It was August 2nd 1979 and we were about to head into a fire of incredible magnitude. But there was no smoke to be seen, just 4 or 5 helicopters in Bruce Meadows of the high central Idaho wilderness and all the overhead was off in a tent deciding what to do with our lives. Us pogues (that means grunt firefighters; I was on the Payette Interregional Crew, now called “Hot Shots”) were laying on the grass of the warm alpine meadow waiting for the directions. We were about to go into the Mortar Creek fire, but that’s another story. When young men are idle there can be creative or destructive occurrences. This one was powerful for me.
The sun was warm, the grass soft, the packs all ready and we were just waiting. Amid the stories and teases and jokes a crew member looked at me and said, “You want to Indian Wrestle?” Russ was about my size, probably more athletic, but I will acknowledge much wiser. I could not resist. He explained the game. We both stand with front feet outside edges side by side touching against each other on the ground. We are faced 180 degrees to each other, like we are greeting each other and we clasp hands. It was almost like a secret fraternity handshake. We stood there, hands locked and whoever can get the other to move either of their feet from where they are placed, wins. I thought it so simple.
I lost the first seven in a row to lots of laughter from the circle of pogues. I tried so many things. Each loss was an opportunity to learn. Push hard, then squat, and he would ease resistance and I would step off the back foot. I gave him no resistance, and he would pull me sideways. I won the eighth game but my victory seemed a fluke, since I lost the next five. I learned a valuable lesson I have carried forward into medicine and now into politics. A sense of balance, when to push and when to pull, and an awareness of ones opponents balance is the key to victory. And also, victory requires just a small movement of the opponent, just a small loss of their balance. But more important, one must keep one’s own. And even greater, to this day I respect and admire the man who gave me the opportunity to learn this, my opponent.
In medicine I studied this for years. I struggled to learn when to push the smoker to quit, when to wait. Or when to bring up the issue of weight loss, one of the many things we can change, but so many think they cannot; or do not want to. I thought I got pretty good at it with patients. For that is where the real economy in health care lies, in behavior change, ultimately in thinking change. Some believe a person’s thinking never changes. I could not have been a doctor if I thought so. Now I am a politician.
I am in the legislature now and I have a new body I try to move. I am learning when to push, when to pull. More, I am learning to know when I am balanced and which way they may be leaning. This session was a good match, even if I didn’t get their feet to move. I learned a lot. But first you need to hear about the build up to it.
After the Affordable Care Act worked its way through the Supreme Court, four years ago our state faced a couple choices: whether to establish a state or federal insurance exchange, and also whether to expand Medicaid eligibility. The governor set up two work groups to study the options. I was appointed to the Medicaid Expansion (then renamed Medicaid “Redesign”) Workgroup. We heard from many experts and eventually recommended full expansion. It would save the state approximately $50 million/year in the first three years, declining to a cost of $20 million per year by the 10th year. More, it would get rid of a burdensome indigent county process, enroll many working poor onto health insurance, as well as serve many probationers released into the community with minimal support. Finally, we believed it would give the state some leverage to ultimately control medical care costs by minimizing the cost shifting that uninsured costs bring into the system.
But the governor threw his weight in 2013 legislative session behind establishing the state based health insurance exchange. It passed, but the fight among the majority party was bitter. Many conservatives blamed my “conservative” colleagues for giving in to Obamacare. I heard of three state senators who voted for the exchange that were sanctioned by their Republican Central Committees. I heard their arguments in the halls. “I hate Obamacare as much as anyone, but at least this is an Idaho solution.” Their defensive rhetoric helped define their stance, then and now.
Right after the legislature had this painful battle, a couple of us minority party legislators met with the governor’s chief of staff. We pushed that now (the end of the 2013 session) was the time to push for Medicaid expansion. We know where the votes are; if your office gets behind it, we can do it.
He pushed back, “Why are you talking to me? This is your job to sell it to the legislature.” We left knowing it would not happen without their help. But I don’t think our feet moved. I know theirs didn’t.
So, we waited. And the governor appointed another work group to study the issue over the summer. I told the majority I would not be on it; others need to learn this issue. And the group made a very good recommendation, one I could support; it was along the lines of what Arkansas did. But three of the four majority party legislators voted against the recommendation, not because they didn’t support it, but because they did not think anything could pass the legislature.
The next year (2014) was an election year and the common wisdom is that nothing significant gets done when legislators are facing the voters. But we talked about it whenever we could. We had presentations from the Department of Health and Welfare that highlighted the benefits. Further, there was a summer project that the state used to apply for a State Health Innovation Program to revamp how healthcare is delivered and paid for, so the cost savings in health care we envisioned (reducing the cost shifting was just the first step) could be realized. I worked hard on that, but I did not push hard on my colleagues. They were firmly planted.
I got reelected, as did most incumbents (indeed, almost all the ones who supported the exchange were reelected), so I hoped maybe we could address Medicaid expansion in the 2015. But instead the push was to address highway funding. I accepted that it was an important issue, I had argued for it for years. So I waited again, another long year. We raised the gas tax and registration fees and got more money for roads and bridges. But I also got the opportunity, since I was on JFAC and did the Health and Welfare budgets, and I was also on the CAT Fund Board, to tell my colleagues in the Senate about the money we were spending. I knew we could be doing all this better. I was pushing, maybe pulling a little whenever I could. I did not think I was being ignored or minimized. I thought they were listening. Some were; I could tell.
So now we come to this session, 2016. I talked with many about Medicaid expansion for the uninsured before the session. All agreed it would not be an issue: election year, too hot a topic. I planned to let it go until 2017. Moreover, I was disappointed that we had lost the maximal savings for the Idaho taxpayer by foregoing the first three years when the Feds paid 100%. We were now down to them paying 97% (it never drops below 90%) and our savings are dwindling as the state picks up more.
Besides, the governor came out with a plan for “helping” folks in “The Gap”. I saw it as a weak and wrong-headed plan. But it indicated their sense of the need. It was a signal to me, like a shift in my opponent’s weight. Was it time to push?
Before the session many of my Democratic colleagues were talking about getting personal bills printed to make a statement about the goals of our party. This becomes a bit arcane, so I must explain. All bills must be printed before they are acted upon. For a bill to be printed a chairman must allow a “print hearing” where there is no public testimony allowed, just the bill sponsor may speak. But a legislator can get a bill printed “personally” before the 12th legislative day. I have avoided printing personal bills in my first five years; I thought they could be seen as statements in futility. I believed we should be working with our colleagues across the aisle to address the states problems, not posturing.
But the very first week of the legislative session in JFAC I learned that the CAT Fund would be returning $29 Million to the state general fund. Many folks who had previously been indigent were now getting insurance on the state exchange. In my first years on the CAT board costs had been rising dramatically, but now they had tapered and indeed were declining. We had appropriated $28M the year before, but county claims were diminished, there was money left over from the year before, so we could return it to the state general fund. This was another opportunity I would have to push, or pull on the body I served. I was on the CAT Fund Board, I would make the motion in JFAC and be able to speak to it, and I would carry the bill in the Senate and speak to it. If we speak, we have the opportunity to push, or pull. I had spent my first years in the Senate listening and building relationships. Speaking now would be an opportunity to test their balance; and of course mine.
But the window for opportunity is narrow, the end of the time to print personal bills was close. I decided to personally print the bills for Medicaid expansion. I had nothing to lose; get the two options from the two different governor’s workgroups out there. The recommendation from the group I was on became S 1204; the next work group’s recommendation was S 1205. We struggled for three days to update the fiscal notes and make them as accurate as possible. I wasn’t sure I could make the deadline and even argued what entailed a “legislative day”, but we got them in to the Senate Secretary and printed. I thought that would be the end of it. I expected my only personal bills to meet the fate of all Idaho Democrats personal bills: no hearing, no movement, just a weak wristed tug on a solidly planted foe.
When the CAT Fund rescission came before JFAC the next week I spoke to the committee about the $29M coming back to the general fund. Idaho was seeing fewer applications for indigent medical support and I believed this was a direct result of the courageous effort on the governor’s part, and the majority party in the legislature to enact the state exchange. When people get health insurance, taxpayers need to pay less for the uninsured. Idahoans had enrolled in the exchange at a remarkable rate. Everybody deserved the credit; I tried to make it as clear as possible how great their effort had been and what credit they deserved. I did the same a week later in the Senate when I presented that bill for them to approve. They listened; it passed unanimously.
The next week I got a message from the Senate Health and Welfare secretary that the chairman wanted my personal bills for the two options for Medicaid expansion to have a public hearing. I clarified with her that indeed, a public hearing was intended; she confirmed the time and place. I let both the press and the supporters know. We had five days to line up emotional testimony that had been pent up for three years.
It didn’t go smoothly, for the chairman or me. I understood that the chairman was under pressure from his leadership. This is a painful discussion they have avoided for three years, solidly planted. His offer for a public hearing caught them off guard, so we needed to be firm but balanced. It was dramatic. Maybe that is what people are looking for in politics; so much is so boring.
More than a hundred came to testify, and only a few got to speak. The chairman decided at the last minute (I am sure under great pressure) that no vote would be taken. But the message was clear, from many Idahoans: insurance coverage for the Gap population is a matter of justice.
I had another thought. I had been on the CAT Fund Board for 5 years, reviewing the applications, and spending the taxpayers’ money on the folks who got injured or sick and did not have their own resources or insurance. It galled me to do this work on something I did not believe was the right way to pay for health care; after the fact, liens filed, bankruptcy insured. So why keep doing the work, reviewing the 1200 annual applications, going to the meetings, reading the litany of misery, when I believed so strongly there was a better way? So I announced my resignation from the CAT Board. I reviewed the statute and strongly suggested appropriate Senate appointment suggestions. I don’t think a truly compassionate person could do this work and consider this system just or a good government process.
My resignation got little notice so I thought again, the fight was over. But since the bills had not been voted on in committee, they were not dead. It was an election year and all politicians pay attention to the election calendar. I was prodded by colleagues to call the bills from committee. They didn’t know exactly how to do this and neither did I, but Senate rules allow it, so I studied and prepared. We waited until after the final date for filing for office: maybe if some Republican Senators did not have primary challengers they would feel freer to have this discussion, like waiting for your opponent to relax a bit.
I called for the bills. The Senate Republican caucus prepared their response, since I let them know my intent; I thought it courteous. It was voted down on a party line. If 2/3 voted against the call for the bills they could not be called again, and Idaho has ¾ Republicans, so there would be no more calls. Again, I thought we were done: they are a solid opponent and getting their feet to move is difficult.
But Wayne Hoffman then inspired me. He had opposed the insurance exchange and declared he would never get health insurance since he considered the individual mandate to buy health insurance in the Affordable Care Act unconstitutional. I respected his stance. So I asked him in a meeting room if he now had insurance. His boss stood behind him and grinned, “Oh, we think he is too valuable to not be insured. We got him insured.” Wayne was a bit chagrined but said; yes indeed he did have health insurance now. I had considered his stance quite principled. If more of us took such principled stands, maybe this country would be better off.
So I decided to forgo my taxpayer paid health insurance. Martha (my wife) and I had purchased an individual high deductible (HSA) policy after I quit the group I was in back in 2007 and before being elected. It had been expensive. But I believe in the high deductible model and had been frustrated that the state did not offer an HSA compatible plan for state employees. We were one of only about a dozen state employees who took the high deductible plan; the cost was about the same for the regular deductible or the high deductible, but we chose it on principle. And now, after discussing it with Martha, on principle, I chose to give up my taxpayer paid state health insurance. If the legislature was not willing to consider getting 78,000 Idahoans health insurance at no cost to the taxpayer, why should I take the taxpayers money for me and my wife? It was a risk, I admit, but when you are trying to move a solidly planted body, risks are in order. To this day I am uninsured.
The end of the session saw some machinations. Many Republicans were very uncomfortable with the stance they had taken. I sensed they were willing to consider moving. There was more public comment, but I really don’t know what the Republican Central Committees in each county were talking about: that is where the true assessment of public opinion in this deeply red state occurs. But in the end, they stayed as firm and as solid as they were in the beginning.
So I am learning the skills of how to move this big body that I am firmly clasped to:
Know your facts
Know the ground
Always respect your opponent
Keep your balance
Don’t be afraid to push (or pull)
Timing is everything
Losing is when you learn the most.
Addendum February 2021: Indeed, I lost my next election, so had no stance to push from. But a citizens initiative was started, gathered enough signatures to get it on the ballot, and in 2018 the Idaho people passed Medicaid Expansion into law. The text of the proposed bill was identical to the first personal bill I proposed, SB 1204.
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