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Posts published in “Schmidt”



So often when faith is mentioned, people jump back, thinking I’m talking religion. I’m not. We need faith to lead our lives. And I am worried about the faith of my fellow citizens right now.

We need to have faith in each other.

I don’t mean the kind we practice and indeed demonstrate at those “team building” seminars when you cross your arms and fall backwards, and we catch you. If we didn’t, you’d be bumped a bit and embarrassed, and we’d be proven to be the jerks you secretly thought we might be.

But imagine driving the Salmon River on Highway 95 heading south to a meeting in Boise. The road is maybe 30 feet wide. Your little pickup takes up a third of that space. You’re a bit above the limit at 70 MPH and that log truck coming in the other lane might be a bit over too. Faith allows you to keep your speed, trusting the Peterbilt will stay over there, and you won’t drift into a fatal collision. You’ll make the meeting in Boise. That’s daily faith.

Swipe the card at the gas station. Faith in the honesty of the card company, the transfer of funds, the security of your assets lets that transaction not require you to go in and hand a twenty to the guy behind the counter selling corn dogs.
Buying a corn dog at the gas station requires your faith that the food is not tainted, and you’ll only have indigestion, not food poisoning down the road.

A worker starts their job with faith that the paycheck will come.

A mother brings a baby into this world with faith that she can invest in this new life.

We live with faith daily. Without faith, all society crumbles.

You may have faith in your God, you may have faith on Sunday, but do you have faith in your fellow human, your neighbor, anyone beyond yourself? I believe you do. Stand up for that faith. Show it, honor it, believe in it.

It has just become fashionable to deny it. Don’t fall for the fashion, the fad.
The unruly crowd who stormed our National Capitol last January 6th probably all used their credit cards to buy gas or airplane tickets to get there. They had such faith, though they so wanted to deny a faith in our government.

The folks who buy “F**K BIDEN” flags online trust the website selling them to honor their card number and protect their security. They have faith in those selling the wares, so they can wave the flag proudly declaring their lack of faith in our representative government.

For that is the fashion these days, to decry the value, the institution of representative democracy.

Don’t think I’m immune to such distrust. I have had my faith shaken deeply. I grew up not believing in a Southeast Asian war my friends were drafted into. I watched as my president committed crimes and resigned from office. No, faith in government doesn’t come easy for me.

Moreover, I’m an Idaho Democrat and I’ve served in the Idaho Statehouse. Can you imagine a lonelier, more isolated role in government?

But I still believe in the institutions our founders crafted for our governance.

Yes, some of those institutions are flawed. But we, the people of this Republic have the tools and the courage to demonstrate our faith in each other and change them. If something our government is doing is wrong, we can change it. It will take time and effort, not just a tweet or a brief Facebook comment. Change has happened in this Republic.

Hopelessness is what we feel when our faith fails. Let that feeling of hopelessness wash over you and drop to the ground like a fall rain. Then get to work. I would appreciate your effort.

Idaho grows


I grew up in a small town that exploded, faster than Meridian or Caldwell has, and that experience shaped me. I decided I wanted to raise my children in a town that didn’t suffer from such booms. But neither did I want to have them feel the busts.

Idaho is booming now, and it has been for a while. Booms bring burdens. I was amazed to hear a Republican colleague stand up and say on the Idaho Senate floor what I had been thinking for quite a while. We had debated and passed quite a few pro-business and development tax schemes right after the 2008 economic collapse. The goal was to bring jobs and business to our state. Idaho had just cut school funding for the first time in its history and our reserve accounts were depleted. I felt that pain. Growth could solve this. But he stood up and said, “We are promoting growth in this state. I have plenty of constituents who like things just the way they are. What should I be saying to them?”

This last legislative session the senior Representative from the legislative district that has had the most growth proposed and got passed a property tax “solution” that tried to balance this growth conundrum.

House Bill 389 put a cap on what cities could raise their budgets at 8%, and only 5% from new construction. But what if a small city with 300 homes on the edge of Boise wants to add a development of 100 homes? This is happening right now. Housing down there is booming, and some folks have designed ideas that fit their needs and will serve the market. Believe me, the local folks who have worked on this development who now find it unsupportable by these legislative constraints are not happy.

And it’s happening in my town. A new manufacturing business with good jobs and great history will be looking for new employees, so three new 50 home developments are platted and scraping the soil.

We don’t have unlimited water up here on the Palouse. Don’t get me started on the traffic.

But the idea that the Idaho legislature has the solution for local growth problems is hubris. They might as well be suggesting we build a wall.

Growth happens, just as long as more humans are on this planet. It becomes a question of how and whether we should plan for it or not, since the planet won’t be getting any bigger. It should be up to local municipalities to manage their growth, not the whiz kids in the statehouse.

Many small Idaho towns right now are struggling with their infrastructure needs. Some have had to ship water in, others are seeing sewage plants condemned. And most of these small towns haven’t had growth. They drilled their wells and dug their sewage settlement ponds 50 years ago, paying for the expense with a bond. The interest on that loan was added to their monthly fees. They laid the pipes and charged their rates based on the maintenance and debt service, but with little account for eventual replacement.

Now, the worn-out plant needs replacement, and the townspeople wonder why they should pay. They won’t get use of a plant after they die or move on.

We are not planning for sustainable growth.

A student in England’s old New College (est. 1379) was sitting around with his buddies in their eating hall and one commented on the old oak beams. “I’ll bet they’re rotten.” A penknife proved it. Where can you get 30-foot oak beams? Another thought of the campus forester.

The old lumberman puffed on his pipe and squinted. “Eating hall? Them oaks are out east.” And he led them to a grove planted and preserved for 300 years.

Boom and bust is no way to lead a state into the future, though, lord knows it’s sure our history.



It was back in my elementary school days when I could have political and philosophical discussions with my father. It was the golden years, before Viet Nam, and his Greatest Generation, WWII credibility still glowed for me. It didn’t matter that he had no visible skills or initiative, other than playing poker and dreaming, I still held him in regard, probably like most children do who aren’t abused.

He would talk about how our society wasted it’s time and effort prosecuting “victimless crimes”. To his way of thinking, prostitution, narcotic use, and his vice, gambling shouldn’t be illegal. “Society has no place victimizing, prosecuting, fining or jailing people who are just hurting themselves.” You can imagine a third grader pondering such wisdom.

But I did. Then, I found myself in medical school. The chronic alcoholics and drug abusers filled the ER bays and hospital beds. They took up my time, my energy. My fatigue, both physical and emotional made me start to feel victimized. Maybe that helped me learn to keep an emotional distance from others’ woes. It sure reminded me of my now estranged father’s wisdom.

When I came to Moscow, Idaho we would take turns being the “on call” doctor for unattended (non-paying) ER admissions. I remember watching one young man dying from his chronic alcohol use. His third admission in two months was particularly rough. He came to the ER skinny, covered in his own feces, unconscious, near death.

By the luck of the draw, I had been his doctor for the previous two admits and got him this time too. When he could talk, I asked him if he wanted to die. He would not answer me.

From all evidence he was doing just that, killing himself.

I had settled in Idaho, a state with my father’s political slant. If people are actively suicidal, they can be declared by the court to be a danger to themselves or others and committed to state custody. I asked the social worker if this man met those criteria. She shook her head. “Idaho statute prohibits commitment for alcohol abuse.”

Thus, to some extent, Idaho law protects the freedoms of people so inclined. I smiled as the quiet social worker explained this distinction to me. People with a mental disease who wish themselves harm and are going to act on it can have their freedoms taken away, but if they wish to drink themselves to death, the state keeps hands off. I think my dad would have appreciated this legal sentiment, though he might have taken it a bit further. “Why commit anyone to protect them from themselves?” I can imagine him saying.

So, when people refuse to be immunized or wear masks, I have an understanding of their choice. The fact that their choice affects others around them is not unlike the young man’s alcoholism. His family was distant, estranged. He lived on the street. If the ambulance hadn’t picked him up and brought him to the hospital, he wouldn’t be causing me problems.

The full hospitals now, the overflowing ICUs, the tired nurses and doctors have my sympathy. I can understand their frustration with the work they have to do.

But similarly, I can understand the refusers perspective too. I have chosen to be immunized. I think it will protect my health and those close to me. Other choices are valid but have their consequences. I do not feel safe from infection because of my immunization, and evidence suggests I am right. But the evidence is still coming in. We could fight about it all day.

Maybe that’s why Dad liked poker. He had to use the evidence he had and make his decision and the flop told you who won. This pandemic hasn’t come to the flop yet, though for many of its victims, it has.



I had two senior pictures taken for my high school yearbook. I got the first done after a summer of beach time and football practice. My hair was long. It was 1971. My parents saw the proof and insisted on a retake. I believe they saw the long hair as a sign of disrespect.

But those were the times. Baby boom kids challenging the Greatest Generation. Respect was expected, and when not given, it was an affront. I found their discomfort with rebellion more evidence that they couldn’t handle “the times that are a changin”.
But I am older now and respect has come to mean more to me than an opportunity to offend.

I can’t remember when this changed. I’m not sure if it was the hard work, the stupid bosses, the danger, and the steep hillsides of fighting fires. I still rode my motorcycle then: no cause, not much of a rebel.

Medical training might have changed me. There were all the things I needed to learn, then the disease and death I was expected to understand and do what I could.
I came to respect disease. Just look at viruses.

There are viruses (Chicken Pox, Herpes) that can infect you as a youth, then hide in your body for decades, then reemerge to cause more disease when you have become old. Same virus, same body; it just waited a long time. For some, there is never a reemergence; such a mystery.

Other viruses have wiped out whole civilizations. It is suspected Smallpox did that in the early 1500’s in North and South America, after Europeans landed, introducing it to the New World. And then, through technology, study and massive effort, the virus has been eradicated from our world, only to exist in whatever bioterrorism facilities might keep a strain. There hasn’t been a reported case on Earth for 40 years. Such an accomplishment is worthy of respect.

I have seen a patient die in a matter of hours from a Hantavirus infection. It’s rare, but deadly. The sudden death of a previously healthy, middle-aged person made me think and wonder about many things. I did not become fearful, but I respected the disease.

Now we are wondering how to manage this novel Corona Virus that has sickened so many and is changing its form as we watch the numbers climb. Idaho has seen cases increase 5-fold in three weeks. We are on the steep slope of a rising curve.

Is this new wave because we haven’t respected this disease? After all, it’s in the category of common cold viruses. Who wears a mask or gets a shot for a common cold? And there’s plenty of conversation out there about how minor this disease is. We’re dissing something that is killing some of us. Is that being respectful?

If we haven’t given Covid respect, it could be just a reflection of our unwillingness to respect anything. We have elected officials who don’t respect the institutions they were elected to take a seat in. We have elected leaders who make mockery and disrespect their standard discourse. We have social media platforms that give the microphone to incivility and amplify rude behavior. We have church leaders who decide who is worthy of respect and who isn’t, unlike the Savior they claim to worship.

So, I don’t know when that changed for me, my willingness to be respectful. I sure didn’t think I owed it to my folks as a teenager. It was Mark Twain that said, “When I was fourteen, my father was the stupidest man in the world. When I talked to him when I was 21, I was amazed at how much wisdom he had gained in seven years.”

Let us give all dignity and respect.

The other epidemic


As the number of Idaho Covid deaths slowly climbs past 2200, the other epidemic still rages. Masks won’t help, but social distancing might, if you stay away from the right people. It is estimated that about 280 people in Idaho died from drug overdoses in 2020.

While we rage about mask mandates, our mainly young (but also some older) folks are dropping off. The US saw overdose deaths shoot up 30% last year, the highest increase ever. The nation-wide death total came to over 93,000. I guess when we are comparing that to Covid deaths (613,000) it’s not that big a deal. Are we getting jaded?

Just as we aren’t really sure how to deal with Covid (those of us who are immunized should wear masks inside now?) I don’t see any single answers for the narcotic issue. Doctors in Idaho now prescribe less narcotics. I think that’s a positive. Back in 2010-2012 Idaho doctors wrote 90 narcotic prescriptions per 100 people. Now we write about 50/100 people. Both numbers are well above the national average. But people have pain and narcotics help acute pain.

But with folks getting less narcotics legally prescribed, the fentanyl-cut street narcotics prove more deadly, and our death numbers climb.

At least our Attorney General Lawrence Wasden has an idea what to do. He joined in a suit with 15 other states against Purdue Pharma and they agreed to settle a couple weeks back. Idaho will be getting some $20M over the next 8 years or so. It is supposed to be used to treat narcotic addiction.

But the Sackler family, founders and main shareholders of Purdue Pharma will still have billions. Wasden testified before congress trying to get them to change the bankruptcy laws that allowed the Sacklers to squirrel away fortunes made on the sale of the popular Oxycontin in the 1990’s. Meanwhile, we wear masks, or don’t and watch as our friends, relatives, and neighbors struggle with addiction.

I’ve seen this from so many sides. I’ve had patients in the ER obviously addicted, faking injuries, wanting narcotics. I’ve seen my physician colleagues prescribe irresponsibly. I’ve had a cousin die of an overdose after getting out of a six-month program. I don’t see any easy answers.

Meanwhile, our clinic has been trying to hire a substance abuse counselor for three months. We run an outpatient program for narcotic abuse. But the structure requires we have a counsellor to evaluate and provide ongoing therapy our enrollees. So, we’ve been three months without being able to enroll anyone new.

It’s not that the pay is low. We provide good pay, benefits, and work support. I have empathy for rural school superintendents in need of new teacher hires. We’ll keep at it.

Not that our program is an answer for everyone struggling out there either. Some folks find other ways to get back on their feet. I support all recovery.

So, what will Idaho do with this money Wasden has bird dogged for us? I’ll bet there will be some new agencies, maybe more people hired by the governor’s Office of Drug Policy. They are up to 6 full time positions now, with a budget of $5M (almost all federal dollars). Will that help lower the addictions, the deaths, the disease that burdens us?

Fundamentally, I think we are going to have to help ourselves, and our neighbors, our friends, and our loved ones. It’s not always easy to know how.

My cousin would call us every couple of months from the program he was in. He always asked me about my motorcycle. He sounded like he was OK, but I knew he was struggling. We couldn’t go see him. When he got out, he overdosed the first week but survived. The second time was fatal. I didn’t know then what I could do. I’m not sure I do now.


Medical debt


The twisted method we pay for our health care in this country just doesn’t seem to get people riled up like immigration, guns, abortion, or any of the other hot button issues. But it got the attention of Frank Vandersloot, conservative Idaho Melaleuca CEO in 2020, and he took his idea to the Idaho legislature. Idaho Republican legislators love to rail against regulations, but they took Frank’s ideas to heart and passed laws regulating the collection of medical debt.

This is not a small problem. A study just published last week pointed out that the medical debt held in collection agencies last year totals $140 billion. It is the largest sector of debt that collection agencies own. Their study estimated 17.8% of the population has medical debt in a collection agency. And these were pre-pandemic numbers.

Mr. Vandersloot got his glimpse into this twisted universe when a collection agency attempted to garnish wages of a Melaleuca employee. The unpaid doctor bill (that the employee had never received because of a bad address) was for $294. The collection agency wanted to tack on $5000 in “legal fees.” Melaleuca refused to garnish the wages and fought the collection in court. Then Frank took his regulatory proposal to the Idaho legislature. And the very conservative body passed his proposed law.

So now Idaho requires billing health care providers to submit a bill within 45 days of services. Seems fair. But if you have a high deductible, and most people do, you pay cash for the first bill you get until you meet the deductible. The later billing entities haggle with the insurance company.

Insurances have contracted payment schedules. Medical providers want to dun the folks who are likely to pay, and health insurers have the deep pockets. I’ll bet a $10,000 deductible would hit most folks hard.

Further, the Idaho Patient Act requires hospitals to send a summary bill of all the services received by the patient within 60 days of discharge. Many folks don’t know that the radiologist who read your CAT scan bills separately from the hospital, since she is an independent businessperson. This is even though they work in the hospital, the CAT scanner is in the hospital, and the radiology techs who ran you through the machine are employed by the hospital.

Same with the surgeon who took out your appendix. But not the nurse who started your IV. So, the hospital now must collate these charges in a summary bill for you, under this new law. It seems fair. We need to know what we owe, don’t we? Aren’t regulations wonderful? But somebody will be paying for somebody to do this work.

The IPA also limited what attorneys can charge for their “collection” services. It turns out this is a lucrative business for some folks, collecting medical debt. When asked to comment, the attorneys shrugged and said they would just charge the hospitals more for the service, so their yacht payments would be protected. And our health insurance costs will keep going up.

So, this is the vision for a solution to the medical debt payment morass in this country from a conservative Idaho billionaire, Frank Vandersloot, and the conservative Idaho legislature. And indeed, it will “solve” some problems. Frank said he was motivated because he saw “people being bullied”.

Interestingly, the study that chronicled the huge amount of medical debt owed to collection agencies saw a sharp distinction, state by state. The states that had expanded Medicaid had much less debt than states that hadn’t.

Medicaid pays hospitals and doctors for their services. Doctors and hospitals hate it because it pays them a lot less than private insurance or private individuals. That’s a different regulation. I wonder what Mr. Vandersloot thought of Idaho when we expanded Medicaid coverage in 2018.


Old men and fire


Back in the antediluvian days, I was a government GS-4, Forest Service fire fighter. I did four summers on a Category One, interregional crew. Folks love the term “Hots Shots”, but the jumpers just called us ground pounders. They figured they were much cooler than us, parachutes and all. Maybe they were.

“Interregional” means we got sent off our home forest to “project fires”. When a fire gets to a certain size, it becomes a “project fire” then the local forest didn’t have to pay the costs, it came out of a national budget. Our home forest only had to pay our wages if we weren’t on a fire. Can you see a budgetary problem here? We talked about the wisdom or folly of policies like these as we chopped and dug.

Have you ever noticed that any news story about wildland fires uses the term “bone weary” when they describe the crews? We always joked about that term as we napped on the airport runway waiting for the DC3. Like any big government deal, there were lots of inefficiencies. And we could see them close up. We all knew when there was waste happening, but most of us knew we couldn’t manage it much better if we were in charge. That didn’t stop our grousing.

It sure was a privilege to see some of the most beautiful country in the West and get paid to do it. Yeah, and some of it turned black, or white or grey, instead of that beautiful green we think of when we say “forest”.

To be honest, project fires needed weather to put them out. Hand crews cannot do much when the forest is dry, the humidity is down and there’s any wind. Except, that is, do your best to not get hurt.

But it was dirty, hot, sometimes cold (woke up under 6” of snow on my first project fire in Wyoming), filthy, exhausting, grimy, work. I really remember the dirt. And I remember the people on the crew. I’m not joking about having forest management policy discussions. It was a great group. I’m still friends with some.

I will admit I had no lofty goals about saving the forest. I needed the money for college. But that first year I stayed late because California burns in September and California was where the money was. Often the 20-man crew would lose guys in August as they went off to college. My first year we were based in McCall, so if we got a call, we could fill out our crew with any jumpers who wanted the work. We took five with us to California. We had seen a lot of fire that summer, mainly in Idaho. We’d run a few times and been burned over on the Middle Fork. So, when the fire came up the California chapparal canyon, we felt OK hunkering in the middle of a three Cat blade wide fire break. We could see it would go up one side first, then the other. We didn’t pop our fire shelters. But the jumpers did.

Staying late I was able to save enough money to pay for college, felt secure enough financially to marry the woman I loved, and started building a career, a life, a family. In that sense, firefighting was very good to me, even though it was dirty. And I never got hurt.

Our family grew to have four daughters. I guess I told too many firefighting stories because three of the four ended up working on fire crews. But they, and I moved on from that dirty work. It’s good when you’re young. Dirt washes.

So, the smoke in the air these days doesn’t bother me so much. I know some firefighters are out there making time and three quarters. I do hope they stay safe.

Political disease


I have wondered why it took so long for Idaho health care employers to require their workers to be immunized against Covid 19. Maybe they were anticipating the political reaction. Three large employers did just that this last week, and of course, they got the predictable reaction: umbrage, outrage, bluster and brouhaha.

When I got matched as a resident to work in Spokane hospitals, back when dinosaurs still roamed the Northwest, my first week of orientation included a bunch of blood tests, skin tests, and shots. They wanted to know if I had HIV, or tuberculosis. They checked that I was immune to Hepatitis A & B, measles, mumps, rubella, chicken pox.

Every different employer I have had over these long years has had similar requirements, now Hepatitis C is added to the list.

Hepatitis B and C and HIV are transmitted through body fluids, not aerosol. But the ER and the OR and labor and delivery have sharp things and lots of blood. The risk of me getting the disease from others was real, and so was the patients’ risk if I happened to be a carrier. So, such a mandate by these employers made common sense. I’ll admit to feeling some initial hesitation, kind of like I feel every year when I have to renew my medical license. But it’s about making tradeoffs in this crowded world, and some pondering and reflection eased my hesitancy.

But Covid is now a political disease, not an infectious virus. Where you stand on the political spectrum, what news you listen to, what flag you fly from your Trump pole will lend more influence than half a million or more excess deaths.
Here’s how many died in 2019 from some of those other diseases we have screened health care workers for since dinosaur days:

Viral Hepatitis: 4,285
HIV:15,815 (total deaths from all causes in HIV infected people, most not directly from HIV)
Tuberculosis: 542
Measles: 0

Half a million Covid deaths seems like a big deal when stacked up to this list.
There is no doubt there is immunization hesitancy out there. I work in a clinic that offered free shots to all employees and about a quarter are still un-immunized. Masks are required, and if you don’t want to wear one you can look for work elsewhere.

I had to put on a fluorescent vest and a plastic hardhat just to tour a lumbermill in Laclede. They also had me sign a waiver their lawyers had written up. I’m still a free man.

And that’s an employer’s choice in Idaho and in most states. Some workplaces have mandatory drug testing. Does that infringe on “freedoms”?

So, when Janice McGeachin, my Lieutenant Governor calls this “medical tyranny”, I have to laugh. You know, and I know exactly what she’s doing. But I’m old and can’t hear dog whistles anymore. But I can see when they are being blown.
If her posturing and misguided pose appeals to you, then I can predict what flag you fly. I’m sorry, but I wish there was a flag for the “Common Sense Militia”.

We’d meet every week and have coffee. We’d laugh at each other’s mistakes and tell stories about ourselves and our silly neighbors. Somebody might bring up politics, but that would get boring real fast. We’d probably talk amongst ourselves about whether we had gotten “the shots” or were taking ivermectin.

Some guys might even wear a side arm, but long guns in a coffee shop aren’t common sense. They belong out in the pickup.

I hope this virus hasn’t robbed us of our common sense. With all the problems we have, we sure need it.

Idaho Laboratory


“…a single courageous State may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.” USSC Justice Brandeis

Us dang Idaho citizens foisted Medicaid expansion on a reluctant legislature through the initiative, Proposition 2 in 2018. For a couple years now all they have been doing is pounding sand. First, they tried adding on every limit the Freedom Foundation told them to: work requirements, private option, sorting out the sick.

This was after the Freedom Foundation’s lawsuit to overturn the initiative failed. Now, in a supreme act of petulant pouting, legislators have tried to virtually eliminate the tool we used, the Constitutional initiative process.

Instead of reading the landscape and trying to figure out the best process, they want to turn the clock back. I suggest, forget trying to invent the flux capacitor; get to work on some real public policy experiments.

They have the data. You do too. Thanks to the Idaho Department of Health and Welfare sharing public information (which legislators are reluctant to do), we can study the information and make some suggestions for some courageous experiments.

Do you get a sense these legislators are more interested in keeping their seats than serving the citizens? But that’s a different rant.

After just six months of Medicaid expansion enrollment data, a study was presented to the Idaho legislature about what was happening. There was no legislation, no policy reactions, no meaningful comments after last December’s presentation.
So, let’s look at the information ourselves.

First, enrollment is a bit ahead of the expected numbers. We did have a significant economic downturn what with the Covid shutdowns and bump in unemployment. I don’t find those numbers alarming. Honestly, I can’t believe the economic gurus sitting on a $800M 2020 surplus in Boise are much alarmed either. But the hand wringing will continue about paying for 10% of the costs. Remember, Idaho pays 10% of expansion costs, the federal government prints the dollars for the 90%.

One of the beauties of Medicaid is that the data about where the money goes is open for us to scrutinize. Somebody should: maybe our elected representatives?
No, they want to fight off the CRT boogeyman, so I guess it’s up to us.
Let’s drill down.

The first six-month data shows the Per Member Per Month costs. PMPM is a useful number to understand. If you pay $300/month for your health insurance and your employer pays $400 and you don’t pay any copays or deductibles, your PMPM is $700. Add in all the annual copays/ deductibles/ out of pocket costs and divide by 12 and then you have the full PMPM.

The Idaho Medicaid Expansion population in that first 6 months sat at $517 PMPM.
In Idaho, Medicare PMPM (remember, older, more expensive) is $707PMPM.

Where did that big chunk of money go? The folks who studied that population for the first six months noticed some interesting things.

Idaho Medicaid Expansion enrollees had spinal fusions at a rate 5X that of comparable expansion states. Their length of stay in the hospital was shorter, but the greater number added $6.50 to the PMPM.

100,000 Medicaid Expansion enrollees x 12 months x $6.50 = $7.8M

Expansion enrollees got general physical exams from specialists, not their primary care physicians. This added about $.80 PMPM, or $960,000.

They looked at knee and shoulder arthroscopic surgeries ($1.80 PMPM), hip replacements ($2.67 PMPM), and a lot of others. Each penny adds up.

If you want to control health care costs you have to find the tools and be willing to use them. The variability and waste in health care spending has long been known. Let’s get to work on it. Be courageous.