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Posts published in “Schmidt”

Confronting loyalty

schmidt

It can be hard to confront a colleague with their misbehavior. I’ve done it a time or two and it sure got me to thinking about my loyalties. When I chose to act, it was out of a sense of loyalty to a purpose, a profession, a greater good that deserved my service. There were also times in my life I passed on the confrontation. I have some regrets.

Ronnie was a gifted high school athlete. He hit the goal post upright from forty yards out with a perfect spiral once at the end of a workout. “You lucky dog.” I said. “Bet me.” he said. He did it again 3 out of four times. He went off to a college career. For a while he led the nation in total offense and punting. I was at home for the summer visiting him when he got a call from his coach to come back for summer school to remain academically eligible. He hung up quietly. “You going back?” he shook his head. I wish to this day I’d confronted him, my friend.

Professions and the higher calling they claim can inspire loyalty in some. But confrontations can become messy; when the dirty laundry airs, some splashes on you and soils the profession. As a doctor, those were the hardest things I had to do, confront a colleague on their behavior. But I tried to be true to the ideals of the profession. I believed we all should be serving higher ideals.
In the political sphere confrontations are even more fraught. Loyalty to a greater good may just become loyalty to a party.

I served on an ethics committee as a freshman state Senator. The ethics complaint was lodged by my caucus leadership, Democrats. A Senator had chaired his committee that heard and voted on regulations that actually affected the Senator without revealing this conflict of interest. After days of adversarial testimony, it became clear to me the Senator had indeed violated Senate rules.

But he had not broken any laws and we were not going to be able to prove he had any substantial monetary gain from his actions: thus, no crime. On the third day of testimony I seconded the motion to dismiss the ethics complaint. This was over strong objections of fellow Democrats who wanted the hearings to keep going. I got a sense they saw political benefit in the proceedings. But when I voted to dismiss, I did not want my vote to mean he was not guilty. I said on the record that he had broken Senate rules but more, he had violated the public trust that makes representative government work.

As it turned out, though there was no official Idaho Senate censure or sanction, the Senator was beat in a primary election the coming spring. Maybe there is some wisdom in the voting electorate.

So, I’m wondering about our Idaho Senators, both loyal Republicans, who serve us in Washington. Just what is their loyalty? Does having this partisan conflict that has shuttered our government serve Idaho, our Union? Do you honestly believe spending $5B for a steel wall on our southern border is the proper use of our dear tax dollars?

To my father’s dying day he thought President Nixon had done no wrong and his resignation was a travesty, the fault of an over zealous press. He was a loyal Republican. Me, I was impressed that our Union could survive the scandal, the turmoil and come through; a nation with a loyalty to the rule of law. May we so be.
 

Lost dogs and outrage

schmidt

My daughters don’t use Facebook. They have their reasons, and I agree with most of them: waste of time, privacy, concern for the level of conversation. So, I was a bit surprised when I got a text from a daughter the day after Christmas asking me to post something on a Facebook site.

They had gone for a ski out in the east county with their dogs. One daughter has a three-year-old 70# mutt she got as a puppy. He was an Attention Deficit puppy, but he has a really good heart and he’s come around. I love him. The other one is new to us. She’s a pretty simple but beautiful 6-month-old Plott hound who follows her nose and not much else. The dogs had run off about 11AM. I got the text about three. They had done the snowy ski a couple times calling, no tracks, no dogs. So, they’d hit some nearby houses and gathering places and someone had suggested the Facebook site for lost dogs in the community.

I asked to join the group, was accepted and posted that night. The daughters came home without dogs.

We went out the next day. Lots of dog tracks, but not ours. Most looked like coyote. My youngest daughter thought she’d seen a wolf track the day before. No dogs that night.

After three days we had kind of given up, but we went out again. We stopped for gas in a nearby town and a guy came out of the store. As the pump was running I said, “Hey we lost a couple dogs out here three days ago.”

“Yeah, I saw it on Facebook.” He responded. He had some local advice about who to check with. But we went home again that night with no dogs.

We didn’t go out the fourth day, but at 3 PM someone called us from a Forest Service road about 3 miles from where they’d run off. We collected the pups. The little one seemed fine, but the mutt had a face full of quills and had lost about 15 pounds. They are doing fine.

Facebook gets no credit for getting the dogs back. The guys who finally called us just read the information on their collars. But it sure was a way to reach out. The posts got over 50 shares. It made us feel connected.

I didn’t successfully use Facebook in any of my campaigns for public office, but the young folks I worked with this last summer on Proposition 2 sure used it to their benefit.

I still see the tool as a very mixed blessing; all tools are. We can use it to connect, communicate and influence. But I think we all need to be a little wiser about that influence aspect. It is difficult for me to communicate clearly in a sentence or two, but that’s what Facebook demands. Influence should require more unless the response you are looking for is outrage. I think that just requires a couple words, maybe a picture.

It’s even more frightening that some folks are spending lots of money to use this tool to their ends, to influence us in ways we might not see. Shame on us for being that simple.

But the simple pup seemed to survive the frozen ordeal the best; then again, she was not outraged at the porcupine.
 

State of the state

schmidt

When Governor Little addresses the legislature Jan 7th with his budget address he’ll be hard pressed to beat Butch Otter's charm or delivery. I hope he feels no pressure to. But Brad will have a chance to strike a new pose.

The speech is required in the Idaho Constitution at the beginning of each legislative session and the governor must describe “the condition of the state, and shall recommend such measures as he shall deem expedient”.

Further he shall, “present estimates of the amount of money required to be raised by taxation for all purposes of the state”.

I’ve been hearing Brad stake out a direction, both in his campaign and since the election that should tell us where he is heading next week. He has said clearly that Idaho needs to be a great place for his (and my) kids to settle and make a good living to raise our grandkids. Maybe they’ll be willing to care for us as we begin to dodder. But right now, these 20-30 somethings are the hard-working plodders that drive strong community growth. We need them, if we are to prosper.

Idaho is one of the fastest growing states in the union, but unfortunately, we are attracting dodderers, not plodders.

What do young families look for when they strike out? Safe, solid communities with good schools and good jobs would be my bet. Will Brad propose increased funding for K-12? How about fully funding kindergarten?

Idaho currently provides funding for ½ day kindergarten, but districts are not required to provide it. Many districts provide full day kindergarten, some even provide preschool, but they support it with local levies. The Idaho School Board Association asked the state to fund this in a resolution this year. Lots of evidence supports early education as a wise government investment, but Idaho struggles with investments. This would be a big leap for Governor Little.

And what can the Governor do about good paying jobs? Even if he went off the deep end and endorsed raising Idaho’s minimum wage, we aren’t really talking about attracting minimum wage workers. But the governor could make a strong statement about wages by trying to make state employee salaries competitive.

Maybe, instead of pushing salaries, he could suggest a “housing allowance” for state workers commensurate with his own. Idaho’s governor gets $138K a year (39th nationally, while Idaho wage earners are 50th) and another $55K for housing or a boost of about 40%. I would bet state workers would be happy with a 5% boost in salary and no housing allowance, but Brad does seem like a fair guy.

I’ll bet he goes for cutting the grocery tax, which has broad support. Idahoans now pay sales tax on groceries; this adds about $200M to state revenue. About $26M of that goes to local governments. But taxpayers get back a grocery tax credit to the tune of about $150M. Eliminating the grocery tax would cost the state general fund about $80M.

So, you can see Governor Little has some real numbers to play with. And the numbers count. Add into all this the uncertainty of the tax revenue, since Idaho’s tax collections since July have been well below projections. Most are writing this off to bad tax estimates offered to employers as the federal and state tax cuts came through together; the expectation is that come April, the taxes owed will add up and we will be writing big checks with our returns. But remember the Constitutional requirement of the Governor: “the amount of money required by taxation”.

I hope Brad holds to his vision. Us dodderers need you plodders: make Idaho your home. We should make it worthy.
 

Really happy

schmidt

Ever get a present that made you really happy? Ever get one that disappointed?

Well, the Idaho legislature got a present from the voters November 6th they didn’t really like: Proposition 2, Medicaid expansion. This citizen initiative passed in 29 of 35 legislative districts; in many of those districts legislators actively opposed it. So, the legislature got a gift. I hope they don’t throw a fit like my daughter did when we got her the knock-off athletic bag instead of the name brand. We still tease her about it.

There are many times when we look for excuses to not do the right thing instead of throwing a tantrum. It usually involves whining. The Idaho Freedom Foundation is giving legislators an excuse through their lawsuit about the constitutionality of Prop 2. I’m glad the Idaho Supreme Court has allowed folks with stronger standing to add their voices to the argument. And the whole question of whether the Affordable Care Act is constitutional, brought up by Republicans before a partisan Texas judge will get to play out. It’s just another excuse for those who want to whine.

But the excuse I hear from what I consider otherwise level-headed legislators is the handwringing, maybe with a little whining involved: “We just can’t afford it.” This excuse is just poppycock.

Every credible analysis of the funding requirements for Medicaid expansion have shown that in the long run, this policy choice either saves Idaho money, or costs very little. The ones that have shown minor costs have not included savings from keeping folks out of prison, expanding Idaho’s economy or keeping rural hospitals afloat. Anybody who has looked at the analysis understands this, even Republicans.

But there will be initial costs for Idaho, since the savings from reducing the CAT Fund and county indigent costs will take a few years to show up. Kind of like when you buy those expensive LED lights, they cost a bit up front, but the lower electric bills actually pay for them in a few years. But that initial cost can be an excuse for you to not conserve, not do the right thing. Please don’t whine as you pass the light bulb isle in Walmart.

This legislative whining about not being able to afford it comes from your representatives that don’t really know the numbers of Idaho’s budget. I will admit, it’s complicated, but after I served on the budget committee a couple years, I got some understanding. All legislators should serve on this committee. Many don’t; it’s hard work.

There is a ready source for over half the initial cost of Medicaid expansion from Millennium Fund money. This is money Idaho gets from the tobacco settlement, about $20M a year. We have passed a Constitutional amendment that this money must be used to build an endowment fund, so it can’t be used directly. The Millennium endowment fund now sits at $300M. That makes over $18M a year available.

Next you have to consider what we have been doing with your tax revenues for the last 10 years. Idaho has replenished our reserve funds to the tune of over $65M a year. One of the reserve funds is now at its maximum amount allowed by law. Even with last year’s tax cut and Idaho’s revenues coming in under projections the last six months, Idaho has plenty of revenue to fund Medicaid expansion. Once we get the train moving out of the station, repeal the CAT Fund, the momentum will take care of itself.

Brad Little knows this; he served on the budget committee. Most legislative leaders know this. Don’t listen when they whine about the present they just got.
 

Suicide in Idaho

schmidt

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 are 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 proud 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.
 

My ex is getting married

schmidt

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.
 

Humbly thankful

schmidt

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, snowmelt 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.

Rip off the bandaid

schmidt

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 backbone. 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 12,000 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.
 

Owning our health

schmidt

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.