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.

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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.

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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.

 

 

 

 

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Advice for Idaho

Advice for Idaho from an Idaho Democrat:

“What I stand for is what I stand on.”  Wendell Berry

If you love where you live, stay put. Get to know your neighbors, your countryside, the history and the institutions. Ask yourself what it is you love, and then find out what your neighbors love; surely you have a lot in common besides your zip code.

You may feel marginalized; indeed you may experience prejudice. There is good evidence that people feel more strongly now about party affiliation than they do about race. It seems now people are more nervous about a family member marrying into the other political affiliation than across a racial divide.

Now relax, don’t hide your face or use a different drinking fountain. Understand we are all in this together, no matter the insults and labels that come too easily to mind. For the community you love and our state to prosper, we all will need to participate. A good conversation is in order. Maybe you could start with what exactly your vision for prosperity means. Listen to your neighbor’s vision. These conversations require patience, respect and time. I hope you have all three, because nowadays it seems they might be in short supply. Show your neighbor you have some to spare.

Know you may be in a Facebook or CNN or NPR or Fox News bubble. The slant of those we listen to can make us think we are all knowing; disabuse yourself of that arrogance. Such humility can be hard when one feels marginalized, and it can be even harder when you feel affirmed. We all are on shaky ground.

Don’t let outrage be the slogan on your t-shirt, even if that’s what you see on your neighbor’s ball cap in the grocery aisle. Be yourself; a citizen with all our rights and responsibilities. And expect  your fellow citizens to be too. Let them know respectfully when they fall short, but never shirk your duty either.

Know your community. There may come a time when your love of community is deeply questioned and my original advice to stay put seems questionable. But remember that there’s something here you love, and your neighbors must also. It is not unreasonable to be in a place where there is conflict. Lend your voice and your effort to this conflict so that a vision for prosperity can emerge. We need a shared vision.

Don’t whine and don’t bitch. Get to work. Is there a cemetery district that needs a commissioner? Could you make your city council stronger? Is your church serving your community, or just the parishioners? Do you have faith in the institutions that make your community one you love, and if not, what can you offer to restore that faith? We need work.

Finally, I ask you to question party affiliation; not give it up, but make sure of the value. Does this branding we do serve us, and the communities we love? It can be such a tribal marker that bears no use for the vision we have for prosperity. If we weren’t looking through the colored lenses of the glasses we have put on, would the world, our neighbors, their vision for the future and ours look clearer? Don’t be afraid to take those tinting lenses off and see people, neighbors, and institutions in the clear light of day. We are all flawed. We all need work. Let’s get to it.

 

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Idaho Economic Development; The Back Story

Senator Keough is right, small towns and rural counties in Idaho need help. Dialing in the details of the Tax Reimbursement Incentive (TRI) to suit smaller marketplaces is an appropriate move. This graph of labor force in the North Central region of Idaho gives you a sense of what rural communities face.

 

 

There are seven regions in Idaho; subtract South West (Boise) and then you can multiply this effect by six.

But I want to tell you the history of this legislation, so maybe you can understand why Idaho government is not functioning “at the speed of business” as former Idaho Director of Commerce, Jeff Sayer used to say was his goal.

The TRI started as a brainchild of Roy Lacey (D Pocatello) and Donna Pence (D Gooding)when they were in the Idaho House. The idea was to give companies who come to Idaho and start a business that pays more than the average salary a tax incentive that they could collect later if their promised development pans out. He initially proposed it to promote value added jobs in agriculture in 2012 and 2013. It got good reception from The Department of Commerce, the Governor’s office and some committee members, but the House Majority Leader Mike Moyle and Wayne Hoffman came out against it as “picking winners and losers”. It got killed. Still, Roy worked all summer of 2013 with Sayer and rewrote the idea to include all businesses, based on a Utah model already in place.  But Donna and Roy knew the slant of the field he was playing on.

So Sayer took the bill, with the Democrats blessing, to Moyle for the 2014 session and he agreed to sponsor. And it passed! Wayne Hoffman still hates it. But this shows that the Idaho Capitol is not quite the “arena of ideas” Speaker Bedke wants it to be. It seems that whose idea it is, or maybe the party affiliation of the person with the idea has influence. Shame on us that our representatives are not there to do the peoples work, but instead find party affiliation as a prejudice to the common good. It may be no accident that both Donna and Roy retired from the legislature this last year.  I question whether the partisan nature of the legislature serves Idaho.

Is this reflected in small towns? I have heard many constituents in these close communities express reluctance to acknowledge minority party affiliation. I can’t blame them. I’ve lived in this culture. And I’ve also seen minority party members dismiss any idea coming from the other side. Such stances almost seem tribal. I hope we don’t start hacking each other’s arms off. It’s bad enough that we kill good ideas.

 

 

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Pay the Piper

excuses

The Idaho Department of Health and Welfare (IDHW) will propose a $11M expenditure to the legislature this session. The goal is to provide mental health and drug abuse services to recently released convicts who are back in the community. The idea is that such an investment ($1500/year) might keep some offenders from returning to prison ($30,000/year). About a third of Idaho offenders released to the community return to prison within three years.

This  seems like a good investment in our community. I have little faith the legislature will see it as such. And here’s why. This cost to the Idaho taxpayer would be nothing if the legislature had considered expanding Medicaid eligibility. And such a consideration is toxic for the legislature, even though most Idaho residents consider it reasonable.

The cost benefit analysis of Medicaid eligibility expansion under the Affordable Care Act was looked at carefully four years ago by a work group requested by Governor Otter.  The analysis showed that enrolling the uninsured would save Idaho taxpayers but did not include any savings for this group of recently incarcerated. They found such calculations too difficult. But with prompts from the Justice Reinvestment Oversight Committee and the Judicial Council, the IDHW looked at this as a source of savings to Idaho taxpayers and brings this recommendation. But they also brought PCAP last year (an expensive compromise) when the legislature had refused to consider eligibility expansion. Both are attempts to get the legislature to solve the problem of access to health care to prevent expensive costs. And I predict the new proposal will die the simple death (as PCAP did) that the legislature wishes would come to all the uninsured, if only such deaths were as cheap as our current ignorance. But the piper will demand payment.

The legislature (and the Freedom Foundation) will see the IDHW proposal as a back door for Medicaid Expansion, which should have been done four years ago and now is dead thanks to Trump and Ryan. Idaho citizens have lost $2B in support thanks to our legislature and lack of leadership on any level. So is the ACA dead? What would be their solution? We have engaged the piper; people expect health insurance. Can Trump and Ryan roll that back? Is that their plan? I haven’t caught the tweet.

I am thankful IDHW has made such a proposal. Should the legislature have the courage to burden Idaho taxpayers with such a program, now, at least we can count the dollars we are spending, so we can know how much we could have saved.

This is a tough issue. Providing appropriate care and paying for it are responsible choices we should all be willing to consider. I wish our leaders had the courage.

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Idaho Economic Outlook, from the backseat

As EORAC (The Economic Outlook and Revenue Assessment Joint legislative Committee) starts it’s meeting for this year, I am reminded of a comment by a fellow member a few years back. EORAC is tasked with recommending a revenue projection to JFAC so a budget can be set for the coming year. Idaho’s Constitution, like many states, mandates that government may spend no more each year than it takes in. Idaho tax revenue is of course mainly dependent on sales tax and income tax. Property taxes (also about a third of the Idaho tax burden) mainly go to local governments. Income and consumer activity is quite dependent on the economic climate, so the committee listens to many experts discuss their weather predictions for the coming year. When we heard from Idaho Department of Labor in 2014, House Speaker Scott Bedke seemed surprised by Idaho low wages. At that time Idaho had the highest percent of minimum wage earners (now we are 49th), and the lowest average wage in the country (still 50th). The Speaker asked that the numbers be repeated to the legislators for emphasis and suggested we consider our policy actions to address this. He’s right; our state leaders should understand this predicament.

But it’s not news. This has been a long time coming.

This paper provides a good analysis of each sector. Interestingly, when I have had this discussion with Republicans who will talk to me about this, they point to 1980’s as when environmental pressures hurt logging and mining. But those Idaho jobs actually pay above the national average and have for the last 30 years. Health care workers have driven this decline the most; their pay has lagged and the sector has grown.

So why hasn’t the market solved this for us? You’d think businesses would want to come to a place where the workers get paid less, then as demand for workers increases, the pay would also. Idaho has had some ups and downs, but overall the 30 year trend is swirling the drain. State Impact Idaho tried to get people’s attention about this issue 4 years ago. They did a great job, but it sure didn’t fire up any voter outrage.

The consequences we see of this trend are that bright young folks are leaving the state for better employment opportunities elsewhere and older, gray haired, fixed income folks are coming in to take advantage of the low pay. Such a demographic change will have a long influence on the economy, and the politics.

A further consequence, since we started talking about revenue, is that since people make less, the state collects less revenue to pay for schools and other services. If incomes rose, we could actually lower the tax rate and still get enough revenue to do the work the state should be doing.

So what should policy makers do? First, I would wonder if any see this as a problem. My sense was that Speaker Bedke did, but I sure didn’t hear others join him. When I can get Republicans to talk about this they usually deflect the low wages to a comparably low cost of living in Idaho. But they are wrong again. Idaho’s cost of living is about 30th nationally, while wages are 50th.

I have heard one lawmaker dismiss low wages as a problem. He also considered the goal of economic growth, especially for rural areas a mistake. “People like things the way they are; otherwise they wouldn’t be livin’ here. Why try to change things?”

As I sit in the distant back seat and watch EORAC hear testimony about Idaho’s economic forecast, I wonder who’s speaking up for the workers in Idaho? Do they have a seat on this bus?

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Legislators Prayer for the Press

May God give you the wisdom
To leave out my stumbling words
And just print the upright phrases
That may inspire.

Please God, guide the photographer
Away from my bald spot and
Instead let the camera capture
My pure and resolute heart.

God give me the grace to know
The slant of the liberal or
Right wing media but still
Keep my solid stance.

Even more God, let me not
Take pride in my name in a title
Or picture above the fold
Nor in a thousand “likes”.

God, help me know my speech
Is for this body, my colleagues
Not pandering to the few I know
Attending to the live feed.

16 May 2016

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Prayer for Parliamentary Procedure

The procedures of the body are governed by the rules of the body (approved by 2/3rds of the body), and when they are unclear, Mason’s Manual. But things go along and most legislators learn from their mistakes, or when something happens that seems out of place. I can remember hearing the Majority Leader ask for the Senate to go “at ease”  hundreds of times, but when I asked for such in my final senate year, I forgot to include in the request that unanimous consent be granted. After, he politely underlined a part of Rule 43: Senate at Ease. — (B) The Senate may be called “at ease” only with consent of the Senate. Rules, words matter.

Please God, forgive my ignorance
Of Senate Rules and Masons Manual
And know I will study and learn
As I should, oh Lord.

Dear God
Do not let my ignorance harm
The work I do for justice
Nor my constituents or
The state I serve.

Dear God
Let the overriding purpose
Be greater than the rules
We all should know and work with
But so often fall short.

Dear God
We know the rules are meant
To preserve my voice, not stifle
Honest meaningful discourse
And should be used as such.

Dear God
Simple rules serve simple goals
And ours here should be simple
Though You know and I know
Many times it is not so.

18 June 2016

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Prayer for Service

Dear God,
Do I assume all I represent live like me?
Please disabuse me my assumption.

Dear God,
Do I believe my beliefs are common?
Please relieve me of my hubris.

Dear God,
Do I carry my righteousness above others?
Then humble me with yours.

Dear God,
Do I know the suffering of my people?
If not, then afflict me.

Dear God,
Have I taken my position for advantage?
If so, please smite me.

Dear God,
Let me know if there is any good I can do.
For to serve the people I must know You.

22 March 2016

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