(08-15-2020 01:25 PM)Hambone10 Wrote:  Not disagreeing with anything else you said... just felt compelled to add to this....

(08-15-2020 01:08 PM)OptimisticOwl Wrote:  

Quote: Or are you saying that, if Medicare reimbursed at the same rate in all areas, providers that currently operate on the city would relocate to rural areas?

I'll let the doctor clarify what he is saying, but what I am hearing is that equal reimbursements would eliminate the incentive for (1) new doctors to locate in big cities, and (2) rural doctors to pull up stakes and relocate to more urban centers.

My kidney specialist practiced here one day a week, then pulled up stakes and moved to College Station. Now I have to travel 40 miles to see a replacement specialist.

I will say this... If Medicaid paid the same for a GP to work in Boerne as they do in NYC, you might get a lot of docs at least working in Boerne long enough to pay off their debts and put money away for that Park Avenue spot.

It's not just about the reimbursement, but also about how and why you become a specialist.

One of the big problems with healthcare reimbursement vs other nations that is so often glossed over here (because there are no 'identical' patients) is that depending on your insurance, a cardiologist can get paid very well to give you bypass surgery. At what point is bypass surgery necessary? Would a stent work? There are so many details, it's really hard to compare apples:apples.

What we know is that if people get paid the same regardless of whether or not they do something (managed care), they're somewhat less likely to do it.... especially if they can simply see another patient and get paid more.... or as in your case, stop paying rent in Boerne and consolidate to a bigger town.

FTR, I don't recall if you're actually in or near Boerne... It's just an example and for some reason, I think of that part of the state when I think of you.

My doctor was already a specialist. No idea why he moved.

I live in the DFW metroplex, in one of the outlying counties. (we can out lie anybody you got...)

For personal reasons, I decline to give out further info, even to people I trust (and I certainly would trust you), but I have given a hint that nobody has picked up on...

(08-15-2020 01:31 PM)OptimisticOwl Wrote:  My doctor was already a specialist. No idea why he moved.

$250 ea for 30 patients/day rather than $150 ea for 20?? HE may not have moved, just his practice. Seriously, it could be that simple. It also could be that like most rural places, Marketplace has replaced a lot of small company/individual policies and Medicaid. I suspect he got paid better under those than he does under Marketplace.... or that the payer mix in College Station is just better.

Quote:I live in the DFW metroplex, in one of the outlying counties. (we can out lie anybody you got...)

For personal reasons, I decline to give out further info, even to people I trust (and I certainly would trust you), but I have given a hint that nobody has picker up on...

Now that you've mentioned this I caught the hint... but I understand completely everything else.

(08-15-2020 01:05 PM)Hambone10 Wrote:  

(08-15-2020 12:12 PM)RiceLad15 Wrote:  I feel like that’s a good comparison, actually.

Payment to send a letter is the same, regardless of the density of delivery. So USPS makes more money if they can deliver 1,000 pieces of mail in a denser suburb in an hour than say 50 in a rural area in an hour.

So it’s also about volume of service in both instances - greater population density means more customers and more efficiencies in both instances.

Sure... if you assume that the delivery of most mail is as important as the delivery of healthcare. That's my point is that MOST mail isn't remotely important... and that that IS important is most often (in one way or another) funded by the government anyway.

Remove the subsidy for junk mail and keep it for government mail. If Junk mailers still want to deliver it to dense populations, that's fine... the post office can charge them a penny more, and reduce the need for government subsidy for prescriptions to BFE.

I don't think that some mail is pointless negates my overall point. Removing all of the junk mail like you advocate for (which is fine by me) still leaves us with the same issue for important mail like payments/invoices, government assistance, medication, etc. - rural areas are less dense, and therefore small margin services that rely on large volumes are less profitable/cost prohibitive.

In the end, your response isn't disagreeing with my point, but rather offering a potential solution (increasing fees for what would be identified as junk mail to offset the extra cost of providing what would be identified as essential mail to rural areas).

Quote:

(08-15-2020 12:16 PM)RiceLad15 Wrote:  My understanding is that USPS is also struggling due to some funding mandates imposed by Congress associated with retirement benefits.

Regardless, I think your argument makes sense, but isn’t realistic. There will need to be a significant transition period where two things happen: broadband is actually extended to all parts of America, and technology to use/access needs to equally penetrate those areas.

If we’re talking about whether we should be subsidizing the USPS in 20 years, then I can understand that position. But since we can’t convert all necessary aspects of USPS overnight, we must continue to effectively fund and operate it until a digital alternative is developed.

So, again, why not both?

I guess i wasn't clear about my 'more' comment.

I've suggested a way for the government to subsidize 'necessary deliveries'... without having to subsidize NON essential deliveries.... just to make sure that people in rural areas get daily delivery of their junk mail just like people in big cities.

As to the pensions, Revenues for all other 'delivery' services have doubled in the past 10 years or so, while USPS has remained flat. Revenues are not impacted by pensions and benefits.

But you DO bring up one of the problems with government sponsorship/co-opting of private enterprise. The company must play by government rules which other delivery services do not. We're not talking about general employment rules, but specific 'we work for the government' rules.

I think this is a good example of the difficulties of this medium for discussion. I didn't disagree with the options you outlined about how USPS could adjust its operation to adjust revenues to subsidize specific types of mail. Since I agreed, and the post was rather long, I only commented on the end statement about you rather subsidizing (more) internet in the country rather than mail delivery.

Quote:

(08-15-2020 12:30 PM)RiceLad15 Wrote:  It sounds less like Medicare makes this worse, and more like Medicare doesn’t address this problem. Or are you saying that, if Medicare reimbursed at the same rate in all areas, providers that currently operate on the city would relocate to rural areas?

Does Medicare keep private practices from opening and operating in rural areas?

Your comments here demonstrate to me that you don't understand what either of us are saying... which is why you don't see this as a medicare problem.

Let's start with this. Medicare sets the standards. Medicaid, Marketplace and Commercial all follow them. If they don't address it, then it basically doesn't get addressed.

That said, let me show you the simple math of RU's example... just as an example

Medicare pays a GP $100 to remove a skin lesion. They pay a specialist $200 for the same service. Because of the volumes, the GP can fill his day without that, and there is plenty of volume now for a specialist as well. LA county (like almost every urban center) is an expensive town, so they get a 25% positive adjustment... so they actually receive $125 and $250.

The rural county doesn't have a specialist... So on the surface, they pay a GP $100 to remove the lesion... however... because of the lower cost of living, they get a 25% 'hit'... and they only get $75. Now in hard to staff areas, they may bump them back up somewhat... but that requires big studies. 'Cost of living' is a much more readily available and trusted measure than is 'hard to recruit/staff'. They might get a 10% bump or more likely, they get something like a one-time bonus... most often funded through medicare/the state, not medicaid/the feds.

$250 vs $75. That's how they make it worse.

Now throw this in.....
You're an MD... There is more to living in Fresno vs LA than simply cost of living.... and Fresno isn't a tiny place. Culture, peers, diversity, beaches, arts... easy opportunity to participate in CME or an opportunity to develop a specialty practice... the availability of qualified staff and local training for them... I mean, the list of differentials is very long...

Do they stop them from opening? Of course not. That question is meaningless. The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills? Every small town doesn't have a Vialula. More often they have Nancy Lee's.

The reason this matters is because they demand the same quality out of both. If they don't deliver the quality, the reimbursement goes down.... which defeats the whole purpose of the location adjustments, unless they also pay to recruit nurses and staff and fund prettier/better hospitals etc etc.

It's like g5 vs p5. Yes, it's harder to win in p5, but you're easily arguably better off being a losing team in p5 than a winner in g5.

I feel like I do understand the gist of what both of you are saying - but I disagree with the framing that RU took. I definitely learned some information on the details of Medicare reimbursement, but it still seems like my initial thoughts hold true. My comment wasn't that this wasn't a Medicare problem, but rather, it's not the problem RU was saying (as in, Medicare is subsidizing urban healthcare at the expense of rural healthcare). In short, it looks like Medicare addressed issues with urban healthcare (cost of living) but haven't addressed the lack of attractiveness for rural healthcare, and I don't think it's a 0 sum game.

The bolded section is why I say it sounds less like Medicare is making the problem worse, and more like it isn't addressing the issues of recruiting to a rural area. You even stated "The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills," which is exactly what I said to RU ("more like Medicare doesn't address this problem").

It's the P5 vs G5 issue, where Medicare isn't incentiving people to be in the G5. And since the original posit was that Medicare is subsidizing urban areas at the expense of rural areas, that question isn't meaningless.

We seem to be on the same page about that idea that, if we set all payment equal, we would not see a flocking of specialist/GPs to rural areas. Personally, I bet that the issues facing recruitment to rural areas are greater than those associated with net income. I say that because of the general ambitions of people who have gone through medical school, which don't really indicate that they would want to move to rural areas, especially once they're practicing, and the labor issue you mention. My gut says, if all payment was equal, you would find people moving to affluent suburbs or low-cost cities, and not rural areas. And your response to OO about Boerne makes me think you agree.

Off the cuff, the best solution would be to adjust Medicare reimbursement across the board for both cost of living AND desire of living (the hard to recruit/staff you mention), unless we're seeing an overabundance of urban healthcare providers. If that's the case, then the incentive structures are likely skewed too heavily for urban positions/specialties and doctors are actively being incentivized to move to urban areas.

(08-17-2020 01:16 PM)RiceLad15 Wrote:  I don't think that some mail is pointless negates my overall point. Removing all of the junk mail like you advocate for (which is fine by me) still leaves us with the same issue for important mail like payments/invoices, government assistance, medication, etc. - rural areas are less dense, and therefore small margin services that rely on large volumes are less profitable/cost prohibitive.

In the end, your response isn't disagreeing with my point, but rather offering a potential solution (increasing fees for what would be identified as junk mail to offset the extra cost of providing what would be identified as essential mail to rural areas).

Or simply paying the 'prohibitive cost' to deliver 'essential' mail.

You're arguing to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them.

In 1950, it was important that people got every bit of mail. It's how people/families communicated. That's not the case today. Almost nobody communicates through letters today.

(08-15-2020 12:16 PM)RiceLad15 Wrote:  I think this is a good example of the difficulties of this medium for discussion. I didn't disagree with the options you outlined about how USPS could adjust its operation to adjust revenues to subsidize specific types of mail. Since I agreed, and the post was rather long, I only commented on the end statement about you rather subsidizing (more) internet in the country rather than mail delivery.

Yes... I want to use SOME of the money currently subsidizing rural mail delivery (that of unnecessary mail) and divert that to 'other' media delivery... same essential purpose.

(08-15-2020 12:30 PM)RiceLad15 Wrote:  I feel like I do understand the gist of what both of you are saying - but I disagree with the framing that RU took. I definitely learned some information on the details of Medicare reimbursement, but it still seems like my initial thoughts hold true. My comment wasn't that this wasn't a Medicare problem, but rather, it's not the problem RU was saying (as in, Medicare is subsidizing urban healthcare at the expense of rural healthcare). In short, it looks like Medicare addressed issues with urban healthcare (cost of living) but haven't addressed the lack of attractiveness for rural healthcare, and I don't think it's a 0 sum game.

The bolded section is why I say it sounds less like Medicare is making the problem worse, and more like it isn't addressing the issues of recruiting to a rural area. You even stated "The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills," which is exactly what I said to RU ("more like Medicare doesn't address this problem").

It's the P5 vs G5 issue, where Medicare isn't incentiving people to be in the G5. And since the original posit was that Medicare is subsidizing urban areas at the expense of rural areas, that question isn't meaningless.

We seem to be on the same page about that idea that, if we set all payment equal, we would not see a flocking of specialist/GPs to rural areas. Personally, I bet that the issues facing recruitment to rural areas are greater than those associated with net income. I say that because of the general ambitions of people who have gone through medical school, which don't really indicate that they would want to move to rural areas, especially once they're practicing, and the labor issue you mention. My gut says, if all payment was equal, you would find people moving to affluent suburbs or low-cost cities, and not rural areas. And your response to OO about Boerne makes me think you agree.

Off the cuff, the best solution would be to adjust Medicare reimbursement across the board for both cost of living AND desire of living (the hard to recruit/staff you mention), unless we're seeing an overabundance of urban healthcare providers. If that's the case, then the incentive structures are likely skewed too heavily for urban positions/specialties and doctors are actively being incentivized to move to urban areas.

Two answers.
First to the 'I seem to agree'. It's actually the exact opposite. My comment to OO was basically... he can travel the same distance and work with the same staff and see more patients for a higher reimbursement in a more urban/generally preferable setting... why wouldn't he? Even if the reimbursement were the same, he can see more patients in a larger and arguably nicer community... and thus make more money/amortize more quickly his investment in equipment. The only way it makes sense is if he gets paid the same, regardless of how many patients he sees. The problem with that is, why should he EVER see more than he has to?

To the overall question about whether Medicaid makes the problem worse...

They do. I don't know how else to tell you than to have two people who have both lived and worked in small town and big city healthcare management telling you the same thing. Let me give you a perfect example... Part of 'outcomes' is to have let's say, 60% of your enrolled members get a flu shot.... and let's say I'm currently at 40% overall. It is almost always more cost effective for me to go to a few, large providers than it is for me to go to a large number of small providers. That's just how it works. I can send a nurse to an office building in Houston and get 500 people 'free' flu shots, or I can drive to a small town business and get 5. That's not the best example because it's more complicated than that, but I think you may follow.

So the big city gets more per patient from CMS, they get more attention (money) for quality initiatives from CMS. Things that matter to urban areas like high costs of living are addressed, but things that matter to rural areas like lower quality of living are not. You're not even addressing the issues of specialty, which can again, increase the revenues in larger cities, but you can't get them to rural areas because they don't have enough potential patients.

I think your difference with RU is a distinction without a difference.

I think it pretty obvious that if RU gets paid 75 to work in Boerne, I get 100 to work in Pearland and you get $200 to be a specialist in Houston... with the same expectations of quality and outcomes, that I'm addressing the needs in the big city but exacerbating the problem of rural healthcare.

It's not just the COLA.

(08-17-2020 04:05 PM)Hambone10 Wrote:  

(08-17-2020 01:16 PM)RiceLad15 Wrote:  I don't think that some mail is pointless negates my overall point. Removing all of the junk mail like you advocate for (which is fine by me) still leaves us with the same issue for important mail like payments/invoices, government assistance, medication, etc. - rural areas are less dense, and therefore small margin services that rely on large volumes are less profitable/cost prohibitive.

In the end, your response isn't disagreeing with my point, but rather offering a potential solution (increasing fees for what would be identified as junk mail to offset the extra cost of providing what would be identified as essential mail to rural areas).

Or simply paying the 'prohibitive cost' to deliver 'essential' mail.

You're arguing to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them.

In 1950, it was important that people got every bit of mail. It's how people/families communicated. That's not the case today. Almost nobody communicates through letters today.

(08-15-2020 12:16 PM)RiceLad15 Wrote:  I think this is a good example of the difficulties of this medium for discussion. I didn't disagree with the options you outlined about how USPS could adjust its operation to adjust revenues to subsidize specific types of mail. Since I agreed, and the post was rather long, I only commented on the end statement about you rather subsidizing (more) internet in the country rather than mail delivery.

Yes... I want to use SOME of the money currently subsidizing rural mail delivery (that of unnecessary mail) and divert that to 'other' media delivery... same essential purpose.

(08-15-2020 12:30 PM)RiceLad15 Wrote:  I feel like I do understand the gist of what both of you are saying - but I disagree with the framing that RU took. I definitely learned some information on the details of Medicare reimbursement, but it still seems like my initial thoughts hold true. My comment wasn't that this wasn't a Medicare problem, but rather, it's not the problem RU was saying (as in, Medicare is subsidizing urban healthcare at the expense of rural healthcare). In short, it looks like Medicare addressed issues with urban healthcare (cost of living) but haven't addressed the lack of attractiveness for rural healthcare, and I don't think it's a 0 sum game.

The bolded section is why I say it sounds less like Medicare is making the problem worse, and more like it isn't addressing the issues of recruiting to a rural area. You even stated "The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills," which is exactly what I said to RU ("more like Medicare doesn't address this problem").

It's the P5 vs G5 issue, where Medicare isn't incentiving people to be in the G5. And since the original posit was that Medicare is subsidizing urban areas at the expense of rural areas, that question isn't meaningless.

We seem to be on the same page about that idea that, if we set all payment equal, we would not see a flocking of specialist/GPs to rural areas. Personally, I bet that the issues facing recruitment to rural areas are greater than those associated with net income. I say that because of the general ambitions of people who have gone through medical school, which don't really indicate that they would want to move to rural areas, especially once they're practicing, and the labor issue you mention. My gut says, if all payment was equal, you would find people moving to affluent suburbs or low-cost cities, and not rural areas. And your response to OO about Boerne makes me think you agree.

Off the cuff, the best solution would be to adjust Medicare reimbursement across the board for both cost of living AND desire of living (the hard to recruit/staff you mention), unless we're seeing an overabundance of urban healthcare providers. If that's the case, then the incentive structures are likely skewed too heavily for urban positions/specialties and doctors are actively being incentivized to move to urban areas.

Two answers.
First to the 'I seem to agree'. It's actually the exact opposite. My comment to OO was basically... he can travel the same distance and work with the same staff and see more patients for a higher reimbursement in a more urban/generally preferable setting... why wouldn't he? Even if the reimbursement were the same, he can see more patients in a larger and arguably nicer community... and thus make more money/amortize more quickly his investment in equipment. The only way it makes sense is if he gets paid the same, regardless of how many patients he sees. The problem with that is, why should he EVER see more than he has to?

To the overall question about whether Medicaid makes the problem worse...

They do. I don't know how else to tell you than to have two people who have both lived and worked in small town and big city healthcare management telling you the same thing. Let me give you a perfect example... Part of 'outcomes' is to have let's say, 60% of your enrolled members get a flu shot.... and let's say I'm currently at 40% overall. It is almost always more cost effective for me to go to a few, large providers than it is for me to go to a large number of small providers. That's just how it works. I can send a nurse to an office building in Houston and get 500 people 'free' flu shots, or I can drive to a small town business and get 5. That's not the best example because it's more complicated than that, but I think you may follow.

So the big city gets more per patient from CMS, they get more attention (money) for quality initiatives from CMS. Things that matter to urban areas like high costs of living are addressed, but things that matter to rural areas like lower quality of living are not. You're not even addressing the issues of specialty, which can again, increase the revenues in larger cities, but you can't get them to rural areas because they don't have enough potential patients.

I think your difference with RU is a distinction without a difference.

I think it pretty obvious that if RU gets paid 75 to work in Boerne, I get 100 to work in Pearland and you get $200 to be a specialist in Houston... with the same expectations of quality and outcomes, that I'm addressing the needs in the big city but exacerbating the problem of rural healthcare.

It's not just the COLA.

Pretty well said. Medicare is making the problem worse. And they are doing it in partnership with private companies.
Here is another example. Medicare has on occasion turned over their care of patients to private companies for care. Basically, Medicare pays a company to take care of patients in an HMO arrangement. All seniors pay their premiums to social security (which is the same for all seniors). Additionally, all wage earners pay a Medicare tax (which is the same for everyone). Medicare then takes the premiums (which are the same for everyone) received and pays it to an insurer to manage healthcare in a disproportionate manner (more goes to the population centers). In most cases, because of the increased volume and payout to larger centers, patients get more services for their premiums than rural locations get for paying the same amount. Therefore, Medicare in partnership with private companies is providing more services to metropolitan areas. It is a zero sum game because premiums and income is fixed and as such the money to pay out without running a deficit is fixed. Unfortunately, rural patients get less services yet pay in the same amount as the more populated areas.
This is exactly what we are saying would happen with the mail. Rural areas will get a baseline of service but less than a more densely populated area.

(08-17-2020 04:05 PM)Hambone10 Wrote:  

(08-17-2020 01:16 PM)RiceLad15 Wrote:  I don't think that some mail is pointless negates my overall point. Removing all of the junk mail like you advocate for (which is fine by me) still leaves us with the same issue for important mail like payments/invoices, government assistance, medication, etc. - rural areas are less dense, and therefore small margin services that rely on large volumes are less profitable/cost prohibitive.

In the end, your response isn't disagreeing with my point, but rather offering a potential solution (increasing fees for what would be identified as junk mail to offset the extra cost of providing what would be identified as essential mail to rural areas).

Or simply paying the 'prohibitive cost' to deliver 'essential' mail.

You're arguing to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them.

In 1950, it was important that people got every bit of mail. It's how people/families communicated. That's not the case today. Almost nobody communicates through letters today.

(08-15-2020 12:16 PM)RiceLad15 Wrote:  I think this is a good example of the difficulties of this medium for discussion. I didn't disagree with the options you outlined about how USPS could adjust its operation to adjust revenues to subsidize specific types of mail. Since I agreed, and the post was rather long, I only commented on the end statement about you rather subsidizing (more) internet in the country rather than mail delivery.

Yes... I want to use SOME of the money currently subsidizing rural mail delivery (that of unnecessary mail) and divert that to 'other' media delivery... same essential purpose.

(08-15-2020 12:30 PM)RiceLad15 Wrote:  I feel like I do understand the gist of what both of you are saying - but I disagree with the framing that RU took. I definitely learned some information on the details of Medicare reimbursement, but it still seems like my initial thoughts hold true. My comment wasn't that this wasn't a Medicare problem, but rather, it's not the problem RU was saying (as in, Medicare is subsidizing urban healthcare at the expense of rural healthcare). In short, it looks like Medicare addressed issues with urban healthcare (cost of living) but haven't addressed the lack of attractiveness for rural healthcare, and I don't think it's a 0 sum game.

The bolded section is why I say it sounds less like Medicare is making the problem worse, and more like it isn't addressing the issues of recruiting to a rural area. You even stated "The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills," which is exactly what I said to RU ("more like Medicare doesn't address this problem").

It's the P5 vs G5 issue, where Medicare isn't incentiving people to be in the G5. And since the original posit was that Medicare is subsidizing urban areas at the expense of rural areas, that question isn't meaningless.

We seem to be on the same page about that idea that, if we set all payment equal, we would not see a flocking of specialist/GPs to rural areas. Personally, I bet that the issues facing recruitment to rural areas are greater than those associated with net income. I say that because of the general ambitions of people who have gone through medical school, which don't really indicate that they would want to move to rural areas, especially once they're practicing, and the labor issue you mention. My gut says, if all payment was equal, you would find people moving to affluent suburbs or low-cost cities, and not rural areas. And your response to OO about Boerne makes me think you agree.

Off the cuff, the best solution would be to adjust Medicare reimbursement across the board for both cost of living AND desire of living (the hard to recruit/staff you mention), unless we're seeing an overabundance of urban healthcare providers. If that's the case, then the incentive structures are likely skewed too heavily for urban positions/specialties and doctors are actively being incentivized to move to urban areas.

Two answers.
First to the 'I seem to agree'. It's actually the exact opposite. My comment to OO was basically... he can travel the same distance and work with the same staff and see more patients for a higher reimbursement in a more urban/generally preferable setting... why wouldn't he? Even if the reimbursement were the same, he can see more patients in a larger and arguably nicer community... and thus make more money/amortize more quickly his investment in equipment. The only way it makes sense is if he gets paid the same, regardless of how many patients he sees. The problem with that is, why should he EVER see more than he has to?

To the overall question about whether Medicaid makes the problem worse...

They do. I don't know how else to tell you than to have two people who have both lived and worked in small town and big city healthcare management telling you the same thing. Let me give you a perfect example... Part of 'outcomes' is to have let's say, 60% of your enrolled members get a flu shot.... and let's say I'm currently at 40% overall. It is almost always more cost effective for me to go to a few, large providers than it is for me to go to a large number of small providers. That's just how it works. I can send a nurse to an office building in Houston and get 500 people 'free' flu shots, or I can drive to a small town business and get 5. That's not the best example because it's more complicated than that, but I think you may follow.

So the big city gets more per patient from CMS, they get more attention (money) for quality initiatives from CMS. Things that matter to urban areas like high costs of living are addressed, but things that matter to rural areas like lower quality of living are not. You're not even addressing the issues of specialty, which can again, increase the revenues in larger cities, but you can't get them to rural areas because they don't have enough potential patients.

I think your difference with RU is a distinction without a difference.

I think it pretty obvious that if RU gets paid 75 to work in Boerne, I get 100 to work in Pearland and you get $200 to be a specialist in Houston... with the same expectations of quality and outcomes, that I'm addressing the needs in the big city but exacerbating the problem of rural healthcare.

It's not just the COLA.

My issue with the assertion that Medicare makes the issue worse is that I don’t see it being better without Medicare. Are there any major private insurers that do a better job addressing rural needs than urban needs?

It seems like we are all in agreement on the issues that rural providers face, and that Medicare doesn’t address them.

(08-17-2020 04:40 PM)ruowls Wrote:  

(08-17-2020 04:05 PM)Hambone10 Wrote:  

(08-17-2020 01:16 PM)RiceLad15 Wrote:  I don't think that some mail is pointless negates my overall point. Removing all of the junk mail like you advocate for (which is fine by me) still leaves us with the same issue for important mail like payments/invoices, government assistance, medication, etc. - rural areas are less dense, and therefore small margin services that rely on large volumes are less profitable/cost prohibitive.

In the end, your response isn't disagreeing with my point, but rather offering a potential solution (increasing fees for what would be identified as junk mail to offset the extra cost of providing what would be identified as essential mail to rural areas).

Or simply paying the 'prohibitive cost' to deliver 'essential' mail.

You're arguing to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them.

In 1950, it was important that people got every bit of mail. It's how people/families communicated. That's not the case today. Almost nobody communicates through letters today.

(08-15-2020 12:16 PM)RiceLad15 Wrote:  I think this is a good example of the difficulties of this medium for discussion. I didn't disagree with the options you outlined about how USPS could adjust its operation to adjust revenues to subsidize specific types of mail. Since I agreed, and the post was rather long, I only commented on the end statement about you rather subsidizing (more) internet in the country rather than mail delivery.

Yes... I want to use SOME of the money currently subsidizing rural mail delivery (that of unnecessary mail) and divert that to 'other' media delivery... same essential purpose.

(08-15-2020 12:30 PM)RiceLad15 Wrote:  I feel like I do understand the gist of what both of you are saying - but I disagree with the framing that RU took. I definitely learned some information on the details of Medicare reimbursement, but it still seems like my initial thoughts hold true. My comment wasn't that this wasn't a Medicare problem, but rather, it's not the problem RU was saying (as in, Medicare is subsidizing urban healthcare at the expense of rural healthcare). In short, it looks like Medicare addressed issues with urban healthcare (cost of living) but haven't addressed the lack of attractiveness for rural healthcare, and I don't think it's a 0 sum game.

The bolded section is why I say it sounds less like Medicare is making the problem worse, and more like it isn't addressing the issues of recruiting to a rural area. You even stated "The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills," which is exactly what I said to RU ("more like Medicare doesn't address this problem").

It's the P5 vs G5 issue, where Medicare isn't incentiving people to be in the G5. And since the original posit was that Medicare is subsidizing urban areas at the expense of rural areas, that question isn't meaningless.

We seem to be on the same page about that idea that, if we set all payment equal, we would not see a flocking of specialist/GPs to rural areas. Personally, I bet that the issues facing recruitment to rural areas are greater than those associated with net income. I say that because of the general ambitions of people who have gone through medical school, which don't really indicate that they would want to move to rural areas, especially once they're practicing, and the labor issue you mention. My gut says, if all payment was equal, you would find people moving to affluent suburbs or low-cost cities, and not rural areas. And your response to OO about Boerne makes me think you agree.

Off the cuff, the best solution would be to adjust Medicare reimbursement across the board for both cost of living AND desire of living (the hard to recruit/staff you mention), unless we're seeing an overabundance of urban healthcare providers. If that's the case, then the incentive structures are likely skewed too heavily for urban positions/specialties and doctors are actively being incentivized to move to urban areas.

Two answers.
First to the 'I seem to agree'. It's actually the exact opposite. My comment to OO was basically... he can travel the same distance and work with the same staff and see more patients for a higher reimbursement in a more urban/generally preferable setting... why wouldn't he? Even if the reimbursement were the same, he can see more patients in a larger and arguably nicer community... and thus make more money/amortize more quickly his investment in equipment. The only way it makes sense is if he gets paid the same, regardless of how many patients he sees. The problem with that is, why should he EVER see more than he has to?

To the overall question about whether Medicaid makes the problem worse...

They do. I don't know how else to tell you than to have two people who have both lived and worked in small town and big city healthcare management telling you the same thing. Let me give you a perfect example... Part of 'outcomes' is to have let's say, 60% of your enrolled members get a flu shot.... and let's say I'm currently at 40% overall. It is almost always more cost effective for me to go to a few, large providers than it is for me to go to a large number of small providers. That's just how it works. I can send a nurse to an office building in Houston and get 500 people 'free' flu shots, or I can drive to a small town business and get 5. That's not the best example because it's more complicated than that, but I think you may follow.

So the big city gets more per patient from CMS, they get more attention (money) for quality initiatives from CMS. Things that matter to urban areas like high costs of living are addressed, but things that matter to rural areas like lower quality of living are not. You're not even addressing the issues of specialty, which can again, increase the revenues in larger cities, but you can't get them to rural areas because they don't have enough potential patients.

I think your difference with RU is a distinction without a difference.

I think it pretty obvious that if RU gets paid 75 to work in Boerne, I get 100 to work in Pearland and you get $200 to be a specialist in Houston... with the same expectations of quality and outcomes, that I'm addressing the needs in the big city but exacerbating the problem of rural healthcare.

It's not just the COLA.

Pretty well said. Medicare is making the problem worse. And they are doing it in partnership with private companies.
Here is another example. Medicare has on occasion turned over their care of patients to private companies for care. Basically, Medicare pays a company to take care of patients in an HMO arrangement. All seniors pay their premiums to social security (which is the same for all seniors). Additionally, all wage earners pay a Medicare tax (which is the same for everyone). Medicare then takes the premiums (which are the same for everyone) received and pays it to an insurer to manage healthcare in a disproportionate manner (more goes to the population centers). In most cases, because of the increased volume and payout to larger centers, patients get more services for their premiums than rural locations get for paying the same amount. Therefore, Medicare in partnership with private companies is providing more services to metropolitan areas. It is a zero sum game because premiums and income is fixed and as such the money to pay out without running a deficit is fixed. Unfortunately, rural patients get less services yet pay in the same amount as the more populated areas.
This is exactly what we are saying would happen with the mail. Rural areas will get a baseline of service but less than a more densely populated area.

And similar to what I just posted, how is a private service going to fix it? That’s the proposed solution that I’m arguing against with regards to USPS.

One benefit of government services is that they are able to go against market demands, right? They are more easily able to act in an interest that isn’t focused primarily on profit generation

Edit: one question about the item above. When you say Medicare takes premiums and pays it to a manager in a disproportionate manner, with more going to a larger population center, are you saying that it’s not just larger than the smaller population center, but that if the larger population center has 70% of the volume of healthcare, it is receiving >70% of the premiums?

And maybe this needs to be said again, but the premise that started this was that the USPS should be dissolved (see privatized, there is not functional difference when talking about a gov’t service) and I disagreed with that notion and offered a potential alternative.

So I’m not arguing that USPS or Medicare is perfect and without fault, but that both of them serve a purpose. Reforming them to address faults is A-OK, but I received pushback when advocating for NOT dissolving the USPS.

(08-17-2020 05:27 PM)RiceLad15 Wrote:  

(08-17-2020 04:40 PM)ruowls Wrote:  

(08-17-2020 04:05 PM)Hambone10 Wrote:  

(08-17-2020 01:16 PM)RiceLad15 Wrote:  I don't think that some mail is pointless negates my overall point. Removing all of the junk mail like you advocate for (which is fine by me) still leaves us with the same issue for important mail like payments/invoices, government assistance, medication, etc. - rural areas are less dense, and therefore small margin services that rely on large volumes are less profitable/cost prohibitive.

In the end, your response isn't disagreeing with my point, but rather offering a potential solution (increasing fees for what would be identified as junk mail to offset the extra cost of providing what would be identified as essential mail to rural areas).

Or simply paying the 'prohibitive cost' to deliver 'essential' mail.

You're arguing to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them.

In 1950, it was important that people got every bit of mail. It's how people/families communicated. That's not the case today. Almost nobody communicates through letters today.

(08-15-2020 12:16 PM)RiceLad15 Wrote:  I think this is a good example of the difficulties of this medium for discussion. I didn't disagree with the options you outlined about how USPS could adjust its operation to adjust revenues to subsidize specific types of mail. Since I agreed, and the post was rather long, I only commented on the end statement about you rather subsidizing (more) internet in the country rather than mail delivery.

Yes... I want to use SOME of the money currently subsidizing rural mail delivery (that of unnecessary mail) and divert that to 'other' media delivery... same essential purpose.

(08-15-2020 12:30 PM)RiceLad15 Wrote:  I feel like I do understand the gist of what both of you are saying - but I disagree with the framing that RU took. I definitely learned some information on the details of Medicare reimbursement, but it still seems like my initial thoughts hold true. My comment wasn't that this wasn't a Medicare problem, but rather, it's not the problem RU was saying (as in, Medicare is subsidizing urban healthcare at the expense of rural healthcare). In short, it looks like Medicare addressed issues with urban healthcare (cost of living) but haven't addressed the lack of attractiveness for rural healthcare, and I don't think it's a 0 sum game.

The bolded section is why I say it sounds less like Medicare is making the problem worse, and more like it isn't addressing the issues of recruiting to a rural area. You even stated "The question is, do they do anything to 'equalize' the desire for Ben Stone to be a GP in Grady as opposed to being a plastic surgeon in Beverly Hills," which is exactly what I said to RU ("more like Medicare doesn't address this problem").

It's the P5 vs G5 issue, where Medicare isn't incentiving people to be in the G5. And since the original posit was that Medicare is subsidizing urban areas at the expense of rural areas, that question isn't meaningless.

We seem to be on the same page about that idea that, if we set all payment equal, we would not see a flocking of specialist/GPs to rural areas. Personally, I bet that the issues facing recruitment to rural areas are greater than those associated with net income. I say that because of the general ambitions of people who have gone through medical school, which don't really indicate that they would want to move to rural areas, especially once they're practicing, and the labor issue you mention. My gut says, if all payment was equal, you would find people moving to affluent suburbs or low-cost cities, and not rural areas. And your response to OO about Boerne makes me think you agree.

Off the cuff, the best solution would be to adjust Medicare reimbursement across the board for both cost of living AND desire of living (the hard to recruit/staff you mention), unless we're seeing an overabundance of urban healthcare providers. If that's the case, then the incentive structures are likely skewed too heavily for urban positions/specialties and doctors are actively being incentivized to move to urban areas.

Two answers.
First to the 'I seem to agree'. It's actually the exact opposite. My comment to OO was basically... he can travel the same distance and work with the same staff and see more patients for a higher reimbursement in a more urban/generally preferable setting... why wouldn't he? Even if the reimbursement were the same, he can see more patients in a larger and arguably nicer community... and thus make more money/amortize more quickly his investment in equipment. The only way it makes sense is if he gets paid the same, regardless of how many patients he sees. The problem with that is, why should he EVER see more than he has to?

To the overall question about whether Medicaid makes the problem worse...

They do. I don't know how else to tell you than to have two people who have both lived and worked in small town and big city healthcare management telling you the same thing. Let me give you a perfect example... Part of 'outcomes' is to have let's say, 60% of your enrolled members get a flu shot.... and let's say I'm currently at 40% overall. It is almost always more cost effective for me to go to a few, large providers than it is for me to go to a large number of small providers. That's just how it works. I can send a nurse to an office building in Houston and get 500 people 'free' flu shots, or I can drive to a small town business and get 5. That's not the best example because it's more complicated than that, but I think you may follow.

So the big city gets more per patient from CMS, they get more attention (money) for quality initiatives from CMS. Things that matter to urban areas like high costs of living are addressed, but things that matter to rural areas like lower quality of living are not. You're not even addressing the issues of specialty, which can again, increase the revenues in larger cities, but you can't get them to rural areas because they don't have enough potential patients.

I think your difference with RU is a distinction without a difference.

I think it pretty obvious that if RU gets paid 75 to work in Boerne, I get 100 to work in Pearland and you get $200 to be a specialist in Houston... with the same expectations of quality and outcomes, that I'm addressing the needs in the big city but exacerbating the problem of rural healthcare.

It's not just the COLA.

Pretty well said. Medicare is making the problem worse. And they are doing it in partnership with private companies.
Here is another example. Medicare has on occasion turned over their care of patients to private companies for care. Basically, Medicare pays a company to take care of patients in an HMO arrangement. All seniors pay their premiums to social security (which is the same for all seniors). Additionally, all wage earners pay a Medicare tax (which is the same for everyone). Medicare then takes the premiums (which are the same for everyone) received and pays it to an insurer to manage healthcare in a disproportionate manner (more goes to the population centers). In most cases, because of the increased volume and payout to larger centers, patients get more services for their premiums than rural locations get for paying the same amount. Therefore, Medicare in partnership with private companies is providing more services to metropolitan areas. It is a zero sum game because premiums and income is fixed and as such the money to pay out without running a deficit is fixed. Unfortunately, rural patients get less services yet pay in the same amount as the more populated areas.
This is exactly what we are saying would happen with the mail. Rural areas will get a baseline of service but less than a more densely populated area.

And similar to what I just posted, how is a private service going to fix it? That’s the proposed solution that I’m arguing against with regards to USPS.

One benefit of government services is that they are able to go against market demands, right? They are more easily able to act in an interest that isn’t focused primarily on profit generation

Edit: one question about the item above. When you say Medicare takes premiums and pays it to a manager in a disproportionate manner, with more going to a larger population center, are you saying that it’s not just larger than the smaller population center, but that if the larger population center has 70% of the volume of healthcare, it is receiving >70% of the premiums?

Private insurance won't fix it.

Let me see if I can say this well to the bolded above. Yes.
There is a cost of providing care to each member per month. This cost is based on the entire population. So, in essence, the "risk" of cost is shared equally among all members. And since the premiums are equal, the care should be equal. However, the cost isn't equal due to volumes and efficiency. It is easier to fully book providers, labs, imaging machines and ancillary services in a denser population which makes them more efficient and decreases the cost per member per month. This makes the cost of care less per member because the cost is fully shared in this subpopulation. So, there is an inherent advantage to receiving care in urban centers. And this advantage isn't put back into ensuring the same level of care in rural areas but put into increasing services to the urban centers to further increase volume by providing them more "perks". This leads to more benefits to urban populations for the same premium while increasing profits to the "haves" and further marginalizing the "have nots" (the P5 to G5 analogy .

(08-17-2020 05:24 PM)RiceLad15 Wrote:  My issue with the assertion that Medicare makes the issue worse is that I don’t see it being better without Medicare. Are there any major private insurers that do a better job addressing rural needs than urban needs?

It seems like we are all in agreement on the issues that rural providers face, and that Medicare doesn’t address them.

'Medicare making it worse' and 'abolishing Medicare' are not polar opposites. More on this later.

(08-17-2020 05:46 PM)RiceLad15 Wrote:  And maybe this needs to be said again, but the premise that started this was that the USPS should be dissolved (see privatized, there is not functional difference when talking about a gov’t service) and I disagreed with that notion and offered a potential alternative.

So I’m not arguing that USPS or Medicare is perfect and without fault, but that both of them serve a purpose. Reforming them to address faults is A-OK, but I received pushback when advocating for NOT dissolving the USPS.

I certainly didn't suggest that USPS be dissolved, nor did I suggest that Medicare be dissolved.

I suggested that the government pay (either directly for the specific mailers or by paying pennies more for every item) the actual cost of 'important' rural delivery. That they by whatever means they feel sells best to voters, pay the actual cost of delivering healthcare, just like important mail, to rural America.

Said differently... and using a simple example... it's more complex than this...

If an urban imaging center can do 10,000 images a year with one machine... which works out to say $20 per image based on a $200,000 annual cost of that machine... and a rural imaging center can only do 1,000 images a year with that same machine... that the government pay $200 per image in rural America to cover the cost of the machine so that rural centers aren't still using 20yr old equipment because they still owe for it, and now getting even lower reimbursement because it isn't 'state of the art' while big cities are on the 3rd advancement. That, or allow rural centers to use older equipment without penalty depending on what we're talking about. I know its not a great example, but the concept should make sense.

If you're going to require the same output, then you need to cover the cost of the same inputs. Maybe rural care can use the lower volume model 100 rather than the high volume model 200, but the cost isn't 1/10th like the usage might be.

Again, just like in the post office, that the government pay what it actually costs to deliver the care that it demands be delivered.

I think the government has 'over' supported rural delivery of non-essential mail... and neglected to support rural delivery of essential healthcare.... mostly because 'mail' isn't a big voting cry, but healthcare is

As RU alluded to, it should tell you something that those greedy private insurance companies (not that you say this, but that is the meme) can take NOMINAL Medicare premiums for patients in bigger cities (which is less than Medicare took in for that person) and pay the doctors the same and sometimes more.... and ALSO deliver more care (Medicare Advantage plans) like vision or pharmacy, plus they often have caps on the OOP max while Medicare does not. The old lines about them denying care to earn their money is categorically false because they are required to cover AT LEAST what Medicare does. They are ALLOWED to cover more.


Medicare advantage plans are a perfect example of how 'managed care' can deliver more care at a lower cost.... and if Medicare addresses the problems of rural care, private insurance will follow if they can do a better job or disappear if they can't.

Ham, it sounds to me that we are on a much more similar page than you might think, as I'm likely much less wedded to specifics than you might think.

Let's focus on the big picture items, as I think the general agreement becomes lost in the weeds, and each of us may read too much into some comments.

1) We both don't think USPS should be completely privatized (i.e. abolished).

- I originally pushed back on the big picture idea that USPS should be privatized that Owl#s posted in post #6. I pointed out a problem with that move (rural mail delivery) and offered one potential alternative to the current model. But I've never argued "to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them," as you suggest in post #44. I either discussed adjusting the USPS operating model (public/private), agreed with OO that rural mail could potentially rely on a rural hub model, or agreed with your idea on adjusting what type of mail USPS subsidizes.

2) We both don't think privatization of Medicare will fix the rural health issue.

- This is where I still maintain that mail delivery and healthcare delivery to rural areas are similar in the grand scheme of things. In both instances, a lack of government action would likely result in services either being cost prohibitive for users or a lack of access to the service.

3) The current execution of Medicare does not adequately address the issue of providing healthcare to rural populations.

- My comments about Medicare making this worse are in comparison to a world without Medicare, and I think yours are in comparison to an alternative approach. If that's correct, then I can agree with the statement that Medicare makes the situation worse.

(08-18-2020 07:42 AM)RiceLad15 Wrote:  Ham, it sounds to me that we are on a much more similar page than you might think, as I'm likely much less wedded to specifics than you might think.

I don't disagree... but the way you phrase it versus the way we phrase it can lead to people who don't care enough to learn or know (unlike you) to believe that M4A means equality. It doesn't. It can't.... and to the limited extent that it can, it is a massive pile of money driven by politicians who are driven by voters which strongly favors larger areas.

I was watching Biden's commercial about COVID and at the end, he says... we need one single solution for everyone as a solution to the problem... and that is exactly the WRONG thing. M4A or any other Federal program simply can't account fairly for all of the variables in healthcare, mostly costs.

Quote:Let's focus on the big picture items, as I think the general agreement becomes lost in the weeds, and each of us may read too much into some comments.

1) We both don't think USPS should be completely privatized (i.e. abolished).

- I originally pushed back on the big picture idea that USPS should be privatized that Owl#s posted in post #6. I pointed out a problem with that move (rural mail delivery) and offered one potential alternative to the current model. But I've never argued "to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them," as you suggest in post #44. I either discussed adjusting the USPS operating model (public/private), agreed with OO that rural mail could potentially rely on a rural hub model, or agreed with your idea on adjusting what type of mail USPS subsidizes.

I didn't say you suggested this. I said this is what is happening. Because it costs the same amount to send a letter to Hawaii or Alaska (a simple example of an expensive delivery) as it does to send a letter down the street... the cost to deliver the letter down the street is subsidizing the letter sent by plane. Similarly, once you've decided that you need a post office in 'nowhere USA', there are fixed costs that like hospital equipment, cost the same in both places but get different levels of use. I don't know the exact setup for package pricing, but obviously there is more competition for packages than for letters.

Quote:2) We both don't think privatization of Medicare will fix the rural health issue.

- This is where I still maintain that mail delivery and healthcare delivery to rural areas are similar in the grand scheme of things. In both instances, a lack of government action would likely result in services either being cost prohibitive for users or a lack of access to the service.

Did someone suggest privatizing medicare?

Similar in some of the issues which is why I mentioned it, but completely different in how we're addressing it.
Said simply, The government subsidizes letters to small towns which cover some of the same costs for packages. Packages are priced 'per mile', but there is competition to keep them reasonable. It says something to me that revenues for package shipping companies are rising consistently while revenues for USPS are flat.

Quote:3) The current execution of Medicare does not adequately address the issue of providing healthcare to rural populations.

- My comments about Medicare making this worse are in comparison to a world without Medicare, and I think yours are in comparison to an alternative approach. If that's correct, then I can agree with the statement that Medicare makes the situation worse.

yes... they take an existing issue and make it worse. They could make it better. Since I don't remember anyone suggesting we eliminate Medicare, that's not in the equation.

(08-18-2020 10:26 AM)Hambone10 Wrote:  

(08-18-2020 07:42 AM)RiceLad15 Wrote:  Ham, it sounds to me that we are on a much more similar page than you might think, as I'm likely much less wedded to specifics than you might think.

I don't disagree... but the way you phrase it versus the way we phrase it can lead to people who don't care enough to learn or know (unlike you) to believe that M4A means equality. It doesn't. It can't.... and to the limited extent that it can, it is a massive pile of money driven by politicians who are driven by voters which strongly favors larger areas.

I was watching Biden's commercial about COVID and at the end, he says... we need one single solution for everyone as a solution to the problem... and that is exactly the WRONG thing. M4A or any other Federal program simply can't account fairly for all of the variables in healthcare, mostly costs.

Quote:Let's focus on the big picture items, as I think the general agreement becomes lost in the weeds, and each of us may read too much into some comments.

1) We both don't think USPS should be completely privatized (i.e. abolished).

- I originally pushed back on the big picture idea that USPS should be privatized that Owl#s posted in post #6. I pointed out a problem with that move (rural mail delivery) and offered one potential alternative to the current model. But I've never argued "to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them," as you suggest in post #44. I either discussed adjusting the USPS operating model (public/private), agreed with OO that rural mail could potentially rely on a rural hub model, or agreed with your idea on adjusting what type of mail USPS subsidizes.

I didn't say you suggested this. I said this is what is happening. Because it costs the same amount to send a letter to Hawaii or Alaska (a simple example of an expensive delivery) as it does to send a letter down the street... the cost to deliver the letter down the street is subsidizing the letter sent by plane. Similarly, once you've decided that you need a post office in 'nowhere USA', there are fixed costs that like hospital equipment, cost the same in both places but get different levels of use. I don't know the exact setup for package pricing, but obviously there is more competition for packages than for letters.

Quote:2) We both don't think privatization of Medicare will fix the rural health issue.

- This is where I still maintain that mail delivery and healthcare delivery to rural areas are similar in the grand scheme of things. In both instances, a lack of government action would likely result in services either being cost prohibitive for users or a lack of access to the service.

Did someone suggest privatizing medicare?

Similar in some of the issues which is why I mentioned it, but completely different in how we're addressing it.
Said simply, The government subsidizes letters to small towns which cover some of the same costs for packages. Packages are priced 'per mile', but there is competition to keep them reasonable. It says something to me that revenues for package shipping companies are rising consistently while revenues for USPS are flat.

Quote:3) The current execution of Medicare does not adequately address the issue of providing healthcare to rural populations.

- My comments about Medicare making this worse are in comparison to a world without Medicare, and I think yours are in comparison to an alternative approach. If that's correct, then I can agree with the statement that Medicare makes the situation worse.

yes... they take an existing issue and make it worse. They could make it better. Since I don't remember anyone suggesting we eliminate Medicare, that's not in the equation.

To the bolded, you may want to read Post #44 again...

"You're arguing to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them."

You're right that no one outright suggested privatizing Medicare, but since the conversation started with the discussion of privatizing the USPS, I assumed we were all on the same page about that as the starting point, which was about privatizing X government service.

It seems like we're actually on the same page about keeping X government service, but addressing the specific failings (i.e. not throwing out the baby with the bath water). Right?

Question for both of you:

In a capitalistic society, would not the abolishment of the USPS create a vacuum that providers would step up to fill, and competition to keep rates reasonable?

I am thinking of the emergence of FedEx and UPS as alternatives to what used to be a USPS monopoly. There was a reason that happened - $$$$.

(08-18-2020 10:48 AM)OptimisticOwl Wrote:  Question for both of you:

In a capitalistic society, would not the abolishment of the USPS create a vacuum that providers would step up to fill, and competition to keep rates reasonable?

I am thinking of the emergence of FedEx and UPS as alternatives to what used to be a USPS monopoly. There was a reason that happened - $$$$.

Yes, someone would step in to the fill the void (technically FedEx and UPS already operate in the space as they ship letters, but I am almost positive they make the $$$$ on package and large parcel shipping).

The issue I have is that it is likely that costs would be significantly higher than what they are now for mail delivery for specific parts of the country (namely rural areas). To me, it makes sense that the government provide a basic mail service to all of its citizens at a reasonable and affordable price.

If private industry would be able to operate in the space and provide the same service for a similar price, then that's a whole other ball game.

The way that private industry is making inroads to rural mail service now is privately rented mailboxes - Pack n' Mail, Mailboxes, Etc., those kinds of places. I would just expect an expansion of services to fill need.

But the need is getting less and less. I go lots of days with no significant mail. I would not miss the ads for oil changes and fast food deals that are the bulk of my mail now. I don't need those delivered to my door. I don't need those anywhere.

My SS is on direct deposit, as are my tax refunds. A lot of services are on direct payment, either directly from my bank account or on a credit card.

I guess in the 30's, there was a need for direct delivery - twice a day.

Not so much now.

I do not extend this attitude toward medical care.

(08-18-2020 11:30 AM)OptimisticOwl Wrote:  The way that private industry is making inroads to rural mail service now is privately rented mailboxes - Pack n' Mail, Mailboxes, Etc., those kinds of places. I would just expect an expansion of services to fill need.

But the need is getting less and less. I go lots of days with no significant mail. I would not miss the ads for oil changes and fast food deals that are the bulk of my mail now. I don't need those delivered to my door. I don't need those anywhere.

My SS is on direct deposit, as are my tax refunds. A lot of services are on direct payment, either directly from my bank account or on a credit card.

I guess in the 30's, there was a need for direct delivery - twice a day.

Not so much now.

I do not extend this attitude toward medical care.

We're still not at a point where broadband and computer penetration is complete enough to assume everyone manage their finances remotely/electronically. Internet penetration rate is only 87% (as of 2017), which leaves >40 MM people without the ability to manage finances electronically. I could see this eventually going the way of the dinosaur, but we're not quite there yet (maybe in 15 years or sooner with a concerted push).

I was also going to make a point about the frequency of mail in rural areas changing, and I realized two things. I assume the frequency of important letter sized mail has decreased, but I really don't know how much change there has been for small packages that USPS handles regularly - I can easily see those having sky rocketed and people relying more heavily on mail delivery. And even if small parcel delivery has increased, do we think that the volume has increased sufficiently to make it a profitable venture across the country?

(08-18-2020 12:04 PM)RiceLad15 Wrote:  

(08-18-2020 11:30 AM)OptimisticOwl Wrote:  The way that private industry is making inroads to rural mail service now is privately rented mailboxes - Pack n' Mail, Mailboxes, Etc., those kinds of places. I would just expect an expansion of services to fill need.

But the need is getting less and less. I go lots of days with no significant mail. I would not miss the ads for oil changes and fast food deals that are the bulk of my mail now. I don't need those delivered to my door. I don't need those anywhere.

My SS is on direct deposit, as are my tax refunds. A lot of services are on direct payment, either directly from my bank account or on a credit card.

I guess in the 30's, there was a need for direct delivery - twice a day.

Not so much now.

I do not extend this attitude toward medical care.

We're still not at a point where broadband and computer penetration is complete enough to assume everyone manage their finances remotely/electronically. Internet penetration rate is only 87% (as of 2017), which leaves >40 MM people without the ability to manage finances electronically. I could see this eventually going the way of the dinosaur, but we're not quite there yet (maybe in 15 years or sooner with a concerted push).

I was also going to make a point about the frequency of mail in rural areas changing, and I realized two things. I assume the frequency of important letter sized mail has decreased, but I really don't know how much change there has been for small packages that USPS handles regularly - I can easily see those having sky rocketed and people relying more heavily on mail delivery. And even if small parcel delivery has increased, do we think that the volume has increased sufficiently to make it a profitable venture across the country?

Just brought in the two pieces the USPS delivered to me today: A direct mail solicitation from an auto dealer I have never done business with and a Valpak of coupons. I took the last leg of delivery myself, straight into the trash.

If there is a need, it will be filled under the capitalist system. I think the idea of the Postal Service is getting outmoded

(08-18-2020 01:28 PM)OptimisticOwl Wrote:  

(08-18-2020 12:04 PM)RiceLad15 Wrote:  

(08-18-2020 11:30 AM)OptimisticOwl Wrote:  The way that private industry is making inroads to rural mail service now is privately rented mailboxes - Pack n' Mail, Mailboxes, Etc., those kinds of places. I would just expect an expansion of services to fill need.

But the need is getting less and less. I go lots of days with no significant mail. I would not miss the ads for oil changes and fast food deals that are the bulk of my mail now. I don't need those delivered to my door. I don't need those anywhere.

My SS is on direct deposit, as are my tax refunds. A lot of services are on direct payment, either directly from my bank account or on a credit card.

I guess in the 30's, there was a need for direct delivery - twice a day.

Not so much now.

I do not extend this attitude toward medical care.

We're still not at a point where broadband and computer penetration is complete enough to assume everyone manage their finances remotely/electronically. Internet penetration rate is only 87% (as of 2017), which leaves >40 MM people without the ability to manage finances electronically. I could see this eventually going the way of the dinosaur, but we're not quite there yet (maybe in 15 years or sooner with a concerted push).

I was also going to make a point about the frequency of mail in rural areas changing, and I realized two things. I assume the frequency of important letter sized mail has decreased, but I really don't know how much change there has been for small packages that USPS handles regularly - I can easily see those having sky rocketed and people relying more heavily on mail delivery. And even if small parcel delivery has increased, do we think that the volume has increased sufficiently to make it a profitable venture across the country?

Just brought in the two pieces the USPS delivered to me today: A direct mail solicitation from an auto dealer I have never done business with and a Valpak of coupons. I took the last leg of delivery myself, straight into the trash.

If there is a need, it will be filled under the capitalist system. I think the idea of the Postal Service is getting outmoded

Is your view that capitalism, without any government intervention, will cure and fill all needs?

And before anyone jumps the gun, my personal view is that capitalism is undoubtedly the best economic model we've found to date. But it's clear to me that there are inefficiencies in capitalism that need to be addressed by government intervention. So the question is how to balance those two items.

(08-18-2020 10:39 AM)RiceLad15 Wrote:  To the bolded, you may want to read Post #44 again...

"You're arguing to subsidize an entire industry (mail delivery to rural areas) in order to make sure that only SOME mail (mostly government mail) gets to them."

You're right that no one outright suggested privatizing Medicare, but since the conversation started with the discussion of privatizing the USPS, I assumed we were all on the same page about that as the starting point, which was about privatizing X government service.

It seems like we're actually on the same page about keeping X government service, but addressing the specific failings (i.e. not throwing out the baby with the bath water). Right?

Let's start with the important comment which is the last....

Yes.

As to the first part, you're mixing comments. I guess that's the problem of me responding to a paragraph of possible choices without being more clear about which portion I'm responding to. Mea Culpa.

You admit that you pushed back on privatizing USPS because of the issues for rural delivery.... That supports the status quo, which IMO made sense in 1950 but is a broken and horrible model in 2020. My response in 44 was to what i was 'hearing'... your pushback.

It probably stems more from the idea in my head that it's easy to say 'that won't work'... but if you agree that something is a problem, the very next word shouldn't be to defend why we did something in 1950, but ask what we should do to fix it in 2020. This isn't a question of Privatizing or not.... In the same vein as many other agencies, it is private... but it's still being run like government. I never suggested that you were against privatizing. I suggested that you were pushing back against change.

(08-18-2020 11:17 AM)RiceLad15 Wrote:  

(08-18-2020 10:48 AM)OptimisticOwl Wrote:  Question for both of you:

In a capitalistic society, would not the abolishment of the USPS create a vacuum that providers would step up to fill, and competition to keep rates reasonable?

I am thinking of the emergence of FedEx and UPS as alternatives to what used to be a USPS monopoly. There was a reason that happened - $$$$.

Yes, someone would step in to the fill the void (technically FedEx and UPS already operate in the space as they ship letters, but I am almost positive they make the $$$$ on package and large parcel shipping).

The issue I have is that it is likely that costs would be significantly higher than what they are now for mail delivery for specific parts of the country (namely rural areas). To me, it makes sense that the government provide a basic mail service to all of its citizens at a reasonable and affordable price.

If private industry would be able to operate in the space and provide the same service for a similar price, then that's a whole other ball game.

I don't think fed-ex delivers anything for 50 cents or whatever a stamp is these days.... Which tells you something, that I don't even know how much a stamp costs. Last I really remember (when they printed it on the stamp) it was 39 cents, but I know it's gone up numerous times since then.

My point is that USPS doesn't deliver that letter to Alaska for 50 cents. They deliver that letter for $10 or whatever it costs... and then they make up for it by charging 50 cents for other deliveries that actually cost less than that. That's what business does sometimes.

By virtue of the fact that UPS and others don't deliver letters anywhere for 50 cents, it may mean that every single letter, even the 50 cent one down the street is being subsidized.... which is only worse.

My OTHER point is that if the government really feels it needs to provide this service that costs $10 (USPS would do it for 10, UPS for 11, Fed Ex for 20 and Joe's rural delivery for $10.50) then they should simply pay that rate. I have a bit of a problem when the government essentially imposes a hidden additional 'use' tax by having USPS engage in 'wealth transfer' on their behalf... Especially in this instance where the people often being subsidized are solicitors and not 'essential services'. If the government purely focused on some list of necessary items... checks, government communications, prescriptions etc... and not on making sure that Bugtussle Ga had a post office... I believe the subsidy would be less, and people who didn't fall into that list would pay more if they wanted to solicit 'the country'. In that vein, I'd include properly registered political groups as qualifying so that such outreach were 'fair'... but this would cut down on random solicitations to those who are most often at risk of fraud.

(08-18-2020 12:04 PM)RiceLad15 Wrote:  

(08-18-2020 11:30 AM)OptimisticOwl Wrote:  The way that private industry is making inroads to rural mail service now is privately rented mailboxes - Pack n' Mail, Mailboxes, Etc., those kinds of places. I would just expect an expansion of services to fill need.

But the need is getting less and less. I go lots of days with no significant mail. I would not miss the ads for oil changes and fast food deals that are the bulk of my mail now. I don't need those delivered to my door. I don't need those anywhere.

My SS is on direct deposit, as are my tax refunds. A lot of services are on direct payment, either directly from my bank account or on a credit card.

I guess in the 30's, there was a need for direct delivery - twice a day.

Not so much now.

I do not extend this attitude toward medical care.

We're still not at a point where broadband and computer penetration is complete enough to assume everyone manage their finances remotely/electronically. Internet penetration rate is only 87% (as of 2017), which leaves >40 MM people without the ability to manage finances electronically. I could see this eventually going the way of the dinosaur, but we're not quite there yet (maybe in 15 years or sooner with a concerted push).

I was also going to make a point about the frequency of mail in rural areas changing, and I realized two things. I assume the frequency of important letter sized mail has decreased, but I really don't know how much change there has been for small packages that USPS handles regularly - I can easily see those having sky rocketed and people relying more heavily on mail delivery. And even if small parcel delivery has increased, do we think that the volume has increased sufficiently to make it a profitable venture across the country?

This link suggests the number is much lower than that... and the amount of broadband necessary to access a bank account is likely lower than these thresholds (cell phone towers). This is why I suggested even more support for rural services. A cell tower would be much cheaper than a post office.

I'd also note that some portion of the estimated 6% included here are the same people who choose not to have IDs or use banks. They either don't have/can't get an ID thus can't legally open a bank account... or they are 'off the gridders' who choose not to participate.

https://www.fcc.gov/reports-research/rep...rding%20to