West of the Rotunda

With the passing of Justice Ginsberg it looks like President Trump will have the fortune to appoint three Supreme Court justices in his first term. Such power might be just what his evangelical supporters hoped for when they excused his unsaintly behavior and voted for him. The hope to make abortion no longer a Constitutional protection, as the Roe v Wade decision did some 47 years ago, might be realized, and I can believe some folks are drooling.

One thing for sure, when abortion is criminalized like it was in many states back before Roe v Wade, it will be much harder to count. And if you care about something, you should count it.

Before abortion was “legalized” by the 1973 SCOTUS decision, there were few accurate numbers. In colonial times and after the revolution, most states modeled their laws after British common law. This prohibited abortions after “quickening”, or the first movements are felt by the mother, approximately 15-20 weeks gestation. Abortifacients were widely available. One estimate suggests 20-25% of pregnancies in the mid 19^th century ended in abortion, but this is just a “best guess”. Nobody was counting.

It is interesting that the medical profession led the charge to criminalize abortion in the 19^th century and into the 20^th. By 1900, all states outlawed abortion. A cynic could say there were financial incentives, since most states that eventually did allow abortions required a physician to be the provider (as Idaho did in 2000).

Idaho held abortion to be a felony before 1973. In 1950 legislature passed a law that made any woman seeking or obtaining an abortion a criminal, as well as any person “abetting”.

But we sure keep good records of abortion now. Federal and state law require the collection and collation of such data. Idaho’s numbers can be looked at on the Vital Statistics website. I’d encourage you to look at the numbers. But maybe numbers don’t matter to you.

Idaho abortion rate has been steadily declining for the last 20 years or so. We have one of the lowest rates in the nation. Don’t think that’s because we aren’t counting them all. Idaho counts abortions performed on our residents in other states too. With only a couple clinics in Idaho, about a third are performed beyond our borders.

So, Idaho has many restrictions on access to and the rules around abortion, all sending a very clear message. But since it is still legal in this state, we can still count it.

I don’t think most abortion opponents want to count something they find morally, ethically, spiritually abhorrent. I can understand that feeling. But we count crimes, we count prisoners, we count deaths, we count child abuse. I doubt we will be able to count illegal abortions.

Counting helps us to manage our expensive, tragic societal problems. I’m an advocate for counting what’s important.

The numbers mattered in an interesting experiment done in Colorado in the past few years.

Colorado had a pretty high unplanned teen pregnancy rate. In 2008 an anonymous donor gave a chunk of change to the state to provide long acting, reversible contraceptives to teen women at no cost. Over the subsequent five years teen pregnancy rates dropped by 40%. And abortions dropped by 64%.

With a reversal of Roe v Wade abortion opponents might just get what they want. Then, it will be back to each state to decide.

A Pew poll from 2014 showed that 45% of Idahoans thought abortion should be legal in most cases; 49% thought it should be illegal in most cases. That’s a narrow margin.

There can be no doubt the direction the Idaho legislature would go. They even passed a law in 2020, saying, immediately upon a Supreme Court reversal of Roe v Wade, abortion becomes illegal in Idaho. They are drooling. And if the cards fall right, they might get what they want. Then we’ll stop counting.

With no Republican Platform and four more years of “the Disrupter in Chief” looking likely, we better start embracing disruption.

I have argued the health care industry in this country could use it. We have a huge, wasteful medical industrial complex that isn’t serving our “health”. It serves our 401k’s maybe, but we are not getting the health care we pay for. But we keep buying it.

The Affordable Care Act was not an attempt at disruption, despite what the Freedom Foundation claims. It tightened some insurance industry regulations, it mandated universal coverage through a tax penalty and it tried to make individual coverage affordable. But it was essentially based on the current health insurance system. Democrats howled that the “government option” wasn’t included. Obama tried to buy Republican votes. He didn’t want too much disruption. Maybe that’s really what the Republicans want, major disruption.

Maybe when our President is reelected and his Supreme Court nominees get to hear the Republican lawsuit to overturn the law, they will find it “unconstitutional”. Then we can go back to the good old days when 40 million were uninsured. No doubt it will be many more now, with the higher costs and higher unemployment. Losing health insurance coverage, through loss of a job or unaffordability, or through SCOTUS decision in the middle of a pandemic will be a disrupter. Maybe that’s what America wants, disruption.

This wave of Covid-caused unemployment has given us a few months to see what disruption feels like. A survey back in June when unemployment was at 13% found about a fifth of the people who had lost their jobs were now without health insurance coverage. Even more telling, the majority who had lost their jobs did not have health insurance coverage through that now-gone employment. Like always, disruption hits the poor hardest.

It was amazing that the vast majority (74%), Republicans (65%) and Democrats (80%) thought the government should make health coverage available and affordable for them if they lost employment-based coverage.

You get disruption when you tear down a system. Heck, even minor tweaks can get peoples shorts twisted. Remember the outrage, the Tea Party fervor, the Fox News tirades about the Affordable Care Act? They made it sound like this middle of the road proposal was as threatening to our freedom as fascism. Where was Antifa then?

Even if you have a plan to replace what you tear down, the change can be painful. But the “repeal and replace” bumper sticker is fading on the Trumpwagen; no replacement in the Republican Platform. Actually, there was nothing in the Republican Platform at this year’s crowning, ahem, convention except “we want whatever He wants”.

So, we are experiencing pandemic disruption and it’s affecting people’s attitudes toward healthcare. If Trump and Republicans get what they say they really want, that is the repeal of the Band Aid Affordable Care Act, we might find ourselves in just the state of chaos we need.

Then, since Congress can’t act, can’t govern, can’t deliberate, we might get the miracle “Executive Order”. Halleluiah.

And that will mean the end of our representative democracy. We might just be proving we are incapable of governing ourselves. I hope not. I fear so.

Many times, when talking with patients about their healthcare decisions, I sensed their confusion, their frustration with the uncertainty of a choice their health was placing before them. Often, they would ask me to decide for them. “What should I do, doc?” It’s very tempting. Indeed, I have seen many doctors decide for patients what they thought “was best”.

But experience has taught me, people always do better when they have ownership of the decisions they have to live with. And that’s what our representative government system is supposed to promote, shared ownership of decisions for the common good. Let’s not give up on it.

As we were having lunch at the park in Kamiah I noticed the voicemail. “Your vehicle has been tagged as abandoned and will be towed at your expense in 48 hours if you don’t move it.”

The polite lady answered when I called back. “Jeez, I took three loads to the dump in her  this week. She’s not abandoned.”

“Well, we received a complaint that it was abandoned so you’re going to have to move it.”

“She’s licensed, registered. I use her every couple a weeks.”

“It has to move.”

“So just pull it up a bit? Should I park it on the other side of the street?” Don’t get me started about all the traffic racing by our house this summer due to road construction. “And I won’t be back from the Selway ‘til Friday. I’m going fishing.”

She paused. “OK, we can give you until Monday, I’ll put that in the system.”

I love that old truck. I will admit I was a bit offended to hear her called abandoned. I found her abandoned in chest high grass next to a wheat field on Paradise Ridge. A bit of tinkering and she hauls tons to the dump. Dumps real nice too.

But this episode with our city government got me to thinking about our seniors in their assisted living or skilled care facilities in this Covid pandemic situation. I wonder if some of them feel abandoned. Lord knows the toll has been high on them, the sickness kills but so can the isolation.

I have heard many propose a strategy for dealing with this deadly infection that focuses on isolating the most vulnerable and turning the rest of us loose to save our economy, our freedoms. Of course, how we select the most vulnerable might be a problem, but heh, at least we’ll get back to full employment.

Covid death tolls are highest in the elderly. And we have all heard about how the disease has ripped through some facilities, even here in Idaho. While deaths and serious illness may affect the elderly residents, the staff is not immune; they get sick too.

A recent analysis showed 78% of Idaho’s 82 nursing homes have had either staff or residents test positive. Over half of Idaho’s Covid death toll can be attributed to folks in care facilities.

It took some doing to get the state to compile and release this information. There was data on the CDC website that suggested Idaho had outbreaks, but Idaho Department of Health and Welfare only agreed to release weekly reports under threat of lawsuit. Still, the state’s numbers and CDC don’t fully add up. I guess we all struggle to know what to count.

So please, think about it. When you pass that young mom in the grocery store, she may have a shift that night at a skilled facility. You might feel fine, but your cousin you went boating with at the lake might have had something. He was coughing; but he does smoke. How can you know? Now that young woman buying groceries will need to get to her low wage job taking care of folks who can’t go see their family, their friends, or their weekly shopping outing. She’s doing her best to make her charges not feel abandoned. We could do our best for her.

So, we got back from the Selway and I moved the truck off the street. She’s parked down at my work site. I’ve torn down an old garage that was about to fall over. Some things you do have to let go. But I saved every stick of lumber I could. I’ll use them to rebuild.

Before I went to medical school, I thought veterinary medicine might be a better calling to live in a small Idaho town. For that was my dream, a small town with a stable economy to raise our kids. I remember the long drives around Council Valley and beyond in Fred Stovner’s 1960 ¾ ton 4WD International pickup on calving calls. He was the local vet for Council.  We would talk a lot about animals and health and God. Then, when we got to the ranch, his language changed. There were more, “She don’t” and “ain’t” and other kinds of speech, different than we shared in the dark front seat. I asked him about this.

“Don’t they think you are talking down to them?”

He chuckled as the steering wheel shimmied over the ruts. “They don’t want to think you think you are better than them.”

Martha (my wife) to this day points out to me when I switch into talking “Ideho”. That’s her term.

There is a strong anti-intellectual feeling in this rural state.

It’s almost like you have a different skin color. If the regular folks I run into as a doctor or representative start to think I’m coming off as superior, the game is over. If I can’t explain to them in common sense language why they need to stop drinking or smoking or lose weight, or vote for me, then I’m just a know-it-all with no standing. We need to share a language.

I want to thank State Senator Steve Thain for pointing this out this week. He said in an interim committee meeting discussing the role of Public Health Districts, “Listening to experts is an elitist approach.” He went on: “I’m also fearful that it leads to totalitarianism, especially when you say well, we’re doing it for the public good. America was founded on the idea that people weighed their own risks, did what they thought was best for their own interests. … The role of experts should be to give us the best information they have, and we should weigh it. They should never set policy.”

He is so right. Having some Ivory Tower elitist telling me what to do with my life is a nightmare.

But, every day, people come to me with their fears, their struggles with their health. How should I convince them to change their behavior?

Public Health in Idaho is distributed to districts. The public health commissioners in each district are mainly county commissioners, elected by us, and they then throw in a couple “health professionals”, a doctor or a nurse who live in the district. The “professionals” must be approved by the elected commissioners to serve. This body then studies the landscape and makes recommendations, from upgrading a local sewer district or shutting down a polluted restaurant. The recommendations from the legislative interim committees this last week went along the lines of Senator Thain’s comments. The vote, while not unanimous, was to remove Public Health districts from having authority to shut down a school or university in the face of this Covid pandemic. The committee would rather the authority to limit any activity rested on the shoulders of the elected school board members or State Board of Education.

Us “experts” felt a swift kick to the groin. We should. We are not speaking the language of risk.

Fred Stovner would sometimes be called to deliver a heifer who couldn’t get her first calf out. He would pose, “Well, we could do a c-section, and that will cost you $100, or I could try to pull her.”

“I done pulled.” The rancher would say.

Fred would reach in and check the heifer. “I could get the calf out, but it might kill the calf. It might kill the heifer. You want I should try?”

The rancher would kick dirt and decide. That’s the kind of decision making we need right now.

Since there are so many people walking around with masks on, it might be time to update your identifying documents. I sure had an adventure with this one. Not that a current ID will help at the recycling center when three people say “Hi” to you and you can’t recognize one of them. But a current ID helps for a lot of things.

For instance, I tried to sign up to get retirement payments this week. I could have done it a year ago, but I knew it would be tough, so I put it off.

Since we are limiting our contacts, I tried to do the application online. I did this about two weeks ago. The state retirement site told me clearly that I would need to call them to request my application, so I waited until regular business hours and called. It went as smooth as could be. She got my identifying numbers over the phone and said she would mail me the information I would need to apply. And she would email me the application forms, but don’t fill them out until I got her information. A week later, the envelope came.

The application for retirement said I would need both my wife’s and my birth certificates, notarized signatures and Social Security cards. My wife is very organized. She had all this up in a file in our desk. Except, that is, my social security card. I do not possess a card. I did at one time, but the flimsy cardboard thing melted in my wallet after some sweaty work and wading in the river. Why do you need a stinking pasteboard card that fades out? Heck, I could make a good-looking facsimile with a Sharpie. But my retirement application wants the card.

So, I think I could get a replacement card online. After all, I signed up for Medicare online. The first website that comes up when you Google “Social Security Card replacement” might look pretty official to you. It sure did to me. But I knew I was being scammed when they asked me if I wanted to pay with a credit card or PayPal. This was after I had given them all my identifying information.

Feeling my fingertips singed and my ego squashed for being an online dupe, I decided this technology stuff was beyond me. So, I called my local office. I’ll bet the nice lady on the phone was in Iowa, not Idaho. But she said she could get me a replacement card. I just needed to mail her my drivers’ license and passport. “Copies of them?” I asked.

“No, the originals.”

She’s asking a guy who just gave his address and phone number to an online Ukrainian scammer to send to her, through the US mail, two pieces of real ID? And I should trust both her and the US Postal Service? I stammered some hesitation.

“You could request one online sir.”

“I tried that but I got scammed.”

She chuckled. “Oh yes, there are a lot of those out there. Only trust SSA.gov.”

“Why don’t you guys take those sites down?”

She chuckled again, like “We could sir, but that wouldn’t make you any less a fool.” But instead she said, “I’m sure the inspector general is looking into that.” She probably winked to her desk mate.

I thank her for her polite demeanor. She didn’t thank me for sharing my internet pratfalls, but did wish me a good rest of my day. It was lunchtime. I took a break.

I found the SSA.gov site and only got a little peanut butter on the keyboard. It turns out my computer remembered my password, and I only had to click a couple places to say I really was me. Then they said it would come in the mail in a couple weeks.

I called the state retirement lady to tell her of my delay. “Social Security card?” she asked. “Oh, you must have gotten the old forms.”

I don’t get a reminder from the State of Idaho that I need to renew my drivers license. I guess they expect me to be mature and responsible and figure those things out on my own. Yeah, right.

Well, I did just renew my drivers license, since it’s due to expire in a few weeks. I forgot one time, and I showed up in their office with a really expired license. They made me take the test and get a new picture. That must have taught me the lesson, because I didn’t forget this time.

And guess what? I could renew my driver’s license ON LINE! It was pretty easy, really. I had to give them some identifying information and confirm I was indeed who I claimed to be, and click on a box that said if I was lying I could go to jail. Oh, yeah, they took my money too. But overall, it was pretty slick. Idaho must trust the process. I do.

 Now this process won’t work for the Star Card. That’s the Patriot Act universal identification the federal government passed after 9/11. Believe it or not the Idaho legislature voted unanimously (all Dems, all Repubs) to tell the federal government to stick it on that one. So now we have the option of giving the feds our information in person (like they don’t have it already); then we’d get the Star Card. We could use it to get on an airplane. If we get the regular old Idaho license TSA won’t recognize it. I went with the Idaho one.

So, since Idaho has entered the digital age in drivers licensing, I am puzzled why our governor believes collecting initiative signatures on line would be a problem.

I have collected a lot of initiative signatures, in the rain, the snow and the sun. I never checked someone’s identification. I always reminded them they needed to put down their address where they were registered to vote on the piece of paper. I also reminded them of the penalty for signing the petition multiple times. Kind of like the online license pages checked my address and information, and warned me about jail time.

Once the paper petitions are filled out, I had to get them notarized, then I had to turn them in to the local county clerk. This is where the signatures were validated.

Don’t get me started on the hurdles, the many different legislative districts required. But, I guess if the legislature wants to change those laws, they can. They have tried. I bet they’ll try again. But that’s fine, laws are made to be changed.

The way it is now, the Idaho Constitution says citizens have a fundamental right to pass and repeal laws. That can be changed too, but it’s a lot harder.

Why is there a need for online initiative signatures?

This problem came about because Reclaim Idaho started collecting signatures for their school funding initiative. They were chugging along, ahead of their pace for the Medicaid Expansion Initiative which they got on the ballot in 2018. But then there was that Governor Little “Stay at Home” order. Reclaim suspended their process and the timeline ran out. Reclaim argues, give us the time now to collect online signatures. Little says no. He wants to take it to the Supreme Court, now that a federal judge has told him to let Reclaim proceed.

If the state trusts me to renew my driver’s license on my laptop, why wouldn’t they trust me to sign an initiative petition?

Reclaim has begun collecting online signatures, even though the outcome is still up in the air. If you are interested, you can go to their website and read about it. Now, why this initiative makes sense is another story.