West of the Rotunda

About a month ago when the shutdown was starting and the Corona virus was just starting to kill people in serious numbers in this country we had an uncomfortable conversation in our kitchen.  It didn’t go well. I share it with you so maybe you can do it better.

Two of my grown daughters live just down the street from Martha and me. We have dinner together most nights. Sometimes we even play pinochle after dinner.

It seems so long ago, but the news was full of the concern for medical supply shortages. I had experienced in the clinic the difficulty with getting tests done, but the shortage of personal protective equipment was hitting my daughter who is an ICU nurse. What got the conversation going was the talk of the shortage of ventilators.

When people get really sick with Covid 19, their lung tissue leaks fluid and they can’t get oxygen in. Lungs are delicate sponges and they don’t function well when those little air sacs are full of your serum. I had read about the seriously ill patients in China and Italy and how many needed ventilator support to oxygenate. A month ago, I could not find good information how well patients responded to the mechanical ventilation, but I assumed they had a high mortality rate. Indeed, a recent report from New York suggests 90% of Covid patient who get intubated and placed on ventilator support do not survive. It’s 97%+ for those of us over 65.

The difficulty in the conversation with my daughters came up when I said, “Don’t let them put me on a ventilator!” They thought I was saying I don’t want to live. But that’s not what I wanted to say. I just don’t want to be treated like that.

I have intubated patients. When a gunshot or car wreck victim shows up in the ER and can’t breathe because of chest or lung injuries, we paralyze them with drugs and slip a tube past their vocal cords, inflate a little cuff near the end and now, their air way is secure and we can pump oxygen into their lungs, then treat their injuries.

I don’t resent patients who might want this level of care. Most patients want to be treated in a way that reflects their values. But unfortunately, when doctors need to slip that tube past your vocal cords, we usually don’t have time to have a comfortable, honest conversation about how the patient wants to be treated. That’s why it is so important that your loved ones can speak for you about your values.

And that’s what caused the difficulty with my daughters. They don’t want me to die. I don’t want to die either. But I will, and so will they. And I want my life, and my death to reflect my values. Mechanical ventilation doesn’t suit me. They came to accept this.

It is a hard assignment for family members to speak for the patient who can’t. So often, the “Do everything, doc” sentiment is a surrogate for an expression of love. If we don’t do “everything” it means we don’t love them. I wanted my daughters to know I felt their love, I know their love, but they could best express their love by sharing my values with my caregivers.

I gave the legislature grief this last session for not updating the End of Life document (POST) the state authorizes. If you’ve filled on out (I have) the piece of paper with your check mark and signature have been in a filing cabinet in the Secretary of States office. The legislature killed a bill to move this to a secure data base managed by the Department of Health and Welfare. But when the Department brought back the same proposal with a 75% discount on the cost, it passed easily; good job.

I encourage you to fill out the form. But more important, share your values with your loved ones. Let them know.

I’ve been plugging away at writing this column for over three years now so I thought I’d take a break. There will be no column this week.

Initially I’d thought, since we are nearing the primary election, I could say something about Idaho politics, but honestly, what’s the point? It’s the same old story.

We have the super-majority Idaho Republicans crowded into their big tent arguing over who really represents the conservative values of Idahoans. There are so many in the tent they can’t all see each other, hear each other, let alone know each other. They can’t even agree on what to eat, so they keep taking a bite out of each other.

Meanwhile, both remaining Idaho Democrats are sitting outside at a picnic table looking at the noisy tent trying to figure who will pay for their lunch. The baloney sandwiches weren’t free. There’s no news here folks, so I will pass on Idaho politics.

I try to focus on Idaho healthcare issues but this pandemic is perplexing, so there’s no point writing a column about that. Once we know if it was just a bad flu or truly the apocalypse, we’ll think we know what we should have done different. But that could be years from now. I choose not to speculate at the moment, so I have decided not to write a column this week.

It’s no news that the natives are getting restless, as natives should, about what authorities are telling us to do. After all, who put them in charge?

At least our wise representatives in Washington DC have decided we all need a check in the mail. They fired up the presses at the Treasury and printed them up pretty fast, didn’t they? I haven’t got mine yet, but I’m comforted knowing it might come soon, so I can’t really write about that. I’ll let you know.

In the meantime, most of us are staying home and wondering where all those spider webs came from. I really have noticed a lot of spider webs, but who wants to read about spider webs? So, I won’t write a column this week.

And there’s no point sharing all the projects I’ve been puttering on. Yours are probably more interesting. I got the 1949 Chevy dump truck running like a champ, but I can’t haul the roof I need to tear off to the dump. It’s closed.

So, I fixed up an old lawnmower a neighbor left me. I’m now blessed with four lawnmowers. See why I shouldn’t write about how I’ve been filling my time?

There is one thing I’ve put off for quite a while that I am tackling now in all this isolation. It’s not really much of a story. I have this old wooden sailboat that takes more time to keep shipshape than it spends in the water; kind of like our government. I’ve sanded and varnished and patched and replaced more than I can list. That too, sounds like this Republic.  It has really big sails and it can go really fast with the right wind, but right now it’s in storage, also like our country. I can get it out in a couple weeks. See, there’s not really a story here.

Right now, I’m fixing the rudder. It was really dinged up and cracked. The third coat of varnish is drying now, and it’s really quite attractive. The image of a beautiful rudder for a boat that doesn’t sail somehow resonates with me right now. But like I said, it’s not a story.

So, to all my readers I apologize for not doing a column this week. We suffer in these troublesome times, socially distanced and worried about the plague upon us. Since you won’t be wasting time reading my column, maybe you can share a story with a loved one. We need to feel close; tell a story.

The buzz drummed up around hydroxychloroquine by our President as a treatment for Covid19 doesn’t surprise me. Honestly, a lot of politics is snake oil and he’s proven to be really good at selling it to some of us.

But it’s a great opportunity to consider what pills we are willing to swallow. I find hydroxychloroquine quite bitter. Maybe you don’t.

Lots of what we do in this modern medical industrial complex is mysterious, but don’t think for a minute its more complicated than human nature. Placebos tell us something about human nature, so it would be wise to understand them if we can. It might tell us something about ourselves, and about the prescriber.

Kind of like Idaho Democrats, placebos have a bad name they don’t deserve. Why disparage something that really has an effect? I guess it depends on the effect you want. It turns out, our bias effects our outcome. What you believe about your treatment influences the effect the treatment has on you.

They frequently do work; placebos I mean, not politicians.

When a placebo is given to a patient it can have an effect on the measured outcome; the “placebo effect”.  Placebos make headaches better, lower blood pressure, improve pain, ease anxiety and improve performance, the list is long. Believe it or not, they can have side effects too. They can cause nausea, ringing in the ears, all number of unpleasant things. Don’t forget that these effects, desired or not, are as real as we perceive them to be. Even the color of the pill can have an effect. We are such marvelous mysterious creatures.

For a drug to be FDA approved it has to show an effect greater than a placebo. That requires a lot of hard, expensive work. The patient has to be blind to whether the drug is a placebo or “real” and further, the treatment team needs to be blinded to the nature of the treatment also. The faith that patients place in their treatment, and the faith that providers have, has an effect. The standard for an effective drug is that it must clear the placebo hurdle of faith. That’s a high bar. Isn’t it refreshing to know our faith is so powerful?

The effect of hydroxychloroquine on the Covid19 illness has not been held to these standards. One very small report without blinded patients or providers reported some benefits; two larger ones showed no effect. Trying a novel treatment in the face of a novel virus in the midst of uncertainty is not irresponsible. Honestly reporting it for others to consider and test is responsible. Testing the treatment against a placebo would be responsible. Such testing might provide some evidence. But such testing takes time, effort and discipline. Do we lack such resources now? Should we be buying snake oil?

I remember my pharmacology lectures in medical school. The pharmacist professor wore a long white coat as he stood on the stage addressing the large theater of students. He spent a whole hour, after beta blockers and before tricyclic antidepressants, talking about the placebo effect. He emphasized how real the placebo effect was, how powerful it was, and how foolish we would be to minimize it. He encouraged us to tell patients the treatment would work. “Use this effect for your patients benefit.” At the time I felt he was leading us down the road to be snake oil salesmen. But it’s really not as simple as that. I think he was encouraging us to choose a treatment we had faith in, and impart that faith to our patients. The foundation for that faith should come from tested evidence. It’s a sad fact that many medical treatments have no such evidence, yet they are prescribed daily.

Maybe that was why I was such a lousy Idaho politician. I couldn’t sell blue pills when red ones were in demand.

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.