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Posts published in “Schmidt”

Owning our health

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The campaign to expand Medicaid health insurance eligibility in Idaho brought some broad health policy questions to the forefront. I am thankful we are having these discussions now; we have put this off for a long time.

One of the recurring counter arguments I heard when talking to voters was how “giving people a free handout” (Medicaid health insurance) made the recipients less likely to be responsible. This is the “moral hazard” argument that is well-studied and documented in economics. I’m not sure why this argument doesn’t apply to employment-based insurance also, but I get the rub. We all want people to be responsible and any program that might discourage responsible behavior should be scrutinized.

So, let’s scrutinize. I’m sorry if this gets uncomfortable. I’ll put on the gloves and you’ll need to bend over. You see, I am a doctor.

When I first meet a patient (before the gloves and bending over) I ask them questions about their symptoms, their medical history. One of the many questions I ask is phrased carefully: “What medicines do you take?”

Approximately 2/3rds of the time the patient response is phrased: “They’ve got me on a pill for my blood pressure, and they have me take a cholesterol medicine.”

I believe the words we use can often reflect how we think about things. In this case, “They have me on” suggests, I believe, the patient feels little involvement in the commitment to take a medication. In fact, the phrase suggests they are forced to take it, like “They have me in solitary confinement.”

When I can have the time, I encourage patients to say “I take a medicine for my blood pressure. I take XYZ for my cholesterol.” I believe in promoting ownership in our health. The passive, unengaged patient is not healthy.

I have no sense that people on Medicaid, Medicare, VA (that is, government-funded) benefits are more likely to use such phrasing. In fact, I have no evidence that such language is in fact related to a sense of disengagement with one’s health. Maybe you can ask yourself how you feel about the medications you take and the language you use to describe them.

If we can promote engagement in responsible behavior, engagement in our health, we may in fact promote better health. Private insurance companies spend a good deal of money with programs like this. In some plans, premiums are lower for people who participate in exercise, weight loss, healthy diet, smoking cessation. The hard part about all these programs is that the return on investment is probably 10-20 years out, and people change health insurance companies every 3 years, so the company rewarding the behavior doesn’t receive their return on investment.

I’m all for promoting healthy behaviors. But the best way I have found to do this is with direct interaction with a person, be that doctor-patient, or friend to friend. Governor Otter started building this plan 6 years ago with the Patient Centered Medical Home model for primary care in this state. It is an ongoing and successful model for healthy primary care relationships that could have leverage to change behavior.

I can’t believe someone writing a law in Boise will suddenly make people change their attitude toward their own health. But I can sure see them trying. Without gloves on.
 

Hold on to the reins

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By the time this is printed the November 6th election will be over and half the electorate will think the world will end and the other half will think their prayers have been answered. And the half that didn’t vote will point to the outcome as justification for their laziness.

If this representative government is going to work, we can’t expect our elected representatives to be smarter, work harder, or care more about our lives than we do. Don’t ever expect you can let loose of the reins if you know where you want to go.

From sewer district commissioner to governor, we ask our elected representatives to do the work we don’t have time for in our busy lives. But representation, by its nature, is a deeply flawed process; we give our voice to someone who votes, acts for us. Who would want to do this work for us? Can we find someone, anyone? It’s not always easy.

In my first elected position, county coroner, I was asked to fill the office when the previous elected coroner resigned. In our county, the new doctor in town was always expected to serve as coroner, and I was the newest. I was appointed. Then, in two years I stood for election, repeating that every four years. Sometimes an opponent filed. I always wondered if the voters actually knew what the coroner did. To be honest, when first appointed, I didn’t have a full picture of all the duties of the county coroner. But I worked at it for 15 years.

I was amazed that every new doctor coming to town refused the position. I started to feel like a bit of a sucker.

County Coroner is a partisan position, but I ran and served as an “Unaffiliated”. If I had been partisan, the local party might have tried to recruit a replacement. Instead, there were 2 or 3 last-minute write-in candidates in the primaries. And it turned out just fine. At that time, I had little faith in the value of party politics, but searching for, seeking people to serve in public office is a valuable function. But partisan loyalty may be their measure of qualification. Do you want to hand the reins of choosing representation over to a party organization?

In my second elected position, state senator, I was asked again to consider running. I chose to, I worked hard and got elected, then reelected twice before getting unelected in 2016. But I’d learned that I needed to start recruiting candidates, encouraging people to consider public service. After every election, I did my best to thank every candidate that ran for office, win or lose, commend them for their interest, and encourage their effort. I met with many people in the district and talked to them about their situations, their interest in public service and encourage their participation in this representative experiment.

If you are exhausted, frustrated, elated or depressed about this election, I want you to think about just where you think this wagon is going, and who might best serve in our communities. If you are thankful for your representation, let them know, and tell your neighbors. If you think the wagon is off the path, start looking around. But don’t think you can let loose. The common good is not served by dangling reins.
 

Rural health values

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Some are arguing that rural Idaho hospitals need Medicaid Expansion to survive. I’m arguing we will need more than a simple yes vote on Proposition 2 on the November ballot. That’s just an important first step. For American healthcare to serve our citizens, big cities and small towns, we are going to need to ask and answer some hard questions.

Thirty years ago, I took a break from my 36-hour hospital shift in residency to listen to a lunch presentation from the CEO of a big Eastern Washington health insurance company; like he was a visionary. The food was free. He outlined the three biggest threats to US health care: AIDS, Alzheimers, and rural hospitals.

I really only remember his solution for the third: “What most small towns need is just an urgent care facility and a helicopter pad. They don’t need hospital beds.”

As a resident learning Family Practice and planning to give full spectrum care to seriously ill folks, deliver babies and do C-sections in a small town I thought he was crazy. But the health care market place as it is currently structured has me wondering, and Idaho is a great place to pose this question.

So, what value does your hospital bring to your community?

I ask this as a doctor who has worked in many small north Idaho towns. Is there value that your baby be delivered close to your home? Is it valuable that your grandparent be cared for close to home? Is it vital that health care jobs are available in your town? Does your small-town hospital add value to your community?
The insurance company CEO saw little value in keeping sick people that couldn’t be quickly patched up in an urgent care facility close to home. Big city hospitals could be more efficient, had more technologic treatments, and thus could bill for more expensive care. The medical business model as his vision saw it provided a simple solution: more helipads.

I also remember this quote from a big city hospital executive: “My hospital earns $50,000 when we amputate a diabetic’s diseased foot. But we lose $50 every time we counsel him to manage his diabetes.” Think about those incentives.

Proposition 2, Medicaid expansion, will simply provide that some folks who don’t have insurance now and get care at your small-town hospital have their care paid for by their insurance: Medicaid. Many currently get care and have no method to pay. The hospital provides the care, then scrambles to make ends meet.

In the last 8 years across the country there has been a spike in small-town hospital closures, though none in Idaho. The county indigent payments (after liens are filed and bankruptcy insured) and state tax funded Catastrophic Fund have barely supported small hospitals. Rural hospitals in states that expanded Medicaid eligibility were very much less likely to close.

Medicaid expansion, Proposition 2 on Novembers ballot will make rural hospitals more secure financially in our current system. But the system has to change. Community conversations about what services add value, are vital, or unnecessary will help this system change. Talk to your hospital board members. Let them know what you think. But if you value your local hospital, you should vote for Proposition 2.
 

Health care needs a backbone

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I watched Brad Little and Paulette Jordan debate on a Boise TV channel. You could catch it online. It was clear to me Brad knows healthcare issues, but I’m detecting some bad symptoms in his approach. It’s a big issue, Idaho healthcare, and Brad will need some backbone, heck we all will, if we are going to get to work on it.

Here’s the first symptom: Brad can’t even say whether he thinks Prop 2, expanding Medicaid insurance is good or bad, just that he will “respect the will of the people”. That’s a sign of a politician wanting cover for doing something that might make some of his constituents unhappy. Expanding Medicaid coverage as Prop 2 will do is just one small step of many steps that will need to be taken. I have diagnosed a weak backbone. And I’m not a chiropractor.

But Brad does understand that the individual market on the Idaho Exchange is not functioning. He points to solutions to reduce premiums for young healthy small business people. His solutions carve up the marketplace, so people not expecting to get sick can pay less. Well, when they get really sick, they won’t have coverage. Brad’s OK turning the marketplace back into a roulette game by abandoning the requirement for “essential benefits”. If we (Idaho voters) aren’t all in this together, his plan will have us playing Russian roulette, not just the spinning casino wheel game.

Little has also embraced the plan to move really sick people with expensive diseases (advanced cancer, organ failure, systemic disease) out of the individual market and onto Medicaid. 90% of health care costs come from only 5% of the population. This sort of cost segregation in the health care pool has long been known to be an effective method to reduce costs. For private insurance companies, after they couldn’t exclude pre-existing conditions, the problems came in the numbers and the geography. If the model is to pool these high-cost folks from different insurance companies onto a government plan, managing more with more leverage, maybe there could be some savings.

Do you trust that the government will fund this program, good times or bad? Diseases don’t fluctuate with tax revenues. That sort of public commitment will take a very healthy backbone. Can Brad’s get stronger?

This last proposal clearly leads one to think of a single payer plan, so I’m surprised Brad Little and Department of Insurance Director Dean Cameron are suggesting it. Maybe they think we won’t see the logical progression. If their goal is just to segregate the very sick, and they expect this model to hold fiscal water without a clear public commitment, they are being either short sighted or cruel. Knowing both these men well, I’m diagnosing nearsighted.

Brad Little’s nearsightedness and weak-spine on Idaho healthcare are correctable. What about his opponent, Paulette Jordan? She displays no understanding of the complex issues and is just trying to ride the populist wave of Prop 2. I’d much rather deal with a patient who wants to understand and work on their problems, than one that is oblivious of them.
 

Appointments

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With the recent Judge Kavanaugh debacle in the US Senate it’s worth reflecting on this process here in Idaho.

The Idaho Senate confirms many gubernatorial appointments as required by law. Some appointments and the boards they serve on have statutory (legal) requirements. Appointees come before an assigned committee and are interviewed. Then the appointment is carried by a Senator to the floor of the Idaho Senate for confirmation.

The legal requirements for serving on a Boards or Commission, or as Director of a department usually had to do with qualifying experience, but often, in statute the makeup of the board was required to have a partisan balance. Statute might read “no more than two members may be of the same party”. That’s what the statute for the Board of Corrections says. Is this legal requirement for partisan balance important? You bet it is.

Without it, cronyism would be more rampant than it is. More, it could affect your vote for Superintendent of Public Instruction.
Cindy Wilson has been active in Idaho government well beyond her classroom work as a teacher. She is a strong leader and a powerful voice. So, I can’t figure out why she got appointed to the Board of Corrections unless Brad Little stood up for her.

Governor Otter has used these appointments as a partisan tool. Brad advocates for good people. But he keeps a political eye on the landscape. Some Fish and Game Commissioners have gone on to the legislature. Some appointments are rewards to moderate Republicans beat by Tea Party republicans. If the statute requires it, they become “unaffiliated”. Butch knows how to stack the deck. Brad has a better eye for the common good.

What better place to see the need for improvement in our public schools than in our prisons? As a Joint Finance and Appropriations Committee member, I toured many Idaho prisons. Not to mention I worked there as a physician. On one tour we observed a classroom working on personal accountability. As we started to leave our Chairman (Dean Cameron) asked the class how many had graduated from high school. He did it politely, with a purpose. One hand of the thirty inmates went up. As we went out to the bus I stood next to him and complemented him for the question.

Legislators need to know these things. “Were you pushing for funding pre-K education?” I asked. He rolled his eyes. He wanted his committee members to make the connections; I might have taken that a bit too far.

Cindy Wilson served on the Governor’s Task Force after the Luna Laws got shot down. Now she serves on the Board of Corrections. Connecting the dots on how our citizens thrive may seem simple to some. A local candidate suggests “getting rid of the dead beats”. Does he mean a deep trench and a firing squad?

I believe Cindy Wilson has watched classroom performance, has watched our corrections system struggle and now balloon, and understands the connection. But if Butch Otter (or Brad Little) wanted to make Idaho safe from Democrats, he never would have offered her for such a position. He did. Thanks Butch (or Brad).

Madame lieutenant governor

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For the life of me, I can’t figure why someone would work their tail off for nine months to get a part-time umpire job that makes you live in Boise.

Because, besides the rare occurrence of filling in for the governor, the Lieutenant Governor has the thankless job of umpiring the Idaho Senate when it’s in session January to maybe April. And that’s about it. Take my word for it, it’s not glamorous, powerful, or fulfilling.

It can’t be the money: an annual salary of $37,000 with benefits would mean you couldn’t afford to buy a house in the booming Boise real estate market. It has been a boon to the Idaho taxpayers that Brad Little, our current excellent Lieutenant Governor, lived in Emmett, close enough that all he had to invest in Boise real estate was a modest condo.

It can’t be the power. If slamming the gavel down on misbehaving Senators brings a warm feeling to your heart, maybe a little smile to your countenance, that will fade if you’re doing your job right. No good umpire enjoys calling a strike more than a ball. No, there’s only one reason besides a pure sense of public service that one might fight and work so hard for such a thankless job. It might just be what the job has become in this one-party state: a spring board to higher partisan office.

Our 34th lieutenant governor, Phil Batt made this a reality, but only because he saw the need to revive the Idaho Republican Party back in 1984. Idaho had suffered under Democrats in the executive offices for 30 years then. He did a great job of it too; Idaho has been dominated by Republicans now for thirty years, thanks in part to his efforts.

Since Phil, the part-time office has served as a farm team job for Idaho Republicans: Butch Otter (36th Lt. Gov.) went on to serve Idaho in congress, then 12 years as Governor. Jim Risch (38th and 40th) took a swan dive off the spring board into the US Senate. And David Leroy (35th) sat in the office while looking around for any available opening (congress twice, governor twice). And we are about to elect a reluctant Lieutenant Governor (Brad Little, 41st) to our states highest office. It’s like Brad got caught on the assembly line Phil created.

When partisan politics is the game you play, constitutional office is just a position on the field, or even on the bench. Lieutenant Governor in Idaho is now the back-up quarterback position for the party in power. Our founders knew politics could be a profession for those so inclined, and such an inclination does not serve the public good. The office was constitutionally kept so nominal in an effort to discourage its use as such. But our founders probably didn’t imagine how partisan politics could be amplified by Facebook or Russian troll bots.

Does any of this tell you who might best serve us in this position? Do you want to elect a good umpire or a back-up quarterback? Do you want your vote to serve the public good, or your partisan persuasion? I’m voting for Kristin Collum. Not because she’s a veteran, or a woman, or a Democrat. She’d be a good umpire. I’m not looking for a back-up quarterback.
 

How do we choose?

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Idahoans have chosen Butch Otter to be governor for the last twelve years, despite not thinking too highly of him. A recent poll showed he had a “net approval” of +12 while the state had a “Republican partisan lean” of +34, so he was actually 22 points behind any generic Republican. Idaho’s partisan lean was the third highest in the country.

A high-priced political consultant from back east presented some information to Idaho Association of Commerce and Industry 4 years ago about Idaho politics. He explained that Idahoans just weren’t politically engaged. His graphic evidence showed that ten times more Idahoans Googled “otter” meaning the cute river or sea mammal, than “Otter” the governor.

I always did a lot of door knocking when I ran for State Senate. I would knock and wait, then introduce myself, “Hi, I’m Dan Schmidt your state senator.” The most common response was, “You are?” and a look of surprise. I would ask about their concerns and explain why I thought they should vote for me. If the door didn’t slam, I would usually ask how they decided who to vote for. I’d hear: “Oh I decide based on the person, what I know about them.” That’s the myth people want to believe about their decisions, that they are informed and make wise choices. The truth is, most people can’t name who are their elected representatives, let alone what they stand for or any work they have done. It’s pretty hard to stay informed on all the details. And it’s boring. Netflix is better.

When an electorate is not engaged, there is usually low participation and certain default choices. Idaho voters show up in presidential year elections at a 70-80% participation of registered voters (which is less than 60% of eligible voters). Midterm years (like this year), it’s about 50-60% of registered voters.

There is no doubt partisan affiliation is the default setting when the voter decides to participate and only has limited information. The very strong Republican Party brand in Idaho right now is complicated by the question “Which Republican Party?” If the polling is accurate, Proposition 2/ Medicaid Expansion has pretty strong statewide support. Even a slim majority of Republicans seem to support it. Yet Republican Lieutenant Governor candidate Janice McGeachen successfully got the state Republican party to condemn Prop 2.

The last time Idaho Republicans went through this sort of test was when Otter (not the cute one) had the gumption to have a fight over establishing the state-based health insurance exchange (Your Health Idaho). Many Republican legislators were condemned by their local county party committees for their support of this brave initiative. YHI went on to be the most popular state exchange in the country; indigent and Catastrophic Health Care costs plummeted, reaping the general fund a tidy return and decreasing Idaho’s uninsured rate significantly. But that bitter fight left some deep scars in that big tent Republican Party.

Will Republicans shy away from an intramural fight before the November election? Some aren’t afraid to make their stance known. Twenty Republican House members signed on to opposition of Prop 2 last week. Most moderate Republican candidates I’ve heard aren’t willing to commit. And if their brand is strong enough, and the voters aren’t too engaged, maybe it won’t matter for them. They might welcome being mistaken for a cute water mammal.
 

Generalizations

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We all know generalizations are wrong, but we keep doing them, don’t we? I’m just going to address one today.

I keep hearing the refrain that bleeding-heart liberals always expect the government to do things for them. Let me tell you this story.

Over twenty years ago an aging married couple wondered how their son, afflicted with schizophrenia was going to fit into his community. They knew they wouldn’t be around forever to supervise his care. They hit upon a plan.

With some help from some others in our small town, they purchased an older home and made it suitable for six residents and a supervisor. The vision declared they would provide housing and minimal supervision for citizens with mental illness to live in the community. They formed a nonprofit entity with a board to oversee the home. The business model was that the rents paid by the residents would cover the maintenance costs, and the supervisor could live there rent free. The residents would be screened and their cooperative behavior was an expectation of continued residence.

Honestly, I don’t know if this founding family was Republican, Democrat, Socialist or pagan; they just sound pretty common sense to me.

I learned about this in my fifth year of my six years in the Idaho Senate. The board president sent me an email, asking for a meeting. I assumed they wanted me to support some sort of state funding, since I was on the Senate Health and Welfare Committee and the Joint Finance and Appropriations Committee. Everybody always wants government money, don’t they? But they didn’t. They just wanted me to know about their institution. They were indeed bleeding-heart liberals. But they didn’t want a dime from the taxpayers.

To be honest, the only way some of their residents could afford the rent had to do with their disability. They did get taxpayer money to support their living. Some had disability payments. Most had Medicaid or Medicare to fund their medical services. Some indeed had regular employment, though often part time and low wage. But work can be important to keep one in community.

It is just six citizens with mental illness this foundation serves, and our community probably has hundreds more eking by. But it truly is a noble vision; and an accomplishment to be proud of.

I have driven by this house many times in my small town. I did not know its purpose or function. I greatly appreciated them sharing their story with me. I worry that elected representatives who won’t meet with either bleeding-heart liberals or flaming conservatives won’t know the stories of their communities.

There is one cliff hanger to this tale. The bleeding-heart liberal board members I met with were all much older than me. And they were having a hard time finding community citizens of a younger age who would take on this role of governance. It is a small job. Let’s hope somebody will step up.

Next time you think you know what’s in the heart of your bleeding-heart liberal neighbor or your flaming conservative boss, take a step back and have the courage to have a conversation. We all need it.

Don’t be cruel

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I forgive ignorance. I tolerate stupidity. I cannot abide cruelty.

If you believe government programs foster or promote or have created slothful citizens, please, look in your heart and figure out where this sort of belief comes from. It is pretty widely held. I just heard a local politician espouse this tripe.

I will not dispute there are lazy people. Sometimes I don’t work as hard as I should, but that’s not because of any government program. The idea that programs developed to ease the burdens we all may experience in life make us lazy and then more likely to wallow in our mistake or misfortune tells me what you think of human nature. And how we react to that concept can be cruel. Don’t be cruel.

When I first ran for office I met with a local group of union workers. Their demeanor and tone told me clearly, they wouldn’t be voting for a Democrat. But I got them to tell me what was important to them. One young man asked, “Why doesn’t Idaho drug test welfare applicants?” I told him I’d look into it.

This is a popular refrain, since many believe those getting a handout from government are slothful, lazy and misusing any of our dear tax dollars. And if this is the case, we could then deny benefits to miscreants, saving tax dollars. I’m all for cutting costs, so I studied it. Many states do such testing. It has told an interesting story. The percentage of welfare applicants who test positive is well below the general population average. This drug screening program, especially when no treatment is available does nothing to reduce tax expenses, in fact the cost of testing far outweighs the money saved in denied welfare benefits.

If your goal is to help people with a drug problem, you’re going to have invest more. If your goal is to just deny benefits, be honest about it and just cut the program. But it would be best to look in your heart before you go designing any program, because that’s where this all starts.

The same can be said for the work requirements being suggested for Medicaid eligibility. Do you really think a single mother of three young kids should go without health insurance because she can’t work more than 20 hours a week?

There is a government program that has this wrong: Social Security disability. I do understand that people can have disabilities that can keep them from doing some work. But to be declared “disabled” then eligible for benefits the rules prohibit the disabled from “Substantial Gainful Activity”. In the past 20 years we have seen our disability rolls skyrocket. About 5% of the workforce are classified as disabled. And they aren’t counted in the unemployment calculations. Less than 1% of folks going onto disability ever return to the workforce. This program can be a cruel trap. A program to help the disabled should not discourage gainful activity.

People can be cruel. Government can be cruel. People are government. Get involved, speak up, vote. Don’t be lazy. Don’t be cruel.