Pulling up Signs

these are easy, not so the big ones

these are easy, not so the big ones

The morning after the election I drove my little pickup around to pull the signs I had pounded in and wired up weeks before. The results were just now sinking in; I had won, but I had a deep sense of dissatisfaction. I was not concerned with the new balance in the US Senate; the state-wide races here in Idaho were a much nearer bother, but the precinct-level results in my district, the voters I had tried to touch were my greatest trouble.

We had focused a lot of time in rural precincts to persuade voters of my ability to give them good representation in the Idaho Senate. But the results were not impressive. In fact, they looked about the same as 2012 just with a very poor turnout. So I was pulling signs with frustration in my ability to sell voters on my qualifications.

You might get a sense of my personality here. When I would see patients all day in the office, maybe five would express great satisfaction, maybe ten would be thankful with another ten seemingly indifferent, but one might express significant dissatisfaction. When I came home for dinner that night, Martha would hear about that one unhappy camper. It took years for me to learn to see the bigger landscape in my role as a physician. I can see I need to keep learning this in politics.

I drove north first and took down the big sign west of the highway. A couple folks honked and waved with a thumbs-up.  A contractor I have known for years pulled over and helped me pull the T posts. “Congratulations!” he grinned and shook my hand, his ¾ ton diesel pickup idling behind us.

“How’s business?” I asked.

“We’re staying busy.” We didn’t talk politics. I know he lives outside this district. But his good wishes and warm handshake made me smile.

The last signs were south of town. These posts were in rocky gravel so I was working hard to get them out when the business owner came out. He too congratulated me, but soon we were talking about his plans for expansion, his family. As I put the posts in the back of the pickup he said, ”You know, I always thought I was a Republican. But I’ve known you for twenty years so I voted for you. I remember the first time you ran and I saw you were a Democrat it really surprised me. Him too.” he gestured at a county commissioners sign. “I guess I vote for the person if I know ‘em. Sometimes I don’t vote for anybody if I don’t know ‘em. It’s kinda hard when you don’t know ‘em.”

Yes it is hard. How do you get folks to trust you, to know you, in this age of national media and sound bites? I drove home with a good feeling but no real answers. I get to keep doing the work and trying to figure this out.

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A Song

 

With Bowe Bergdahl’s return in the news, the VA scandal,  and this last Memorial day I have been thinking of military service, how it serves our country and how it can shape the lives of the soldiers and sailors and Marines who serve.

I never served in the military. I was close to the draft for Viet Nam, but just a year younger than the last issued draft lottery numbers in 1973. I dreaded being drafted. It just didn’t seem like a war we needed to fight. Still, I was drawn to war. I read books all through elementary school about the Revolutionary and Civil wars. I studied the maps of Gettysburg and the Battle of the Bulge. Even in my first year of medical school I devoured the Bruce Catton Civil War histories. But I never got my father to tell me of his time in the great WWII.

Dad was lucky to go to college. He entered Oregon State with scholarships and a job washing dishes in 1938. His junior year Pearl Harbor struck and I’ll bet he weighed his odds just like he did in poker. He enlisted because then he had a better chance at being an officer and thus a slightly better chance at survival. He was no rah-rah gung ho hero. But he could read the cards that were dealt and he knew his hand, so he became a lieutenant in the Army infantry.

One story he willingly told was about ants. Officer Candidate School was his ticket out of the foxholes and a step up in a meritocracy, so he worked hard to qualify and clear the bar to pass. He told of the school somewhere in the South with heat and constant drills. A call to the parade grounds might come at any time. He hung his jacket on a hook behind the door with a half-eaten candy bar in the pocket. Where he grew up in Eastern Oregon, ants were not such a presence, but those Southern ants found that sweet quickly. When a sudden call was given to “Fall in!”, Dad grabbed the coat and stood at attention in rank in the heat and sun. The ants moved from the pocket and swarmed all over him. He told that they began stinging as if on signal; all at once he was getting stung all over. He stood at attention until he passed out.

I gathered that he served through the invasion of Sicily and then up through Italy though he would tell me no stories. I remember how difficult it was to wake him. Mom would be finishing Sunday dinner and say, “Go wake your dad, it’s time for dinner.” He would be napping on the couch or in the bedroom. I went with trepidation, since I’d done this before.

“Dad”, I would say softly. That never worked. I always thought if I could do it just right: “Dad, it’s time for dinner,” a little louder. He would still be asleep. I would reach out and touch, with my own fear, then he would startle, as he always did, his loud “Hunh?”  sitting up quickly, alert, sometimes even an arm thrown out just for a second, but it is so frightening to see your father scared.

He was wounded going up The Boot, he called it a million dollar wound, shrapnel in the buttocks. It got him off the line and he survived, that was his goal. He did tell me how he developed his skill at poker going across on the troop ship and coming home. He never told me why he got the Bronze Star. bronze_star_in_boxHe did say, “They gave those to everyone.”  His Purple Heart was the ticket home.

My fascination with war has faded as the clear purpose for young men to die for a cause has become so diffuse. Last legislative session the Idaho Senate ceremoniously honored the Idaho military that had fallen in service in the previous year. One family had us note the hymn sung at their son’s funeral, his choice or theirs, I know not, but one that echoed my feelings of these wars we fight and the people we send to kill and be killed; one I have sung too many times in our church and one that still brings tears.

 

 

 

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Words Not Said

 

Debate on the floor but long before adjourment

Debate on the floor but long before adjournment

It was late and we all were very tired. I could look around the Senate floor and see the sagging shoulders and the drooping eyelids. The “Ayes” were soft and the rare “Nays” even softer as we were passing the last of the budget bills, expecting to get done that day before 7PM. We all wanted to leave. The old adage of giving the last presentation before lunch or adjournment was never more true, but I had a budget bill to present that was an opportunity to say some things I thought needed to be said. I just didn’t think they would be heard. The opportunity was forsaken. I missed it. And so did the state of Idaho. I have my regrets, so I say it here.

I have served two years now on JFAC, the Joint Finance and Appropriations committee and have become very familiar with the many Health and Welfare budgets. Legislators can hate working these; they can be a morass of matching Federal funding that requires certain state investment to receive the match and metrics to show. One can feel like a teenager who hates school but has to get certain grades to get your allowance. Still, I worked to understand them, push here, pull there, cut this, and add those to best serve our state. I get very little help from other legislators. Since these budgets must pass both House and Senate, last year in 2013 I even had to conscript a House member to work on them so there would be a sponsor on that side to explain them.

There was even worse than reluctance to do the work. Last year (2013) there were legislators who sat in on the working meetings with the analysts and me so they could get ammunition to vote against the budgets. They offered no suggestions, no alternate proposals but sat through it all so they could try to understand the arcane details. Some even volunteered to make the budget motion in committee. I asked them to since I thought everyone was getting tired of my voice; maybe I thought I could enroll some help in this work. Instead some would agree to make the motion in committee, but then would debate against the motion and vote against the motion on the floor. This year I did more work alone.

There are 13 divisions to the Health and Welfare Department, but the biggest budget, over 80% of the whole $2.5 Billion, is in the Medicaid division, and that was the last-day budget I was carrying before the very tired Senate. I wanted to say some things, because there are some things I had learned, and I wanted to help my fellow Senators to learn them, indeed, our state. But I wasn’t sure there would be an audience. Heck, I doubt many will read this. Still, I need to say it. Thank you for reading.

First, let’s understand Medicaid. It is essentially a federally subsidized, state managed health insurance program for the poor and disabled. There are three kinds of Medicaid insurance here in Idaho. The Enhanced Plan covers the aged and disabled. It enrolls about 40,000 ( thus <20% of the total  Medicaid population) Idaho children and adults yet it costs over half the total budget. The dual eligible (Medicaid AND Medicare, think impoverished nursing home population) comprise about 10% of the population but spends about 30% of the budget. The universal 80:20 rule applies to Medicaid spending too; 80% of costs come from 20% of the population. The Medicaid Basic plan covers pregnant women and some children below a certain income level (generally less than about 150% the Federal Poverty Level, FPL). Here we have 75% of the enrollees but about 30% of the costs.

Under the federal Medicaid law, states can set eligibility levels. Idaho makes it tough to qualify for Medicaid. Here is a graphic of which plan has what eligibility in Idaho:

For reference, 100% FPL = Income for a single adult $11,500/ year, for a family of three $19,500

eligibility

 

Now think about the Affordable Healthcare Act, basically a reluctant deal between the federal government and the private health insurance industry. The goal of this program was to get everybody covered by insurance, so that the cost shifting hospitals and doctors do when they provide uncompensated care can be limited. This is the first step needed to control healthcare costs in this country. The exchange was a tool to get individual and small group insurance affordable and to bring market forces to bear on the cost of these products. But private insurance didn’t want to deal with the people they hadn’t dealt with before, the working poor whose income was below the federal poverty level. So, the decision was to get these folks enrolled in Medicaid. The federal government would pay for it, 100% of the cost for the first 3 years, then at a reduced rate down to 90% in 2024. But states could buy into this plan or not according to the Supreme Court in June 2012. Idaho convened a workgroup to study whether this made sense. After much work we recommended the governor support it. We could get rid of the Catastrophic fund and county indigent programs that cost the state $70 Million a year. Prisoners released to parole could receive some level of support in the community. But the governor and the legislature flinched from embracing anything to do with ObamaCare after a painful exchange confrontation the year before. So we tired Senators were wanting to go home and I needed to present a Medicaid budget for 2015 that was not everything I thought it should be.

SB1424 was on the schedule for a long time. It got held up for a day or two because the House killed a bill the Senate had passed, so Senate leadership needed a hostage to force some negotiations. The deal was made but I got an extra day to contemplate my debate on the Medicaid budget presentation. Should I beat the Republicans about the head and shoulders for their unwillingness to consider the change in eligibility? Should I hammer on the fact that a change in eligibility would have not cost the Idaho taxpayer one thin dime, yet brought coverage to 70,000 low wage, working Idahoans? Should I rail about political courage? Should I pound my chest about the millions I had saved over the governors recommended budget as I had studied the details? Should I wax on about how health is a measure of productivity and pursued happiness, not dependency and poverty? I chose not to. I stuck to the budget, the numbers, the 20,000 foot view of a complicated subject. We were too tired to deal with the devilish details. But here’s what I could have said:

Mr. President, I bring to the Senate for your consideration the fiscal year 2015 Medicaid budget. It includes$1.3 billion for approximately 70,000 disabled adults and children who meet eligibility, and $500M for approximately 175,000 eligible pregnant women, children and adults. It is a lot of money. In other budgets we have already approved the money for the processes, the people and the functions to determine who is eligible. This appropriation bill does not address where we have set those limits for who might be eligible. Such would be a policy decision that we have not considered this year. I would like to point out to this body that if we had changed those limits to those recommended by the governors work group, this budget would be bigger, but it would not have cost the Idaho taxpayer another dime; in fact we could have skipped a previous budget for $35 million dollars. We have also passed a bill in this body to improve prison policies, Justice Reinvestment, and a policy decision to reform eligibility would have provided services for parolees in the community, to support their success. And an eligibility change might have gotten 70,000 Idaho working folks access to primary and preventative care, to keep them productive and strong. I remind you that businesses asked us to do this. We did not.But I must speak to the bill before us.

So, fellow Senators, such is not in this budget. But it is a good budget. I have worked for weeks to limit any waste, to trim what I could to meet the needs of those currently eligible. What is more, the Senator from 24 and I worked all summer with a large group of interested stakeholders to reform all aspects of health care delivery and payment in Idaho, to ensure that we provide the right care, at the right place, at the right time for the right price. Idaho is poised to do the right thing.

But today all I ask is that you support this small step to take us in a direction I’m not sure we should be headed. You see, 95% of this budget goes directly to payments to doctors and hospitals for the care they provide. Therefore, about 3% is going to managing these payments. Almost nothing goes to managing the care that is provided, or incentivizing patients or providers to give appropriate care. That is the work we must do.

For those opposed to any consideration for expanded eligibility I say, this one small step to enrolling people into a manageable, transparent payment system is a step we must have the courage to take. There is no other way to manage our county’s runaway healthcare costs than to get everyone involved in a manageable system. Markets cannot be effective when costs are constantly shifting and when price and value are hidden from the consumer. The vital work to change this system cannot be delayed. It will take more than a late session vote, more than political courage, more than the politics of getting reelected. It will take another summer or two, maybe even some fall and spring work to get this state on the road to prosperity. Because our ability to manage healthcare costs is the golden ring on this merry go round of public policy. This problem defines our national debt, not just our states future prosperity. We all should be reaching for the golden ring as we spin. But that is not what is in this bill. For now, at the end of this long and tiresome day, at the end of this compressed session, all I can do is ask for your “Aye” vote. Mr. President, debate is open.

I didn’t say this to my fellow state senators. I stuck to “just the facts m ‘am” approach and the debate was weak, including mine. The Medicaid budget passed the Senate 26-9, and then the House 44-26 and we adjourned Sine Die. Maybe another day we can have this discussion. I don’t know about the courage it will take, but it will take a lot of work.

 

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No Names Please

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I get hand-written letters from the penitentiary a half dozen times a year or so. I read them and often do not respond since I find the allegations so outlandish or unbelievable I fear my response would be like throwing gasoline on a smoldering fire. I will look into the concerns in my own way.  But my time on the Joint Finance and Appropriations Committee (JFAC) made me sit up and pay attention to a recent letter. It described problems in a parole hearing. It made me reflect on the JFAC presentations I had heard in the last two years from the Commission on Pardons and Parole(CPP). At the annual hearing the agency makes their case for funding. Committee members may ask the presenters questions, but JFAC doesn’t take public testimony at this time. We must rely on the presentations and any information we can glean from our own investigations.

I write this with no names to protect the individuals involved. But my job as a legislator on JFAC is to decide how the taxpayer’s dollar should be spent, not blame someone for mismanagement. We cannot hire and fire; that power lies in the executive branch. The commissioners and the director are appointed by the governor.  So I struggle with my role here. At this point I just want to tell this story. Soon I will have to decide what to do with what power I have. I have my responsibility within my role; others have theirs.

The five member Idaho CPP was established in the 1940’s. The Idaho Constitution says the authority over prisoners on parole lies with the Board of Corrections (BOC), but both websites claim the CPP is an independent body from the Board of Corrections, and in my opinion, the statute isn’t clear.  I cannot find a clear delineation of which entity has what responsibility. I fear we, the legislature, the designers of this system have created a structural problem. There can be multiple reasons why a system isn’t working; inadequate support, improper personnel, or faulty structural design. A bill that is proposed this session tries to address this structural, statutory problem, and I support it, but I fear such remedy may not be enough.

The decision to create the CPP was a policy decision 60 years ago that honestly makes good sense. I can imagine a prisoner and a warden not getting along, some personal conflict, so an independent body to review the application for parole, without such a history might give a semi-judicial distance. Think of the Shawshank Redemption scene. The intent was, I believe, to create an opportunity for a fair and just hearing.

shawpar

But I have grave concerns about how the Idaho Commission on Pardons and Parole functions. It is hard to be just and be dysfunctional. I first became aware of these issues when I was running for office in 2010 and was made aware of Idaho’s high incarceration rate. I did some online research and ran into two studies with many follow up reports from the Office of Performance Evaluations (OPE) that mentioned long delays from time of eligibility for parole and the actual parole hearing.  This means more time in prison for inmates and more taxpayer cost, as well as delayed justice. Then, I got appointed to JFAC in 2013 and heard my first JFAC presentation for CPP. The director showed a simple bar graph that indicated the average wait time from when prisoners were eligible for parole and when they had actually had a hearing had decreased by 12% from 2010 to 2012. I would imagine the goal would be to reduce this number to as close to zero as possible, indeed the OPE study showed that even with the improvement in 2012,  57% of prisoners had a delayed parole hearing at a cost to the state of $7.2 million. I was even more troubled by this conclusion in the report:

Unless the commission makes substantive changes in the way it manages offender data, we believe a third follow-up review will be of little use and suggest that the Oversight Committee close this report.

 

After the 2013 budget presentation I asked the committee leadership and was assured there were plans for change at the commission, so I supported the budget request.

Now, in 2014 we have another CPP budget presentation and request. I asked the director if there was any more data on the time from eligibility for parole to the time of the hearing. There was no data available I was told. There was also a budget request to pay an outside contractor to get their minutes reviewed and available for publication. All meeting minutes should be reviewed in a timely fashion by any public agency and approved so they can be available should there be questions about what happened. I asked why the amount was $400,000. That seemed like a lot, how many minutes needed review? The director said they were four years behind in their minutes review.

After the hearing I was again assured by leadership that changes would be made in the commission. But that decision comes from the governor, not the legislature.

Now I come to the letter from the inmate, four pages, both sides, hand printed on lined paper, with the Parole Commission response stapled to the back. He has been sentenced for aggravated battery to a three year fixed sentence, and three years indeterminate and was eligible for parole September 2013. At his parole hearing (August 2013, thus before his due date)  he had an employer show up who had a job for him taking care of pheasants and chukars that were raised for a hunting operation. The employer was given 1 minute to speak. The parole board denied the application, the inmate said because they were concerned he might be close to guns at the hunting operation, a parole restriction. So he can apply for parole again in a year. He has completed his GED in prison, as well as a couple computer classes and Commercial Drivers license training. His “institutional behavior” has classified him as “a minimum”. The employer changed the operation so he would only take care of the birds, never be close to the hunters who come out mostly on weekends. But he must wait another year, August 2014, for another review. And he was so frustrated with the process he said he might just “top out”, meaning finish the full 6 year obligation.

My wife read the letter and commented that the inmate never acknowledged his guilt, said he was sorry for his crime. I remember Morgan Freeman talking about “rehabilitation” in Shawshank Redemption. I appreciated her input, but in my opinion, I am looking for rehabilitation in a government agency. And I don’t hear anyone saying they are sorry.

 

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Flat Tire Politics

 

flatdark

It is hard to be away from home for the legislative session, but Boise gets many visitors from around the state and I enjoy the visits. It isn’t always easy but I try to make the time. A good friend from the old days came to town a few weeks ago and I am still thinking about it.

We shared many things in years past; our kids are about the same age, we both hunt and played sports, but we have always been on different ends of the political spectrum. Still, we are friends and I hope we remain that way. That’s how I believe we can move this state forward; friendships and conversation.

I picked him up at the airport and we found a place downtown to eat. Parking was tight but my pickup is small so I did my best to parallel park in a short spot. We had a beer and some good food. He asks good questions and listens well. At one point, I’m not sure in response to what, he objected to the “gay agenda”, and I found myself reacting.

“Dick, there is no ‘gay agenda’ They just want fair treatment and the justice we all should share.”

He paused, listening and asked, “So you think, if I own a business and I don’t support their lifestyle, I should be required to make a cake for their gay wedding or required to take pictures at it, when I don’t think what they are doing is consistent with my values?”

I paused and considered, because this is a real question our country faces now. So I was honest. “Well, no, I don’t believe a private business should be compelled to provide services it doesn’t support. At the same time, shouldn’t we all respect each other? Shouldn’t we all treat each other with dignity?”

“So is suing a business owner for standing up for their values and beliefs respecting their dignity?”

I paused, and I thought about Rosa Parks. If she had not stood up for what she perceived as injustice, our community awareness of the respect we all deserve would be diminished. Her courage to confront the community expectation that African Americans sit in the back of the bus has ennobled us all. So why is this a “gay agenda”? Why is this not just a reasonable request for human dignity? I guess both sides feel attacked and on the defensive. And so our differences can become a battle instead of a respectful conversation.

After our dinner we went out into the dark downtown Boise night. We found my little truck had a flat on the right rear. My first reaction was to suspect someone had knifed the tire, since the parking spot was now much wider, a car had left and another pulled in not as close. I suspected the guy I had squeezed in next to was angry about my closeness as he tried to pull out and decided to show me what he thought with a spiteful act of vandalism. But as I got out the jack and resigned myself to laying in the gutter on broken glass in my Senate-required suit, I decided maybe I had hit the curb and cut my own sidewall. We got it changed and I took him out to his hotel. The next day the tire store told me it was a knife to the sidewall after all. So much for me trying to think better of human nature.

I was thinking about how we treat each other when the February 3 protest in front of the Senate happened. Forty some folks with hands in front of their mouths with T-shirts proclaiming “ADD THE FOUR WORDS” blocked the front of the entrance to the Senate chambers and would not move. They were arrested, quietly, respectfully, but none the less arrested for trespassing in our state capitol.

Pro Tem Senator Brent Hill asks protesters to move.

Pro Tem Senator Brent Hill asks protesters to move.

Idaho has a Human Rights Task Force that is empowered to investigate disputes in housing or employment that might be based on discrimination due to race, religion, etc. We have tried to add the words “ gender identity” and “sexual orientation” to this list for eight years now, but have been blocked in our Republican dominated legislature. I imagined that some may see this as another expression of the “gay agenda”.

But in the legislature, we don’t discuss, we posture.

Chapter two (or three or four) of our state’s inability to talk with each other this year was the “Luker Bills” . They were designed to “protect” professionals from a sanction by their licensing board if the professional refused to provide a service they objected to on religious grounds( like the wedding cake for the gay marriage). The second bill prohibited any municipal ordinance from restricting the practice of religious activities. I have not heard of this being an issue in our state, but I guess it needs defending. When one feels attacked, defense is normal. And it seems the “gay agenda” is a strong threat to some. These bills have died, but I don’t know if we feel any closer to a conversation.

Chapter next comes with a sidearm.

 

Concealed weapon holster

Concealed weapon holster

We now have a bill requiring the public universities and colleges relinquish control of fire arm possession on their campuses. It is universally opposed by the college officials and the police chiefs in these towns. But this election year the fact that these districts all have Democratic legislators when the state is 80/20 Republican, the politics of such a stance is not lost on me.

 

So our legislative session progresses, with little conversation about substantive issues. We have a growing deficit in road maintenance, our public schools are still 6 years behind in funding, and we have now claimed the position of the “lowest wage” state.

How can we build a healthy community relationship? I believe only through such a  relationship can we make the best policy for our next generation. No one is better off when we are both feeling attacked.  We should be sitting down and having honest discussions, even if we disagree. That might change our culture. We may even need to change fewer  flat tires.

 

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The Mess we are in: eRate, IEN, ENA, USAC and the Idaho Taxpayer

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This week in JFAC we heard from Department of Administration Director Teresa Luna that we need $7 million to keep our schools connected to the internet. She is also asking for another $7 million for 2015. She is asking Idaho taxpayers to pay for something that previously has been paid by a telephone tax. She did her best to explain this situation, but honestly it wasn’t clear at the time to me how we got here, but I really wasn’t too surprised, since when I read a Supreme Court decision last spring I got concerned. It is a complicated story with many acronyms so let’s get started.

Last March Betsy wrote about an Idaho Supreme Court decision. This goes back to before I was even running for office, 2009 when players were vying for a state wide contract to get broadband to schools. The Court said the contract had been awarded incorrectly and should be set aside, “for further proceedings”. I wondered quite a bit about the concurring judges reference to the charges not filed, but I was mainly worried about what this meant to Idaho taxpayers.

How does payment for broadband to the schools work? If you get lost or confused, click on a link for further reading. Here come the acronyms. On your phone bill you will see a small tax. This is collected by the FCC and administered by USAC. Newspaper reporters, even Director Luna called this “federal money” but it actually isn’t, the initials make one think of Uncle Sam, but it is the Universal Services Administration Company. Schools and libraries can apply to USAC for E-Rate payments for approved services. The application is awarded based on the cost of broadband services and the percent of free and reduced lunch students in the district. In Idaho this can range from 50% to 95% eligible, but the state average is about 75%, a measure of our poverty. Schools can receive E-Rate money directly or have it sent to a service provider. Before the legislature made Idaho Education Network (IEN)  a law, many schools were getting the money and paying local service providers, but with IEN, the plan was to develop a statewide network and have the contractor receive the E-Rate payments directly; thus the contract in 2009 between Idaho Department of Administration, Qwest and ENASyringa bid on the contract but got pushed out, even though they had the lowest bid and were an Idaho company; thus the lawsuit that led to the March Supreme Court decision. ENA has been collecting the E-Rate dollars from USAC up until the payments were shut off in May of 2013, after the Idaho Supreme Court decision.

By the way, ENA was also awarded the multi-year wireless contract for grade schools this last summer by Superintendent Tom Luna (brother of Teresa Luna) over competing and lower bidding Idaho companies.

As best I can tell from 2009 to 2012 ENA has received about $7 million from USAC in E-Rate payments. So far this year they have not received about $7M, after the payments were held.  If the Supreme Court decision is upheld and the contract is invalid, I am afraid the state will need to reimburse all the E-Rate payments sent to ENA. I can respect USAC being prudent about payments since they are under scrutiny themselves.

I hope the citizens of Idaho can get some clarity on this mess. I am working on it.

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Justice

 

welcome to Cache Valley, Idaho

Welcome to Cache Valley, Idaho

An Oregon congresswoman spoke at my sister’s memorial service 20 years ago. It was a painful time for me, but her words stayed. She said, “If you value freedom you must work for justice.” In doing this legislative work I find that justice is not always easy to see, and the work to do for it may come down to how you chose to spend the money you have. Working for justice requires deeper thought, longer looks, and getting off a comfortable bus to see what could be missed.

Serving on Joint Finance and Appropriations Committee (JFAC) has been a joy and a burden. There is so much to learn that it can seem overwhelming. But the people on the committee are a joy; the staff and the co-chairmen encourage the work, forgive the ignorance and reward the effort. And the ultimate reward is having a voice in how the state spends. I hope to give good service to my constituents and my state.

This September 2013 the JFAC “bus” toured state facilities in southeast Idaho. It is important for members to know how we are spending taxpayer money. We saw what Idaho State University was doing in health care education and the struggles they had with some buildings. We visited a state crime lab in an old building down by the train tracks and the women’s prison in Pocatello. We got down to Bear Lake State Park and Lava Hot Springs. We heard from passionate educators in Grace, Idaho where they give the kids a week off early in the school year to help with the potato harvest. Each stop made me wonder how taxpayer dollars can help, or if they should “help” at all. Our state doesn’t have much to spend and most communities help themselves best. But I believe we legislators are obliged, indeed entrusted, to serve the common good.

Each stop also provoked questions:

Why does the state own and operate a hot springs resort? Is there more value in public access to a beautiful high desert lake or in private ownership? Do schools need state direction to solve their education issues or can they manage best locally? Can convicted criminals contribute to society?

I have many more questions but I want to tell you a story from the last day of the tour.

Franklin, Idaho, has the distinction of being the first white settlement in Idaho. No honor is lost that the founders thought they were in Utah until the territorial surveyors corrected this false impression. They had been sent here by their leader, Brigham Young and they persevered.  They irrigated the desert, grew crops, built a railroad and a thriving community. We visited a State Historical Society site that included the stone house of the pioneer Bishop Lorenzo Hill Hatch.

se_hatch_left

The pamphlet described his as the town’s first mayor and a “legislator”. From reading The Tie That Binds about the state convention to write the Idaho Constitution I knew that the biggest issue facing the body  was whether Mormons should be allowed to vote(they weren’t), so how could a Mormon Bishop be a legislator? I asked our guide, a retired legislator himself,”It says here he was a legislator, but I thought Mormons couldn’t vote.”

He shook his head, unsure. “No, you’re right. I’m not sure how that happened. At early statehood we were right down there with the Indians.”

I researched further and found that Bishop Hatch served in the Territorial Legislature, before statehood and Mormon disenfranchisement. In one of his letters from his service he described Boise as “a city of great wickedness and debauchery of all kinds.” His work in the Territorial Legislature may have given gentiles a view of an upstanding Mormon, but the Idaho Constitution went on to prohibit the Mormon vote. Indeed, as Idaho approached statehood Bishop Hatch was arrested and charged with polygamy, testament to the many struggles this state has had and continues to have with the concept of “common good”.

As we prepared to leave Franklin the State Historical Society Director encouraged us to stop at the Bear River Massacre site on our way out of town. She warned that it is not always easy to see and it is not easy to pull a big bus over by the side of the road but she said it was worth the stop. The retired legislator said he would meet us there. I had read about the site and the only Civil War “battle” in Idaho, where an estimated 250-500 Shoshone-Bannock natives were killed by a contingent of US Army sent north from Salt Lake City in January 1863. The village was encamped at the confluence of Beaver Creek and the Bear River when the US (Union) army came upon them. The young US soldiers were California Volunteers, sent to Utah to maintain our Union as the carnage in the East mounted. It was very cold and it is said the whiskey ration doled out the night before the attack froze in their canteens.  Still, I couldn’t imagine what they thought on that freezing January day.  At the dusty wayside I stepped off the bus and looked. Two other legislators joined me.

 

696px-BearRiverMassacreMonument

There is a stone plinth, probably erected in the 1930’s with brass plaques on the four sides. The first one I read commemorated the local Mormon families taking in the orphans of the massacre. As I focused on the monument, a fellow legislator pointed to a scrubby tree and said, “Hey, what’s this?”  We walked over and came under its shade. When I described the vision to a young friend and how  I imagined tourists driving by at 65 MPH, and if they didn’t stop, pull over and get out but caught a glimpse of the tree and it’s adornments by the monument, they may not notice much, he said as summary of my stumbling description, what I couldn’t: ”Hey, what’s all that garbage in that tree?”

800px-ShoshonePrayerTreeBearRiver

 

But it wasn’t garbage.

Iphone 10-2013 012

How easily we can misinterpret. Hanging from the branches of this scrubby high desert tree behind the state sign and the stone monument with brass plaques were offerings no doubt to the suffering of ancestors, and maybe a testament to their own. The intention, the honor, the reverence was palpable. It might not be an official state sign, but it was a moving place to stand, under that tree, with all that care and devotion.

I was so happy that I got off the bus.

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Ride for the Brand

I spent one summer moving cows around Cuddy Mountain near Hells Canyon with my grandfather Henry.

Some of the top of Cuddy Mountain is flat, but there's a lot of steep too.

Some of the top of Cuddy Mountain is flat, but there’s a lot of steep too.

I learned a lot about him, horses, cows and the work we need to do. This reflection comes because of a phrase I have been hearing around the statehouse, “Ride for the Brand”.

At the beginning of our legislative session this year, I was sent down with two fellow State Senators to the Governor’s office to tell him the Senate was ready to hear his State of the State address. The lead Senator greeted the governor with a hearty hello and declared, “Governor, I want you to know, we are here to ride for the brand!” They shook hands and clapped each other on the shoulder. I stood in the back ground. And then later I heard a Republican House freshman describe his campaign motto had been “Ride for the Brand”. I remember receiving an invitation in 2010 to our reelected Governor Otters inaugural party with the “Ride for the Brand” motto on the inside of the card. So this motto has caught my eye. Just what does it mean, to me and to my fellow public servants?  Am I branded, a “D” behind my name on the ballot? Do we work for the brand or for the greater good? I am wondering.

I met Henry on the Snake River at the base of Brownlee Dam the summer of my thirteenth year. He put me on a horse to ride in to the “retirement” ranch they had settled into, Starveout Ranch, high up above the Wildhorse River on the flank of Cuddy Mountain.

That summer Henry and Helena, just newly retired, had agreed to ride the Cuddy Mountain range for Helena’s cousin Holworth Nixon.  His cows were up on the Forest Service range that had been theirs before retirement. We left Starveout, with its green pastures, milk cows and chickens, running water and propane lights, no electricity, no phone to climb to the top of Cuddy Mountain, stay in a cow camp shack with a wood stove, haul water and herd cows. I loved it.

We rode for the brand of Holworth Nixon, which was a Circle “C”. Henry and Helena’s brand was an “O Cross Bar”. Henry rode for years for Albert Campbell and the OX ranch. I found out the “O Cross Bar” brand is still available from the Idaho Brand Board, one of the first registered in 1949 and last renewed in 2000, the year Helena died. I don’t think I will pay the $126 to get it registered.

Up on Cuddy Mountain at the cow camp at Summer’s Grave we would have a predawn breakfast of sourdough pancakes, collect the horses that had been hobbled and saddle and ride off to move cows. The top of Cuddy Mountain is a timbered rolling expanse all above 6000 elevation. I was at the mercy of Henry and Helena’s local knowledge. But by the end of the third week, places did start to look familiar. In the morning we would head out to “Paddy Flat” or “Windy Knob” or “Jims Point” and find some cows grazing. We would ride around until we had a bunch, then start moving them across to “Green Saddle” or “Bacon Meadows”. Along the way I often got the story about why it was called “Bacon Meadows”.

Henry had a colorful vocabulary. I counted once and it came to a fifth of the words he uttered were profane. He only used four cuss words, but he used them a lot. “She’s a damn good mare.” “That sumbitch fooled me.” “Helluva fine day.”  As we were trailing the ambling white face cows Henry nodded ahead and informed me, “There’s a goddamed OX cow”.  I hadn’t noticed. But I looked closer and she had a big OX brand on her side. We were riding Circle C cows.

“What do we do?”

“Oh hell, they’ll come git the sonovabitch come fall. Damn stupid to run her off up here, but that ol’ sonovabitch Albert Campbell used to make us do that.” Henry grinned and shook his head. “He was a helluva businessman.”

We didn’t drive off the cows that weren’t our brand that summer. But we noted it, or at least Henry did. He kept track, but kept them together. It seemed to work on the mountain. It seemed the fair thing to do. I would hope we can keep the work of our state in such perspective.

I’ll always remember that summer. Henry died that fall, a stroke. I barely got to know him. I hope my grandkids know me better. And I hope I have as much to teach them.

Schmidt Grave

 

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What I Did Last Summer

 

 

Last summer I thought I could change things. I tried to be a force for justice. In the process I learned a lot about the politics of power and people. I’m not sure I made a dent.  You let me know what you think.

Why I’m A Family Doctor                                    

I never watched Dr. Welby

I never watched Dr. Welby

 

I chose to be a Family Physician because it suited my personality. I don’t like facing limits imposed from the outside; I want to set my own. A Family Doctor is trained to deal with problems from the cradle to the grave and must know one’s own limitations. But I also believed what the professors in my medical school said, that well- trained, hardworking, primary care physicians could solve the nation’s health care problems. Good primary care would lower costs and improve outcomes.  So I did Family Medicine for 20 years. I loved the work and thought I was paid well. But I saw that I was paid a third of what specialists were paid, outcomes were ignored, and less and less medical students were choosing primary care.  Then, two years ago, here in the Idaho legislature, I saw a chance to try to solve a very small part of this huge problem.

Getting Started

Idaho has an insurance program that pays doctors for treating injured workers. The Idaho Industrial Commission is required to annually bring to the legislature its schedule for payment to physicians who treat injured workers. In 2012 they suggested a 10% increase in payments since there had been no increase for the three previous years. By itself, this seemed reasonable, but here it gets complicated, so pay attention. We are going to get into the nitty-gritty of how doctors are paid for what they do.

Into The Weeds of Physician Compensation

 

Even big problems can be lost in the weeds

Even big problems can be lost in the weeds

In 2006 the state of Idaho changed Industrial Commission payment to doctors from the Usual Customary and Reasonable (UCR) method to the Resourced Based Relative Value Scale (RVRBS) method. The UCR method says the doctor can charge and be paid what is usual, customary and reasonable for the area in which they practice. In other words, you can charge what is “usual” and insurance companies pay. But the RVRBS method says the charge for a certain service is based on what resources are brought to such an encounter. It was an attempt to develop a fair payment system, not based on charging history, but instead on what “work” or resources are required to do different “doctor things”.

When the Idaho Industrial Commission made this switch some doctors were mad. Indeed, it ended up in court, with the state of Idaho suing some surgeons for fixing prices. But the RVRBS method of payment is considered fair and most insurance companies use it, as does Medicare and Medicaid. But, because of historic differences in payments most insurance payment scales use conversion factors. Here’s how these work.

Dr. Jones sees a kid in the office for a rash. The RVRBS method would say her effort is worth, let’s say, 0.7 Relative Value Units (RVUs).  A surgeon takes out little Johnny’s appendix and that work comes to 5.9 RVUs. (All these are hypothetical values.) As a Family Doctor working in a clinic we would negotiate with insurance companies for payment and we might get paid $50/RVU. Surgeons negotiate with insurance companies and get $95/RVU. So even though the RVRB System is supposed to account for the different skills, time, effort and risk brought to the doctor’s work, payments still valued specialty and procedural care more than primary care.

When the Idaho Industrial Commission made the conversion to RVU payments, there was such an outcry from some Idaho surgical specialists that the Commission was afraid some would refuse to see Industrial commission patients, so they put in conversion factors. These conversion factors were applied to the different codes that doctors used to submit payments. Surgical codes would have an RVU multiplied by a conversion factor (in this case approximately $135). Office codes would be multiplied by a different conversion factor (approximately $55).  So again, we are valuing different care differently, even though the RVRBS payment method is supposed to account for this.

When the Industrial Commission came to our Senate committee in 2012 to increase payments to physicians, they just applied a small change to just a few the conversion factors.  I thought we should be narrowing the difference between the conversion factors faster.  They listened politely but said they had a subcommittee that made recommendations to them, and they were just passing on their recommendation. I asked to visit with the subcommittee. And I called the representative for the Idaho Medical Association.

Politics is about relationships and working with people. Passion can become an obstacle for compromise and process. I tried to maintain respect for the process, but I will always have a passion for the value of primary care.

Changing Oil and the Idaho Medical Association

I'm not this neat

I’m not this neat

 

The IMA said they could not support me to decrease the conversion factor difference unless they were directed by their board. It was suggested I come to the July House of Delegates meeting in Sun Valley and plead my case. I have only sparingly been a member of the Idaho Medical Association, since I didn’t think primary care was well represented in this group. But the new President was a Family Doctor, half the Board was in Primary Care, so I have been a member now for 3 years. I signed up for the July meeting and drafted a resolution to present to the body.

The Industrial Commission subcommittee met in June and I phoned in my concerns from my Moscow garage where I was changing the oil in my pickup. They were receptive but wanted input from the IMA.

I also met with the Idaho Academy of Family Physicians in June and tried to get them to support my effort. They said they had just had a board meeting and wouldn’t meet again until September, after the IMA House of Delegates. They encouraged my efforts, but could not officially take a stance.

So you are getting to see what I did for part of last summer.

Failure

I was disappointed in my political abilities with the Idaho Medical Association House of Delegates. I drafted a resolution that would move the multiple Industrial Commission conversion factors to a single one in a revenue neutral fashion over time. This would mean the highly paid surgical procedures would get less and the office visits would get more, but they would still be based on the RVU formula. I suggested a ten year transition period. Honestly, who knows what will be happening in health care in ten years, but I am a moderate guy, I like my burgers medium and I drive old cars, so there it is. But there were folks who wanted to make it happen right away. I feared this was asking too much and indeed, the motion got referred back to the Executive Board to decide. I felt I had not spoken up strongly enough for my vision. But I did learn the people, the trends and ways of acting.

I was also somewhat confident that the Executive Board would support the transformation, since most were primary care providers. I was heart-broken in the fall when I learned they had voted to take no action.

Success, sort of

So last summer, besides trying to adjust Idaho Industrial Commission physician payment, meeting in McCall and Sun Valley with a lot of doctors, I was also working in the ER and campaigning for the Idaho Senate in my new district. It was a close election, but I got voted in to come back to the Senate. And then I got reappointed to the same committee that reviewed IIC physician payments. I was very surprised to see their proposed rule that reduced the conversion factors from 7 to 6 and reduced the differences between the conversions. I asked them, why did they propose this? They said it was what their subcommittee suggested. I asked if the IMA was opposed. She shook her head and smiled.

I don’t think I won this battle, but we gained some ground. Health care costs are killing our country. And if this small skirmish in this small state in this small theater of the medical conflict is any sign of the effort it will take to turn this around, be prepared for the battle ahead.

 

All comments are read but not posted.

 

 

 

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Ms. Information

EB-5-Visa-Misinformation

As legislators we study bills, and then we vote to pass or kill them in our legislature. It is a process set in our Idaho Constitution, written in 1889.  But there is a way to subvert this process and technology has made this easier.

We Idaho citizen legislators are supposed to be receptive to our constituents, and I try to be. I assume my colleagues are making the same effort. A couple weeks ago in a Senate committee two bills were proposed that made simple sense to me. I believe the truth around these laws was subverted.

If you want to, read SB1011 and SB1012. I encourage you to read them, since that is what we will vote on, or not in this case. I will try to tell you the story. It goes from zebras to the Koch brothers, but there are connections.

Idaho has had a long history of having a low rate of childhood immunizations. When I was a doctor practicing in Moscow, I spent time explaining immunizations, their risks and benefits to young moms and families and encouraged them to make a decision and proceed. I believe immunizations have saved a lot of lives. Indeed antibiotics are a distant second to immunizations when we talk of reducing childhood mortality.infant headstone

Still, many parents don’t trust immunizations and chose not to have their children immunized. And many believe immunizations cause more harm than good. I did my best to respect the wishes of the families I served. And as a legislator, I try to maintain such respect for these choices.

 

Doctors kept immunization records in their offices on messy paper hand written charts, and sometimes parents would keep “shot records” on little folded yellow cards. I had one in my wallet for years. But Idaho got epidemics of whooping cough, and I saw cases of measles early on in Moscow. So either the

11173-280x190r1-messy-papers

immunizations weren’t working or we weren’t immunizing enough kids to prevent these potentially fatal diseases. At this point I could digress to discuss “herd immunity”, which means, if most of the members of a herd are immunized, those that aren’t still receive a benefit, since they are exposed to less disease. But I will avoid the digression.

If 95% are immunized, the remaining 5% are protected.

I believed Idaho was immunizing at a rate similar to the rest of the nation, we just weren’t recording it very well. Others thought our immunization rate was low. To try to answer this question Idaho developed an immunization registry, IRIS. When first put in place parents had to “Opt In”, meaning parents had to say, when they chose to have their children immunized, that it was OK to transmit this information to the state registry. Our reported immunization rates stayed low. But a few years later the choice was made to switch to an “Opt Out” procedure, meaning, unless the parents asked to be excluded, the information would be entered into the state maintained data base. Suddenly, our immunization rates were now comparable to the national rates. It matters how you ask the question. My suspicions of poor recording were confirmed.

When the switch was made to the “Opt Out” protocol we made the law as specific as we could to protect the privacy of individuals “opting out” so that, if they didn’t want their information in the data base it would not be entered. But along comes electronic records and data gets entered often automatically. So let’s say a kid comes to my office for a well-child exam and the Mom is OK with the kid getting shots but doesn’t want her child in the state data base. We don’t send the information in, respecting her wishes. But four years later little Johnnie gets a cut, goes to the ER and gets stitches, and they ask, “Does he need a tetanus?”  Mom can’t remember and so they give him a tetanus shot and this information is entered automatically since the electronic system is programmed to do this, and the ER doesn’t ask. I agree this is just as bothersome as a website keeping my log in data. But we are in the information age.

So the SB1011 is an attempt to solve this issue. If a mother says, “I don’t want Johnnie in the data base,” then we keep Johnnie’s name and date of birth on a list so when another provider tries to enter Johnnies tetanus at the ER, the data base can immediately stop that entry. SB 1011 is trying to respect the wishes of people who want to “Opt Out”.

In the last 5 years there have been over 3 million immunizations entered into the Idaho immunization data base and 185 cases of people wishing to “Opt Out”.  But the proposed legislation is trying to bring us into the electronic age. Adults get flu shots, pneumonia shots, shingles immunizations. Do they want their information in the registry? Can we further protect the people who want to be excluded by retaining an identifier that protects them from their data being entered without their permission? This is what we want to accomplish with these bills.

Now we come to politics. Our state is engaged in a great debate. Many fear the intrusion of government in health care. And some are flexing their muscle in this debate. When this bill first came up I received 10-20 emails opposed. At the committee hearing many testified, including Wayne Hoffman,Wayne Hoffman leader of the Idaho Freedom Foundation, with ties to ALEC and the Koch Brothers. Now I have received nearly 100 emails opposed to these bills. But the testimonies and the emails oppose this legislation because:

SB1011, and SB1012, are both an intrusion into your personal privacy.

It has become clear that some of our children are being sacrificed.

Those who wish to research vaccines won’t have a hard time finding the unthinkable ingredients used and the mass amounts of both physical and mental problems they create.

(Quoted text from emails)

I wondered how this had gotten so confused, so obfuscated, so misdirected with misinformation. Then a constituent sent me the text of an email he had received:

URGENT: New legislation has been introduced in the state of Idaho that would register every man, woman, and child in the state-run Immunization Registry (IRIS) to monitor their vaccine status. This sort of information has been used around the nation by Child Protective Services (CPS) to remove children from their parents because CPS deemed vaccination avoidance to be a form of medical neglect.

 

SB 1011 would require that every child in Idaho be registered in IRIS, even if you have chosen to opt them out of some or all vaccines. This would enable your child to be red-flagged by the Idaho Department of Health and Welfare.

 

SB 1012 would require all Idahoans from cradle to grave to be registered in IRIS. Can you imagine the wasted tax dollars monitoring everyone’s flu vaccine status, sending out reminders, and bothering folks who have decided a different path than that suggested?

 

If you know anyone in the state of Idaho, please make sure to forward this to them! Please email the members of the Idaho Senate Health and Welfare Committee and ask them to oppose this legislation. A two-minute email stating why you are opposed and copied to all the committee will suffice.

 

Suggested talking points pick one or a few:

 

-This is an intrusion into your privacy.

-Your medical records belong to you and the physician of your choice.

-You do not want the state to have the power to access your medical records either through IRIS or a state health insurance exchange.

-It is an unnecessary gathering of your personal information that could be abused in future

-As more parents educate themselves about the risks of the current vaccine requirements for daycare and school in Idaho, it would be a good idea for law makers to ask their constituents why the increase in recommended vaccines are not in their children’s best interest.

-While public health officials reassure that public that vaccines cause no harm, there is a Federal tax-payer funded program that compensates those who have been injured by vaccines

-There is abundant science showing cause for concern

-You have educated yourself about the best path for your family and do not need or want intrusion into these private matters from the state.

 Frightening. These are great misrepresentations, in fact, these are lies. To what purpose?

There are many who do not want their children immunized. There are many who do not trust their governments. But I believe this campaign is using the fear these folks have to a different end. Who benefits from such tactics? I believe this is just a run up to the Otter-Hoffman lead ticket we will see in the coming weeks about the Health Insurance exchange. Fear-driven politics is being twisted to serve someone else’s purpose.

This week, the Department of Health and Welfare proposed a new bill that gave up on keeping data to protect the ones who want to opt out. So now, because of all the misinformation, those wishing to not be in the IRIS data base are going to be more likely to be accidentally included. Yes, it is complicated, and it takes some study to do these things right. Connecting to someone’s fear is much faster, much easier, and the internet helps.

So, you have just learned more than you wish to about immunizations and politics. I don’t know if this new bill will pass. And I don’t know if the state exchange bill will pass. But I believe the two are tied together. And misinformation about both is most of what we talk about. Please be patient. I believe the truth and freedom, and responsibility can win in this fracas, and our state will be served.

 

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