“We thank UCHealth for working with us to resolve this issue in a manner that protects all Colorado hospitals,” Kim Bimestefer, executive director of the Colorado Department of Health Care Policy and Financing, said in a news release.

UCHealth sued the department, alleging it had incorrectly labeled two of its hospitals as public, rather than private nonprofits. A , and ordered the state to reclassify Memorial Hospital in Colorado Springs and Poudre Valley Hospital in Fort Collins. The department filed an appeal in July.

Their classification matters because of the state’s provider tax.

Hospitals pay about $1.3 billion each year, gaining about $500 million in federal matching funds. Most come out ahead, though those with relatively few patients covered by Medicaid lose out. In future years, the state will have to reduce its tax rate under provisions of H.R. 1, colloquially known as President Donald Trump’s “big beautiful bill.”

The state pools the money by hospital type, and distributes it based on how each facility’s Medicaid share compares to the others in their group.

Moving Memorial and Poudre Valley from the public to the private bucket means that less money remains for all public hospitals to divide up, and that Memorial and Poudre Valley likely will get more back from the provider tax, because they’re being compared against hospitals that generally see fewer Medicaid patients.

The state said that to retrospectively reclassify the UCHealth hospitals and distribute the funds accordingly, it would have to take back $59.7 million paid last year to 29 publicly owned hospitals.

Denver Health didn’t comment on the possibility, but a group representing 13 Eastern Plains hospitals said some wouldn’t be able to hand over a significant chunk of cash, because they already used their share of the provider tax to pay employees and cover other expenses.

Under the agreement, the Department of Health Care Policy and Financing will drop its appeal, and UCHealth won’t demand redistribution of provider taxes it paid in previous years.

UCHealth president and CEO Elizabeth Concordia said the system supports the provider tax program, and thanked the state for working together on a solution.

“The greatest successes for patients and our state happen when hospitals, HCPF and the administration work together collaboratively,” she said in a news release.

The hospital system also agreed to donate $5.7 million to compensate public hospitals that may lose out with less money coming into their bucket. The Colorado Hospital Association will help determine how to divide up the donation.

“Instability or uncertainty in the fee could have pushed vulnerable hospitals past the breaking point,” Jeff Tieman, president and CEO of the Colorado Hospital Association, said in a news release. “UCHealth’s approach to waive changes for last year and invest millions this year demonstrates a real commitment to protecting access to care in rural Colorado. We are deeply grateful for their partnership.”

We’ve been down this road before, about a dozen times since Obamacare first became law in 2010. The Affordable Care Act dramatically increased the number of people who would qualify for Medicaid health insurance, which is funded by a combination of state and federal dollars. That expansion was expensive, but it helped reduce uncompensated care costs that were stressing the private health care and insurance systems.

Remember when Sen. John McCain saved the Affordable Care Act¶¶Ňőap Medicaid expansion with a dramatic thumbs-down vote on the Senate floor that rejected President Donald Trump’s attempt at a skinny repeal? Well, McCain isn’t in the Senate anymore, and now Republicans are trying (again) to roll back the Medicaid expansion.

That is bad news for all Coloradans, not just those on the Medicaid bubble who are making more than the bottom threshold for Medicaid (about 35% of the federal poverty level) but less than the expansion threshold (138% of the federal poverty level).

Those already living on the bubble would likely lose their insurance immediately if Congress were to dramatically slash funding to states for Medicaid programs. And the program also wouldn’t be available to those who suffer a job loss in the future. Medicaid isn’t just for those who find themselves in chronic poverty. Our health care system is so broken that private insurance is cost-prohibitive for most Americans unless their employer is picking up much of the tab, and incentives on the Obamacare exchanges rarely are enough to fill the gap. Job loss is stressful. Add in the cost of intermediary health insurance, and savings, if they exist, can get depleted rapidly. Going uninsured is an unacceptable risk for most, as a single hospital stay could cost tens of thousands of dollars.

The popular refrain from supporters of ending the expansion is that able-bodied, single individuals shouldn’t be eligible for government-funded health care. But the KFF (formerly the Kaiser Family Foundation) found that data from the Census Bureau shows that , and we’re pretty certain that traumatic injuries, cancer, and liver failure aren’t solely reserved for people with children and spouses.

For reference, 138% of the federal poverty level is about $21,000 for individuals and $36,000 for families. Annual premiums on the exchange vary widely by county but can range from $1,700 a year to $3,756 a year for someone who is single.

Republicans who are backing the Heritage Foundation’s plans in Project 2025 to reduce the federal government¶¶Ňőap coverage of the Medicaid expansion need to know that their decision will cost lives and life savings.

Colorado could be particularly hard hit. Gov. Jared Polis told The Denver Post that the result would be some combination of a reduction in the number of people covered, a reduction in coverage, and a reduction in reimbursement rates to doctors and hospitals.

The state covered the relatively small amount needed for the expansion population by creating the bipartisan Hospital Provider Fee, landmark legislation that assessed a fee on hospital stays to cover the cost of expansion to the state. That fee could, in theory, be increased to cover some of the funding lost from a Republican drawdown, but political support for further taxation on hospital stays is unlikely to emerge, especially given that hospitals are not transparent about the fee.

Republicans are not wrong to attempt to tackle this issue. Medicaid is a hungry federal program that gobbles up a huge share of our out-of-control federal budget. Reducing the federal portion of the expansion from 90% to 50% could save the federal government $1.9 trillion over 10 years, according to a KFF (Kaiser Family Foundation) analysis from 2025.

Those savings will be illusory.

The impact to hospitals and clinics would be dire, and states would be forced to step in with their own funding. Unlike the federal government, Colorado can’t go into debt to cover a shortfall, which is a blessing of fiscal responsibility but a curse when overnight federal funding is getting slashed left and right.

The KFF also estimates that 20 million people across America would lose Medicaid coverage and that a majority of those enrollees would be unable to get alternative coverage. Because in America, we don’t deny people suffering acute emergencies urgent care because they cannot pay, uncompensated care would soar, hospitals could fail, or more likely, states will pick up the costs one way or the other. Solving the federal budget crisis by passing it off to states is taking money from one pocket to put it in another. Our taxes are still our money, no matter the level of government.

Is there another way to save $1.9 trillion in Medicaid spending in the next decade? Maybe, but it’ll take a lot more work and nuanced policy analysis than this slash-and-burn effort that hides the damage being done by Congress, instead handing the knife to states to do Congress’s dirty work.

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The Colorado Department of Health Care Policy and Financing recently released its , which showed that rising costs outpaced increases in payment for patient care. The drop in profits was less dramatic when the department also counted investment income and support services, such as parking and cafeteria meals.

“This has been a really hard time for hospitals because of the increased cost of labor,” said Kim Bimestefer, the department’s executive director.

Hospitals in the state earned a combined $8.5 million on patient care, $750.4 million on all operations and $1.5 billion in total profits, including investments, Bettina Schneider, the department’s chief financial officer, said in a webinar Thursday morning. All three types of profit margin are lower than in 2019, and profits on patient care hit their lowest levels since at least 2009, . (CHASE collects a fee from general hospitals and uses it to claim matching funds from the federal government, increasing health care funding overall.)

Small hospitals that don’t have significant savings to invest haven’t benefited from the stock market rebound in the way that large systems have, Schneider said. Even with investments included, 32 out of 84 hospitals lost money, and profit margins ranged from a low of -18.1% at Pioneers Medical Center in Meeker to a high of 32.9% at OrthoColorado Hospital in Lakewood. (Lutheran Medical Center had the largest loss, on paper, but that mostly reflected the accounting cost as its old building shut down.)

Overall hospital revenues grew 4.8% in 2023, while expenses grew 6.5%, . Most of the increase in expenses came from growth in wages and benefits. Spending on contract labor dropped in 2023, when the worst of the pandemic was over, though it remained above 2019 levels.

While labor costs started to level in 2024, supply costs and uncompensated care went up, said Tom Rennell, senior vice president of financial policy and data analytics at the Colorado Hospital Association. Revenues rose slightly, as hospitals and insurers negotiated new contracts reflecting the increased costs, but margins are still tight, he said.

“Expenses are continuing to run really high,” he said.

The reports arrived as lawmakers consider a bill to limit urban hospitals’ reimbursements from the state employee health plan and plans covering employers with fewer than 50 workers to 165% of what Medicare would pay for the same services. – though at higher thresholds than Colorado is contemplating – saving about $108 million in two years and $48 million in three years, respectively.

Given uncertainty about what Congress and the Trump administration will attempt to do, now isn’t the right time to make major changes, Rennell said.

“We’ve got some potentially really sizeable challenges ahead of us,” he said.

Pre-pandemic, Colorado hospitals had some of the highest prices and costs per patients in the country, and some of the highest profits, Bimestefer said. As of 2023, it had the 10th-highest prices, 11th-highest costs and 19th-highest total hospital profits, she said.

“Every single metric we’re tracking is going the right way,” she said. “They’re managing things more effectively.”

As a cohort, hospitals with at least 25 beds still made money on patient care in 2023, while smaller hospitals fell deeper into the red, losing a combined $163 million on care.

The reports included more recent data on hospital systems’ finances, as of June 2024. At that point, only Denver Health and CommonSpirit Health were operating in the red, while HCA HealthOne had a profit margin on patient care and other operations of 12.9%. The data for multistate systems includes hospitals outside Colorado, which Rennell said skewed the numbers.

A in December found costs were no longer rising faster than revenues, but raised concerns that the cost of care that hospitals didn’t get paid for was starting to grow because fewer patients have Medicaid insurance.

The effects of an increase in migration that started in late 2022 and of Coloradans losing Medicaid coverage after the COVID-19 public health emergency ended aren’t fully captured in the most recent report, said Nancy Dolson, the department’s special financing division director.

“We expect we’ll see that in next year’s data,” she said.

Overall uncompensated care costs increased by about $866,000, or less than 1%, from 2022 to 2023, according to the CHASE report. The category includes both charity care, where a hospital doesn’t expect to get paid, and bad debt, where it expected the patient to pay but eventually determined it was unlikely to collect.

The largest hospitals, with more than 90 beds, spent about 0.5% less on uncompensated care than in 2022, while the cost went up for smaller hospitals. Bad debt dropped overall, while charity care rose, perhaps because of a directing hospitals to assess if patients qualify for financial assistance.

The median number of days’ cash on hand that hospitals statewide had dropped from 183 in 2022 to 164 in 2023, but remained higher than in 2019, according to the financial transparency report. Cash on hand refers to how long a hospital could operate if it didn’t receive any new revenue. While that scenario is unlikely to ever happen, a higher number of days indicates that a hospital could better handle an unexpected expense, such as a damaged roof or a broken boiler.

The average obscures significant variation, though. St. Vincent General Hospital in Leadville had only 11 days cash on hand in 2023, while Intermountain Health’s Colorado hospitals averaged 348 days’ worth. Bimestefer said hospitals can feel comfortable with about 150 days’ cash on hand, while Rennell said the correct level depends on each hospital’s circumstances.

Hospitals would like the state to simplify its data requests, because the information is delayed and doesn’t lend itself to immediate action, Rennell said.

“Is (collecting data) the best way to spend our time and energy?” he said.

Operating profit margins

January-June 2024 (includes hospitals outside Colorado)

• HCA HealthOne: 12.9% • UCHealth: 9.3% • AdventHealth: 8.7% • Intermountain Health: 3.8% • Children’s Hospital Colorado: 2.8% • Banner Health: 2.4% • Denver Health: -0.9% • CommonSpirit Health: -2.8% Source: Colorado Department of Health Care Policy and Financing Hospital Transparency Report

is in a dire financial position with the cost of providing care – especially for those with no means to pay — outstripping the revenue coming in.

The state stepped up and has allocated $5 million in the 2023 budget to shore up Denver Health’s budget, but it is not enough.

Providing life-saving care for those who cannot pay is a moral imperative. Denver Health not only saves lives with expert trauma care for car crash and gun violence victims, but the hospital is a last resort for uninsured individuals with chronic, treatable illnesses like homeless individuals or undocumented Coloradans with diabetes, renal failure or cancer.

The City of Denver has long recognized the civic good of having a public hospital and has propped up the hospital’s operations with additional funding. Taxpayers may not realize the good of a publicly funded hospital until their moment of most dire need when their insurance has lapsed between jobs, and they fall from the roof while cleaning gutters.

But Denver has not increased its contribution — $30 million a year – for 10 years, even as the cost of health care has skyrocketed.

Denver Health CEO Donna Lynne says both the amount of uncompensated care they are providing and the cost of providing it has increased in the aftermath of the pandemic. In 2020, uncompensated care was $60 million at Denver Health; in 2022, it was $120 million. Despite efforts to close the deficit, the hospital still loses monthly money.

“Right now, because of an increase in the number of patients we are seeing that are uninsured, the costs of health care which have really escalated post COVID and staffing, we’ve seen a doubling in two years of the cost of caring for people who are uninsured,” Lynne said.

Additionally, the patients who do arrive at Denver Health are more frequently severely ill, suffering from substance abuse or mental illness, Lynne said.

Denver Health is not alone in its financial troubles, as The Denver Post’s Meg Wingerter reported on the front page, that with the notable exceptions of HealthOne, and SCL Health, most hospitals across the state broke even or were in the red for the first half of 2022. Experts say 47% of hospitals in the state lost money on patient care in 2021.

Hospitals are suffering a staffing shortage spiral that is afflicting health care across the nation. Following the pandemic, there was a mass exodus of doctors and nurses who had worked selflessly and tirelessly to prevent systemic collapse during the worst days of COVID-19. Now, the nurses who remain can ask for higher salaries (they also deserve the extra pay) given the shortage in the labor market, and hospitals have turned to expensive traveling nurses to fill vacancies on an emergency basis.

Giving Denver Health a direct cash infusion will allow the hospital to attract permanent full-time staff, saving money on overtime and traveling nurses.

Stability is critical for any institution.

Gov. Jared Polis and Colorado’s Joint Budget Committee members recognized the situation’s urgency. Now we hope the incoming administration of the city does the same.

Denver Health will be a key partner as the state recovers from the drug crisis, the housing crisis, and the mental health crisis. If Denver Health fails, so will the Front Range.

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Under the federal program, rural emergency hospitals must keep an emergency room staffed around the clock, but can’t offer inpatient beds. In exchange, they get extra payments, estimated to average around $3 million a year, to support outpatient and emergency care.

It’s a drastic trade-off, but one that, in Colorado, would require regulatory and legislative action before any hospitals could take advantage of the new funding.

The idea behind the program is that areas of the country that can’t financially support a full-service hospital might be able to sustain emergency services with extra support.

In the earlier stages of the pandemic, however, Colorado came close to filling every bed in its borders, raising questions about whether the state could handle a future emergency if some hospitals stop handling inpatients.

A projected 1,569 hospitals could be eligible nationwide, though substantially fewer may choose to participate.

The program is only open to , which are generally rural facilities with 25 or fewer inpatient beds that are at least 35 miles from another hospital and generally have patient stays of four days or less. (There are some exceptions, because states could designate critical access hospitals before 2006.)

The majority of the 32 critical access hospitals in Colorado didn’t respond to inquiries from The Denver Post about whether they were considering a switch. Nine hospitals said they weren’t: Aspen Valley Hospital, Grand River Hospital District, Gunnison Valley Health, Heart of the Rockies Regional Medical Center, Lincoln Health, Memorial Regional Health, San Luis Valley Health, Southeast Colorado Hospital District and UCHealth Pikes Peak Regional Hospital.

No hospitals confirmed they were considering dropping inpatient care. Two others responded, but declined to comment at this time.

Dave Engel, CEO of Southeast Colorado Hospital District in Springfield, said converting doesn’t make sense for them, both because of lost revenue and because people would perceive their hospital as failing and go elsewhere for services they still could have gotten locally.

He said he doesn’t know of any hospitals on the Eastern Plains that want to give up inpatient care, and that most people would rather stay close to home.

“It would be unsustainable,” he said.

Donna Wehe, director of communications at San Luis Valley Health, said their two hospital campuses have found a model that works for them, so a shift isn’t necessary. It could turn out to be right for other rural facilities, though, she said.

“We really support the idea of this, because it gives rural emergent care more choices,” she said.

Before any Colorado hospitals join, the state would have to create a new type of license for rural emergency hospitals, said Megan Axelrod, director of regulatory policy and federal affairs at the Colorado Hospital Association.

The hospital association plans to survey its members to determine how many are interested in the new model, and what would need to change to make it successful.

“We’re at very, very early stages,” she said.

The legislature also would have to pass a bill granting rural emergency hospitals a share of the federal funds the state gets to match the provider fee collected from hospitals, Axelrod said. Currently, that money is distributed based on how many inpatients are covered by Medicaid, which obviously wouldn’t work for a hospital that only offers outpatient and emergency services, she said.

Ideally, the legislature won’t just pass the regulatory fixes necessary for rural emergency hospitals, but will take the opportunity to study what else the state could do to support them, Axelrod said.

“Rural hospitals, and all of our hospitals, have been struggling with unique circumstances over the last few years,” she said.

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Utah, a Republican-dominated state, had raised taxes three times in the past ten years and made substantial investments in infrastructure and expanded highway lanes, giving them a distinct economic and quality of life advantage over Colorado.

At the time, Utah spent about $660 million a year on highway projects to expand capacity, compared to Colorado’s $159 million. And, while Colorado was dependent upon federal funding for 65% of our highway spending, Utah relied on it for only 25%.

Utah was the gold standard, spending billions on their transportation infrastructure from expanding Interstate 15 in Salt Lake and Utah counties, building a new mountain view corridor extension and constructing rail systems, while Colorado’s roads and bridges were dangerously crumbling with frustrated drivers stewing while sitting in traffic with no relief in sight.

Colorado leaders were looking to flip the script and struggling with the realities of our transportation challenge. Last year, transportation and finance experts Ben Stein and Henry Sobanet authored a paper for the Common Sense Institute that highlighted the challenge and sketched out a possible way forward. I wrote that the paper was evidence that thought leaders were not giving up.

The predominant problem is that most of the funding in Colorado now comes from gas taxes that are charged a flat amount per gallon. Unleaded gas has been taxed at $0.22 per gallon for the past 30 years. The decline of this revenue stream has been exacerbated by fuel efficiency, the advent of electric cars and major technological changes. Meanwhile, the costs of asphalt, concrete, and steel, have been growing faster than those declining revenues can keep up.

In just the last 10 years, over 30 states have responded and reformed their transportation finances. Colorado, with the extra challenge of TABOR, was not on that list.

But the state made do within tight constraints: In 2009, the state’s FASTER legislation added badly needed bridge and maintenance dollars and  2017’s reform of the hospital provider fee added $1.8 billion over four years to capacity and maintenance. But these efforts could not make up for three decades of neglect.

Enter Senate Bill 260.

Credit Governor Polis, his policy team and Shoshana Lew, executive director, of CDOT for focusing on this issue and making it a priority.

Bill sponsors Senate Majority Leader Steve Fenberg and Speaker Alec Garnett kept this legislation moving and Senator Faith Winter and Representative Matt Gray spearheaded and led countless stakeholder meetings.  Together, these leaders had the political backbone to push through Senate Bill 260, landmark legislation that will provide $5.36 billion in transportation funding to fix Colorado roads and bridges, improve transit options, and meet Colorado’s climate goals.

While this may not be the transportation package everyone would have wanted, it is the transportation package that this state needs. Perfect cannot be the enemy of the good.

Every corner of the state had a significant interest in this legislation. And it received support from a broad coalition of highly engaged groups, like Colorado Concern, Colorado Contractors Association, Colorado Municipal League, Colorado Counties, the Metro Mayors Caucus along with well-respected Colorado Springs Mayor and former Attorney General John Suthers, who worked hard on this legislation and dug deep to find a compromise.

With the exception of Republican Senator Kevin Priola, Senate Republicans opposed the package primarily because of its reliance on new fees to fund the improvements. Politics can make for strange bedfellows as conservative groups like Americans for Prosperity opposed this along with environmental groups who were either trying to amend or otherwise opposed.

The bill raises an estimated $3.784 billion in new fee revenue for purchases of gasoline and diesel fuel, electric vehicle registrations, retail deliveries, passenger ride services and short-term vehicle rentals.

Another $1.58 billion in revenue comes from general fund state budget transfers and federal stimulus money.

The benefits: Colorado gets more transportation options and we will spend less time on our improved roads.

The legislation invests in our infrastructure while improving air quality, and pays for most of the Colorado Department of Transportation’s 10-year, $5 billion priority project plan. It makes important investments in rural and disproportionately impacted communities. It will pay for more multimodal projects along state highways; cover projects that mitigate environmental problems in some Front Range communities; and support the adoption of electric vehicles, from fleet conversions to charging infrastructure.

And, there is something else it does that Coloradans demand: it builds trust by providing accountability for its spending and transparency about its implementation, funding and expenditures on the state’s website.

Oh, and a bonus…let¶¶Ňőap get those bragging rights back from Utah.

Doug Friednash is a Denver native, a partner with the law firm Brownstein Hyatt Farber and Schreck and the former chief of staff for Gov. John Hickenlooper.

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The lawsuit was initially filed by the Tabor Foundation in 2015, challenging the constitutionality of the fees, which are collected by the state Department of Health Care Policy & Financing from hospitals and matched by the federal government. The money is redistributed to hospitals to help them cover Medicaid patients and people in rural areas.

“Our Department is now providing health care coverage to about 1.5 million Coloradans through Colorado Medicaid,” said Kim Bimestefer, executive director of the Department of Health Care Policy & Financing in a statement. “The (hospital provider) fee is critical to our ability to fund and serve more than one-third of those individuals.”

A previous ruling by the Denver District Court found hospital provider fees were fees, therefore not subject to the state’s Taxpayer’s Bill of Rights.

But the tax vampires are trying again to drain our bank accounts of more of our hard-earned money, and they want to do it without our consent. Again. Coloradans need a garlic-like ballot measure to protect us before the legislature bleeds us dry.

Except for the voter-approved excise tax on wacky tobaccy in 2013, voters have rejected seven straight, ginormous statewide tax increases since 2011, including last year’s soundly defeated Proposition CC. During those same years of rejecting grandiose statewide tax increases, Colorado voters have repeatedly proven we will consent to raise taxes on ourselves at the local and school district level, but only when we trust the limited cause and the government officials spending our money.

Bottom line: voters will not trust the legislature yet to spend any more of our money until the legislature can prove that they can appropriately spend the $34.5 billion budget they already have. Coloradans trust themselves and the Taxpayer’s Bill of Rights far more than they do politicians.

Just like the bad-penny boyfriend, legislators think the problem is us, not them. Rather than trying to earn our trust by changing the substance of their approach, the legislature has stopped trusting us and appears intent on trying to end-run around TABOR using semantics.

The enterprise model is being considered for the paid family leave act and was part of the discussion with a task force studying the issue. It has not yet become part of the drafted legislation, though, and there is the potential for it to be part of a ballot measure instead which — to the supporters’ credit — would require a vote.

It is not the first time they have broken out Roget¶¶Ňőap thesaurus to avoid our consent.

Forty-two states have a “bed tax,” a charge on overnight patients collected by hospitals and sent to the state. We do too. Specifically to avoid allowing us vote on that tax — as our constitution requires, the legislature called it the hospital provider fee. A fee can be approved by mere politicians. The hugely successful tax, er … fee … raised so much money from us the legislature was confronted with having to give some back to us through a constitutionally-mandated refund. The legislature does not like to return our money to us … ever. So, they passed a law to move the entire $600 million out from under the TABOR limit on government growth by calling it an “enterprise.” Presto. The legislature exploded the amount of our tax money they could spend and never once asked for our consent to do so.

As well, remember when the legislature dramatically increased or car registration taxes … dang it, I mean fees … in 2009? They created another “enterprise” and put the new revenue in there to make sure it would never be subject to the limitations on government growth imposed by TABOR in our constitution. It’s currently $250 million each year.

This year, legislators are back again for another bite, and again they would really like to avoid having to get our consent. This time, Roget has revealed another synonym to describe hundreds of millions of dollars in additional gas taxes: a “surcharge.”  Despite the fact that such a sur-tax-fee thing could raise our taxes by hundreds of millions of dollars, the legislature would deliberately deprive us of the right to vote on it.

We need a law to end this deception and protect our constitutional rights.

One simple solution proposed for the ballot this year would mandate that any new fee or surcharge funded “enterprise” that exceeds $100 million over its first five years in existence would have to earn voter approval through the ballot. Legislators would again be required to convince us, and not just each other, that they need more of our money. This would help prevent the perennial end-runs around TABOR by politicians. Coloradans are smart enough to know that whether the legislature calls the tax a levy, duty, tariff, surcharge, contribution, or fee, it all comes out of our pockets.

You can almost hear the eye roll from the progressive elitists who remain convinced that taxpayers just aren’t smart enough to make such important decisions about our money. That¶¶Ňőap why we elect them, to do the big thinking for us. I am looking forward to their arguments explaining why allowing us the ability to vote on raising our taxes is bad.

In the absence of a ballot measure that protects us, legislators will continue to avoid us through deceptive semantics and enterprises.

We must send this bad boyfriend packing. It¶¶Ňőap not us. It’s you.

George H. Brauchler is the district attorney for the 18th Judicial District, which includes Arapahoe, Douglas, Elbert and Lincoln counties.

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Americans pay twice as much for our health care than those living in other developed nations, and in exchange, we enjoy middle-of-the-pack results and the lowest life expectancy in the developed world.

Here in Colorado, nearly one in five people forego needed care because of the cost, and one in three can’t afford their prescription drugs.

So if all the money we spend on health care isn’t making us healthier, then where is all the money actually going?

The short answer is that it¶¶Ňőap going to the middlemen — insurance companies, pharmaceutical companies, and hospitals — whose business model is to act as a tollbooth standing in between patients and caregivers like doctors and nurses.

Last month, a new report released by the Polis administration on hospital finances shed some light on just how bad the problem has gotten.

For years, large hospital systems have attributed their ever-rising prices to something they call “cost-shifting.”

They claim that they have to charge higher prices to cover the cost of caring for folks without insurance, folks whose bills exceed what their insurance covers, and people on public programs like Medicare and Medicaid.

So in 2009, Colorado enacted the Hospital Provider Fee — which I co-sponsored — to leverage federal dollars to cover uncompensated care and bolster payments to hospitals caring for Medicaid and Medicare patients.

At the same time, the federal Patient Protection and Affordable Care Act passed; Colorado adopted the Medicaid expansion, which covered about 400,000 people, set up a health care exchange with lower premiums, and parents were able to keep their children on their insurance until age 26. These policies cut our state’s uninsured rate by 60%.

On paper, it worked. The number of Coloradans with insurance went up, uncompensated care went down, and rural and critical access hospitals were able to keep their doors open.

We thought we had solved the cost-shift puzzle.

There was just one problem. As this new report makes clear, instead of shifting the savings to consumers, hospitals instead kept raising prices and shifted the savings into the pockets of executives and corporate shareholders.

Meanwhile, hardworking Coloradans got slapped with higher insurance premiums to cover the hospitals’ rising prices and inflated profit margins.

Here are some of the report¶¶Ňőap findings:

●     Between 2009 and 2018, hospital prices grew by a staggering 71.3%.

●     In the same period, hospital profit margins in Colorado increased by more than 280% and today, Colorado hospitals enjoy the 2nd highest profit margins in the entire nation.

●     Here’s the real whopper: In 2018, Front Range hospitals — including nonprofit hospitals — cleared over $2 billion in profits in a single year! And now those profits are being used to pay for political advertisements against legislation that could save families money.

Now, we need to draw some important distinctions. The problem is being driven largely by Front Range mega-hospital systems and a few mountain resort hospitals.

By contrast, our rural hospitals — including our critical access hospitals — still require assistance to continue serving their communities, and we have a variety of initiatives in process to help them.

Furthermore, our independent hospitals — like Denver Health, Boulder Community Hospital, Parkview, National Jewish and Community Hospital in Grand Junction — are pillars of their communities, and we need to help protect these hospitals from predatory mega-system acquisitions, which most often result in higher prices.

And finally, we need to separate the life-saving work performed in the operating room from the business decisions made in the boardroom.

The doctors, nurses, and other medical professionals who work in our hospitals do amazing things every day to save the lives of patients. I should know. As a four-time cancer survivor, I owe my life to my local hospital and those medical professionals four times over.

But the pursuit of profit at the C-suite level has pushed life-altering medical debt for tens of thousands of Coloradans and sent insurance premiums through the roof for millions more.

Last session, the Polis administration and the legislature made progress on managing costs, and we need to do more — from getting a handle on prescription drug prices to establishing a public option that will reduce costs by injecting competition into the individual market.

But most importantly, policymakers need to ensure that the savings will actually make their way into the pockets of hardworking Coloradans instead of being intercepted by the middlemen.

We were naive to trust large hospital systems to pass savings on to consumers.

Policymakers should not make that mistake again.

Dianne Primavera is the lieutenant governor of Colorado and a four-time cancer survivor.

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Strawberry fields are forever. Rod Stewart wants us to stay “Forever Young.” The best forever is when my son says, “I love you dad … forever!”

Never getting your excess tax refunds again, ever, well that¶¶Ňőap a bad forever. And that¶¶Ňőap the forever we’ll have if Proposition CC passes this fall.

Our Taxpayer’s Bill of Rights is all about consent. Politicians can tax and spend the state into oblivion; all they have to do is ask our permission first through an election. That¶¶Ňőap it.

Politicians can keep our excess tax revenue as well. Again, all they have to do is ask first.

But Prop CC says you agree to give up your tax refunds not for just this year, not for the next four years, but forever. No future generation will be able to give or withhold their consent over their tax refunds.

Our children’s children’s children will never get a TABOR refund. Nor even be asked.

Not only does TABOR require a public vote to raise taxes or debt, it sets a spending limit for our governments. Should the state collect more in tax revenue than that limit, it must return the excess back from where it came, you.

Well, doesn’t the state need that excess revenue? Even the TABOR-loathing Denver Post Editorial Board admits, “we are no longer convinced that the state needs more revenue for the general fund. The state’s economy is booming and thanks to the Tax Cuts and Jobs Act, revenue from state income tax filings has spiked in Colorado … It’ll be tough to argue that the state is hard-pressed for cash, or that it is crippled by TABOR, a year after historic investments were made in K-12 education, roads and higher education.”

The state is swimming in your cash because of three basic reasons. First, the new Trump tax reform lowers our federal taxes, but as The Post notes it has the reverse effect for Coloradans via our state income tax. That¶¶Ňőap because your Colorado state income tax is based on your “Federal Taxable Income.” And that line item actually goes up under the Trump tax code.

An important aside on that — the Colorado legislature voted down a bill to adjust your state income tax so you wouldn’t be getting a huge state tax hike because of the federal tax changes. Think about that one.

The second reason the state gobbles up so much more of your money is because of the many tax increases the state legislature passed without your consent. They do that by calling a tax increase a “fee.”

Without asking you they have passed the growth dividend, the Faster fee, the mill-levy freeze, and the hospital provider fee. These are all tax increases. These “fees” have ballooned so much that around two-thirds of the state budget falls in this category of “we didn’t ask you” taxes.

And thirdly, the state is awash in your cash because in 2005 voters gave the state permission to keep our tax refunds for five years, not forever, and permanently ratchet up the TABOR spending baseline. Now in 2019, the state is able to keep about $2 billion a year more because of that higher spending limit.

You should know the key players who helped pass that five-year, not forever, timeout in 2005, former Gov. Bill Owens and former U.S. Senator Hank Brown, are strongly endorsing a no vote on Prop CC today.

It¶¶Ňőap not just good that you get your TABOR refunds, estimated at about $650 million in the next couple of years, it¶¶Ňőap good for state government. You read that right.

The point to remember about government spending is that any dollar the state spends this year is a commitment to spend a dollar and five cents next year. Government programs grow at least by inflation, often more.

Prop CC doesn’t put this excess revenue into an emergency fund for a rainy day. The money goes right out the door as new spending.

So when, not if, the next recession hits, the state budget would be falling from a much higher cliff, causing great pain. This happened in 2009 with the great recession during that five-year, not forever, TABOR timeout and it triggered budget havoc. Just ask those dealing with the “education negative factor.”

While diamonds are forever, economic good times aren’t.

Don’t rip away your kid’s taxpayer’s rights.

Jon Caldara is president of the Independence Institute, a libertarian-conservative think tank in Denver.

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