May 15, 2018. http://www.
cofluoridefacts.org/know-the-facts.html

12. “Know the Facts.” Colorado Fluoride Facts. Accessed May 15, 2018. http://www.cofluoridefacts.org/

13. Arnold, Francis, et al. “Effect of Fluoridated Public Water Supplies on Dental Caries Prevalence.” Public Health
Reports: Tenth Year of The Gran Rapids-Muskegon Study. Accessed May 15, 2018. https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC2031043/pdf/pubhealthreporig00151-0024.pdf

14.“Water Fluoridation Basics.” Centers for Disease Control and Prevention. Accessed May 21, 2018. https://www.cdc.
gov/fluoridation/basics/index.htm

15.“Tooth be Told...Colorado’s Basic Screening Survey. Children’s Oral Health Screening: 2016-17.” Colorado
Department of Public Health & Environment. Accessed May 15, 2018. https://www.colorado.gov/pacific/sites/default/
files/PW_OH_BSSReport.pdf

16. “Colorado’s New Normal: State Maintains Historic Health Insurance Gains.” Colorado Health Institute &
The Briefing Book-- 55
Community Health: Oral Health

The Colorado Trust. Accessed May 15, 2018. https://www.coloradohealthinstitute.org/sites/default/files/file_
attachments/2017%20CHAS%20DESIGN%20FINAL%20for%20Web.pdf

17. “Family Matters in Oral Health. Connecting Children’s and Caregivers’ Dental Health Habits.” Colorado Department
of Public Health & Environment. Accessed May 15, 2018. https://www.coloradohealthinstitute.org/sites/default/files/
file_attachments/Parent-child%20oral%20health%202018.pdf

The Briefing Book-- 56
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