One of the most important recent challenges of health care in the USA has been the quest to improve the delivery of preventive and chronic condition care while also reducing the task burden and subsequent increase in burnout experienced by primary care providers. Many entities, including the American College of Physicians, have offered guidance to assist in this effort. Recommended elements include the increased use of team-based care, coupled with standing orders that allow more team members to deliver recommended care; prudent implementation of EHR-based clinical reminders; and an increasing recognition that some elements of care can be delivered outside of face to face visits.1 Although important progress had been made in these realms over the past several years, the COVID-19 pandemic has disrupted entrenched practices, and offered an opportunity to accelerate changes in the delivery of care, including rapid implementation of tele-health services.

While much attention has rightly been paid to the potential for the increased use of tele-health, other opportunities to deliver care outside of direct, one-on-one physician-patient encounters are crucial to reaching the twin goals of improving care and reducing caregiver burden. One that has not been well-recognized but offers significant current and future potential: the delivery of health care via mail and the US Postal Service.

The US Postal Service began as the US Post Office in 1792, and has provided service to all Americans, at a uniform price, as part of its mission since that time.2 In this sense, it is differentiated from private delivery services, and hence has a particular mission to serve otherwise hard-to-reach and rural residents, many of whom lack access to proximate health care services and are at risk for health disparities. Some elements of “postal medicine,” such as the mail delivery of medications, have become commonplace. But the wide reach and near-daily availability of the postal workforce (the USPS has over 600,000 employees nationwide) coupled with the relatively low cost of delivery offers exciting opportunities to re-imagine how the USPS can play a critical role in improving health and health care, while also helping provide an additional revenue stream during a time where traditional revenue may be threatened by COVID-19.

One established, but incompletely implemented, example of mail-based health care is the use of mailed stool testing for colorectal cancer screening.3 Mailing stool-based tests, most commonly fecal immunochemical tests (FIT), to patients who are not up to date with screening can overcome several important barriers: those who were unaware of screening and options for being screened can be informed about their options in a manner that does not require either nursing or physician time, allowing such time to be allocated for other health issues or for targeted discussions with patients who need additional support or navigation; patients can complete the test at home and return it by mail, reducing their need for transportation (a challenging issue for rural or low-income patients); and health systems can benefit from the relatively low cost of mail-based outreach. Mailed FIT has additional appeal in the context of COVID-19: the self-sampling and mailed return of the test kit is especially appealing when face-to-face care may be challenging.4

Over the past three years, we have implemented mail-based screening in our local community health center network. Mailed FIT has resulted in a doubling of screening rates, at a manageable cost of approximately $5 per mailing. Such an approach would not be cost-effective without the infrastructure of the US Postal Service. Many other large US systems have also demonstrated the reach of mailed FIT programs, as have other countries.5

Other preventive and chronic disease services could follow the model that has been established for mailed FIT. Increasing availability of self-administered sampling and self-testing for other disorders has enabled such innovation. For example, given the near-universal recommendations for HIV and HCV screening, practices could mail patients self-sampling or self-testing kits to complete at home, linked with easy access for patient follow-up, counseling, and treatment. Similarly, studies have suggested that women can perform cervical self-sampling for HPV DNA testing, and such tests could be provided by mail as well.6 In the realm of chronic disease monitoring, many patients are already successfully monitoring their blood pressure from home. More aggressive provision of home blood pressure cuffs has the opportunity to improve adherence, especially for patients for whom transportation is a challenge.

The types of services described above take advantage of the wide range and low cost of USPS mail service. An even more radical re-imagining of the postal carrier as essential health care worker would take advantage of US Postal Service’s unprecedented reach and size to deliver certain elements of care directly to patients. Such a program has been implemented in France as a means of checking in on frail, potentially isolated elders.7 Moving forward, our country will need a massive effort to vaccinate the majority of our population against influenza and hopefully COVID-19. Trained and equipped appropriately, postal workers could become a key force for reaching those for whom leaving home would be unsafe or infeasible, an idea that was incorporated in post-9/11 disaster response planning but that has yet to be realized in practice.

COVID-19 has placed unprecedented stress on both the US health system and the US Postal Service. Structurally, the US Postal Service is threatened by its ongoing pension funding obligations, and Congress has to date not offered specific relief for its financial condition. Postal workers have also raised concern about access to sufficient personal protective equipment, a concern that must be addressed if such workers are to play a greater direct role in patient health during the COVID-19 era. Overcoming these challenges will not be easy, but the COVID epidemic has unlocked degrees of innovation and flexibility that seemed impossible just weeks ago.