Election of Heroes

Image courtesy J. Howard Miller

The top of the ticket seems to drive our political conversations, indeed, our political manners, when it really shouldn’t. Politics really is, despite what Facebook or Fox News tries to sell us, local. And the local folks we elect are heroes.

Those elections are coming up soon enough. Maybe you have already voted. Good for you. Those who represents us in our city, our county, our school, or highway district deserves our attention come election time. We are asking them to do the difficult work of representing us, let us honor their task with an informed vote. And then, we should be paying attention to the work they are doing. They deserve our attention.

I am very happy with the number of folks who have turned up asking for my vote locally. That’s a good sign this representative government experiment might work. I looked through some of the other city and school board races in this North Idaho neck of the woods, and we shouldn’t be griping about a lack of choices.

I am just happy folks are willing to do this work, given the animosity addressed their way these days. I thought County Coroner was a pretty thankless position, but school board members are getting threatened, screamed at, called names. But that’s what the top of the ticket “leaders” we elect emulate, so it’s acceptable behavior for some, I guess. I can’t imagine those parents would tolerate such behavior around the dinner table.

Don’t think this running for office thing is easy. There’s a lot of forms to fill out about the money you raise, who gives it to you and how you spend it. The legislature decided this was important public information back in 2015, so anybody running for school board in a district with more than 500 students must file such reports. Let me know if you find any dirty politics.

But even if the legislature has made it a little harder for folks to run for school board, after you get elected, our leaders in Boise haven’t made serving any easier either. The funds sent out from their overfull coffers are meager, so school boards across the state have to decide whether to run supplemental levies.

Most district do go, hat in hand, and ask their neighbors to pony up so the teachers can be paid, and the heat stays on. The legislature is proud they have pushed this job downstream. They like to keep politics local.

And our governor and legislature don’t want to make any Covid decisions easier for the locals either. No direction about masks or shots from Boise, you guys decide. Those wily legislators and Boise Bureaucrats know who can take getting yelled at. I guess local yelling is better in their mind.

City councilors might have it easier that school board members. They get all the glory of raising sewer rates or passing a bond when the treatment plant fails. But God forbid they try to institute any restrictive measures about this pandemic. Those mad-as-a-hornet Freedom anti-maskers know where they live.

For representative government to work well, it’s best if the representative is approachable, knowable. If you live in a town of 1000 and you have 4 city council members, that’s a 250:1 ratio. Odds are, you would know one of those councilpersons. Same with school boards, it’s a similar ratio. You could, at any time you chose, make a phone call, and get an answer to your question. Or you could instead go to their home about dinner time with a tiki torch and burn them in effigy. Each of us has different methods of dealing with our elected representatives.

These representatives we elect are heroes, folks. Sure, they don’t always make decisions we agree with, but neither do our spouses. But please, don’t burn any effigies of the old man on your front porch.

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Professional Discipline

Photo via Jupiter Images

The Idaho Medical Association has asked the Idaho Board of Medicine to look into sanctioning Dr. Ryan Cole. He is a dermatopathologist who was recently appointed to the Ada County Public Health Board by Ada County Commissioners. The IMA’s gripe against Dr. Cole is based in their reading of the statutes that prescribe lawful patient care. But the gripe is also based on the public claims Dr. Cole has made, that he has treated patients “from California to Florida” with the questionable Covid drug, Ivermetin. So, their point: if he’s being honest, he has violated the lawful standards for Idaho physicians. It’s up to you, The Idaho Board of Medicine to investigate and determine if he has in fact broken the law, or he’s just a braggart.

I wish the IMA good luck. I also wish the best to Dr. Cole, though I disagree with his self-proclaimed actions. How can you treat such a wide expanse of patients and have a relationship with them? And just how does a pathologist, with no training in patient care have that skill? Is it any different than selling drugs online? Oh yeah, that’s mostly legal too.

But that equivocation I voiced right there is what makes policing myself and my colleagues in the medical profession so difficult for the Idaho Board of Medicine. We rarely confront each other when we see a fellow colleague straying from the “Community Standard” of medicine.

Maybe that’s because we physicians don’t spend much time establishing or reviewing that peer standard anymore. I’m pretty long in the tooth and I can’t say I have ever seen that practice in the community. It should be.

We did it in medical school and residency. We presented our “cases” (sick people) to each other with an older doc in attendance and we critiqued our diagnoses, our care decisions. I had thought this was how the medical culture would be once I got out into the community practicing. But it just didn’t happen. I wish it would.

I have some real community experience with this. I was the Chief of Staff for our local hospital. Any doctor who practiced in the hospital came under the review of the medical staff. But now a days, with the proliferation of “hospitalists”, employed by the hospitals, many doctors never see their patients in the hospital. And the possibility of reviewing their level of care is lost.

But the clinic, the office practice of medicine has never been subject to much scrutiny. The main driver of sanctions has been malpractice suits, civil litigations usually brought by patients unhappy with their treatment. You can see the pressure on physicians to make the patient happy. And then opioids became widespread and “nonaddictive” and doctors made many demanding patients happy; and some dead.

So, the Idaho Board of Medicine is in a difficult position here. They can investigate Dr. Cole, but I’ll bet those “thousands” of patients he has written Ivermectin prescriptions for are pretty happy with his “care”. At least those that are alive will swear by the treatment. Those who succumbed may think the mask-wearing nurses and doctors in the crowded hospitals didn’t give them enough hydroxychloroquine. Can you see the bind our profession has created for ourselves? And for you?

I doubt Dr. Cole has clinical partners who he presents his “cases” to. Remember, he’s a pathologist who is in the business of running lab tests, vials of blood, serum, or urine. There are few colleagues to review one’s care in that setting.

Idaho’s medical practice “Community Standard” is a sham. The medical profession loves it because it makes doctors harder to sue. Idaho’s medical malpractice premiums are very low. To prove negligence the plaintiff must get some other local doc to testify against the defendant.  So, like some Idahoans prefer, we are the medical wild west.

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Lines Crossed

There have been recent calls from Idaho Republicans asking Idaho Democrats to cross over and register Republican for the May primary to “save Idaho Republicans”. It seems Idaho Republicans are afraid of being run over by Idaho Freedom Foundation Republicans.

I’m not sure what to call these two groups, since they haven’t picked names for themselves. But they do call each other names. The slur I hear most commonly addressed to mainstream Idaho Republicans from the Freedom Foundation faction is “Rhinos”. And the backatcha from the mainstream Republicans toward the IFF R’s might be “wacko” Republicans.

Usually there are no quotations marks around wacko: I just put those there for the sake of politeness. As an Idaho Democrat commenting publicly on the Idaho Republican landscape, I feel like I’m walking on thin ice. But polite behavior in politics rarely wins any votes these days. Like I said, I’m an Idaho Democrat.

Both former Supreme Court Justice Jim Jones and former BSU President Bob Kustra have publicly made the pleas to the dozen or so Idaho Democrats remaining in the state. It was quite an honor to be recognized as living humans, since most learned individuals have accepted that Idaho Democrats are an extinct species. Like Sockeye Salmon, Chinook and Steelhead, some species just have to fade away, dwindle to nothing for our state to progress as the majority see progress in this very odd state.

I am so glad this is now a subject we can openly discuss. Like our nephew’s sexuality or our own gambling addiction, it’s best to get all these perplexing positions out in the open. Code words just confuse. Honesty and openness are always the best policy.

But let’s just start with what we call ourselves. If you want the dozen or two Idaho Democrats to help you out, could you fellow Idahoans asking for our votes please identify yourselves?

In the old days, political parties organized and took a name. The Bull Moose faction was a split from Republicans to support Teddy Roosevelt. They made bull moose signs and campaign pins.

Southern Dixiecrats were racist Democrats opposing civil rights. They were Democrats only because Lincoln was a Republican. They didn’t ditch racism to make Democrats look better.

At least we had a name for who we supported, who we opposed.

It’s time for Idaho Republicans to choose a name for themselves.  The wackos and the Rhinos must be different since they hate each other so much.  Quit hiding under the big tent. I’m not sure I want in if I can’t tell who is in there and you are fighting so bitterly. What is the difference between you since you all voted for Trump?

Let me know your name! I’ll consider it. But honestly, when I register with your “normal = rhino” group (Pro Trump with a wink) , I’ll be signing up with the “wacko” group (Pro Trump with a roar) too. Or should I just ignore that? Jeez, you guys are confusing.

It would be strategic for the 10 or 11 other Idaho Democrats out there to act in unison and throw our weight all in one direction in an organized fashion. Wouldn’t that be the best way to have some influence in this unbalanced state?

But the 5 or 6 Bernie Idaho Democrats hate the 6 or 7 Biden Idaho Democrats. Believe me, I know. I get their emails.

It truly is an honor that the Idaho “Not Crazy” (I think that’s a great label by the way) Republicans want my vote. I might love to support your needs with my vote. But can we negotiate? Since you need my vote so desperately, can we talk about some other issues? Like all-day kindergarten, or funding public schools?

Oh, I’m sorry. Was that impolite? I thought we were negotiating.

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Sheep

Idaho Sheep

I remember how I felt the wool growing on my back when they first taught me to scrub in medical school. I knew in my heart they were making me into a sheep. Why has it taken me so long to admit it?

They first had us change clothes in the dressing room. We had to put on “scrub suits” that the hospital provided. The blue cotton made us all look the same. What a sheepy way to start the indoctrination.

Next, they had us put on masks. We had to do this BEFORE we washed our hands because theoretically, the hands would be clean after we washed them, and the masking process required that we use our hands. I can remember forgetting to put on the mask FIRST a time or two, then halfway through the hand scrubbing process I remembered. Had to go get the mask, tie it on over the cap or hood over the hair, then return to the hand washing, but had to start the whole process over. I was just like a sheep going through the pens. I had to go one direction, first gate first, no freedom.

The hand washing was expected to take a certain amount of time. The water over the sinks could be turned on with a bump of the knee and it ran on a timer. I was expected to scrub each finger, backs, fronts, forearms for the time the water ran. When it shut off you could proceed to the next step. Just like sheep in the sheep dip.

My freedom loving nature rebelled a bit against this oppression. I had learned about bacteria, viruses, the transmission of contagion in my undergraduate classes in microbiology.

Indeed, I’d heard the heart-breaking story of Ignaz Semmelweis advocating for handwashing in the early 1800’s. He was a young doctor who watched women who had babies in hospitals die of “child bed fever”. At the time he didn’t know, nobody knew about bacteria. But it struck him as odd that women who delivered in the midwife ward had much lower fatality rates than those delivered in a hospital. At the time, it was expected medical procedure for the physician to perform an autopsy on the patient who died the day before. Midwives didn’t do autopsies on their dead patients. If he(the physicians were all men back then) had to run from the necropsy room to the delivery room, no hand washing was required. If the woman delivered that day died of the same fever as the cadaver had the day before, the connection was lost on 19th century doctors. Antisepsis had not been invented.

Semmelweis instituted the practice of hand washing in one ward and reduced the incidence of “child bed fever” deaths by 90%. He had no explanation for why such a practice worked, only evidence that it did.

But his recommendation that doctors wash their hands was not met with approval. Doctors back then knew, Ignaz just wanted us to be sheep. Their reaction to his affront was strong. Can you imagine a doctor being accused of spreading a disease? Semmelweis was shamed and demeaned. Eventually he was committed to an asylum and beaten, dying from the infected wounds.

It took another thirty years for other doctors to advance the “Germ Theory”. Remember, it’s just a theory.

Doctors have a long and proud history of defending our freedom to do what we think is best. And when someone presents evidence that flies in the face of our practices, we assail the messenger.

It’s looking like this pandemic might hang around for another thirty years. Maybe by then we won’t feel like sheep, and we’ll know the right thing to do. In the meantime, my colleagues will do their best to care for the unimmunized as they clog our wards and ICUs.

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DNR ≠ Do Not Care

When Idaho extended “crisis standards of care” to all of our hospitals in this state, there quickly arose the social media meme that all patients in hospitals were being declared “Do Not Resuscitate” =DNR. I guess that got some folks attention. It sure didn’t push for a big wave of folks asking for Covid vaccinations. But we have outrage to spare nowadays.

While some of that meme is a bit true, most of it isn’t. The “Crisis Standards” mean that the institution can use its resources how it believes would best serve the community. So, if a patient with metastatic cancer had not signed a DNR suddenly stopped breathing, the hospital was not obligated to intubate and ventilate this terminal patient, whereas, without the standards in place it had such an obligation.

Why do we do such wasteful, violent, and destructive things in healthcare? Chest compressions break ribs. But they can save a life; I have done so. When a fifty-year-old man walks into my ER from his bowling night, sweaty and clutching his chest, then collapses as we are hooking him up to oxygen and putting the monitor leads on his chubby chest, we start chest compressions. And when he gripes to me a week later about how his chest still hurts from the broken ribs, I apologize and smile.

Why would a patient with a terminal illness want such treatment? I have come to understand it is because we medical professionals are so lousy at communicating. We often just talk amongst ourselves and don’t fully listen to our patients.

When the question of resuscitation is presented, it can be a brief, almost perfunctory conversation. It can be left to the admitting clerk who talks to the elderly patient or a family member when she is brought from the nursing home to the ER at midnight. “Do you want us to do everything?” Who wouldn’t want that for their loved one?

But an 89-year-old with pneumonia, Covid or bacterial, will most likely die with that tube down their throat and the machine pushing air into their drowned lungs, should it come to that. The question that should have been asked, one that takes time and sensitivity and care could or should have been, “How do you want us to care for you?”

Because that is what we should be asking from our medical industrial complex: care. It seems like we go to the hospital or the doctor in this adversarial culture with the chip on our shoulder, I gotta get what’s owed me. Instead, we should be expecting care.

Maybe we just aren’t caring about ourselves or each other much these days.

For to care about a person in their final, special days is to honor the values they have built their lives around. Many have led dignified, independent lives and to be connected to machines, unable to hold their daughter’s hand or whisper their love to their family is the ultimate indignity. We, my fellow healthcare colleagues need to see this and honor this. Signing a paper form about DNR is not a way to honor a life, or to honor their death. We need to be present and open to the values of those we care for.

But patients, citizens need to see this too. If the choice one makes in life is to be uncaring, unthoughtful, inconsiderate to one’s neighbors, what kind of death should we be expecting? It could be brutal and lonely, not unlike the life we have lived.

This “crisis standards” that Idaho hospitals now have should be an opportunity for us to look in the mirror. Those of us on the “caring” side need to resolve to do better as we listen to the values and lives of those in our care. The folks who come to us for care need to understand that their values are not always clear. Work to make them so.

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Faith

Idaho DOT

So often when faith is mentioned, people jump back, thinking I’m talking religion. I’m not. We need faith to lead our lives. And I am worried about the faith of my fellow citizens right now.

We need to have faith in each other.

I don’t mean the kind we practice and indeed demonstrate at those “team building” seminars when you cross your arms and fall backwards, and we catch you. If we didn’t, you’d be bumped a bit and embarrassed, and we’d be proven to be the jerks you secretly thought we might be.

But imagine driving the Salmon River on Highway 95 heading south to a meeting in Boise. The road is maybe 30 feet wide. Your little pickup takes up a third of that space. You’re a bit above the limit at 70 MPH and that log truck coming in the other lane might be a bit over too. Faith allows you to keep your speed, trusting the Peterbilt will stay over there, and you won’t drift into a fatal collision. You’ll make the meeting in Boise. That’s daily faith.

Swipe the card at the gas station. Faith in the honesty of the card company, the transfer of funds, the security of your assets lets that transaction not require you to go in and hand a twenty to the guy behind the counter selling corn dogs.

Buying a corn dog at the gas station requires your faith that the food is not tainted, and you’ll only have indigestion, not food poisoning down the road.

A worker starts their job with faith that the paycheck will come.

A mother brings a baby into this world with faith that she can invest in this new life.

We live with faith daily. Without faith, all society crumbles.

You may have faith in your God, you may have faith on Sunday, but do you have faith in your fellow human, your neighbor, anyone beyond yourself? I believe you do. Stand up for that faith. Show it, honor it, believe in it.

It has just become fashionable to deny it. Don’t fall for the fashion, the fad.

The unruly crowd who stormed our National Capitol last January 6th probably all used their credit cards to buy gas or airplane tickets to get there. They had such faith, though they so wanted to deny a faith in our government.

The folks who buy “F**K BIDEN” flags online trust the website selling them to honor their card number and protect their security. They have faith in those selling the wares, so they can wave the flag proudly declaring their lack of faith in our representative government.

For that is the fashion these days, to decry the value, the institution of representative democracy.

Don’t think I’m immune to such distrust. I have had my faith shaken deeply. I grew up not believing in a Southeast Asian war my friends were drafted into. I watched as my president committed crimes and resigned from office. No, faith in government doesn’t come easy for me.

Moreover, I’m an Idaho Democrat and I’ve served in the Idaho Statehouse. Can you imagine a lonelier, more isolated role in government?

But I still believe in the institutions our founders crafted for our governance.

Yes, some of those institutions are flawed.  But we, the people of this Republic have the tools and the courage to demonstrate our faith in each other and change them. If something our government is doing is wrong, we can change it. It will take time and effort, not just a tweet or a brief Facebook comment. Change has happened in this Republic.

Hopelessness is what we feel when our faith fails. Let that feeling of hopelessness wash over you and drop to the ground like a fall rain. Then get to work. I would appreciate your effort.

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Victims

Not my Dad, from Forbes…

It was back in my elementary school days when I could have political and philosophical discussions with my father. It was the golden years, before Viet Nam, and his Greatest Generation, WWII credibility still glowed for me. It didn’t matter that he had no visible skills or initiative, other than playing poker and dreaming, I still held him in regard, probably like most children do who aren’t abused.

He would talk about how our society wasted it’s time and effort prosecuting “victimless crimes”. To his way of thinking, prostitution, narcotic use, and his vice, gambling shouldn’t be illegal. “Society has no place victimizing, prosecuting, fining or jailing people who are just hurting themselves.” You can imagine a third grader pondering such wisdom.

But I did. Then, I found myself in medical school. The chronic alcoholics and drug abusers filled the ER bays and hospital beds. They took up my time, my energy. My fatigue, both physical and emotional made me start to feel victimized. Maybe that helped me learn to keep an emotional distance from others’ woes. It sure reminded me of my now estranged father’s wisdom.

When I came to Moscow, Idaho we would take turns being the “on call” doctor for unattended (non-paying) ER admissions. I remember watching one young man dying from his chronic alcohol use. His third admission in two months was particularly rough. He came to the ER skinny, covered in his own feces, unconscious, near death.

By the luck of the draw, I had been his doctor for the previous two admits and got him this time too. When he could talk, I asked him if he wanted to die. He would not answer me.

From all evidence he was doing just that, killing himself.

I had settled in Idaho, a state with my father’s political slant. If people are actively suicidal, they can be declared by the court to be a danger to themselves or others and committed to state custody. I asked the social worker if this man met those criteria. She shook her head. “Idaho statute prohibits commitment for alcohol abuse.”

Thus, to some extent, Idaho law protects the freedoms of people so inclined. I smiled as the quiet social worker explained this distinction to me. People with a mental disease who wish themselves harm and are going to act on it can have their freedoms taken away, but if they wish to drink themselves to death, the state keeps hands off. I think my dad would have appreciated this legal sentiment, though he might have taken it a bit further. “Why commit anyone to protect them from themselves?” I can imagine him saying.

So, when people refuse to be immunized or wear masks, I have an understanding of their choice. The fact that their choice affects others around them is not unlike the young man’s alcoholism. His family was distant, estranged. He lived on the street. If the ambulance hadn’t picked him up and brought him to the hospital, he wouldn’t be causing me problems.

The full hospitals now, the overflowing ICUs, the tired nurses and doctors have my sympathy. I can understand their frustration with the work they have to do.

But similarly, I can understand the refusers perspective too. I have chosen to be immunized. I think it will protect my health and those close to me. Other choices are valid but have their consequences. I do not feel safe from infection because of my immunization, and evidence suggests I am right. But the evidence is still coming in. We could fight about it all day.

Maybe that’s why Dad liked poker. He had to use the evidence he had and make his decision and the flop told you who won. This pandemic hasn’t come to the flop yet, though for many of its victims, it has.

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Respect

This was the one with the long hair…

I had two senior pictures taken for my high school yearbook. I got the first done after a summer of beach time and football practice. My hair was long. It was 1971. My parents saw the proof and insisted on a retake. I believe they saw the long hair as a sign of disrespect.

But those were the times. Baby boom kids challenging the Greatest Generation. Respect was expected, and when not given, it was an affront. I found their discomfort with rebellion more evidence that they couldn’t handle “the times that are a changin”.

But I am older now and respect has come to mean more to me than an opportunity to offend.

I can’t remember when this changed. I’m not sure if it was the hard work, the stupid bosses, the danger, and the steep hillsides of fighting fires. I still rode my motorcycle then: no cause, not much of a rebel.

Medical training might have changed me. There were all the things I needed to learn, then the disease and death I was expected to understand and do what I could.

I came to respect disease. Just look at viruses.

There are viruses (Chicken Pox, Herpes) that can infect you as a youth, then hide in your body for decades, then reemerge to cause more disease when you have become old. Same virus, same body; it just waited a long time. For some, there is never a reemergence; such a mystery.

Other viruses have wiped out whole civilizations. It is suspected Smallpox did that in the early 1500’s in North and South America, after Europeans landed, introducing it to the New World. And then, through technology, study and massive effort, the virus has been eradicated from our world, only to exist in whatever bioterrorism facilities might keep a strain. There hasn’t been a reported case on Earth for 40 years. Such an accomplishment is worthy of respect.

I have seen a patient die in a matter of hours from a Hantavirus infection. It’s rare, but deadly. The sudden death of a previously healthy, middle-aged person made me think and wonder about many things. I did not become fearful, but I respected the disease.

Now we are wondering how to manage this novel Corona Virus that has sickened so many and is changing its form as we watch the numbers climb. Idaho has seen cases increase 5-fold in three weeks. We are on the steep slope of a rising curve.

Is this new wave because we haven’t respected this disease? After all, it’s in the category of common cold viruses. Who wears a mask or gets a shot for a common cold? And there’s plenty of conversation out there about how minor this disease is. We’re dissing something that is killing some of us. Is that being respectful?

If we haven’t given Covid respect, it could be just a reflection of our unwillingness to respect anything. We have elected officials who don’t respect the institutions they were elected to take a seat in. We have elected leaders who make mockery and disrespect their standard discourse. We have social media platforms that give the microphone to incivility and amplify rude behavior. We have church leaders who decide who is worthy of respect and who isn’t, unlike the Savior they claim to worship.

So, I don’t know when that changed for me, my willingness to be respectful. I sure didn’t think I owed it to my folks as a teenager. It was Mark Twain that said, “When I was fourteen, my father was the stupidest man in the world. When I talked to him when I was 21, I was amazed at how much wisdom he had gained in seven years.”

Let us give all dignity and respect.

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The Other Epidemic

From the New York Times

As the number of Idaho Covid deaths slowly climbs past 2200, the other epidemic still rages. Masks won’t help, but social distancing might, if you stay away from the right people. It is estimated that about 280 people in Idaho died from drug overdoses in 2020.

While we rage about mask mandates, our mainly young (but also some older) folks are dropping off. The US saw overdose deaths shoot up 30% last year, the highest increase ever. The nation-wide death total came to over 93,000. I guess when we are comparing that to Covid deaths (613,000) it’s not that big a deal. Are we getting jaded?

Just as we aren’t really sure how to deal with Covid (those of us who are immunized should wear masks inside now?) I don’t see any single answers for the narcotic issue. Doctors in Idaho now prescribe less narcotics. I think that’s a positive. Back in 2010-2012 Idaho doctors wrote 90 narcotic prescriptions per 100 people. Now we write about 50/100 people. Both numbers are well above the national average. But people have pain and narcotics help acute pain.

But with folks getting less narcotics legally prescribed, the fentanyl-cut street narcotics prove more deadly, and our death numbers climb.

At least our Attorney General Lawrence Wasden has an idea what to do. He joined in a suit with 15 other states against Purdue Pharma and they agreed to settle a couple weeks back. Idaho will be getting some $20M over the next 8 years or so. It is supposed to be used to treat narcotic addiction.

But the Sackler family, founders and main shareholders of Purdue Pharma will still have billions. Wasden testified before congress trying to get them to change the bankruptcy laws that allowed the Sacklers to squirrel away fortunes made on the sale of the popular Oxycontin in the 1990’s. Meanwhile, we wear masks, or don’t and watch as our friends, relatives, and neighbors struggle with addiction.

I’ve seen this from so many sides. I’ve had patients in the ER obviously addicted, faking injuries, wanting narcotics. I’ve seen my physician colleagues prescribe irresponsibly. I’ve had a cousin die of an overdose after getting out of a six-month program. I don’t see any easy answers.

Meanwhile, our clinic has been trying to hire a substance abuse counsellor for three months. We run an outpatient program for narcotic abuse. But the structure requires we have a counsellor to evaluate and provide ongoing therapy our enrollees. So, we’ve been three months without being able to enroll anyone new.

It’s not that the pay is low. We provide good pay, benefits, and work support. I have empathy for rural school superintendents in need of new teacher hires. We’ll keep at it.

Not that our program is an answer for everyone struggling out there either. Some folks find other ways to get back on their feet. I support all recovery.

So, what will Idaho do with this money Wasden has bird dogged for us? I’ll bet there will be some new agencies, maybe more people hired by the governor’s Office of Drug Policy. They are up to 6 full time positions now, with a budget of $5M (almost all federal dollars). Will that help lower the addictions, the deaths, the disease that burdens us?

Fundamentally, I think we are going to have to help ourselves, and our neighbors, our friends, and our loved ones. It’s not always easy to know how.

My cousin would call us every couple of months from the program he was in. He always asked me about my motorcycle. He sounded like he was OK, but I knew he was struggling. We couldn’t go see him. When he got out, he overdosed the first week but survived. The second time was fatal. I didn’t know then what I could do. I’m not sure I do now.

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Medical Debt

The twisted method we pay for our health care in this country just doesn’t seem to get people riled up like immigration, guns, abortion, or any of the other hot button issues. But it got the attention of Frank Vandersloot, conservative Idaho Melaleuca CEO in 2020, and he took his idea to the Idaho legislature. Idaho Republican legislators love to rail against regulations, but they took Frank’s ideas to heart and passed laws regulating the collection of medical debt.

This is not a small problem. A study just published last week pointed out that the medical debt held in collection agencies last year totals $140B. It is the largest sector of debt that collection agencies own. Their study estimated 17.8% of the population has medical debt in a collection agency. And these were pre-pandemic numbers.

Mr. Vandersloot got his glimpse into this twisted universe when a collection agency attempted to garnish wages of a Melaleuca employee. The unpaid doctor bill (that the employee had never received because of a bad address) was for $294. The collection agency wanted to tack on $5000 in “legal fees”. Melaleuca refused to garnish the wages and fought the collection in court. Then Frank took his regulatory proposal to the Idaho legislature. And the very conservative body passed his proposed law.

So now Idaho requires billing health care providers to submit a bill within 45 days of services. Seems fair. But if you have a high deductible, and most people do, you pay cash for the first bill you get until you meet the deductible. The later billing entities haggle with the insurance company. Insurances have contracted payment schedules. Medical providers want to dun the folks who are likely to pay, and health insurers have the deep pockets. I’ll bet a $10,000 deductible would hit most folks hard.

Further, the Idaho Patient Act requires hospitals to send a summary bill of all the services received by the patient within 60 days of discharge. Many folks don’t know that the radiologist who read your CAT scan bills separately from the hospital, since she is an independent businessperson. This is even though they work in the hospital, the CAT scanner is in the hospital, and the radiology techs who ran you through the machine are employed by the hospital. Same with the surgeon who took out your appendix. But not the nurse who started your IV. So, the hospital now must collate these charges in a summary bill for you, under this new law. It seems fair. We need to know what we owe, don’t we? Aren’t regulations wonderful? But somebody will be paying for somebody to do this work.

The IPA also limited what attorneys can charge for their “collection” services. It turns out this is a lucrative business for some folks, collecting medical debt. When asked to comment, the attorneys shrugged and said they would just charge the hospitals more for the service, so their yacht payments would be protected. And our health insurance costs will keep going up.

So, this is the vision for a solution to the medical debt payment morass in this country from a conservative Idaho billionaire, Frank Vandersloot, and the conservative Idaho legislature. And indeed, it will “solve” some problems. Frank said he was motivated because he saw “people being bullied”.

Interestingly, the study that chronicled the huge amount of medical debt owed to collection agencies saw a sharp distinction, state by state. The states that had expanded Medicaid had much less debt than states that hadn’t. Medicaid pays hospitals and doctors for their services. Doctors and hospitals hate it because it pays them a lot less than private insurance or private individuals. That’s a different regulation. I wonder what Mr. Vandersloot thought of Idaho when we expanded Medicaid coverage in 2018.

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