West of the Rotunda

Fascioloides magna

Chairmen of committees have a lot of power. They are appointed by the majority party.

At the end of our Tuesday morning Agricultural Affairs Committee meeting the chairman announced he would be bringing a rule before us for consideration at the next meeting Thursday morning. He said the rule had to do with importing domestic elk.

Last year we had fought in this committee over rules that affected domestic elk ranchers. This year the chairman is different but the members of the committee are the same. That fight had been ugly with lots of public testimony. You will not know the back story to this issue unless you study the links I have attached.

I looked for the agenda to study up on the rule and the bigger issue before the meeting. I have learned you can’t always rely on the testimony that is presented to get the full story. The agenda was only put out Wednesday afternoon with no link to the specific rule so I could not prepare.

The chairman presented his perspective on the issue. There is a rule (page 19, 02.04.21 600.01) in place that requires elk imported intoIdahoto be immunized against Brucellosis within 30 days of entry. There is another rule (page 19, 02.04.21 601.01)  that required elk to be treated for liver fluke parasites at least 60 days and not less than 29 days before entry. So that just gave importers just one day to do both treatments if they were going to just handle their animals once. Our chairman was asking our committee to adopt a concurrent resolution that would eliminate the rule requiring treatment for the liver fluke.

I asked the state Department of Agriculture veterinarian if this would put our wild herds at risk for infestation with this parasite. He didn’t know. We had no one else there to testify.

The motion for the resolution passed. I knew we only had three votes to beat it, but it was the process, the self interest, the ethics that galled me. I had both unanswered questions and a bad taste.

We have asked the chairman to return the issue to the committee for a full hearing. He is considering our request.

The Living Years

Last year, 2011, was my first session so I had no comparison. Other legislators with more experience said it was difficult. I believed them. This is my second session and I am gaining perspective.

Last year in Senate Health and Welfare committee we reviewed rules about day care centers. There was disagreement and dispute in committee testimony. The meeting room was full and many testified.  Folks from day cares thought the rules were unfair. We worked it out but it took a lot of effort. There was a palpable tension in the meeting room, a tension in the voice of people testifying.

Now this year, some new rules came up just last week about day care fees. They had been presented in three venues around the state and NO ONE had showed up to give input. There was no disagreement at committee testimony and the rules passed easily.

Maybe it’s early, maybe I’m optimistic, but I sense a different tone this session. Having the “Luna Bills” sprung on us last session sure made one feel like we weren’t listened to, that we were being tricked. I hope the public feels less that way this year. I would hope we can all listen as well as we hear.

We had a “Kitchen Table Economics” presentation Monday night in the Senate Auditorium. It was quite well attended, with many union and Occupy folks milling in the hallway. I came out of my office planning to go to the meeting but we had to wait because Joint Legislative Oversight Committee (JLOC) was still using the auditorium. I had wanted to hear the presentation of the JLOC study “Reducing Barriers to Higher Education” so I slipped in.

The conclusion, which was all I could get, was disappointing. The barriers seemed to be multiple: cost and preparedness as well as perceptions of value (is college worth it?). Our Republican dominated legislature has been making higher education more expensive for the past ten years by not supporting the universities in the budget, and reducing preparedness by cutting funding to schools. So maybe the perception of low value in Higher Education is shared by our elected leaders. This year, for the first time in his administration, Governor Otter increased the budget for Universities.  I hope they can recover.

The “Kitchen Table Economics” was lead by a minister who quoted Martin Luther King. The auditorium was full with many burly guys wearing t-shirts signifying Firefighters Unions or other Union locals. The minister introduced the main speaker, Dr. Stephen Cooke from Moscow. We got an economists lecture, not a rousing alliterative sermon. I was impressed that the crowd was so attentive. Steve’s point was that Idaho has chosen the path of low wages (Idaho average annual wages are $10,000 below the national average.) thus low revenues, and then we cannot attract businesses that need highly educated and skilled workers, so we have a vicious cycle.

After Professor Cooke’s presentation we had folks get up and tell their stories.  There were young teachers who couldn’t afford to pay their college debt and raise a family. There were laid off workers getting foreclosed on. There were carpenters not getting paid by their employers and then turned in to immigration.

But one story really resonated for me. A young man got up and told how he had become a pipefitter right after high school. He was working non union and kept in low paying jobs, given no security and no extra training or certifications. After 6 years of this he joined the union. In the last 5 years with the union he has completed his apprenticeship and gotten 5-6 certifications (further skills training). He is buying a home and raising a family. So the trades can be a way to a middle class success, if the wages are adequate. Why aren’t they?

Let’s go back up to the graph. We follow the three lines, Colorado, US and Idaho wages. Idaho is below the other two, but following along until about the mid 1980’s. And I’ll bet most people in that auditorium don’t even know what happened in Idaho in the mid 1980’s. Union membership plummeted.

Interestingly, the Idaho “Right to Work” law didn’t pass until 1987, well after the significant drop in union membership in Idaho. After “Right to Work” large manufacturing increased in Idaho and our average wages have dropped.

So Idaho has low wages, now high unemployment and increasing poverty. State investment in higher education, even K-12 is floundering, and we aren’t sure how to get out of this cycle. Could union membership, on the job training and increased wages for trades be a solution for middle class success?

In 1987 I was in Residency training in Spokane, Washington so I couldn’t have voted for or against the “Right to Work” bill. I think I would have voted for it because I don’t think Union membership should be compulsory based on the workplace. But honestly, I’m not sure that’s what the law was about. I remember a lot of union-bashing publicity. It was the most expensive political campaign in our state’s history. It changed Idaho politics, with the Democratic Party never recovering. I think the unions were losing popularity before that. Maybe we need them back.

If I was a young tradesman I think I might join the union. If they could help me earn a living wage and better myself and my family. I’d be nervous about them getting into politics. Maybe that was the problem.

I have written before about all the laws that get passed in this conservative state. Hundreds of bills make it into law each session, at least half, I swear, are working to fix problems from bills passed the year before. Sometimes I think it’s just legislators trying to get credit for being effective, actually doing something. Believe me, it can be tempting.

I went to a conference for legislators in November about energy in the northwest. I was struck by one suggestion that selling automobile insurance by the mile has been shown to decrease driving, thus save energy. People are more thoughtful, more conservative about choosing to drive if they realize the mile by mile cost. Most auto insurance is sold by the year, or six months and the different amount you drive isn’t really considered. The presenter who suggested this thought most states needed minor changes to their insurance code to make the sale of “per mile” auto insurance legal.

I love conservation. I also thought maybe I could get some credit, some splash for a good idea. Ah, beware vanity. So I started investigating the Idaho Code. I got some help since it can be confusing. The first guy I talked to in Legislative Services office thought indeed we would need to change the code. Maybe I should write a bill! But I thought I should talk to the Department of Insurance before I started a draft. I talked to the Director when he wasn’t in meetings about the insurance exchange. He told me the Idaho code allowed for “by the mile” automobile liability insurance. In fact, Progressive had just applied to the Insurance Commission to sell such a policy. So we don’t need a bill.

I don’t mind not getting the credit. Maybe I’ll just check out the policy and see if I can save some money.

All comments are read but not posted.

Last winter when I was in Boise for the legislative session I got a call late one evening from Katy my oldest daughter. She is in nursing school and lives just down the hill from us.

“Dad? Mom fell and hurt her wrist and it is really painful.” She went on to say it had happened a few hours before on a steep, icy graveled street. Now it hurt to bend it.

“Is it deformed? Does it look swollen or bent?” I’m trying to see if we can skip an ER visit at 8PM. But it sounded like the pain was significant so I suggested they go to the ER.

When I signed up for health insurance with the State of Idaho as State Senator I was given just a few choices. There was the usual plan with a $500 deductible, a $5000 deductible or an HMO. I chose the $5000 deductible because that was like the Health Savings Account plan we had before as an individual. I hope the state allows HSAs soon.  On the state plan I pay $36 twice a month. My wife and I had paid $400 a month when we bought the high deductible HSA on our own. I assume the state is subsidizing the cost some, but that is a huge difference. I believe a lot of the price difference has to do with the size of the risk pool.

On Martha’s trip to the ER I figured with our high deductible we would pay the whole ER charge. I called my wife back later in the evening and was happy to find out the x-ray (necessary?) was negative and an elastic brace and some ibuprofen had really helped the pain. Martha even admitted the pain was better before she got to the ER. I found that happened a lot in my practice, folks started feeling better soon as they made an appointment. It seems when Katy had called me she had suggested the ibuprofen to Martha and I guess it kicked in while she was waiting. A week later it was fine.

I waited for the bill. It came in a couple weeks: $800. $450 for the x-ray alone. But it said not to pay anything until they submitted it to insurance. I didn’t understand that, since we had the high deductible. But we waited some more. A couple months later we get a statement from the hospital saying we now had to pay just $400, since that was what the contract with the insurance allowed them to charge. So we got a discount just by being in the insurance pool, even though we had the high deductible. This is the magic of risk pools. And it is also the cost of going alone.

I believe this pricing shell game has allowed cost shifting between purchasers of health insurance. Medicaid lowers what they will pay, prices for employer based insurance goes up. They drive a hard bargain and then the small group purchasers see their premiums go up. This cost shifting as well as the indirect cost of insurance has blunted the market strength to drive down costs.

But we are talking about what health insurance costs here not health care. The REAL savings we can arrive at will be when we can appropriately decide to use the test (x-ray of the wrist). This is where real savings will occur. Read this about ankle x-rays. There is hope.

Cartoon of the original Massachusetts redistricting map that started the name Gerrymander

Our Founding Fathers required a census every ten years to make sure there was appropriate representation. Indeed, what matters to people is evident in what they keep track of, what we count. People matter. Our representative democracy was founded on ONE MAN-ONE VOTE. We have subsequently come to welcome into the voting booth women, different racial groups and even some excluded religious groups. (One of the hottest issues discussed at the Idaho Constitutional convention was whether Mormons would be allowed to vote.)

Every ten years, in response to the census, Idaho resets the district boundaries. Currently I represent District 6, which is all of Latah County. But our district needs more population for fair representation so our borders need to expand. This last summer a commission was appointed to come up with a solution. They took testimony around the state and I testified when they came to Moscow. I posed that it made the most sense, given the constitutional guidelines and our geography and trade patterns to combine Latah County with Benewah County.

My opponent in the last election and his campaign manager and two of his supporters testified that they thought Latah County should be split up, with the rural areas separated from Moscow. This would combine folks who had “similar interests”. They also drove up to Coeur d’ Alene to testify a second time.

I don’t think our founding fathers expected us all to agree or only be represented by people we agreed with. One of the beauties of a representative democracy is how it tends toward balance. Even if an election is a landslide (55-45), the elected official still represents the 45% that voted against him. That is the job; it shouldn’t be easy.

The first commission couldn’t agree on a map for redistricting so a second one was appointed. They proposed combining Latah and Benewah counties. Some folks aren’t happy about the arrangement and have filed suit. Benewah County is party to that lawsuit. We should have a decision from the Idaho Supreme court in the next couple weeks. I’m hoping the recommended map is upheld. Then I plan to go up to St. Maries to visit the commissioners and get to know folks.

How we pay for health care in this country is complex and distracting. I would like to describe a part of the picture here in Idaho. Don’t let it distract you.

Idaho requires counties to pay for healthcare costs for people who cannot pay their medical bills. Many states do this. A few years ago it became obvious that one car wreck and a paralyzed driver in a small county could threaten their budget. A reinsurance plan was proposed, so the state would cover any costs over $10,000 for each county. Thus the Catastrophic Insurance Fund was formed. The level has since been raised to $11,000, but the principle is the same. Any amount over the limit is passed from the county to the state.

I ask you to pause for a minute and think about whom this benefits. A person with no insurance in a car wreck or having a heart attack shows up at the hospital and they are cared for. I have never seen a person denied appropriate care based on their ability to pay. Maybe they are 50 years old, not on Medicare or Medicaid, live in a single-wide, drive an old Ford pickup, and sell fire wood for a living. No health insurance. They get care and the county hospital and the referring hospital (since they probably get shipped by helicopter or ambulance) have performed services. The bill is sitting on the table. Who should pay, how much, and for what? Well, our laws say the county, but our laws aren’t clear on how much should be paid. We on the Catastrophic Fund Board (CAT Board) struggle with this monthly.

Last session we needed legislation to allow the state Catastrophic Fund to use mechanisms to control costs. Hospitals submit bills to the county(and the State CAT Fund) for the care provided at full cost. Now we can pay at Medicaid rates, thus reducing the payment to hospitals by half. A Republican Senator sponsored the bill and I rose to support it. After it passed he came up to me to suggest I consider a position on the CAT Board. I got appointed. So I serve.

Back to the issue of who benefits from this money. The hospitals have provided the service, now they want payment. If the county or the state doesn’t pay the cost will be shifted to the insured. Somebody will pay. What kind of payment is appropriate? Was the care appropriate? If it wasn’t, should the state taxpayer pay? We are trying to pressure the hospitals and doctors to provide appropriate care. But after care is provided is not the time to influence behavior.  And our leverage is weak.

Each month we Board members receive 100 or more cases to review. I study them as best I can. For example, last June we go two cases of appendectomies, one cost $12,000 and the other $40,000. Now, as a physician I know that complications occur. But is $12,000 an appropriate charge? Is $40,000 excessive? How are we as a society going to control these costs?

Every month I study the cases. One was a 19-year-old man injured in a bull-riding contest. He was paralyzed from the neck down. Wouldn’t you think rodeo cowboys should have insurance? Or is this system good enough?  The most common claim is a fifty-year-old with cancer. If we were all in the pool of insured wouldn’t we better able to manage these costs? But our state is currently arguing over whether we can offer an insurance exchange which would make shopping for insurance easier. Some argue even this level of support for getting more folks into the pool of insured is too much.

As best I can figure, in 2010 the state of Idaho paid $32 million from the general fund for indigent health care. All 44 counties paid (in claims under the $11,000 limit) $40 million themselves. Thus, as a state we see a $75+ million burden from the uninsured shifted on the taxpayer. We have no effective way to control these costs. We are throwing money at a problem that will keep taking our savings and not adding value to our society. We have to do this differently. We need to have a system that can manage costs. We could do this in Idaho.  We should not be distracted by the complexity. And an insurance exchange could help.