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Series: High-country residents find partial solutions to health-care costs

Editor's note: This is the last story in a six-part series on health care costs in the Colorado mountains.

The arid garden of affordable health care has sprouted some promising blooms in Colorado's mountain valleys thanks to innovation, generosity and cooperation.

In Pitkin County, a five-way partnership covering 21 percent of the people in the county and emphasizing nutrition, weight loss and everyday health has helped stem annual price bumps and even prompted a decline in premium costs for county employees.

It's called the Valley Health Alliance, comprising employees and their families of Aspen Skiing Co., Aspen Valley Hospital, Aspen School District, the city of Aspen and Pitkin County. It is one of the many Accountable Care Organizations that have sprung up since the advent of the Affordable Care Act.

The two variables of health care are cost and usage, Pitkin County Manager Jon Peacock said. Keep the employees healthier and total costs go down, even if the per-visit costs do not.

The emphasis on primary-care relationships, in which ailments and chronic conditions are spotted and treated early and efficiently, is beginning to pay dividends. By focusing on nutrition, weight loss, high blood pressure and stress, primary care doctors can stay ahead of problems that can cost thousands of dollars later.

It has saved so much money that the people who work for the county haven't had a premium bump in three years, and last year they saw a 15 percent decrease in what the insurance company charged the employer, Peacock said.

The alliance wouldn't have worked without buy-in from the hospital and other health providers in the county, Peacock said. "We created a partnership between payers and providers."

Recently, the alliance offered $200 to any member who showed up at a health fair and then brought the results of the blood tests to his or her primary care doctor for analysis and conversation.

With the county paying about $10,600 a year for health premiums per worker — and at least double that for a family of four — the $200 sop was money well spent, Peacock said.

Large employers in Pitkin County had been getting killed by the annual spikes in premium costs, which were typically double the inflation rate, Peacock said. "We wanted to preserve the vitality of our local provider community, but we needed them to realize we can't continue to foot these bills."

Now it looks like it is paying off.

"We put a lot of energy into it," Peacock said. "I wish we had a silver bullet, but frankly, I don't think there is one. I do know that organization needs to happen at a local level just as much as on a national level. If you want to decrease costs, you have to have a five- to 10-year vision of success."

"It's about building strategic relationships," said Kathleen Killion, Valley Health Allicance executive director, who hopes the VHA model can spread to communities throughout Colorado. She said such alliances "can position Colorado as having its act together relative to transformational health care services."

HEALTH SAVINGS ACCOUNTS

Aspen Skiing Co. gives its employees with families a $2,500 health savings account each year, spokesman Jeff Hanle said. It inspires them to shop around for the biggest discounts they can find. "We tell them, 'Look at your options.'"

From Aspen to Glenwood Springs, there are several different orthopedic outfits, for example. The company thinks there are good options in the valley, but if it means saving a lot of money, they're encouraged to leave the region for a particular test or procedure.

When the employee or a family member finds a good deal, it saves money because there is still money left in the healths avings account for the next medical need. And that saves money for Skico, which, like many larger companies, self-insures.

"It's been an important benefit. I can tell you that from personal experience," Hanle said.

Skico also offers many counseling and exercise classes for employees.

"Stretching, yoga, diet, education classes," Hanle said. "We do everything we can to keep them healthy," with the idea that healthy people are going to use medical services less.

Elsewhere, employers out of necessity are finding ways to save money for themselves and their employees. Colorado PERA, the pension system for teachers and state employees, carved out a special contract with one health system to try to save money on knee and hip replacements. PERA negotiated a steep discount with the provider in return for assuring that provider that a lot of business would surely come its way. Why? Because PERA also told its members that if they went through that provider, PERA would waive all the deductibles and co-pays, saving the individual retiree a lot of money.

Employers can be creative in other ways, too, including not treating all their employees the same. Lindsay noted his former employer, Lockton, puts money into a Health Savings Account for all its employees — but puts in more for those earning less than $50,000 than for those earning more.

"It's just in recognition that those earning less needed more help."

low-income HELP

Instead of complaining about the extra costs that the Medicaid population brings to health care, clinics and hospitals here are showing that the system can work.

The Colorado Mountain Family Health Clinics have sites in Glenwood Springs, Rifle, Basalt, Edwards, Avon and El Jebel, serving people who are at the federal poverty level or just slightly above.

Aspen Valley hospital contributed space and equipment, and other providers have contributed time and equipment.

The key to its success, CEO Ross Brooks said, is that it:

• Emphasizes preventive care.

• Tries to connect each customer to a primary care physician.

• Combines medical, dental and mental health care under one roof, and trains personnel to be on the lookout for those needs whenever they see patients.

• Saves money by reducing unnecessary trips to the emergency room, thus tamping down the rise in insurance premiums.

The best part is that the clients "are living healthier lives," Brooks said.

In all, Mountain Family serves 17,000 people. About half are on Medicaid and most of the rest are uninsured because of their immigrant status. Just a handful are young, healthy people who chose to pay the tax penalty rather than pay for insurance, Brooks said.

Brooks said health care costs are rising much faster in the commercial insurance market than in the Medicaid population.

Rather than scapegoating Medicaid or gutting it, lawmakers should take note that "investment in up-front primary care for the poor has saved the system billions of dollars," Brooks said.

"We're proud to be their partner," Peacock said, speaking for Pitkin County. "We want folks to have primary care physicians. We don't want to treat them in the emergency rooms — the least effective way."

Brooks wants to see more transparency in costs, so consumers and employers, not just health professionals, can see that while one hospital or outpatient clinic might charge $5,000 for a procedure, another will charge just $2,500. Software tools such as Health Advocate would be a boon to employers who self-insure, he said.

Still, Brooks laments that Mountain Family Clinics are reaching only about half of the low-income people in its areas. "There are more than 35,000 people here living on $24,000 a year or less," he said. "Our goal is to reach 75 percent — and when we reach that, we'll reset the goal for 90 percent."

Measuring quality by value

There are two ways to lower prices. One is the blunt instrument of demanding that providers accept a substantial discount from the insurer.

The other is more subtle and is called payment reform: Pay doctors and other providers based on the quality of service they provide and the value their services contribute to the health of the individual and the community.

"We have to incentivize the physician, give him or her the latitude to experiment on ways to improve the value and reduce the cost," said Bill Lindsay, chairman of the Colorado Commission on Affordable Health Care.

For years, hospital quality was defined by such things as infection rates, how quickly patients were discharged and the rate of positive incomes, Aspen Valley CEO Dave Ressler said. The new paradigm pushed by the Affordable Care Act — value — is more focused on cradle-to-grave health, healthy lifestyles and efficient care.

"How the whole system keeps them healthy, reducing overall resource costs. We are happy to be part of that," Ressler said.

After Children's Hospital of Denver started looking at value, it made a significant switch in how it treated children who came to the ER with symptoms of appendicitis. Historically, 90 percent of the kids would be given an MRI, which not only is very expensive but exposes the child to radiation.

Children's Hospital suggested to its doctors to only give MRIs when the appendicitis symptoms seem to indicate a complicated case. That brought the MRI rate down from 90 percent to 15 percent.

"That is a significant savings and, I would argue, better medicine," Lindsay said.

Championing affordable care that features the relationship between the primary care physician and the patient could have a downward effect on hospital revenue. Peacock applauded local hospitals for realizing that and said, "Even so, it's the right way to deliver health care in a community."

It's as much a mandate as it is altruistic, said Aspen Valley CFO Terry Collins. If America can't find a way to rein in health care costs, the whole system is in danger of collapse, he said.

More primary care docs

One proven way to lower health costs is to have a greater ratio of primary care physicians — family doctors, internists and pediatricians. But the trend is going in the wrong direction, nationally, in Colorado, and in the mountain valleys of the state, said Kim Marvel, executive director of the Colorado Association of Family Medicine.

Studies have shown that regions that have more than their share of primary care physicians per capita have lower overall health care costs, Marvel said. He cited a study that found that when there are only two family or internal medicine physicians per 10,000 people, the average health care costs are 33 percent higher than when there are five primary care physicians per 10,000 people.

The region needs another 22 primary care physicians to meet the goal of one PCP for every 1,900, according to Colorado Health Institute's "Colorado's Primary Care Workforce: A Study of Regional Disparities." That would be an increase of 30 percent. But in Colorado, family doctors are retiring faster than they're being replaced, Marvel said.

Obamacare exacerbated the shortage of family doctors, because with 20 million extra people gaining insurance, primary care physicians are stretched even thinner, Marvel said.

The research demonstrates that when most of the population has access to primary care, treatment is more likely to occur before severe problems develop, and there are fewer unnecessary trips to the hospital and ER, Marvel said. Also, primary care doctors tend to use fewer tests and are better at protecting people from overtreatment. Especially for the poor, access to a family doctor correlates with better blood pressure, more vaccines and reduced mortality.

Countries with the best health outcomes have a physician mix that includes 40 percent to 50 percent primary care physicians — family doctors, internists and pediatricians, Marvel said. In the United States, only a third of doctors are primary care physicians, and currently only a fifth of medical school students are on the PCP track.

Medical school is expensive and most graduate with huge loans to repay, so the incentive is there to go into a high-priced specialty.

If medical students do their residencies in rural areas, they are much more likely to establish practices there, Marvel said. But of the 13 residencies that require at least some time spent in rural Colorado, the only one in the mountain resort region is in Basalt and requires just one month there out of a three-year residency.

A break for locals

The mountain communities have one eye on the long-term solutions, but the other eye on the short-term solutions needed to stop the bleeding.

• The Pitkin, Summit, Garfield, Eagle, Routt region is the most expensive area of the state to buy health insurance.

• It has a higher percentage of people buying insurance on the individual market — 20 percent versus 8 percent statewide.

• And it has a higher rate of uninsured — about 11 percent versus 6.7 percent statewide.

Residents who are aware of those stats readily see the connection between the first two numbers and the third.

That's why they continue to push for cooperation from the rest of the state. If you want our water, want to ski on our slopes, soak in our hot springs, hike our trails, how about sharing the cost of health care?

In the meantime, nothing prevents hospitals and doctors in the mountain regions from offering two-tiered pricing — a lower rate for locals, a higher rate for outsiders, say, people from Texas or California who spend a day, a week or a season in the high country, Lindsay said.

It can get tricky — does a local utility bill prove you are a local resident? — but it is worth doing, and a way to lower premiums for the majority of full-time residents of Garfield, Eagle, Pitkin, Routt and Summit counties, he said.

Aspen Valley Hospital not trying to be like big city hospitals

Aspen Valley Hospital is required to keep on hand enough cash that it could continue to operate for 180 days even if it never collected a single bill in that time, hospital CEO Dave Ressler said.

Over the past decade, Aspen Valley has expanded its office space for practices and clinics. The first two phases are complete, one is half complete and the fourth is expected to cost about $11 million out of the entire $150 million project. Of that total, $50 million in general obligation bonds will be repaid through property taxes. Aspen Valley is two-thirds of the way through a $60 million campaign to raise money through philanthropy. Hospital reserves will be paying the balance.

Ressler has heard the complaints that the hospitals are palaces, with the gleam of bigger urban hospitals but much higher costs. But he says Aspen Valley isn't trying to duplicate bigger hospitals.

Aspen Valley doesn't have a cardiac catheter lab and doesn't do radiation oncology, which is very expensive, and doesn't do surgery of the heart, lungs or brain. So cancer patients go to Denver or elsewhere for their radiation but return to Aspen Valley for follow-up chemotherapy treatments.

Physicians don't open blocked arteries at Aspen Valley, but they manage lipids, administer medications and do follow-up care for heart patients.

Collecting bills is a delicate balancing act for rural hospitals. There are people who can't pay and people who choose not to pay — and they're treated differently, Aspen Valley Chief Financial Officer Terry Collins said.

If a patient can but doesn't pay, that's a bad debt — and that constitutes between 2.5 percent and 3 percent of Aspen Valley's budget. Notices are sent, but the hospital never takes, say, a car or a house over an unpaid bill. It does, though, make the debt known to credit agencies. So when the patient next applies for a car loan, say, and is refused, he or she will call the hospital, Collins said. "All of a sudden they're eager to pay."

The second category are people who are indigent or otherwise simply can't afford to pay the bill. That's called charity care. The hospital tries to connect the cash-strapped patients to state programs that offer assistance, or will try to extend the payment period. The charity care that goes uncollected amounts to several million dollars a year, but has dropped significantly since the advent of Obamacare.

The Affordable Care Act years also have seen a steep decline in the number of patients categorized as self-pay, that is, uninsured, with a corresponding increase in those who are on Medicaid. The ACA's Medicaid expansion provides government-paid for those whose household income is as much as 139 percent of the federal poverty level.

In Pitkin County, residents generally have a positive view of their hospital, even as they contribute $4 million in property taxes to it yearly. For the owner of a $600,000 home in Basalt, that is $240 annually for Aspen Valley Hospital. At those prices, they wouldn't mind a break on costs, especially with the health margins between revenue and expenses.

But Ressler notes that those margins fluctuate — skinny some years, broader others. The 2016 numbers are going to show a very thin margin, he said.

At Aspen Valley Hospital, charges are evaluated regularly to assure they are competitive and appropriate, Ressler said, acknowledging that prices at his hospital likely will continue to be significantly above the prices in Denver or Colorado Springs.

Aspen Valley does a lot for the community, Ressler said.

It teams with Aspen Skiing Co., the school district, the city and the county in the Valley Health Alliance, which aims to cut costs by improving overall health care, thus lowering usage of the system. And it contributes space and money to help the Colorado Family Mountain Health Clinics provide care to low-income people.

Aspen Valley has already seen a decline in admissions because of the two initiatives, Collins said, and if it means a hit to the hospital's bottom line, that's OK.

"We are owned by the community," Collins said. "The only reason we exist is to meet their medical needs."

It's a major pivot, being part of a system of care that focuses on the entire patient — wellness, mental health, staying on top of chronic conditions such as diabetes and asthma, said Elaine Gerson, Ambulatory Services administrator for Aspen Valley.

"It is exciting," she said, "the shift from patients for volume to patients for value."

Series: Colorado’s mountain hospitals have higher net income margins

Editor's note: This story is the fifth in a six-part series on health care costs in the Colorado mountains.

Hospital bills in the high country are higher than in metro Denver — but that's inevitable anywhere there is a small population base, say hospital executives.

The hospitals have to be big enough for the crush of ski season, when the number of people in the communities triples, and there are large numbers of fractures, sprains and concussions. But they can't hire nurses and doctors just for the ski season — or if they could, they would have to sweeten the deal with salary bumps.

"We have extremely low economies of scale" due to having to maintain staffing levels and equipment while having much lower usage per day, Aspen Valley Hospital CEO Dave Ressler said.

Whether they have one patient or 10, facilities need to maintain core staffing levels. That means a nurse for the first patient and a second nurse in case a second patient arrives during the shift.

But with insurance premiums in Pitkin, Routt, Summit, Eagle and Garfield counties 50 percent to 100 percent higher than they are on the Front Range, many high-country residents are wondering whether the hospital bills are justified — or whether the amenities have to be so nice.

Lynn Kirchner, a real estate agent from Carbondale, said her husband's navel hernia procedure would have cost more than $10,000 locally, but that he got it done for $800 in a suburban Denver hospital. "We could have gone to London — that would have been $4,000."

She said Valley View Medical Center in Glenwood Springs provides very good care — "they're a class act, I'm not denying them that" — and it has its share of people whose lives were saved and who contribute generously to the hospital.

But when she sees the expansion, the robotics lab and the valet parking, "I tell people, you are paying for that luxury."

A recent analysis of Colorado hospitals by hospital consultant Allan Baumgarten found that hospitals in the mountain recreation areas of the state have higher net income margins — net revenues less net expenses — than in metro Denver or than at other rural hospitals. For 2014, the margins were:

• 8.3 percent, Yampa Valley (Steamboat Springs).

• 13.1 percent, Valley View Medical Center, (Glenwood Springs).

• 23.3 percent, Aspen Valley Hospital (Aspen).

• 27.2 percent, Vail Valley Medical Center (Vail).

• 29 percent, St. Anthony Summit County (Frisco).

For metro Denver hospitals, the average margin was 15.6 percent; for rural hospitals the average margin was 7.2 percent.

Hospital CEOs agree that it is frustrating that insurance premiums here are so high, but they don't think their hospitals are the main culprit. They note that they've been raising their prices by just a couple percent a year, while overall health care spending has risen about 5 percent annually.

Confounding care prices

But that's not the whole story. One of the most confounding mysteries of the 21st century is the price of services at an American hospital.

Rural hospitals may announce that their "charges" are about the same as hospitals in urban areas. But what patients or insurance companies pay can vary greatly from those charges — and vary greatly from hospital to hospital.

In urban areas, insurers can negotiate rates for tens of thousands of people with a single hospital. And if the hospital doesn't accept a stiff enough reimbursement discount, the insurer can try with a half dozen more facilities.

In Colorado ski country, it's usually one hospital per county — and one or two insurers per county.

Hospitals can't resolve the issue of high health care costs alone, the executives say. "This is an issue involving all medical providers, insurance companies, drug manufacturers and the general wellness of the people accessing healthcare," Vail Valley President/CEO Doris Kirchner (no relation to Lynn Kirchner) said.

Hospital executives point to some of the popular aspects of Obamacare as driving up insurance costs, such as requiring that insurers not jack up rates for those with pre-existing conditions. The 20 million newly insured, especially those on the individual market, turned out to be sicker than anticipated, they say, driving the big increases in rates the past two years.

Typically, young people in the system offset the more expensive care for older adults, but in ski country, the young people tend to fracture bones, pull tendons, snap hamstrings and the like in their pursuit of outdoor sports, Vail Valley's Doris Kirchner said. So the young people here don't provide that hedge, even if they're in the system. And if they require expensive hospital care and are uninsured, they drive up hospital costs for all.

"I doubt if you are ever going to get health care as cheap in the resort areas as in Denver," Valley View Medical Center CEO Gary Brewer said. "It's just not going to happen."

If an insurer has only 1,000 clients — or "lives" in health insurance jargon — it's far riskier. If just one or two of those 1,000 come down with extremely expensive problems, the risk pool loses money — and insurance premiums skyrocket again the next year.

"If you don't bring us a large number of lives, it is very difficult to offer a good discount because there are just not enough lives," Brewer said.

The insurer always has the incentive to negotiate as steep a discount as possible, whereas the hospital tries to do the opposite — the thinner the discount, the better.

More transparency needed

Eagle County Commissioner Jill Ryan would like to see more transparency on hospital charges to get a better idea of whether what people pay at the hospitals in Vail, Aspen, Glenwood Springs and Frisco actually is significantly more for most procedures. There is a database for that, but most procedures come with an asterisk — "data not available."

Medicare operates a "hospital compare" website that compares hospitals on patient satisfaction, appropriate use of imaging tests and costs of procedures. In the most recent published survey on patient satisfaction, St. Anthony Summit, Vail Valley, Yampa Valley Medical Center and Aspen Valley all scored above average compared with other hospitals in Colorado and the nation. Valley View in Glenwood Springs was given average scores.

On price, most of the rural hospitals didn't have enough data for a fair comparison, or were deemed to not vary significantly from the average for similar hospitals.

The mountain resort hospitals ranked within a point or two of average on the appropriate use of imaging tests such as CT scans and MRIs. The exception was Valley View, which gave MRIs about 58 percent of the time to patients complaining of lower back pain, without first trying physical therapy. The state and national average is about 40 percent.

Overuse of MRIs is considered a major driver of health care costs.

'Charge master' pricing

The hospital patients who get hit with the astronomical bills are generally the uninsured who are asked to pay the notorious "charge master" prices.

Those prices are four or five times what insurance companies pay, after they've negotiated steep discounts with the hospitals. In areas where there is just one hospital and few insurers, the discounts aren't as steep, so what the insurers pay is higher, and what they charge their customers for premiums is higher.

The "charge master" prices are about eight times higher than what Medicare and Medicaid pays. Hospital officials say those reimbursements don't cover costs, variously complaining that they lose anywhere from 50 cents on the dollar to 20 cents on the dollar for each senior (Medicare) or very low-income (Medicaid) patient.

For treating simple pneumonia, hospitals charge $53,000 to the uninsured, but Medicare reimburses $9,400; for chest pain, the "charge master" price is $25,600, the Medicare price $3,600.

In between those extremes is the price paid by those who are insured. Simple pneumonia might be $15,100 instead of $53,000.

But it can still be costly for insured residents of the resort regions. A bronze plan costing some $400 a month might come with a $6,000 yearly deductible, so that has to be paid before the insurer starts kicking in.

Obamacare's expansion of Medicaid — providing the care for those whose household income is as much as 139 percent of the federal poverty level — has helped lower the pot of uncompensated care at both rural and urban hospitals. But Medicaid reimbursements only cover about three-fourths of the costs of treatment.

Who's looking at numbers?

Executives of the nonprofit hospitals in Colorado's mountain resort communities note that every dollar they collect in excess of expenses is pumped back into the operation. But that's the rub. Margins can look tiny or huge, trumpeting thrift or largesse depending on who is looking at the numbers.

Allan Baumgarten, who contracts with several states to examine hospital expenses and revenue, noted that nonprofit hospitals don't pay dividends to shareholders or offer stock options to executives.

But saying that every dollar goes back into the operation is a very broad statement, he said. "It can include providing rich compensation packages to executives, it can be used to acquire physician practices or build new clinics, it can be used to improve facilities for certain specialties like oncology and orthopedic surgery and provide additional compensation to the doctors that practice at the hospital.

"In concept, those hospitals could say, 'Our reserves are strong, our bond rating is solid, we want to benefit the community by not increasing payments from insurers for the next three years.' But I would be surprised if I ever saw that happen."

Hospitals counter that they need those big margins year after year to be able to expand — and seemingly they are always expanding.

With expansion plans in the works, the only way to earn a low interest rate on bonds is to show investors that there is a good margin. And the way rating services such as Moody's measure that is to require hospitals to have cash on hand equal to a certain amount of days of operational costs.

Series: A look at how Coloradans in the mountain benefit from Obamacare

Editor's note: This story is the fourth in a six-part series on health care costs in the Colorado mountains.

Sometimes, Obamacare stories have happy endings, even in the mountain valleys of Colorado.

And they are reminders of the potentially disastrous consequences of attempts to dismantle Obamacare, piecemeal or wholesale.

Last year, Richard Backe of Glenwood Springs testified that health care costs for his family were so crushing that he might have to shut down his construction business and move to Denver, where premiums were about half the price he was paying. Last year, his family's premiums were $1,540 monthly; for this year, he was looking at $2,100.

But then he discovered that he qualified for a tax credit through Connect for Health Colorado because his family's income was less than — barely — 400 percent of the federal poverty level.

Now, his monthly premiums are relatively reasonable and he's staying put. And while he thinks the Affordable Care Act needs improvement, he has vowed to campaign against any politicians who "are a part of dismantling this good law."

Health experts in the mountain resorts and in metro Denver warn critics to be careful what they wish for — tossing out all or part of the Affordable Care Act can make things a lot worse.

Year after year, health care costs rise about twice as fast as the cost of living. A consensus of studies has suggested that without the ACA, health care costs in the United States would be 19 percent of gross domestic product, instead of the 18 percent it is today.

The ACA has made it possible for 20 million additional Americans to be covered by health insurance. It is a boon to many. While the majority are still covered by employer insurance and haven't seen big changes in their plans, it has been a godsend to those with pre-existing conditions who previously couldn't find coverage, and to those at or just above the poverty level who previously couldn't afford it but now enjoy generous government benefits.

And as many resort-town residents can attest, it's at least bearable, if not affordable, for those who can stay inside 400 percent of the federal poverty level and thus qualify for a tax credit.

The White House's Council of Economic Advisers December 2016 report on Obamacare noted that since 2012, Colorado went from 15.9 percent uninsured to less than half that, with 419,000 gaining coverage. Almost 3 million Coloradans are covered via employer plans (includes family members).

Due to the Affordable Care Act:

• 5,900 fewer Coloradans had catastrophic out-of-pocket costs.

• 18,700 fewer needed to take out loans to pay health care bills.

• There was a $140 million reduction in uncompensated care (hospital or doctor bills not paid).

• 2.25 million Coloradans have some kind of pre-existing condition, but can't be denied coverage.

• 108,000 have a plan on the individual market through Connect for Health Colorado.

• 67,000 of those received the tax credit, lowering their monthly premiums to an average of $318 per month.

• 52,000 could qualify for tax credits but haven't applied.

• Among Coloradans above 400 percent of poverty, just 3.2 percent are uninsured, down from 14.3 percent in 2013.

• 820,000 Coloradans are enrolled in Medicare. ACA gives them an average of $983 in savings on prescription drugs by eliminating the doughnut hole.

Colorado Insurance Commissioner Marguerite Salazar said Americans "don't have a firm idea of what is Obamacare and what isn't."

They like the part about not denying service to those with pre-existing conditions, so much so that they now feel it should be the natural floor for all plans. Until ACA came along, insurers could deny coverage to the 2.2 million Coloradans who had diabetes, asthma, heart conditions or a number of other pre-existing conditions.

And most people like that children can stay on their parents' plans until age 26. And those who get the tax credit love that aspect.

But they don't like the idea of being told they have to have insurance. That protestation "is as American as apple pie," Salazar said. But the various parts of ACA — or anything that replaces it under the Trump administration — have to stitch together or the whole thing falls apart.

Some women beyond child-bearing years ask why they're forced to buy a plan that includes maternity benefits. But younger people could just as readily ask why they're forced to buy a plan that subsidizes the greater health needs of people in their early 50s and early 60s.

Salazar notes that 15.3 percent of Coloradans were without insurance on the eve of Obamacare, and that has dropped to 6.9 percent. Over the long run, that will mean rates will go down as more people get a handle on their health, thanks to insurance.

Amy Downs, vice president at the Colorado Health Institute agrees. There were big increases — about 30 percent — in the individual market this year, but the rates were relatively low in 2014 and 2015.

"The carriers were either intentionally or unintentionally underpricing their plans. Now they have to catch up," Downs said.

That catch-up can hurt, especially for those who get no financial help to pay for premiums. "But that doesn't mean the market is broken," Downs said.

Experts who devote their lives to trying to rein in health care costs say it's hard to say which lever should be pulled at any given time. "So many things are contributing to the cost conundrum," said Adele Flores-Brennan, executive director of the Colorado Consumer Health Initiative, a consumer-oriented health advocacy organization.

Health costs comprise one-sixth of the gross domestic product, yet most people here aren't spending 18 percent of their incomes on health care, at least not directly.

In the mountain resort areas, 22 percent of the population is on Medicare due to their advanced age, and 23 percent qualify for Medicaid due to their low incomes. Those two groups pay very little; Medicaid relies on subsidies, including a new tax on the wealthy; Medicare relies on the FICA tax taken out of paychecks.

There is the large group that gets their health insurance from work. Typically the employer pays about 80 percent, with the employee paying the rest. If the employee needs to cover the whole family, the employer isn't as generous in its share for the whole family. Still, it typically adds up to a fairly small proportion of the income — if workers don't count the salary they could be earning if the employer didn't have to pay most of the premium.

The group seemingly getting the rawest deal are those in the individual market, typically self-employed people — and while they comprise only 8 percent of Colorado's population, they comprise 20 percent of the population of the mountain resort counties, according to the Colorado Health Institute.

They're the ones shocked to see a 30 percent rise in premium prices this year, the ones not failing to notice that they're paying double the premiums of self-employed people in metro Denver.

But more than half of the people in that group qualify for tax credits that are supposed to lower health care costs to 10 percent of their income. It often doesn't work that way because of the large deductibles that many feel forced to opt for. Nonetheless, for most of those with the tax credits, the costs are not catastrophic.

And there is a small slice of the population of Pitkin, Eagle, Garfield and Summit counties who are self-employed but earn so much money that the high premiums still don't account for much of a percentage of their total incomes.

That leaves some 6 percent of the area's population — maybe 10,000 people — bearing the toughest weight.

Backe is just relieved he is no longer in that group.

And while it can be frustrating to be constantly vigilant that he doesn't make too much money, he is grateful.

"The Affordable Care Act is not at heart of the problem," he said. "The problem is runaway health care cost and insurance costs."

His wife had cancer 10 years ago, and though she is doing well now, "we know what a $1 million hospital bill looks like" and what it can do to a family that doesn't have insurance.

"We were so close to the line. I'm not the only person walking the fine line. You either get the Advanced Premium Tax Credit or you have a hard choice. I know plenty of people who are going without."

Health care in America is like those crazy-shaped balloons — poke one side and the air moves to another side but still stays within the balloon.

President Donald Trump's proposal to keep pre-existing conditions but eliminate the mandate could encourage younger people to buy plans, but it also could cause an even greater exit of healthy people from the system, causing prices to rise faster for the slightly sicker population that remains in the system.

His proposal to give states more flexibility will bring back less comprehensive plans, eliminating maternity benefits, and others, and increase premiums for older and sicker people, while improving affordability for younger, less expensive people.

Encouraging health savings accounts as a replacement for the high deductibles in lower-priced plans is a boon to those who can afford to save, but crippling to those who can't.

Some think undocumented immigrants are getting a better deal than the self-employed middle class because they frequent the low-income health clinics and pay out of pocket on a sliding scale based on income. But Adela Flores-Brennan, executive director of the Colorado Consumer Health Initiative, disagrees.

"Undocumented immigrants are completely left out of ACA, they can't access Medicaid or CHP and they're not eligible for tax credits for bringing down the costs," she said. Despite paying into Social Security and Medicare with dollars they likely won't recoup, "they don't have a lot of options for coverage. They have to pay as they go."

It's human nature, all of this grumbling, and calling for better care, lower costs and more freedom to buy health care on their terms, Salazar said. But every tweak that helps one group hurts another.

"They like the candy and desserts, but they have to eat the vegetables that are the mandate," Salazar said. "Otherwise, everyone games the system and buys insurance only when they need it."

Series: State commission taking “deep dive” into health care costs in mountains

Editor's note: This story is the third in a six-part series on health care costs in the Colorado mountains.

People in the mountain resort towns of Colorado are used to spending as much as 15 percent more for gasoline, groceries and housing. But why 50 percent or 80 percent more for health care?

Aren't we healthy? Aren't we responsible?

They in particular want to know why Colorado nixed the idea of putting the entire state in one geography zone so people from all corners of the state would pay about the same for health insurance.

There are reasons why that didn't happen, some that make grudging sense to high country residents and some that don't.

Before Obamacare, "no one paid attention to what things cost," Colorado Insurance Commissioner Marguerite Salazar said. "Now, there's much more transparency."

While transparency generally is good, in this case it illuminated the differences in health costs between metro Denver and the mountain resorts. And that difference was huge.

Under the Affordable Care Act, no longer could insurers charge more to those with pre-existing conditions, and limits were placed on how much extra they could charge older people or women of child-bearing age.

They could charge more to people who admitted to being smokers, but couldn't charge more to people who were couch potatoes or made bad judgments or went to the emergency room for all their care. And they couldn't exclude a long list of services that are required under the tenets of Obamacare.

So, the focus was on geography — and the data showed that in places such as Aspen, Vail and Glenwood Springs, health costs in many categories were double what they were in places such as Denver, Boulder and Colorado Springs.

Outpatient care per person per year was $2,022 in Zone 9, but $1,075 in Colorado overall in 2014. People here were using MRIs and other imaging services as well as pathology and lab work at three times the rate of the rest of Colorado.

In particular:

• Advanced imaging (MRIs, CT scans, etc.) cost $185 per person per year in Zone 9 versus $47 statewide.

• Physical and occupational therapy was $49 per person per year in the mountains versus $19 statewide.

• Outpatient surgery was $852 here versus $409 statewide (see chart on page A12).

It's a combination of higher costs and more use of services, Salazar said. Yes, many people are in good shape in the mountain resorts, what with their snowboarding and hiking, rock climbing and bicycling, she said. But with those pursuits come the danger of fractures, tears, lacerations and separations of body parts.

The new rules say an insurer must contract with a local orthopedic specialist, must pay for MRIs and CT scans and such. When it's a small town, that often means there is only one of each kind of specialist. And that means that specialist has the clout to keep prices high. The insurers can't negotiate the steep discounts that they could if they had their choice of a dozen specialists to play off against each other.

Pitkin, Summit, Routt and Eagle counties have only one hospital each, and the choice of insurers is thin with Humana and United Healthcare leaving the individual market last year. "When a hospital has that kind of monopoly, it can make it difficult" for an insurance company to offer affordable rates, said Colorado Lt. Gov. Donna Lynne.

Insurers that want to compete in a geographic area of the state must by law establish contracts with providers and hospitals that are reasonably close to clients' homes. "In that respect, sole community hospitals have a lot of leverage over the health plans," Lynne said.

And so the prices are high, the usage is high and therefore what people in the mountains and valleys pay in monthly health care premiums also is very high.

But not all the data agree. The state's Single Geographic Area study found that outpatient care in Zone 9 was indeed double the statewide average, but that the overall health care cost here was about $6,300 in 2015, compared with $5,100 in Denver and $5,200 statewide.

That's just about a 21 percent difference, say mountain resort residents. Why the 50 percent to 90 percent differences in monthly premiums?

"Our cost of care in the mountains isn't double what it is in Denver, yet we're paying double," Garfield County Commissioner Tom Jankovsky said. "To cover your whole family, you are paying as much as you do on a mortgage for a $400,000 house."

The overall health care cost is only about 21 percent higher here than statewide, but that includes everyone, from Medicaid and Medicare customers to the more than 50 percent who get their coverage from their employers to the self-employed purchasing their own plans. It is in the individual market that premium prices are double here. And for better or worse, insurance companies showed that the costs of covering that group justified the big jumps in premiums, according to the Colorado Division of Insurance.

"It still doesn't explain to me why our premiums are so much higher," said Colorado State Rep. Diane Mitsch Bush, whose district encompasses Eagle and Routt counties.

"My constituents are in an emergency. They can't afford health insurance," and if they don't renew because of the high cost, not only is that going to hurt them, it's going to hurt everyone, she said. When healthy people leave the system, those left in the risk pool incur higher per capita costs, and premiums shoot up again.

Jill Ryan, Eagle County commissioner, recalls the high hopes when a coalition of county commissioners, state lawmakers and other stakeholders first tried to get the state to look at changing the geographic zones.

State lawmakers and county commissioners from the ski counties eventually pushed to make all of Colorado one zone, so everyone would pay approximately the same, whether they lived in Carbondale, LaJunta, Denver or Basalt.

Consumers testified before the task force and lawmakers.

"They described their rates as paying a second mortgage — $1,200 to $1,900, and that's with a high deductible," Ryan said. They both couldn't afford to go without health insurance and couldn't afford to pay for it. Several said they were on the verge of giving up on their dream of being independent businesspeople — that they would have to get a "real job" where the employer foots most of the insurance costs, or move to Denver or somewhere where the premiums are about half the cost.

Experts studied it, and concluded that a single zone would raise costs for more people than it would lower them — 19 percent less for those in Zone 9, but 10 percent more for those on the Front Range. And they said that with one zone, insurance companies would likely drop out of the state, reducing competition and causing rates to soar even more. Also, a single Colorado zone would spark a rush to enroll in the formerly high-cost zones, but an exodus from the system by people in the formerly low-cost zones — driving up prices for all.

Equalizing cost for all rewards the person who doesn't take care of himself, the hospital that doesn't cut costs to the bone and the provider who is too quick to order up a test, said Bill Lindsay, who chaired the Colorado Commission on Affordable Health Care that delivered a report to Gov. John Hickenlooper and state lawmakers last year.

The commission still doesn't have all the answers as to why costs and utilization are higher in the mountains. It has hired an actuarial firm to "do a deeper dive for us."

It could be that more people here than in, say, metro Denver, got health insurance for the first time, and therefore booked a flurry of appointments to catch up on long-neglected medical issues.

If that is true, then in a couple of years, the mountain region's costs should creep closer to the state average. But no one knows for sure yet.

Ultimately, Salazar nixed the idea of one geographical zone for Colorado. Lynne agreed, saying redrawing zones "wasn't the right answer."

CRUSHING SETBACK

County commissioners from the mountain resort regions were distraught.

"We had hung our hopes on one single geographic zone, so to get a no answer, we were all profoundly disappointed," Ryan said.

The experts at the request of lawmakers also looked at creating one big rural zone in Colorado to widen the pool and lower the risks. That would have lowered rates in Zone 9, "but not significantly," Salazar said. They would have gone up in the Arkansas Valley and most other rural areas of Colorado, she said. The data showed doctors in the western part of the state are paid much more than doctors on the eastern part of the state.

Mitsch Bush wishes the Division of Insurance had given more thought to rezoning, particularly one proposal to make six metro zones and two western zones — one in the east, one in the west. That would have given a reduction to people in five of the regions and a relatively modest rise in the single digits to people in Boulder, Denver and Colorado Springs, she said.

Another proposal by lawmakers was to force insurers to offer plans in all counties if they offered them anywhere at all. But the Division of Insurance can't force insurers to do that, Salazar said.

"Kaiser's network doesn't work in all areas of the state," she said. "Colorado Choice works in Alamosa but it can't cover the whole state."

Last year, when United Health Care and Humana dropped out of the individual plan market, it left 20,000 Coloradans scrambling for an alternative.

"That's their prerogative. We can't get into their business," Salazar said.

Lynne agreed, noting that in America, health insurance is a business.

"At the end of the day, health plans want to take business away from other health plans and hospitals want to take business away from other hospitals," she said.

"The big problem is that health care is too expensive," Salazar said. What is driving the cost and what can we do about it?

Insurance companies have to justify their proposed premium increases each year, and have to show that for every $1,000 they collect from customers they pay providers $800 for health services, Salazar noted.

Insurance companies argue that after paying benefits and administrative costs, their margins are skinny: Collectively, there was a negative 3 percent margin in 2014 in Colorado's individual market. Cigna Health and Life reported a negative 12 percent margin; Anthem a positive margin of less than 1 percent, according to the Colorado Health Market Review 2015.

Of the two companies that left Colorado's Individual Market this year, Humana reported a 5 percent margin in 2014 and United Healthcare a minus 18.9 percent.

But those skinny margins reflect the net after not just essential administrative costs, but such things as bonuses and handsome compensation packages for company executives. Those will be especially huge if the big companies merge with one another. Anthem wants to buy Cigna and Humana wants to merge with Aetna, but so far courts are blocking the attempts on grounds that it will be bad for consumers, leaving them little choice and driving up prices.

SALARIES AND COSTS

According to Modern Healthcare Magazine, UnitedHealth Group CEO Stephen Hemsley earned $14.5 million in 2015, but has shares worth $430 million.

• Cigna's David Cordani earned $17.3 million but would get an $82 million golden parachute if there is a merger.

• Humana's Bruce Broussard earned $10.3 million but would get $40 million more if a merger deal closes.

• Aetna CEO Mark Bertolini made $17.3 million but will get $131 million if a merger goes through.

By comparision, Vail Valley CEO Doris Kirchner was paid $762,543 in 2014, Valley View CEO Gary Brewer was paid $913,700 and Yampa Valley CEO Frank May was paid $358,577.

Richard Backe of Carbondale is grateful for his subsidized Obamacare plan that saved him and his wife from possible financial ruin. But he blames insurance companies, hospitals and other large providers for failing to rein in costs. And he blames Colorado's Insurance Commission for rejecting the proposal to turn Colorado into one insurance zone so everyone would pay about the same for health premiums.

The rural population is small, so it doesn't have the clout to force a change, he said. The commission has "chosen to ignore the exorbitant insurance and health care costs in rural areas of Colorado, … causing our costs to skyrocket."

In part, it comes down to values.

If the healthy weren't subsidizing the sick, or if the middle-class wasn't subsidizing the poor, premium prices would drop for the middle class. But a lot of poor people and seniors might die sooner rather than later.

About 40 percent of the American population and about 40 percent of the population in the mountain resort areas of Colorado have their health care subsidized in the form of Medicare for seniors or Medicaid for the poor. And the reimbursements from the federal government only cover about 70 cents on the dollar for those two programs, say hospital administrators and doctors.

So, to recoup that $3,000 on the $10,000 cost of a service, hospitals theoretically need to collect a bill of, say, $12,000 for $10,000 of costs from the majority of the population that has private health insurance.

Meantime, insurance costs stay high in Pitkin, Routt, Eagle, Garfield and Summit counties.

The western Colorado coalition isn't giving up on its efforts to bring all stakeholders together for an honest conversation about prices and geographic zones, Ryan said. But it's a conundrum.

"Every solution seemed to have some kind of negative consequence somewhere else."

Series: How health insurance can cost more than housing

Editor's note: This is the second story in a six-part series on health care costs in the Colorado mountains.

Garfield County resident Heather McGregor simply can't afford health insurance anymore, although she had it most of her life.

Working part time at a nonprofit, her cost this year would be a bit more than $1,000 a month for a plan that requires her to meet a $6,500 deductible before she gets any benefits.

"You add it all up and that's almost $20,000 a year," she said. "Health insurance for someone in my situation — I'm in good health, I have some savings — is just not a smart economic choice."

McGregor said health care in the mountain resort communities "is very good. I could go right here in Glenwood and get an MRI or an EKG or any of those fancy tests. The convenience factor is very good. But the prices …"

She looks forward to the day she turns 65 and qualifies for Medicare like her husband. "I'm hoping it's still there. It's amazing to see what coverage he can get for a real reasonable cost."

How did we get here? How did western Colorado reach a point where for some people, health care costs more than a large mortgage?

It has to do with the idiosyncrasies of Obamacare, but it also has to do with the American health care system and various attempts to make it either uniquely our own or more like the rest of the world's, health-policy experts say.

The United States spends 18 percent of its gross domestic product on health care — way more than any other nation, according to the Commonwealth Fund. Other developed nations spend an average of about 10 percent.

And by many measures, the U.S. has worse outcomes, despite spending much more. The U.S. is worst among the countries in infant mortality, has the highest obesity rate and ranks in the bottom half in life expectancy, according to the Commonwealth Fund study.

Fifty-five years ago, the U.S. was already first in spending as a percentage of GDP, but that percentage was a relatively modest 5 percent. That was before the proliferation of surgeries and lifestyle drugs and the expectation that people should live actively and well into their 80s.

Why is the U.S. so much more costly for health care than other nations? Studies point to the better salaries for health professionals here, the greater use of tests, the higher costs for hospital stays and the higher cost of drugs. While the U.S. is the world leader in developing new drugs — both life-saving and lifestyle — its citizens pay more for those drugs than do people elsewhere, and also consume more per capita.

But there may be an even more critical factor.

Other countries are able to keep per-capita health care costs at about half what we pay here because "everyone has health insurance; no one is outside the system," said Colorado Lt. Gov. Donna Lynne, whose career has been in public health. The young and healthy can't opt out in the European countries; they have to pay more than they probably will recoup during their 20s and 30s, eyeing the days in their 50s and 60s when they likely will get more in services than they pay in premiums.

OPTING OUT

Here, with a maximum $695 yearly fine for not carrying insurance under Obamacare, young people can pick and choose when they want to enter the system. Single women who are 26 and plan to wait until they are, say, in their early 30s to start a family can opt out of the system and the maternity benefits they won't need for a few more years. And they can opt out again after their child-bearing years.

The European nations also have more aggressive government intervention in setting rates, which at least indirectly set limits on how much a physician can earn. And they're more willing than the United States to say no to certain procedures for people of a certain advanced age.

All of that smacks as un-American to some but a pretty good idea to others.

The U.S. health care system still largely operates on fees for service rather than paying doctors a set salary for helping keep a slice of the population healthy, Lynne said. The fee-for-service model can be like the old adage, "If you have a hammer, everything looks like a nail." If you have a license for orthopedics, everybody can look like they have bad knees or joints; or if you have an MRI machine, everyone with lower back pain might look like they could benefit from a scan.

As in other nations, the healthy subsidize the sick here. The difference is that instead of coming primarily from taxes, health-coverage dollars come right out of Americans' paychecks or pocketbooks.

And that can be startling or aggravating and can spark complaints that the poor, the obese, the illegal immigrants, everyone but us are getting a good deal.

That certainly happens in Garfield, Eagle, Summit and Pitkin counties, especially among the self-employed who are classified as upper-middle class but certainly don't feel that way in the face of $400,000 to $1 million median home prices and $4 for a gallon of milk.

IT ALL ADDS UP

Tamara Drangstveit, executive director of the Family and Intercultural Resource Center in Silverthorne, said it's not just milk and housing. Everything costs more in the mountain valleys — gasoline transportation and, of course, health care.

"The problem in the high country is just to live here and raise a family, you have to make more than 300 percent of the poverty level. And at that level the tax credits aren't enough to make health care affordable."

In Summit County, 24 percent of people are at or below 139 percent of the federal poverty level — an individual earning less than $16,394 or a family of four earning less than $33,534. At those income levels, households qualify for Medicaid or Expanded Medicaid, and pay very little for health care coverage.

Thirty-eight percent in Summit County are in what is sometimes called the middle class, meaning their earnings fall between 139 percent and 400 percent of the poverty level. This is the group that qualifies for tax credits that subsidize their health premium costs. The goal — not always reachable — is to limit total premium and deductible spending to less than 10 percent of income.

To squeeze under that 400 percent of the poverty level, a single person can earn no more than $33,534 a year; a family of four can earn no more than $97,200.

A family of four bringing in $57,700 will pay $599 a month for health insurance because it qualifies for a $721 per month tax credit.

A family making $86,300 gets just a $430 tax credit per month, so its health care costs are $887. A family making $104,000 gets no subsidy, so its health care costs are $1,320 per month, with a deductible of some $6,000.

Whether the household income is $57,000 a year or $120,000 a year, if they're all paying high mortgages and for food, day care, transportation and other necessities, all of those families of four are living close to the edge.

Monthly premiums have gotten so high that both employers and those on the individual market have flocked to higher deductibles to dampen the monthly costs. The percentage of Coloradans who have deductibles in their health plans rose from 60 percent in 2005 to 90 percent in 2015.

Insurers in the individual market, which covers about 12 percent of Coloradans, offer gold and platinum plans if the household wants to pay more in monthly premiums, but less in deductible and out-of-pocket costs. They offer silver and bronze plans under the Affordable Care Act if the family wants to go vice versa, lower monthly premiums but big costs in the form of deductibles and co-pays if someone gets very sick.

OTHER COSTS EAT INCOME

And those who have to pay the full freight are opting for cheaper plans. Bronze is the top choice for those above 400 percent of the federal poverty level, while silver is the top choice for those who are getting help on premiums via the tax credit.

Department of Health and Human Services officials in Washington, D.C., are quick to note that the majority of people on the individual market can find a plan for less than $100 a month per person.

But most residents of the Colorado high country cannot.

The discounted plans are available only to those whose household incomes are below 400 percent of poverty, and in Vail and Aspen particularly, that doesn't apply to most people. The cost of housing is such that self-employed people might earn $70,000 a year and find most of their income swallowed by $2,500 house payments and the bare essentials. Do you spend another $2,000 a month for health insurance or do you run the risk that the family will stay healthy — and that you can cover the occasional doctor visits out of pocket?

Health care is simply not affordable for people in the high country, Drangstveit said. She supports the idea of extending tax credits — and thus lowering monthly premiums — for singles and families whose incomes are between 400 percent and 500 percent of the FPL. That would give a break to individuals earning as much as $59,400 a year, and families of four earning up to $121,500 a year.

State Rep. Diane Mitsch Bush, a Democrat whose district encompasses Eagle and Routt counties, is introducing such a bill. It would provide a financial subsidy for those who are spending more than 15 percent of their income on health care and who are between 400 percent and 500 percent of the federal poverty level. She thinks it could help several thousand individuals and families throughout the state, including a disproportionate share in western Colorado.

"We have a perfect storm — a higher cost of living, lower than average wages and such high premiums that people simply can't afford them,"

Drangstveit also likes the Maryland all-payer model that gives more incentives to doctors and hospitals to keep their patients healthy. It produced a $116 million Medicare savings its first full year.

"I believe that health care is a right, not a privilege," Drangstveit said. "The bottom line is we have to find a way to bring down prices so everyone can afford to access insurance."

COSTLY ER VISITS

There are other reasons health premiums are so high here, and some of them can be maddening.

After a quarter century of public-service campaigns, too many people in Colorado and elsewhere still go to emergency rooms for nonemergencies, jacking up the prices for everyone. Among those surveyed by the Colorado Health Institute, 40 percent acknowledged that their last visit to the ER was for a nonemergency. And now there is a new phenomenon — the free-standing emergency room, affiliated with hospitals, geographically separate, but every bit as expensive.

Pain in the abdomen? A free-standing emergency room charges an average of $5,634.58. An urgent care center charges about 2 percent of that — $151.49, according to the Colorado All Payer Claims Database. Even if the patient foots only a small co-pay, the insurance company is paying a whole lot more than it otherwise would have to, and next year recoups the money via premium bumps for everyone.

When people go out of their provider network for services, the prices skyrocket. It may be worth it to the person who wants, say, the very best surgeon for his prostate cancer, but the bills tend to push up the costs for all.

Universal coverage would promote better health by staying on top of health risks via partnerships between patients, primary care physicians and physicians assistants, many health professionals say. Switzerland and Taiwan had systems similar to the United States, but significantly reduced costs when they moved to systems of universal coverage.

Meantime, President Donald Trump and the Republican Congress still want to repeal and replace the Affordable Care Act.

"I wish I had a crystal ball," Drangstveit said. "Obamacare certainly has things that need to be improved. But you can't ignore the fact that 20 million more people are insured because of Obamacare and they're more able to access health care when they need it.

"I hope cooler heads prevail, recognize the good things about the act and make it better. Let's not move ourselves back 10 years."

Series: Active lives, few providers push up med costs on Western Slope

Editor's note: This is the first article in a six-part series on health care costs in the Colorado mountains.

No, Colorado mountain resident, it's not just your imagination. You still are paying some of the highest health care costs in the nation.

Despite — or perhaps because of — the region's love of hiking, skiing, bicycling and all things physical, Zone Nine in the Colorado mountains is stuck stubbornly at about 145 percent of average health care costs.

People in Glenwood Springs, Basalt, Avon and Carbondale talk of paying more for their family's health care than they do for their mortgage — and their mortgages are steep enough, thank you very much.

Health costs are driven by two main factors: price per unit — say, a doctor's visit or a heart bypass — times the frequency of those visits. And Pitkin, Garfield, Eagle and Summit counties score poorly on the former and not so great on the latter.

Getting a hip and knee replaced costs about $69,000 in the hospitals in the Colorado mountains, but about $40,000 in metro Denver. Visiting a doctor costs an average of $195 in Boulder, but $301 in the mountain resort cities. The patient may never see that bill, but it's being paid one way or the other — by the insurance company, Medicaid or Medicare, the patient's employer, or by the person who is without insurance.

And mountain resort residents are using some services much more often than average, particularly visits to specialists and imaging tests such as MRIs and CT scans. Specialist visits per patient per year average $260 in Boulder, but $602 in the mountain resorts.

That combination of higher charges and more frequent usage drives up insurance costs.

It's hitting almost everybody — from the people who get their insurance from work and are seeing premiums and deductibles rise every year, to the employers who say costs are getting unsustainable, to the freelance writers and ski instructors, the self-employed and the entrepreneurs.

"It's no hyperbole to say that costs are oftentimes 300 percent to 500 percent more in the mountains than for the same services in Denver," said William Lindsay, who chairs the Colorado Commission on Affordable Health Care.

"Everyone focuses on the insurance premium because that is the bill they get every month," Lindsay said. "But the underlying cost is alarming."

This year the western Colorado residents getting especially zapped and especially scrutinized are the self-employed and others in the individual market who earn a bit more than 400 percent of the federal poverty level — about $64,000 for a couple or $98,000 for a family of four — but not enough more to make their premiums affordable.

Rates rose for that group 30 percent for 2017, and are 40 percent higher than they were in 2015. Earn slightly less than 400 percent of the federal poverty level, and you get a nice subsidy in the form of a tax credit — knocking an average of about $225 per month off the premium. That's because those who fit below that number aren't supposed to pay more than about 10 percent of their income on health care — it's one of the more popular provisions of the Affordable Care Act, which withstood the first attempt at repeal under the Republican Congress and Trump administration.

But earn a bit more and there is no financial assistance. Twenty-seven-year-olds without families price themselves out of financial assistance if they earn more than $47,500 yearly.

In that case, the young person choosing a middle-of-the-road silver plan under the Affordable Care Act will pay $514 if he or she lives in Garfield, Routt or Pitkin counties — just about double the rate in Denver, Boulder and El Paso counties. If he or she lives in Summit or Eagle counties, the monthly premiums would be about $350.

Blame can be found in all directions. Some say costs are so high because young, healthy people are opting to go without health insurance, taking their chances that they will stay hale and fit — and not, say, tear an ACL on a snowboard fall.

Insurance companies need healthy people enrolled to counterbalance those who are elderly or sickly. But with premiums at $500 a month for a young, healthy single person, the maximum penalty of $695 a year for not carrying insurance can seem a relative pittance.

DOUBLE WHAMMY

"We're getting a double whammy," complained Garfield County Commissioner Tom Jankovsky. "The young, healthy individuals aren't buying health insurance because it is so expensive. So we end up with a smaller pool, with a lot of people with pre-existing conditions who have no choice but to buy the expensive insurance — which exaggerates how much is being spent by those in the pool, which keeps driving up premiums."

A couple years back the Kaiser Family Foundation officially declared the Pitkin-Garfield-Eagle-Summit region the highest in the nation for health care costs. The average inpatient cost at St. Anthony Medical Center in Frisco was $786 — 61 percent above the state average, according to the Colorado All-Payer Claims Database. And in Pitkin County, costs per patient per year for doctors and other medical professionals were 2.2 times the state average.

That's what you get when the cost of living is high, when insurance choices are few, when there is usually just one hospital per county and when there is a big incentive to order imaging tests so the machines to do MRIs and CT scans pay for themselves and generate profit, said Amy Downs, senior director for policy and analysis at the Colorado Health Institute.

The relentless rise in health care costs "has nothing to do with the Affordable Care Act," contends Lt. Gov. Donna Lynne, who led a task force last year examining disparate premium costs throughout the state.

"It has to do with all of us getting older, living longer and having the expectation to live in a very healthy state" into our 80s and 90s, hiking, skiing, bicycling. Indeed, the number of Americans living with knee and hip replacements doubled between 2000 and 2010, according to the Journal of Bone and Joint Surgery. The prevalence of Americans in their 80s having one or the other replacements grew tenfold between 1980 and 2010.

WONDERFUL … AND EXPENSIVE

Hip and knee replacements are now a huge cost driver for the health care system. That they cost about 40 percent above the mean in the mountain valleys of Colorado exacerbates the costs and aggravations here.

The drugs and surgeries and high-tech imaging tests that extend our lives and cure diseases "are wonderful and they're also very, very expensive," Lynne said. Repeal of the Affordable Care Act won't change that, she said.

The ski resort counties are a world apart. Pitkin, Summit, Eagle, and Routt each have only one hospital — Garfield has two — yet each of the hospitals has to be big enough to handle the influx when skiers multiply the size of the towns every winter: year-round overhead for a seasonal rush. Vail and Aspen have their slices of millionaires and billionaires who won't blink at health care prices and who, unconsciously or not, up the demand for luxuries and amenities.

Yet the year-round residents are mostly average Joes and Janes, earning almost enough to pay for the expensive housing, food, clothes and necessities. Many of them look askance at the valet parking and grand pianos at the small-town hospitals, the robotics labs and world-class orthopedics units.

All those dichotomies help push up prices.

Lynn Kirchner, a real estate broker from Carbondale, said "it drives me crazy" that she can get an MRI in Denver for $500, one in the valley for $1,000 if she pays cash, but that her local hospital charges $3,000 to those without insurance. She knows that smaller volumes in small towns lead to higher prices, which leads to less competition, which leads to fewer insurers, which leads to providers and hospitals having the clout to charge yet higher prices.

"This thing is like an onion," Kirchner said. "The more you peel, the more you cry. There are so many different layers. What is the one root of the problem? There probably isn't one. They're all intertwined like a rope — a big ugly rope."