I have not been able to make this work here in WordPress, so I have moved my archive and new post to Substack.

Here is the link.

You may get an email from Substack about this too. Sorry for the redundancy.
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How, Just How?

I don’t know if we all agree that folks with disabilities or low income should have access to health care services. I’d love to have that discussion.

It seems that our nation thought this, and so the Medicaid program was passed into law in 1965. But those were different times. Don’t ask me what I was under the influence of back then.

Medicaid was built as a federal-state partnership. If a state chose to enroll and abide by the federal requirements, the federal government would agree to pay no less than half of the cost, but no more than 80% of the cost. The target population back then was folks with severe disabilities and those under the federal poverty level (FPL).

Idaho might have had a different soul back then, because our legislature signed us up to enroll in Medicaid in 1966. We were an early state to enroll. Maybe the Freedom Foundation wasn’t born then. I was just twelve. It was a long time ago.

So that matching/ shared payment program applied to the traditional Medicaid folks. That matching formula (called the FMAP) is calculated every year based on the average income of the state’s residents compared to the national average.

Idaho has had a generous FMAP match for many years, often 70% federal, 30% State, based on our lower incomes. Most states are 50/50. This year we get a bump. Our state income went up. This year we will now have to pay 2% more.

For those of you here in Idaho still burning about Medicaid Expansion, this is NOT a flag to wave. I know, this is complicated and confusing, and you probably don’t even care. But how, just how are we going to get this done? Please, pay attention and understand the details.

The Medicaid Expansion population will always be supported federally at 90%. The state will only have to pay 10% of that cost. This FMAP bump only applies to those below 100% FPL and the disabled. Believe me, those folks are expensive, but deserving of our care.

I write this to teach, but also to learn. I went to a forum tonight where my local legislators were talking to the crowd about their plans for the coming legislative session. I asked if they had any reaction to this FMAP change. NEITHER representative even knew what I was talking about. NEITHER knew how Medicaid is funded.

So, I wish to ask the crowd, should we be providing healthcare to the disabled and poor? If not, just say so, and a simple vote by you legislators who represent me could disenroll us from the Medicaid program. I can write the bill for you.

But if not, if you think people with disabilities and those who don’t get health insurance from their work should have access to health care, then how, just how are we going to do this?

I have read many other plans. The Idaho Freedom Foundation foisted one a few years back when they were opposing Medicaid Expansion. It proposed everybody have a health savings account. I guess they hadn’t read that 60% of us couldn’t finance a blown transmission let alone cancer.

Paul Ryan, remember him? He quit being Speaker of the House right after he got the Trump Tax Cuts through. Maybe he saw the folly. Maybe he saw a more stable job. But his argument was to replace the Medicaid formula with block grants.

I was just entering state politics at the time. I saw the value in his proposal. Look carefully at the formula. If Idaho figures out how to save a ton of money on Medicaid, we only get 30% of the savings. Block grants would build in more incentive.

But then I spent some time in the Idaho legislature. Sorry. I was not impressed.

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Just as people start things in all sorts of ways, so do they quit them.

Some people describe “falling into” a job or a profession. Others tell the story of seeking it, “knowing” from a young age that it was their calling.

I’ve seen some folks bounce around, swapping professional hats from one career to the next. I admire that fluidity.

Me, I’ve been a doctor, or in training to be one for over half my life. Not much of a bouncer am I.

I have dabbled widely, from fixing old cars to remodeling houses, but all the while, I have had a singular profession. I was a family doctor.

But I have decided to retire.

I have let go of many things in this career.

I used to practice intubations. That is when you stick a tube down someone’s airway, past the vocal cords, inflate the cuff, then pump air into their lungs when they aren’t breathing. Such a violent act can save a life. I thought I should keep that skill sharp when I was covering emergency rooms. That skill faded long ago.

Same with all the interventions to gain access to a dying patient’s blood stream. I thought I was pretty good at it, but like welding, you need to keep in practice.

I used to love providing obstetric care, delivering babies. I got training to do C-sections, since such an intervention was sometimes called for when you deliver babies.

But after many years of delivering babies, I began to notice a change in myself. During training, as a resident on the delivery ward, two or three women could be in labor at a time. I would check on then regularly, and catch a nap whenever I could, since back then, we did 24–36-hour shifts.

Out in practice, a woman might go into labor midday. I’d check on her, have dinner with the family, check on her again, then sleep a few hours, knowing I had a full clinic schedule the next day. Then I would go in at 2 or 4AM and do the delivery, sew up what needed to be sewed, write the orders, check on the baby, then go back home for a couple more hours of sleep.

As I aged, and I slowed down the number of deliveries I was doing, I found I could not sleep as she labored. I could not put my mind to ease that I had done and checked all that was needed. So, I would sit at the nurses’ station or go check on her more frequently. My inability to nod off was telling me something. My mind was not at peace with the process. Too many worries. I realized it was time to let go of this aspect of the profession I loved.

It has been a bittersweet process, this deciding to retire thing. I thought I had kept sharp, but I found I was looking up more of the medicines my patients had been prescribed. I was looking into the newly recommended medications and studying their chemistry. My natural skeptical nature made me wonder about the wisdom of this pharmaceutical investment. But I needed to know the wisdom of the treatment and make a wise recommendation. I worried I wasn’t as wise as I should be.

So, at the age of 69 I have decided to quit being a family doctor.

It truly was a passion for me. The fact that I earned a bit less than the local superintendent of schools seemed fitting. I saw too many of my colleagues make way too much money. And that should never be what inspires.

I valued the patients, their stories, their suffering, and their willingness to share their plight with me. They were very generous.

I tried to be too. Letting go can be a gift.

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Our new County Clerk has announced she is going to conduct an experiment in the next election. Our county uses machines to tabulate (count) the paper ballots. She has put out a call for volunteers to perform a hand count on all the ballots. She has calculated she needs 88 volunteers. That’s in addition to all the poll workers.

So, after the election is over, we will have two results: one done by the tabulation machines and the one done by hand.

She states the reason for such an experiment is to restore trust in elections. It will, she hopes, demonstrate that machine counted votes can be trusted.

I hope she is right. We need to trust our governance processes, and election trust is pretty basic.

So, let’s hypothesize.

Let’s say both results end up identical. What conclusion would you draw? Will your faith in elections be restored? Will you suddenly believe Joe Biden got more votes than Donald Trump?

What happens if the vote counts are different? Will your skepticism over fraudulent machines make you have more faith in the hand count? This would be contrary to all other evidence. Time and again machines have been shown to more accurately tabulate ballots than humans.

Maybe our new county clerk is trying to show elections can be trusted within her jurisdiction. She has never claimed our elections were corrupt. Election fraud must only happen elsewhere.

She did cite two examples of election fraud when prompted by the Idaho Republican Party in her campaign literature last year. Both examples were dismissed by judges when the Big Lie campaign disputed them.

So maybe we can’t trust the judiciary either. If our guy doesn’t win, then we should scream fraud.

As someone who has lost an election, I still believe in the voters. Lots of them didn’t vote for me. Lots did. In the only election I lost, I got more votes for me than I ever had in any previous election. But the other guy got more than I did. And he is now representing me. That’s the way our representative democracy works.

It’s not that my faith is blind. We had observers at the polls, and we had observers in the counting room. So did the other guy. It’s the law.

The fraud that I believe occurs is not at the courthouse when the votes are being counted. It happens at the polling booth when my neighbors don’t show up to vote. That negligence makes this process of representation weak.

Our founders sure didn’t think everybody should vote. Heck, the 1889 Idaho Constitution blocked Native Americans and Mormons from the polls.

Who gets to vote has long been used as a tool by the ruling class, or party, or race, or religion, or sex to maintain power. Long before voting machines were invented, those who understood power knew how to manipulate it.

Now days, those with the power to vote may not exercise it. City council elections, school board elections affect our local governance. If you want to fret about voter fraud, maybe you should have some faith in the hard-working folks who count those ballots or run them through the machines. And maybe you should enfranchise yourself with some information and go to the polls on election day. Or vote early. It might restore some of your faith. But don’t just believe the outcome if your guy wins.

I hope our county clerk has her faith in government restored. But her experiment will have little influence on me. My faith in governance would be bolstered by a record turnout November 7th. You, the voters are our insurance against fraud and corruption. This 234-year-old experiment of representative democracy is being tested.


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I’ll bet you have been riveted to the goings on of the interim Idaho legislative committee looking into whether adopting a managed care contract for Idaho Medicaid would solve all our problems.

What? You don’t know about this?

 It’s more important for you than who will be the next Republican sacrifice for Speaker of the House of Representatives.

Idaho Republican legislators seem to have decided the best way to rid themselves of the cost of health care for the poor, disabled and uninsured is to somehow involve private enterprise. This is even though the Idaho Freedom Foundation is cool to the proposal.

Shucks, we all know corporate business runs things so much better than any guvmint outfit, don’t we?

Well, I guess maybe not prisons. Idaho tried that for a while. We all know paying for incarceration is a drag on the economy. So, let’s just farm out the prisons and running them to corporations and we’ll sign a taxpayer funded contract. Win-win.

Well, it didn’t work out so well, if you choose to remember.

But healthcare should be easier, right? It’s just keeping all those people from wasting our money. Why can’t corporations figure out the way to stop that waste? Jeff Bezos gets us what we want real cheap with free delivery, doesn’t he? My next day delivery comes next week.

I don’t know if our legislators have looked hard at others who had this fantasy. It is telling.

I vote for people who are willing to acknowledge they might be wrong about something. Maybe you like the ones who are sure they are always right. But then, I’m an Idaho Democrat, and you’re probably not.

I think it was the second President Bush (the Iraq invasion, WMD guy) who instituted Medicare Advantage programs. Well, he had congress approve it. Back when the House had a Speaker…

Some of you folks my age might be enrolled in such. As it turns out, about 160K over 65 Idahoans are so enrolled. This number has grown four-fold in the last ten years. I’m sure you’ve seen ads somewhere.

Once you hit the magic 65, you can get health insurance through regular Medicare (guvmint plan), or you can choose from a Medicare Advantage plan. These are private insurance corporations who contract with Medicare to provide insurance for their enrollees, then they get paid from the guvmint based on complicated formulas and calculations.

The theory was, since private enterprise is so damn efficient, they would be able to provide health insurance at a lower cost, and still make a profit, thus saving the taxpayer money AND rewarding their investors. Win-win, high fives all around.

Shucks, I wish it was that easy.

It turns out, Medicare Advantage plans cost the taxpayer about $7 Billion more than if the enrollees had been in regular Medicare in the year 2019. Add up the years, add up the numbers and the growth in enrollment, and then look at your retirement portfolio. Maybe you have invested in some healthcare stocks. Maybe you like the way this is spinning.

Medicare Advantage plans make a profit for their investors by finding the cheapest providers. That’s what managed care does. Enroll the cheapest, most cost-efficient programs in your panel, and only allow your enrollees to use your panel.

Small town hospitals and providers won’t make the grade. You guys provide care locally. Local doesn’t always make the balance sheet look good.

Idaho, beyond Boise, can be pretty rural. Does such a model serve us?

Idaho legislators need to be focused on making Idaho communities healthy. Their worry about the Medicaid budget is wise, but too narrow.

Good schools, good jobs, good housing makes people healthy.

But shucks, I’m an Idaho Democrat.

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I’ll admit that I am not fully aware of the Idaho Code sections when I talk with patients. I believe I have a good sense of right and wrong, but legalese confuses me. And I was a State Senator for a few years, voting on this stuff. I should know better.

I did know that I had a legal obligation to convey my concern for child or elder abuse. That was drummed into me in my training. It did put me in some awkward spots at times, but I believe I toed the line. I did make some folks mad when I called CPS about the bruises on their three-year-old that didn’t fit with the story they told. I lost their business. Don’t forget, the profession of medicine is based on principles, ethics, but fundamentally, it’s a business.

When I was first taught about this obligation I bridled. What right does the law have to oblige me to contact them? This is between me and the patient. But then you start thinking about the duty our society has to protect the vulnerable, “preserve the common good, domestic tranquility, blah blah…” While some may see this duty as just, some may see such as an infringement on their freedom.

Me, I was just a doctor, seeing patients, trying to make a living.

My hubris might have been less had I worked in the trades. Building codes are there for reasons. Understanding these reasons is worth our time.

I’m reflecting on this because tomorrow I plan to attend a seminar presented by an eminent Idaho law firm about the current state of law in Idaho around abortion.

Even the legislators who have voted for these laws admit they are a mess. Maybe they will try to sort out the problems. Maybe not. Maybe they just want to “make a statement” like our House Freedom Caucus, that ousted Speaker McCarthy.

To me, the act of governing should be considered a serious business. Maybe it’s just theater. If so, keep scrolling your feed.

Me, I was just trying to take care of the patient in the room.

So, let’s get down to the nuts and bolts. Do you want abortion to be considered a capital offense, as my State Senator has stated? Murder has no statute of limitations. Our Attorney General and county prosecutors would be very busy with this obligation.

But the lawyer arguing for Idaho’s muddled laws said “no prosecutor is stupid enough” to enforce such laws. So, these laws are just theater?

But no, the courts have weighed in again. Idaho doctors who treat women whose life is threatened by their pregnancy will not be shielded from prosecution.

Can’t you see the mess? Maybe more legislators, and I, should have done some trade work.

So, I will attend this seminar. Not because I care for pregnant patients or have ever done abortions, though, according to current Idaho law, I might have.

The Idaho legislature has bombasted itself to a current legal position of outlawing abortion, and paying an attorney with your taxpayer dollars to say, “Don’t worry, nobody would be stupid enough to enforce these…” But they haven’t done the work to actually define the issue.

Do you want to decrease abortions? We have the tools to accomplish this. We count abortions. Even out-of-state abortions performed on Idaho residents are counted. This counting has been done for years. And it showed a steady decline, for years.

If you really want to decrease abortions, we could do what Colorado did. Providing free, long-term reversible contraception to young women cut their abortion rates dramatically.

Maybe that’s not really the goal. Maybe this is just theater.

Why don’t we just burn somebody at the stake?

I’ll bet she’s female.

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If you do electrical stuff, you know continuity means you have a connection from one end of the wire to the other. I want to talk about continuity in healthcare. It’s related.

I’m sure you’ve all experienced it. You call for an appointment with your provider about a health problem you’ve put off for too long. The next available appointment with your usual is months off, so you take what they offer. You are now getting to share your intimacies with someone new.

A lot of caring for people is about trust. Trust develops, or it doesn’t, over time.

That first interaction with someone is often about getting to know and trust that person.

I always thought I gave better care to the patients I knew. I have spent a lot of time working in ER’s and urgent care, where continuity cannot be expected. I still thought I gave pretty good care in acute situations. But some things need a broader perspective.

Some people don’t need that kind of sustained continuity. Healthy people without chronic problems don’t need “annual physicals”. If your insurance company or doctor offers you this as some sort of perk, beware. Such a practice has never been shown to improve population health.

I had some patients insist on it, along with regular blood tests. I tried to discourage them, citing the evidence for the wastefulness, and the little value I might add to their general health. After a few of my admonitions, they probably sought care with a doctor who sold such.

There are some occasional screenings that the general population should receive, especially as we get older, but an annual physical for a healthy forty-year-old just pads somebody’s pocket.

But people with chronic health problems should have consistent care, and that consistent care should come from a regular provider they know and trust.

The clinic where I work now has a pharmacy attached and refills get reviewed. I got sent a refill request for a patient with diabetes. I didn’t know them. They hadn’t seen a provider in our clinic for a couple years. A doc had left suddenly and there were some balls dropped, but I only authorized a month’s worth of this person’s meds and insisted they come in for an appointment. They finally came in to be seen after three months of one-month refills, then finally I said two weeks at a time.

They were pretty mad with me. “You just want my money! Just give me the meds!”

“Do you check your blood sugars?” I asked.

“That’s none of your business! I got a buddy I fish with, and he tells me how to handle my diabetes.”

“Then he should be prescribing these medicines for you. Because right now, I am responsible for these prescriptions. And I will not be if we don’t have a relationship.” And we didn’t after that, not prescribing, nor trusting, nor therapeutic. I hope they get the care they need. But I need some limits.

Providers can promote continuity or inhibit it. Patients have acute needs, unscheduled. If providers don’t keep openings in their schedules for such “walk in” needs, then they get pushed off to the new guy with openings, or the urgent care or the ER. The biggest time investment for me in the ER was understanding the patients’ medical history, since that was usually unavailable.

Back to the wire. The current can flow, one end to the other. That’s continuity. Health care should provide care from one end to the other, cradle to grave. That’s why I wanted to be a Family Physician. I wanted that kind of continuity.

Last week I saw a young mother in the clinic, whose mother I had cared for and whom I had delivered. She was well. It felt good.

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From New York Times

I have watched the Idaho Freedom Foundation and their mouthpieces rant against Medicaid for years now. Rants can be fun, but honestly, there’s hard work to do. I invite your shoulder to our shared grindstone. I believe managing health care costs is one of our generational tasks. Griping, ranting, finger pointing may fire up the crowd, but what we need are solutions.

First, we should make sure we know just what it is we are talking about. In case you haven’t noticed, rants can often focus on generalizations. We need some specifics.

Idaho Medicaid provides health insurance to low-income people and special needs, high cost, disabled folks. Does the fact that these folks are different than those who get insurance through their workplace make them more expensive?

So, let’s get grimy. Here come the filthy, greasy numbers.

Idaho numbers can and are parsed into easily compared numbers. The Per Member Per Month (PMPM) Idaho Medicaid cost for “basic plan”, meaning the low-income folks without special needs for FY2023 comes to $341.14. If you add in the total PMPM costs for the higher needs population (adults, $3103.54, children $1370.73) it comes to $2045.66. There’s a small group of very high needs folks in a “Coordinated Plan”, and they cost $2724.66 PMPM.  The Medicaid expansion population is cheap at only $625.10 PMPM.

Per Member Per Month Idaho Medicaid Costs by Plan:

Basic Adult    Basic Child   Enhanced Adult Enhanced Child  Coordinated  Expansion

$647.67          $281.74.         $3103.54.           $1370.73.           $2724.31.       $625.10

Add all these together and the PMPM for the total Idaho Medicaid population comes to $780.16.

What does the general working population pay for its health care costs, combined employer and insured expenses? In Idaho, for 2022 that came to $607.66.

Very few private insurers cover the severely disabled population. So then let’s compare the “Basic Medicaid” to private insurance costs.

PMPM Basic Idaho Medicaid Adults and Children               PMPM Private Insurance

                                                            $341.14                                             $607.66

Then let us consider administrative costs. Private insurers, since the Affordable HealthCare Act, are required to pay out 85% of their revenues for medical expenses. In other words, their administrative overhead (CEO compensation, care management costs, advertising, etc.) can only be 15% of their revenue.

How much does Idaho Medicaid suck off the top? Five Percent is estimated for FY 2024. In the past it’s been below 3%.

The goal of the Idaho Freedom Foundation is to decrease Medicaid enrollment. They must be really happy that the Department has kicked 150,000 folks off Medicaid in the past 12 months. During the pandemic the federal government prohibited any disenrollment, but the rolls have been cleaned up now. The vast majority of the folks lopped off couldn’t be contacted. We’ll hear about them when the get hauled into the ER by ambulance.

I guess it comes down to the fundamental question of whether you believe people should have health insurance or not. Maybe you think only people with “good” jobs should have insurance. Maybe you think only people who are “good citizens” should have insurance. Maybe you think insurance itself is evil, a “moral hazard” that promotes excessive use. If your goal is to control health care costs, all of these preconceptions have implications in the solution you will propose.

There is some amazing, good news I’ll bet you haven’t heard. The growth rate in Medicare (NOT Medicaid…they are different animals) spending has flattened since 2010. Nobody can really explain why. But the consequence is that in the last 13 years, since we didn’t keep up that killer growth rate, we have saved our future generations almost $4 TRILLION dollars.

We need to have honest, open conversations about health care costs. Maybe the big kerfuffle about Obamacare was the magic that flattened that curve. Let’s do that for Medicaid in Idaho.

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Coroner Story—-Thanksgiving

This call came on a Thanksgiving holiday weekend. It might have been Friday or Saturday, probably a Friday, I think. My sister and her husband were visiting. So, it was a long time ago. She died as I turned 40, and I’m old now.

They were sleeping on the living room floor, our “guest room” since we hadn’t added on to the house yet. Our little girls were so little then. Katy, the oldest, just in third grade and Mattie not in kindergarten yet.

We’d had our dinner of turkey leftovers and were cleaning up when I got the call from the ER doctor. He was covering for this holiday weekend. I knew him well from medical school. But when you get that call from the ER it could be for an admission, since I’m covering for my group, or for me as the coroner, since I wore that hat too.

This was a coroner call. He did quite a few shifts in our small-town ER, so I had discussed coroner cases with him before. He was usually quite composed and matter of fact, but this time was different. His voice was quite soft, and he sounded a bit shaken. He was describing a five-year-old girl who had come to the ER in full cardiac arrest. They had tried to resuscitate but were unsuccessful. They’d coded her for twenty minutes but never got pulses with CPR.

She’d been brought in from the University football stadium where there had been a high school playoff game. The story from the parents was that she had been playing on some heavy welded 2” steel pipe barriers up in the concourse at halftime. They were used to block off areas, but they had bars at just the right height for kids to climb on. The barriers had square steel feet for stability.  But when a kid stands on the lower bar and leans back, clutching the top bar to pull themselves up, the heavy steel barrier can fall over.

It seemed there were a lot of kids cavorting on the concourse at half time, little brothers, and sisters of the football boys in the locker room. Dad told me this story when I went into the ER. He said he had been talking with some other parents and had seen her fall. The heavy steel pipe had fallen across her abdomen as she climbed and tried to get up higher than the other kids. He said she was like that, always wanting to outshine the others, a real go getter. He’d rushed over to pick her up.

I’m in the ER now, his wife is quiet and petting the hair of the dead girl, white sheet up to her neck, face ghostly pale. I could clearly imagine the trauma of the resuscitation this little peaceful body had endured.

He has told me all this with just a few questions from me. He is calm and trying to be collected, but he, like his wife, cries too.

He describes the look of shock on his daughter’s face as she lay on the concrete concourse with the heavy bar on her tummy. He rushed over and picked up the bar. I would have been embarrassed by the loud clang, the crash. Maybe he was too. Kids can get so wound up. But he reaches down to pick her up and sees the worry in her eyes, the fear, the visceral pain. There is a question suspended between their eyes, from the child to the parent, “Am I alright?”.

He probably says the same with his eyes to her, “Are you alright?”

He picks her up from the cold concrete floor and puts her to his shoulder, comforting, maybe now speaking, “Are you okay?” He feels her head, no bump, no blood, but she cries a little, but then she quiets, and he is relieved.

I have introduced myself to these traumatized parents in this bright ER bay with pulled curtains and the white sheet over their ghostly dead little girl. The father has told me the story. I ask him to go on.

He carried her back down to where they had been sitting so they could take in the second half of big brother’s football playoff game. She had almost fallen asleep on his shoulder. After a few minutes she got very agitated. She was confused. He got alarmed at how she appeared, so he took her up, again on his shoulder, comforting, cradling, to the concourse where a first aid station was staffed with EMT volunteers. They looked her over, radioed the ambulance that was on standby for these games, and shepherded the father down to the ambulance. He handed his daughter over to them, the doors swung closed, and she died as the ambulance left the stadium.

I look at this grieving couple and their beautiful dead child. My own daughters, now asleep in their beds, could, but for so many small circumstances, be this pale corpse. And here, in my empathetic sadness, in my own grief for this stricken family, I make a mistake. It is a mistake I have remembered. It was a mistake I have learned from. It was a mistake I have vowed never to repeat.

I spoke to the father and mother softly, trying to convey empathy. Indeed, that’s what I felt, their suffering. But in trying to be kind, empathetic, I softly asked for their permission.

And that was cruel.

You need to understand that it is not polite or kind to relinquish your authority when it is in fact yours, not theirs. For I knew what must be done, and I was the person to decide, not them. I somehow twisted into my mind that asking for their permission was a kindness. That was my mistake.

I knew this death must be investigated. I knew there must be an autopsy.

But I asked, out of foolish misguided kindness, for their permission. It was not theirs to give. It is my decision to make, not theirs. That was the horrible unkindness on my part, to place them in that position.

As I was softly speaking this begging their permission, I knew it was wrong. When the mother refused, her face folding into terror of the final examination, I knew just how cruel I had been.

“No, you’re not going to cut up my little girl!”

I had to look at the floor for a while to collect myself. She was now sobbing and agitated at my suggestion.

“I apologize. It was rude for me to ask your permission. That was a mistake and I apologize. I am the coroner, and it is my duty to investigate deaths in this county. I will be ordering an autopsy to investigate your daughter’s death.”

Giving the sham of authority to someone who does not rightfully have it is not a kindness. It is cruel. I was cruel that night, trying to be kind.

My little girls were in bed when I got home. I didn’t tell much of this to my wife, my sister, or her husband. I was shaken.

Maybe that’s when I started being the “petty tyrant” in our home my wife accused me of. When I knew what my children were doing was wrong, maybe dangerous, I would bark my orders. She told me this over and over. I should be kind, use a softer tone of voice.

Maybe years later, I imagined the father, up on the concrete concourse asking his daughter not to climb on the barriers. “Please don’t, hon.” Being kind.

And maybe I became a parental martinet, barking. “Get down!”  I don’t really know how this affected me. But it did.

The autopsy showed the steel bar had landed on her abdomen and crushed her liver against her spine. The soft organ was cut in half, crushed between the heavy steel bar, her spinal column, and the hard concrete floor beneath. Her abdominal cavity held most of her blood volume. She had bled to death.

Cause of Death: Exsanguination from liver laceration

Manner of Death: Accident

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I have migrated late in my medical career to working part-time in a Federally Qualified Health Center. (FQHC…sorry but the anagrams may start piling up.)

These centers grew out of a 2001 plan from President George Bush II. He wanted to improve access to primary care in underserved communities. Back in 2000, 14% of our country’s population was uninsured. There was back then, and is now, plenty of evidence that access to primary care improves community health.

 I guess back then even Republicans were comfortable solving our national healthcare problems with federal programs.  So, he threw money at it in the form of a pilot program. It was buried in a budget bill. But unlike the Covid money, these bucks didn’t just buy new RV’s for clinic administrators. These centers saw a 60% growth in patient visits for the five years after the investment.

But more community clinics didn’t solve the national problem. The number of uninsured continued to grow. By 2010 we were up to 16% uninsured.

Then along came the ACA (Obamacare). Rather than saying “NO” to anything Republican, the value was seen. The Community primary care clinics got morphed into FQHCs.

Here’s my FQHC elevator description. I’ve learned to do this because people’s eyes glaze over midsentence when talking about health care funding and delivery. Yours probably did in the first paragraph.

FQHCs must have a community governance board. They must provide a range of health services including primary medical care, dental, behavioral health, substance abuse services, among others. They must provide a sliding fee scale and agree to see all patients regardless of their ability to pay.

In return, the clinic receives enhanced reimbursement for Medicare and Medicaid services.

“Who cares?” you may ask.

Idaho does. Because this model has been advanced into behavioral health care and Idaho is embracing it. Welcome the Certified Community Behavioral Health Clinic. (CCHBC).

CCHBCs are required to provide an array of services. But the CCHBC model requires community governance and agreement to provide service regardless of the patient’s ability to pay, just like the FQHC.

The Idaho Department of Health and Welfare (IDHW) Behavioral Health (BH) Division has announced a couple big moves in the past few months. First, there is a move to establish multiple CCHBCs throughout the state. Full disclosure, the clinic where I work has committed to this.

One of the services required of a CCHBC is 24/7 availability for crisis care. IDHW can thus diminish their staff obligation for crisis teams.

Make no mistake, somebody is going to pay. It’s just who, when and how. And that brings me to the next big announcement from IDHW. A managed care contract has been awarded for both inpatient and outpatient BH. It’s the biggest contract ever awarded in Idaho, $1.2 Billion, with a “B”.

The two companies who weren’t awarded the contract are both suing, so maybe there’s some uncertainty.

It is of note that the company that has had the Idaho BH managed care contract for the last ten years, Optum, bid on the contract and did not win. This is despite their claim they saved the state $400M in Medicaid costs.

I hope the interim legislative committee looking at managed care for Idaho Medicaid is paying attention to this. Behavioral health is small potatoes compared to all of Medicaid. I’ll bet there’s a lot of lawyers who would love to see that contracting lawsuit walk through their office door.

I hope the acronyms haven’t swamped you. It’s an interesting swamp to me. I’m just trying to keep my boots on for now.

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