Now What?

Posted on December 19, 2018 by ddxdx

It’s been over eight years since the Affordable Care Act (ACA) became law with NO republican votes. Since, we have had many political campaigns propped up on “Repeal!”, then “Repeal and Replace!” and now we have the decision of a Texas Federal judge that the whole thing should just go away. He bases his opinion on the fact that the Trump tax break for corporations and the wealthy passed last year overturned the individual mandate. OK. I get it. You Republicans don’t like the Affordable Care Act. But just what did you have in mind to get us out of this mess we are in?

Americans pay almost twice as much per person for healthcare as the next developed country in the world. And ALL of the other developed countries have universal coverage, either through a single payer plan or regulated private insurers like the ACA was headed toward. So just what do you Republicans have in mind for us? I hear all these “free market” and charity care notions. Is that the direction you want to take a 21st century American economy? It’s about time we heard your plan. Obstruction politics is getting old, don’t you think?

Most Americans get their health insurance from their workplace. If they have a medical condition, they then become a slave of that expensive benefit. If they try to change employers, thanks to the Texas judge who heard from lawyers with Republican support and funding, their preexisting condition can exclude them from coverage. If they don’t have a medical problem, they just think they could start a business on their own that might be a real economic driver, now they can’t afford to buy their own or their employees’ coverage since the individual marketplace is in shambles, thanks to eight years of republican obstruction. The ACA tried to address this. It didn’t very successfully, since there was no real congressional oversight of the individual health insurance marketplace for the last 8 years, thanks to Republican posturing.

And that’s what it’s all about here is posturing. Strike the pose that gets the crowd roaring. I guess we can afford to waste this time. We are all so comfortable with our Netflix and ATV’s that we don’t see the money we are wasting on this health care industrial complex. After all, it’s only a $20 Trillion-dollar national debt we hand to our children, and if our economy just grows at 5%, then that will all disappear. I am not comforted.

Where are the Republican ideas? Is it too painful to admit that the ACA was actually a pretty conservative plan put forth by a charismatic Democratic president who had to twist a lot of left arms to get it to pass? Is it too painful to admit that the ACA resembles Romney’s plan for Massachusetts or McCain’s 2008 plan? I’m sorry it is so painful, but we need you Republicans to start giving us some answers. And please, one without a promise that the Mexicans will pay for it.

We have serious issues regarding our national health care. Why can’t we have serious discussions about the solutions? Do you republicans who hate the individual mandate think all people should have health insurance? Do you republicans who have fought the individual market place think health care coverage should be portable and affordable for people who don’t get insurance through their big employer? Come on, let us know your plan. I’d love to hear it.

 

 

 

 

 

 

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Suicide in Idaho

Posted on December 12, 2018 by ddxdx

A man I knew well and considered a friend killed himself this last week. The feelings that wash over us survivors might mirror the feelings of the victim: anger, sadness, despair, failure. I will admit to all those. I imagine someone close to you has killed themselves. I am sorry. It sounds so inadequate, doesn’t it? What else can we offer?

Like any painful issue, if we are not willing to look at it, talk about it, try to understand and respond, then it will stay with us. We might get better at hiding the pain, denying the pain, but it’s still there. And if our best response after honest reflection is prayer, then let us pray. I will join in the prayer.

Let me offer some numbers for this moment of reflection. Idaho has consistently been in the top ten in states for rate of death by suicide; 8th nationally in 2016. The rate of death by suicide for Idahoans is over 50% above the national average. In Idaho, suicide is the second leading cause of death for ages 15-34. Teen suicide rates rank higher than our overall suicide rates. Did you know the highest rate of suicide is in men over 80?

But numbers don’t tell a story, do they? I got my share of stories as a county coroner. Suicides, like homicides or any “unnatural” death got the time and attention (and tax dollars) of this lowly public servant. I will admit to a pretty libertarian viewpoint toward suicide early in my career. We are all going to die. So what if someone makes the choice? I did not see it as a mortal sin, but then I was not brought up in that faith. But so many of the deaths I struggled to come to peace with, beyond the mere investigation; I changed my view.

The many older men (some my age) failing in their strength, their independence who chose to end their lives, I could somewhat accept, though I could hear the pain and suffering in their loved ones.

The ones who had struggled with addiction or depression, sometimes were not a surprise to their family. But I could clearly hear the sense of failure, their sadness, their shared despair at the loss.

But the young deaths, sometimes impetuous, fueled by anger or lubricated with substances or an impetuous nature left me very burdened. And I am sure their families still struggle.

I have come to believe suicide, like homicide deserves our attention, our investment as a society. Not all violent deaths can be prevented. But if we cannot prevent all, should we give up on preventing some? If we as neighbors, as fellow citizens are not willing to even make such a commitment, what does that say about us, the survivors?

I am thankful that Idaho has made this commitment. You taxpayers invested in this, with the legislatures and the governor’s approval. In 2016 a small investment was made to coordinate existing suicide prevention programs, to educate youth, to support the statewide hotline, and advance public awareness. Like all investments, we need to pay attention to the wisdom of each dollar spent. But it’s about time we did something. There is so much to do.

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My Ex is getting Married

Posted on December 5, 2018 by ddxdx

It was front page news in my town that a family practice clinic was being purchased by the local hospital. Before I reflect on this, you need to know I was once a partner in the clinic but left over 10 years ago. Similarly, I was on staff, on the board and chief of medical staff at the hospital that is purchasing my ex-clinic. So, my reflections could be biased by my prior experience.

The stated reasons for the change in relationship are that both parties will benefit. The clinic has had a hard time recruiting new doctors and they see the new hospital ownership as a way to help this. The hospital sees the move as a way to be bigger: “A deeper bench…We’ll have about 650 employees…” Neither of these reasons hold water, but they reflect the dismal situation we have come to in our health care environment.

First, bigger is not always better for the consumer. Bigger bargaining power may allow the hospital/clinic more leverage to bargain higher payment from insurers. Then our insurance rates go up. Just four years ago the US District Attorney and the Idaho Attorney General sued to unwind a larger hospital purchase of a much larger medical clinic in the Treasure Valley on the grounds it was anti-competitive. The court upheld the suit and the clinic purchase was nullified.

Second, the only way the hospital can help recruit and retain primary care physicians is to shift some revenue to pay primary care doctors more. Think about the high-paid physicians the hospital supports now. Radiologists (who make three times what a family doc does) have hospital-funded scanners and hospital-paid technicians to do the scans. Surgeons (who make 3-4 times what a family doc does) have hospital-paid operating rooms and nurses to help them perform their well-paid surgeries. Is the hospital going to somehow pay the specialists less so the family docs can make more? Or will the nurses earn less? Or will health care costs just go up as they have?

What we pay for in health care is the problem, and maybe this consolidation will address this, though neither executive cited this as a goal. If we don’t start paying for value in health care and move away from paying for procedures, we will just keep having more procedures, more things done, and we will not be healthier. Did you know this is the third year in a row that US life expectancy has decreased, despite ever increasing health care expenditures?

I hope our local hospital shares this vision for adding value to our community instead of promoting more procedures. But here’s the pudding. The hospital dropped two community services, hospice and an adult day health program, because they didn’t “make money”. But they now have a full-time marketing director and development director, as well as bill boards all around town touting their care. They maintain a “critical access” designation while they spend money to drum up business. Does this make our community healthier? I’m sure it bumps their revenue.

So, the clinic purchase may benefit both entities, as any good business deal should. But will it make our community any healthier, make health care more accessible, affordable and appropriate? I hope so.

 

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Humbly Thankful

Posted on November 28, 2018 by ddxdx

The turkey and dressing leftovers may be gone but the time for thankfulness is not over. It’s a blessed day in Idaho when the sun sets westward and we draw comfort that it will rise again. Such blessings are symbolized annually by the gathering of our elected representatives in the darkest months at our state’s capital. We are comforted that come spring, the trees will bud, grass will sprout, snow melt will fill the rivers, fawns are born, but most blessed of all, the lawmaking will cease and our elected representatives can return home where they can do us no more harm.

Each season bears its tasks, and meaningful tasks deserve our thanks. Spring for planting, summer the weeding and watering, fall the harvest and winter for bearing up under the burdens of the long dark legislative session. What solution will some yahoo propose to make our children want to learn? He surely knows education best; he won an election! What fiasco will be proposed to make more water available, when most of our senior legislators have trouble making their own water pass? What tax scheme will come forward that enriches the rich and pulverizes the poor, but for sure shrinks government to suit the Idaho Freedom Foundation? We should not spend our winters under such a thankless burden. I suggest instead we pursue more meaningful winter tasks, like taking a long walk and giving thanks for the icy footing and chill wind in our face.

This particular season I give thanks that Idaho citizens had the initiative to tell their lawmakers what to do. We elect these people, but thankfully, sometimes we get to tell them when we think they are getting it wrong. A few years back we were able to signal clearly to the legislature that their Luna Laws were poppycock. The laws were hatched in secret by an arrogant Tom Luna, recently reelected Superintendent of Public Instruction, who made no mention of this idea just months before in his campaign. The legislature passed these education reform laws despite overwhelming public testimony in opposition. Well, the referendum to repeal the laws passed with a wide margin. Governor Otter took the hint and then set up a work group to make recommendations. When arrogance and hubris fail, I guess open and broad discussions around a difficult topic can provide direction. Lesson learned?

This year the electorate sent a clear message to our leaders too: expand Medicaid health insurance eligibility to the working poor in Idaho. This was in the face of many legislator’s strong opposition or more often, silence but definite inaction on the issue for the last 6 years. I am thankful we had the opportunity. I will be even more thankful when the legislature decides to listen.

For what is being thankful if it is not humility? None of us gets everything right all the time. Admitting to being wrong is not a show of weakness or ineptitude. And such an admission is no guarantee one won’t be wrong or inept once again. But not admitting to one’s mistakes, not reflecting humbly on past actions is arrogance. And arrogance is a guarantee for future mistakes.

I hear the legislature has expanded its “civility” training for this year. I hope somewhere in those lessons there might be some time for them to be humbly thankful for the opportunity they have to represent us in state government. It is very tempting, once one is anointed by 50.1% of the voters to think you have all the answers. Be thankful; be humble.

 

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Rip off the Band-aid

Posted on November 26, 2018 by ddxdx

 

I hear the Idaho Department of Health and Welfare wants to wait until January 2020 to start enrolling people in the newly expanded Medicaid eligibility passed under Proposition 2 this last election. I’m sorry, but this is a pressing need. You state workers will need to git ‘er done.

Here’s why. Idaho has a taxpayer funded system, conceived way back in territorial days to pay for folks who need medical care but can’t pay for it. This is the county indigent health care system. It seemed to work OK for maybe a hundred years, but then small counties realized they could be bankrupted by one premature baby. So, the state Catastrophic Fund was conceived and now any bill over $11,000 goes on to the state. These county property tax dollars come to approximately $25M for all the counties and another $25M in state income taxes.

This system has propped up our small (and big) hospitals for too long. It needs to go. The sooner we get Idahoans enrolled onto health insurance, the sooner we can put this 19th century health care payment system in the dust bin. Git ‘er done.

I have questioned our new governor’s back bone. But this is just ripping off a band aid. We can do this; c’mon Brad.

Sure, there will be work to do. Folks who are now on the exchange but who would newly be eligible for Medicaid will need to be transitioned. That’s work the DHW will need to do sooner or later. We have a good number on this. Maybe 19,000 Idahoans could be affected. But there is another troubling number.

As the County indigent and CAT Fund costs have risen in the last couple years (since Trump and the repeal of the individual mandate) we are finding that more and more folks who are getting Idaho taxpayer funded indigent payments for their health care emergencies would not have been eligible for Medicaid. They make enough to buy insurance on the exchange. They just have chosen not to. But then they fall off a ladder and we pay for it. OK, they will be bankrupt, liens filed, but why can’t we make them enroll in an affordable health insurance plan. Maybe some folks like being free riders.

In my second year of medical school my first daughter got very sick and needed a complicated and life-saving surgery. My student health insurance wouldn’t cover it because it was due to a congenital (preexisting) condition. But the hospital and the surgeon did that surgery and we never got a bill. We benefited from their charity and I am to this day thankful to the point of tears for their generosity. But it meant I rode the system for free. And I resent that.

We all need to pay a share for the care we get. Idaho’s current system does not encourage people to think ahead, consider that they are part of the greater good. Instead we are encouraging people to play roulette, or more likely, Russian roulette with their health and our tax dollars. We are encouraging people to try to see if they can get a free ride. This makes no sense.

C’mon Idaho, Git ‘er done.

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Owning our Health

Posted on November 15, 2018 by ddxdx

The campaign to expand Medicaid health insurance eligibility in Idaho brought some broad health policy questions to the forefront. I am thankful we are having these discussions now; we have put this off for a long time. One of the recurring counter arguments I heard when talking to voters was how “giving people a free handout” (Medicaid health insurance) made the recipients less likely to be responsible. This is the “moral hazard” argument that is well-studied and documented in economics. I’m not sure why this argument doesn’t apply to employment-based insurance also, but I get the rub. We all want people to be responsible and any program that might discourage responsible behavior should be scrutinized.

So, let’s scrutinize. I’m sorry if this gets uncomfortable. I’ll put on the gloves and you’ll need to bend over. You see, I am a doctor.

When I first meet a patient (before the gloves and bending over) I ask them questions about their symptoms, their medical history. One of the many questions I ask is phrased carefully: “What medicines do you take?”

Approximately 2/3rds of the time the patient response is phrased: “They’ve got me on a pill for my blood pressure, and they have me take a cholesterol medicine.”

I believe the words we use can often reflect how we think about things. In this case, “They have me on” suggests, I believe, the patient feels little involvement in the commitment to take a medication. In fact, the phrase suggests they are forced to take it, like “They have me in solitary confinement.”

When I can have the time, I encourage patients to say “I take a medicine for my blood pressure. I take XYZ for my cholesterol.” I believe in promoting ownership in our health. The passive, unengaged patient is not healthy.

I have no sense that people on Medicaid, Medicare, VA (that is, government-funded) benefits are more likely to use such phrasing. In fact, I have no evidence that such language is in fact related to a sense of disengagement with one’s health. Maybe you can ask yourself how you feel about the medications you take and the language you use to describe them.

If we can promote engagement in responsible behavior, engagement in our health, we may in fact promote better health. Private insurance companies spend a good deal of money with programs like this. In some plans, premiums are lower for people who participate in exercise, weight loss, healthy diet, smoking cessation. The hard part about all these programs is that the return on investment is probably 10-20 years out, and people change health insurance companies every 3 years, so the company rewarding the behavior doesn’t receive their return on investment.

I’m all for promoting healthy behaviors. But the best way I have found to do this is with direct interaction with a person, be that doctor-patient, or friend to friend. Governor Otter started building this plan 6 years ago with the Patient Centered Medical Home model for primary care in this state. It is an ongoing and successful model for healthy primary care relationships that could have leverage to change behavior.

I can’t believe someone writing a law in Boise will suddenly make people change their attitude toward their own health. But I can sure see them trying. Without gloves on.

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Hold on to the Reins

Posted on November 8, 2018 by ddxdx

 

By the time this is printed the November 6th election will be over and half the electorate will think the world will end and the other half will think their prayers have been answered. And the half that didn’t vote will point to the outcome as justification for their laziness. If this representative government is going to work, we can’t expect our elected representatives to be smarter, work harder, or care more about our lives than we do. Don’t ever expect you can let loose of the reins if you know where you want to go.

From sewer district commissioner to governor, we ask our elected representatives to do the work we don’t have time for in our busy lives. But representation, by its nature, is a deeply flawed process; we give our voice to someone who votes, acts for us. Who would want to do this work for us? Can we find someone, anyone? It’s not always easy.

In my first elected position, county coroner, I was asked to fill the office when the previous elected coroner resigned. In our county, the new doctor in town was always expected to serve as coroner, and I was the newest. I was appointed. Then, in two years I stood for election, repeating that every four years. Sometimes an opponent filed. I always wondered if the voters actually knew what the coroner did. To be honest, when first appointed, I didn’t have a full picture of all the duties of the county coroner. But I worked at it for 15 years. I was amazed that every new doctor coming to town refused the position. I started to feel like a bit of a sucker.

County Coroner is a partisan position, but I ran and served as an “Unaffiliated”. If I had been partisan, the local party might have tried to recruit a replacement. Instead, there were 2 or 3 last-minute write-in candidates in the primaries. And it turned out just fine. At that time, I had little faith in the value of party politics, but searching for, seeking people to serve in public office is a valuable function. But partisan loyalty may be their measure of qualification. Do you want to hand the reins of choosing representation over to a party organization?

In my second elected position, state senator, I was asked again to consider running. I chose to, I worked hard and got elected, then reelected twice before getting unelected in 2016. But I’d learned that I needed to start recruiting candidates, encouraging people to consider public service. After every election, I did my best to thank every candidate that ran for office, win or lose, commend them for their interest, and encourage their effort. I met with many people in the district and talked to them about their situations, their interest in public service and encourage their participation in this representative experiment.

If you are exhausted, frustrated, elated or depressed about this election, I want you to think about just where you think this wagon is going, and who might best serve in our communities. If you are thankful for your representation, let them know, and tell your neighbors. If you think the wagon is off the path, start looking around. But don’t think you can let loose. The common good is not served by dangling reins.

 

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Rural Health Values

Posted on October 31, 2018 by ddxdx

Some are arguing that rural Idaho hospitals need Medicaid Expansion to survive. I’m arguing we will need more than a simple yes vote on Proposition 2 on the November ballot. That’s just an important first step. For American healthcare to serve our citizens, big cities and small towns, we are going to need to ask and answer some hard questions.

Thirty years ago, I took a break from my 36-hour hospital shift in residency to listen to a lunch presentation from the CEO of a big Eastern Washington health insurance company; like he was a visionary. The food was free. He outlined the three biggest threats to US health care: AIDS, Alzheimers, and rural hospitals. I really only remember his solution for the third: “What most small towns need is just an urgent care facility and a helicopter pad. They don’t need hospital beds.”

As a resident learning Family Practice and planning to give full spectrum care to seriously ill folks, deliver babies and do C-sections in a small town I thought he was crazy. But the health care market place as it is currently structured has me wondering, and Idaho is a great place to pose this question.

So, what value does your hospital bring to your community?

I ask this as a doctor who has worked in many small north Idaho towns. Is there value that your baby be delivered close to your home? Is it valuable that your grandparent be cared for close to home? Is it vital that health care jobs are available in your town? Does your small-town hospital add value to your community?

The insurance company CEO saw little value in keeping sick people that couldn’t be quickly patched up in an urgent care facility close to home. Big city hospitals could be more efficient, had more technologic treatments, and thus could bill for more expensive care. The medical business model as his vision saw it provided a simple solution: more helipads.

I also remember this quote from a big city hospital executive: “My hospital earns $50,000 when we amputate a diabetic’s diseased foot. But we lose $50 every time we counsel him to manage his diabetes.” Think about those incentives.

Proposition 2, Medicaid expansion, will simply provide that some folks who don’t have insurance now and get care at your small-town hospital have their care paid for by their insurance: Medicaid.  Many currently get care and have no method to pay. The hospital provides the care, then scrambles to make ends meet.

In the last 8 years across the country there has been a spike in small-town hospital closures, though none in Idaho. The county indigent payments (after liens are filed and bankruptcy insured) and state tax funded Catastrophic Fund have barely supported small hospitals. Rural hospitals in states that expanded Medicaid eligibility were very much less likely to close.

Medicaid expansion, Proposition 2 on Novembers ballot will make rural hospitals more secure financially in our current system. But the system has to change. Community conversations about what services add value, are vital, or unnecessary will help this system change. Talk to your hospital board members. Let them know what you think. But if you value your local hospital, you should vote for Proposition 2.

 

 

 

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Backbone

Posted on October 29, 2018 by ddxdx

I watched Brad Little and Paulette Jordan debate on a Boise TV channel. You could catch it online. It was clear to me Brad knows healthcare issues, but I’m detecting some bad symptoms in his approach. It’s a big issue, Idaho healthcare, and Brad will need some backbone, heck we all will, if we are going to get to work on it.

Here’s the first symptom: Brad can’t even say whether he thinks Prop 2, expanding Medicaid insurance is good or bad, just that he will “respect the will of the people”. That’s a sign of a politician wanting cover for doing something that might make some of his constituents unhappy. Expanding Medicaid coverage as Prop 2 will do is just one small step of many steps that will need to be taken. I have diagnosed a weak backbone. And I’m not a chiropractor.

But Brad does understand that the individual market on the Idaho Exchange is not functioning. He points to solutions to reduce premiums for young healthy small business people. His solutions carve up the marketplace, so people not expecting to get sick can pay less. Well, when they get really sick, they won’t have coverage. Brad’s OK turning the marketplace back into a roulette game by abandoning the requirement for “essential benefits”. If we (Idaho voters) aren’t all in this together, his plan will have us playing Russian roulette, not just the spinning casino wheel game.

Little has also embraced the plan to move really sick people with expensive diseases (advanced cancer, organ failure, systemic disease) out of the individual market and onto Medicaid. 90% of health care costs come from only 5% of the population. This sort of cost segregation in the health care pool has long been known to be an effective method to reduce costs. For private insurance companies, after they couldn’t exclude pre-existing conditions, the problems came in the numbers and the geography. If the model is to pool these high-cost folks from different insurance companies onto a government plan, managing more with more leverage, maybe there could be some savings. Do you trust that the government will fund this program, good times or bad? Diseases don’t fluctuate with tax revenues. That sort of public commitment will take a very healthy backbone. Can Brad’s get stronger?

This last proposal clearly leads one to think of a single payer plan, so I’m surprised Brad Little and Department of Insurance Director Dean Cameron are suggesting it. Maybe they think we won’t see the logical progression. If their goal is just to segregate the very sick, and they expect this model to hold fiscal water without a clear public commitment, they are being either short sighted or cruel. Knowing both these men well, I’m diagnosing nearsighted.

Brad Little’s nearsightedness and weak-spine on Idaho healthcare are correctable. What about his opponent, Paulette Jordan? She displays no understanding of the complex issues and is just trying to ride the populist wave of Prop 2. I’d much rather deal with a patient who wants to understand and work on their problems, than one that is oblivious of them.

 

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Appointments

Posted on October 16, 2018 by ddxdx

Senator Siddoway debating against F&G Commission nominee in 2013.

With the recent forced resignation of a Fish and Game Commissioner, it’s worth looking at the appointment power the governor has here in Idaho. The Idaho Senate confirms many gubernatorial appointments as required by law. Some appointments and the boards they serve on have statutory (legal) requirements. Appointees come before an assigned committee and are interviewed. Then the appointment is carried by a Senator to the floor of the Idaho Senate for confirmation.

The legal requirements for serving on a Boards or Commission, or as Director of a department usually had to do with qualifying experience, but often, in statute the makeup of the board was required to have a partisan balance. Statute might read “no more than two members may be of the same party”. That’s what the statute for the Board of Corrections says. Is this legal requirement for partisan balance important? You bet it is. Without it, cronyism and partisan pandering would be more rampant than it is. More, it could affect your vote for Superintendent of Public Instruction.

Cindy Wilson has been active in Idaho government well beyond her classroom work as a teacher. She is a strong leader and a powerful voice. So, I can’t figure out why she got appointed to the Board of Corrections unless Brad Little stood up for her. Governor Otter has used these appointments as a partisan tool. Brad advocates for good people. But he keeps a political eye on the landscape. Some Fish and Game Commissioners have gone on to the legislature. Some appointments are rewards to moderate Republicans beat by Tea Party republicans. If the statute requires it, they become “unaffiliated”. Butch knows how to stack the deck. Brad has a better eye for the common good.

What better place to see the need for improvement in our public schools than in our prisons? As a Joint Finance and Appropriations Committee member, I toured many Idaho prisons. Not to mention I worked there as a physician. On one tour we observed a classroom working on personal accountability. As we started to leave our Chairman (Dean Cameron) asked the class how many had graduated from high school. He did it politely, with a purpose. One hand of the thirty inmates went up. As we went out to the bus I stood next to him and complemented him for the question. Legislators need to know these things. “Were you pushing for funding pre-K education?” I asked. He rolled his eyes. He wanted his committee members to make the connections; I might have taken that a bit too far.

Cindy Wilson served on the Governor’s Task Force after the Luna Laws got shot down. Now she serves on the Board of Corrections. Connecting the dots on how our citizens thrive may seem simple to some. A local candidate suggests “getting rid of the dead beats”. Does he mean a deep trench and a firing squad?

I believe Cindy Wilson has watched classroom performance, has watched our corrections system struggle and now balloon, and understands the connection. But if Butch Otter (or Brad Little) wanted to make Idaho safe from Democrats, he never would have offered her for such a position. He did. Thanks Butch (or Brad).

 

 

 

 

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