I used to be disgusted, and now I try to be amused.

[sebastian_dangerfield]

Originally Posted by Adder

Except that this isn't really true: "If we simply fall back on our standard numbers, we lose."

This election was decided by a combined 70k or so votes in Wisconsin, Michigan and North Carolina, all states with new voting restrictions. Which means, very small amounts of voter suppression likely made the difference in this election.

We can respond to that by emulating Trump or by trying to get slightly better turnout in the cities in these states next time around (among other options). I know which I prefer.

And the fact of the matter is we do have an answer for these people: move.

"Move" isn't the only answer. There is an alternative. But it's anathema to most conventional thinking (in fact, I kind of recoil at at it a bit).

Here it is: Re-Ruralization.

The problem with a lot of rural economies is they are still connected to the broader state and national communities around them. The little guys in town have nothing to do because they work against outside competitors with far superior economies of scale. The small construction company loses bids for local projects to the statewide firm, mom and pop shops lose out to Wal Mart, the local inns are wiped out by the Holiday Inn Express franchise down the street. The local doctor can't compete with the emergency care clinic in the national drug store or owned by the statewide health care network.

At every level, in every industry, someone delivering at a cheaper price beats the local operator.

You can't fight internet competition. Amazon is going to bury all the mom and pop retailers inevitably, and it'll probably also bury Wal Mart over the long term. But as to services which can be provided locally, perhaps we can allow these communities to cut themselves off from the rest of us. Allow some protectionism that immunizes them from competition with the national and statewide goods and service providers who wipe out local concerns.

Effectively, we allow these Oxycontin Hamlets to return to the old days. To get small, disconnect a bit, and stick to themselves in certain limited, economic realms. I don't know exactly how this would work, but I think it can be done. If these people don't want to interact with the Coasts, and the neoliberal economic trends and policies favored by the Coasts don't favor these communities, why not do an economic quasi-divorce?

The details of such a thing would be complex, yes. But this divorce is already occurring. In almost all regards, the cities and the communities that ring them are moving away from the truly rural areas of the country. The only problem is, we're still competing in the rural marketplaces. We're not allowing those marketplaces to contract and become their own little walled-off economies, as bigger statewide, national, and multinational firms are still servicing these people at very low prices, which keep their locals out of business.

Perhaps the cities should just let the rural areas go backward -- focus instead on the global market. The rural areas are going to do it anyway. The only question is whether we give them a chance to do so and become self-sufficient, or we continue to allow them to devolve into transfer dependent addict colonies.

[sebastian_dangerfield]

Originally Posted by Tyrone Slothrop

Agree that health-care jobs are growing. Not sure how much of that is due to the ACA, since health-care's share of the economy was growing anyway, but it surely doesn't hurt employment to expand coverage. Also not sure that these jobs are in rural areas. In my experience, health-care jobs tend to cluster in larger population centers, which service large rural areas around them. For example, in Eastern South Dakota, the health-care jobs are going to cluster in Sioux Falls, where people go to get health-care. From your perspective, that may be creating rural jobs, but I don't think people who live in Eastern South Dakota will see it that way.

There's a model I've seen gaining traction in flyover areas:

1. Set up practice or clinic in sticks;
2. Gobble up huge patient base due to lack of competition;
3. Flip to larger provider.

[Tyrone Slothrop]

Originally Posted by sebastian_dangerfield

Perhaps the cities should just let the rural areas go backward -- focus instead on the global market.

But do we let them continue to vote?

[Replaced_Texan]

Originally Posted by sebastian_dangerfield

There's a model I've seen gaining traction in flyover areas:

1. Set up practice or clinic in sticks;
2. Gobble up huge patient base due to lack of competition;
3. Flip to larger provider.

That's the model here too, and it has ramped up considerably since 2010 when the ACA was passed, especially in the last four years.

In my career, though, I've seen this happen three times. When I first started out, in the early to mid 90s, there were a ton of consolidations and practice acquisitions. They were undone when the first model of HMO managed care didn't work out and it turned out that hospitals are terrible practice administrators. There was a more tepid version in the mid-2000s when physicians were trying to build their own hospitals. We'll see if it finally takes, and I suspect that it probably will because of the lessons learned the first two times, and frankly because physicians seem to be a lot more risk adverse than they used to be in setting up private practices. The first 12 or so years of my practice, every single conference had a session on the corporate practice of medicine prohibition (there are only a handful of states that have such a rule), but I haven't even heard it mentioned in the last three or four years, much less have a whole half hour dedicated to it.

Also add telemedicine to the mix. There is litigation ongoing between Teladoc and the Texas Medical Board. (Latest on that: http://www.modernhealthcare.com/arti...NEWS/161019900) New rules came down last spring, and there may be legislation this session, but with a geographical area so big, sooner or later the physical docs are going to lose ground to the computer docs even if they prevail in the lawsuit.

[Adder]

Originally Posted by sebastian_dangerfield

"Move" isn't the only answer.

Thus the presence of the word "an" immediately before the word "answer."

Here it is: Re-Ruralization.

The problem with a lot of rural economies is they are still connected to the broader state and national communities around them. The little guys in town have nothing to do because they work against outside competitors with far superior economies of scale. The small construction company loses bids for local projects to the statewide firm, mom and pop shops lose out to Wal Mart, the local inns are wiped out by the Holiday Inn Express franchise down the street. The local doctor can't compete with the emergency care clinic in the national drug store or owned by the statewide health care network.

What you're saying is that it would help to make all of rural America poorer - that is reduce the value of their wealth and income relative to the price of their wants and needs.

This will not help.

In almost all regards, the cities and the communities that ring them are moving away from the truly rural areas of the country.

Sort of, although at least around here, the reddest places are the exurbs (i.e., places ringing cities), not truly rural areas.

ETA: It's also amusing for a proponent of "creative destruction" to advocate insulating those who are losing from competition. Nope. Let the competition play out and the necessary adjustments be made. Even if they are painful, doing otherwise only delays the inevitable.

[Tyrone Slothrop]

Originally Posted by Adder

Thus the presence of the word "an" immediately before the word "answer."



What you're saying is that it would help to make all of rural America poorer - that is reduce the value of their wealth and income relative to the price of their wants and needs.

This will not help.



Sort of, although at least around here, the reddest places are the exurbs (i.e., places ringing cities), not truly rural areas.

ETA: It's also amusing for a proponent of "creative destruction" to advocate insulating those who are losing from competition. Nope. Let the competition play out and the necessary adjustments be made. Even if they are painful, doing otherwise only delays the inevitable.

Creative destruction has avatars. Municipal-ordinance reform has proponents.

[Pretty Little Flower]

Originally Posted by Tyrone Slothrop

Creative destruction has avatars. Municipal-ordinance reform has proponents.

I'm going to work this into my next brief.

It's James Brown Thursday here on the Daily Dose. Accordingly, I present you with some James Brown. Which may seem a little too "thinking inside the box" for all you geniuses. But it's at times like this that I think of those inspirational Cypress Hill lyrics: "If you don't like it, here's my dick, bite it." Here's "I Can't Stand Myself (When you Touch Me) (Parts 1 & 2)":

https://www.youtube.com/watch?v=yP1wtIfs8lg

[Greedy,Greedy,Greedy]

Originally Posted by notcasesensitive

I forget who here was arguing with me about whether our extreme exceptionalism is an issue or not, I think it was GGG (the argument was something like "no, all countries think they are exceptional in their own way"). Anyway, I'd refer that person the Oliver Stone's series Untold History of the United States (streaming now on Netflix) for a 10-12 hour exposition on what I was trying to say.

And yes, (1) I am rather embarrassed to say the Oliver Stone has my proxy on this and (2) I did get a kick of some of his conspiracy theories which he alluded to tangentially for good measure.

10-12 hours explaining what you mean? We already have a Sebby here.

I have no doubt we are exceptional, as is every other country currently existing and throughout history. The weird thing about exceptionalism as a concept is that most people pushing the idea of exceptionalism posit some unexceptional norm as a contrast (usually, in the case of American exceptionalism, a sort of generic Europeanism). And I just can't find that.

[ThurgreedMarshall]

Bias in sentencing in Florida:

http://projects.heraldtribune.com/bias/sentencing/

TM

[taxwonk]

Originally Posted by sebastian_dangerfield

Similarly, nowhere in any of my text that you cited did "increased tax revenues" appear.

These projects provide so much savings when done right they're easily afforded using a projection of zero increases in available tax dollars for a decade.

Okay, explain what you're talking about, please. Apparently we are talking about different structures.

[Greedy,Greedy,Greedy]

Originally Posted by ThurgreedMarshall

Bias in sentencing in Florida:

http://projects.heraldtribune.com/bias/sentencing/

TM

But, but, but.... Identity politics!! All lives matter!!

[taxwonk]

Originally Posted by Tyrone Slothrop

(1) I posted something about Medicare, not the ACA.

(2) Your second sentence is wrong.

(3) I agree that the Democrats fucked up the politics of healthcare. To put it simply, and this goes beyond healthcare, I think Obama stopped investing in the political struggle, focused on governing, and thought that good results would speak for themselves. Either they didn't, or they did (the Dems picked up House and Senate seats in the last election) but HRC was a bad candidate.

(4) With regard to the ACA, people don't distinguish very well between what is happening in the healthcare market generally and what the government is doing. So they hold things like price increases against the ACA, even though prices would have gone up anyway.

(5) Because of (4), once Trump and the GOP start messing with the ACA, the Pottery Barn rule will apply, and people will blame them for the mess that is our healthcare system.

The reason that people don't distinguish between ACA and the healthcare market generally is that ACA failed to provide an affordable means for lower income people to obtain health care. They should have set up a public option. They failed to do so. As a result, too many people are left in the unfortunate position of being forced to pay either a premium they can't afford for coverage that is illusory, or paying a penalty they can't afford for failing to obtain a policy that doesn't provide any actual benefits.

The ACA was a good bill in the limited sense that it did way with lifetime caps and pre-existing conditions. Other than that, it's about as useful as tits on a bull.

[taxwonk]

Originally Posted by Adder

ARTICLE I, SECTION 4, CLAUSE 1

That provides that voting rights may, but need not, be left to the several states.

[Adder]

Originally Posted by taxwonk

That provides that voting rights may, but need not, be left to the several states.

The question was how can a state law the limits the right to vote vary from state to state. The answer is that the constitution expressly allows it.

[Greedy,Greedy,Greedy]

Originally Posted by taxwonk

The reason that people don't distinguish between ACA and the healthcare market generally is that ACA failed to provide an affordable means for lower income people to obtain health care. They should have set up a public option. They failed to do so. As a result, too many people are left in the unfortunate position of being forced to pay either a premium they can't afford for coverage that is illusory, or paying a penalty they can't afford for failing to obtain a policy that doesn't provide any actual benefits.

The ACA was a good bill in the limited sense that it did way with lifetime caps and pre-existing conditions. Other than that, it's about as useful as tits on a bull.

There is lots of other stuff in there that is very helpful - including provisions that are moving us from a service-based to outcome-based reimbursement scheme, which is the best bet for controlling care in the current system.

I'd have loved to have seen a public option, but having a public entity contracting wouldn't have significantly altered the price structure in health care. Public entities are already among the largest purchasers of healthcare in the US - why would adding another to the mix be hugely different? It might make some different, which is why I'd like it, but nothing radical.

The key way ACA planned to help the lower income seeking healthcare in particular was through subsidized insurance and an expansion of Medicaid. Of course, a lot of states have opted out of Medicaid expansion, to the disadvantage of their citizens, but there is a fair bit of subsidized insurance out there.

I won't pretend to have a lot of answers, but the reform I'd really like to see next would be to make the US part of a bigger market for drug approval and distribution - so we had, for example, a common drug market in the EU and US. Drug companies would have less hassle in approvals but we'd get the benefit of systems that have been much more successful at keeping drug prices down. I'd be hoping the larger market supported innovation, even if the approach took a lot of money out of the pharma pipeline.

Parts of TTIP might have set the stage for this, but with the TPP dead, we can be pretty certain that's going nowhere. And with Brexit we don't even know if EMA will continue to hold for the UK as well as EU.