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Posts published in “Schmidt”

The sham of testimony

schmidt

We elect our representatives. They are our voice in making the laws that govern us. Why do they need our input except at the ballot box every two years? What purpose does this public testimony on proposed legislation serve? If we do not have the backbone to hold them to account come election, then why should they listen in their deliberations?

It was almost relieving to see ten-term, 20-year State Senator Lodge acknowledge this last week. As Chairman of the Senate State Affairs committee she had a roomful of people who had come from far and wide to speak on SB 1159, changes to the Idaho initiative process. She let the three who wanted to speak in favor and then four of the 100+ who were opposed speak, then wanted to call for a vote. In her defense she said, “All the rest are opposed.” So, it’s like she knew what the committee was going to hear and didn’t see the purpose. After all, they are our elected representatives. Let them get on with it.

There was another time I have seen such an overt sham of public testimony.

In my first term in the State Senate, 2011 Tom Luna, newly reelected Republican Superintendent of Public Instruction proposed his LUNA Laws. He had not mentioned them on the stump, campaigning just months before. But here he had a new legislature and what he considered to be a mandate, so he proposed his new laws; funding technology over teachers in the classroom. Public testimony ran for days, 95/5 opposed. But the laws passed. Then came the referenda and the laws were repealed at the next state-wide election 2 years later by an overwhelming 70/30 vote.

But here’s the thing: every legislator who voted for those laws was reelected.

Figure it out voters. I applaud that you might use the referendum process to rebuke your legislators for passing stupid laws. I acknowledge your wisdom when you want to initiate action like Medicaid Expansion because your elected legislators have ignored a problem with an easy fix. But I am amazed at the insanity of reelecting the same people to represent us, when we disagree with their decisions. Shame on us.

Idaho’s citizen Legislators, one Senator and two Representatives each serve districts of approximately 40,000 people. It is estimated that people can only closely know approximately 150 people. That means, for each of us to know our representatives in the legislature well, we have to make a big effort; have a cup of coffee, go to a town hall, make time for a meeting, or read their newsletters.

When I was in the Senate I sent out a weekly newsletter that approximately 1500 people read. If they were all talking to 150 different people, I would have been reelected easily. But I came to believe all these people knew and talked to each other. We are talking to the people who agree with us. Can we change this?

Who are these elected officials who represent us talking to? Where are they getting input? First, I would hope it’s from the elected officials in their district: the county commissioners, the city councilors, the highway district commissioners, the school board members.

Can this be dismissed to partisan affiliation? If so, we all should be questioning that insanity. But it may be true. I have heard a legislator say he met with his party central committee before each legislative session to consider legislation. Welcome to the echo chamber.

Don’t expect your passionate testimony to persuade the citizen legislators you have elected. It may be heartfelt and in fact, it may represent the sentiments of many of your fellow voters. But it is much more powerful to elect people who actually do represent your values. Share your values.
 

Brad’s right

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While the legislature struggles with modifying Medicaid Expansion, costing more, getting less insured, Governor Brad Little on the campaign trail was beating a different drum. He was looking beyond the twisted shorts condition of legislative Republicans who fought Proposition 2: he can see the bigger picture. Health insurance for those beyond Idaho’s exchange, Your Health Idaho, are getting squeezed out of health care insurance.

To be eligible for participation in the exchange you have to make between 100%-400% of the federal poverty level. Medicaid expansion addresses those below 138% FPL.

If you are a 60-year-old and you can participate on the YHI exchange and you make $45K per year, you might only have to pay 3% of your income for health insurance since you get subsidies. But if you make more than the 400% upper limit to participate in YHI, say up to $50K, you wouldn’t be eligible for exchange subsidies and the cost might jump to 32% of your income. This is called the health insurance “subsidy cliff”. Many Idahoans are standing on it. That’s me folks. And it’s steep. Why would I pay a fifth to a third of my income for something I might not use? I’d be a fool. Most Idahoans aren’t.

This is where the growing numbers for Idaho’s Catastrophic Health Plan are coming from. There is “the gap” population, the 70,000 below the 100% limit for enrollment on YHI, who will now be covered by expanded Medicaid; they won’t be the uninsured anymore. But those above 400% are going to or have dropped health insurance because they aren’t fools. Brad pointed this out whenever he could. I didn’t hear his solution.

The trouble with Idaho’s indigent program is, we take your assets if you can’t pay your medical bills. The really low-income folks, those below 100% often had few assets. But I imagine those making $50K have some tools, a work truck, maybe a back hoe the county can file a lien on. There goes their health and their means of income if they get unlucky and sick. Welcome to Idaho and medical bankruptcy.

So, beyond Bernie’s “Medicare for All”, what can Idaho do about this?

It’s a head scratcher. Brad keeps talking about the Idaho High Risk Pool model and it’s worth consideration. The HRP was developed 20 years ago by State Senator Dean Cameron (now Director of the Department of Insurance) for people with preexisting conditions who couldn’t get health insurance. It was funded by a tax on all other health insurances sold in the state. It worked well for the ten years before the ACA eliminated preexisting conditions as an exclusion, then the enrollment dwindled to double digits and the fund ballooned to $20M. Could such a plan work again?

Some states have tried it, the reinsurance model, but each has varying success based on how much cost they are willing to shift. That’s the key, the willingness to properly fund the investment.

It’s worth fixing this. Most businesses in Idaho have less than 50 employees. There are many small shops or self-employed folks who drive this economy and need this support to make health insurance affordable.

A recent suggestion from the Trump administration was for states to apply for waivers to Medicaid to allow subsidies for those above 400%. Of course, for this to fit the budget neutral requirement, the subsidies for lower income folks would have to go down to pay for the higher income folks cost reductions. Isn’t that how it always goes?

Polls show most people are not happy with how health insurance works in this country. Why can’t Idaho take some time and effort and make this work for our citizens? It’s worth the effort.
 

Standing up to the public

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In a noble effort, Idaho Representative John Vander Woude is bravely standing up to the bully majority voting public and protecting his fellow aggrieved minority legislators. He has vowed to fight the will of the “uninformed” voters. “We don’t always let the majority make all the decisions because our Constitution is to protect the rights of everybody, not just the majority,” he said.

Thank God for brave legislators standing up to protect us from ourselves. We need it don’t we? After all, Idaho voters have made so many mistakes in our initiative votes.

The Fish and Game Commission (passed by initiative in 1938) ought to be thrown out; why do we need such folly? At the very least we should require some means testing for all who wish to take public game from the taxpayer’s trough.

And the publicly passed Sunshine Laws (1974) to insure open government might need a test too. Vander Woude should champion IQ testing of all those who want to run for office and gain income and health insurance at taxpayer expense.

The first trouble with losing is how it makes you feel. Wayne Hoffman and the Idaho Republican Party felt so bad about losing their fight over Medicaid Expansion that they took their pouting all the way to the Idaho Supreme Court. Well, the only thing they won there was being excused from paying the winning sides (the voters) legal fees.

The second trouble with losing is what you learn from it. In this case, “wrongness” is not being considered by Republicans. It was wrong for the Idaho legislature to avoid this topic for six years while many of our working poor citizens were without access to health insurance. It was and is wrong to wastefully spend taxpayer money for medical bills for catastrophic and indigent care.

Losing can teach humility. It shouldn’t teach shame. There is nothing wrong with losing if you have done your best and you fought for what was right. Believe me, I know this; I’m an Idaho Democrat.

If Representative Vander Woude has the honest intent of making Medicaid expansion work best for Idaho, let’s ask questions through clear, not red Republican or blue Democrat, but clear glasses at Medicaid Expansion. After all, many Republicans voted for it. And it is now law for all Idaho.

Here are some questions to help you frame your decisions.

Do you believe all Idahoans should have health insurance? If the answer is NO, you should be fighting for full repeal. 40% of Idahoans agree with you. If the answer is yes, then the next question:

Do you think the program to get all Idahoans covered by health insurance should be done at the lowest expense to the taxpayer? If the answer is YES, then you should support Proposition 2 unaltered. If the answer is NO, then the choices become wide and range from cheap to costly.

Honestly, these are the sorts of questions that are critically important to public policy. If you want people to participate in a program (immunizations, sex education, car insurance) then you design the program to maximize participation. You would automatically enroll them and give them the choice to “opt out”. If you don’t want them to participate, you require them to “opt in”. There are all kinds of incentives to use. It just comes down to where do you want to go.

Here’s my bias. I wanted the most Idahoans covered by health insurance at the lowest cost to the Idaho taxpayer. I support enacting Proposition 2 unaltered. But if you can show me how an investment of taxpayer dollars makes our citizens healthier, more productive, more engaged, better parents, better students, maybe clearer underwear, show me the plan and how much it will cost, and I might support it. It’s all about our vision for our state. I’m fiscally conservative. Show me what my tax dollars earn.
 

Sideboard, springboards, spanking boards

schmidt

I understand the Idaho legislature has twisted shorts with the Medicaid Expansion initiative approved by 61% of Idahoans.

They sat on their hands for six years and did nothing. They might have nodded quietly three years ago that those in “The Gap” were stuck in an unfair, unjust situation, unable to access healthcare insurance. They might have even agreed five years ago that paying for Catastrophic health care was the wrong way to deal with this problem, though it’s been the “Idaho Way” for decades. But they never got to work on the problem.

Well, voter support for Medicaid Expansion in Idaho slowly grew and come November 2018, most Idahoans supported the simplest, most cost-effective way to get our Idaho working poor health insurance. But now many of our proudly elected legislators think they know better than the voters.

One of the beauties of this behemoth called Medicaid is that it’s a partnership between the federal government and the states. So, states can experiment; many have. Idaho has and does. The experiments are telling. Let’s learn from them.

We’re hearing a lot about “sideboards”. When I hear that term, I think of the panels we used to get cows or calves into a squeeze chute for branding, vaccinations, dehorning or castration.

The main “sideboard” bandied about in the marble halls of our beautiful Capitol has to do with work requirements. I wonder if our legislators know anybody in “the Gap”. I see these folks every day. But here’s the Idaho statistics. Over 60% of people in “The Gap” are working the equivalent of full time, many in multiple jobs. Another 30% are caring for either children or elderly in their homes or are full time students. So, 10% might need a boost.

Let’s look at what other states have done and learn from them.

Arkansas instituted a “work requirement”. It cost the state $10+M to build the system, and effectively kicked 18,000 out of Medicaid. So, this program used a broad brush, painting all who gained access to Medicaid health insurance under their expansion as needing to prove their work. What did they find? In Arkansas, as we have said about “the Gap” folks in Idaho, 90% of those eligible for Medicaid were already working, caring for others or students. Of the folks kicked off Medicaid, 80% lost coverage for failing to report through the online portal. Dollars to donuts, Arkansas’ online service doesn’t come close to Amazon's.

This “sideboard” seems more like the paddleboard hanging in the principal’s office. If you’re poor and have limited online access, then bend over.

But Montana painted their program with a fine tipped brush. They knew what we and our legislators should know. Most poor people need a springboard, not a paddling. Montana used the Medicaid expansion program to offer job training assistance. On enrollment the offer was made and a follow up letter was sent. There was no significant taxpayer cost. About 10% of the enrollees sought the help. They had a meeting with a Department of Labor staffer, got directed toward training, education, skills opportunities and Montana has seen movement toward higher paying jobs.

Montana offered a springboard. Many who needed it took the offer and we are all better off for it.

Idaho has a robust and widely available Department of Labor with a new energetic Director, Jani Revier. I’m sure the department could handle the 5000 referrals from the new Medicaid enrollment and they would welcome the motivated clients.

I wonder if this is the springboard Brad Little has been referring to. I know many in the Idaho legislature prefer the paddle. Since we’re so late to the game, why don’t we learn from other's experiments? Let’s do it right.
 

Booze, bucks and buyouts

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Idaho territory was a rugged place. While LDS settlers were diverting streams and cultivating fields in the southeast, the mining camps in central and North Idaho were raucous, unruly and not ashamed of it. But the drafters of the Idaho Constitution in 1889 were feeling the wave of temperance rising: Article 3, Section 24 reads:

PROMOTION OF TEMPERANCE AND MORALITY. The first concern of all good government is the virtue and sobriety of the people, and the purity of the home. The legislature should further all wise and well directed efforts for the promotion of temperance and morality.

Idaho went on to establish a Prohibition amendment to our state Constitution in 1917, two years before ratifying the 18th Amendment to the US Constitution which established nation-wide prohibition.

But then came repeal in 1933 and Idaho, somewhat reluctantly followed suit. The Idaho Liquor Act was passed the legislature in 1939 and its framework exists today with some modifications. It’s an old, complicated system of regulating liquor licenses controlling the manufacture, sale, distribution and serving of alcoholic beverages. It has created an artificial market for liquor licenses that means for some regions they are dear, expensive or unattainable. Other markets they go unclaimed. Make no mistake, this law has created winners and losers. And the winners aren’t about to embrace the losers.

You see, the State Alcohol Control Board (ABC) limits licenses in cities based on their population. But if there are no licenses available from the state, you can buy someone else’s license or lease it. Here’s a broker where you can shop.

A license that cost you $200 from the state, if you put your name on the waiting list and bided time, is now worth $200,000 on the “liquor license market”. You can’t just sit on a license, you have to operate a real functioning bar for at least 6 months or you lose your $200 fee and the license. But if you “season” your license, it becomes very valuable. Last year a license in Coeur d'Alene was worth $300,000. Add to this, the state collects a 10% fee on any liquor license transaction. Throw in the changing populations of towns and this amplifies the obscurity of this system. The people who paid a lot don’t want to see their investment devalued should some crazy legislator want to shake up the 80-year-old system. I don’t see how this promotes temperance and morality.

I respect any legislator willing to address this mess. Many have. Governor Otter tried in 2009. But he gave up after his bill died in the Senate that year. Issues as tough as this require perseverance. A couple years ago Representative Luke Malek (R, Couer D Alene) brought a bill but again it died; then he decided to run for Congress. This year Senator Jim Rice (R Nampa) has brought a bill very similar to Malek’s. It got killed in a Senate committee last week.

I applaud Senator Rice. I hope he’s willing to stick around and see it through. He might have to hand this one off to someone younger; I suspect it will take a few years. And he’ll have to have tough skin because lots of liquor license owners think their ox is going to get gored.

Probably the only solution will be for the taxpayers to buy out all those over-priced liquor licenses so we can start over. I doubt Senator Rice can promise us that Mexico will pay for the buyout. That one’s getting sour.
 

Pain and suffering

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Idaho can’t say we’re winning the war against accidental opioid deaths, but we’re fighting a good fight. As you can see, the numbers are climbing. If you want a very in depth and excellent analysis of the situation, read this from the Idaho Department of Health and Welfare. I will focus on two points.

Idaho has a higher rate of prescribing opioids than the national average. We as a state have a long way to go in educating prescribers on best practices to avoid overdose deaths. We have made education available for prescribers through both the Board of Medicine, the Board of Pharmacy, the DHW; many resources are available. Indeed, there’s education but also sanctions. The legislature has made it possible for the two independent Boards (Pharmacy, who keep the data on prescribing and Medicine, who has the power to sanction) to communicate about prescribing practices. The BoP maintains an accurate data base of controlled substance prescriptions that can be accessed 24/7 by prescribers and pharmacists. The legislature has made this access easier, but not mandatory. Use of the data base has steadily increased. Still, the number of narcotic prescriptions continues to rise.

Of interest, the highest rates of prescribing narcotics are in our rural and frontier counties. I don’t think it hurts more to live on the frontier, but the association between chronic pain and poverty and rural or frontier life is real. Caring for chronic pain is a demanding task and resources can be limited for a rural practitioner. Still, with this information, with proper education, incentives and support, I believe this can improve. We shall see.

But we can only see how we are doing if we have good information; that gets to the second point. Idaho is quite likely underreporting accidental overdose deaths from prescription narcotics. Of all reported overdose deaths in Idaho only 2/3rds had a drug listed as a cause on the death certificate. Overdose deaths without a drug listed as the cause don’t get counted as narcotic overdoses. Some weren’t; some were. We won’t know unless we investigate and report.

Overdose deaths are investigated and reported by the county coroner. Idaho has 44 county coroners and I can tell you, they all don’t have a CSI lab. Heck, many don’t even have an official vehicle; I didn’t. You’d think the counties most likely to have lax reporting would be the rural ones, and indeed some are. In Ada County about 90% of the overdose deaths designate a drug; but Bonneville County reported just 40%. Canyon County only hit 35%. Maybe we have a faulty system. Studies of death investigations nationwide have shown that states that have a county coroner system (as opposed to a Medical Examiner system) are much lower at determining which drug caused the overdose death.

Ever since I was the Latah County Coroner for 15 years I have wondered about the wisdom of the county coroner system for the state of Idaho.

I write this as a practicing physician who prescribes controlled substances and as a former County Coroner. I appeal to my physician colleagues: we can do a better job prescribing narcotics, treating pain, preserving the health of our communities.

To all the County Coroners, ask yourselves, are you happy with the system you have for investigating deaths? Are you doing a good job? Are there ways this could be done better? Just because it’s the law we have now doesn’t mean we can’t improve the system. Think about it.
 

The Idaho Way?

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Brad Little has made many statements about how we need to do Medicaid Expansion “The Idaho Way”. The first time I heard it I smiled. The second time I smirked. The third time, I rolled my eyes. C’mon Brad, just what “Idaho Way” are we talking about here?

If you are going with the regional approach to the “Idaho Way” you will have to decide between the North Idaho Way where we bunked down, pile up the ammo and wait for the Feds. Maybe it’s the Blaine County Way where we drink chardonnay and give everybody a guaranteed wage.

But I have a sense you are thinking bigger than regions.

I know you are a student of Idaho history. Is there some historical example that resonates as the “Idaho Way”? We have bargained with the Federal government on water issues and highway funding, nuclear materials and wolves and sage grouse. The only time we stood up strong was when it looked like Idaho was going to be a dumping ground for nuclear waste. I hope you can maintain that stance, but it doesn’t really give me much direction here.

Most states that have gone through Medicaid expansion have seen it as a strong positive. It’s the ones that have tried to mess with it by adding “side boards” that have struggled. Maybe that is the Idaho Way you are suggesting: we struggle?

There’s the example of Arkansas that added work requirements for new Medicaid enrollees. They effectively booted 18,000 off the Medicaid rolls, but costing the state tens of millions to institute. Is that the Idaho Way? Spend lots of taxpayer dollars to get less people health insurance?

You could do the same math with any other “sideboard”: drug testing, co-pay requirements and lifetime limits. The cost of administration for any of these comes from the Idaho General Fund, which takes away from schools, your stated priority.

We both know the legislature is feeling burned by the voters on this one. The Idaho legislature sat on their hands for six years and turned away billions of Idaho federal tax dollars from returning to this state to insure low income Idahoans and felt just fine about that choice. I sure hope you don’t think that’s the Idaho Way. Idaho voters have said it isn’t.

The Idaho legislature has been just fine with spending Idaho tax dollars to pay for these uninsured to the tune of hundreds of millions for the Catastrophic fund and indigent costs. That money could have gone to Idaho schools. I sure hope this isn’t the Idaho Way you keep promoting.

Butch Otter had a little courage a few years back when he decided Idaho could set up a state-based exchange to make health insurance available for those above the poverty level. He had a big fight with the more conservative members of his (and your) party on this one and many dear colleagues heard strong words from their central committees and the Idaho Freedom Foundation. I saw in that move a faint glimmer of the “Idaho Way”. Decide what is right and fight for it.

The most effective way to get the most Idahoans enrolled in health insurance is simple, direct implementation of Proposition 2; now Idaho law as the voters have endorsed. That seems like the Idaho Way to me. How about you?
 

Who does he work for?

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If you had a really smart employee, who indeed worked hard, but refused to do the work you had assigned; what would you do?

Idaho State Representative Joe Palmer serves the 20th legislative District, a densely populated area in west Ada County south of Eagle, north of the Interstate, that is mostly Meridian. He has served five terms, ten years, and risen to a committee chairmanship.

He has refused to do his job when asked by the governor and directed by the Speaker of the House, even when commanded by statute. But he doesn’t work for them; the voters of District 20 keep him in office.

Governor Otter asked the legislature to study Idaho’s religious shield laws in 2015. These laws protect parents from being charged with neglect should their child die from a treatable illness if they withhold treatment for religious reasons. An estimated 2-3 die annually in Idaho from this neglect. Representative Palmer was appointed as co-chair of this group. One meeting was held with good testimony about a very difficult subject. Palmer refused to call another meeting or offer any recommendations. Yes, it was a tough assignment, but children in Idaho are still dying from parental neglect of curable illness. His constituents must support this.

Representative Palmer has shirked his duty in Idaho law, despite his oath to uphold Idaho laws. The gas tax and registration bill from 2015 hiked fees and taxes to pay for road maintenance, but did not address the difference that big trucks pay compared to smaller vehicles. The premise of Idaho highway funding is that of a “user fee”: we are all supposed to pay for the wear and tear we cause on the roads we use. Analysis shows big trucks pay less than the wear and tear they cause, and cars pay more. The 2015 Highway bill directed the legislature to study this and make recommendations. Palmer, chairman of the House Transportation Committee, has refused to meet for the past three years, despite the law calling on him. He has been quoted as saying “any tax put on big trucks will just be passed on to consumers”, which is true. But Joe, if you don’t believe highway funding should be based on a user fee principle, please, Joe, what principle would you propose?

No doubt, his district loves him. He got over 80% of the votes in the last election. The vote totals might just reflect his deeply republican district, since the other two republican district representatives were unopposed. So, he knows he ain’t going to be fired by his boss, the voters. I always wondered how my constituents knew what work I was doing in the Capitol. Maybe Representative Palmer’s constituents are happy with his nonaction. I’ll bet they don’t even know he represents them in Boise.

But all Idaho Representatives, regardless of political affiliation answer to the Speaker of the House. Why hasn’t Speaker Bedke let Palmer know he’s shirking his duty? Palmer was a childhood friend of Representative Mike Moyle, Majority Leader of the House. Are we just good old boys in the Idaho House?

Representative Palmer is a bright man, but I suspect he avoids tough issues. We all do this too much. If Idaho wants to lose the taint of cronyism, we are going to have to step up and have some hard conversations. Facing difficult issues is hard work. Elected officials are going to have to expect hard work of themselves and each other. Voters should expect as much too.
 

Medical loyalty

schmidt

I really do value loyalty, despite the things I say about it both last week and this. It’s just that I think we need loyalty to values or ideals, not people or groups.

I hate taxes as much as the next guy, but I see their purpose if they serve a goal I embrace. I got elected to the Idaho legislature right after the Affordable Care Act passed and the Republican animus against this health care policy was palpable in the state house. It might have been my second year serving when a resolution came through castigating the Affordable Care Act’s tax on medical devices. The resolution was telling our representatives in Washington DC to work to repeal the tax; the list of reasons for the repeal was long. The tax has been postponed, not repealed, thanks to another government shut down deal.

Why should medical devices pay an extra tax? They can save lives, heck most of us are walking around with one in us. I am. I had a hip resurfaced about eight years ago. I researched the different choices and made my decision, then found a surgeon that used that kind and had the procedure done.

But then consider the situation I have seen in a nearby hospital. This hospital has three different orthopedic surgeons and they all do hip replacement surgery. (Not the resurfacing like I had, the total replacement kind, whole new ball and socket.) Here’s the catch: each surgeon uses a different model of hip replacement device. Each believes strongly that the model they use is the best. So, the hospital where they work has to stock multiple sizes of each model, keep on hand the different tools required for the procedures, and keep the OR personnel trained in the use and surgery of all three different devices and tools.

Do you think this might contribute to the high cost of healthcare?

This is something else you need to understand: there is no clear evidence that one type of device is better than the next. And device manufacturers are always coming up with “new and improved” versions, requiring new tools, different training and OR procedures.

I can understand the loyalty of the surgeons who have used a certain device. They trust their familiarity with the tools and their skills with the procedures. But when there is no clear evidence, the surgeon’s loyalty to their preference costs all of us. Why shouldn’t a tax on these devices help the market perform better?

There is no doubt “health care is complicated”. I agree with President Trump on this one. I appreciate you readers sticking with me through this maze. But if we Americans are going to solve our health care fiasco, we are going to have to be willing to have loyalties to our greater good. We should be considering the best policy based on evidence, not partisan “wins or losses”. So, the medical device excise tax made some sense to me.

But my perspective might be different than yours.

Why should lots of medical device companies making a profit worry me, or you for that matter? My IRA probably has some in there. But what I’m most concerned about, my deepest loyalty, is having affordable healthcare, accessible to all. If my IRA takes a hit, but my health insurance premium goes down, I’m OK. But it shouldn’t be our own self-interest driving this decision. It should be all of ours; the greater good.