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

"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.

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

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.

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

But do we let them continue to vote?

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

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.

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

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.

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

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

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

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

Re: Usa usa usa
 

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.

Depressing Article of the Day
 

Bias in sentencing in Florida:

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

TM

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

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

Re: Depressing Article of the Day
 

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

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

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.

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

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

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

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.

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

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.