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Posts published in August 2019

Fallacy of ‘debates’


Many decades ago, I got my first horse racing introduction with a friend who said he was “experienced” in horse racing. I knew nothing about it so figured this would be an education.

An “education” it was.

We walked to the paddock area where horses for the next race were on display. I watched and listened to my “experienced” friend and those around us as they sized up the animals. It wasn’t long until my “education” expectations died.

“Look at the color of that Chestnut,” someone said. “He’ll win.” “Oh, that brown horse - I’ll bet on him,” was heard. Another “expert” liked the green and gold jockey’s outfit. Another “winner.”

That racing experience of long ago came to mind after watching the last Democrat presidential “debate.” And the ensuing “expert” commentaries. There were many parallels.

“This one’s up, that one’s down.” “For an unknown, she made some good points.” “Not much experience but handled himself well.”
Sounded like the “experienced” racing crowd.

I wouldn’t go so far as to say these crowded “horse shows” mean nothing. But, they don’t mean much. The minority of Americans who care to watch and listen can see their favorites in action and watch the rest of the crowd. Others at least learn the names of the previously unknowns. And who will be unknown again before the 2020 election. But, if you’re watching for substance or decision-making, well, good luck.

Debates don’t win presidential elections. Oh, there was that Nixon-Kennedy debacle in 1959. Kennedy cool and articulate. Nixon with five o’clock shadow and sweating like an NFL down lineman in an August exhibition game. Might have been some significance in that. But, debates 18 months ahead of elections, don’t count for much. Remember Clinton-Trump debates? She got three-million more votes than he did but he won in the Electoral College. Winning is not done in debates.

Several things have been disappointing in these free-for-all’s. For me, it’s the things that haven’t been said. What must be done quickly - and massively - about climate change? How to undo the immigration shame wrought by Trump. What about homelessness and housing people can’t afford? What about the VA health care mess? How to stop or at least clean up gerrymandering which is a proven cancer in many of our elections? What can be done effectively to stop foreign governments from screwing with our elections. None of these - none - have been addressed. As the old gal said, “Where’s the beef?”

We’ve been “treated” to attacks, prepared ad libs, snarky comments about him or her and lots of meaningless chatter about this and that.
Even criticism of Barrack Obama - a guy the finalist is going to need big time before November.

Most of those faces now peering out from the crowd on stage will be gone in a few weeks. They won’t be able to raise the necessary money, create a large enough staff, be able to get thousands of volunteers “on the ground” in 50 states, compile the massive data base necessary for communications with voters and more. And those are the things - the absolutely necessary things - needed to survive. Warren, Biden and Sanders either have those things or can get them in short order. None of the other 17 has or can.

One bit of mystery getting my attention has nothing to do with debating. Obama and Eric Holder are deeply involved with something called the National Redistricting Committee - a vehicle they created to deal with gerrymandering congressional and legislative districts and to undertake such other “related political affairs that may be of interest.” They’ve got reps in most states and I’d guess turning the organization to a candidate-backer would be just a short step.

Both gentlemen are keeping low profiles at the moment. Except Holder’s well-publicized warning to Democratic “debaters” last week not to keep attacking Obama. Given Obama’s well-known 50-state grassroots history, and Holder’s proven abilities of effective organizing, those two may be the secret weapon necessary for a Democrat victory in 2020. I’m keeping an eye on them.

As for “debates” over the next 16 months or so, well, if there’s little “beef” and more personal attacks, they won’t mean much. If the subjects listed above - and a few others - aren’t addressed with some creative thinking and solid plans, it’ll just be talk, talk, talk. We - the voters - won’t have what we need to make intelligent choices.

And, don’t forget, the changes necessary in our elected federal government won’t mean a damned thing if Democrats win the White House but don’t take the Senate. If “Moscow Mitch” or some other Republican is Majority Leader in 2021, we’ll have four more years of nothing. Just more stalemate and division.

We’re not seeing real debates. We’re watching those old horse displays with people instead of nags. We’re watching a beauty contest. The real issue isn’t who “won” or “lost” the last gab fest. It’s who among them has the savvy and the ability to quickly mount a successful winning campaign with all the absolutely necessary tools.

Warren, Biden and Sanders are in for the long haul. It really doesn’t matter who you “like” now or who looks good. The real issue is can we all get together behind the name on the ballot in November, 2020? Can we turn away from our favorite of the moment to cast a ballot for someone else when it counts? Anyone else.

The use of teaching health centers

From a guest opinion by Ted Epperly, MD, CEO, Family Medicine Residency of Idaho, Boise; Boyd Southwick, President, Idaho Academy of Family Physicians, Idaho Falls, and Neva Santos, Executive Director,
Idaho Academy of Family Physicians

James needed a sports physical and a vaccine booster in September. In November, he fell from his bike and broke his arm. In February, his parents made appointments for preventive colonoscopies. In March, his younger sister developed an ear infection. In August, his grandmother was diagnosed with high blood pressure and started a long-term treatment plan.

All of them went to the same doctor for their health needs. That doctor, a family physician, was trained in a teaching health center—a community-based residency training program that analysts say is an invaluable tool for increasing primary care physicians and addressing the maldistribution of doctors.

Since their inception in 2010, teaching health centers have been very successful in recruiting medical students into primary care and training them in comprehensive patient care at less cost. Currently, 56 teaching health center residencies are training 728 residents in 23 states and the District of Columbia.
In fact we have a Teaching Health Center (THC ) right here in Boise Idaho. The Family Medicine Residency of Idaho was one of the original 11 THC’s in the United States and has done a lot to help train family medicine physicians for rural and underserved parts of Idaho.

Equally important, they and their graduates have provided much-needed health services to 66.4 % of people in Idaho and nearly 80 million Americans living in health professional shortage areas. Research shows that more than nine out of 10 teaching health center graduates remain in primary care practice and more than three out of four plan to work in underserved communities. Studies also have documented that teaching health center residents are three times more likely than traditionally trained residents to practice primary care in a community-based clinic. Other data show that nearly twice as many residents who trained in teaching health centers went on to practice in underserved settings compared to their counterparts who trained in hospital-based programs.

That’s important because we know that an increase of one primary care physician per 10,000 people reduces deaths by more than 5%. Patients—particularly the elderly—with a usual source of care are healthier and have lower medical costs. They have better care coordination and fewer expensive emergency room visits, unnecessary tests and procedures. In contrast, those without a usual source of care have more problems accessing health services and more often do not receive appropriate medical help when it’s necessary.

Teaching health centers’ continued success now depends on Congressional action. Unless Congress reauthorizes the Teaching Health Center Graduate Medical Education Program, federal support ends on Oct. 1. Ensuring a robust program requires a five-year extension and increased funding that can support new teaching health center programs, particularly in rural and underserved areas. Currently, the Training the Next Generation of Primary Care Doctors Act reflects family medicine’s goals of reauthorizing the THCGME program for five years, authorizing adequate and sustainable funding for existing residency programs, and supporting expansion into more rural and underserved communities.

This is critical. A Robert Graham Center survey of teaching health centers found that more than four out of 10 teaching health center residency programs would be very unlikely and more than two out of 10 would be unlikely to continue supporting residency positions without continued federal funding. Due to funding uncertainty, some programs have slowed their recruiting or closed over the past few years. Congress should pass this legislation immediately to prevent a disruption in the pipeline of primary care physician production.

The current primary care physician shortage and maldistribution remain significant physician workforce challenges. An Annals of Family Medicine study projects that the changing needs of the U.S. population will require an additional 33,000 practicing primary care physicians by 2035. With reauthorization and expansion of the THCGME Program, however, the United States can make significant strides in meeting the challenge.

Plead for the future


You wouldn’t know it from watching the cable television food fights that masquerade as Democratic presidential debates, but the 2020 presidential election will not be about “socialism” or “Medicare for all,” or “climate change” or even the great Democratic unifier Donald J. Trump.

No, the next presidential election will be about what all presidential elections are about: a choice.

A choice between two people: a racist, polarizing, pugilistic incumbent with the power of Twitter and a reptile brain understanding of how to always put himself at the center of everything, and a Democrat. How that Democrat frames the contest and how Trump has already framed it will determine the outcome.

Democrats better make the frame a simple and forward-looking one. The election is, after all, about what kind of country we want. Trump has made his vision clear. He wants a racially polarized country where fear and resentment constitute policy. Trump is betting, and Republicans on the ballot next year are meekly going along, that he can channel George Wallace one more time and draw an inside straight in the Electoral College and repeat his narrow victories in Michigan, Wisconsin and Pennsylvania. If he wins again he will almost certainly do so without again winning the popular vote.

It is a risky strategy, but it’s all he’s got. Pre-Trump, American politics was always about addition. He’s made it about subtraction. He’s done nothing – less than nothing, really – to grow support. His only possible political path is to further divide, while insulting and demeaning his way to a second term on the strength of an angry, resentful, mostly white middle class.

There are clear signs that this approach will fail. The Associated Press recently went to suburbs in Michigan, Colorado and Pennsylvania, three states critical to Trump’s re-election or a Democrats chance to win, and found that many women – often swing voters – have grown weary of Trump and his tactics.

“I did not think it was going to be as bad as it is — definitely narcissism and sexism, but I did not think it was going to be as bad as it is,” said Kathy Barnes while shopping in the Denver suburb of conservative-leaning Lone Tree. “I am just ashamed to be an American right now.”

Ms. Barnes just framed the election for whomever wins the Democratic nomination. What kind of America do you want? What kind of place will this American experiment produce? What the future for your kids and grandkids?

Having sorted through all the post-mortems on the 2016 race between Trump and Hillary Clinton, and believe me that is a lot of sorting, I conclude that Trump won for two fundamental reasons.

First, Trump was – and is – a disrupter, a bull in the political china closet, throwing fits and smashing the place settings. I thought it odd back in 2015 when a friend in his 70s told me he thought Trump was a joke, but would vote for him because “things couldn’t get any worse.” He was willing to burn the house down, throw the dice and elect a con man simply to shake things up.

Second, and because every election is a choice, Trump won because of who his opponent was in 2016. Clinton was – and remains – every bit as polarizing, if better mannered, than Trump. When Barack Obama said during his 2008 contest with Clinton that she was “likeable enough” he understated that factor by half. In a contest with a superbly unlikable guy she came in second.

I haven’t a clue at this point who will emerge from the bloated Democratic field, and since two news cycles in our politics is now a lifetime absolutely anything can happen in the next 15 months. However, I am pretty sure Elizabeth Warren’s plan for everything or Joe Biden’s record on forced busing won’t matter much in the fall of next year.

Plans and proposals and platforms won’t beat a guy who is all about fear and fights and fiction. You don’t beat a demagogue with a five-point plan. You need what George H.W. Bush famously called “the vision thing.”

“I am pleading for the future,” the famous trial lawyer Clarence Darrow once said. “I am pleading for a time when hatred and cruelty will not control the hearts of men, when we can learn by reason and judgment and understanding and faith that all life is worth saving, and that mercy is the highest attribute of man.”

That’s a vision.

Another of those suburban women, Yael Telgheder, 36, of Novi, Michigan, told the AP she was a reluctant Hillary voter in 2016, unhappy with her either/or choice. Yet, she can’t imagine a 2020 vote for Trump. “To be honest, there are certain things that — he’s a businessman — so I understand the reasons behind them. But all of the disrespect and lies and stuff like that, it’s just too much for me.”

Maybe Trump wins again. Incumbent presidents usually do, but then again he is no typical politician. To counter a president who has hastened America’s decline, who has embraced a political strategy of division and discord, whose appeal is increasingly only to a white nationalist America you need to offer an optimistic vision of America for Americans.

Trump’s “American carnage” was both a warning and a prediction. Democrats need to plead for the future.

The insurgency succession


A week after the last of the full candidate events - debates of a sort, maybe - for the Democratic presidential nomination, before the real sifting begins, the contender topping the polls will head to of all places Idaho. The reason for that is at least understandable reason: fundraising.

Former Vice President Joe Biden will visit homes at Ketchum and Boise, and raise money, primarily from people with long-standing connections to Democrtic politics; and yes, Idaho does have some people like that, lightly visible though they often are in state politics.

No particular news there. But the events of last week and this week do start to open the question of where Idaho’s Democratic support will go in their party’s nomination battle. And that’s worth considering, because while the odds are overwhelming that the state will stay red in next year’s general election, the battle over the Democratic nomination may be up for grabs, in Idaho as well as nationally. And right now there’s little certainty about how that will play out.

And that support can move in some interesting directions. Idaho Democrats looking toward the national picture increasingly have moved toward the more activist, outsider-ish and non-establishment contenders among presidential prospects. In 2016, they preferred Bernie Sanders over Hillary Clinton; in 2008 they went for Barack Obama over Clinton.

What does that portend for this cycle?

It might mean that if part of Biden’s strategy involves reeling in delegate votes from smaller states like Idaho - and that was an important part of Obama’s nomination strategy in 2008 - he has his work cut out. Biden is the closest thing to an establishment contender in the race, and he’s the sort of candidate who recently has had the hardest time getting traction among majority of caucus-going Idaho Democrats. Biden has a large enough base of support that he likely will be in the race as the calendar flips to 2020, something you can say with less certainty of most of the other contenders. But will he be hanging on in the face of a strong challenge, or consolidating support? If the race is competitive then, Idaho may be one of the kinds of places where he has to hustle.

Of course, we have little clarity of exactly what the field will look like by the new year. We can be reasonably certain it will narrow. The 20-plus field of candidates of July is likely to be cut in half by mid-fall; for many candidates the inability to make the next debate stage in September will be a fatal blow.

Odds are, though, that most of these candidates will be around for a while: Sanders, Massachusetts Senator Elizabeth Warren, California Senator Kamala Harris, New Jersey Senator Cory Booker, South Bend (Indiana) Mayor Pete Buttigieg. Maybe in the next few months another candidate or two catches fire, but these candidates and Biden seem most likely to be those scrambling for market share.

Who might generate some appeal in Idaho? Who might get the Idaho insurgency vote that seems not to have coalesced yet?

Sanders, as noted, did last time, and maybe he could again; he has a base of support in the Gem State. But his kind of insurgency seldom maintains the same sort of emotional drive for very long.

The Idaho Democrats conducted a small-scale straw poll after last week’s debates, and that showed Warren in first place, Buttigieg second, Harris third, Booker fourth, Sanders fifth. (Geography isn’t all, since Washington Governor Jay Inslee was down in the cellar.) But that was a small sample.

My best guess for a 2010 Idaho Democratic insurgency would be Warren or Booker, depending on how they present themselves and pick up support - or fail to - nationally in the next three to four months. There will be significant support for Biden among Idaho Democrats, but at the moment I’d guess he will occupy something closer to the Hillary Clinton spot.

But that’s guesswork. Crunch time for sifting through the Democratic contenders is only just beginning, and we all might wind up with a surprise short list half a year from now.

A nation of laws


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 to. 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 9th, 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 5th 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 5th 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.