West of the Rotunda

It had been a long day for Brad and Teresa touring the noodle factories of Taiwan. He pulled off his cowboy boots in the Presidential Suite in Taipei wanting to take a break before the big dinner tonight. He clicked on the TV, searching for the Vandals game figuring the kickoff was soon. Instead the airwaves were full of the Ukrainian Trump telephone conversation. Brad skipped the Fox News analysis.

“What should I wear tonight?” Teresa called from the walk-in closet.

“The black and gold dress!” Brad yelled, hoping she’d bring good luck to his Alma Mater.

She gave him “the look” and he laughed. “Go Vandals!” he retorted.

They went down the stairs before halftime and the Vandals were ahead so Brad was in good spirits.

“Governor, your table is here.”

They were escorted to the head table in the large banquet hall. Brad took off his jacket and threw it on the back of the chair, his Black and Gold suspenders complementing his wife’s dress.

As the hall filled he chatted with the Taiwan Minister of Economics. The minister asked, “Do you anticipate any tariff issues?”

“Oh, I don’t think our government would want to obstruct the free trade of agricultural commodities with Taiwan.”

The minister frowned. “Taiwan will always be a good trader and Idaho offers good wheat. We have agreed to take more. We are always willing to do favors.”

Brad laughed and clapped his shoulder. “It’s no favor. We grow good wheat. You make good noodles. We all benefit.”

The minister looked down, his frown deeper. “But surely, we can do more.”

Brad swirled his wine glass. “Well, we’ll grow more wheat.” Then he turned away as the Taiwan Minister of Security touched his elbow.

“Governor, I hope the noodle plants were to your satisfaction today. The Vandals are now down by 4 points in the third quarter.”

Brad didn’t skip a beat. “We’ll come back.”

“Maybe so.” The Minister of Security offered with a soft smile. “We have connections everywhere, but we cannot influence football games in Moscow, Idaho.”

Brad looked off, troubled by the news of the Vandal deficit. “We’ll come back.” He said again but distracted.

The Minister of Security cleared his throat and nodded his head to the man next to him who quietly moved away. “Governor, I am here to tell you if you need any favors in your state, we are here to help.”

Brad sipped the Washington Merlot and nodded. “We really appreciate all the wheat you guys buy.” He looked over to where Teresa was chatting with the wife of some Minister of Something. “Can you get your people to like potatoes more?”

The Minister of Security laughed and Brad did too. But as he started to turn away, the minister touched his arm. “We have many resources that could be an advantage to you. We know the political landscape of your state. Your primary election was very close. We study and have information. Let us know if you have any need, any need for any favors.”

Brad bowed toward the minister and the minister bowed back and before they parted he leaned in and added, “The Vandals just scored.”

Teresa gladly introduced Brad to her chatty companion, the wife of the Minister of Political Affairs. After the smiles and chatting Teresa leaned in to Brad and whispered, “Why does she keep asking me if we need any flavors?”

Brad frowned. “Maybe she has some influence on what dessert we get.”

Teresa didn’t give him “the look”, but she gave him the public look. “I think they are trying to tell us something and I just don’t get it.”

Brad nodded.

Now that Purdue Pharma has filed for bankruptcy, I wonder if Idaho State Attorney General is smiling or wincing. Either way, he’s shown courage and conviction.

Purdue Pharma famously produced Oxycontin, a powerful controlled-release narcotic they marketed as a magic pain reliever that wouldn’t lead to addiction. At least that’s what I remember their well-dressed salesmen saying to me over an expensive catered lunch they provided for all our office staff. But that was in the mid 1990’s. As the body count started to climb in the early 2000’s they toned back their claims.

But this drug made a lot of money for the Sackler family who 100% own Purdue Pharma. The family net worth is estimated to be over $13 Billion. And surprise, surprise, recently discovered documents have shown they have hidden billions of assets in preparation for this planned bankruptcy.

Purdue/Sackler have already settled lawsuits with the federal government and states for hundreds of millions. Indeed, some executives plead guilty to criminal charges in federal court for misleading advertising. But a large group of states, municipalities, even tribal governments have signed onto a much larger suit that is pending.

Idaho AG Lawrence Wasden joined many other states just this last June in suing Purdue Pharma. It’s Wasden’s second dance with the drug company in court. He (representing Idaho) was a co-complainant when Purdue settled in 2007 for $19M.

Wasden isn’t just focused on Purdue. Idaho has filed lawsuits in Federal Court against many other opioid manufacturers.

But now Purdue is declaring bankruptcy. Before they filed Sunday night, they offered to settle with the long list of states and entities suing them. It is interesting who agreed to settle and who didn’t. One analyst painted a map of the states that agreed and who refused. Idaho stands out as the only Red (Republican) state that refused. I can hear the “RINO” howls already echoing against Wasden. It won’t be the first time. But Red- Blue is the wrong way to look at this.

The analyst had some interesting conjecture on the relationships between Republican AGs and a big-time lobbyist for Purdue. It seems Purdue contributed three times as much money to the national Republican AG Association ($680K) as they did the Dem AG Association ($210K). It’s hard for me to believe this colored their decisions.

Fundamentally, either Republican or Democratic, I believe an elected state Attorney General would want to pursue justice for their constituents; color me naive. Maybe the AG’s who settled were just being pragmatic and figuring the pot would be reduced dramatically when the imminent bankruptcy was filed.

So, what was Wasden thinking? His only public comment was that he did not believe the settlement was in the best interests of the people of the State of Idaho. Since we don’t know all the details of the offers, indeed, we probably don’t know where all the money is hidden, it’s hard to second guess his decision. But he didn’t take the easy off ramp. He’s got a lot of work ahead of him.

It’s tempting to look at the bottom line and just see what the dollars would have been if a settlement had been taken compared to the route AG Wasden has steered. “What’s in it for us?” Such thinking is driven by self-interest, not justice.

There is no doubt our state has suffered. Idaho’s accidental overdose death rate has tripled since Oxycontin was rolled out. And there is no doubt some people have profited greatly from that suffering.

I blame Purdue Pharma/ Sackler for misrepresenting their product. I blame my profession for falling for their lies. I blame patients for expecting life to be without pain. But all this blame gives me little sense of where justice lies. I believe Lawrence Wasden has that sense.

Maybe I’ve grown callous from a career as a family physician. I hope not. Years of talking to people about their aches and pains, their bodily functions, their private feelings and fears might have made me so. I sense people’s shame and I respect their privacy. But I believe somethings need to be talked about and sometimes publicly. One of those is how we die.

The number of people dying from accidental prescription overdose deaths started climbing in 1999. We have all heard how the big drug companies started pushing their drugs on the medical profession in the mid 1990’s. It wasn’t until 2006 that a CDC data analyst saw some numbers and thought there might be a problem. Interestingly, there were also murmurings from state medical examiners that reinforced the impression. But the rate of deaths has only recently begun declining.

Some states have a medical examiner system, unlike Idaho where we have county coroners who are only responsible for their own jurisdiction. I have written before about the variation in Idaho’s county coroner death investigations. The Canyon County coroner only specified type of drug overdose death in 35% of death certificates. Next door Ada County specified 91%. There is little doubt Idaho has undercounted our problem.

But that is the official government system responsible for death investigation and reporting. I appreciate that some are looking to change that system.

But I wonder how the change in local reporting of deaths also might have contributed to the rise in accidental overdoses.

Some of you may remember when obituaries were written by the local newspapers. They were “reported”. I’m sure the youngest or newest reporter got the tedious and uncomfortable job of calling the family and doing some background on the recently deceased. It might have been mundane, but it would have required some sensitivity too. We all deserve that. I believe the profession of journalism has lost some sensitivity. But the balance of privacy, sensitivity and public awareness is the job of a journalist.

In my hometown paper the formula always included age and cause or manner of death. I noticed many times the death was referred to as “natural causes”, which I took to mean cancer, since back then, there was some shame associated with that dreaded disease. That has changed. But that is truly a “manner of death”, since there are only five categories: natural, accidental, homicide, suicide, or indeterminate. I can appreciate skipping the details of “cause”. But sometimes the cause, say pneumonia or heart attack, was specified. I suppose this was sensitive.

The official report, the death certificate is required to be complete and detailed, but death certificates are not public record. They are shared with people who can demonstrate a need to know, like family or an estate agent. Life insurance companies demand a death certificate.

But in the early 2000’s many papers stopped reporting on deaths and obituaries became paid-for family written pieces. Most families don’t want to share such a tragedy as an accidental overdose or a suicide publicly. I can’t blame them. But it might have helped our communities have an earlier awareness of this wave of deaths.

I have asked some old newspaper guys and they explained this change with the simplest answer: money. Newspapers were being starved for revenue; Craigslist siphoned off the want ad revenue, online news depleted subscriptions, readership declined. They couldn’t afford to hire those young reporters and break them in on writing obituaries.

I really don’t know if more accidental overdose deaths would have been reported locally. Would the community benefit from knowing the young man died from an overdose? Would our awareness of the lethal effect of these drugs have made us a little less likely to demand them from our prescribers? It’s a sensitive question. We should all be a little more sensitive.

The national news amplifies our awareness of mass murders. Maybe Idahoans feel immune to the tragedy. But my little Idaho town has had two incidents of at least three people murdered in an event since I have lived here. Maybe that meets the criteria.

I can understand why we hear the reflexive reaction to mental health issues. The first perpetrator had demonstrated domestic violence; his wife was his first victim before he shot a cop and a church sexton, wounded a vigilante student before shooting himself.

I knew the second perpetrator from childhood. His behavior had become more unbalanced; his family was deeply concerned and reached out to him. But their concern couldn’t stop him from killing his mother, his landlord and the manager of his favorite fast-food establishment.

I don’t see any clear connection, and I don’t see how such rare, albeit tragic events can give one a sense of direction. I suspect both perpetrators struggled with deep emotional or psychological conflict, even disease.

But few people with mental illness harm others. In fact, in Idaho if you just got shot and killed, it is 13 times more likely you just shot yourself than some else shot you. I’m not sure how a “good guy with a gun” is going to help you there. But maybe access to mental health services might.

Do Idahoans have access to mental health services? Most measurements say we do poorly. A 2019 report from Mental Health America ranked Idaho 50^th out of 51 in overall response to mental illness. Mental Illness Policy Org. ranked Idaho 48^th in state funding for mental illness.

The Idaho legislature took a bold step 10 years ago and asked for and funded an assessment of how the state was addressing mental health needs. Further, they asked just what should we be doing. The independent evaluation suggested Idaho’s system was fractured and dysfunctional. They made some 35 recommendations.

To the credit of the Department of Health and Welfare, they asked for a follow up evaluation now ten years out. It’s nowhere near as gripping as the Mueller report, but it gives some good direction.

It seems Idaho has made some strong positive steps.

First, we established Regional Behavioral Health Boards. These give regional input to Boise about our varying needs from North to South to East. But they have not gone further to be funded for local or regional contracting of services. Boise can’t let loose of the purse strings.

Second, the DHW established a managed care contract with a state-wide provider (Optum) for behavioral health services to insure quality. It has not been a smooth roll out, but this was a strong step. Of course, making sure the contractor is doing their job will be a job in itself. Remember how contracted prisons went?

Third, Crisis Centers have been established in an attempt to prevent unnecessary incarceration or acute mental health crises. They were to receive full start-up funding from the state for three years, but after they had demonstrated their effectiveness to counties, more funding would come locally. That will be a hard sell.

Finally, through Millennium Fund grants, many local Recovery Centers have been started. They are peer support centers; they aim to help folks in recovery from substance abuse. But Millennium Funding is just year by year and I can see such support fading from the legislature. Many expect those dollars to fund Medicaid expansion.

The bottom line comes down to funding. Do you really mean to help those struggling? Our founders told us to:

 Idaho Constitution, Article X Section 1.  STATE TO ESTABLISH AND SUPPORT INSTITUTIONS. 

Educational, reformatory, and penal institutions, and those for the benefit of the insane, blind, deaf and dumb, and such other institutions as the public good may require, shall be established and supported by the state in such manner as may be prescribed by law.

Harvest is well along here on the Palouse, tomatoes are ripe, and it’s the second season for waivers thanks to our state leaders. The open comment period for this round began last Friday and runs through Sept 22^nd; you can read about commenting here. And here is a website where you can submit a comment, just click on the “Take Action” tab.

We haven’t heard any response from the Trump administration on the first waiver application, “Idaho Coverage Choice”. That one would allow folks on the Idaho Exchange to choose to “keep their insurance”. That was submitted back in mid-July. It would add to our expanding federal budget deficit. I can’t see how it will be approved. I’m waiting for a tweet.

But the current waiver application has to do with the “work requirements” the legislature added and the Governor signed.

I’m all for helping, indeed expecting folks to climb out of poverty, and a good paying job is one honest way to do it. But the requirements for reporting and maintaining eligibility for health insurance have proven difficult for many states to implement. In Arkansas 18,000 folks got kicked off the rolls just because they couldn’t (or didn’t) file timely reports. I would hope Idaho could do better. But keep in mind, doing better costs more money. Do you want to grow government to keep nudging people to get to work?

Montana did it right. They tied Medicaid applicants to job training and work openings through their Department of Labor. It didn’t add any bureaucracy to their system, but boosted employment.

One of the blessings of being in a conservative state is we can learn from early-adopters mistakes.

Kentucky’s efforts to add work requirements were initially approved by the Trump administration but then thrown out twice by a Federal Court; same with New Hampshire. There are currently six states with Trump-approved Medicaid work requirements, but not enacted yet. I suspect Idaho will join this group. And then we will send our Attorney General to defend a lawsuit in Federal Court. Our tax dollars would be better spent helping the working poor, not paying lawyers.

One of the dirty little secrets of work and Medicaid is that there are lots of folks working even full time who would still be eligible for Medicaid. It’s because their employer doesn’t offer health insurance and their wages are so low. There are currently in the US over 5 million workers (35% of adult Medicaid enrollees) on Medicaid. They are janitors, food service, construction, hospital, retail workers. But not in Idaho; up until Medicaid Expansion passed, able-bodied adults without children were not eligible for Medicaid.

In Idaho, where our wages are so low, the Department of Health and Welfare estimates 60% of the newly eligible Medicaid population would be working the equivalent of full time. Keep in mind, Idaho’s unemployment is rock bottom.

So, this waiver proposal would set up reporting requirements. We saw what that did in Arkansas. Somebody forgets to file their monthly work report, falls off a ladder, goes to the ER, and who’s paying the bill then? Yup, the taxpayer pays, and our costly county Indigent Program and state Catastrophic fund pony up.

It makes sense to expect good behavior from folks getting public support. When I first was running for office I met with a group of union workers at the local. They didn’t seem too keen to see a Democrat. I asked them what was most important to them. One guy offered, “Why don’t we drug test people on Welfare?” I told him I’d look into it since it made some sense. Some states have done this. It turned out the expensive tests proved drug use in applicants for assistance was less than a third of the general population. And states paid out millions to deny benefits to less than 1% of applicants.

If we want folks to act responsibly, we should expect our government to also do so with our dear tax dollars.

A lot of people have the dream of a cabin in the woods: peaceful, close to nature. But fire is a part of nature. Most folks woodsy cabin dream doesn’t feature a 50-yard cleared “defensible zone”. But hey, it is your property. You should be defending it.

Back when I fought fires I couldn’t believe all the man-hours spent by Forest Service crews protecting cabins in the wilderness. I’ll never forget the sight of a rolled over tanker truck after a direct retardant hit from a C 130 on a fire in the chaparral in California. All this to protect a dilapidated shed in the bottom of a canyon.

As the Nethker fire up near Burgdorf Hot Springs in Idaho County slowly grew in the last couple weeks, some home owners got the word from the Forest Service that “structure protection” was not their priority. It seems the shared agreement between Idaho County and the USFS had not been renewed. When the property owners appealed to Idaho County officials for support Commissioner Skip Brandt gave them the news:

“People who choose to live where there are no tax or subscription based fire protection districts and where it can be difficult to get insurance must realize that there are risks involved and that a key component of private property rights is personal responsibility.”

He’s right. Folks can form fire districts, vote to tax themselves and spend the money they collect from themselves according to district governance. But I’m not sure I’d want to pay my taxes for a rural cabin I cleared around when my neighbor let the pine needles pile up on his shingle roof. But that gets around to how you structure your governance.

People come to these agreements with sewer districts, water districts, highway districts. Sometimes sharing a cost for a valued service is worth it.  But expecting to be rescued as the brush burns closer to your wood pile is too big a stretch for me.

The State of Idaho has shared agreements with both the USFS, Bureau of Land Management and other entities. This shared agreement means if a fire starts on BLM land and they dispatch resources, when the fire spreads onto Idaho State land and they keep fighting it, they will send a bill to the state for these expenses. I guess Idaho County Commissioners saw no real up-side for sharing in these expenses. I have no opinion about that decision. But I sure agree with Commissioner Brandt not sending the cavalry to save every threatened structure.

Maybe I’m biased by a family history. My grandfather Henry had ranches along the rugged Wildhorse River near Brownlee Dam. It was the end of haying season and the second cutting was stacked, the fields were stubble and it was a dry August. He thought the fire started down by No Business Creek where some fishermen had been that morning. He, Grandma Helena and his hired hand plowed furrows around the haystacks and they tried to beat back the flames with wet gunny sacks. The Basin Ranch was surrounded by BLM and Forest Service land so a plane came over in the afternoon and dropped a stick of jumpers up above the house a quarter mile from the slowing flames. No wind had kicked up, it was looking like things would be OK.

But the plane lost an engine as it circled and couldn’t climb out of the canyon. It came back around and tried to land in the 400-acre hayfield. But it nosed down and tumbled, killing both pilot and copilot and now extending the fire for another couple hundred acres off to the west and north. Henry only lost a couple haystacks. The house and barn were OK. He never had much good to say about fishermen after that.

Living off by yourself demands some self-sufficiency. It’s hard to build shared resources when you can’t see the lights of your neighbor.

I was skeptical when the well-dressed drug salesmen told us in the 1990’s the new long acting narcotics (Oxycontin) wouldn’t lead to addiction. I remembered the processes taught to me long ago in medical school how our bodies change the number of neuro-receptors we have, so we can develop tolerance to drugs over time. Our bodies understand just how important the sensation of pain is to our survival.

As a physician skeptic, I rarely prescribe the new drugs as they first come out. Call me conservative.

I was also skeptical when I started reading about the new narcotics developed to treat narcotic addiction.

Maybe it was because I knew the history of humans and narcotics. Opium extracted from poppies has been used from ancient times. The dark paste could be smoked or eaten. It offered some benefits but addiction was a problem for many. Hundreds of years ago it was discovered that a mild acid extraction of raw opium produced morphine. This new drug was used for pain, but also to treat opium addicts.

Then, after the Civil War, a stronger acid extraction of morphine produced heroin. Many horribly wounded veterans had become addicted to morphine, and heroin was at first considered a treatment for this addiction. Heroin was effective for acute pain, but its faster action produced a euphoria, and addiction again became an even greater issue.

Methadone was another new narcotic 40 years ago developed specifically to deal with heroin addiction. It has migrated to be used for chronic pain, but it has a very narrow window of pain relief before it suppresses the drive to breathe; fatal overdose is a significant threat. Federally licensed methadone treatment programs are available for patients with narcotic addiction, but patients may be required to come in every day and be observed taking their dose. It makes holding a job or travel a real problem. And there are only a few treatment centers in Idaho and they are in urban areas.

So, when another “new” narcotic drug was suggested for the treatment of opioid addiction I was skeptical. But I read the studies and the reports.

This new synthetic narcotic buprenorphine, binds to the narcotic receptors on our nerve cells very strongly, but it doesn’t fully stimulate the nerves. It is effective at reducing cravings but doesn’t produce a “high” feeling. It has been used in Europe for 20 years, but only for a decade here in the US.

I understand the Drug Enforcement Agency being reluctant to authorize the use of another narcotic to treat narcotic addiction. I’ve just described for you the tawdry history of such attempts. So, the DEA requires any physician prescribing this drug to get extra training and limits the number of patients they can treat.

I had little reason to prescribe this drug until recently. Now I work in a clinic with a program for the treatment of patients with substance abuse disorders. My skepticism is being challenged daily.

I took the extra training and got the DEA certification. I learned the pharmacology of the drug, its side effects and drawbacks. It is no miracle drug, but for some folks it can provide a real benefit. And that’s the goal, isn’t it? Get people healthy.

Patients must see a counsellor as part of our program. We test urine specimens for any illicit substances. We call patients in to count their pills to make sure they aren’t selling them. And believe me, there is a market for these pills too. Almost every patient we have enrolled on our program admits they have tried the drug “from a friend”.

In our program I’ve seen patients who haven’t used illicit drugs for years now, on a low maintenance dose. They are in stable relationships, working regular jobs. Most expect to be off the medicine someday.

I hope so too.

Many physicians I have spoken with are very skeptical about the value of such treatment. I know their skepticism. I wonder why they weren’t so skeptical when the fancy suit drug salesman came knocking with Oxycontin coffee cups 25 years ago.

Everyone rails against the cost of healthcare in these United States, but honestly, we have done just a little to address the problem. I’m not sure things are bad enough yet for us to have the motivation to look in the mirror. Because, for healthcare to cost less for all of us, some of us, maybe all of us will have to give up something, and right now we Americans are blaming everyone else for our problems. Americans aren’t really in the mood for any small sacrifice, no matter if we would all be better off; just look at Congress’ and our President’s spending habits of late.

No, this mess is wholly ours. It’s not Muslims, Mexicans or the Chinese who have driven our healthcare costs to be unaffordable to middle income Americans; it is us.

If we are going to start laying blame, we can all bear some.

We have come to expect medicine to solve every problem, from our kid’s behavior to the existential malaise of working hard at a thankless job. Pharmaceutical companies are glad to profit greatly off this desire for peace. And we are happy see our 401K’s swell as Pharma stock climbs.

More, we don’t have the patient understanding that most ailments are self-limited; many things resolve with “benign neglect”. And the medical profession responds happily to these instant needs with instant access: Redicare, QuickCare, UrgentCare. But the continuity of care is missing and tests are piled on tests. Treatment pleases most consumers more than watchful waiting, so medications, quick fixes are prescribed.

We value “the best” when often “good enough” will do, so specialty care is well-compensated and much desired by both patients and practitioners, when primary care has been shown time and again to be the most cost-effective care.

We avoid difficult conversations, with our healthcare providers or even ourselves about painful, but health-affecting behaviors. We should reflect on our weight, our exercise, our diet, our habits, our sleep, our spiritual and interpersonal relationships. Sometimes we pretend our deaths are not inevitable.

How does the truth that 50% of health care costs can be attributed to 5% of the population strike you? If you are in the less costly 95% do you feel lucky for your health, or are you angry that you are paying for someone else’s greater needs? Do you find yourself questioning their treatment choices? Would you like to be a part of the discussion around their bedside about the chemotherapy, the transplant? If you see the sick 5% as the enemy, then I challenge you to define who is “us”.

There are things public policy can do to pinch the costs of healthcare. The Affordable Care Act did a scant few.

Hospitals were not paid for any costs of complications they caused. Guess what, complications went down.

Taxing medical appliances was another attempt to make the highly profitable medical appliance market more competitive, but it quickly got overturned by Republicans.

Fees proposed on “Cadillac Health plans” to pay for the costs of health insurance subsidies on the individual health insurance exchange was another attempt to even the health care benefits playing field. But Democrats and Republicans are going to throw this under the bus and the Federal deficit will balloon another $400B. No, there’s not a lot of courage out there in the healthcare discussion right now.

We cannot expect our elected representatives to have courage in the face of these difficult policy decisions when we aren’t prepared to have these cost discussions with ourselves; in the mirror, with our family, with our doctors. Don’t be afraid to know yourself. Please; the only way to defeat a strong enemy is to know them well. In this instance, they are us.

We are a nation of laws, not proclamations, despite what our current (and previous) president seem to think. Sometimes laws are passed that enable the executive branch to have some discretion in the enactment of the law. Thus, Presidents and indeed governors can make some policy decisions if the law allows them. When the executive branch acts contrary to a law, we sometimes get the judicial branch deciding just what the law should say. But clearly written laws avoid such a mess.

  When Proposition 2 passed by initiative last November and the Acting Governor Brad Little and Secretary of State Lawrence Denney signed it two weeks later, it became the law of the state of Idaho. It was a simple law that directed the Idaho Department of Health and Welfare to change Medicaid eligibility in Idaho. With this law people who previously could not access health insurance on the Idaho health insurance exchange because they had too little income, become eligible for Medicaid health insurance. The initiative language was consistent with the language of the Affordable Care Act, which became federal law in 2010, and still is the law of the land.

Six months later the Idaho legislature passed, then Governor Little signed SB 1204 and that became law immediately, April 9^th, 2019. This law had many provisions asking the Idaho DHW to request waivers of the federal government so that Idaho’s Medicaid plan could be different than laid out in federal law.

But the drafters of the “Medicaid Sideboards” knew they were out on a limb. They were warned and considered that what they were asking might not fly with federal statute. They did the honorable thing and included an escape clause in amongst their laundry list of waiver requests. Here it is, from Idaho Code Title 56, Chapter 2:

Eligibility for medicaid as described in this section shall not be delayed if the centers for medicare and medicaid services fail to approve any waivers of the state plan for which the department applies, nor shall such eligibility be delayed while the department is considering or negotiating any waivers to the state plan. The department shall not implement any waiver that would result in a reduction in federal financial participation for persons identified in subsection (1) of this section below the ninety percent (90%) commitment described in section 1905(y) of the social security act.

This is important for Idaho because this is exactly where the state of Utah finds itself now. Utah passed a similar initiative to Prop 2, but then the Utah legislature did about what the Idaho legislature did and directed the state to ask for waivers to limit the full expansion. The Trump administration has indicated they will deny those requests.

Obama administrators did the same, denying waiver requests from states who wanted partial expansion or added tough sideboards. Their intent was to encourage states to do full expansion.

But now, the Trump administration is betting on its lawsuit to get the whole ACA declared unconstitutional, as they argued before the US 5^th Circuit Court of Appeals. A decision on this will be coming in the next few weeks. Then it likely will be appealed to the US Supreme Court.

But for now, the ACA, and Idaho’s Proposition 2, and the sideboards bill are all laws of the land. It was a noble thing for Idaho lawmakers to include the “escape clause” in their bid for sideboards and I applaud them for that consideration. It is hard to proceed on these shifting sands.

The ACA was a baby step in health care reform. It reinforced the private health insurance industry but did little to control costs.

Should the 5^th Circuit support the Republican argument to repeal the ACA, we will have significant turmoil in the healthcare marketplace. But significant change usually only comes out of turmoil. Maybe that’s what we need, turmoil not tweets.