Set to launch down a ski slope at Breckenridge, where he was celebrating his engagement with his fiancée and their friends, Everett glanced at his phone before pushing off.

A notification informed Everett that he had just won $55,000 on a $15 fantasy-golf wager on the . The money was in his PayPal account by the time he finished the run.

“That was more than my salary at the time,” he said. “You convince yourself that you’re so good.”

The money was gone almost as fast as Everett, high on dopamine from his big score, flew down that mountain. By the end of the ski weekend, he had blown the entire $55,000: drinks and food for his friends, a gold watch and, worst of all, more bets, including an $18,000 loss with one tap on his phone to bet — incorrectly — on the Big 10 football championship. He did not have enough money to buy gas to get home.

For Everett, the next two-and-a-half years would be “incredibly off the rails.”

“After I lost that money, I couldn’t get it out of my head chasing that,” he said. “I was basically trying to win it all back.”

Colorado, much like Everett, plunged headfirst into legalized sports betting after voters approved it in 2019. Since online sportsbooks opened in May 2020, the state’s residents have bet more than $30.6 billion on the outcomes of games and on the performances of the athletes who played them, netting the state more than $154 million in tax revenue.

But the growing popularity comes at a cost.

Mental health and addiction experts are sounding the alarm about a growing crisis that Colorado was not prepared to handle. The state does not sufficiently fund services for people who become addicted to gambling via the sports-betting apps on their phones, mental health experts say, and there are not enough therapists trained to treat gambling addiction. Colorado also provided little funding to promote awareness about gambling addiction and put limited guardrails in place to help people slow their betting habits.

It’s not clear how many Coloradans have gambling problems. There’s never been a study to determine that, but the results of a national survey suggest that more than 100,000 people in the state could suffer from that mental health disorder.

Jamie Glick, executive director of the , calls gambling addiction the “next big public health crisis.”

“Unfortunately, we are hearing a lot of rock-bottom stories,” Glick said. “People aren’t seeking help until they hit rock bottom. We are seeing people whose marriages are destroyed. They’re financially destroyed.”

Six years after legalization, Colorado is trying to catch up. The General Assembly this spring passed a bill that will put some controls on sports-betting apps, including by limiting the number of daily deposits a person can make. The state also increased the share of tax revenue funneled annually to problem-gambling awareness and prevention.

Gambling companies told The Denver Post they are creating new features to help people limit how much they spend, saying it is in their best interest to retain customers who view betting as entertainment, not a problem. Five sportsbooks stopped accepting credit cards in the past year amid growing criticism that people should not gamble with money they don’t have, and Colorado will ban credit card deposits, beginning in August.

“We want our customers to play with us month over month or year over year,” said Cory Fox, senior vice president of public policy and sustainability at . “If they have a problem, they will be off the platform.”

The Post examined the impact of legalized sports betting in the state by interviewing those involved in the industry and those who regulate it, mental health professionals, the groups who benefit from the tax dollars, athletes and coaches, and the gamblers. The Post also analyzed the money spent to show how much people are wagering, which sports are most popular for betting, and how much revenue sportsbooks are earning.

The first installment of this three-part series looks in-depth at gambling addiction and the attempts to get it under control before it becomes a public health crisis. The second part will examine how water conservation advocates bet on sports gambling to obtain funding to rescue communities and industries dependent on the state’s scarce water resources.

And the final story will explore how betting is changing sports itself as professional leagues embrace sportsbooks as business partners, even as gambling scandals make headlines and athletes report increasing hostility from fans who lose money when players fail to perform.

The launch of sports betting

Colorado was among the early adopters of legalized sports betting when voters approved Proposition DD in November 2019.

The state had moved quickly after the the 1992 , a federal law that had prohibited states from allowing sports betting.

In exchange for legalizing sports betting, Colorado voters agreed that sportsbooks should be taxed at a 10% rate to fund water conservation. That bargain pushed Proposition DD toward a narrow win, and the rushed to put rules in place.

By May 2020, sportsbooks in Colorado were open for business, and amid the COVID-19 pandemic, people found a new avenue for entertainment. Although the pandemic paused major sports in the U.S., including the Kentucky Derby, the NCAA basketball tournament and the NBA season, Coloradans still found sports to wager on.

Bettors spent more than $25.6 million that first month, with the largest percentage of bets being placed on table tennis at $6.6 million.

Table tennis remains one of the most popular sports for Colorado gamblers to bet on, with $989 million wagered since legalization. In April, it was the fourth most popular sport for wagering, with $28.5 million bet on it.

Those who want tighter controls on sports betting cite table tennis wagers in their arguments, saying it’s an example of problem gambling because Americans do not care about or understand ping-pong and only bet on it because it’s played in other parts of the world when most people in this country are asleep.

Professional basketball is the state’s favorite sport when it comes to betting, with $7.3 billion wagered on the NBA and overseas leagues, as of April. The NFL is second, followed by baseball, tennis and NCAA basketball, according to the revenue department’s data.

Sports betting continues to grow year after year.

In April, the most recent month of data available, Coloradans bet $521 million on sports — 20 times more than that first month in 2020. The state raked in $4.4 million in taxes.

, director of the state Division of Gaming, said interest in local sports teams is driving the growth, especially with the Broncos, Nuggets and Avalanche fielding championship-caliber teams.

“It’s becoming more and more exciting to watch our teams here in Colorado,” he said. “Every time we have a lot of interest in sporting events featuring our local teams, we see that continued growth. It’s more accessible with attention and advertising.”

Colorado has a healthy sports-betting market with 13 online companies and 10 in-person sportsbooks, Schroeder said. The goal, he said, is to have the best odds available for the gamblers.

The state also offers a with 5,866 approved events and wagers, ranging from which team will win the Super Bowl to whether someone will get knocked out in the U.S. SlapFIGHT championship to who will win the Chinese Basketball Association’s Club Cup.

At the same time, Schroeder said the state is committed to responsible gaming, which is the term the industry uses instead of gambling.

“We want individuals to bet smart,” he said. “Betting should be entertainment. It shouldn’t be something where you’re adding on a second level to the house by gambling.”

Colorado offers a through which gamblers can ban themselves from online apps and in-person sportsbooks at the state’s casinos. There were 1,245 people on that list as of June 15.

The state also promotes March as and operates the . Each year, the state awards millions in grants to nonprofits that are focused on gambling addiction.

Yet even as sports betting grows, public opinion is becoming more critical.

An found 43% of Americans say sports betting is bad for society, up from 34% in a 2022 poll. Still, 22% of respondents said they had bet on sports in the past year, up from 19% in the prior study.

Chasing the high

It’s impossible to know how many people in Colorado bet on sports, let alone to understand how many might suffer from a gambling addiction. Sports betting companies do not release their data and the state does not conduct public health monitoring of gambling addiction.

Sports betting is prolific among young people, said Evette Marquez, a 26-year-old, diehard Broncos fan.

She learned to gamble on a sports app from an ex-boyfriend and routinely places wagers on her favorite sport — pro football. Most of her friends do, too.

“Everyone is betting these days, especially at my age,” she said. “Some people may not be paying rent.

“I think people my age get stuck on the dopamine. You get that green ticket,” she said, referring to an icon on the DraftKings app that signifies a winning bet, “and it����ap the best feeling.”

That dopamine hit certainly contributes to the addictiveness of gambling, said assistant professor of psychiatry at the .

“It’s something pleasurable like hearing your favorite song or eating chocolate,” she said.

People who become addicted to gambling can naturally have lower dopamine levels, making them crave a high, Hemendinger said. And some people are just hardwired to take risks, and that makes them more prone to gambling addiction, she said.

Researchers have also linked gambling disorders to the parts of the brain that respond to rewards and regulate social behaviors and impulse control, Hemendinger said. But the prefrontal cortex is not fully developed until a person reaches their mid-to-late 20s, making young people more susceptible to impulsive behavior while gambling.

The profile of a heavy sports bettor is a male younger than 35 who is single, employed and well-educated, according to the . And they think sports betting involves skill, not luck, which makes them “prone to distortions in thinking,” according to a coalition summary of sports wagering and addiction studies.

Matt Ferraccio, 38, started gambling in middle school, continuing into adulthood. He found it an escape from other problems in his life.

Ferraccio said he used legal gambling apps as well as the unregulated, overseas sportsbooks and bookies. He took advantage of special promotions, and when he ran out of credit on one, he opened another account.

“A compulsive gambler just doesn’t stop,” he said.

Ferraccio and Everett each talked about “chasing” their losses. Both men said they were never satisfied with a big win. They placed more bets rather than pocketing their winnings, and when they lost, they tried to win the money back — usually losing even more.

“It’s really hard to replicate that feeling you get when you win a lot of money,” Ferraccio said. “It means higher bets and longer sessions. You’re just chasing.”

Gambling addicts can stay awake for days, betting on obscure sports happening in other countries.

“You can log in at 3 a.m. and find tennis that����ap going on in China, ping-pong in Russia, basketball in China, cricket games. The possibilities are endless if you want to be compulsive and keep going, which I did,” Ferraccio said.  “Obviously, you don’t know anything about them, but you just pick.”

Ferraccio always promised himself he would stop once he dug himself out of a financial hole. It never happened.

Unprepared for a crisis

The National Council on Problem Gambling estimates that 9 million Americans have a gambling disorder, which is recognized as a mental health illness in the Diagnostic and Statistical Manual of Mental Disorders.

Brianne Doura-Schawhol, director of the , said a 2023 study by the estimated about 2.4% of the population struggles with gambling addiction, which would mean about 110,000 adults in Colorado suffer from it.

But Colorado never conducted a study to gauge the prevalence of problem gambling before it legalized sports betting, and public health officials have no plans to do one.

“How can you make policy decisions without the proper data?” Doura-Schawhol said.

Colorado also ranks among the worst in the nation when it comes to funding gambling addiction resources, multiple people told The Post. The state law that legalized sports betting established a 10% tax on net sports betting proceeds, but only allocated $130,000 annually to problem gambling.

In 2023, the legislature boosted the annual amount to $2.5 million. Since 2023, the Colorado Division of Gaming has awarded $11.2 million in grants to organizations that raise awareness about addiction and help those who suffer from it.

The state allocated less than a penny per person for gambling services in 2023, by the National Association of Administrators for Disordered Gambling Services.

The bill passed in May did not include additional money for prevention and treatment. And as lawmakers faced down a $1.5 billion budget deficit, there was little room to set aside extra money. The legislature could shift some funds set aside for water to gambling addiction issues, but that has not been proposed.

Nationally, there is no federal revenue stream to support gambling addiction prevention and treatment, even though experts estimate that the social cost of gambling addictions exceeds $14 billion annually in the U.S.

In March, a group of bipartisan representatives in Congress introduced the Providing Opportunities for Individuals In Need of Treatment and Support, also known as the , which would divert a third of federal taxes collected on gambling to awareness, prevention and treatment of gambling addiction. If approved, it would raise an estimated $100 million per year, according to the National Council on Problem Gambling.

But in Colorado, there is no movement to increase funding for gambling addiction, even as the state rakes in tax revenue from sports betting.

Doura-Schawhol said the National Campaign for Fairer Gambling ranks Colorado at the bottom of the 39 U.S. states that have legalized sports gambling when it comes to funding treatment and prevention for gambling addiction.

Liesl Leary-Perez, co-founder of , said Colorado has long ignored mental health problems, and sports betting addiction is now one more thing on the list that needs to be addressed.

“To answer your question of ‘Were we prepared?’ No! We were not prepared,” Leary-Perez said of Colorado’s swift entry into the online sports-betting world. “And no one seems to care because we aren’t increasing that budget.”

When legalized sports betting came online, those who work in the addiction-treatment field were not prepared for clients struggling with gambling addiction.

The , which establishes the best practices for counseling gambling addicts and issues certifications to professional therapists, lists just 17 people in Colorado who have received certification. Only two are practicing in Denver, the state’s largest city.

The Problem Gambling Coalition of Colorado lists 18 counselors who treat gambling addiction and two behavioral health centers that offer telehealth appointments for gambling addiction on its website. And the coalition has developed a four-hour certification program for counselors on college campuses to help them recognize and treat the problem, Glick said.

Daniel Umfleet, founder and chief executive officer of , a behavioral health company focused on gambling addiction, left the United Kingdom to move to Colorado to start up his company after sports betting was legalized in the U.S.

Treatment for gambling addicts is in its infancy in the United States, Umfleet said.

“The unfortunate reality today is there are not enough health systems that understand this and have adopted it into their service mix,” he said. “The infrastructure wasn’t there.”

Ryan Canaday, founder of the in Denver, said he received a warning in 2020 from a doctor who called sports betting the “new dopamine dump,” and recommended his church and its associated nonprofit, which focuses on addiction recovery, prepare for it.

Then more people started showing up, seeking help, and Canaday had to learn what those addicts needed to recover.

“When I heard someone say, ‘Last night I lost $100,000,’ it was hard for me to fathom. I thought, ‘Well, why’d you place that big of a bet? And why couldn’t you just stop?’ and all the questions a rational mind asks,” Canday said, “but this disease of addiction is not rational, or else none of us would be here, right?”

‘Modern-day get-rich-quick scheme’

Arty Smith, a math teacher, last year launched the , a program that teaches teenagers the pitfalls of wagering.

Smith’s lessons on sports betting involve PowerPoint presentations with bar graphs and pie charts as he breaks down how it’s nearly impossible to beat the house.

He gathered data from every NFL game since 1966 and crunched numbers to show that picking the over/under bets — guessing what the total points scored by both teams in a game will be and whether it will be higher or lower than the points total set by the house — is no different than picking heads or tails on a coin toss.

It is a certainty that people lose money in the long run, Smith said.

“It doesn’t matter how well you know the game of football,” he said. “You could be Peyton Manning for all I care, you still won’t be able to pick football games any better than you could pick the outcome of the coin flip.”

On the over/under bet, the house has a 4.5% edge, Smith said. But when it comes to parlays, the house edge jumps to 40%. In a parlay, gamblers wager on multiple things happening at one time.

For the April 30 playoff game between the Denver Nuggets and the Minnesota Timberwolves, offered a “Joker Jackpot” parlay that would pay out if all-star center Nikola Jokic scored more than 30 points, recorded more than 10 assists, grabbed more than 10 rebounds, and hit more than three three-point shots. In gambler parlance, that’s a “four-leg parlay.” A winning bet on a $10 wager would return $70.

The parlays are wildly popular with gamblers because they have higher payouts, and they benefit sportsbooks because they have higher odds and bigger profits.

“It����ap a way for the sportsbooks to take gamblers’ money even faster,” Smith said. “It’s the modern-day get-rich-quick scheme. It doesn’t seem that hard to win the bet.”

Smith developed the Gambling Awareness Initiative after a friend consulted him about how to respond to his preteen son’s request to create an online sportsbook account because the boy was too young to open his own.

“He knew what he wanted to tell his boy about drinking and drugs and unprotected sex, but he was unprepared for the question about gambling,” Smith said. “It occurred to me that we need to talk about this.”

Zach Everett’s love of gambling started as a child at a race track when his father allowed him to pick a horse and placed a bet on his son’s behalf.

He gambled through a bookie for a couple of years in college. In 2018, Everett obtained his first credit card while earning $36,000 per year. Sports betting would not be legal for another two years, but daily fantasy sports were legal and growing in popularity in the U.S.

The daily fantasy sports apps run by DraftKings and FanDuel were not considered gambling because participants played against each other rather than the house. But those games gave both companies footholds in the market before sports betting became legalized, and they continue to reign as the biggest sports-betting companies in the country.

Everett, a self-described “big-time sports fan,” used his new credit card to make deposits into a DraftKings account to enter those fantasy sports contests. But he couldn’t handle winning a big prize.

“My brain couldn’t comprehend it was life-changing money,” he said. “You’re not holding the cash and you don’t have a moment to breathe. It����ap just so fast and then you blink and it����ap gone.”

Sportsbooks and responsible gaming

The sportsbook operators say they take measures to promote responsible gambling, arguing it would be short-sighted to drive people away through increasing addiction.

Lori Kalani, chief responsible gaming officer at DraftKings, said it is in her company’s best interest to establish controls that players can use to limit themselves.

“It����ap the right thing to do,” she said. “If people are out of control and they’re spending money on entertainment that they don’t have to spend, they’re not going to be a happy customer and we’re not going to be a happy business. We want long-term customers. Not only is it the right thing to do, it’s the smart thing to do.”

At DraftKings, Kalani has a staff of 50 who work on the company’s responsible gaming programs. Those include a budget builder that lets players determine how much they want to spend and how long they want to be on the app. They can set alerts that notify them when they’ve hit their limits.

DraftKings also provides customers with a personal stat sheet they can use to review how much they’ve deposited, how much they’ve wagered, how much time they’ve spent on the app, and even which sports they’ve bet on. It’s like getting a monthly spending report from a credit card company, she said.

Meanwhile, Kalani’s staff also manually reviews individual accounts flagged for abnormal betting patterns, such as a customer suddenly making much larger or more frequent deposits. Last year, 92,000 accounts were reviewed, she said.

When Kalani, who is a lawyer, first took the job at DraftKings, she was surprised by how few people used the various tools that help control time and money on the app. People saw responsible gaming tools as something only those who have problems need, she said.

“I thought that was upside down,” she said. “The whole point is you use them so nothing gets out of control. It����ap a lot of work to change how people think about that.”

Fox, Kalani’s counterpart at FanDuel, said his company also makes an effort to boost participation in the app’s responsible gaming features.

FanDuel’s parent company, , wants 75% of its average monthly players to use its responsible gaming tools by 2030. Individual performance bonuses for employees on his team will be tied to that goal, Fox said.

One tool introduced in the past year by FanDuel is an artificial intelligence program that can quickly detect when a person has deposited an amount that is much larger than that player’s previous deposits on the app. The program then asks the player if they are sure about the amount, Fox said.

A staff of 30 people reviews accounts that get flagged for abnormal betting patterns, and after users threaten customer service representatives or even mention they can’t pay their mortgage. Those employees can send emails with responsible gaming information, put players in time-out, set deposit limits and, in some cases, ban them from the app, Fox said.

“There’s still a lot of work to be done in this field. We are not declaring victory,” Fox said. “We are working hard to figure out the best ways to identify and protect that small percentage of our user base who may be struggling to manage their play on our site.”

While the sports betting companies say they limit problem gamblers, others insist that’s not the case.

Josiah Clarke, 40, is a lawyer and a sports betting sharp — meaning he figured out how to win consistently.

Clarke played fantasy football for years and casually bet on offshore sportsbooks. But when sports betting was legalized in Colorado, and the pandemic gave him a lot of spare time, he decided to “take a real go at it.”

Clarke, who lives in Greeley, built a system of analyzing games and created his own model for statistical analysis. He raised the stakes as his model improved.

He won — and the sportsbooks noticed his winning pattern.

DraftKings was the first to limit him after he won $24,000 over two football seasons, Clarke said. FanDuel followed.

“I’d try to bet like $2,000 on an NFL game, and they’d say you can bet up to $47,” he said. “And I was like, it����ap not worth all the effort I’m putting into it for $47.”

Ferraccio and Everett said no sportsbook ever cut them off, even when it was clear they were gambling too much.

“Responsible gambling from these sportsbooks doesn’t even come close to identifying people,” Ferraccio said. “If they see me spending all night doing it, guess who’s getting the free bet? Guess who’s getting the big promotions? It����ap not the people who are winning.”

Bonus bets are not free money. Instead, gamblers must put something into their accounts first. Gamblers are never allowed to withdraw those “bonuses,” and they expire.

FanDuel’s Fox took exception to accusations that sportsbooks do not actually limit gamblers who show signs of addiction.

“First and foremost, we absolutely identify problem gamblers and prevent them from being on our site any longer,” he said. “Any suggestions that we don’t actually do that on that basis are inaccurate and wrong.”

Doing a lot with a little

Colorado has boosted its addiction awareness and prevention efforts in the six years since sports betting went online.

The state’s Gaming Division funds responsible gaming grants, doling out $3.8 million in March. Those grants were awarded to nonprofits, including the Problem Gambling Coalition of Colorado, which will use its $1.5 million to certify therapists treating gambling addiction, to support a project that works with college students, and to promote gambling addiction awareness.

The , a nonprofit advised by Umfleet, received more than $1 million to work with the military to address gambling addiction within the ranks. He said Colorado is doing a lot of work with little funding, and some efforts are gaining national attention.

“You’re doing it half the speed of what you would prefer,” he said.

In its most recent legislative session, the General Assembly passed , setting some first-in-the-nation standards to control addiction through state law. The law will go into effect in August.

The new law bars gambling companies from sending push notifications to their app users, something that emerging research shows triggers people into betting more. It also restricts advertising from targeting people younger than 21.

The new law will limit gamblers to six daily deposits on an app. But it does not limit the amount a person can deposit, and people can have multiple apps, meaning they still could deposit an unlimited amount of money in a 24-hour period.

The bill was watered down after its sponsors, under pressure from the gambling companies and their lobbyists, struck a provision that would have banned all proposition bets. A prop bet allows gamblers to wager on an individual athlete’s performance, and those prop bets can be rolled into the wildly popular parlays. Colorado already bans prop bets on college athletes.

Sen. Matt Ball, a Denver Democrat who was one of the bill’s bipartisan sponsors, said the new law should put some friction between gamblers and their impulse to place bets.

It was needed, he said, because technology has rapidly changed since Colorado legalized sports gambling, making it easier and faster for people to bet. Industry advertising works, Ball said, because he sees its effect on his preteen son.

“It works on his brain,” Ball said. “He asks me about placing bets. He thinks he can make a big hit, win $100. We need to put reasonable guardrails on sports betting to protect our kids.”

‘There is hope’

Ferraccio has no idea how much money he lost over the years. He said he could go on a winning streak and have as much as $200,000 in his accounts, only to lose it all over again.

“It����ap a lot,” he said. “Everything I’ve ever earned basically.”

Ferraccio placed his last bet on July 1, 2024.

“I was hitting a point where I had nothing but debt and darkness, and it just made me sick,” he said. “When you get to that point, it doesn’t feel like you have a way out.”

Ferraccio was afraid that if he did not stop and get help, he would become part of the statistic that haunts gambling addiction — the high suicide rate.

Multiple studies in the U.S. and internationally have found that people with gambling disorders have higher suicide rates than people suffering from other addictions, such as alcohol. One in five people with a gambling addiction has attempted suicide, according to the National Problem Gambling Coalition.

Ferraccio found help in recovery groups. He formed friendships with other recovered gamblers, and they hold each other accountable.

“There is hope,” he said. “You have to look in the right places. You have to admit you lost control. If you can’t admit you have a serious problem, you’re never going to get right.”

For three years after his big fantasy golf prize, Everett said he gambled so much that he alienated almost all of his friends and family.

He maxed out six or seven credit cards. He burned through at least six payday loans. He ran out of friends and relatives willing to loan money. He pawned a $12,000 TAG Heuer watch that his dad had given him as a wedding present. He wrecked his car — also on loan from his dad — while checking a bet on his phone.

Everett, who worked as a sales director and ranked first in sales for his company, was fired after his boss learned he had asked a client for a loan.

“Getting called into the office that day…” Everett said, unable to finish explaining what happened.

He dreaded telling his wife he had lost his job because of his gambling. She quit wearing her wedding ring.

Everett gambled away his severance. Loan sharks came calling. His first inpatient stay had failed, and support groups and regular therapy were not helping. He considered fraud. He considered overdosing.

So he flew home to Minnesota and the one person who still took his calls — his dad, Brad Everett.

Looking back, Brad Everett said he did not realize that gambling addiction strangles people much like alcohol and drug addiction.

“I didn’t understand why he just couldn’t stop,” he said. “It was a complete lack of understanding. And a complete lack of understanding of how easy it is with your phone and the apps.”

Brad Everett had already flown to Denver multiple times to help his son, crafting lists of people from whom his son had borrowed money. “But it was never the end,” he said.

Brad Everett checked his son into another rehab center in Minneapolis with a warning: If Zach Everett did not complete rehab and stop gambling, he would be financially cut off.

“He’s the most generous man in the world, and it was eye-opening to me to see him get to his breaking point,” Zach Everett said.

Everett placed his last bet on April 24, 2024.

Since then, he said he has kept his promise to his father. He repaired his marriage. He is slowly paying off debts and earning his old friends’ trust. He attends regular meetings with other recovering gamblers.

And he is becoming more comfortable telling his story in hopes of helping others struggling with gambling addiction.

“It’s such a hidden problem,” Everett said. “You’re definitely not alone. I know how scary it is. If you do not address it, it����ap only going to get worse. You’re not going to win yourself out of whatever hole you’re in. You can’t bet yourself out of it.”

READ PART 2 NEXT: How sports betting became Colorado’s ticket to funding $140 million in water conservation projects

Updated 10 a.m. June 18, 2026: This story has been updated to clarify Daniel Umfleet’s relationship to the Kindbridge Research Institute.

Brandon, 41, already relied on his dad for all of his daily needs, ranging from setting up the lift to move him from bed to his wheelchair to scrubbing him down in the shower and pouring his morning coffee into a cup with a straw. That was the way it had been since Brandon broke his neck in a vehicle accident almost nine years earlier, and they made it work, with a hefty dose of gallows humor to keep from screaming.

Monty Patterson trusted the doctors at knew what they were doing, but opening someone’s skull always carries the risk of doing further damage. What would happen if Brandon lost control of the limited muscles he could use in his arms or his ability to speak?

“I said, ‘If you’re just doing this so you can play video games, I’m gonna smack you,'” Monty said in an interview at in Aurora while Brandon was hooked up to a computer tracking his brain activity. “He said, ‘No, I’m doing this so I can play video games and further science.'”

Brain-computer interfaces that allow people to control artificial limbs using their minds exist at the boundary of science and science fiction. As is, a paralyzed person who has had the surgery and undergone the lengthy process of training the program can control objects on a screen and complete some movements with a robotic arm. But a system that would allow patients to regain the full abilities they had before their injuries, while possible, remains only a hope.

Brandon Patterson, who is paralyzed from the chest down and has limited use of his arms, was the into a part of his brain involved in decision-making during a surgery in February.

The researchers working with him aim to determine whether putting electrodes there, rather than in areas specific to movement, will produce better control of screens or artificial limbs. They are also investigating whether they can send signals the other way, to produce semi-natural sensations in limbs that can’t communicate with the brain.

Dr. Daniel Kramer implanted six arrays of electrodes, which resemble patches of tiny needles, to pick up signals from the surface of Patterson’s brain. A computer then has to learn how to decode what the electric signals in the brain mean, because two people thinking about the same action produce different patterns.

“Each brain is totally different,” said Kramer, an assistant professor of neuroscience at CU’s and a neurosurgeon at University of Colorado Hospital.

The current setups are good at moving a robotic arm in the right direction, but don’t always know when to stop: something like a toddler who knocks over the toy they want to grab, Kramer said. Putting the electrodes in a part of the brain involved in higher processing might improve that, he said.

If a computer could send signals back, the brain could judge whether it needs to tighten or loosen the grip of a robotic arm, in the same way that a person using their natural hand finds the balance where they don’t crush or drop the thing they’re holding, Kramer said.

“There’s lots of things that go into making a hand movement correct for an object,” he said.

Private companies and researchers are working on parallel tracks with the technology, with the businesses trying to prove their products help patients enough that the should approve them, Kramer said. At universities, they’re more focused on learning about how the technology and the brain work together, which could lay the groundwork for future advances, he said.

Kramer made clear that he couldn’t guarantee any benefits and that the goal of the research was to improve the technology for future patients, Patterson said. He doesn’t have any robotic devices or a computer capable of linking to his brain at home, so he only uses the technology during sessions with the research team.

“If I see some things now, fine, that’s cool, but it’s not for me,” he said.

Patterson’s wildest dream for the brain-computer interface is to someday be able to drive his wheelchair with his mind, like Professor X in the X-Men comics. But being able to use a computer more easily would also be a significant improvement, he said.

He currently uses a combination of voice controls and a stylus that attaches to his hand like a brass knuckle, allowing him to peck at a screen. Neither was enough to succeed with Microsoft Excel and pass the statistics class he took as part of his psychology major at , he said.

On a Friday in April, researchers hooked Patterson up to a computer, plugging wires into ports sticking out of his scalp like a stegosaurus’ back. He didn’t have on the decorative metal spikes he sometimes attaches to them when going out.

“If I’m going to get looked at funny because I’ve got spikes, I’m going to make it as punk rock as possible,” he said.

Set-up complete, the researchers assigned Patterson mental tasks, such as visualizing putting his fingers through the holes of a pair of scissors or holding a cup. Just thinking about the tasks didn’t produce a significant reaction that they could detect, but holding up the scissors as a visual aid and asking him to pretend he wanted to drink from the imaginary cup got the signals firing.

Later, they set up something that looked like a 1980s computer game, with a green disk sliding on top of gray disks in a circle around it. The researchers were moving the green disk at that point while telling Patterson to imagine sending it in the right direction, Kramer said. Eventually, once the computer learns to decode his brain’s patterns, he’ll be able to move the virtual disk with his thoughts.

When he tried again, about two weeks later, Patterson could move the disk without as much support from the computer. He couldn’t budge it when asked to imagine he was playing air hockey, but a prompt to think about how the Jedi move things with their minds in the “Star Wars” movies clicked.

“The Force is strong with me,” he joked later.

People can somewhat understand the challenges of not being able to use his arms fully or his legs at all, but having quadriplegia brings a whole different set of challenges that a brain-computer interface probably can’t solve, said Tammy Neuman, Monty’s partner and Brandon’s co-caregiver.

Patterson — who lives with his father and Neuman in Elbert, about 50 miles southeast of Denver — had to relearn how to cough because his diaphragm no longer contracted and figure out what he could do with limited control of his arms. His biceps still work, but his triceps don’t, and his fingers usually stay curled under.

“Life with a quadriplegic is always about overcoming,” she said.

On top of that, the stillness can lead to blood clots, including one that went into his lungs and landed him in the hospital, Patterson said. Pressure sores from sitting or lying too long in one position are a constant threat.

Something as comparatively minor as a full bladder or bowel can trigger a because his body senses something is wrong below his spinal injury and doesn’t know how to manage it.

“I say I’m on 13 of my nine lives,” Patterson said.

And yet, when February rolls around again, the gyms suddenly aren’t so crowded as New Year’s resolutions lose their shine. Nationwide, only about 30% of people , and even in famously outdoorsy Colorado, just 35% do.

So if exercise gets the endorphins flowing and gives a quick mood boost, why do many people find it hard to stick with?

The popular perception that exercise produces endorphins, which then raise mood, isn’t wrong, but it oversimplifies complex interactions between brain chemistry and mental states, said Katrina Oselinsky, a post-doctoral researcher at the on the .

The same person could experience the same workout differently from day to day, depending on how they’re feeling, what else is happening in their lives and the setting where they exercise, she said.

“While endorphins are part of the picture, there’s a lot more going on,” Oselinsky said. “The same workout can feel energizing for one person and uncomfortable for another.”

While a subset of people get an immediate “runner’s high” in response to intense exercise, not everybody has the same experience, which can set others up for disappointment, said Emily Hemendinger, an assistant professor of psychiatry at CU Anschutz.

Brains differ in how sensitive they are to rewards, so some people are primed to get more or less enjoyment out of exercise – though, obviously, factors such as past experiences with exercise matter, she said.

Exercise does trigger a release of chemicals that give most people at least some sense of pleasure, but it doesn’t generate a tsunami that could drown out a person’s lack of comfort in their body, fear that others are judging them, perfectionism, boredom, physical pain or exhaustion, Hemendinger said.

“It’s not like doing drugs, and what that lights up in our brain right away,” she said.

For most of human history, exercise didn’t exist as a separate activity: We moved because we needed to find food or because we were doing something inherently rewarding, such as dancing, said Marcelo Bigliassi, an assistant professor at .

Now, people need to find a motivation for exercise, which isn’t always readily apparent, he said.

“We don’t do anything without a reason,” Bigliassi said.

While the brain releases dopamine, triggering the desire to repeat exercise, it can also get “really creative” in coming up with ways to avoid something uncomfortable, Bigliassi said. To get around that, people need to focus on finding something challenging enough to give them a sense of accomplishment, but not so tough that they give up, he said.

“We don’t want people to find something they don’t like, exercise at high intensity, probably injure themselves and… feel like a failure,” he said.

The data is clear that, over time, exercise improves both mental health and cognitive abilities such as problem-solving, Bigliassi said. But many people give up long before they see those benefits because they set themselves up to fail or aren’t prepared for bumps along the way, he said.

“Consistency is much more important than everything else,” he said.

People who believe they’ll be able to accomplish what they’re trying to do report more enjoyment from a workout than those who feel defeated at the start, Oselinsky said. Having support from the people around you also improves the experience, and new exercisers tend to develop more positive feelings as they get better at the activity, she said.

Of course, we humans aren’t always great at sticking to something we don’t like, even if we know it brings benefits. So a non-exerciser’s best bet is to choose an activity they like or to bundle exercise with something else they enjoy, such as getting outside, spending time with a friend or pet, or listening to music or podcasts, Oselinsky said.

“If you’re trying to force yourself to stick with something you don’t like, it’s going to be harder,” she said.

People often feel that they have to go to a gym, but movement throughout the day can be as good as a dedicated exercise session, Oselinsky said. That could look like doing physical labor at work, schlepping toddlers whose motivation to walk is shaky, or tending a backyard garden come spring.

Federal guidelines recommend 150 minutes of moderate activity or 75 minutes of vigorous activity each week, with some sort of muscle-strengthening exercise on two days.

But any movement that someone enjoys is a step in the right direction, whether that means jumping on a trampoline or playing with their dog, Hemendinger said.

“Joyful movement’s hard to find, but it’s important,” she said.

Martin Luther King Jr. Boulevard, less than a block from my house, sports fast, anxiety-inducing traffic that barely abates outside rush hour. I’ve ridden it to work on miles of unbroken bike lanes and, while I’m thankful they exist, I also quickly realized there are fewer reckless motorists on the side streets.

The cars are slower and more sparse about 10 blocks south on , which runs east from Denver’s City Park to the University of Colorado Anschutz Medical Center in Aurora — a roughly 6-mile stretch of diverse residential and commercial areas.

Montview’s mix of painted and buffered bike lanes starts at the Denver Museum of Nature & Science, on the edge of City Park, and continues east along a picturesque stretch lined with mansions, churches and libraries in Denver’s historic Park Hill neighborhood. Each Halloween, kids in our part of town flock to this stretch for the scenery and outsized Halloween decorations. Some of the modest neighborhoods around it have practically been drained of trick-or-treaters, given that the people who live on Montview are so happy to welcome their neighbors.

This stretch has in recent years also added more stop signs and crosswalks for pedestrians and cyclists, and the calming effect has been palpable as drag racers, careening Hummers, and otherwise alarming vehicles seem to avoid it (unlike MLK, unfortunately). As you move east on Montview, you’ll see not just pretty houses and parks, but also working-class neighborhoods in Aurora as you approach Montview’s end at Peoria Street.

Aurora over the last decade on Montview, between Oswego Street and Fitzsimons Parkway through the Anschutz Campus, although my visits over there are usually car-based. (If you’re a parent in east Denver, you know there’s a Children’s Hospital at CU Anschutz, and Montview provides a direct route.) This stretch passes public schools, auto shops, tacquerias, Thai diners, tidy houses and apartment buildings, and it feels markedly different than the multimillion-dollar milieu to the west.

Just off Montview, and right where Denver ends and Aurora begins, you’ll find the Stanley Marketplace, which hugs Central Park (formerly Stapleton) with a number of the city’s best eateries and boutiques. It’s eminently rideable if you don’t mind moving a bit to the north and winding around Central Park’s handsome greenways and trails.

I’m a casual cyclist and usually ride with my family on the weekends, which means I have a certain, relaxed view of the boulevard that may not always be true. But certainly, it’s not as dangerous as riding along 17th Street to the south, where speeders have reportedly crashed into the same house at the corner of Monaco Street and 17th Avenue . And even when you’re riding along marked bike lanes on the streets parallel to Montview, such as 23rd and 26th streets, there’s still a shaky urgency to the all-residential traffic.

Eating and riding — two things Montview is really, really good for. Try it if you’re in the area, and you’ll see how quickly one will make you want the other.

The plaintiffs had religious objections to the vaccine, but the university determined their objections weren’t legitimate and fired them, according to the , which represented the former CU employees and .

CU’s in Aurora considered whether employees’ religions had an established doctrine prohibiting them from receiving any vaccines; if not, the school asked whether the employee had received other shots, and what made this one different.

The 10th U.S. Circuit Court of Appeals that CU’s process was an unconstitutional religious test by a government entity.

The university could have appealed to the U.S. Supreme Court, whose current justices have generally favored plaintiffs alleging religious discrimination.

When the vaccines first became available in December 2020, they were more than 90% effective in preventing infection, meaning they could stop further transmission of the virus to health care workers’ patients or colleagues. Since then, COVID-19 variants have become increasingly good at evading the immune system, so that vaccination primarily benefits individuals by reducing the risk of severe illness.

Michael McHale, senior counsel for the Chicago-based Thomas More Society, said nothing could compensate the plaintiffs for career damage from having to choose whether to go against their convictions.

“At great, and sometimes career-ending, costs, our heroic clients fought for the First Amendment freedoms of all Americans who were put to the unconscionable choice of their livelihoods or their faith during what (Supreme Court) Justice (Neil) Gorsuch has rightly declared one of ‘the greatest intrusions on civil liberties in the peacetime history of this country,'” McHale said in a statement. “We are confident our clients’ long-overdue victory indeed confirms, despite the tyrannical efforts of many, that our shared constitutional right to religious liberty endures.”

Julia Milzer, a spokeswoman for CU’s Anschutz Medical Campus, said federal agencies required health care facilities to have a vaccine mandate at the time. The policy is no longer in force, but was right during that stage of the pandemic, she said.

A separate state mandate required health care workers to get the shot or receive a medical or religious exemption is also no longer in place.

“While some chose to challenge the policy, the evidence remains clear: Vaccination was essential to protecting the vulnerable, keeping hospitals open and sustaining education and research,” she said in a statement. “We stand by the decisions made in that moment and remain deeply grateful to the health care professionals, faculty, staff and students whose courage and commitment protected our community and advanced our mission when it mattered most.”

The community and the University of Colorado’s Anschutz and Boulder campuses have partnered on the first “living lab” in the state. The model brings existing health studies to retirement communities and gives residents a say in future research.

Older people are underrepresented in medical research, and bringing studies to them makes it more feasible to take part, said Jodi Waterhouse, director of strategic partnerships and programs at the .

The underrepresentation is a particular problem because older people typically have a greater need for new medications and therapies.

Roughly three-fifths of people over 65 reported high blood pressure, half had high cholesterol, one-quarter had a history of cancer and one-fifth had diabetes as of 2022, . About one-third said they had a disability, most commonly difficulty walking or climbing stairs.

Studying how treatments perform in older people is also important because they are at an increased risk for some medication side effects, such as grogginess and confusion. The that could interact poorly. As of 2016, about 84% of people between 60 and 79 used at least one prescription drug, and 35% used five or more, .

The living lab at Balfour is a first step toward including older people, but ultimately the goal is to involve more communities, whether by setting up labs there or conducting “research road shows,” where scientists visit retirement communities and long-term-care facilities for a day and do surveys or basic tests with interested residents, Waterhouse said.

As more residents get the option to participate, researchers will be able to explore how their ideas work in older people in different parts of the state and with varying socioeconomic levels and care needs, she said.

Fifteen Balfour residents are on the committee that decides which studies are a good fit. Organizers aren’t sure how many of the roughly 400 people living on the Louisville campus will ultimately opt to take part in research.

As part of the partnership, Balfour set aside a small apartment in its independent living building for the studies, where participants can go over the risks and benefits of taking part and do some basic procedures, such as blood draws. People who aren’t residents on its campus can also participate there.

Residents and some staff members formed an advisory council that identifies health priorities and assesses whether proposed studies are a good fit before allowing researchers to recruit.

Wendell Bell, a member of the council, said medical studies typically excluded people over 85, but plenty of his fellow residents are active and mentally sharp into their 90s. In addition, many of them are highly educated and can use their life experiences to improve research, he said.

“Do you really want to exclude those 90-year-olds?” he said.

As of 2022, about 6.5 million Americans were 85 or older, and by 2040, that age group is expected to grow to about 13.7 million people, according to the Administration for Community Living.

Anne Duckett, another member of the council, described the research process as a way for residents to feel “purpose” and to give back to the broader community. Combining residents’ and the researchers’ experiences is like a chemical reaction that can produce something greater than the inputs, she said.

It also could help fight stereotypes about older people’s abilities, she said.

“Just as every kindergartener performs differently, every person who is 85 years old performs differently,” she said.

And, of course, the studies might directly benefit the participants and people like them, Bell said.

“In the long run, you hope that they come up with something that’s important to people our age and older,” he said.

So far, the council has signed off on two projects: one testing whether treating hearing loss can help lower blood pressure, and the other trying electrical stimulation to increase walking speed.

Slow walking isn’t just an inconvenience; it also increases a person’s risk of falls, which are a major cause of injury and death for older people, Waterhouse said. About 41,000 people over 65 died from falls in 2023, .

Bell said he tried to sign up for the blood pressure study, but the intake screening found his wasn’t high enough to qualify. Duckett said neither of the current studies was a fit for her.

For now, CU researchers are pitching existing projects that appear to fit with residents’ priorities, but over time, they’ll move toward co-creating studies, Waterhouse said.

“Eventually, they might be able to write papers together,” she said. “We’ve done research in a certain way for so many years. This is a way to think outside the box.”

Since 2003, the required a “black box” warning — reserved for the most-serious side effects — on products that use estrogen, progesterone or both to treat symptoms such as hot flashes and vaginal dryness. The black box warned of an increased risk of blood clots and certain heart problems.

On Monday, Secretary Robert F. Kennedy Jr. , and described the decision to place the warning as a betrayal of women that denied them “strength, peace and dignity,” and may have shortened their lives.

Other top officials said in a news release that estrogen would help women prevent chronic diseases while “extending their vigor,” and that female brains need estrogen to function at their best.

“With the exception of antibiotics and vaccines, there may be no medication in the modern world that can improve the health outcomes of older women on a population level more than hormone therapy,” FDA Commissioner Dr. Marty Makary wrote in an .

Removing the black box is the right call for forms of hormone therapy delivered directly to the vagina, and may be for pills and other “systemic” medications, though those require a nuanced conversation about risk, said Dr. Jill Liss, an associate clinical professor of obstetrics and gynecology at .

But despite what Kennedy and other federal officials said, no studies have proven that hormone therapy prevents heart disease or dementia, said Liss, who is on the board of the . It is, however, a highly effective and generally safe option for treating hot flashes and vaginal symptoms of perimenopause, and delays bone loss that can lead to osteoporosis, she said. Some women also report better sleep and mood.

“It’s a really nice tool for the menopause transition,” she said. Some of the comments from federal officials “gave this notion that hormone therapy is more miraculous than it really is.”

Older women who didn’t get hormone therapy while the black box was in place likely suffered more symptoms than they would have if it had remained widely available, but they don’t need to worry that their long-term health took a hit, Liss said.

Black box warnings don’t technically limit availability, but doctors are more reluctant to prescribe medications that carry one, and women who saw media coverage of hormone therapy’s risks were less likely to seek it out, she said.

“It’s not an anti-aging medication,” Liss said.

Views on hormone therapy have shifted dramatically over the years. In the 1960s, doctors recommended it for almost all women in menopause, . Concerns about a kind of uterine cancer dampened enthusiasm in the 1970s, though interest started to pick up again as data showed combining two hormones largely eliminated that risk.

While the research clearly showed that hormone therapy was effective for treating some of the more bothersome symptoms of menopause, no one knew whether it had any effect on women’s risk of chronic diseases.

In the 1990s, the study tried to answer that question. The trial stopped early, in 2002, after finding an increase in breast cancer diagnoses and blood clots among women taking one type of hormone therapy.

For the first decade or so of the millennium, most gynecologists took the view that women should avoid hormonal therapy, said Dr. Katie Rustici, one of the gynecologists certified in menopause care at , which has a clinic for holistic menopause care in Denver.

, about 5% of women who reported they were in the menopause transition were taking estrogen, progesterone or a combination product, down from more than one-quarter in 1999.

Later analyses found that women who started hormone therapy in their 40s and 50s had , with about six additional breast cancer cases and five cases of heart disease or stroke for every 10,000 people treated. They had a lower risk of broken bones, diabetes and dying during the follow-up period.

The risks are higher for women who start hormone therapy after 60. The study didn’t last long enough to generate conclusions about the safety of starting early and continuing to take hormones well past when perimenopause symptoms typically end, though the risk is clearly lower than starting late, Liss said.

Rustici said she typically sits down with patients to reevaluate hormone use after about five years. The risk of breast cancer continues to rise with longer use, but some women are willing to accept that trade-off because they report more energy and better sexual functioning, she said.

“There really is a piece here that is patient autonomy,” she said.

Even so, systemic hormone therapy isn’t an option for breast cancer survivors or women who’ve had heart attacks, strokes or certain high-risk blood clots, Rustici said. Those patients generally can use estrogen products applied in the vagina, however, because only trace amounts of hormones reach the rest of the body.

Vaginal estrogen won’t help with hot flashes and night sweats, but patients can get some relief from using antidepressants or the anti-seizure drug gabapentin, Rustici said. A works on the brain’s temperature control mechanisms, though those aren’t an option for women with liver problems.

Ultimately, each woman’s symptoms, risks and priorities — all of which shift over time — need to guide conversations with her doctor about treatments during menopause, Liss said.

“What’s right for your friend or your mother or your sister could be different from what’s going to be right for you,” she said.

Physician Lauren Hughes was heading to see patients at a clinic about 20 miles from her Denver home in February when another driver T-boned her Subaru, totaling it. She was taken by ambulance to the closest hospital, in Brighton.

A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians recommended immediate surgical repair, she said.

“They said: ‘You have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she said. “As a clinician, I thought, ‘Yes.’”

She was taken to the operating room in the early evening, then admitted to the hospital overnight.

A friend took her home the next day.

Then the bills came.

The Medical Procedure

Surgeons cleaned the cut on her right knee, which had hit her car’s dashboard, and realigned a broken bone in her right ankle, stabilizing it with metal screws. Surgery is typically recommended when a broken bone is deemed unlikely to heal properly with only a cast.

The Final Bill

$63,976.35, charged by the hospital — which was not in-network with the insurance plan she got through her job — for the surgery and overnight stay.

The Problem: Should I Stay or Should I Go?

Hughes’ insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER, but denied the surgery and overnight stay charges from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes said. “Just to stay there overnight. It����ap crazy.”

Insurers have broad power to determine — that is, what is needed for treatment, diagnosis, or relief. And that decision affects whether and how much they will pay for it.

Four days after her surgery, Anthem notified Hughes that after consulting clinical guidelines for her type of ankle repair, its reviewer determined it was not medically necessary for her to be fully admitted for an inpatient hospital stay.

If she had needed additional surgery or had other problems, such as vomiting or a fever, an inpatient stay might have been warranted, according to the letter. “The information we have does not show you have these or other severe problems,” it said.

To Hughes, the notion that she should have left the hospital was “ludicrous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When she asked for further details about medical necessity determinations, Hughes was directed deep inside her policy’s benefit booklet, which outlines that, for a hospital stay, documentation must show “safe and adequate care could not be obtained as an outpatient.”

It turns out the surgery charges were denied because of an insurance contract quirk. Under Anthem’s agreement with the hospital, all claims for services before and after a patient is admitted are approved or denied together, said Anthem spokesperson Emily Snooks.

A hospital stay is not generally required after ankle surgery, and the insurer found Hughes did not need the kind of “comprehensive, complex medical care” that would necessitate hospitalization, Snooks wrote in an email to KFF Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”

Facing bills from an out-of-network hospital where she was taken by emergency responders, though, Hughes did not understand why she wasn’t shielded by the , which took effect in 2022. The federal law requires insurers to cover out-of-network providers as though they are in-network when patients receive emergency care, among other protections.

“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”

There was one more oddity in her case. During one of many calls Hughes made trying to sort out her bill, an Anthem representative told her that things might have been different had the hospital billed for her hospitalization as an overnight “observation” stay.

Generally, that����ap when patients are kept at a facility so staff can determine whether they need to be admitted. Rather than being tied to the stay’s duration, the designation mainly reflects the intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for an observation stay than admission, Fiedler said.

That distinction is a big issue for patients on Medicare. Most often, the government health program will not pay for if the patient was not first formally admitted to a .

“It����ap a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler said.

The Resolution

As a physician and a , Hughes is a savvier-than-usual policyholder. Yet even she was frustrated during the months spent going back and forth with her insurer and the hospital — and worried when it looked like her account would be sent to a collection agency.

In addition to appealing the denied claims, she sought the help of her employer’s human resources department, which contacted Anthem. She also , which contacted Anthem and the Platte Valley Hospital.

In late September, Hughes received calls from a hospital official, who told her they had “downgraded the level of care” the hospital billed her insurance for and resubmitted the claim to Anthem.

In a written statement to KFF Health News, Platte Valley Hospital spokesperson Sara Quale said that the facility “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously sent Hughes a bill before working out the balance with Anthem, she wrote.

“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”

Anthem spokesperson Stephanie DuBois said in an email that Platte Valley resubmitted Hughes’ bill to the insurer on Oct. 3, this time for “outpatient care services.”

An explanation of benefits that was sent to Hughes shows the hospital rebilled for around $61,000 — about $40,000 of which was knocked off the total by an Anthem discount. The insurer paid the hospital nearly $21,000.

In the end, Hughes owed only a $250 copayment.

The Takeaway

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, in particular during a phase that may be nearly indistinguishable to the patient, known as “post-stabilization.”

Generally, that occurs when the medical provider determines the patient is to an in-network facility using nonmedical transport, said Jack Hoadley, a research professor emeritus at the McCourt School of Public Policy at Georgetown University.

If the patient prefers to stay put for further treatment, the out-of-network provider must then ask the patient , agreeing to waive billing protections and continue treatment at out-of-network rates, he said.

“It����ap very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurer, in addition to asking the hospital’s billing department: Are you being fully admitted, or kept under observation status, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a key role in whether coverage is approved or denied, even after services are provided.

That said, Hughes did not recall being told she was stable enough to leave with nonmedical transportation, nor being asked to sign a consent form.

Her advice is to quickly and aggressively question insurance denials once they are received, including by asking for your case to be escalated to the insurer’s and hospital’s leadership. She said expecting patients to navigate complicated billing questions while in the hospital after a serious injury isn’t realistic.

“I was calling family,” Hughes said, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done — coming to grips with what just happened.”

Bill of the Month is a crowdsourced investigation by and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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Unlike typical osteoarthritis, where cartilage in joints breaks down, rheumatoid arthritis results from the immune system attacking healthy tissues. The main treatments suppress parts of the immune system, leaving patients more vulnerable to infections.

Dr. Kevin Deane, director of the on CU’s Anschutz Medical Campus, said a study following patients at risk for rheumatoid arthritis for seven years found a consistent pattern: The participants all had one type of antibody against their own tissues, which gave them about a 30% risk of going on to develop rheumatoid arthritis.

Antibodies are supposed to flag infections, so the immune system can destroy the invader. People who developed the disease had other changes that would show up on a blood test, meaning that early screening for rheumatoid arthritis could be feasible in the future, he said.

About 1% to 2% of people have the first antibody, indicating they could be at high risk and might benefit from further monitoring, Deane said. A second study, , will follow people with that particular antibody for five years, to test preventive measures.

People who might be at higher risk because a relative has rheumatoid arthritis can get tested for the antibody to see if they’re eligible.

Right now, the only prevention options for people at risk of rheumatoid arthritis are lifestyle changes, such as quitting smoking, exercising and eating a healthy diet, Deane said. With more understanding of the underlying changes in the immune system, researchers can start testing whether other treatments could prevent or delay rheumatoid arthritis, or lead to less-severe symptoms when it eventually develops, he said.

As is, about 70% of people with rheumatoid arthritis need more than one drug to get it under control, Deane said. Hopefully, if they can start treating the disease before it causes joint damage, patients can take fewer drugs and avoid some side effects, he said.

The idea has precedent: Children at risk for type 1 diabetes can now , though it doesn’t entirely stop the disease process.

If they can study the right antibodies, researchers could also discover and possibly delay the changes leading to other autoimmune diseases, such as lupus and celiac disease, Deane said.

While stopping a disease altogether would be ideal, “that would also be a victory,” he said.

Colorado has recorded more confirmed measles cases so far this year than it has in almost two decades. Rural pockets of the state are undervaccinated, and large counties have seen their protection erode since the pandemic.

The country as a whole has more than three times as many measles cases already this year as it did in all of 2024, and federal health officials are pushing vitamins as an alternative to vaccines.

“I think what’s clear is, we’re going backwards,” said Beth Carlton, chair of environmental and occupational health at the . “We’re creating conditions where we have the right ingredients for measles to spread.”

Statewide, about 94% of Colorado students in preschool through 12th grade were up-to-date on their measles shots in the 2023-2024 school year, creating an imperfect but relatively solid wall around people with compromised immune systems and babies too young for the vaccine.

But that average conceals more-vulnerable pockets in the state: in two counties, one-quarter of children didn’t have their shots, and in eight schools, less than half did.

For the last 25 years, communities typically didn’t see any consequences from those low rates. Measles no longer circulated in the United States, and outbreaks popped up only when travelers brought the virus back. While public health officials warned that declining vaccination rates could set the stage for the virus to start circulating widely again, Colorado reported only six people who had measles .

Those days may be over. As of Thursday, across the United States, and public health officials have started to worry that the outbreak could last into 2026.

Colorado has confirmed five measles cases since January, making this the first time since 1996 that the state had more than two in a single year. Those infected include an adult in Pueblo County; a Denver baby and an unidentified person who lives in the same household; a Denver adult; and an adult in Archuleta County.

State health officials also warned the public last week about two infected and contagious travelers who recently visited Colorado: a person from another state who stayed at a Pueblo hotel on May 9 and 10, and an international traveler who passed through Denver International Airport and stayed at a nearby hotel on May 13 and 14.

Most of the state’s confirmed measles patients got sick after visiting Mexico, though the Archuleta County adult hadn’t traveled, which raises concerns about missed cases.

Nationwide, uptake of routine vaccines as of 2023, and resistance to COVID-19 vaccines led to increased skepticism of shots that once had bipartisan support. State legislatures have considered expanding exemptions to school vaccination requirements or , and a bill in Minnesota would have classified one type of vaccine technology as a

Health officials in the Trump administration have been lukewarm in endorsing the shots as a way to stem the current outbreak. Secretary of Health and Human Services Robert F. Kennedy Jr., who has promoted misinformation that vaccines cause autism and falsely claimed that vitamin A could prevent measles, .

Two shots of the measles vaccine are about 97% effective in preventing infection and virtually eliminate the risk of serious complications, such as pneumonia and neurological damage.

At current vaccination rates, a series of simulations published by the Journal of the American Medical Association gave measles an in the United States, with an estimated 850,000 cases and 2,500 deaths projected over the next 25 years.

But rates would only have to rise about 5% to prevent reestablishment and knock cases down to a few thousand in the next quarter century, the scientists running the simulation said.

Models never reflect reality perfectly, but seeing such a high risk from a simulation that used relatively conservative estimates is worrisome, Carlton said. As outbreaks continue to spread in other states, and possibly in countries that have lost American aid for their health systems, Colorado communities will face an increased risk of imported cases that could turn into outbreaks if they land among undervaccinated people, she said. Essentially, they’ll roll the dice more often, and their luck could eventually run out.

Of course, parents who weren’t sure about measles shots may opt for them when the virus no longer seems like a far-off risk.

Dr. Lauren Brave, a pediatrician in Boulder County, said a few already are starting to make that calculation. Two families in her practice who’d decided not to vaccinate their children against measles recently changed their minds, and others have said they’ll come in for the shots if cases start popping up closer to home, she said.

“All parents are just trying to protect their kids, so when people hear scary things online, it plays to their natural parental fears,” she said. “It’s a long game” to get children vaccinated.

Striving for herd immunity

Public health officials cite 95% vaccine coverage as the threshold for herd immunity — the point where a virus can’t find new hosts to allow it to jump from one susceptible person to the next.

Like most things in nature, however, herd immunity isn’t quite that clear-cut, said Dr. David Higgins, a pediatrician and preventive medicine specialist on the . A community where 90% of children are up-to-date on their measles shots isn’t as protected as one where 95% are, but it is safer than a community where 80% are.

“It’s not a light switch, on or off. It’s more of a dimmer,” he said of vaccination levels.

In 23 large and small counties scattered around Colorado, K-12 students met the herd immunity threshold in the 2023-2024 school year, which was the most recent with data. In the Denver area, Broomfield, Adams and Douglas counties had at least 95% of their students vaccinated against measles, while Jefferson, Denver and Arapahoe counties fell between 93% and 95%.

On the opposite end, in 13 counties, at least one in 10 K-12 students didn’t have full protection against measles, and in Hinsdale and Dolores counties in the state’s southwest corner, more than one in four didn’t.

The actual rates may be lower, because states collect vaccination data through their public schools, and rates tend to be lower for kids attending private schools or who are homeschooled, said Dr. Michelle Fiscus, chief medical officer at the nonprofit .

Tracy Beanland, director of , said last year’s rates don’t reflect progress the county has made since 2023. In the current school year, all children were up to date on their measles shots, she said. The county has about 600 children attending public schools, which makes large swings in the vaccination rate more likely than in urban areas.

Health officials in Hinsdale County didn’t respond to questions.

Even county and district averages can conceal unprotected pockets. In Saguache County in the San Luis Valley, about 88% of students were up-to-date on their measles shots, but only 60% were in tiny — and only 20% were in the district’s .

Vulnerable pockets don’t only appear in rural areas. While almost 96% of K-12 students in Adams County had their measles shots, at in Brighton, only 30% did.

A similar pattern existed in Texas. In Gaines County — the epicenter of the current outbreak — about 90% of public school students were up-to-date on their measles vaccine by middle school, but fewer than half of students had their shots in a few individual schools. (Texas only publishes vaccination rates for kindergarteners and seventh graders.)

Communities can nudge people who don’t have strong feelings about vaccines in either direction, Higgins said. People who send their children to the same school or child care center tend to have similar media diets, meaning that interacting with other parents can reinforce either facts or misinformation, he said.

“We know that social norms within communities are strong motivators for health behavior,” he said.

Rates drop in large counties

Vaccination rates have fallen in Colorado’s larger counties since the 2017-2018 school year, with most of the decline happening since the pandemic.

Of the 16 counties with at least 50,000 residents, eight saw a statistically significant drop in their K-12 measles vaccination rate. Six remained stable, and Boulder and Garfield counties increased their vaccination rates.

Boulder County started working with neighboring counties and the and school districts on measles back in 2019, which was the last time the United States had major outbreaks, said Stephanie Faren, manager of the communicable disease and emergency management division at .

About 90.7% of students across Boulder County had their measles shots during the 2017-2018 school year, but in the most recent year, 94.9% did, putting herd immunity in reach.

Part of the improvement was on paper, as the department got a more accurate count of children who’d received their shots, but part represented a real change, Faren said.

Reminding parents when their children were due for shots was an effective measure, because measles just wasn’t top of mind for everyone, Faren said. The health departments also worked with health care providers so they’d feel prepared to field their patients’ questions and concerns, she said.

“Boulder was one of the first areas where vaccine hesitancy and sort of a natural health movement started,” she said. “But it’s also a highly educated community with a lot of health-minded people.”

Arapahoe and El Paso counties had the steepest drops in vaccination rates among the large Colorado counties, to about 93% and 90%, respectively. (Rural counties see more fluctuation because of their small populations.)

Kristi Durbin, immunization and travel division manager at , said parents delayed routine health care during the pandemic. The department has been sending reminders to families that are behind on shots and offering vaccine clinics at schools and community organizations, to make it easier to catch up, she said.

“EPCPH saw many 13-year-olds coming in for vaccines they should have received around 11, or 6- and 7-year-olds who missed their kindergarten routine immunizations, which includes the (measles, mumps and rubella) vaccine,” she said in a statement.

“Make it as convenient as possible”

Some families fell behind on shots because they have difficulty finding a provider who stocks all the vaccines their children need, said Kaitlin Wolff, immunization nurse manager for . They’ve also seen an increase in parents who aren’t opposed to vaccines, but want to set their own schedule — though that trend may be reversing now that they’re hearing about children hospitalized because of measles, she said.

“If we don’t have a disease circulating, a slight delay presents no problem,” she said.

Arapahoe County’s health department has worked with schools for years to bring the shots to children whose parents don’t have the time or transportation to take them to a doctor, Wolff said. They’ve also reached out to religious communities and partnered with community health workers, who help people in specific populations to navigate the health system, to reach immigrants who speak a language other than English or Spanish, she said.

“As humans, we are most impacted (in our decisions) by people close to us,” she said.

Vaccines may not be a family’s top priority, so some of the most successful efforts bring the shots to places that are already meeting their other needs, said Sarah Waraniak, program director of .

Last year, the group and its partners gave out about 7,300 shots at more than 70 clinics around the Denver area, including a food box distribution site off Colfax Avenue and “community baby showers” where low-income mothers-to-be can pick up gear, she said.

“Our goal is to make it as convenient as possible,” Waraniak said. “We find that does tend to drive rates up.”

The right strategies to boost vaccination rates will depend on families’ reasons for not getting their children vaccinated, said Fiscus, with the Association of Immunization Managers.

Outreach geared toward specific religious groups, such as Orthodox Jews in New York or the Amish community in Pennsylvania, has helped persuade members to accept the vaccine during outbreaks. In other places, such as Chicago, offering vaccine clinics during the school day helped catch kids up, because parents didn’t have to worry about taking time off work or finding transportation, she said.

“You really have to be using micro-level data and planning,” Fiscus said.

Federal funding cuts to public health will limit state and local agencies’ ability to do that sort of work, though, said Carlton, with the Colorado School of Public Health. So will the Trump administration’s decision to end federal support for research on vaccine hesitancy and trust, she said.

“I feel like it is the elephant in the room,” she said.