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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Connecting with Constituents

It seems our Idaho Congressional delegation was ducking some heat last week. I can’t blame them; who likes being called to task? But such is the duty of the public servant. At least I thought so; but it’s tough work. That’s why we call these elected officials “leaders”. Who you listen to and how you listen makes for a good leader. We the people should expect more from our public servants.

A few years back a group of soil conservation commissioners asked legislators in the North Idaho region to come to a lunch presentation to explain the work they did. I was familiar with their work; I’d met with my county conservation commissioners at least annually since being elected. They are elected officials too. I had studied their budget on JFAC and understood their governance and the problems some districts were having throughout the state. But I had encouraged Donna to set up this meeting since I had the impression many legislators didn’t know the work they did. She was the most active commissioner in that county. Her presentation was brief, the lunch modest and then the conversation started. Don, a North Idaho legislator was frank. He said he saw no appropriate role for government in this and did not support the idea of taxpayer money being wasted on these projects. Donna thanked him for his honest response and asked him if there were things he was working on to help Idaho in the coming legislative session. He responded that he would meet with his Republican Party central committee and get their thoughts before he started on any legislative work. I believe this is all the work some complacent legislators do; talking to like-minded party members. That’s not leadership.

It’s a lot of work to stay connected to 47,000 people, the population of the average legislative district. But public servants should do this work.

Some legislators write email newsletters, a decent attempt at one way communication. The Capitol legislative support staff facilitates this, but I always did this on my own dime. I’d send out an email newsletter weekly during the session to about 1500 recipients. I wanted more for the mailing list, but it’s amazing how many rural folks don’t do email. Some thanked me for the updates and the links to other articles. I saw some other legislators do this, but not many. And honestly, that’s only 3% of my constituents.

The Idaho State Senate gives each state senator a budget to go to meetings (about $1200/year) and to mail “End of Session” letters (also about $1500/year, so that means less than 3000 letters). I always sent these out  (though less than a third of senators do) and I went to as many meetings as I could. This funding is quite generous, I hope it is continued. It is not intended for campaigning. One Idaho Senator got in trouble when she sent her letter to Republicans in the new district she got redistricted into back in 2012 asking for their support. The line between constituent work and campaigning needs to be clear, though good constituent work should make campaigning easier.

I held town halls during the legislative session on a Saturday when I would return to the district. I’d hit both county seats and five or six of the towns in the counties. The attendance would range from 3-4 folks in Juliaetta and Kendrick to 40-50 in Moscow. I was always a little perplexed that most who attended were supporters. Rarely did folks show up to give me a hard time, though it did happen.  I welcomed it; I saw such as an opportunity to exchange ideas, listen, for them to persuade me, or for me to explain my positions. I didn’t think we should all be in agreement, but that seemed like what it often was. Too often we only spend time with those we agree with.

I served a split district. That means our legislative delegation (one senator, two representatives) had both Democrats and Republicans. Idaho has 35 legislative districts and after this last election there are now just three split districts (5, 26,29 ). In a district dominated by one party, outreach is probably not necessary to get reelected. One-party dominance fosters a disconnection between elected representatives and their constituents.  Why are we so segregated? Why does the map of red and blue show such bright differences between urban and rural?

Idaho has some problems to solve. Both sides need to be talking, but more, we should be listening and hearing each other. Don’t be afraid. Talk and listen to those you may disagree with. Who knows, maybe you’re a leader.

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Packer John and Idaho Politics

Rebuilt Packer John Cabin in Meadows, Idaho

I have been wondering about Idaho and how voters here are so inclined to vote by party. Maybe they are everywhere, but I’m here so I tend to think about Idaho. A recent trip to visit my daughter in Utah brought Idaho history into this contemplation.

Three quarters of the way back to the Palouse from Salt Lake City on a long late-winter drive I was feeling lucky coming down Goose Creek from McCall to Meadows Valley. I might make it home by dinner with the time change. When I hit a pot hole just past Packer John Cabin I winced, like I had the 50 times before on these winter-worn roads, but I thought I was still lucky. The thump-thump-thump I heard in Old Meadows told me I had a problem. I drove on the flat to the junction; no place to pull off with the snow banks.

Could it be a coincidence that Packer John Cabin was my downfall? It is a little visited Idaho State Park. In 1862 “Packer” John Welch was hauling goods from Lewiston to the Idaho City gold fields but deep snow brought him to a halt. He built the cabin to cache his goods, then came back in the spring to finish the trip.

In 1863, the Democrats tried to meet there to nominate a territorial representative to congress, but their communication was about as good then as it is now, and half the delegates got the wrong date, so they reconvened a couple weeks later to make the nomination.

The summer of 1864 the Republicans chose the midway location to meet. Their stock appreciated the lush grazing, there were fish in the creek and if the small cabin couldn’t hold them all, the big pines formed a fitting auditorium.

In those days, Idaho was populated with many refugees from the bloody Civil War. Democrats hated Lincoln and the Yankees who were attacking the southern “way of life”, though I doubt any of those early miners were slaveholders. Just look to the names of old mining towns: Dixie, Atlanta, Leesburg, and Sesesh (for secession). This faction also included most the southeast Idaho Mormon votes, since their way of life was threatened by a Federal government too. It was generally believed that Democrats outnumbered Republicans in those days. But Lincoln was a Republican and he appointed the territorial governors and judges.

Idaho, even before statehood had a political climate colored by national politics.

The recent changes in political power at the federal level must make Idaho republicans pretty comfortable. I sure wish they could agree on fixing some local problems, like the potholes and narrow shoulders that led to my shredded tire and $500 expense for repairs. We would all be better served if our representatives could keep their focus on the needs of our state.

Maybe the next state Democratic or Republican convention should meet at the small cabin by the creek. The delegates might notice the creek doesn’t have much fish, the grazing is all fenced and privately owned, and the big pines have long ago been logged. And they should watch out for the potholes.

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Legislative End Run

 

Idaho voters thought it wise to place the legislative authority for administrative rule-making review into the Idaho Constitution this last November (HJR5). Now we are seeing the arrogance and hubris of the legislature in action. The recent rejection of some of the Education Standards by the House Education committee is using this authority to bypass the legislative process.

This decision to reject some rules was based solely on the whim and preference of some committee members. The newly passed Article III Section 29 of the Idaho Constitution reads in part: The legislature may review any administrative rule to ensure it is consistent with the legislative intent of the statute that the rule was written to interpret, prescribe, implement or enforce.

Show me the statute or legislative intent that declares it is not appropriate to teach global warming in Idaho classrooms or have such expectations for standards. Please point out the law; I can’t find it. If the legislature wants to pass such a law, they are free to. They have passed laws to require the daily reading of scripture in the classroom (33-1604); a prohibition of consideration of global warming shouldn’t be so tough. But instead of writing a law, voting on it and getting it into statute, they have bypassed the policy making process the Constitution gives them and injected policy by rejecting an administrative rule. They broke the law and ignored the Idaho Constitution and violated the principle of the separation of powers. But who will hold them accountable to this? Would our executive, Governor Otter defend the principle of our government?  Will we the people? Will the voters who elected these legislators be offended by this violation? There are too many legislators in our Capitol with a conscience to let this transgression go by with a shrug.

The legislature has clearly violated the Idaho Constitution, both Article II Section 1 and the newly passed Article III Section 29. My complaint has nothing to do with how or whether I perceive the planet to be changing. I object to the arrogant disregard for the process, the rule of law.

Arrogance is a trait that needs constant vigilance to check. But arrogance is just offensive and rude, not illegal. This act was illegal. The legislature is empowered to make laws but we are all obligated to uphold the laws. If the legislature chooses not to follow sworn oaths and disregard the very laws they have written and instead act on whim, our tenuous faith in government is in jeopardy. What next?

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Idaho’s Uncounted Deficits

Idaho conservatives are proud that the state runs a balanced budget and doesn’t do deficit spending like “the Feds”. But I have long maintained we do sustain deficit spending in three areas, we just don’t put these figures on the balance sheet, so they are easy to ignore. Our infrastructure maintenance deficit for just our roads and bridges amounts to about $190M a year; further, deferred maintenance on state owned buildings adds another $500M, not annualized. I don’t consider it a conservative value to neglect what you own.

The second running deficit not on a balance sheet is the constitutionally required investment in public education. Governor Otter even acknowledged we weren’t sustaining this obligation a couple years back, and we are paying the costs of this deficit in our low wages. The symmetry of Idaho being 49th in the nation in education spending and 50th in average household wages is not just a coincidence.

But two articles in our local paper this week highlighted the third area where we run a deficit: governance. In two separate incidents, two employees of different small water or sewer districts have been charged with misuse of public funds. One seemed a pretty clear case of fingers in the cash drawer, but the other made me think of a slowly crumbling stone wall, falling down out of neglect.

The commissioners of these small districts are elected officials, thus responsible to their constituents. They should have procedures in place to maintain the integrity of entrusted funds. Such procedures require work and deserve reward. But I doubt the small towns have many citizens clamoring for this thankless responsibility. I know how hard it is to get people to run for school boards, but think what happens to institutions that aren’t supported: they crumble.

One of the employees charged with misuse had been the treasurer for 16 years, after all the other board members resigned. She collected payments in a jar by the register in the small town’s café. She employed her son to do maintenance work because she couldn’t physically do it at the age of 80.

I am hearing all the time from folks in our rural areas how things would be better if “the guvmint would just get out of our business”. This sentiment ignores the fact that we, the people are our government. And if you have an institution you rely on be it water from the tap, the waste you flush, the power in the socket, the roads or the schools, if you aren’t willing to contribute something, your valuable time or some of your wealth or income to that institution, it will crumble. But even more insidious is the growing belief that our elected officials are all corrupt or incompetent or self-serving. When or if this proves true, prosecution is in order. But if we citizens have failed to invest in our civic duty and we let the institutions we value degrade, there is some blame looking back at us in the mirror.

Finally, if you have a neighbor who does donate some of their time to city council or cemetery district service, thank them and maybe wonder what they deserve for such effort besides your generous gratitude. If you expect such service for free, you will probably get what you pay for, maybe worse. Public service deserves our respect, our vigilance and our gratitude. It is a debt we owe.

All comments are read but not posted.

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Throwing Ideas into the Abyss

 

Senator Risch recently restricted access to his office for security concerns

Small ideas take a lot of words; big ones need just a few. This was a small idea I stumbled upon, and the idea itself is not that important, but what happened, more so, what didn’t is the story. People here in Idaho are dying and Idaho’s US Senators aren’t doing much for us. That’s the real story here.

The Prescription Drug Abuse Prevention Workgroup was started 6 years ago to address the prescription opioid epidemic in our state. Idaho, like all states has a prescription monitoring program (PMP). At one of the workgroup meetings I was made aware of a gap in our state monitoring system. Federally sanctioned methadone treatment programs and Veterans clinics are not required to enter their controlled substance prescriptions into the Idaho PMP. That means if a veteran is on oxycodone for chronic pain and he comes into the ER wanting something for pain and doesn’t tell the ER doctor he’s taking the VA meds, the doctor can’t see the prescriptions in the system.  I know; this has happened to me as an ER doctor.

The reason for this exception lies in federal law. I asked the Director of the Board of Pharmacy about this and his eyes lit up. “Do you want to know about this? I have all the research.”  He shared with me the specific US code, some proposed changes from different US Senators over the years. It seems not just the uninsured are dying from lack of action. Congress isn’t dead yet; but the reaction I got to this small idea from Idaho’s Senators was moribund.

This should have had some traction since the prescription opioid epidemic was in the news so much and it is rampant in our state. I drafted a brief letter on my state senate letterhead describing the issue and asked for a conversation. I was sensitive to party affiliation issues and got a Republican state senator to introduce this idea to our US Senators and sent off the email. That was a year ago.

THREE MONTHS later I got an email reply thanking me and telling me there would be follow up. THREE MONTHS after that I got a call from an intern working with one of the senator’s offices. We had a polite conversation and the intern asked me a bunch of questions that could have been answered if he had read my initial email. Now we are six months later, I am no longer a state senator, and I doubt there will be any action. Was it a bad idea or that it came from an Idaho Democrat, or just that Washington DC is so crippled? I would have appreciated some response either way. Maybe a new administration will invigorate Congress.

I understand that things take time. I understand that many of the folks with different interests need to be involved, but there is no reason I can understand why Methadone Clinics or VA clinics should not be reporting their prescriptions to a state PMP. In fact, the Virginia Attorney General sent a letter to HHS last spring asking for the same change. Idaho did not sign on to that request, but 31 other states did.  Hello Congress: people are dying. Get to work.

All comments are read but not posted.

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Crisis Centers: What are we measuring?

Crisis Centers and Mental Health: What’s the Plan? : What are we counting?

Idaho has many problems in our mental health system. I have always argued that access to community behavioral health care would save money from prison budgets. There was a good study in 2008 that made some clear recommendations. Starting Crisis Centers* was not one of them.

Governor Otter proposed funding for three Community Crisis Centers in 2014 and I only supported one in the JFAC motion. I sure heard from his representatives that three was what we needed, but they couldn’t answer my questions, so I stuck to my guns, and here’s why. I was hesitant to jump all in for two reasons. First, I suspected if there was a substantial contract there might be a bid from an outside contractor to do the services. I felt strongly that local people should be managing this problem; that’s what’s been shown to work elsewhere.  We are trying to address a community need, so why shouldn’t the community have the responsibility? Second, no one could tell me how we would know if this project was working. There were no clear metrics involved in the proposal. What would we be measuring?

At the committee presentations to support this plan we were frequently shown this graph:

There was no doubt that requests for mental holds was climbing, but the actual commitments were not. This was interpreted at the time to reflect that mentally ill folks in communities were presenting in crisis and we had no good options short of commitment; makes some sense. So would that be the metric we would use to see if this program was working? The first crisis center was sited in Idaho Falls and has been working now for almost three years. But the number of requests for mental holds in Bonneville County (Idaho Falls) last year actually increased even with a Crisis Center. So if that’s the metric, we aren’t spending wisely.

Other states have tried crisis centers and there is some evidence they can save inpatient costs. But when the Crisis Centers were proposed we saw clearly that the number of actual commitments (not requests) had gone up only marginally. So we probably wouldn’t see a real change in that number if they were working.

A further point used to support the Crisis Centers was that many folks with mental illness or substance abuse problems were being incarcerated or jailed. No real numbers were available on jail populations, but we do know that about a third of the prison population is treated for mental illness. It makes good sense that mental health care should be available in the community and if it were adequate and appropriate, we may see less incarceration and folks in jail. Governor Otter sees this now and will ask the taxpayers of Idaho to make a small investment, but only for the recently released from prison. In medicine we call this “secondary prevention”, like treating a guy’s high cholesterol after his heart attack. I believe this is a wise investment. We can count the offenders that are released and return, so we’ll know the value of this effort. Too bad the legislature couldn’t have considered Medicaid eligibility for this population four years ago. I also believe there is a role for crisis centers. But if the evaluation, the data is not clear, how will we know our effectiveness?

We do measure some things in Idaho carefully. Statute passed in 1977 requires all abortions in Idaho or in surrounding states for Idaho citizens be carefully counted.  Consider this graph:

I don’t know if the act of measuring has directly had an effect to reduce abortions, since this actually reflects the national trend. But without the accurate metric, how would we know? Of course, there are those that think this number should be zero.  But that’s not management, that’s prohibition. It’s been tried.

In his State of the State speech Governor Otter said voters spoke loud and clear in the last election that they want “government that works”. So let’s do that in mental health services in Idaho. Why shouldn’t the state money going to a regional Crisis Center go along with a requirement that data be collected to reflect the impact of the investment? Each region could tailor their data to their perceived problem; jailed mental patients, inadequate community services, delayed hospitalizations, etc. This would mirror the block grant process the state is begging Medicaid to become. Idaho could lead, instead of kicking the can down the road.

If we are serious about “government that works” we need to be measuring our effort. If it’s important, count it. Otherwise, it’s just throwing money at a problem.

 

*A Crisis Center is defined in Idaho Statute. They are facilities where a person in crisis may stay for less than one day and receive “evaluation, stabilization and referral”. The statute also requires communities to provide data on the cost effectiveness of the programs. The statute further requires communities to provide support funding “as they are able”.  I am unaware of any such reporting or funding to this date.

Posted in Health Care, Policy | Leave a comment

The Idaho’s Weather in the Health Care Storm

 

It’s cold here on the Palouse, lots of snow on the ground and near zero temperatures. But hot politics continues with a new Congress and Chief Executive vowing to “replace and repeal” the ACA. Health care policy has always been one of my interests, so I am very thankful we are finally talking about the difficult decisions that lie ahead. I welcome it. I can’t wait to dig into the details. I’m not afraid of the devil there.

I first got elected to the Idaho legislature in 2010, the year the Affordable Care Act was enacted. It was deeply unpopular in this deeply Republican state. I was cautioned to not talk about healthcare with voters when door knocking, the subject was so toxic. It struck me as such political posturing for the entire Republican congress to vote against a plan that had so many features of a Senate bill introduced and cosponsored by many Republicans seven years earlier. Indeed, a template for the ACA was the conservative Heritage Foundation’s plan for state exchanges, though they roundly disavow the similarity now. That posture I believe has harmed our republic.

The ugliest fight in the Idaho Senate during my six years, worse than the Luna Laws in 2011, was the debate in 2013 about whether Idaho should have a state or a federal health insurance exchange. There were references to the Holocaust. We established a state exchange and we’ve seen record enrollments.  Idahoans, despite their hate of “Obamacare” like having affordable health insurance. Who wouldn’t?

But the “repeal and replace” flurry in D.C. threatens the affordability Idahoans have embraced. 85% of the Idaho exchange enrollees qualify for subsidies, funded by taxes on health insurance plans. This funding mechanism is at risk in the repeal proposals. Who would buy health insurance they cannot afford?

Health care in Idaho, despite our lack of physicians and rural and frontier demographics, is actually pretty cheap. One reason is we tax our citizens to pay for those who are uninsured through the county indigent and state catastrophic plans. This prevents a small shift of the cost of the uninsured onto the insured, but it is shifted directly onto the taxpayers. Further, we pay after the catastrophic care is given, like fixing a bridge after it collapses. I favor a maintenance plan.

Idaho had a High Risk Health insurance Pool for people denied health insurance for pre-existing conditions. It was established in 2000 (before the ACA) and has served over 10,000 enrollees. But enrollment plummeted with the ACA (can’t be denied for preexisting conditions) and now there are only a dozen or so folks still on the plan, but a $20M+ fund balance( in conservative Idaho). If the ACA is repealed as promised, I have heard that this will be a state solution that is revitalized. Here’s an analysis of why they won’t work.

Did the state marketplace (Your Health Idaho) work? Yes, it did. We have seen strong enrollment and strong insurance participation. The failure of this deeply Republican state to expand Medicaid eligibility has kept our uninsured rate high. And insurance premiums are still going up, especially for those in the individual marketplace of the exchanges. This is directly related to health care costs climbing faster than inflation, and the risks the insurers feel in these uncertain markets. Throw in the Trump card and I can understand the insurers trembling. Idaho will feel this.

Bottom line is Idaho is well positioned to do the right thing, thanks to DHW Director Dick Armstrong and the new Dept. of Insurance Director Dean Cameron. Both understand the landscape. Dick has seen the need for payment reform and he understands the value of primary care. Idaho has invested in a Patient Centered Medical Home, but it will take strong leadership to carry this across, and Dick has announced he is retiring in June. Best wishes. Too bad for the rest of us, there is a lot left to do.

 

 

 

 

Posted in Health Care, Idaho Politics | Leave a comment