Senate committee approves new mid-level dental provider category for reservation clinics

By Melissa Davlin, Idaho Reports

On Wednesday, the Senate Health and Welfare Committee passed legislation from the Coeur d’Alene Tribe that seeks to address gaps in dental care for American Indian tribal members, despite opposition from some dental professionals.

The bill would legalize a new type of mid-level dental provider in Idaho. Dental health aide therapists, or DHATs, are trained in a limited number of procedures like fillings and extractions.

The legislation now goes to the Senate for a vote.

Gaps in care

Nationwide, American Indian and Alaska Native children experience four times the amount of untreated dental disease compared to white children, with nearly half of American Indian five-year-olds experiencing tooth decay, according to a 2015 Indian Health Services policy brief.

American Indian adults also experience the highest rates of dental disease among any demographic, with two-thirds of adults between the ages of 34 and 49s experiencing decay and other ailments.

There are multiple reasons for that. Though 90 percent of Idahoans live within a 15-minute drive of a dentist, many of those dentists don’t accept Medicaid. In short, it doesn’t matter if you live by a dentist if that dentist won’t see you.

Generational trauma and cultural sensitivity play into the lack of care as well.

Matthew Stensgar, chairman of the Coeur d’Alene Tribe’s Marimn Health Board of Directors, told Idaho Reports in January about the terror he felt as a child when visiting the dentist.

In the past, dental providers from outside the Coeur d’Alene Reservation would treat children in mobile clinics, with the line snaking out the door, Stensgar said. Because those dentists had to treat everyone at once, they hurried patients through, sometimes drilling or pulling teeth before painkilling shots had taken effect.

“They didn’t really care about if we were in pain while we were receiving our dental care,” he said. “A lot of times the numbing shots didn’t take effect, and you could really feel them drilling.”

Dental procedures have changed, but Stensgar is still afraid of going to the dentist.

Having tribal members train to be DHATs could relieve those concerns among his fellow community members, Stensgar said.

The United States DHAT program started in Alaska to address far-flung native communities with no dental care. In other states that have adopted the program, DHATs are trained in a limited number of procedures that they can perform, unlike dental hygienists, who are limited to cleaning and preventative treatments. Dentists learn how to do about 500 procedures in four years of dental school, while DHATs learn 46 over the course of two years, plus 500 hours of supervised training after graduation.

Unlike dentists, who are required to have a four-year degree before applying for dental school, or dental hygienists, who require an associate’s degree, students can apply for the DHAT program right out of high school.

An uneasy compromise

The Idaho State Dental Association opposed a previous proposal from the tribe, citing patient safety concerns. In short, DHATs receive fewer hours of training than a dental hygienist, but have the ability to do more procedures without the direct supervision of an on-site dentist.

But in recent weeks, the ISDA worked out a compromise with the Coeur d’Alene Tribe, and is now neutral on the legislation.

“As in any good compromise, no one got everything they wanted,” said Coeur d’Alene Tribe legislative director Tyrel Stevenson.

Under the new proposal, DHATs are limited to working on federally qualified health clinics on reservations, and can do limited preventative care in facilities that are adjacent to reservations. Additionally, dentists may supervise only three DHATs at a time.

Though both the ISDA and the State Board of Dentistry are neutral on the legislation, the Idaho Dental Hygienists Association voiced its opposition, as did individual dentists who broke with the ISDA.

Ultimately, the Senate committee voted in favor of sending the bill to the Senate floor.

“I think it’s fitting to point out that not one of us (on the committee) will be affected by this bill, and that’s because we don’t live on a reservation,” said Sen. Lee Heider, R-Twin Falls. “We’re not privy to the care, or the lack thereof, that reservations receive.”

 

Watch our January 29 story on the DHAT proposal and dental care on tribal reservations at this link.

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Idaho GOP chairman Parker resigns

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Jonathan Parker. Source: idgop.org

By Seth Ogilvie, Idaho Reports

Idaho Republican Party Chairman Jonathan Parker is stepping down.

Frank Terraferma, executive director of the party, confirmed Parker’s resignation to Idaho Reports on Monday.

“Jonathan notified the state central committee that he was stepping down,” said Terraferma.

According to the GOP State Rules, current First Vice-Chairwoman Jennifer Locke now assumes all duties and responsibilities of chairman until the next GOP state meeting.

Locke was a Trump elector at the 2016 convention. She currently works as a Deputy County Clerk in Kootenai County.

According to the Coeur d’Alene Press, Locke has a bachelor’s degree in economics from the University of Southern Maine and has lived in north Idaho for almost a decade.

Locke did not respond to requests for comment immediately.

In a statement sent out Tuesday morning, Parker cited family as his reason for stepping down.

“(M)aintaining a full-time job and being a fully engaged Father has been harder than I imagined, so much so that I have reluctantly decided that I should no longer continue to serve as Chairman of the Idaho Republican Party so that I can focus on the priorities I place above all others,” Parker wrote.

According to the party rules, the Idaho Republican Party will likely vote on a new Chairman at the party’s June summer meeting.

 

 

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Medicaid bill would void expansion if feds change funding structure

By Melissa Davlin, Idaho Reports

The next round in the fight surrounding Medicaid expansion has begun.

On Monday, Sen. Mary Souza introduced legislation that would void expansion if the federal government changes its 90/10 cost-sharing formula and establish a voluntary workforce training requirement program. Read the bill here.

The proposal would also direct the department to provide subsidies for insurance plans through the insurance exchange for those in the gap who are above 100 percent of the federal poverty line instead of enrolling them in Medicaid. That part of the proposal would require a waiver from the federal government.

Another section instructs the Idaho Department of Health and Welfare to seek waivers to use Medicaid funds for substance abuse and mental health care. The idea behind this, Souza said, was to help lessen the impact for counties who may receive less financial help for these services through catastrophic health care and indigent funds.

I believe these are not restrictions on Medicaid expansion,” Souza said. “These are protections and enhancements.”

Ultimately, the Senate Health and Welfare Committee was split 5-4 on whether to allow a hearing on the proposal, with Senators Fred Martin, Lee Heider, David Nelson, and Maryanne Jordan voting no.

My preference has always been simply to fund it,” Martin said.

 

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Idaho Supreme Court upholds Medicaid expansion

By Melissa Davlin, Idaho Reports

Updated 5:48 pm Feb. 5

The Idaho Supreme Court upheld Medicaid expansion in an opinion released Tuesday.

The opinion states Medicaid expansion does not delegate lawmaking authority to the federal government, as plaintiff Brent Regan argued in his November lawsuit.

Read the opinion, written by Chief Justice Roger Burdick, at this link.

Here are my initial takeaways:

-Justices didn’t buy the argument that the state is delegating its lawmaking authority to the federal government. “Idaho’s ongoing participation in Medicaid, even prior to expansion, requires a yearly appropriation of funds from the legislature,” the opinion says. Through that annual appropriation, the Idaho legislature will control the ongoing nature of Medicaid.  “Additionally, as the United States Supreme Court has said, ‘[t]hough Congress’ power to legislate under the spending power is broad, it does not include surprising participating States with post-acceptance or ‘retroactive’ conditions.’“

In other words, Congress can’t suddenly withdraw the 90/10 match for Medicaid funding. If that change happens, states will get plenty of notice.

-Almost everyone wanted a say. It’s normal to have a unanimous opinion; It’s also normal to have a dissenting opinion. This ruling has the majority opinion written by Chief Justice Roger Burdick, a concurring opinion by Justice John Stegner, an opinion that concurs in part and dissents in part by Justice Robyn Brody, and another concurring-dissenting opinion by Justice Greg Moeller. The only justice who didn’t weigh in was Justice Richard Bevan, who, incidentally, was also the only justice who didn’t ask questions during last week’s oral arguments.

Remember, too, how new this court is. Of the five justices, only Burdick has been there longer than two years; Three have been there less than a year. We may be getting a peek at how this dynamic is going to shake out.

-The dissents don’t agree with Regan; If anything, some of the arguments are more strongly worded. Both Moeller and Brody both say they would have rather the Supreme Court not heard Regan’s lawsuit, with Brody saying she would have sent the case to a lower court, and Moeller saying he would have dismissed it outright on its procedural weaknesses.

In his dissent, Moeller says Regan’s petition “suffers from serious justiciability defects,” going on to argue Regan is asking the court to weigh in on political and philosophical arguments instead of constitutional ones.

“This became readily apparent at oral argument, when counsel for Regan, in urging the Court to strike down the new law, argued that what the Supreme Court is really being asked to do is to decide whether this state will “act or be acted upon” when it comes to its relationship with the federal government,” Moeller writes. “Counsel (Bryan Smith) began his presentation with this phrase, and later repeated it when asked by the Chief Justice whether the state could simply “opt out” of Medicaid expansion if the federal government changed the current standards. Such arguments are largely ideological and dogmatic in nature—not legal—and demonstrate that the intent behind the petition is to have this Court redefine the proper role of federalism in Idaho. In sum, this Court is not really being asked to address an urgent constitutional issue created by the passage of section 56-267; rather, Regan is asking this Court to take sides in an ideological debate concerning political philosophy. “

-The court does cite a section of code as unconstitutional — just not the one Regan had been hoping for. Regan argued he had standing to sue as a “qualified elector” under Idaho Code section 34-1809(4). That statute “attempts to broaden this Court’s jurisdiction,” Burdick writes, creating a separation of powers issue.

Boy, that was fast. I was under the impression the Supreme Court wasn’t bound by any timeline regarding this decision, even if the Idaho Department of Health and Welfare had to meet a deadline for submitting Medicaid plan amendments and the Legislature had to fund it. We discussed this on last week’s Idaho Reports with Idaho Supreme Court Administrative Director Sara Thomas.

Still, the justices cited the deadlines and 2019 legislative session as a reason to take up the case, and rule quickly: “(W)e recognize the need for a determination of the constitutionality of section 56-267 during the 2019 legislative session given the fast-approaching 90-day window for the Department to submit any necessary plan amendments, and the Legislature’s need to consider funding for Medicaid expansion. Accordingly, due to the urgency of the alleged constitutional violation and the urgent need for an immediate determination, we will exercise our original jurisdiction over Regan’s petition.”

Well, I’ve been wrong before.

 

I’m still awaiting comment from the Idaho Freedom Foundation. In the meantime, here are reactions from other stakeholders. I’ll continue to update as I receive comment:

Rep. Fred Wood, chairman of the House Health and Welfare Committee: “I’m not an attorney, but I think it’s a good decision.” As to whether this would speed up some of the discussions surrounding Medicaid funding, he said he didn’t think the pending court decision had slowed down the Legislature.

Luke Mayville, Co-Founder of Reclaim Idaho: “I am ecstatic…. We know it was upheld in the court of public opinion by the voters, but it’s an extra boost for the cause of securing health care for 62,000 Idahoans by having the court uphold it as well.”

“With the court having ruled, there is no longer any excuse for inaction on the part of the Legislature. Their job is clear to fund Medicaid expansion and to allow it to be implemented without restrictions.”

Mayville also noted it was a “special joy” to see the ruling the day after the Medicaid expansion advocacy day at the statehouse, at which advocates met with lawmakers to encourage them to expand Medicaid without sideboards like work requirements. “It’s a special prize for them, for all the advocates who worked for this, to now have this sense of relief that knowing the constitutionality of Medicaid expansion is secure.”

 

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Idaho is one of seven states without a maternal death review panel. This proposal would change that.

Updated Feb. 8, 8:10 am

By Melissa Davlin, Idaho Reports

A proposal by the Idaho Medical Association would establish a review panel to track maternal deaths in Idaho.

Idaho’s maternal death rate of 27.1 deaths per 100,000 births is higher than the United States rate of 26.4, said Susie Pouliot, CEO of the Idaho Medical Association. That US rate is also more than twice as high as most European countries.

According to the Centers for Disease Control and Prevention, Idaho is one of seven states without a maternal mortality review panel, and, as of December, was one of just two states without a plan to implement one.

A 2008 legislative effort to establish one didn’t go anywhere, though Idaho does track maternal deaths.

Currently, Idaho death certificates have a checkbox to indicate the pregnancy status of women who have died between the ages of 10 to 54 years, said Niki Forbing-Orr, spokeswoman of Idaho Health and Welfare, in a December e-mail to Idaho Reports.

The checkboxes are: Not pregnant within the past year; pregnant at the time of death; not pregnant, but pregnant within 42 days of death; and not pregnant, but pregnant 43 days to 1 year before death.

The death certificate doesn’t always indicate at what point during the pregnancy the woman’s death occurred.

According to IDHW, between 2008 and 2017, there were 121 deaths to Idaho women who were reported as either pregnant or pregnant within one year before death. Of those, 70 were determined to be pregnancy-related, 34 were from accidents, 7 were from suicide, 7 were from homicide, 1 was undetermined, and 2 were from all other causes. Of the 34 accidental deaths, 10 were from drug overdoses.

There were also racial disparities, with American Indian women experiencing the highest maternal death rates in that time period.

pregnancydeathratesrace

Source: Idaho Department of Health and Welfare

Though IDHW tracks maternal deaths, no entity exists to make recommendations to improve Idaho’s maternal death rate.

The proposed panel would be funded by a four-year grant from the Centers for Disease Control and Prevention, Pouliot said, and would include physicians, a coroner, a labor and delivery nurse, and others. The panel would have the ability to look into deaths with records and make recommendations regarding medical care, but would not have disciplinary powers.

The House Health and Welfare voted to print the bill on Thursday.

Chairman Fred Wood, R-Burley, supported the panel during a Monday meeting. “(The death rates are) an embarrassment, and we need to find out why,” he said.

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Rule debate highlights shortcomings in Idaho’s prescription tracking program

By Melissa Davlin, Idaho Reports

A new rule designed to prevent Medicaid participants from abusing opioid prescriptions sparked debate in House Health and Welfare on Friday, and in the process highlighted issues with the state’s prescription tracking system.

The rule, presented by Medicaid program manager Tiffany Kinzler, would prevent Medicaid recipients from paying cash for controlled substance prescriptions.

The idea behind the rule: Medicaid participants who have obtained prescriptions through legitimate means wouldn’t normally be paying for their prescriptions in the first place, explained Tami Eide of the Idaho Medicaid Pharmacy Program.

Rep. Sue Chew, D-Boise and the only pharmacist on the committee, said it raises red flags when someone with a Medicaid card ends up paying for a pain killer prescription.

Rep. John Vander Woude, R-Nampa, expressed concern that the state’s prescription tracking program wasn’t catching abuse. That system, Eide replied, is imperfect.

Most pharmacies don’t have access to look at that,” she told the committee. Chew agreed.

“Our system to try to mitigate (abuse) electronically, it’s getting there, but it doesn’t work that great,” Chew said.

Matt Wimmer, Administrator for the Division of Medicaid, told the committee that the prescription tracking system helps when physicians use it — but not everyone does.

We don’t have a legal requirement that you must (update it) all the time,” Wimmer said.

Ultimately, the committee voted to adopt the rule, with Vander Woude joining Reps. Bryan Zollinger, John Green, Chad Christensen and Marc Gibbs in voting no.

After the meeting. Chew explained that the current rule mandates that pharmacists and physicians register with the prescription tracking system, but nothing forces them to actually participate and update the tracker.

That’s why we’ve got a dilemma,” Chew said. “If we had a magic wand, we’d mandate that all pharmacists look on those things before they dispense.” The problem? “In this state, no one likes mandates.”

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A lesson in compromise from water users

On Thursday afternoon, the House Resources and Conservation Committee was filled with water users and representatives from the Idaho Department of Water Resources.

For the past several years, you wouldn’t have been able to find those stakeholders in the same place, at the same time, agreeing on hardly anything proposed by IDWR.

But that changed last year with a settlement on a long-running fight between Boise Basin water users and the state.

The fight involved flood releases from Idaho reservoirs during high water years, senior and junior water rights, and irrigation concerns. In short, if the Bureau of Reclamation releases water from Lucky Peak early in the season to avoid spring flooding in the Treasure Valley, should those releases count against water users’ rights — even if it’s too early for them to use that water for irrigation?

The fight resulted in litigation, as well as the threat of a special session during the summer of 2018. That was avoided with a settlement — moderated in part by House Speaker Scott Bedke, who started bringing together the different parties for lengthy meetings during the 2018 legislative session.

On Thursday, Bedke presented one piece that compromise in the form of House Bill 1 to the House Resources and Conservation Committee. The bill codifies how storage is filled after those flood releases from reservoirs.

“From my perspective, it’s a credit to the water users, both in the Treasure Valley and the state,” said IDWR director Gary Spackman. He also praised Bedke for bringing together the different parties, even when they were cantankerous. “He dedicated time to this he didn’t have to,” he said.

The water users agreed.

“It was a very divisive, very angry issue…. Three years ago, you would not have heard all that praise for the director, for the state, for the legislative leadership,” said Paul Arrington, executive director and general counsel for the Idaho Water Users Association. “There was a lot of frustration about this issue.”

Clinton Pline agreed.

“They were very dug in,” said Pline, president of Treasure Valley Water Users Association and a board member of the Nampa and Meridian Irrigation District.  “We’ve come to a point where we’ve realized that everybody needs to give and take some, and this is where we are today.”

Does this mean Bedke needs to head to DC to solve the federal funding impasse over border security?

When asked, Bedke rolled his eyes.

“(Compromise) is something they know how to do,” he said. “They do it every day.”

 

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