Posts published in “Schmidt”

I have migrated late in my medical career to working part-time in a Federally Qualified Health Center. (FQHC…sorry but the anagrams may start piling up.)

These centers grew out of a 2001 plan from President George Bush II. He wanted to improve access to primary care in underserved communities. Back in 2000, 14% of our country’s population was uninsured. There was back then, and is now, plenty of evidence that access to primary care improves community health.

I guess back then even Republicans were comfortable solving our national healthcare problems with federal programs. So, he threw money at it in the form of a pilot program. It was buried in a budget bill. But unlike the Covid money, these bucks didn’t just buy new RV’s for clinic administrators. These centers saw a 60% growth in patient visits for the five years after the investment.

But more community clinics didn’t solve the national problem. The number of uninsured continued to grow. By 2010 we were up to 16% uninsured.

Then along came the ACA (Obamacare). Rather than saying “NO” to anything Republican, the value was seen. The Community primary care clinics got morphed into FQHCs.

Here’s my FQHC elevator description. I’ve learned to do this because people’s eyes glaze over midsentence when talking about health care funding and delivery. Yours probably did in the first paragraph.

FQHCs must have a community governance board. They must provide a range of health services including primary medical care, dental, behavioral health, substance abuse services, among others. They must provide a sliding fee scale and agree to see all patients regardless of their ability to pay.

In return, the clinic receives enhanced reimbursement for Medicare and Medicaid services.

“Who cares?” you may ask.

Idaho does. Because this model has been advanced into behavioral health care and Idaho is embracing it. Welcome the Certified Community Behavioral Health Clinic. (CCHBC).

CCHBCs are required to provide an array of services. But the CCHBC model requires community governance and agreement to provide service regardless of the patient’s ability to pay, just like the FQHC.

The Idaho Department of Health and Welfare (IDHW) Behavioral Health (BH) Division has announced a couple big moves in the past few months. First, there is a move to establish multiple CCHBCs throughout the state. Full disclosure, the clinic where I work has committed to this.

One of the services required of a CCHBC is 24/7 availability for crisis care. IDHW can thus diminish their staff obligation for crisis teams.

Make no mistake, somebody is going to pay. It’s just who, when and how. And that brings me to the next big announcement from IDHW. A managed care contract has been awarded for both inpatient and outpatient BH. It’s the biggest contract ever awarded in Idaho, $1.2 Billion, with a “B”.

The two companies who weren’t awarded the contract are both suing, so maybe there’s some uncertainty.

It is of note that the company that has had the Idaho BH managed care contract for the last ten years, Optum, bid on the contract and did not win. This is despite their claim they saved the state $400M in Medicaid costs.

I hope the interim legislative committee looking at managed care for Idaho Medicaid is paying attention to this. Behavioral health is small potatoes compared to all of Medicaid. I’ll bet there’s a lot of lawyers who would love to see that contracting lawsuit walk through their office door.

I hope the acronyms haven’t swamped you. It’s an interesting swamp to me. I’m just trying to keep my boots on for now.

 

I find myself stifling a smirk when I hear a new term for a group. The homeless have become the “Unhoused”. I stifle the smirk because such a response is disrespectful. And the intent of the renaming is to offer respect and dignity to the renamed group. And the smirk may also be because I see such renaming as paltry effort, though, indeed well intentioned.

We cannot address the despair and dysfunction of the people living under tarps, near underpasses and in our metropolitan alleys with a softer new name. It may reflect our kind intent, but I’m sorry, there’s work to do. Creating a kinder, gentler name isn’t enough.

Other countries have addressed this complex problem. The solutions are complex and require significant investment. The price of housing, the availability of healthcare, the livability of cities are complex, swirling issues that some countries have addressed. And indeed, their solutions may not suit our problem. But we have the resources. I suspect we don’t have the will.

And now I smirk at my own last comment regarding “the will,” because such a criticism would probably be leveled at the unhoused/homeless by those not willing to address a solution. Dismissing our shared responsibilities on this planet by pointing to others’ bootstraps is quite the style. Always has been.

I have come to realize my smirking reaction is not healthy. Not for me, or those I care for. I must do better. But it’s an old habit. It doesn’t dignify.

I found myself brought up short in mid smirk by a daughter a while back. I was bemoaning the low unemployment/ work force shortage we are experiencing. “People just don’t want to work anymore.” Was my smirking phrase.

She lit into me. She detailed the position our generation has saddled theirs with.

If they are a two-parent household, both making a bit above average income, and they pay for childcare, health insurance, taxes, and try to buy a home, they are just above water. Make that a single parent household and the drowning starts. Add a special needs child, or big student loan debt, or some other burden and it becomes evident the rising tide did not float all boats.

And we maintain the illusion of our 1960’s financial model for Social Security and Medicare. The demographics have inverted, yet we still cling to the Ponzi miracle of sustained economic and population growth that was true in 1960 but is no longer. These two great dignifying social programs that progressives point to as accomplishments need some major work if they are to live up to their founding ideals.

My generation has kicked this down the road. No wonder we witness disengagement. We have not been true to the founding principle that these dignifying programs deserved to be sustained. We have shirked; and maybe smirked, gesturing to their bootstraps. Like ours were what got us where we are.

And this is just the economic indignity which we have dropped on the sidewalk and pretended we did not leave. No baggie, we just walked away.

The environmental injustice of melting glaciers was not mentioned. But she could have.

I came away from my daughter’s admonishment knowing her response had more dignity than my whine. And I could see there was work still for our generation to do. It is not as simple as giving them bright shiny new bootstraps.

So, if you catch me stifling a smirk, raise a warning finger at me and smile. I will take the hint, I hope, with dignity.

 

It’s going to be a hot drive down to our state capital tomorrow. But I’m excited to be making it. I got the AC in my old Volkswagen van charged up. It doesn’t blow cold, but it does blow cool.

Martha claims me driving the old VW around is a bit like the guys with the Trump, Let’s Go Brandon flags strapped in the beds of their pickups. She worries the VW pushes their buttons, like their flags push ours.

I shrugged at that, but she does have a point. Bumper stickers, yard signs, what is the purpose of such emblems? Is it to declare our position, thus provoke the opposition? Or is it just a weak attempt to persuade?

I know the flag guy with the pickup that U-turns to tailgate me in town doesn’t persuade me. He provokes my stubbornness. It’s irritating. Maybe that’s his intent.

The vanagon is not my tool for provocation. It just takes me down the road, and then I can sleep in it by the Salmon River on my way back home.

I don’t really like to provoke. I like to persuade.

These written words are my best effort to persuade, and I fear they are pretty weak too. Why read 600 words when there’s a Tik Tok video about cats to watch?

I’m thinking about provoking and persuading because of this upcoming trip to Boise. You see, I’ve been appointed to the Idaho Board of Health and Welfare by our governor. And the Idaho Senate confirmed my appointment. Whew. I thought that might be a hurdle.

We have a meeting in Boise on Thursday. The agenda is public. See if there’s anything there that interests you. Then give me a call. Or if there’s anything else bugging you about the direction or function of the Department of Health and Welfare, let me know.

Mainly I’ve gotten calls about specific services. I can’t really fix much, but it’s good to hear gripes. Sometimes there are trends.

The H&W Board is defined in law . There are seven members, one from each of the seven regions of the state. We are supposed to have political balance, with only four members from one political party.

One of our duties shall be to:

“Advise the director and the governor on department fiscal, policy and administrative matters”.

For an appointed board to advise, there must be a clear understanding of the capabilities, and an even clearer vision for the responsibility. I’m working on those.

But if we as a board are to advise, we will need some consensus, some agreement. That’s where the provocation and persuasion come in. I can’t imagine wearing a “Let’s Go Brandon” T-shirt would persuade my fellow board members. It will take more effort than that.

Further, I hope my dented VW in the parking lot would not provoke. It will be a fun meeting.

I understand we have limited resources to deal with the Health and Welfare needs of our state. My bias is to find effective practices. We have had some significant shifts in how care is provided. It is our job to make sure that care is effective and cost efficient.

Before I head down the road let me leave you with some things to consider.

55,000 Idaho children have lost Medicaid health insurance this year. Approximately 53 of those children will have appendicitis next year. Who pays? Will their parents face bankruptcy? Will the hospital shift the uninsured costs to your bill? Is this how you want things run?

Idaho leads the nation in women incarcerated. The vast majority are in prison or jail for drug offenses. Is this the way we want to treat this problem?

I’ll be thinking of these things as I try to stay cool going to Boise. Wave if you see my blue beat-up van. Stay cool.

 

We took a family vacation up toward the Cabinet Mountains in western Montana. This meant we got to go through the beautiful town of Libby on the Kootenai River.

Libby is famous for asbestos. And asbestos gives you more than 15 minutes of fame.

There was a vermiculite mine there, operated at a wonderful profit for the mine owners for some 70 years. The vermiculite contained asbestos. They declared bankruptcy when the cancer claims started rolling in. See, profit isn’t forever, but dead is.

The US government did what they could, I guess. In 2009 EPA declared a public health emergency. Haven’t such declarations always fixed things?

Max Baucus, a Democratic Senator from Montana thought he had a solution. He was in a pivotal position as ObamaCare got debated back in 2011. He had anyone testifying before his Senate committee who brought up the suggestion of “Medicare for All”, universal coverage, arrested. Though he found voicing such a solution to our health care problems criminal in testimony, he was not above slipping such a solution into some of those thousands of pages of the Affordable Care Act for Libby and Franklin County, Montana citizens.

His amendment offered free, never had to pay a dime into FICA, don’t have to be over 65, Medicare coverage to anybody living in Franklin County Montana exposed to asbestos. This might explain why Medicare has a payment code for “vaginal delivery”. Not everybody on Medicare is over 65.

This coverage follows qualifiers after they leave Franklin County. I’ll admit, I delivered a baby of a resident who moved to Moscow, Idaho from Libby. So, I am guilty of dipping my finger into this cookie jar.

I guess for Max Baucus an environmental/ public health emergency warrants universal health coverage, but public discussion of such a solution is criminal? Welcome to the American Healthcare Follies.

We like piecemeal, not universal solutions in this cowboy country.

Another such bite at the apple occurred back when the invention of kidney dialysis put the “God Committee” in charge of who lives or who dies. Swedish Hospital in Seattle had 17 machines, and there were thousands dying from kidney failure, so a committee chose the folks who got the treatment. In response to the uproar when Life Magazine did a cover story, our government offered universal Medicare coverage to anybody with the diagnosis of “end stage renal disease”. Not only would someone with this diagnosis get their dialysis covered by Medicare, but their erectile dysfunction is paid for too.

So, we offer universal government coverage based on county of residence, your exposure to a bad chemical, or if you have a qualifying diagnosis. We sure love piecemeal solutions, don’t we?

Some argue we should expand this piecemeal approach to medications. Say you need insulin. Then it should only cost you $XX a month. The Big Pharma CEOs and stockholders will expect their whittled down returns to be made up on the cost of blood pressure medications.

It’s a lot like me fixing the dripping faucet on a rundown house with a falling in roof and a settling foundation. Sometimes it’s just best to scrape the failing structure and start over.

Have we come to that point with American Healthcare? Max Baucus, no longer in the Senate, now says maybe we should be considering universal coverage and single payer.

Just how should healthcare be paid for and apportioned? Oops, will I get arrested for bringing this up? I’m not in front of a Senate Committee, so I’m probably OK. But I sure won’t get elected to public office anytime soon. No, to please the public you have to propose piecemeal solutions for poor, innocent victims.

If we keep this up, we’re all guilty.

 

Our neighborhood has been terrorized by a motorcycle rider for the last couple months. He has a Honda crotch rocket with a modified exhaust I can hear a mile and a half off.

I know you guys with the Trump flags in the back of your rigs think you are annoying me, but I can shrug at your silly efforts. This guy woke me up with his 120-decibel staccato. That is annoying.

We talked about it, me and Martha. Should I go knock on his door? He rents down the hill; I know the house. Absentee landlord who used to live here five years back but now just rents to whoever and doesn’t care about the neighborhood.

I thought about just calling the cops. Complain to the officials is the way, right? I even took the effort to look up the code. The Idaho legislature has had the foresight to put into Idaho law that modified exhaust on motor vehicles beyond factory and decibel allowances is illegal. I wonder, what does the Idaho Freedom Foundation think about the freedom to blast noise into my neighborhood? Maybe they will let me know about this freedom.

We kept listening to the BRAAAH as he came up the hill for the last couple months.

But last night after dinner I was out on my porch, and I could hear him coming more than a mile away. So, I did what any young person would do, I got my phone out, put it on video as I walked out to my driveway and stood there recording his climb up the hill.

He saw me as he rounded the curve and throttled down. He was only about 90 decibels as he went by, but he circled and stopped. He waved me over and flipped up his visor.

We were going to have a conversation.

That’s what needs to happen. Conversations about our differences might bring us together. Why should the annoyance we project have to be the substance? There are so many more important issues to consider.

The motorbike rider and I did not discuss school funding or gun rights. We did not argue about abortion or immigration. Maybe we should have. We all should. Instead, we are trying to annoy, poke the buttons on the sensitive spots of those we think we hate. How silly.

He and I talked about his noisy motorcycle and keeping the peace in our neighborhood.

It got difficult.

We too often avoid these difficult conversations. It is unwise to go into any negotiation thinking you have the same goal or even frame as the person you are talking to. But we need to listen and respond.

He apologized for the noise. I appreciated that.

I asked him when he would get it fixed. He demurred.

I pointed out to him his motorcycle was in violation of the law. He argued and I showed him the law.

But this is where our laws on paper meet the reality of how we live.

And it’s also why the laws we have on paper in our Idaho statutes are so valuable.

I told my neighbor, if he didn’t get his exhaust fixed, I was going to complain to the police: file a complaint.

We have all these laws on our books, but the cops can’t go around enforcing everything. So much is complaint driven.

I remember a cop car stopping in front of our house twenty years back and telling us we had to get rid of the red poppies along our lower retaining wall. We talked. I think he decided we weren’t harvesting heroin.

But I haven’t filed a complaint about my neighbor’s motorcycle yet.

This morning he went down the alley on idle as he went off to work. He didn’t disturb me. But maybe those alley folks got jarred out of sleep. Will they complain? Should I?

We should be good neighbors. Unless our goal is to annoy those around us. Then we need the law.

 

Idaho’s grandstanding Attorney General, Raul Labrador, has decided he doesn’t like the process whereby the University of Idaho entered into a business deal with the University of Phoenix. He’s threatening the Idaho Board of Education with a lawsuit unless they “do over” an executive meeting where this forth coming deal was discussed. He’s insisting the deal be discussed in public.

I’m all for shining the light on public processes. But private companies might find this a chilling consideration, should any future businesses consider trading assets our way. Maybe that’s Labrador’s plan: throw cold water on state business deals. I am scratching my head about what he’s thinking unless it’s just my original assertion: he’s grabbing for the spotlight.

I can’t say I like the U of Idaho/ Phoenix deal, but the confidential business process is a long-standing Idaho tradition. Public institutions acquire, partner with, or somehow deal with private entities all the time. The Boards that ostensibly govern those state entities (appointed by the governor, approved by the State Senate) might hear some generalities about the process, or not. The discussions might be in public meetings, or they may not.

Take the 2016 affiliation of the private, for-profit medical school in Meridian with Idaho State University. Those deals were done in similar confidential ways. I don’t know if the Board of Education had discussions back then in executive session. But Labrador wasn’t AG then, he can rightly declare.

The announcement of the conclusion of that deal was heralded by most (but not all) as a wondrous accomplishment. Idaho College of Osteopathic Medicine is still a private, for-profit entity, paying Idaho State University an annual sum on their thirty-year lease for the buildings on ISU’s Meridian campus. The payments go right into ISU’s operating budget, with no legislative appropriation. I wonder how many thirty-year leases there are in state contracts. I’ll bet there are a lot. I just know about this one because I asked some questions.

Maybe Labrador is “just asking some questions”. If so, he’s being pretty public about his process.

What business would want to subject a major investment with the whimsical Idaho legislature?

Labrador’s point that there are public meeting laws is fair. And agreeing to support a long-term binding deal by the Board of Education in executive session is clearly not public.

But how is our state going to do business? And a lot of what our state does involves business deals.

I’m no lawyer. But I did spend some time on the easily read “Idaho Open Meeting Law” website that has AG Labrador’s picture quite prominently above the introduction. There, on page 17, in discussing when governmental entities can go into executive session, taken straight out of Idaho Code it says:

(e) To consider preliminary negotiations involving matters of trade or commerce in which the governing body is in competition with governing bodies in other states or nations;

It seems our state, indeed our governing bodies can have nonpublic sessions to consider preliminary business deals.

Since this seems OK under the law, and it’s something Idaho government has been doing for a long time, just what point is AG Labrador making?

Does he have the same sour taste I do about the University of Idaho, the “Flagship University of Idaho” getting in bed with a disreputable, private, for -profit University? If so, that’s a poor excuse to twist the plain words of the law into a bullying action by our states elected head lawyer.

This action, and quite a few others are making Idaho the state doctors are fleeing, and soon lawyers will flock to. Esto Perpetua.

 

We citizens have decided it is best to let our legislature call itself into session whenever they can get enough to sign on. So be such folly. But while our august lawmaking body does their potato field, or insurance sales work and makes no laws, not in session, some small legislative groups labor on. For there is work to do. This is a wiser strategy.

The House and Senate Health and Welfare Committee chairs, during this last legislative session agreed to sponsor a resolution to call an interim committee together to consider whether it would be wise to move Idaho Medicaid toward managed care. They are thus meeting. I’ll bet you missed it. There were no headlines. But the meeting is available for your review if you have the hour to spare for the download.

I took that time.

They aren’t dummies, this group. That is deeply reassuring to this skeptic.

Just what the heck is “managed care”? Since in modern parlance, we can put a fancy name on anything we want to sell, the buyer should always beware. Make no mistake, we taxpayers are the buyer. Just what are they selling?

And I found the legislative group to share my skepticism. When someone goes into this sort of inquiry with a passionate bias, I expect somebody somewhere to make a lot of taxpayer profit. I did not see such bias as I watched the 4-hour download.

Managed care does not rile up folks like critical race theory does. Or indeed like “death panels” did. Health care policy puts people to sleep. It’s not like you are protecting your children from groomers or predators. The sad truth is, if you want to make some progress on public policy, saving the taxpayer a dime, you need to focus on some details. And that is boring, slogging, sit in the chair and pay-attention work. And that’s what this group seems ready to do. I was a bit thrilled. Are you?

Maybe instead you want to bring your semiauto to a pizza parlor to save the children. It seems that’s the prevalent mood out there. So, I want to speak up about the courage to pay attention to the details. Nobody brandished a weapon. But we are talking big money.

For contracting with a firm to “manage care” for Idaho Medicaid mean we, the Idaho taxpayers, are entering into a $3B dollar contract. Puleeze, notice the “B”. We might spend a million on a bridge, or a new school, but BILLIONS? Who is going to ride herd on such a contract?

It was telling that the spokesperson to the Department of Administration early on in the hearing admitted, meekly, that indeed it would require another full-time hire.

So, we’re going to hire one more person to make sure they don’t rob us blind?

Idaho has, since the Republicans have taken over, continually hummed the off-tune hymn “Business is Better than Government”.

Can I remind you of these mistakes? I know, all you guys with the Trump flags on your ¾ ton pickups will consider this a waste of time, but here I go.

Idaho tried privatizing our prisons. After lots of evidence for failures, a Republican governor who had advocated for this, abandoned his run.

Then there was the IEN fiasco, for broadband in schools.

Then the Luna Laws.

Wherever there is a lot of money in Idaho government, there are contractors out there willing to do our work for us. For a slim(?) share of the (?)profit.

Forty states have Medicaid managed care contracts. We have a lot to learn from them.

Heck, Idaho even has tried managed care with our Medicaid mental health contract. We contracted managed outpatient care back in 2014.

What did other states learn from these efforts? What have we learned?

Our poorly paid interim legislators have some hard work to do.

 

This woke rant will probably mean as much to you as it would have to the Idaho Constitution drafters back in that hot summer of 1889. I specify Article X Section 1:

STATE TO ESTABLISH AND SUPPORT INSTITUTIONS. Educational, reformatory, and penal institutions, and those for the benefit of the insane, blind, deaf and dumb, and such other institutions as the public good may require, shall be established and supported by the state in such manner as may be prescribed by law.

Our state founders wrote constitutional sections delineating how mines could appropriate private property to dump their tailings, but the “insane, blind, deaf and dumb” got a cursory “shall be established”. And our legislature has continued this short shrift.

I must admit, the legislature has not totally ignored this edict. We have a Department of Corrections. We have a School for the Blind. Indeed, the largest state department, the most employees and the highest budget is for the Department of Health and Welfare.

So why this woke rant? It’s because we are doing this job so poorly. We can do better.

You only need to read this piece in the Idaho Capitol Sun about a mentally ill man in our prison because we have no other place to put him. He is not charged with crimes, no convictions. He’s just not safe to keep in our weak state mental facilities.

Everyone familiar with this sees the problem. But then, we’re probably just woke. Maybe you have some solution. Firing squad?

Our Governor saw this problem. Indeed, the previous director of Idaho Department of H&W told me of this need. We need a place to care for the dangerous, severely mental ill.

Brad’s budget request for this year proposed building a facility to care for these afflicted people. His budget request got ignored by the Joint Finance and Appropriations Committee. So, I guess our 21st century legislature has the same flippant attitude as our 19th century founders.

Go to the old penitentiary: sandstone blocks with guard towers in the desert east of Boise. Idaho has not welcomed woke.

Let me tell you why I rant. It’s because I see and care for many of these people in my practice.

I see a patient released from State Hospital North. Two weeks after discharge, they are doing okay on the meds, and they have some group housing. But they don’t want to keep taking their medications. I prescribe the pills and tell them to come back in two weeks. They stop taking them. They miss their next appointment. I check the online county jail roster. My patient is now in custody.

Do we, citizens of Idaho, want the mental health care of our severely ill fellow citizens to be managed by jails?

I can tell you, the jailers, the sheriffs deputies, don’t want this job. And I can tell you, they aren’t woke. They know, and you should too, that caring for severely mentally ill people takes a lot of work. But maybe it’s not something our legislature “shall” do, even though our State Constitution directs it.

I’m sorry if this woke rant burdens you. But I live in a town where severely mentally ill people have taken up arms and killed people.

I can’t say that Brad’s $24M facility would have prevented any of these deaths. But I can say that when Republicans respond to mass murders with calls for mental health considerations, not woke gun control appeals, then vote down a small effort, it’s a bit crazy.

But woke and crazy may actually be two sides of the same coin. Maybe we should talk about it.