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Posts published in “Schmidt”

Waiver season

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It’s summer, so it’s time for wilderness hikes, river floats, stream fishing and reading Medicaid waiver applications.

Many don’t believe it, but the Federal government is our partner in Medicaid. It is a Federal law, but states have a say. Heck, if Idaho wanted to we could withdraw from the whole program. We could thumb our noses at the $1.8 Billion Federal dollars we get every year to provide care for our severely disabled, aged poor and pregnant women. Many legislators vote against the budget. In fact, Idaho House Republicans split evenly this year on approving the Medicaid budget. If they really don’t want to participate in the program I’d like to see them come out and vote to end the partnership. But they haven’t been so bold.

Instead, they asked our state agencies, the Department of Insurance and the Department of Health and Welfare to work to modify the plan approved by voters, simple Medicaid Expansion. These proposed modifications will need approval of the Trump Administration, and they will need to be lawful, that is, follow the law of the land. Of course, the Trump Administration could approve an unlawful waiver request. Then someone would need to sue to get a judge to interpret the legality.

The first waiver application is “Idaho Coverage Choice”. The DOI has closed their comment period, but now the DHW has learned they must apply for a waiver for this program also, so their comment period is open. This modification to Simple Medicaid Expansion would allow folks between 100-138% of the Federal Poverty Level who currently have health insurance through the exchange to choose: either enroll in Medicaid or “keep your insurance” on the Idaho Exchange. It is estimated this would affect about 18,000 Idahoans.

I’m all for giving people choices. But this program would be very costly to our federal government. If you read the reports from DOI and DHW they claim a “savings” for the budget. But the savings claimed are reduced tax credits and subsidies when people go OFF the exchange and enroll in Medicaid. Doesn’t it make sense that the more people we moved that direction, the more we would save?

Their own figures claim an average “cost” of tax credits and subsidies for exchange enrollees Per Member Per Month between $430-$802. But they also estimate the cost of enrollment in Medicaid PMPM would range $212-$496. It’s pretty clear to me this proposed waiver would not be budget neutral for taxpayers.

There is no mention of other costs to those who choose to “keep their insurance”, like deductibles, copays, out of network fees that insurance companies use to try to keep their costs down and reduce “overuse”. I guess that’s because it comes out of their own pockets.

Why would conservative Idaho Republicans want to offer people the freedom of choice of more costly health insurance on the taxpayers’ dime? If the real reason for this “Idaho Coverage Choice” plan is to save some enrollees on the exchange, effort would be better placed to make plans more affordable for folks above 200% FPL who buy insurance on the exchange. They are going uninsured in droves. Can’t blame them; the subsidy and tax credit tables need a big adjustment. But that would take a congress that wants to fix the Affordable Care Act. Republicans won’t go there and Democrats are too busy wanting to abolish private insurance or promote “Medicare for All”.

It’s no mystery why Medicaid health insurance is cheaper than private plans. Medicaid and Medicare set what they pay. Providers either take the low payment or refuse to participate. Private insurers are stuck negotiating with providers. Moreover, reducing costs reduces their cash flow.

I appreciate the Idaho legislature trying to make some innovative changes to the health payment system. But choice, in this case, is too expensive.

There are many more waivers coming. Stay tuned.
 

The 4th of July

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Twelve score and three years ago our fore fathers brought forth on this continent a new nation, conceived in liberty and dedicated to the proposition that all are created equal. I ask you to reflect today on the past work done, the work at hand and the work before us, that we may continue to reap the blessings of liberty. For work it is to maintain this republic. And I propose that we are called to do this work. We must so resolve.

A rumored and actually documented exchange from 1787 exists that sounds almost like a Facebook post or Twitter exchange from today. After independence was won, the states chose an initial attempt at governance under the Articles of Confederation. This held states together but gave no power to an authority to make them cooperate. All could see how such a loose confederation was failing. And there were significant threats close by. So, a convention of the states was called to craft a “better solution”. It was a hot spring and summer in Philadelphia, a stifling hall, and heady discussions. The delegates came and went daily.

Imagine, a frustrated Benjamin Franklin, doddering, a wobbly man, leaving the hot and stuffy Independence Hall where the framers had been arguing for three months. A passing lady asked him, “Doctor Franklin, just what sort of government have you fashioned for us, a monarchy or a republic?”

He replied, “Madam, a republic; if you can keep it.”

He knew, they all knew back then, this would be hard work. I doubt they envisioned global warming, the internet, or a world population of 9 billion people. But they knew people.

After the Constitution was passed by the delegates, state conventions needed to ratify. The Federalist Papers were persuasion pieces by Hamilton, Madison and John Jay to convince, the State of New York, the big dog in New England to come on board. Here from Federalist #51 on how the Constitution protects us, mainly from ourselves:

It is of great importance in a republic not only to guard the society against the oppression of its rulers, but to guard one part of the society against the injustice of the other part. Different interests necessarily exist in different classes of citizens. If a majority be united by a common interest, the rights of the minority will be insecure.

The argument the Federalist Papers were making is that we can build a structure, a set of laws we agree to, that will direct our different and varied interests to serve the common good.

We have much work before us to maintain this republic.

We have societal problems to solve and budgets to balance. Our founders knew we were just people, not special, of course we would have “different interests and be in different classes”. But they believed, as I do, we were then and now are equal to the task. May we know the worth and dignity of all as we work to:

Form a more perfect Union,
Establish Justice,
Insure domestic tranquility,
Provide for the common defense,
Promote the general welfare
To secure the blessings of liberty for us and our posterity.

May it be so.
 

Critical access

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Back before we got into a stalemate when talking about healthcare costs, long ago when I had good knees and my hair wasn’t grey, funding for small town hospitals was recognized as a problem.

After Montana demonstrated they could support critically needed remote hospitals with a federal project, Congress rolled the “Critical Access Hospital” designation into the Balanced Budget Act of 1997. Do you remember when we had balanced budgets?

Medicare had been working hard to cut hospital spending since the 1980’s and had instituted a payment system to hospitals based on a global fee. If a patient was admitted for pneumonia, the hospital got paid a flat amount, whether it took 2 days or 7 days to get the patient back on their feet. But the value of having small hospitals especially in remote areas could not be ignored, so the “Critical Access” designation called for a different payment system to such hospitals.

These hospitals were paid on a cost-plus basis. Whatever it cost, Medicare would pay for the services based on their fee scale, plus a small percent; currently it’s +1%.

But the hospitals had to fulfill certain criteria. They were supposed to be more than 17 miles by primary road, or more than 35 miles by secondary road from another hospital. They were also supposed to have less than 25 hospital beds.

Here’s the catch, and it’s a big one. No congressman wanted to go home having voted to close Podunk Hospital in their district, so the bill allowed states to declare a hospital a “necessary provider” and escape the distance requirement. And states opened the barn doors.

As it stands, approximately 65% of CAH’s are between 17 and 35 miles from another hospital. I live in a town with a CAH 8 miles from another CAH; but it’s across the state line into Washington. Just down the hill from me another CAH is less than 5 miles from a regional medical facility, also across the state line.

Most small-town hospitals in Idaho serve remote and rural communities. They deserve such payment consideration. But I walk past one every day I go to work that is abusing the critical access system.

I guess what bothers me the most about this abuse is the billboards and radio ads I see and hear every day for my town hospital AND for the CAH just 8 miles away across the border. The hospital in my town has a full-time director of “promotion”; I suspect the same is true across the border. If they both are so critical, why do they need the media blitz?

Many see this problem. The Obama administration made proposals to reduce Medicare payments to CAH’s to a flat 100% of costs and eliminate CAH designation for hospitals less than 10 miles from another hospital. It was met with howls of protest from the American Hospital Association; didn’t get far. The Trump administration has revived another Obama rule that would require more patient protections and documentation; more regulations, more costs. We’ll see how far it can go.

I don’t see the advertising by CAH’s as a huge cost. It just tells me their designation as “critical” might be more a political favor than a community reality.

One thing is for sure; if a small-town hospital has to compete against the big city mega-medical centers on a level payment field, most of us in rural Idaho will end up driving a long way for hospital care.

It’s time to start analyzing just what care should be given in small hospitals, then paying appropriately for it. The “critical access” designation system needs a big overhaul.
 

Equitable assessment

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This week in Boise there will be an interim committee meeting on Monday. By the time you read this they will be back home, not done with their work, but maybe started. The title of the committee is the “Equitable Assessment of Costs Related to Medicaid Expansion”.

I applaud the legislature for looking carefully at costs incurred to the taxpayer for the laws they (or in this case, the voters through initiative) pass.

May I make some further suggestions?

How about the legislature study the costs of funding facilities for charter schools? The legislature passed a law in 2014 to send cash from income and sales tax revenue to charter schools for their facility costs. Public schools have to get a local bond passed to build a school; charter schools get an automatic cut from everybody’s sales taxes or income taxes. Sixty-six + percent must approve a local bond, then it comes off the property tax of local district residents. Charter schools just get a check out of the general fund. That charter school facility fund has come to $40M over the past seven years. And its dollars straight out of the budget for teachers and schools, which is what our property tax levies pay make up for, since the state can’t seem to find the money in the general fund. Seem equitable to you?

How about the legislature study the property tax exemptions county commissioners are handing out? How is that affecting home owners’ rates? Canyon County commissioners just handed out millions in exemptions to businesses who expanded or opened new facilities. A couple years back Nez Perce County commissioners did the same for Clearwater Paper. This was right before they laid off a few dozen workers in the Lewiston plant. Does it seem equitable that businesses don’t have to pay for the roads and services their trucks and employees use? Does it seem equitable that the local property owners foot that bill?

But I suspect the interim committee will focus their “equitable assessment” on the costs of Medicaid expansion, as the law they themselves passed has directed them to do. If you keep the window narrow there is no big picture to see. I expect my elected representatives to see the big picture.

The charter school facility funding inequity came about because the legislature was afraid to look at the big picture of all schools’ facility funding. This was even though there is an Idaho Supreme Court decision declaring our current system, before the charter school facility funding scheme, unconstitutional. This decision has never merited even one hearing from our busy legislators.

Keeping a narrow focus on the Medicaid costs might bring some comfort to the legislators who opposed Medicaid expansion. While they tally the costs, will they even try to balance the benefits? We all heard their bias before the election, before the citizens over-ruled their six years of inaction. Will they consider the costs of those six years of doing nothing when the Federal Government paid up to 100% of the costs? I doubt it.

There is no doubt the expansion of Medicaid will cost the Idaho taxpayer. And costs are the easiest things to count. But the benefits deserve some tallying too. What do you think one life saved is worth?

Can they tally savings to our prison costs when a felon doesn’t return to prison because they got their drug addiction treated? Can they consider the value to a small community whose critical access hospital climbs out of the red? Is there any way to count the shifted costs of the uninsured onto those paying premiums? Will the decline in county property tax funded indigent costs be part of their calculus?

I’m all for counting costs. But how we spend our money is an expression of our values. And values aren’t just about dollars and cents. Values should reflect the big picture.

Summer reading

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We’re short of the solstice, but with school getting out soon it’s time to start talking about summer reading. I’ve started early.

With all the furor about the two-year-long Mueller investigation and his recent public statement where he said, “Read the report!” I decided to. It’s available online. Don’t let the 448 pages scare you. I’ve only spent a couple hours and I’m up to page 175. The first part is about the “Russian Interference campaign” in the 2016 presidential election. I figure I’ll get to the exciting volume two (about the “cover up”) before we’re picking raspberries.

It’s a good read; well- written and direct. So far, I’ve basically learned the Logan Act is dead, even though it still occupies space in the Federal Code. (18 USC Sect. 953). The Logan Act was passed back in 1799 in response to a US citizen lobbying France to soften up its stance to the new United States. Congress and President Adams didn’t like that a private citizen could act on behalf of the US government without clear authority, so they made it illegal.

There have only been two indictments under the act in its 220-year history. The section I’m working through in the Mueller report shows multiple clear violations of this law. But all the folks who have plead guilty in the Trump circle copped to lying to the FBI, not violating the Logan Act. Mr. Mueller must not think the law is prosecutable.

To me, if you have a law on the books and don’t want to enforce it, get rid of it. I don’t like ignoring laws. I thought we were a nation of laws.

The second reading I’m into now is the Federalist Papers. They aren’t in clear language, but after a few minutes you get a sense of the colonial dialect. They were written as “letters to the editor” to convince New Yorkers to support the new Constitution that needed state ratification. They too are online. They are each about as long as this column, but there are 87 of them. It’s OK to skip around; there aren’t any plot twists.

As I was jumping back and forth between Mueller and Hamilton (the main author of the Federalist Papers, with Madison and Jay) I skipped forward to number 66, on why the US Constitution’s structure for impeachment proceedings was such a nifty solution. Hamilton didn’t mention all the negotiations that took place to define an impeachable offense, he just argued that The Senate was the best place for such a trial of impeachment to take place. He argues the Supreme Court had too few brains to properly contemplate the issue, though they are by definition the “Judicial” branch of government. He defended having Senators acting as judge and jury by saying we all have to wear different hats at times:

“This partial intermixture is even, in some cases, not only proper but necessary to the mutual defense of the several members of the government against each other.”

By splitting the duties, giving the role of investigating and indicting a Federal Official to the House of Representatives (The Popular Body, Hamilton called it), then having the trial and judgement in the Senate, he figured it was a Goldilocks solution. The balance of power is the guiding principle.

It’s wonderful that we can read such documents right there at our fingertips. I would hope you can find time; at least before the pumpkins are ripe.

More can be less

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Consider these two facts:

1. The United States spends more per capita on healthcare than any other nation.

2. The United States is the only developed country in the world where life expectancy has declined in recent years.

How does one square these two seemingly contradictory facts? Could it be that more healthcare can actually contribute to lower life expectancy?

US healthcare expenditures have long led the world. Back in the 1970’s the US was in the middle of the pack compared to other countries, but since 1980 we are number one. We’re now at the point we spend almost twice what other counties spend. So, this has been a thirty-year trend.

But the decline in life expectancy is recent. When we compare total life expectancy to other developed countries, we have always lagged a bit. The Japanese have outlived us for decades. But the last two years of declining US life expectancy are remarkable. When the details are teased out, the US decline can be attributed to a dramatic rise in early deaths, specifically in middle-age (45-54) non-hispanic white males. This started in the late 1990’s and continues. The increase in deaths is attributed to accidental overdose, suicide and alcohol related diseases; the diseases of despair. And when the population is further refined, this increase is even more dramatic in non-college graduates. Advanced education saves lives. Maybe it relieves despair. Higher education does promote long-term employment and thus makes employer-based healthcare more reliable.

Opioid prescribing started to go up sharply in the 1990’s. Doctor-written prescriptions for narcotics more than doubled from 1999-2011. Thankfully, it has gone down significantly in recent years with all the talk of the “Opioid Epidemic”. But I believe we can lay a lot of the blame for the recent increased mortality in this country in the lap of the medical profession. Big Pharma will get their share of the blame, but they just make the drugs; doctors prescribe.

But it’s not just the narcotic prescribing we doctors do that can harm people. We can test you into anxiety, even bankruptcy. Or we can operate on you with the promise of a life free of pain. After all, US healthcare is the best in the world, isn’t it?

Some people are cured, some pain is relieved, but has American healthcare reached the point of too much of a good thing? If we have too much, why do we over-consume?

Overtreatment (defined as care provided that causes harm) is studied. It’s higher than you think. Why would the market-driven business of healthcare sell more product than serves the health of the customer? Maybe I’m naive to think healthcare is different than fast food. Further, why would consumers (patients) buy unnecessary or harmful care?

Some may be due to perceived scarcity. We all fear the day we have a tragic accident or dismal diagnosis and inadequate insurance coverage. So, grab what you can when you have the chance; not a healthy strategy. Such a mindset is unavoidable when health insurance is unreliable.

Idaho’s fifth annual Healthcare Summit concluded this week. Six years ago, Roger Plothow, former publisher of the Idaho Falls Post Register decided such a get together would be a good idea. Get the leaders of one of Idaho’s largest and fastest growing economic sectors together and see if they can align their incentives. The conference is sponsored and attended by all the major insurers, healthcare systems, professional groups and even some legislators. Heck, Governor Little spoke over lunch.

There is hope, but a lot of work to do. Idaho has disparate communities, from frontier towns with a county ten-bed hospital to huge systems in the Treasure Valley and Eastern Idaho. But a small state with strong leadership can turn things. We just need to agree on where we need to go.
 

Getting better

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Maybe you’ve heard the statistic quoted that Idaho is last (or near) among states in doctors per capita. If medicine was a simple business that ratio might mean the dearth of physicians would ensure doctors in Idaho are among the best paid, supply and demand being what it is. But in fact, Idaho doctor salaries are about average to below average. Medicine may be a business but the economics are complicated.

Former Governor Otter’s commitment to boosting medical education in Idaho was supported in the legislature when I was there. In that tenure, the Idaho WWAMI program grew from 20 seats to 40. WWAMI is a medical education consortium of 5 states: Washington, Wyoming, Alaska, Montana and IDAHO. Those 40 seats are reserved for Idaho resident applicants. Idaho students now spend their first year and a half of the four years of medical school in Idaho. Many are based in small towns and rural communities, learning from the local physicians and patients about managing disease and chronic illness.

Medical training takes many steps. After receiving a bachelor’s degree (usually a four-year process) the next step is four years of Medical School. Then there is the residency step that takes 3-10 years, depending on the specialty one chooses. After residency docs go hang a shingle and see what they will be paid. Most doctors in Idaho make over $150K, so it’s not a shabby income. But many could do better elsewhere; market forces are real.

But for most doctors it’s not just the money that motivates. Most want to serve; their patients, serve their communities, serve their profession, serve their families. Unfortunately, many doctors put their service in that order. Families can suffer. If you are a small community in need of a doctor, think about what you can do to make a family thrive in your community. Could the schools be better? Do you have a good library? Do you have opportunities for a spouse, a family to thrive? Doctors will like such opportunities; so should you.

But getting a doctor is just part of the process. Keeping one and keeping them good is another. The Idaho WWAMI program is not just about running students through the four years, they are also committed to supporting doctors in small communities stay strong, stay informed, practicing good medicine.

Two of the toughest fields of practice for rural family physicians is behavioral health (the new term for psychiatric-emotional-personality-addiction problems) and chronic pain. The explosion Idaho and our nation have seen in overdose deaths from narcotics is just one indicator. Docs haven’t been doing the best managing pain. And most psychiatric care in Idaho is provided by primary care providers; we are last in the country for psychiatrists and behavioral health specialists. WWAMI saw this need and responded.

Two years ago, WWAMI set up the ECHO program. Providers (physicians and nurse practitioners, physician assistants, social workers or counselors) participate remotely in an interactive online session to discuss the difficult problems they face. The sessions focus on how to prescribe narcotics appropriately and managing behavioral health. Such support will go a long way to keeping providers at the top of their game in this rural and frontier state.

We hear about the cost of care, Medicaid and Medicare, who pays and who doesn’t. There is no doubt that the medical industrial complex has a strong presence in “the swamp” as our president refers to the business-political morass. And I’m sure there’s plenty of ideas about how to get out of this mud hole. Payment affects behavior; sometimes. But we, in our communities can make health care about being healthy. I would hope our dear state of Idaho has such a vision.
 

Quit griping: get to work

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The favorite pastime of the day seems to be railing against government. Isn’t that what these editorial pages are for? If you can’t find a good word to say about your government, then I think you ought to join it. Of the people, by the people, shall not perish; or maybe you just want to gripe. We are better than gripers; republic up.

For this republic needs our service if it is to prosper. It’s not just your vote in November, it’s your voice we need. You, my fellow citizen, have a valuable voice to offer to our common good. Keep your AR15’s, keep the stockpiles of ammo and rations, but invest in this republic. I still believe in it. Do you?

If you don’t have the temperament for elected office but you care about your community, here’s a way to serve: look through the list Governor Little updates regularly on his website. Below the banner of the beautiful capitol in Boise there’s a heading “Administration”. Click on it and a list pops down that includes “Appointments”. There is a simple description of how you apply, a link to download and print the forms, then a list of all the appointments that are coming up.

I’ll bet you thought these appointments were just handed out to Brad’s old buddies. Not so. His office is making a strong effort to reach out and include all of us in this process so many disparage. Good for him. Better for us if we show up.

Many of the positions require some professional experience and that makes sense. But even the Electrical Board (which will have 5 vacancies in July) has an opening for an at-large member. If you are passionate about electrical codes, here’s your chance.

I’d encourage you to look into the legal responsibilities of each board. You can look up the duties for the Electrical Board in statute (54-1006). Same goes for the Building Code Board; they have a great website and a contact number to call.

It’s a long list of appointments the governor has to work through. Something ought to suit you.

Keep in mind, some of these boards have a “political requirement”, not just a professional one. That means the governor will be looking for a Democrat or a Republican. Why does that matter? In the best of all worlds, it shouldn’t. But there have been many times in the history of this country, and this state, when partisan affiliation was the test applied to governance. Sorry fact, but it’s true.

The Idaho legislature saw such party politics a few decades ago harming our common good and decided to impose in law a balance. So, there may be a legal requirement that a board have three members from the “majority party” and two from the “minority party”. Such a requirement was designed to embrace balance and service to the common good, not promote partisanship. The good old boy system needed a legal thwart. The legislature gave it.

Imagine that, the Idaho legislature embracing balance. Like I said, it was a while ago. But I respect the concept of balance. I doubt todays legislature would see such wisdom. Partisan affiliation has become the test before service to the common good. We need to show up folks.

I encourage all citizens to participate in this process of governance. Lincoln’s phrase, “of the people, by the people, for the people” was not in any founding document. In fact, he might have plagiarized it from a sermon by Theodore Parker. I don’t really care; it is an ideal I can embrace. I would hope you can too. Quit griping; get to work. Our republic may perish.
 

New rules

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Darrell had finally gotten his small office just the way he wanted it. When he’d been hired last year as the Coordinator for the Liaison and Edification of Administrative Rules (CLEAR) he’d had a thorough introduction to the state health insurance from HR but hadn’t been told his office would be next to the hot water pumping station in the basement of the Hall of Mirrors. But the work was rewarding. He had spent all summer preparing for legislative review of new rules.

And the first three weeks of the legislative session were busy but it seemed he had prepared well and the rules review went without much drama. Legislators always had good questions. They had insisted their review of rules was important and even got it into the Idaho Constitution. But when the session ended and all those new rules had been dropped by the legislature, he was kind of scratching his head.

“Hello, Dennis?” He called his old boss. “What are we going to do now?”

“Heh, heh.” Dennis chuckled. “Start from scratch.”

“You mean rewrite all the rules?”

“You’ll have to. All rules, not just the new ones they reviewed this session, expire on the first of July unless renewed by the legislature and they didn’t renew them. Start over. Should be fun. I gotta go. If I birdie this I’m three up. Click.”

Darrel called the Governor’s office. “Oh, Darrell, I was looking for your number, thanks so much for calling.” Linda was always so cheerful. “We are having a meeting this afternoon and you need to be there.”

“Sure. What should I bring?”

“Well, bring your thinking cap and a smile would be good.”

Darrell looked up at the top shelf of his small neat office. Four feet of binders held the 8000 pages of fine print of administrative rules. When the legislature passes a law, the details of just how to follow the law are written up into rules and these rules hold the effect of law. They started on the left with the Accountancy Board and ran south to the Wheat Commission. By the dust on the binders he knew they weren’t up to date. The real rules lived in the cloud, on servers, who knows where.

The meeting was called to order and introductions were made. Darrell was after the Commissioner on Commissions and before the Director of the Department of Redundancy Department. Darrell had some ideas right away.

Alex, the Chief of Staff, spoke boldly. “I know this is a surprise, but the Governor and I look at this as an opportunity. He has been wanting to reduce rules since he signed his second executive order.”

“You mean the one that told us to cut two rules for every new one?” asked the Logic Department Director. “If we follow that order we’ll end up with a negative number.” He smiled at his logic.

“Those legislators wanted complete control of the administrative rules, and then they go and do this.” Hissed the Chairman on Consistency.

“Now don’t go complaining. This is an opportunity!” exclaimed Alex again with a grin. “We can start over! Our governor wants government streamlined and made more efficient and the legislature has given us this gift.”

“I’ll have my secretary just paste in the old rules with a different font.” Offered the Chairman of Furniture.

“I was planning on a smaller font so there were less pages. Are we counting pages or words?” asked the Director of Measures.

“Can we combine two rules into one? Will that work?” the Director of Efficiency was eager.

“It all seems pretty silly to me.” Offered the Commissioner on Common Sense.

The room got quiet except for some murmuring between the Finance Director and the Human Resources Commissioner. Darrell thought he should add his part. “Well, you all need to know that the legislature is required to review all new rules. And since all the rules will be new next session, I think they will be too busy to do much else. It could take them months.”

Alex grinned. Governor Little walked in and smiled to the room. “We settled?”