West of the Rotunda

The pool hall is closed, the streets are quiet but there’s still work to do. You should be reading the Draft Environmental Impact Statement for the Columbia River System and submitting a comment. The deadline is April 13^th, so get on it.

This report was speeded up by a presidential order back in October 2018. Some have asked for extending the comment period, but like me, I’ll bet you have the time right now. The salmon are waiting. Get on it.

You could go fishing instead. Idaho Fish and Game allowed a steelhead season this year; hatchery fish only. But if you care about the future of Idaho salmon, I suggest you read the report and comment.

The full report is available online, but I would recommend the Executive Summary (it’s only 35 pages). The detail and extensive analysis are impressive. I just disagree with their conclusion.

The conclusion of The Army Corps of Engineers (who build and run dams) and the Bonneville Power Administration (who buy and sell electricity) is that bypassing the lower four Snake dams would cost too much. Power costs would go up, and transportation costs would go up. But they clearly conclude, breaching would have the greatest improvement for salmon survival.

“Breaching” isn’t dam removal, it’s just opening up the bypasses that were used when the dams were built. The dams would still be there, the river would just go around them. They couldn’t generate electricity, they couldn’t stop floods and they couldn’t hoist or lower barges. But the young salmon would get a boost to the ocean. And the adults could come home easier.

The Corps and BPA argue for more “mitigation”; like the barging of smolts we do now and the modification of flows. We have already spent $17 billion on these strategies. They still think in that box.

There is no doubt a lot of the predictions about what will help Idaho salmon recover are unknown, just like we don’t really know how many ventilators we will need next month for COVID patients. But we do our best, don’t we?

If salmon recovery is important to you, why not chose the best option?

There is strong evidence that those four dams take a big toll on our salmon. In the Yakima River, where the fish have to pass four Columbia dams, regeneration is over twice as high as in Idaho. In the John Day and the Deschutes Rivers, with only three and two dams to pass, salmon have three time’s Idaho’s regeneration. Idaho’s rivers have had a regeneration rate well below sustainability for a long time. Hatchery fish have kept the seasons going. I want to keep fishing.

I am amazed at how this has been politicized. The first time I ran for county coroner, back in the 1990’s, I attended all the community forums, though I was unopposed and unaffiliated. If the crowd questions waned, I would ask the legislative candidates what they thought of the lower four Snake dams. The Republicans all had similar phrases, how vital they were to our economy. And since Palouse farmers love that cheap shipping, it made sense. It wasn’t long until I started seeing the “Save our Dams” bumper sticker. It was like somebody was planning to dynamite them. It’s been years now, and the discussion has continued. That’s good.

I have been encouraged that one of our deep Red and all Republican congressional delegation is willing to consider the question. Congressman Mike Simpson has stated he wants to see salmon recover. He has not endorsed any plan, but he has said he wants healthy salmon runs in Idaho. The other three are strongly with BPA and the Corps.

So, spend some time on the report and send in your comment. I did. It was sure easier than catching a steelhead; but not as much fun.

I loved the Calvin comic strip. He and the tiger played Calvinball. There were no rules in Calvinball. The Idaho legislature must love Calvinball too. For the second year in a row they have not approved any rules.

The legislature passes laws (we hope with clear intent) and the details are left to administrative departments. The departments publish proposed rules, take public comment and often negotiate with the businesses or organizations that will be affected by the rules. The rules are then brought back to the legislature for review to make sure the rules reflect the legislative intent.

You may remember in the 2019 session no resolution was passed by the legislature to approve or reject the rules. That’s because the House and the Senate could not agree on how they should be doing this process. So newly elected Governor Little sent his departments to work and trimmed a lot of obsolete rules. They worked hard to make sweet lemonade from legislative sour lemons and sold it as such quite publicly. Good work; now do it again.

This session the legislature (at about $20K/ day) spent the first five weeks reviewing and not agreeing on the big pile of rules. And they adjourned AGAIN last week with no concurring resolution. We’re wasting our money paying these children.

Also remember, the legislature fought to get their review protected by the Idaho Constitution. They ran an amendment on the ballot in 2014; it failed. They brought it back in 2016 and with lots of Farm Bureau support, got voters to approve. It seems like they desperately wanted to protect their right to review, approve or reject administrative rules so bad they needed a Constitutional amendment to protect it. Now that they have the right protected by the Constitution, they don’t even bother to do the work. They are acting like Calvin.

Big deal you may say. The Idaho didn’t grind to a halt in 2019. All the rules were made new. And why do we need these silly rules anyway? Idaho does great playing Calvinball.

Consider the law that we all have to live by, even the legislature. They passed this law thirty years ago. It reads in part:

…no pending rule or portion thereof imposing a fee or charge of any kind shall become final and effective until it has been approved by concurrent resolution. Idaho Code 67-5224(5)(c)

Of all the rules review I did for weeks on end the first weeks of the legislature, fee rules were the ones I paid attention to the most. Most of the time when a law is passed, fees are directed to be charged for specific state services. A certified Death Certificate will cost you $16. (Admin Rule 16.02.08.251.01) I pay $200 every year to the Idaho Board of Medicine to renew my medical license, though the rule says they can charge “less than $600”.

Rather than raise your taxes, if you want government to do some work for you, they charge a “user fee”. Seems fair to me. Only, without a legislative resolution to adopt these fees on record, to quote the law: “no fee or charge of any kind shall become final and effective”.

I think a lot of folks should be scratching their heads when they are asked to pony up for state fees. When I get my license renewal request from the Board of Medicine, I’ll be asking them “Why do I have to pay this?” The way I read the law, I don’t see how they have any authority to charge me a fee. But I appreciate that they are doing their job.

Don’t get me wrong, I kind of like when government does work for us. And I haven’t run into any specific fees that seemed onerous. Think of it though; vehicle registration fees, hunting and fishing tag fees, cattle brand registration fees; all of them are not “final and effective” because our legislators love playing “no rules” Calvinball. Some adult should send them to “time out”.

March 15 2020, Moscow Idaho

The world and my little town seem to be preparing for a wave of Covid19 infections, and some critically ill patients. Let’s hope it doesn’t happen. But just how would we do in the face of such an occurrence?

First of all, I trust most people have common sense; maybe I’m naïve. All my years of doctoring have not convinced me otherwise; although I could tell you some stories that would make you think I’m a fool for holding onto that faith.

But sometimes, common sense isn’t enough. We know the virus can be spread even when the infected person has no symptoms, so common sense won’t help you there. The widespread decisions by colleges, sports associations, and now our President to limit travel and large events may reduce the spread, but these decisions sure have raised the awareness. And common sense won’t keep you alive when your lungs fill with fluid. It is clear this happens to a small percentage of those infected. So, we need more than common sense to deal with this.

We need information, for one. I’ve been happy with the information I have gotten, but I don’t get mine from Facebook. I read reputable websites, the CDC website, my professional sites and local authorities.

Information comes from data, and we are short of that right now. We can infer some from other counties experiences, but that only goes so far. The limited availability of testing is frustrating many. The US has only tested about 65 people per million inhabitants (31,000 test total) as of last Friday. Without adequate data, information can be speculation. Speculation can contribute to fear.

A couple weeks ago testing was available here in Idaho through the state Public Health districts. They were using the CDC recommendations for who to test: symptoms (cough+fever and shortness of breath) as well as high risk exposure (direct contact with known infected person or travel from high risk area).  But now, the clinic I work at and many others have a commercial test available. I expect lots more test results in the coming weeks.

Then we are left with the accuracy of the test. This can be frustrating too. The recommended screening test is a nasal and throat swab (long wire Q-tip up your nose and then the back of your throat). But in China, this test was only about 30-60% accurate. Thus, many early cases were missed. A blood test for antibodies is now also available, but it also has limitations. So, more testing would be helpful, but not all questions will be answered.

The number of new cases diagnosed in China has continued to decline since a peak in mid-February. The outbreak started a month earlier.  But world-wide we are seeing a steady increase; the US is early on the upward slope. Idaho was one of the last states to report a case. But Washington, our neighbor was one of the first.

Only a few of the people who get the illness get real sick, and fewer die. China had about 4% fatality of their confirmed cases. Interestingly, many of the fatalities in China were in health care workers. Italy so far as seen about 8% death rate in confirmed cases. The US is just 2% fatality, but we are early on the curve again.

When people get real sick, our resources will be stretched. The viral lung infection requires intense treatment.

I appreciate that so many people are paying attention and working hard on this. And I appreciate that people are staying patient and calm. Some states have closed schools. Governor Brad Little has declared each district should make that decision.

We didn’t have church this Sunday, but I’m going to work on Monday. I’ll wash my hands and cough into my elbow. Our clinic has systems in place and we’ll do our best. But I doubt this will be the last time we go through something like this; stay prepared.

With the Idaho legislature in session, a pandemic threatening, and health care costs on their steady climb I want to catch you up on all the Idaho health care news. Well, this could be short. Just to save you the time right off, I’ll say there has been no health care news in Idaho this week.

The legislature has considered some things, and is considering some things, but mostly, they have said they don’t want to consider most things.

The Department of Health and Welfare went out on a limb and suggested to the legislature that they be the repository for “Advanced Directives”. You know, there’s that POST form your kids and your lawyer want you to sign to take the pressure off them when you stroke out or hit your head falling off a ladder taking down the Christmas lights. It says whether you want everything done, machines and tubes, or you just want to be comfortable and let the end come. When the state set this up back in 2005, the Secretary of State was determined to be the depository of these records. I assume these valuable documents are in a file. There are now over 40,000 of these. But try getting hold of your dad’s off business hours. Health and Welfare planned to make a secure website. The House didn’t like the cost. So that idea died. I suggest you keep yours taped to the refrigerator; then only get incapacitated near the kitchen.

There have been no legislative suggestions to control health care costs. But they are going to hobble the lawyers and debt collection agencies that want to garner your wages for what you owe on medical bills. Frank VanderSloot, billionaire CEO of Melaleuca has championed this one. The backstory is deep, but it really says something about our “best in the world” health care system that we can support a cadre of lawyers and debt collection agencies. And it says something about our legislature that such an idea has to come from a guy who “saw a problem”. Good for him.

A suggestion to limit “surprise medical bills” has gone through three iterations, but seems to be dead. It was nowhere near the refrigerator so resuscitation is unlikely.

It looks like vaping products might be regulated like tobacco, since this bill got through the House. It faced tough opposition especially from the legislator who owned a vape shop. He convinced 31 of his colleagues to vote with him.

But the Senate did kill a bill the House passed unanimously. It would have allowed prescribers to treat heroin addicts over the phone. I was skeptical that this was a good idea, so in this case, no news is good news.

And since we are speaking of no news, I’m sure you are glad that Idaho has reported no cases of the new, novel corona virus: Covid19. But we’re ready. Since the Feds are handing out dollars faster than you can wash your hands, the Budget Committee appropriated $2M, expecting to get back $4M from a federal fund. How’s that for double your money? And they didn’t even have to buy a scratch ticket.

Even though Idaho has not seen any cases of Covid19, we had lots of reassurance from our State Epidemiologist, Christine Hahn. I don’t know about you, but I’m comforted knowing our state even has one of those epidemiologists.

Meanwhile, if you get a fever and a cough, if you feel sick, the advice is you should stay home. Wash your hands while you sing “Happy Birthday”. You should cough into your elbow, but I suggest aiming for the inside, where it bends because I hurt my shoulder bad trying for the pointy part. Oh, and stay near your kitchen.

The publisher of our local paper has promoted some community discussions about civility recently. It has given me pause to wonder about this goal: civil discourse.

I attended the one locally and the big one that included a lunch down at LCSC. I heard many comments that wondered if the paper was truly promoting civility by publishing some rants and personal attacks in the letters to the editor. The defense was, and I agree with it, that reading someone’s comments is a great way to get to know your neighbors. And that really is what we need to be doing, getting to know each other. Civility helps.

Most of us have dealt at some time in our lives with name calling, bullying behavior. It was really hard to convince my daughters that responding in kind was wrong. When behavior or words cause you pain, the first response is to strike back. But I believe such behavior is wrong, for many reasons. It would have done no good to quote Abraham Lincoln: “I don’t like that man. I must get to know him better.”

I went about public service with the presumption that civility was expected behavior. It made sense. If our elected representatives are going to debate and decide on laws, we need them to be listening to each other, and more, listening to us constituents. Listening is the foundation for civility.

Civility is the basis for negotiation and compromise; and such is the foundation that our convoluted form of governance, (you know, three branches, separation of powers, etc.) our representative democracy require to function.

But why do we need compromise? Why negotiate? Isn’t it all about who is in power and what that power can accomplish? I hope President Obama regretted saying “Elections have consequences”.

Imagine that from the position of the minority. When President Obama had majorities in the House and Senate and it became evident there would be no Republican votes for the Affordable Care Act should he have insisted on bipartisan support and stopped the process? Let the minority, now no longer negotiating the details of the bill, prevail? The majority ruled, and it was seen as tyranny by many. The resulting bitterness has delayed meaningful negotiation on health care reform for 10 years. And the ACA truly has done little to address our health care dilemma. Who knows, our failure to negotiate might get us stuck with Medicare for All. We sure haven’t cut the cost of health care. We aren’t negotiating.

Our framers built this system to require compromise and negotiation. Getting a majority to support something in committee, then in the body on one side of the legislature, then another committee and the body on the opposite side of the rotunda; this is a monumental task. That makes four hurdles to clear, not to mention the deep pits of the chairmen’s drawers between the hurdles. If you have, through rudeness or slight or provocation (or unfortunately now, party affiliation) offended someone in this path who you now ask to listen to your arguments, you’ve just made the hurdles higher, the pits deeper. And you will need an agreeable executive to sign the law.

The framers built this system to protect the minority from the tyranny of the majority.

Maybe you believe your ideas have such merit on their own that you don’t need to persuade. All you need is the power of the majority. When that is the case, we have succumbed to the tyranny of the majority. And if that is the ideal we embrace; the most efficient form of government becomes a supreme authority. Is that what we want?

Is our current incivility an expression that we no longer value this republic?

I hope not. The least we can do as citizens is engage and demonstrate the civil behavior we expect from those we elect to represent us. We must.

Last week Idaho’s three branches of government, legislative, judicial and executive made a joint announcement. They agreed through resolution and executive order to form a Behavioral Health Council and Advisory Board. It’s a wise move. But hasn’t this been done before?

If this sounds familiar, it might be because there already exists a Behavior Health Planning Council. It was established in law in 2006. Of note, there was expected to be $4M in funding to support the duties assigned to the Council that year, which included the development of transitional housing. This Council was directed to give a yearly report to the Governor and the legislature. They are interesting reading.

Maybe this new executive order sounds familiar because there have been many studies in the past. But they were different. Usually these were done by outside entities that would come in and review what Idaho was doing around our “Behavioral Health System” and make recommendations. The most recent ones I am familiar with include the first WICHE report (2008) and their 10 year follow up in 2018. Further, there was another recent report evaluating Idaho’s Crisis “System of Care” which reviewed the performance of the regional crisis centers.

But maybe this time the work will be different. The work you get out of an effort often reflects the people doing the work. This Council will have appointees from the Governor, the Chief Justice and the legislature. This is not an independent evaluation. This is Idaho folks with skin in the game.

The Council has four directives:

1. Develop a plan to inventory expenditures, access and utilization
2. Assess the effectiveness of the current system and look for ways to efficiently coordinate
3. Determine Idaho’s unique needs
4. Recommend actions to “materially improve” Idaho’s behavior health system

Finally, the Council is supposed to develop a strategic plan and deliver it to the governor, legislature and judiciary this coming Halloween. I kid you not, that’s the deadline. Any ideas for a costume?

I applaud these goals. Why not get all the folks who see this problem from their many perspectives together?

Let’s look at number one: counting up where and how much we are spending. Did you know that the courts have money for “specialty courts”? These can be called behavioral health court, family court or “Drug Court”. Offenders may have a plea or sentencing delayed if the court decides the main problem they are dealing with is drug addiction or alcoholism. If the offender agrees to the recommended treatment plan and sticks with it, they might get off without incarceration.

Further, the Department of Corrections pays for treatment of incarcerated addicts, and supports recently released offenders with drug problems on parole or probation. Many are now eligible for Medicaid, which can also support treatment. So, we pay through the state judiciary budget, the state corrections budget and the Department of Health and Welfare. It seems adding all this up, counting what we are treating makes common sense.

Number two might be harder; assessing effectiveness. I have wondered before, what are we counting? But I have no doubt there are efficiencies that coordination could accomplish, but remember how some legislators reacted to classroom standards? Maybe setting standards for behavioral health will be easier.

Number three, assessing Idaho’s unique needs can’t be any tougher than driving to Boise from the panhandle in January.

The final task, recommend “material” improvements, is easy, unless there is a budget item to consider.

I suspect the people who put this together, the governor, the judges, legislators are all tired of dealing with this problem from their limited vantage point. Maybe they see hope that together, maybe we can make a difference. That’s an inspirational view. I wish them the best.

Most of us live with chronic pain. For some, it can be crippling.

As a young doctor, I quickly came to realize it was a difficult condition to manage. Whether it was headaches, back pain, fibromyalgia, pelvic pain or joints, the suffering could disrupt people’s lives, lay them low. It could be depressing, isolating, ruining.

When the pharmaceutical industry started claiming to doctors in the 1990’s such pain could be “cured” with their new formulation of timed-release narcotics, I understood the temptation to treat these conditions with such. But our past twenty years of opioid over-prescribing and subsequent sky rocketing accidental overdose deaths should have taught us that easy cures, though tempting, can be fatal. That didn’t satisfy my oath to do no harm.

I did my best to study the research. I attended conferences and listened to experts. But more, I listened to the patients.

I went into medicine thinking my job was to fix what ails the patient, when possible. I remember in residency; our patient interactions would be viewed by a behavioral health specialist who would give us feedback. Toni, the specialist watched me once and commented, “You need to be careful. You want to fix patients.”

I was struck dumb. “That’s my job!” I countered.

“No, it isn’t.” She replied firmly. I pondered that one for a long time.

 It was a hard lesson for me to learn that many ailments aren’t fixed, but managed. When a cure isn’t available, the focus has to move to maximizing function. That adjustment can be hard to accept. It often was for me.

But I worked at learning. I thought that was my job, as a primary care physician, to care for the patient. So, I am troubled now when I see so many patients with chronic pain sent away from their primary care providers to pain specialists. I think some of this is a reaction by my colleagues to our years of excessive prescribing. Doctors got on the opioid bandwagon too easily. So now some won’t even take a short ride. I see signs up at the receptionist: “We do not treat chronic pain”. This too, is I believe, a mistake. Patients need our care.

Don’t get me wrong, pain management specialists are valuable. I have made such referrals. They have much greater depth of experience than I do in their fields. But most primary care providers can manage most chronic pain patients.

In rural Idaho, chronic pain is common and specialists are far apart. We need to help our primary care providers serve their communities. And we are.

I get a quarterly report from the Board of Pharmacy on my patterns of prescribing controlled substances. It lists the number of prescriptions, the daily dose and comparisons to my colleagues. This is helpful.

If I have concerns that a patient might be “doctor shopping” for controlled substances I can access a data base that lists all prescriptions, sorted by prescriber and patient. It even links to most surrounding states. This is a great resource.

But one of the best tools has been developed by the Idaho WWAMI program, the medical school affiliated with the University of Washington School of Medicine. It is Project ECHO. Twice a month any provider can log in to an hour-long conference with specialists. Colleagues from around the state will be on the screen. After a short presentation there is time for questions, case presentations and discussion. Management of these challenging conditions is supported.

Currently, the Idaho legislature is considering whether it should support this program with taxpayer dollars. It would be a worthwhile investment. I wish it had been available when I was starting out.

Separation of powers is a fundamental principle in both our state and federal Constitutions. The framers figured that by splitting up the powers that govern us, we, the governed would be less oppressed by our government (read Federalist 51). But what happens when one branch relinquishes its power or another infringes? Does the loss of separation from this disrupted balance lead to increased oppression of the governed?  We have two examples to consider.

Impeachment is the biggest test of this separation. Our federal Constitution gave Congress the power to remove the President. I’m sure you have heard about our recent civics lesson. The verdict has been given, though it was probably a foregone conclusion. Many trials are. But the failure of the US Senate to hear witnesses, review documents or even stay awake to “impartially” consider the charges doesn’t bode well for the power they are supposed to hold. The majority declared themselves submissive to the executive they were judging.

In fact, the previous administration exulted in and abused Congress’ impotence. When one branch abdicates, the other usurps. Executive orders have become fiat. Budgets are managed by “continuing resolution” from one threatened shutdown to the next. Our debt to GDP ratio is higher than any time except right after World War Two. Only when Congress, the House and the Senate, Republican, Democrat and Independent resolve to put aside differences and govern, can they reassert their separate constitutional power. Meanwhile, the executive sucks up the foregone power.

I believe the wisdom of the electorate desires separation and balance. The first midterm election after a new president is elected has almost always seen Congress swing the other way. Obama lost 63 House seats in the Tea Party wave of 2010; Trump lost 37 at his first midterm. Could this be the electorate pleading with Congress to assert its power?

Here in Idaho, it’s the opposite imbalance. The legislature is leaning on the executive branch. Take the recent Administrative rule dust-up example.

When the Idaho legislature passes a law, the executive branch that enacts that law writes administrative rules to fill in the details. For instance, Idaho code 33-1612 (Courses of Instruction) list in outline the general principles for classroom instruction, then delegates:

The state board shall adopt rules… to establish a thorough system of public schools with uniformity as required by the constitution.

The Idaho legislature reviews and approves or rejects all new administrative rules. They even got this power into the Idaho Constitution. But then, last session, the House and the Senate could not agree on the process for review and ended up not renewing ALL the administrative rules. Governor Little made lemonade out this and put a lot of government employees to work reviewing all 8000 pages of rules. He successfully reduced some, but, by law ALL these new rules needed to be reviewed by the legislature.

Legislative review of executive branch rules can blur the separation of powers that keeps government weak, like it should be.

Last week, the House Education Committee voted to reject the rules for teacher certification standards. They also voted to reject all K12 classroom standards for Math, English and Science.

There can be great temptation to re-legislate when the rules come before you. Imagine being in the position of opposing legislation that gets passed. Or, more often, opposing funding for the department. Now imagine those rules come before you and your job as a legislator is to make sure they conform to the intent of the statute that you opposed. You might be tempted to throw a wrench in the works. The House Ed Committee is acting like a mechanic on meth.

The Idaho legislature has slowly over the years usurped power from the executive branch through rules review.  It’s gotten to the point of micromanagement, wasting our taxpayer dollars. If the Idaho legislature really has so little productive to do, I propose they take January off and shovel snow.