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Posts published in “Schmidt”

Pain and suffering

schmidt

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

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

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

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

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

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

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

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

The Idaho Way?

schmidt

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

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

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

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

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

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

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

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

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

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

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

Who does he work for?

schmidt

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

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

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

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

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

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

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

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

Medical loyalty

schmidt

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

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

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

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

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

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

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

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

But my perspective might be different than yours.

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

Confronting loyalty

schmidt

It can be hard to confront a colleague with their misbehavior. I’ve done it a time or two and it sure got me to thinking about my loyalties. When I chose to act, it was out of a sense of loyalty to a purpose, a profession, a greater good that deserved my service. There were also times in my life I passed on the confrontation. I have some regrets.

Ronnie was a gifted high school athlete. He hit the goal post upright from forty yards out with a perfect spiral once at the end of a workout. “You lucky dog.” I said. “Bet me.” he said. He did it again 3 out of four times. He went off to a college career. For a while he led the nation in total offense and punting. I was at home for the summer visiting him when he got a call from his coach to come back for summer school to remain academically eligible. He hung up quietly. “You going back?” he shook his head. I wish to this day I’d confronted him, my friend.

Professions and the higher calling they claim can inspire loyalty in some. But confrontations can become messy; when the dirty laundry airs, some splashes on you and soils the profession. As a doctor, those were the hardest things I had to do, confront a colleague on their behavior. But I tried to be true to the ideals of the profession. I believed we all should be serving higher ideals.
In the political sphere confrontations are even more fraught. Loyalty to a greater good may just become loyalty to a party.

I served on an ethics committee as a freshman state Senator. The ethics complaint was lodged by my caucus leadership, Democrats. A Senator had chaired his committee that heard and voted on regulations that actually affected the Senator without revealing this conflict of interest. After days of adversarial testimony, it became clear to me the Senator had indeed violated Senate rules.

But he had not broken any laws and we were not going to be able to prove he had any substantial monetary gain from his actions: thus, no crime. On the third day of testimony I seconded the motion to dismiss the ethics complaint. This was over strong objections of fellow Democrats who wanted the hearings to keep going. I got a sense they saw political benefit in the proceedings. But when I voted to dismiss, I did not want my vote to mean he was not guilty. I said on the record that he had broken Senate rules but more, he had violated the public trust that makes representative government work.

As it turned out, though there was no official Idaho Senate censure or sanction, the Senator was beat in a primary election the coming spring. Maybe there is some wisdom in the voting electorate.

So, I’m wondering about our Idaho Senators, both loyal Republicans, who serve us in Washington. Just what is their loyalty? Does having this partisan conflict that has shuttered our government serve Idaho, our Union? Do you honestly believe spending $5B for a steel wall on our southern border is the proper use of our dear tax dollars?

To my father’s dying day he thought President Nixon had done no wrong and his resignation was a travesty, the fault of an over zealous press. He was a loyal Republican. Me, I was impressed that our Union could survive the scandal, the turmoil and come through; a nation with a loyalty to the rule of law. May we so be.
 

Lost dogs and outrage

schmidt

My daughters don’t use Facebook. They have their reasons, and I agree with most of them: waste of time, privacy, concern for the level of conversation. So, I was a bit surprised when I got a text from a daughter the day after Christmas asking me to post something on a Facebook site.

They had gone for a ski out in the east county with their dogs. One daughter has a three-year-old 70# mutt she got as a puppy. He was an Attention Deficit puppy, but he has a really good heart and he’s come around. I love him. The other one is new to us. She’s a pretty simple but beautiful 6-month-old Plott hound who follows her nose and not much else. The dogs had run off about 11AM. I got the text about three. They had done the snowy ski a couple times calling, no tracks, no dogs. So, they’d hit some nearby houses and gathering places and someone had suggested the Facebook site for lost dogs in the community.

I asked to join the group, was accepted and posted that night. The daughters came home without dogs.

We went out the next day. Lots of dog tracks, but not ours. Most looked like coyote. My youngest daughter thought she’d seen a wolf track the day before. No dogs that night.

After three days we had kind of given up, but we went out again. We stopped for gas in a nearby town and a guy came out of the store. As the pump was running I said, “Hey we lost a couple dogs out here three days ago.”

“Yeah, I saw it on Facebook.” He responded. He had some local advice about who to check with. But we went home again that night with no dogs.

We didn’t go out the fourth day, but at 3 PM someone called us from a Forest Service road about 3 miles from where they’d run off. We collected the pups. The little one seemed fine, but the mutt had a face full of quills and had lost about 15 pounds. They are doing fine.

Facebook gets no credit for getting the dogs back. The guys who finally called us just read the information on their collars. But it sure was a way to reach out. The posts got over 50 shares. It made us feel connected.

I didn’t successfully use Facebook in any of my campaigns for public office, but the young folks I worked with this last summer on Proposition 2 sure used it to their benefit.

I still see the tool as a very mixed blessing; all tools are. We can use it to connect, communicate and influence. But I think we all need to be a little wiser about that influence aspect. It is difficult for me to communicate clearly in a sentence or two, but that’s what Facebook demands. Influence should require more unless the response you are looking for is outrage. I think that just requires a couple words, maybe a picture.

It’s even more frightening that some folks are spending lots of money to use this tool to their ends, to influence us in ways we might not see. Shame on us for being that simple.

But the simple pup seemed to survive the frozen ordeal the best; then again, she was not outraged at the porcupine.
 

State of the state

schmidt

When Governor Little addresses the legislature Jan 7th with his budget address he’ll be hard pressed to beat Butch Otter's charm or delivery. I hope he feels no pressure to. But Brad will have a chance to strike a new pose.

The speech is required in the Idaho Constitution at the beginning of each legislative session and the governor must describe “the condition of the state, and shall recommend such measures as he shall deem expedient”.

Further he shall, “present estimates of the amount of money required to be raised by taxation for all purposes of the state”.

I’ve been hearing Brad stake out a direction, both in his campaign and since the election that should tell us where he is heading next week. He has said clearly that Idaho needs to be a great place for his (and my) kids to settle and make a good living to raise our grandkids. Maybe they’ll be willing to care for us as we begin to dodder. But right now, these 20-30 somethings are the hard-working plodders that drive strong community growth. We need them, if we are to prosper.

Idaho is one of the fastest growing states in the union, but unfortunately, we are attracting dodderers, not plodders.

What do young families look for when they strike out? Safe, solid communities with good schools and good jobs would be my bet. Will Brad propose increased funding for K-12? How about fully funding kindergarten?

Idaho currently provides funding for ½ day kindergarten, but districts are not required to provide it. Many districts provide full day kindergarten, some even provide preschool, but they support it with local levies. The Idaho School Board Association asked the state to fund this in a resolution this year. Lots of evidence supports early education as a wise government investment, but Idaho struggles with investments. This would be a big leap for Governor Little.

And what can the Governor do about good paying jobs? Even if he went off the deep end and endorsed raising Idaho’s minimum wage, we aren’t really talking about attracting minimum wage workers. But the governor could make a strong statement about wages by trying to make state employee salaries competitive.

Maybe, instead of pushing salaries, he could suggest a “housing allowance” for state workers commensurate with his own. Idaho’s governor gets $138K a year (39th nationally, while Idaho wage earners are 50th) and another $55K for housing or a boost of about 40%. I would bet state workers would be happy with a 5% boost in salary and no housing allowance, but Brad does seem like a fair guy.

I’ll bet he goes for cutting the grocery tax, which has broad support. Idahoans now pay sales tax on groceries; this adds about $200M to state revenue. About $26M of that goes to local governments. But taxpayers get back a grocery tax credit to the tune of about $150M. Eliminating the grocery tax would cost the state general fund about $80M.

So, you can see Governor Little has some real numbers to play with. And the numbers count. Add into all this the uncertainty of the tax revenue, since Idaho’s tax collections since July have been well below projections. Most are writing this off to bad tax estimates offered to employers as the federal and state tax cuts came through together; the expectation is that come April, the taxes owed will add up and we will be writing big checks with our returns. But remember the Constitutional requirement of the Governor: “the amount of money required by taxation”.

I hope Brad holds to his vision. Us dodderers need you plodders: make Idaho your home. We should make it worthy.
 

Really happy

schmidt

Ever get a present that made you really happy? Ever get one that disappointed?

Well, the Idaho legislature got a present from the voters November 6th they didn’t really like: Proposition 2, Medicaid expansion. This citizen initiative passed in 29 of 35 legislative districts; in many of those districts legislators actively opposed it. So, the legislature got a gift. I hope they don’t throw a fit like my daughter did when we got her the knock-off athletic bag instead of the name brand. We still tease her about it.

There are many times when we look for excuses to not do the right thing instead of throwing a tantrum. It usually involves whining. The Idaho Freedom Foundation is giving legislators an excuse through their lawsuit about the constitutionality of Prop 2. I’m glad the Idaho Supreme Court has allowed folks with stronger standing to add their voices to the argument. And the whole question of whether the Affordable Care Act is constitutional, brought up by Republicans before a partisan Texas judge will get to play out. It’s just another excuse for those who want to whine.

But the excuse I hear from what I consider otherwise level-headed legislators is the handwringing, maybe with a little whining involved: “We just can’t afford it.” This excuse is just poppycock.

Every credible analysis of the funding requirements for Medicaid expansion have shown that in the long run, this policy choice either saves Idaho money, or costs very little. The ones that have shown minor costs have not included savings from keeping folks out of prison, expanding Idaho’s economy or keeping rural hospitals afloat. Anybody who has looked at the analysis understands this, even Republicans.

But there will be initial costs for Idaho, since the savings from reducing the CAT Fund and county indigent costs will take a few years to show up. Kind of like when you buy those expensive LED lights, they cost a bit up front, but the lower electric bills actually pay for them in a few years. But that initial cost can be an excuse for you to not conserve, not do the right thing. Please don’t whine as you pass the light bulb isle in Walmart.

This legislative whining about not being able to afford it comes from your representatives that don’t really know the numbers of Idaho’s budget. I will admit, it’s complicated, but after I served on the budget committee a couple years, I got some understanding. All legislators should serve on this committee. Many don’t; it’s hard work.

There is a ready source for over half the initial cost of Medicaid expansion from Millennium Fund money. This is money Idaho gets from the tobacco settlement, about $20M a year. We have passed a Constitutional amendment that this money must be used to build an endowment fund, so it can’t be used directly. The Millennium endowment fund now sits at $300M. That makes over $18M a year available.

Next you have to consider what we have been doing with your tax revenues for the last 10 years. Idaho has replenished our reserve funds to the tune of over $65M a year. One of the reserve funds is now at its maximum amount allowed by law. Even with last year’s tax cut and Idaho’s revenues coming in under projections the last six months, Idaho has plenty of revenue to fund Medicaid expansion. Once we get the train moving out of the station, repeal the CAT Fund, the momentum will take care of itself.

Brad Little knows this; he served on the budget committee. Most legislative leaders know this. Don’t listen when they whine about the present they just got.
 

Suicide in Idaho

schmidt

A man I knew well and considered a friend killed himself this last week. The feelings that wash over us survivors might mirror the feelings of the victim: anger, sadness, despair, failure. I will admit to all those. I imagine someone close to you has killed themselves. I am sorry. It sounds so inadequate, doesn’t it? What else can we offer?

Like any painful issue, if we are not willing to look at it, talk about it, try to understand and respond, then it will stay with us. We might get better at hiding the pain, denying the pain, but it’s still there. And if our best response after honest reflection is prayer, then let us pray. I will join in the prayer.

Let me offer some numbers for this moment of reflection. Idaho has consistently been in the top ten in states for rate of death by suicide; 8th nationally in 2016. The rate of death by suicide for Idahoans is over 50% above the national average. In Idaho, suicide is the second leading cause of death for ages 15-34. Teen suicide rates are higher than our overall suicide rates. Did you know the highest rate of suicide is in men over 80?

But numbers don’t tell a story, do they? I got my share of stories as a county coroner. Suicides, like homicides or any “unnatural” death got the time and attention (and tax dollars) of this lowly public servant. I will admit to a pretty libertarian viewpoint toward suicide early in my career. We are all going to die. So what if someone makes the choice? I did not see it as a mortal sin, but then I was not brought up in that faith. But so many of the deaths I struggled to come to peace with, beyond the mere investigation; I changed my view.

The many older men (some my age) failing in their strength, their independence who chose to end their lives, I could somewhat accept, though I could hear the pain and suffering in their loved ones.

The ones who had struggled with addiction or depression, sometimes were not a surprise to their family. But I could clearly hear the sense of failure, their sadness, their shared despair at the loss.

But the young deaths, sometimes impetuous, fueled by anger or lubricated with substances or an impetuous nature left me very burdened. And I am sure their families still struggle.

I have come to believe suicide, like homicide deserves our attention, our investment as a society. Not all violent deaths can be prevented. But if we cannot prevent all, should we give up on preventing some? If we as neighbors, as fellow citizens are not willing to even make such a commitment, what does that say about us, the survivors?

I am proud that Idaho has made this commitment. You taxpayers invested in this, with the legislatures and the governor’s approval. In 2016 a small investment was made to coordinate existing suicide prevention programs, to educate youth, to support the statewide hotline, and advance public awareness. Like all investments, we need to pay attention to the wisdom of each dollar spent. But it’s about time we did something. There is so much to do.