Where’s the leverage?

 

Idaho leaders are considering plans to carve up the health care market to save you money. You better be sure which side of the health and wealth teeter totter you fall on, because this could be great news for you or catastrophic. Blue Cross of Idaho is already on board. Should you be?

Do you know if you are going to be hit by a drunk driver? Will you have cancer next month? Or will your wife have a baby too early? I’m a doctor, I studied predisposing conditions, risks and genetics, and I can’t say I knew the answers to these questions. Sometimes I did, but it was usually long after any enrollment period.  Insurance companies are multibillion dollar financial betting organizations; they have experts to answer these questions. And they have a bottom line to meet. I figure they know a good deal when they see one. They don’t want expensive patients, and you don’t want expensive patients in your insurance plan.

The fundamental premise of insurance is to pool risk. Before the Affordable Care Act, if insurance companies saw your risk as too great, they could refuse you; no more. They got more customers with the (now repealed) mandate to buy insurance, but they gave up denying folks with preexisting conditions.

The ACA tried to get people to be good shoppers; you would assess your risk, and then chose on the exchange from comparable plans that would suit your needs. It’s been pretty popular here in Idaho, with record enrollments, year after year. Before the ACA, if you wanted to shop for individual plans, it was worse than shopping for jeans that made you look good, with no changing room.

True, the ACA mandated there should be a minimum level of benefits, and limited the range of benefits (Gold, Silver, Lead), but this was to make the marketplace press the insurance companies to cut health care costs. They have barely made a dent, even though Medicare and Medicaid has been effective at containing costs in the last 6 years. They have leverage. Private insurers have not been able to leverage health care providers, or consumers (YOU) to decrease consumption, improve efficiency, and thus lower costs. So now the white knights arrive.

Cameron and Otter suggest more choice; they claim more slices of the insurance pie will lower costs. Well, they will for you if you don’t get hit by a bus or get cancer and you have chosen the right plan that covers such events. If not, then what? Then somebody else pays.

No, these guys embrace the Wild West solution to the health care conundrum. You get to look at the cards in your hand and make a bet.  And if you go bust, the county takes your horse and saddle and your neighbors insurance rates go up.

We need leverage folks, and leverage is in numbers. Splitting us up, as Cameron and Otter propose just weakens our leverage.  It is no mystery that the leading employer in most Idaho counties is a health care institution. It is a huge industry, a huge sector of our economy. If we don’t like how it’s working, we can try to organize and get the leverage to solve the problem. That’s what our leaders should be doing.

 

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My First Bill

 

I learned about politics and civility my first year in the Idaho legislature. If one doesn’t pay attention it can seem brutal.

The state and the nation were facing the 2010 downturn, so budget cuts were proposed to Medicaid. It was a 60 page bill I needed to study; the new text was underlined and the deleted text crossed out, but I read it all, for they included each section of the law that was to be changed. I found language in an unchanged section that seemed to be giving a special exemption. When I asked about this I saw ears prick up.

As the downturn approached a couple years before, almost all the hospitals in the state had agreed to an “assessment”, that is, the hospitals agreed to pay back to the state of Idaho 10% of their Medicaid receipts and these would then be used to match federal dollars. Idaho gets from the feds $3 for every dollar it spends, so this was a way for hospitals to send off 10% and get more back. It’s a win-win unless you are looking at the US Treasury deficit. But the language in the bill seemed to carve out special hospitals from the assessment. Who were these special hospitals?

It turned out they were private, for profit hospitals, mostly doing specialty care. There were just five in the state that so qualified. When they bargained to be excluded from the assessment they claimed they got very few Medicaid dollars, thus should be excluded. I asked just how much money these 5 hospitals had gotten the year before from Medicaid. It turned out to be about $25M.

I asked around amongst my Senate colleagues if they would object to removing this exemption. My chairman said she’d have no objection. I asked the senators who had a hospital in their district. None warned me off. But I waited. Late in the session the chairman came up to me and asked if I wanted to make a change in that law. “You have done the research, why don’t you run this?” I agreed.

She called the hearing and I presented the bill to the Senate Health and Welfare Committee, where I was a member. The Department of Health and Welfare was there to support me, since I didn’t really know all the details of how this funding scheme worked. The committee voted unanimously to send the bill to the full Senate.

The day before I was to present the bill to the full Senate the chairman approached me and said there was a problem. “We have to bring this back to committee.”  Why? “It seems there are some people who want to testify on this.” I knew.

The hearing the next day had no representatives from the Department of Health and Welfare to support me. And there were three men in suits in the back of the room. I presented the bill again to the very same committee that had voted unanimously for it a few days before. One of the suits came up to testify. “We just don’t think this assessment should apply to us.”  When the bill came up again for a vote, my Democratic colleague moved that it be approved. There was no second. He leaned into me and said, “You can second it!”

I did not pause but whispered back, “Why would I want to do that?” It died for lack of a second.

I got in the elevator with a senior senator on my committee to return to floor debate. “That was a wise thing you did there, not seconding that motion.” Why? “Well, putting colleagues in the position to be on record can make for real enemies. You did the right thing.”

I don’t really know if I did. I didn’t pick a fight. I knew where the cards were in this hand, and I was going to lose. But sometimes, a fight is worth it. It wasn’t that day for me.

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Harass, Uncivil, Who Cares

My last session in the Idaho legislature leadership decided legislators needed training in “civility”. It was a required afternoon and I attended, though some skipped it. We all first met in the lunch room before being assigned to working groups. They asked if anyone could define for the group “integrity”. I had an immediate reflection, but said nothing. I went to my assigned “group three”.

As I entered the room where 30 legislators were to sit I looked around for a seat. Many were standing, chatting, laughing, but you see, I’m a Democrat. No one was smiling at me. So I sat down in a lonely chair. The room slowly settled and late legislators wandered in. One came up to me and asked if he could sit next to me and I smiled and nodded. It’s brave for a Republican to talk to a Democrat in the Idaho legislature.

The leaders discussed the hallmarks of civility, respect for colleagues, acknowledging their effort despite differences. They suggested one of the ways to enact such behavior would be to write a note or an email to a colleague about such. The man who had sat next to me leaned in winked and whispered, “I’ve gotten such a note.” It was my practice after each legislative session to write notes to at least 50 fellow legislators I had worked with, expressing my gratitude for their work, their integrity. He had gotten a note from me.

The session continued, talking about just what made civil discourse and what didn’t. I did not speak. I looked around the room. All legislative districts have three representatives, one Senator and two House members. I knew everybody in the room, and I could tell that my district was the only one with all three representatives in the room. I thought this odd.

At the very end of the discussion a legislator from my district raised her hand. “I don’t have problems with how I am treated here in the Capitol. I think everybody is respectful. But when I return to my district I don’t think my fellow legislators treat me with respect.”

“And just how does that manifest?”

“Well, they don’t include me in the events they have planned. They schedule a town hall and don’t invite me.”

The time was up and many had already risen from their seats. I felt stung, even back stabbed. I walked up to this legislator in the hall as she was talking to someone and waited for a chance to speak to her. “Is there something we need to talk about?”

She stared at me. I waited, and then said, “Would you like to visit? I heard you say you felt you weren’t being treated fairly.”

She still did not respond. After a long wait I said, “Why don’t you email me and we can talk.” She never emailed.

The next town hall I scheduled I made sure she was aware and invited. She did not respond to the invitation.

You can try to teach people. But if it’s in their nature to harass or be uncivil, I’m not sure an afternoon session will change much. And it seems the voters aren’t real discerning that such behavior is an important criteria for their support. No, this representative democracy is really just a reflection of us, the public, civil or uncivil, respectful or dis. If we don’t like our representatives, then look in the mirror.

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A Modest Proposal

It’s hard having discussions about difficult issues, but we need to. The state legislature should be a place for our elected representatives to have these difficult but necessary conversations. Getting the discussion going is an art. Advice can be helpful; I sought it when new to the office. After I first got elected to the legislature I called the person who had served in the seat before. He wouldn’t talk to me. And I have had no conversations with the person who defeated me in November 2016. So I send this advice out to Senator Foreman, knowing it is unsought and probably unwelcome.

Senator Foreman, I appreciate your strong stance on abortion. I believe a civil and honest discussion might help us all understand just how important this issue is to each other.  I understand from what I read in the press that your “solution” would be to make abortion once again a crime: murder. And since you won your seat with the majority vote in your district and you clearly voiced your position in your campaign, I can understand that you may believe the majority of your constituents support your proposal. So, let us all see what in fact you propose, for I have many questions about your intentions.

I came to understand the legislative process as one of building support among my colleagues. But the legislature allows for another process, if such support is thin. All legislators can have bills printed for all to read and consider through printing a “Personal Bill”. This must be done early in the session. So, Senator Foreman, if you have been unable to get the support of chairmen or leadership, print a personal bill. Let the public and your constituents know just what you have in mind, for I have questions.

You must know about this process. Indeed, I did this after waiting three years for Republicans to address the Gap population and Medicaid expansion. I thought we needed some discussion on this important issue. Maybe you’ll get a generous chairman to give you a public hearing, like I did. Understand this will not please leadership.  Maybe the hearing will be longer than 40 minutes and more than 10 people can testify. Maybe the conversation and consideration will be civil and thorough. I would hope so. For I have questions.

If abortion is to be a capital crime, will you propose any statute of limitations? Will women or practitioners who have made this painful choice ten years ago be subject to prosecution? Will the data on abortions collected by the Department of Health and Welfare, as required by law, be subject to review of prosecutors? Since abortions are carefully counted by the DHW, how will we know if there are actually less occurring, as most people want, since they will now be a crime? Who will care for the families of women incarcerated for this crime, since many who have abortions are already mothers? As you have pointed out, murder is illegal, but it still happens. And we do prosecute. I have heard you consider an exception to this crime to be allowed if the mother’s life is in jeopardy. Who makes this determination, a judge? A medical professional? There are many more questions.

Senator Foreman, you could help us all with this important discussion. Let us see your proposal.

 

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Health Care and Justice: No Slogans

I want to applaud Director Cameron and former Director Armstrong for their creative and courageous work to bring down health care costs for all Idahoans and bring more of our neighbors out from under the threat of medical bankruptcy. If more of us would pay attention to this critical problem that all of us face maybe we could get past the slogans and sound bites and do some work for the common good. It shouldn’t be about Democrats or Republicans, because we are all in this mess together.

The Medicaid expansion I fought for under the Affordable Care Act was not a final solution. No, it would have been a simple first step: get all Idahoans covered by some health insurance plan. No more Catastrophic Fund tax burdens, no more liens filed on weak assets and medical bankruptcy ensured. Unburden our low wage workers from this threat. But that didn’t happen. Maybe the voters will consider the initiative and it could move forward. But their path is steep.

If Idaho would have (or chooses to) expand Medicaid coverage, the next step for all insurers (Medicaid is an insurance) would have been exactly what Armstrong and Cameron have proposed. Managing the most expensive patients is the holy grail for lowering health care costs. Fifty percent of all health care costs can be attributed to 10 percent of the population. Can private insurance companies do this better, or a government program, such as the Directors have proposed? I believe the market could have answered this. Whether Medicaid or private insurers had better success, the voters could have decided where these patients are best served, on the exchange, or on Medicaid. I would hope in such a consideration the voting public would consider the justice of such a program, not just what it would mean to their own pocketbook.

Medicaid already cares for many disabled and expensive care patients. Private insurers see these folks as outliers in their actuarial calculations. Before the ACA, these patients would have been denied coverage. No, a couple dozen expensive medical conditions in a small insurance pool will drive up costs for all. I can imagine the insurance industry would gladly welcome the Armstrong/ Cameron proposal. Will Idaho taxpayers commit to support folks with these expensive conditions when the next economic downturn hits and revenues drop? Will budget writers cut schools, or expensive cancer patients?

Their proposal means we will sort sick people for insurance by their diagnosis and prognosis. Does this remind you of the slogan of a former Vice-Presidential candidate? I am trying to avoid slogans. I ask the careful reader to consider what it means to sort people in such a way. Does such a law, such a program fit your sense of justice? It doesn’t fit mine.

The inscription carved in marble above the US Supreme Court pillars reads: “Equal Justice Under Law”. I can think of no higher ideal.

All people deserve access to appropriate health care. We can afford it. We already spend twice as much per capita on health care as other developed counties. We just have to think more of the common good.

All comments read but not posted.

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Nobody Minding the Store

Democrats are getting their hair on fire about all of Trumps executive orders. Well, I’m an Idaho Democrat so I’m concerned with Idaho’s Acting Governor’s executive orders. My hair isn’t burning, but I can see why the public isn’t paying attention. No CNN coverage, no FOX News, and no real change from the same good old boy network that’s been ignoring our state governance for the last eleven years.

Lt. Governor Little issued an Executive Order recently in Governor Otter’s absence.  It was almost a sad joke. I can’t blame the audience for not laughing.  Executive Order 2017-6 committed state agencies to review professional licensing boards in Idaho. In my six years in the legislature I watched many professions come to the legislature asking for licensure. Understand that such a legal power actually gives a monopoly to those licensed. You aren’t allowed to cut hair for money unless you are a licensed cosmetologist. The list of professions licensed in Idaho is long; from acupuncturists to plumbers to morticians, the legislature has chosen to protect the public by requiring professional licensure. My criteria for such requests for licensure required two questions to be answered: #1. How is the public health and safety promoted by this monopoly you request? #2. Will you be able to administer your profession? Apparently Acting Governor Little has questions. I do too.

Does this legal monopoly status really protect you? Recently a dental hygienist in Payette, Idaho was convicted in Federal Court for getting paid while misrepresenting herself as a dentist. Notice, no state prosecution, and the state Board of Dentistry only “pressured her” to  give up her hygienist license a year ago. Nowhere in this indictment is the question of quality of care addressed, just whether the provider actually had the legal license to do what she was doing, and charge for it. It begs the question of whether professional licensure actually serves the public welfare or instead regulates the marketplace. What do we want from government regulation of a profession?

The legislature washes its hands of that question by turning the administration of the professions over to, guess who, the professions themselves. The only governance over all these 50+ state-granted professional monopolies is given to the executive branch: the governor. That elected official appoints the board members who then regulate themselves. Or are supposed to.  Only through that office can we the voters have a voice if a profession abuses its monopoly.

Our elected governor is supposed to appoint people to each professional board with the public welfare in mind. If the appointees are only interested in protecting their own piece of the pie, the governor should see that and act. He hasn’t been doing his job.  And that is the joke Brad Little offered to a disinterested electorate May 19th. “Hey, no one’s minding the store! I’ll ask some bureaucrats to make your change!”

Here’s an example: In 2005 the Idaho legislature enacted licensing of naturopathic physicians. Governor Otter appointed a five member board. The board met and issued 11 licenses, then never functioned again, to govern themselves, to repeal or issue more licenses, but in fact sued each other and been sued, proving its inability to self-govern. And the executive branch didn’t do squat. The legislature finally repealed the statute in 2015. How many other licensed professions out there are not functioning? The legislature can’t make the governor do his job. But the voters can.

Pocket Medical License Card

Full disclosure, I answer to one of these professional boards. I am a licensed physician. I pay my annual fee to the Board, and they decide if I should get a license. I pay attention to their actions and applaud their efforts. I wish we could do more to improve the performance of our profession.

It’s just an issue of who’s in charge. And the joke is: it’s us, the professional licensees and the voting public. We ought to wake up. It’s only fair to expect our elected executives to do their job.

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Idaho’s Unfair Religious Shield Laws

We just had a woman here in our county convicted of animal cruelty to her horses. They were found starving, dehydrated in a pen here in town. How people treat their animals is regulated in Idaho law. And all people are judged the same under that law.

Not all laws in Idaho are so even handed. For some reason we have decided how we treat our children requires special consideration for religion. If this woman had five children who were found starving and neglected, she could have gotten off if she’d claimed to be treating them with spiritual means. If she was Muslim and she claimed she was following Sharia law; if she was Christian and following the tenets of her religion, if she was Mormon and used prayer and anointed with oils, and any of these children were injured or died of an easily treatable disease, she would not be held to the same civil or criminal standard as a heathen who was just as cruel. But if her children were considered animals, she’d have no religious shield.

This isn’t an idle rant. There is good evidence children die in this state from such neglect. True, Idaho’s law allows a judge to order treatment, but this means someone needs to be aware of the suffering and then be willing to bring the case to a judge. Last summer we heard that three such times in the last six years the Department of Health and Welfare had intervened in such a way. Twice, the children were beyond treatment and taken home to die; one received court ordered treatment. There is evidence many more children did not come to this level of intervention.

The variety of state stances in this realm is broad. It seems we all want to respect the family, the culture, and the religious practices of our citizens. But there is no doubt the state has an obligation to protect children.

I am a doctor, but not a strong believer that medical treatments are always the correct choice. Medical treatments always benefit from spiritual support; likewise, spiritual practice should be open to other interventions. I grew up with Christian Science relatives. I treated some Christian Science patients. They were some of the best to serve, since they accepted such a strong sense of responsibility for their health. I respected their beliefs and I knew when they came to me for medical treatment they were conflicted. Honoring such conflict is our duty.

We do not honor this by carving out exceptions in the law. All citizens, regardless of faith or practice should be held to a similar standard. In fact, the Idaho Constitution prohibits such exceptions: “…nor shall any preference be given by law to any religious denomination or mode of worship.”

Idaho must change its laws. The change need not be intrusive or rigid; it should promote open and trusting relationships in the community. But children in Idaho deserve this. We all do.

 

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Let’s Fix our Roads

State Highway 5 between St. Maries and Plummer

photo KHQ local news

 

The Idaho legislature is tied in knots at the end of a do-nothing session. They got their budgets filled out with very small exceptions to the governor’s recommendations and want to head out of town. But the Idaho House, where all revenue bills must start wants to cut taxes. And the Idaho Senate wants to fix our roads, but they can’t write a revenue bill, so they propose borrowing money based on future federal gas tax payments (GARVEE). And in the mean time we citizens better all slow down, swerve around the potholes, fix our blow tires and replace our bent rims.

Idaho has known about the road funding deficit for years. Maybe Trump’s infrastructure promise will bail us out, but he’s also trumpeting tax cuts and a border wall. Why can’t we step up and solve our own problems? It’s courage folks, not asphalt we lack.

This winter exposed some real weakness, but it really didn’t happen with the rain and snow. It’s happened because we haven’t had the courage to confront our problems. How bad is it? You can’t get from Plummer to St. Maries along State Highway 5 now, it’s slumped and impassable. And that county elected a state senator that thought “Idaho roads are just fine”; he campaigned that the gas tax increase was “stealing money out of your pocket”. I 84 between Boise and Nampa was one lane this winter due to deep potholes, even closed for a few days. House representatives staged a little press conference to say “something needs to be done!” but their spokesman and 5 others in the gaggle voted against the gas tax increase in 2015. So what are your suggestions, elected leaders?

Our governor had the courage and insight to commission a poll a few years back to ask the voters what their solutions might be. Guess what? Voters wanted the roads fixed, but they didn’t want to pay for the job. I want my house fixed up too, but I understand I should pay for it. But then, I own my house. Do Idahoans think they are renting this state? Do they expect some landlord to step up and fix it?

In so many areas Idahoans say they want the Federal government to back off, leave us alone. So why would we trust the feds to bail out our crumbling roads? Idaho leaders are listening to you, their constituents, and that is their job. We the people need to tell our leaders we accept the responsibility of ownership. Shared ownership is still ownership. And we want to share in the costs to maintain what we own.

Good leaders are barely felt; it’s like we all want something and it gets done as if by our own will. But leaders can set the tone; they say things over and over, giving us ear worms, and sometimes we come to believe these phrases. We have elected local leaders who sing the song of less government, less taxes. We can’t fix roads without paying for it. I’m asking for a little help from our leaders. But we need to let them know we are ready to be responsible.

 

 

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Abortion: Can We Please Talk about it? Please?

I’ve seen this from so many sides. I’ve been yelled at as a politician, I’ve delivered babies as a doctor, and I’ve investigated deaths of infants as county coroner. But none of this makes my perspective more valid than yours. Most important, I have never had a life growing inside my body, dependent on me for its growth and existence. The emotional and personal aspect of this public policy matter makes the discussion difficult. If we cannot talk with each other about the stories we have, the values they reflect, and the goals we have for our society, how can this society of 300 million function as a representative democracy?

Since the Supreme Courts divided Roe v Wade decision in 1973, state legislatures, interest groups and political parties have lined up on one side or the other. Every country in the world has laws limiting the performance of the act of destroying a growing life within the body of a nurturing mother. The balance of when the mother or the growing life has authority is the crux of all these laws. My perspective is reflected in the stories I remember.

After four years of medical school that included embryology and anatomy, I went off to a three year residency training to become a family doctor. Most of the rotations are mandatory, but there is some room for electives. I remember being asked if I wanted to learn “terminations” as a procedural skill. I deferred; I wanted to deliver babies and work in a small town. I didn’t believe a small town could accept that dichotomy, and I wondered if I could.

The residency I chose was known for its excellent obstetric training. Residents worked with two perinatologists who handled most of the high risk obstetrics for a large area. We participated in the management of these complicated cases, learned the surgeries and medicines and saw the issues up close. We also worked with low risk cases and our own patients. It was excellent training for a family doctor planning to do obstetrics in a small town.

Marilyn was a young woman, acting even younger than her late teen years from a small town north and west of us. She was referred to us because her pregnancy was very complicated. She came from a narrow religious background but her family had cut attachment since her baby was conceived out of wedlock. She had a close friend, older than her and more assertive but of the same faith community who attended and advised her. Marilyn was a juvenile diabetic. That alone made her pregnancy high risk, but by 20 weeks gestation a severe brain fetal anomaly had been detected. It was not considered to be compatible with independent life. On top of this, as her gestation progressed she developed pre-eclampsia a condition that puts the mother’s life at risk.

She was a quiet gentle soul. I remember the friend more; she often spoke for Marilyn on our twice daily hospital rounds. I was never present when the option of “termination” was discussed, but I was told the community family physician and the consultants had all offered the option. “She wants the baby; though she knows it cannot live. And her friend wants the baby for her.”

We did our best to control her blood sugars as she stayed at bedrest in the hospital for weeks, but her blood pressure rose and her kidney function started to fail, so early delivery was recommended. After two days of a difficult induction of labor she came to complete cervical dilation and strong contractions but could not deliver vaginally.

The attending perinatologist I was working with that weekend had practiced in a South African hospital where thousands of babies were delivered monthly, many brought from distant villages in the backs of Toyota pickups in severe distress. There were more maternal mortalities at that hospital in a month than our state experienced in a year, and infant mortality had a similar proportion. I remember his downcast look as we prepared for surgery. “We are going to put her life at even greater risk with this surgery for a non-viable fetus.” Further, once the surgery was started, we had to use a classical incision in the uterus, putting any future pregnancies into greater risk.

She survived, though I know nothing of her life after she left the hospital. The baby did not breathe at birth.

Twice in my small town baby-delivering career I delivered infants with malformations incompatible with life. The first time it was a healthy mid-twenties woman who had hid her pregnancy until near term. She delivered the fetus spontaneously at 38 weeks with no complications, but it did not breathe at birth. The second time it was a mid-thirties mother of three. The malformation was detected by ultrasound at 30 weeks when fetal growth was lagging. She wished to terminate the pregnancy, not carry it to term. This choice would now be illegal by Idaho law, even though that law has been held unconstitutional. She also delivered a fetus that did not breathe at birth. If causing a woman to deliver a non-viable fetus before term is illegal in our state, what should be the legal status of not attempting resuscitation of such a fetus? Is this something we can talk about?

 

In my first few doctor years in town, I reluctantly accepted appointment to the public office of county coroner. I believed the investigation and determination of the cause and manner of death was an extension of serving the health of my community. But this dichotomy of serving life while attending deaths stretched my patients’ limits of acceptance and I got lots of teasing humor, and some sharp criticism.

The call came midmorning from the city police to respond to a death behind a college dormitory. It was a sunny fall day and only eight blocks so I rode my old Schwinn one-speed. On the way I imagined a student falling or a suicide since the college semester had begun and our community has seen such tragedies. But I was led to the back of the tall building near the industrial dumpster and shown the bloody body of a dead new born infant. A young woman was being questioned after a house keeper had noticed blood and checked the refuse.

She had hidden her pregnancy, no classmates knew, nor her family. The cause of death was asphyxia, but whether the baby died from the mother’s act of intentional suffocation or inattention or bungled attempts at resuscitation I do not know. I listed the manner of death on the death certificate as homicide, but the coroner is not the prosecutor, the judge nor the jury. She pled guilty to involuntary manslaughter and was not incarcerated.

Justice is a goal and I believe no fixed formula makes the effort pure or true. But admission of guilt and reparations for those wronged fits into the calculation. When a life is taken, what reparation can be given? Some have a ready answer. I do not.

There was another child killed by its parent in my time as coroner. Such is a rare occurrence; infant homicide happens 2-5 times a year in our state. But the incidences of abuse and neglect are probably 100 times that. Do numbers tell a story?

Elective abortions in Idaho have declined in both rate (number of abortions per 1000 women age 15-44) and total number for the last seven years. This may be a reflection of the national trend, which is also declining, or the reduction in abortion providers available. Approximately a third of the abortions are performed in surrounding states, but these are reported and counted nonetheless. Or the decline could be a reflection of the increased availability of birth control and education. Colorado carefully studied the rate of abortions when they made long acting birth control readily available and they saw abortion rates drop by almost half.

I tried debating against a 20 week abortion ban on the floor of the Idaho Senate by referring to these numbers. I pointed out how Idaho’s abortion rate is about a third of the national rate and declining. I believe Idaho is doing a good job with the goal that abortion be legal, safe and rare. The floor sponsor told a story of looking at his new baby grandson then argued that even one abortion was too many. The bill passed and is still on the books, though found unconstitutional in Federal Court. Stories persuade; policy discussions don’t. I am not sure how long we can rely on the courts to hold this stance if we are not prepared to tell our stories about this issue.

Simple answers are attractive. Many believe a strict prohibition, even criminal penalties against the woman carrying the embryo is a way to accomplish their goal. And what would that goal be: Justice? Prosperity; that all children lead healthy, productive lives? Or is the goal the elimination of all abortions? Prohibitions have been tried; they did not accomplish this goal. Murder is prohibited and prosecuted, but it is not eliminated. In my years in the Idaho Senate I saw many attempts at laws nibbling at the corners of prohibition on abortion. Idaho passed a “Fetal Pain” statute that would have banned all abortions after 18 weeks gestation. We debated a mandatory ultrasound bill, and passed laws to require women to be counseled according to written laws.

As a physician, I have never seen a woman be cavalier in this consideration. As a coroner, I always wondered about the thinking of a person that would kill a child. As a State Senator, I never thought I could fashion a law that would advance the humanity of a child murderer, but I was quite comfortable that statute defined the consequences for such an action. Neither did I believe I could craft a law that would make a mother choose the right path for her and her embryo or fetus. I was always amazed at the hubris of my colleagues, that they thought they could know best what a woman should choose for herself, her child, her body. The life of a fetus should be protected if it could live without the support of the mother’s nurturing body, but before that line is crossed, the law is a poor substitute for a nurturing mother’s judgement. Indeed, the laws we pass can be more like an abusive parent when they are wielded without compassion. Lawmakers should strive to make all life prosper; such a goal requires wisdom and balance, not absolutes and edicts.

We are going to need to talk about what our goals are for each other, for our state and our nation. Tell your stories. Listen to theirs. Then have the courage to advocate.

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Keep the Puppy

The ObamaCare replacement plan the House Republicans are offering gets me off the hook for paying the penalty for being uninsured, but it’s like they want to give me a puppy. There’s a bigger obligation behind this little cute furry thing. Policy makers need to be honest about the puppies they are handing out. And we the voting public should be honest about whether we want a dog.

I dropped my state funded health insurance as a State Senator last year to try to prod my fellow legislators onto action. It didn’t work; they are still sitting on their hands about health coverage for all here in Idaho. Even though I voluntarily joined the 80,000 uninsured here in Idaho to make a point, I was still subject to the Individual Mandate penalty. The House “Repeal and Replace” Trumpcare solution would get rid of that penalty retroactive. It seems they think a tax incentive is a better motivator than a penalty. It’s like they think the Obamacare penalty is a kitten and their Trumpcare puppy is way better than a kitten.

All this posturing, from both Democrats and Republicans about how to “fix” the healthcare problems in this country is skipping some fundamental questions.

  1. Do we as a country believe that all people should have access to health care?
  2. Is private insurance the way such healthcare should be funded?
  3. Does the answer to these first two questions have anything to do with the overall cost of healthcare?

The answer to the last question is YES.

So let’s look at #1.  As long as people do not accept the universal need (or requirement) to pay into the risk pool of health care, and instead want to roll the dice about their future health care needs, then the health care industry will shift the costs for the uninsured onto those who are enrolled. And the cost of insurance will climb like it has for years now. When costs are shifted, they cannot be controlled, no matter how transparent or vibrant the market.

I can appreciate the incentive to “go bare”. 95% of health care costs can be attributed to 50% of the people. It’s tempting to think you could just flip a coin and stay out of that expensive group. I served on the CAT Fund Board here in Idaho for 5 years and we paid millions to hospitals for those who wanted to choose heads. Bad things happen:  medical costs lead bankruptcy filings. This thinking is antithetical to the principle of shared risk when one enrolls in an insurance plan. Fundamentally, are we willing to join a group and share our risk?

If we as a country cannot agree that EVERYBODY should be in the insurance pool (note, I did not say “private” insurance), then we have little hope to control rising healthcare costs.

The answer to #2 starts another rabbit hole of “what if’s”. As long as we stick with the private insurance model, and the majority of the insured get their insurance through the workplace, the self-employed, the small businesses will get the short stick. Private insurance companies don’t want to deal with the individual or small group health insurance market. Their business model works best with large groups of patients. This was what the “Exchanges” tried to fix in the ACA. But such markets needed constant adjustments as the players responded to cost pressures. And we have not had a willing congress to make any adjustments for 6 years now. The kittens can’t play with the puppies.

I want people to have access to healthcare. I want healthcare coverage to be portable, adequate and affordable. The Trumpcare proposal will result in more uninsured, rising costs and less leverage to manage costs. I want my elected representatives to act like adults and consider the importance of this issue. Health care costs are robbing the middle class and fear of catastrophe is crippling our productivity. These clowns can keep the puppy. And I don’t want the kitten either. We need real solutions.

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