But amid the stark beauty in one of the state’s most productive agricultural regions, there was a sense of unease among the community’s leaders as Congress debated a budget bill that could radically reshape Medicaid, the government health program for low-income people.

“I’m trying to be worried and optimistic,” said Konnie Martin, CEO of San Luis Valley Health in Alamosa, Colorado, the hub for health care services for 50,000 people in six rural counties.

Martin said Medicaid is vital to rural health care.

“I think in Colorado right now, nearly 70% of rural hospitals are operating in a negative margin,” in the red, Martin said.

The health system’s annual budget is $140 million, and Medicaid revenue makes up nearly a third of that, according to Shane Mortensen, chief financial officer for SLV Health.

The operating margin is razor-thin, so federal cuts to Medicaid could force difficult cuts at SLV. “It will be devastating to us,” Mortensen said.

The region is one of the state’s poorest. In Alamosa County, 2 in 5 residents are enrolled in Health First Colorado, the state’s Medicaid program.

It’s a lifeline, especially for people who wouldn’t otherwise have easy access to health care. That includes low-income seniors who need supplemental coverage in addition to Medicare, and people of all ages with disabilities.

Envisioning a future with deep Medicaid cutbacks leaves many patients on edge.

“I looked into our insurance and, oh my goodness, it’s just going to take half my check to pay insurance,” said Julianna Mascarenas, a mother of six. She said Medicaid has helped her cover her family for years. Mascarenas works as a counselor treating people with substance use disorders. Her ex-husband farms — potatoes and cattle — for employers that don’t offer health insurance.

Across the state, Medicaid covers 1 in 5 Coloradans, more than a million people.

That includes children in foster care.

“We’ve had 13 kids in and out of our home, six of which have been born here at this hospital with drugs in their system,” foster parent Chance Padilla said, referring to SLV’s flagship hospital in Alamosa.

“Medicaid has played a huge part in just being able to give them the normal life that they deserve,” he said. “These kids require a lot of medical intervention.”

Chris Padilla, Chance’s husband, said: “At one point, we had a preteen that needed to be seen three times a week by a mental health professional. There’s no way that we could have done that without Medicaid.”

Staff and administrators at SLV Health wonder whether federal cuts will make it hard for the system to keep its cancer center running.

“It could be pretty dramatically affected,” said Carmelo Hernandez, SLV’s chief medical officer.

The hospital in Alamosa has its own labor and delivery unit, the type of service that other rural hospitals across the U.S. have struggled to keep open. About 85% of the hospital’s labor and delivery patients are covered by Medicaid, Hernandez said.

“If we don’t have obstetric services here, then where are they going to go?” said Hernandez, whose specialty is obstetrics and gynecology. “They’re going to travel an hour and 20 minutes north to Salida to get health care. Or they can travel to Pueblo, another two-hour drive over a mountain pass.”

Tiffany Martinez, 34, was recently forced to think about that possibility after giving birth to her fourth child.

Her pregnancy was high-risk, requiring twice-a-week ultrasounds and stress tests at the hospital. She’s enrolled in Medicaid.

“Everything down here is low-pay,” Martinez said. “It’s not like we have money to just be able to pay for the doctor. It’s not like we have money to travel often to go to the doctor. So it’s definitely beneficial.”

Providing Health Care — And Jobs

With 750 workers, the health system is the valley’s largest employer. Clint Sowards, a primary care physician, said having less Medicaid funds will make it harder to attract the next generation of doctors, nurses, and other health care workers.

Certain medical specialties might no longer be available, Sowards said. “People will have to leave. They will have to leave the San Luis Valley.”

Kristina Steinberg is a family medicine physician with Valley-Wide Health Systems, a network of small clinics serving thousands in the region. She said Medicaid covers most nursing home residents in the area. “If seniors lost access to Medicaid for long-term care, we would lose some nursing homes,” she said. “They would consolidate.”

Audrey Reich Loy, a licensed social worker and SLV Health’s director of programs, said the system utilizes Medicaid “as sort of the backbone of our infrastructure.”

“It doesn’t just support those that are recipients of Medicaid,” she said. “But as a result of what it brings to our community, it allows us to ensure that we have sort of a safety net of services that we can then expand upon and provide for the entire community.”

Seeking More Efficiency

Republicans in Congress who pushed for the big spending and tax law, which estimates suggest will result in large cuts to Medicaid, say they want to save money and make the government more efficient.

Many in the Alamosa County region voted for Donald Trump. “He’s potentially affecting his voter base pretty dramatically,” Hernandez said.

He said Medicaid cuts could give President Trump’s supporters second thoughts, but he noted that politics is a sensitive topic that he mostly doesn’t discuss with patients.

Sowards said he understands that some people believe the Medicaid system is ailing and costly. But he said he has grave doubts about the proposed cure.

“Losing Medicaid would have drastic repercussions that we can’t foresee,” Sowards said.

Cuts Would Create Ripple Effect

SLV Health’s regional economic impact is more than $100 million a year, with Medicaid accounting for a major part of that, Martin said.

Any Medicaid cuts would hit the health system hard, but they would also affect small businesses and their employees. The region is feeling economic stress from other changes, like recent cuts the Trump administration made to the federal workforce.

The San Luis Valley is home to the Monte Vista National Wildlife Refuge, Great Sand Dunes National Park, and other federally managed lands.

Joe Martinez, president of San Luis Valley Federal Bank, said that recently laid-off federal workers are already coming to banks saying: “‘Can I find a way to get my next two months’ mortgage payments forgiven? Or can we do an extension?’ Or: ‘I lost my job. What can we do to make sure that I don’t lose my vehicle?’”

Ty Coleman, Alamosa’s mayor, traveled to Washington, D.C., in April to talk to Colorado’s congressional delegation. He said his message about Medicaid cuts was straightforward: “It can have a devastating economic impact.” Coleman put together a long list of possible troubles: More chronic disease and higher mortality rates. Longer wait times for care. Medical debt and financial strain on families.

“It’s not just our rural community but the communities, rural communities, across Colorado as well, and the United States,” Coleman said. “And I don’t think people are getting it.”

This article is from a partnership that includes CPR News, NPR and KFF Health News.

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“There’s a lot of action up here. It can be very stressful at times,” said Kristina Fraser, an OB-GYN in blue scrubs.

Nurses wheel a very pregnant mom past.

“We’re going to bring a baby into this world safely,” Fraser said, “and off we go.”

She said she feels ready in part due to a calming moment she had just a few minutes earlier with some canine colleagues.

A pair of dogs, tails wagging, had come by a nearby nursing station, causing about a dozen medical professionals to melt into a collective puddle of affection. A yellow Lab named Peppi showered Fraser in nuzzles and kisses. “I don’t know if a human baby smells as good as that puppy breath!” Fraser had said as her colleagues laughed.

The dogs aren’t visitors. They work here, too, specifically for the benefit of the staff. “I feel like that dog just walks on and everybody takes a big deep breath and gets down on the ground and has a few moments of just decompressing,” Fraser said. “It’s great. It’s amazing.”

Hospital staffers who work with the dogs say there is virtually no bite risk with the carefully trained Labradors, the preferred breed for this work.

The dogs are kept away from allergic patients and washed regularly to prevent germs from spreading, and people must wash their hands before and after petting them.

Doctors and nurses are facing a growing mental health crisis driven by their experiences at work. They and other health care colleagues face high rates of depression, anxiety, stress, suicidal ideation, and burnout. Nearly half of health workers reported often feeling burned out in 2022, an increase from 2018, according to the Centers for Disease Control and Prevention. And the percentage of health care workers who reported harassment at work more than doubled over that four-year period. Advocates for the presence of dogs in hospitals see the animals as one thing that can help.

That includes Peppi’s handler, Susan Ryan, an emergency medicine physician at Rose.

Ryan said years working as an emergency room doctor left her with symptoms of PTSD. “I just was messed up and I knew it,” said Ryan, who isolated more at home and didn’t want to engage with friends. “I shoved it all in. I think we all do.”

She said doctors and other providers can be good at hiding their struggles, because they have to compartmentalize. “How else can I go from a patient who had a cardiac arrest, deal with the family members telling them that, and go to a room where another person is mad that they’ve had to wait 45 minutes for their ear pain? And I have to flip that switch.”

To cope with her symptoms of post-traumatic stress disorder, Ryan started doing therapy with horses. But she couldn’t have a horse in her backyard, so she got a Labrador. 

Ryan received training from a national service dog group called Canine Companions, becoming the first doctor trained by the group to have a facility dog in an emergency room. Canine Companions has graduated more than 8,000 service dogs.

The Rose medical center gave Ryan approval to bring a dog to work during her ER shifts. Ryan’s colleagues said they are delighted that a dog is part of their work life.

“When I have a bad day at work and I come to Rose and Peppi is here, my day’s going to be made better,” EMT Jasmine Richardson said. “And if I have a patient who’s having a tough day, Peppi just knows how to light up the room.”

Nursing supervisor Eric Vaillancourt agreed, calling Peppi “joyful.”

Ryan had another dog, Wynn, working with her during the height of the pandemic. She said she thinks Wynn made a huge difference. “It saved people,” she said. “We had new nurses that had never seen death before, and now they’re seeing a covid death. And we were worried sick we were dying.”

She said her hospital system has lost a couple of physicians to suicide in the past two years, which HCA confirmed to KFF Health News and NPR. Ryan hopes the canine connection can help with trauma. “Anything that brings you back to the present time helps ground you again. A dog can be that calming influence,” she said. “You can get down on the ground, pet them, and you just get calm.”

Ryan said research has shown the advantages. For example, one review of dozens of original studies on human-animal interactions found benefits for a variety of conditions including behavioral and mood issues and physical symptoms of stress. 

Rose’s president and CEO, Casey Guber, became such a believer in the canine connection he got his own trained dog to bring to the hospital, a black Lab-retriever mix named Ralphie.

She wears a badge: Chief Dog Officer.

Guber said she’s a big morale booster. “Phenomenal,” he said. “It is not uncommon to see a surgeon coming down to our administration office and rolling on the ground with Ralphie, or one of our nurses taking Ralphie out for a walk in the park.”

This article is from a partnership that includes CPR News, NPR, and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“Daba unas 1,200 bocanadas en una semana”, contó Kumar.

El vapeo se convirtió en una adicción para él y sus amigos. Al igual que perder un celular, perder un vapeador desencadenaba una locura.

“Tenía que estar junto a mi cabeza cuando me dormía por la noche y, por la mañana, tenía que revolver las sábanas para encontrarlo”, recordó Kumar.

Él y sus amigos se enfermaban a menudo, incluso se contagiaron covid-19 unos a otros, y todo por vapear.

Kumar, que ahora tiene 24 años, acabó dejándolo. Pero muchos de su generación no pueden dejar el hábito.

“Todo el mundo sabe que no es bueno y todo el mundo quiere dejarlo”, afirmó Jacob Garza, estudiante de la Universidad de Colorado que trabaja para concientizar sobre adicciones, como parte del programa de promoción de la salud de la universidad.

“Pero a estas alturas, después de hacerlo durante todos estos años… ya es algo natural”, agregó.

El marketing de las empresas de cigarrillos electrónicos, que promocionan atractivos nombres con sabores frutales similares a los caramelos, llevó a muchos adolescentes a probar el vapeo. A medida que más jóvenes y estudiantes de secundaria experimentaban con estos cigarrillos, médicos e investigadores advertían de que podría generar una adicción generalizada y crear la Generación del  Vapeo”.

Investigaciones han demostrado que la nicotina es muy gratificante para el cerebro de los jóvenes.

Nuevos datos sobre el consumo de sustancias entre adultos de 18 a 24 años sugieren que muchos ex fumadores adolescentes siguen consumiendo cigarrillos electrónicos. Las tasas nacionales de vapeo para adultos jóvenes aumentaron del 7,6% en 2018 al 11% en 2021.

“No nos sorpende que muchos de ellos comiencen en la escuela secundaria por razones sociales, por todo tipo de razones”, dijo Delaney Ruston, médico de atención primaria y documentalista. “Y muchos de ellos ahora —lo estamos viendo— han continuado hasta la universidad y más allá”.

Su película más reciente es “Screenagers Under the Influence: Addressing Vaping, Drugs & Alcohol in the Digital Age”.

En Colorado, la proporción de jóvenes de 18 a 24 años que regularmente vapea aumentó un 61% de 2020 a 2022, casi una cuarta parte de ese grupo de edad.

“Es un aumento asombroso en solo dos años”, señaló Ruston.

Las tendencias en ese estado son dignas de mención porque, antes de la pandemia, Colorado lideraba la nación en vapeo juvenil entre los estudiantes de secundaria, superando a otros 36 estados encuestados.

A nivel nacional, las tasas de vapeo entre los estudiantes de secundaria cayeron de 28% en 2019 al 10% en 2023, según la Annual National Youth Tobacco Survey. Pero para muchos jóvenes que comenzaron a vapear en el apogeo de la tendencia, se generó un hábito.

En el Children’s Hospital de Colorado, la neumóloga pediátrica Heather De Keyser mostró en su pantalla una radiografía nublada del pulmón de un adulto joven dañado por el vapeo.

Durante años, médicos y expertos en salud pública se preguntaron por el impacto potencialmente dañino del vapeo en los cuerpos y cerebros de los preadultos, especialmente por el gran riesgo de adicción.

“Creo que, por desgracia, las lecciones que nos temíamos que íbamos a aprender, las estamos aprendiendo”, afirmó De Keyser, profesora de pediatría en el Breathing Institute del Children’s Hospital de Colorado.

“Observamos aumentos entre los adultos jóvenes. No fueron capaces de dejarlo”.

No es casualidad que las tasas de vapeo se dispararan durante la pandemia, según varios expertos en salud pública.

En los últimos dos años, los universitarios han hablado de los retos que supone el aislamiento y el consumo de más sustancias, dijo Alyssa Wright, que gestiona los programas de promoción de la salud de intervención temprana en CU-Boulder.

“El hecho de haber estado confinado en casa, estar aburrido, estar un poco ansioso, no saber lo que está pasando en el mundo”, explicó Wright. “Perdimos la conexión social, y parece que la gente aún está tratando de recuperarse de esa experiencia”.

Otros factores que favorecen la adicción son los altos niveles de nicotina en los dispositivos de vapeo, y la “cultura del silencio”, apuntó Chris Lord, director asociado del Collegiate Recovery Center de CU-Boulder.

“Los productos que utilizaban contenían cinco veces más nicotina que los vapeadores anteriores”, explicó. “Así que engancharse con eso era… casi imposible de evitar”.

Por “cultura del silencio” Lord entiende que vapear puede resultar emocionante, algo prohibido y secreto. “En la adolescencia, muchos de nosotros tenemos el cerebro conectado de esa manera”, afirmó.

En todo Estados Unidos, gobiernos estatales y locales han presentado demandas contra Juul Labs, alegando que la empresa tergiversó los riesgos para la salud de sus productos.

Las demandas argumentan que Juul se convirtió en una de las principales empresas de cigarrillos electrónicos gracias a una agresiva campaña de marketing dirigida directamente a los niños, quienes a su vez corrieron la voz publicando sus productos en redes sociales como YouTube, Instagram y TikTok.

El fiscal general de Colorado, Phil Weiser, ha declarado: “Lo que ha hecho el vapeo, al enganchar a los estudiantes de secundaria, y en algunos casos incluso más jóvenes, se nota ahora”.

Juul acordó pagar cientos de millones dólares. La empresa no respondió a las solicitudes de comentarios para este artículo.

R.J. Reynolds, que fabrica otra popular marca de productos de vapeo, Vuse, envió esta declaración: “Nos mantenemos alejados de los sabores atractivos para los jóvenes, como la goma de mascar y el algodón de azúcar, posicionándonos claramente contra los productos de vapeo desechables ilícitos”.

Otras grandes empresas de vapeo, como Esco Bar, Elf Bar, Breeze Smoke y Puff Bar, no respondieron a las solicitudes de comentarios.

“Si viviéramos en un mundo ideal, los adultos llegarían a los 24 años sin haber experimentado nunca con sustancias para adultos. Pero los adultos jóvenes ya lo hacen”, señaló Greg Conley, director de asuntos legislativos y externos de American Vapor Manufacturers. “Esto es anterior a la llegada del vapeo con nicotina”.

En 2020, la administración de Drogas y Alimentos (FDA) prohibió los cartuchos de vapeo con sabor como medida contra la comercialización a menores, pero los productos siguen siendo fáciles de encontrar.

Joe Miklosi, consultor de Rocky Mountain Smoke-Free Alliance, un grupo comercial de tiendas de vapeo, sostiene que las tiendas no aumentan las tasas de vapeo entre los adultos jóvenes en Colorado. “En nuestras 125 tiendas tenemos datos demográficos. La media de edad [de nuestros clientes] es de 42 años”, afirmó.

He hablado con miles de consumidores que dicen que el vapeo les ayudó a dejar de fumar cigarrillos, dijo. Según Miklosi, las tiendas de vapeo venden productos para ayudar a los fumadores adultos a dejar de fumar.

Las estadísticas de Colorado desmienten esta afirmación, según Stanton Glantz, investigador del tabaco desde hace muchos años.

Los datos son “totalmente incompatibles con el argumento de que la mayor parte del consumo de cigarrillos electrónicos corresponde a fumadores adultos que intentan utilizarlos para dejar de fumar”, afirmó Glantz, ex director del Centro de Investigación y Educación para el Control del Tabaco de la Universidad de California-San Francisco.

Para G Kumar, flamante graduado y ahora escalador, el impulso para dejar de fumar fue más por razones ecológicas que de salud. Le disgustaba la cantidad de basura generada por los dispositivos de vapeo y el dinero que se gastaba.

Kumar recibió ayuda del programa de promoción de la salud de la universidad, que incluía cajas de palillos de dientes con sabor a eucalipto, que sabían fatal pero distraían y aliviaban las ansias de fumar.

Le costó un tiempo y mucha fuerza de voluntad superar la intensa ansiedad.

“Creo que el hecho de poder morder esos palillos durante semanas y semanas fue lo que me mantuvo cuerdo”, afirmó Kumar.

Este artículo es parte de una alianza que incluye a CPR News, NPR, y KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“I’d go through, let’s say, 1,200 puffs in a week,” Kumar said.

Vaping became a crutch for them. Like losing a cellphone, losing a vape pen would set off a mad scramble.

“It needs to be right next to my head when I fall asleep at night, and then in the morning, I have to thrash through the sheets and pick it up and find it,” Kumar recalled.

They got sick often, including catching covid-19 — and vaping through all of it.

Kumar, now 24, eventually quit. But many of their generation can’t shake the habit.

“Everyone knows it’s not good for you and everyone wants to stop,” said Jacob Garza, a University of Colorado student who worked to raise awareness about substance use as part of the school’s health promotion program.

“But at this point, doing it all these years … it’s just second nature now,” he said.

Marketing by e-cigarette companies, touting the allure of fruity or candy-like flavors and names, led many teens to try vaping. As more high schoolers and younger kids experimented with e-cigarettes, physicians and researchers warned it could lead to widespread addiction, creating a “Generation Vape.”

Research has shown nicotine is highly rewarding to the brains of young people.

New data on substance use among adults ages 18-24 suggests that many former teen vapers remain e-cigarette users. National vaping rates for young adults increased from 7.6% in 2018 to 11% in 2021.

It’s not surprising that many of them start in high school for social reasons, for all sorts of reasons,” said Delaney Ruston, a primary care physician and documentary filmmaker. “And many of them now — we’re seeing this — have continued to college and beyond.”

Her latest film is “Screenagers Under the Influence: Addressing Vaping, Drugs & Alcohol in the Digital Age.”

In Colorado, the share of those 18 to 24 who regularly vaped rose by about 61% from 2020 to 2022 — to nearly a quarter of that age group.

“That’s an astounding increase in just two years,” Ruston said.

Trends in that state are worth noting because, before the pandemic, Colorado led the nation in youth vaping among high school students, surpassing 36 other states surveyed.

Nationally, vaping rates among high schoolers dropped from 28% in 2019 to 10% in 2023, according to the Annual National Youth Tobacco Survey. But for many young people who started vaping at the height of the trend, a habit was set.

At Children’s Hospital Colorado, pediatric pulmonologist Heather De Keyser displayed on her screen a clouded X-ray of the lung of a young adult damaged by vaping.

For years, doctors like her and public health experts wondered about the potentially harmful impact of vaping on pre-adult bodies and brains — especially the big risk of addiction.

“I think, unfortunately, those lessons that we were worried we were going to be learning, we’re learning,” said De Keyser, an associate professor of pediatrics in the Breathing Institute at Children’s Hospital Colorado.

“We’re seeing increases in those young adults. They weren’t able to stop.”

It’s no coincidence the vaping rates soared during the pandemic, according to several public health experts.

For the past couple of years, undergraduates have talked about the challenges of isolation and using more substances, said Alyssa Wright, who manages early intervention health promotion programs at CU-Boulder.

“Just being home, being bored, being a little bit anxious, not knowing what’s happening in the world,” Wright said. “We don’t have that social connection, and it feels like people are still even trying to catch up from that experience.”

Other factors driving addiction are the high nicotine levels in vaping devices, and “stealth culture,” said Chris Lord, CU-Boulder’s associate director of the Collegiate Recovery Center.

“The products they were using had five times more nicotine than previous vapes had,” he said. “So getting hooked on that was … almost impossible to avoid.”

By “stealth culture,” Lord means that vaping is exciting, something forbidden and secret. “As an adolescent, our brains are kind of wired that way, a lot of us,” Lord said.

All over the U.S., state and local governments have filed suits against Juul Labs, alleging the company misrepresented the health risks of its products.

The lawsuits argued that Juul became a top e-cigarette company by aggressively marketing directly to kids, who then spread the word themselves by posting to social media sites like YouTube, Instagram, and TikTok.

“What vaping has done, getting high schoolers, in some cases even middle schoolers, hooked on vaping, is now playing out,” said Colorado Attorney General Phil Weiser.

Juul agreed to pay hundreds of millions in settlements. The company did not respond to requests for comment on this article.

R.J. Reynolds, which makes another popular vape brand, Vuse, sent this statement: “We steer clear of youth enticing flavors, such as bubble gum and cotton candy, providing a stark juxtaposition to illicit disposable vapor products.”

Other big vape companies, like Esco Bar, Elf Bar, Breeze Smoke, and Puff Bar, didn’t respond to requests for comment.

“If we lived in an ideal world, adults would reach the age of 24 without ever having experimented with adult substances. In reality, young adults experiment,” said Greg Conley, director of legislative and external affairs with American Vapor Manufacturers. “This predates the advent of nicotine vaping.”

The FDA banned flavored vape cartridges in 2020 to crack down on marketing to minors, but the products are still easy to find.

Joe Miklosi, a consultant to the Rocky Mountain Smoke-Free Alliance, a trade group for vape shops, contends the shops are not driving vaping rates among young adults in Colorado. “We keep demographic data in our 125 stores. Our average age [of customers] is 42,” he said.

He has spoken with thousands of consumers who say vaping helped them quit smoking cigarettes, he said. Vape shops sell products to help adult smokers quit, Miklosi said.

Colorado statistics belie that claim, according to longtime tobacco researcher Stanton Glantz. The data is “completely inconsistent with the argument that most e-cigarette use is adult smokers trying to use them to quit,” said Glantz, the former director of the Center for Tobacco Control Research and Education at the University of California-San Francisco.

For recent college graduate G Kumar, now a rock climber, the impetus to quit vaping was more ecological than health-related. They said they were turned off by the amount of trash generated from used vape devices and the amount of money they were spending.

Kumar got help from cessation literature and quitting aids from the university’s health promotion program, including boxes of eucalyptus-flavored toothpicks, which tasted awful but provided a distraction and helped with oral cravings.

It took a while and a lot of willpower to overcome the intense psychological cravings.

“The fact that I could just gnaw on toothpicks for weeks on end was, I think, what kept me sane,” Kumar said.

This article is from a partnership that includes CPR News, NPR, and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The program that fed 50.6 million U.S. students expired in September, but some states are figuring out ways to extend it. California and Maine have both passed legislation to fund universal free lunch.

In Colorado, a coalition of parents, teachers, and anti-hunger advocates are pushing to make permanent universal free school lunches, and lawmakers in the Democratic-controlled legislature put it on the ballot.

GlendaRika Garcia, a bilingual food assistance navigator for Hunger Free Colorado, strongly backs the idea.

“I think that the kids being able to eat for free at school is really important, for all families, all kids,” said Garcia, a widow and a single mom of four boys.

Two of them, Alonzo and Pedro, tossed a football around in front of their apartment building, as Garcia explained the Healthy School Meals for All proposal on the ballot.

“Kids can’t learn if they don’t have good nutrition,” said Garcia, whose job entails signing up people for benefits and making sure they’re eligible.

The measure, known as Proposition FF, would use state funds to offer free meals for all public school students. It would also fund pay increases for school cafeteria workers, helping schools deal with staff shortages, and would incentivize schools to buy Colorado-grown food. That has some families, workers, and farmers cheering.

But critics point to a steep price tag for a new government program, which raises $100 million annually from a tax on households that make $300,000 or more a year.

School-aged members of a family of four making less than about $51,000 a year are eligible for free lunch. But supporters of the measure say that right now more than 60,000 Colorado kids can’t afford school meals yet aren’t eligible.

Garcia sees the proposal as a game changer, an equalizer. Depending on her job, Garcia at times qualified for her sons to get free lunches and at times didn’t, a blow to her budget.

Another issue, Garcia said, is that some kids bully others for getting a free lunch. It happened to her as a child when she also qualified for free lunch, and it happened to one of her sons.

“They know that people can identify if they can’t afford it. It hurts my heart,” she said.

Her son Alonzo said that at his high school some kids avoid the lunchroom rather than admit they qualify for free lunch.

“I think that they get embarrassed because they can’t afford it,” he said.

Many Colorado districts reported a clear uptick during the pandemic of kids eating lunches provided for free at school.

“We were feeding kids that we have never fed before, and it was good to see them coming up, and not just buying junk food,” said Andrea Cisneros, the kitchen manager at West Woods Elementary School in Arvada.

Many students arrive at school without food, said Dan Sharp, the school nutrition director in Mesa County Valley School District 51 in Grand Junction.

The district saw a 40% year-over-year increase in meals served during the pandemic, said Sharp.

“I really believe there’s more households here and students that could qualify but don’t, due to the stigma that goes with applying for free and reduced meals,” he said.

Proponents said they did several food insecurity surveys throughout the pandemic and, according to a recent survey, 44% of respondents with kids at home reported struggling to have access to nutritious food.

Low-income students will keep receiving free meals through federal funding, whether the proposal passes or not. There’s no organized opposition to the measure, but it does have critics.

“Nobody wants to be evil enough to say it, but this is a really stupid idea,” said Jon Caldara, president of the Independence Institute, a libertarian think tank. “Most kids in Colorado do not need this. And in fact, those who do, already have this.”

The group’s voter’s guide recommends a no vote.

“This proposal is, ‘Hey, let’s get the rich guys to buy our kids’ lunch,’” he said. “This is another expansion of state bureaucracy that is just not necessary.”

The governor told Colorado Public Radio’s Colorado Matters he hasn’t made his mind up about how he’ll vote on it.

“I don’t have an objection to the funding mechanism, but at the same time I sort of ask myself, ‘If we had this, would it be better just to be able to pay teachers better, reduce class size?’” said Gov. Jared Polis, a Democrat. “Or is the best use of it lunches for upper-middle-income families?”

He added that the measure “doesn’t affect the state finances one way or the other because it’s effectively revenue-neutral with the mechanism.”

His Republican opponent seemed to lean toward supporting Proposition FF in her interview on the show.

“I haven’t had a chance to look at it, but I do want to make sure that every child has access to healthy food and lunches, so I’m certainly open to it,” said Heidi Ganahl.

The Common Sense Institute, a nonpartisan free-market think tank, analyzed the measure and raised several concerns, with modeling that showed it could be underfunded or raise more money than is needed.

“There needs to be some good oversight on the program so that costs are managed well, and also that they don’t develop a huge surplus,” said Steven Byers, the group’s senior economist.

Despite concerns about cost, universal free school lunch appears popular throughout the nation.

California allocated $650 million from its state budget to fund and support its universal free school meals program for the 2022-23 school year. Maine’s program was estimated by lawmakers to cost around $34 million a year.

Washington, Minnesota, Wisconsin, Ohio, Pennsylvania, New York, Massachusetts, and North Carolina introduced bills similar to the one on the Colorado ballot, most of them during the current legislative session. All of them are still in committee and have yet to go up for a vote.

A report published in June 2022 by the Urban Institute, a nonpartisan think tank focused on social and economic research, found that 76% of adults living with children enrolled in public school and 67% of adults not living with children enrolled in public school supported permanent free school meals.

This story is part of a partnership that includes Colorado Public Radio, NPR, and KHN.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“At the end of that article, it said, ‘If you have a wastewater facility and you’re interested in participating in this study, please contact us,’” he said.

As a matter of fact, Van Ry did have a wastewater facility. He is the director of South Platte Renew, a wastewater treatment plant in Englewood, Colorado, that serves 300,000 people. He filled out the form, and South Platte joined the first facilities in the nation to start testing wastewater for covid-19.

Now, as the federal government expands its wastewater testing effort, Colorado has begun to extend its surveillance project to the entire state. The state’s public health agency is now working with 47 wastewater utilities that serve about 60% of Colorado’s population.

People infected with SARS-CoV-2, the virus that causes covid-19, shed viral RNA — genetic material from the virus — in their feces. In wastewater tests, scientists use that RNA to tell what’s there.

Rachel Jervis, an epidemiologist with the Colorado Department of Public Health and Environment, noted that wastewater testing can offer an early warning sign about where covid spread is highest. “We found that up to 50% of people will shed covid virus in their stool regardless of whether or not they have symptoms,” she said.

The state compiles the data from a variety of sites on a public dashboard. It also shares its numbers with the Centers for Disease Control and Prevention. About $9.4 million in federal funds is paying for the state’s wastewater testing project from January 2021 through at least July 2023. The total includes personnel, supplies, equipment, and contracts.

From the start, lab results from the South Platte plant’s samples showed exactly what the virus was doing, Van Ry said: “It was spreading rapidly through the community.” He showed a slide of data from samples. All the surges were clear: alpha, delta, and then a spectacular spike driven by the omicron variant in early 2022.

The South Platte team sends the wastewater samples it collects to a Massachusetts company called Biobot Analytics. Its mission: “population health analytics powered by sewage.”

The technique caught on around Colorado and the country. Colorado Mesa University, in collaboration with the Broad Institute of MIT and Harvard, was another early adopter in the state.

Emily Travanty, director of the state lab in Denver, said Colorado’s public health agency started testing wastewater five years ago for foodborne illnesses like salmonella. “We were able to pivot that expertise toward covid-19 as the pandemic emerged, and build upon that expertise within the laboratory,” she said.

While the approach is groundbreaking in the U.S., it’s been used overseas for decades in polio eradication efforts. “They use it essentially the same way we do — to look for communities where polio is circulating and then use that as a trigger for additional clinical surveillance in those communities,” Amy Kirby, CDC microbiologist and team lead for the National Wastewater Surveillance System, said during a recent conference call.

In fall 2020, during the first weeks of the school year, a response team at the University of Denver started pulling samples from pipes on campus.

Corinne Lengsfeld, a mechanical engineer who oversees the campus’s saliva testing lab, said a wastewater sample taken at one dorm early in the semester showed high concentrations of the virus. “It was a million virus units per one liter,” she said. “Holy Toledo!”

School officials had the dorm’s residents undergo rapid nasal testing. The wastewater data, followed up with quick testing, allowed school officials to quickly identify and isolate 10 infectious students.

Without that, Lengsfeld said, perhaps 100 more students in the dorm of 300 might have caught it. “It works,” she said. “It definitely is a case study, I think, of exactly how to control spread.”

Jude Bayham, an assistant professor at Colorado State University and the Colorado School of Public Health, said that as overall covid trends improve and Colorado pivots to the next phase — and maybe scales down other testing — still-evolving wastewater analysis promises to step up. “Wastewater surveillance is a relatively cheap alternative that can provide a lot of information,” said Bayham, who is also a member of the state’s covid modeling team.

That kind of information can guide coronavirus response.

“We are really excited about this new tool,” said state epidemiologist Dr. Rachel Herlihy. “It will help us understand regional differences. It’s also been incredibly useful for us in understanding the emergence of new variants.”

“We’re still really figuring out how to best put it to use,” Herlihy added.

Kirby, of the National Wastewater Surveillance System team, said the CDC anticipates using the system to monitor infectious diseases, as well as other public health issues, like substance use disorders.

“One of the strengths of wastewater surveillance is that it is very flexible,” Kirby said. “So once we have built this infrastructure to collect the samples, get them to a laboratory, get the data to CDC, we can add tests for new pathogens fairly quickly.”

Should a new pathogen of interest pop up, she said, they could ramp up this system within a few weeks to start gathering community-level data on it.

This story is part of a partnership that includes Colorado Public Radio, NPR and KHN.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“A veces es totalmente estresante porque todas mis mesas con las que estoy interactuando no usan sus máscaras”, dijo Nikki Perri, mesera en French 75, un restaurante en el centro de Denver, Colorado. “Estoy a menos de 6 pies de personas que no tienen cubrebocas”.

Perri tiene 23 años, es DJ y productora musical. Y no solo se preocupa por su propia salud.

“Estoy más nerviosa por mi pareja. Está discapacitado. No tiene el mejor sistema inmune”, dijo.

Después de la primera orden de aislamiento, French 75 tuvo problemas para encontrar empleados cuando reabrió. También otros restaurantes.

Para averiguar por qué “pusimos una encuesta en Survey Monkey y el pago fue la razón número 3”, dijo su chef y propietario Frank Bonanno. “La salud mental fue la número 1. Los empleados querían seguridad y salud mental, y luego el pago”.

Su empresa, Bonanno Concepts, administra 10 restaurantes en Denver, incluidos French 75, Mizuna y Denver Milk Market. La encuesta se envió a los empleados de los 10. Bonanno dijo que estos trabajos ofrecen salarios competitivos y un buen seguro de salud, pero los beneficios de salud mental no son muy buenos.

“La gente debe pagar de su bolsillo para visitar a la mayoría de estos psicólogos y psiquiatras. Y estábamos buscando una manera de hacer felices a nuestros empleados”, dijo Bonanno.

Según su esposa y copropietaria, Jacqueline, esa información hizo que tuvieran una revelación: contratar a un especialistasalud mental de tiempo completo.

“No conozco ningún otro restaurante que esté haciendo esto, grupos o restaurantes individuales”, dijo. “Es un gran gesto de fe”.

Tomó un poco de tiempo averiguar qué querían exactamente los empleados y qué sería más útil. Los grupos focales comenzaron en el verano de 2021 y realizaron una contratación en octubre de 2021.

La licenciada Qiana Torres Flores, consejera profesional, asumió el nuevo e inusual papel. Su título es “directora de bienestar”. Anteriormente había trabajado de manera individual con clientes y en salud mental comunitaria. Dijo que aprovechó la oportunidad de desarrollar una profesión dentro del mundo de los restaurantes.

“Especialmente en la industria de servicios, este espacio de estrés está realmente lleno la mayor parte del tiempo. Así que creo que tener a alguien con este tipo de capacidad, simplemente accesible, puede ser realmente útil”, dijo.

En los 10 restaurantes, Flores ha dirigido sesiones grupales y mediado en conflictos entre empleados. Ha enseñado a los 400 empleados de la compañía técnicas para lidiar con el estrés y ha organizado el Taller de Salud Mental de Santa para ayudar con la tristeza y el duelo relacionados con las fiestas. También ha brindado asesoramiento individual y referido a algunos empleados a tipos de terapia más específicas.

“No solo hay ayuda, sino que está literalmente a 5 pies de distancia y es gratis y confidencial. Y es solo para ti”, dijo Flores.

Los propietarios dicen que su presencia les da una ventaja competitiva y esperan que les ayude a retener a sus empleados.

El personal del restaurante a menudo trabaja horas difíciles y pueden ser propensos a problemas de adicciones: una mentalidad de trabajo duro es parte de la cultura laboral. Muchos trabajadores no piden ayuda o no siempre consideran importante el autocuidado mental.

“Ha sido una opción realmente importante y un recurso para nuestro equipo en este momento”, dijo Abby Hoffman, gerente general de French 75. “Me llenó de alegría cuando me enteré que estaba comenzado este programa”.

Le da una excelente calificación a este esfuerzo y dijo que se basa en esfuerzos anteriores para reconocer el costo psicológico de los trabajos en restaurantes.

“Creo que la conversación realmente comenzó en torno a la muerte de Anthony Bourdain, sabiendo lo importante que era la salud mental y el cuidado de nosotros mismos”, dijo Hoffman.

La muerte por suicidio del chef Bourdain, que luchó abiertamente contra la adicción y la enfermedad mental, impactó a muchos trabajadores de restaurantes.

Bourdain murió a mediados de 2018. Luego, dijo Hoffman, vino la pandemia, que ayudó a relanzar conversaciones difíciles sobre el impacto psicológico de sus trabajos: “Pudimos, nuevamente, decir: ‘Esto es tan estresante y aterrador, y necesitamos poder hablarlo’”.

Al expresar estas preocupaciones, habla en nombre de toda una industria. La Asociación de Restaurantes de Colorado realizó recientemente una encuesta y un vocero dijo que más del 80 % de sus miembros informaron un aumento en los niveles de estrés de su personal durante el último año. Un tercio de los restaurantes recibieron solicitudes de servicios o recursos de salud mental en 2021. Más de 3 de cada 4 restaurantes informaron un aumento en la agresión de los clientes hacia los miembros del personal.

Denise Mickelsen, vocera de la asociación, dijo que no tiene conocimiento de otros restaurantes o grupos que contraten a un miembro del personal de tiempo completo dedicado a la salud y el bienestar.

“Es justo llamar a lo que están haciendo único e innovador”, dijo Vanessa Sink, directora de relaciones con los medios de la Asociación Nacional de Restaurantes. “Es algo que algunas de las cadenas más grandes han estado intentando pero que no está muy extendido”.

Ahora están surgiendo otros proyectos en la misma línea. Uno se llama Fair Kitchens. Se describe a sí mismo como un “movimiento que lucha por una industria hotelera y de servicios de alimentos más resistente y sostenible, que pide un cambio al mostrar que una cultura más saludable genera un negocio más saludable”. Citó una investigación de Unilever Food Solutions, con sede en Gran Bretaña, que encontró que la mayoría de los chefs estaban “privados de sueño hasta el agotamiento” y “se sentían deprimidos”.

De regreso en Denver, la mesera Perri dijo que está agradecida de que sus empleadores vean a los trabajadores como algo más que recipientes anónimos e intercambiables que traen la comida y las bebidas “y en realidad se preocupan por nosotros y nos ven como humanos. Creo que eso es genial. Y creo que otros lugares deberían seguir este ejemplo”.

Y si eso sucede, dijo, podría ser un legado positivo de algo que ha sido un momento difícil.

Esta historia es parte de una alianza que incluye Colorado Public Radio, NPR y KHN.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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