The musings of a Philadelphia Physician who has served the community for six decades

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Obamacare: Spare Parts for a Book
Maybe these should have been included, but it was decided to leave them out.

Right Angle Club: 2014
New topic 2013-11-19 20:22:11 description

Health Savings Accounts, Regular, and Lifetime
We explain the distinction between Health Savings Accounts, Flexible Spending Accounts, and Lifetime Health Savings Accounts. Sometimes abbreviated as HSA, FSA, and L-HSA. Congress should make it easier to switch between them. All three are superior to "pay as you go", health insurance now in common use, only slightly modified by Obamacare. It's like term life insurance compared to whole-life. (

Reflections on Impending Obamacare
Reform was surely needed to remove distortions imposed on medical care by its financing. The next big questions are what the Affordable Care Act really reforms; and, whether the result will be affordable for the whole nation. Here are some proposals, just in case.

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Lifetime Health Insurance: Some General Ideas Behind the Proposal.

The longer we wait to make drastic changes, the more difficult they become, and more proof of benefit will be demanded. In the proposed case of switching health insurance from term insurance to whole-life, a century of health insurance development is affected. But remember, the past fifty years have seen plenty of dissatisfaction come to the surface, only to be dashed by a (generally correct) opinion that the old system was working better than the proposed one.

Health Cost Monitor Center. This time, let's start in advance with establishing a monitor center where public data is most complete -- in Medicare, particularly the sources and audited cost of terminal illness in the last years of life. Every American has Medicare, and every American must someday die. It follows that substantially everybody who dies, does so as a Medicare recipient. Not exactly, but in a population of 350 million people, it's close enough for information needs.

Conversely, in a population this large, enough people of younger ages will also die; so we can still estimate in advance what difference our proposals make to costs at almost any age. At least then, the public could judge what is actually happening, instead of relying on the anguished pronouncements of political candidates. Half of hospital cost experience already resides in Medicare data, the last years of life are well documented, and the first year of life is fairly predictable for these purposes. So we start the data with pretty good anchors and a considerable portion of cost. With at least a stated goal of offering prices for lifetime planning, but not necessarily universal ones in a voluntary system.

Footnote: An experience forty years ago makes me quite serious about this monitoring issue. While I was on another mission, I discovered Medicare and Social Security are on the same campus in Baltimore, with their computers a hundred yards apart. So I proposed to the chief statistician, that the Medicare computers already contained the date and coded diagnosis of every Medicare recipient who had, let's say, a particular operation for a particular cancer. Conversely, the Social Security computer contains the date of everybody's death; the Social Security number links the two. So, why not merge one data set into the other, and produce a running report of how long people seem to be living, on average, after receiving a particular treatment or operation -- and how it seems to be changing, over time. He merely smiled at the suggestion, and I correctly surmised he had no intention of following up on it. This time, I resolved to write a book, to see if that has more effect.

Let's ponder about some of the uncertainties which can only result in guesses at the moment, but which in time can be more precise, and provide the material for mid-course corrections: Transition Calculations. Let's say we have politicians with the skill to persuade the public to phase out Medicare in order to put an end to the foreign borrowing of half its costs, and persuade them to do so by buying it out. It has been our extrapolation that this could be done with a single payment of $40,000 at age 65, earning income of 10%. However, we also must recognize that a large foreign debt has been obligated to pay for shortfalls in the years now past. For the sake of argument, let us assume that debt has grown while we debate it, to the point where the 10% income from an additional $40,000 would pay it off; that's just a guess, for discussion, that the past debt is equal to one year's addition to it. It's very likely an underestimate, but it serves for the point.

At 10%, the entire future cost of one person's Medicare is estimated to be funded by a single deposit of $40,000, paying an aggregate cost of $433,000. So we double that to pay off the back debts, generating another $433,000 for debt service. A President with the right amount of leadership might be able to persuade the public that paying off a $866,000 expense for $80,000 is a bargain worth considering. Even with a great deal of expense estimation, that sounds like a reasonable offer. If not, projecting another ten years accumulation would show the disparity will not go away by itself, and only gets far wider under any proposal yet made for it. Presumably, our creditors would help with the persuasion, and presumably by then someone has dredged up more accurate numbers, reinforcing the same general conclusion. An even more strident conclusion is possible: fixing this particular problem is probably considerably more urgent than fixing the cost of care of working-age people. At the very least, we should stop making this problem worse by mistakenly addressing the other problem, first.

Since we are mainly trying to argue how universal lifetime Health Savings Accounts might finance a lifetime of medical care, let's skip over sensitive issues and temporarily agree to retain current maximum limits of HSA deposits indefinitely. (Obviously, inflation will eventually require them to be raised.) Anyone 25 to 65 is permitted to contribute $3300 a year to a Health Savings Account. Everyone is also permitted not to contribute that much, or even anything, but suppose for present purposes, everybody did. Ignoring any periods of recoverable illness or hardship, the average person is limited to contributing a maximum of $132,000 in a lifetime. Supppose for further example, there is no other source of medical revenue. Would $132,000 plus compound income suffice to carry the entire nation's health costs, from cradle to grave? To that, the astounding but gratifying answer is a somewhat qualified Yes, as long as inflation affects revenue and expenses equally. So with that mildly reassuring news, let's look at the issues related to selecting a new HSA account.

Tax Exemption First of all, every bit of HSA deposits, both contributions and compound income, is tax-exempt to the individual beneficiary. In Canada, an IRA also permits a (second) tax deduction, both when you deposit, and when you withdraw. But in America, only one choice of the two is covered by a tax exemption (Roth and non-Roth). Only in the American case of the Health Savings Account is there a double exemption, where a second deduction at withdrawal is offered, conditioned on purchasing health care with it.

After that, things get more complicated. Contributions to an HSA are now limited to $3300 a year, but tax-free withdrawals stop on attaining Medicare, even though internally-generated income continues to be tax-exempt for life. After attaining Medicare, annual tax-free contributions of $5500 to an IRA may continue until age 70.5, but $6500 may annually be contributed to a follow-on Roth IRA indefinitely. Effectively, there is a $133,000 lifetime double contribution limit, which could easily be simplified by replacing the annual aggregate with a lifetime limit. Because the system is intended to be fair, it would seem fair to allow catch-up contributions to attain the full average calculated for the age group. It is not clear whether anyone bothers with contributions for healthcare after age 65, and pays for healthcare from a Roth IRA; there might be some legal uncertainty about it.

For unexplained reasons, recent regulations during the Obama Administration provided that Health Savings Accounts may not be started after the age of 30. One would hope this is a temporary measure. Furthermore the Catastrophic health insurance, which is required to be purchased, is not itself tax-deductible, nor may its premiums be paid out of the Accounts. The new constraint is certainly crippling. By removing this constraint, the present unfairness could be removed from the choice between an HSA and regular employer-based health insurance. For a tax discrimination based on the place of employment to persist for seventy years, more justification should be offered than just the expediencies of World War II.

(Proposal 7a) Waive the annual limit to HSA contributions, for aggregate catch-up contributions bringing an account balance to the permitted aggregate for a subscriber's attained age. (2720)

(Proposal 7b) Permit required Catastrophic Health Coverage premiums to be paid out of Health Savings Accounts balances.This would correct a 70-year injustice in the differential tax deduction solely based on the nature of employment.(2720)

(Proposal 67c) Permit the premiums of catastrophic insurance attached to HSAs, to be tax deductible. Opponents of all tax-deductibility for health insurance should reflect that equal treatment is more important than tax revenue. Once equality is achieved, the tax deduction could be reduced by 25% for every taxpayer, roughly maintaining revenue neutrality for the U.S. Treasury.(2720)

By contrast, unless ordinary health insurance is first purchased by an employer, at present all deductions for healthcare are precluded for the self-insured and the uninsured. Big solvent business employers take a 48% corporate tax deduction (38% federal, 10% state) purchasing HSAs for employees and treating the contribution as a business expense. If an employer is already struggling to meet the payroll, of course he won't do it, although more employers are finding ways to make employees pay an important portion. Extending this deduction to HSAs as a choice under the Affordable Care Act would make employers more likely to offer the choice, although the present confused state of employer mandate under the ACA makes it uncertain. To a certain extent, it continues to be unfair between employers to confer a huge tax advantage based on the number of employees on the payroll, although even this leveraging feature can be overlooked during periods of high unemployment.

A related mathematical issue is, a deposit when you are young is much more valuable than the same deposit later. Since young people in general are relatively healthy, while older ones are relatively sick, a deposit by a young person ordinarily has many decades to grow before it is used for health care. True, young people have colleges and cars and houses to compete for their savings, but just listen to this: If the limits were liberalized (not confined to employees) someone could pay for a 90-year lifetime with a deposit of less than $100 at birth. The liberalization would benefit employees more than the present limitation does. The contrast is so large, few luxuries could compete with it in a competition for disposable income. At the least, the subscriber should try to pay for administration and trivial medical expenses from some other account (in order to build this tax-sheltered one up), whenever it can be done without running up high interest charges. By the same reasoning, the issuance of discounted tax-exempt bonds might lock it up until commercial investment managers would charge sustainable fees to manage it as a fair-sized HSA. But let's not exaggerate. The main financial differences between an HSA and an IRA, are that an HSA is entirely tax-exempt when withdrawn for health purposes, whereas for deposits an HSA has a top annual limit of $3300, while the IRA allows $6000 (for persons over age 50, $5000 below that age). The big obstacle is that IRA contributions are also limited by the amount of money paid by an employer in that year, something a newborn obviously cannot match. Therefore, the following considerations all have a bearing on whether a switch to lifetime Health Savings Accounts should also involve cutting the linkage to employment:

Issues like Portability, Job-Lock, pre-existing conditions, and individual choice would disappear if HSAs were freed of linkage to employers, since these issues are traceable to the mandatory link between health insurance and the employer. We really do have an employer-based system, which has its price to be paid. Since lifetime policies place considerable strain on portability and choice, it would be wise to review the advantages and disadvantages of having it remain a gift from employers.

Obviously, receiving a big gift is welcomed more than paying for it, yourself. But economists who have examined the matter are fairly unanimous that fringe benefits are rapidly merged in the minds of employers and employees alike as "employee cost." Within a few years in a competitive environment, both sides of the gift soon treat fringe benefits as only a tax benefit, with comparable reductions in the pay packet to adjust for them. The cost of the gift soon equilibrates, with only the tax deduction as a true transfer.

In fact, the employer probably gets more of a gift than the employee. State and local corporation taxes vary, but a profitable corporation pays 38% federal corporate tax, and the total tax burden is about 50%, the highest in the developed world. By defining fringe benefits as a cost of doing business, major corporations effectively increase their net income by half. It becomes their choice to reduce prices more than their foreign competitors are able to do, or to increase their dividends, or to pay more lavish salaries to executives. All of these things help support the price of their stock, so the stockholder benefits. Since the employee gets both a gift and a tax deduction, he is happy, although some of the benefit is illusory. Those who lose from the transfers are mainly foreign and domestic competitors, and the rest of the public has to pay higher healthcare costs, because no one is deceived about the effect of insurance on prices. Free trade, domestic competition, and healthcare prices are bearing this burden.

The competitor deserves a word, here. About half of business is made up of big business, and half is small business. Wall Street and Main Street, if you will. The accidents and opportunities which Henry Kaiser stumbled upon in 1945 only apply to big business, and probably much of that anomaly can be traced to the fact that big business is more likely to be profitable because that's how it got to be so big, and also is more likely to be engaged in international trade, where the competitors don't get a vote. Some of the tax benefits like Subchapter S, are probably an effort to help small domestic competitors without helping foreign competitors. But self-insured people, and uninsured ones, are excluded. Very likely, much of the politics of healthcare is intended to help these people, without helping small business, without helping big business, and without helping foreign competitors. Pretty soon, you have a tangle of interests which would be affected by removing the obvious tax inequity which Henry Kaiser is given credit for discovering. Just about everybody has something to gain, something to lose. So it begins to be impossible to say, whether on net balance, the country would be better for abolishing it. That's essentially what would happen, if we changed the health system to something different; and unnoticed in the process, abolished the tax inequity which everyone agrees is a bad thing.

Just how bad things are, is hard to say. We know about job lock and the other features directly attached to employer-based insurance, and we more or less decided to live with them. But the escalation of healthcare costs, and the soaring international debts being used to pay for them, are getting too much to handle. We can tolerate a lot of things, but it's not clear we can tolerate devoting 18% of GDP to healthcare, particularly if the price keeps going up. It's hard to imagine anything one would want to spend his money on, more than on longevity. But when serious people, or at least people who take themselves seriously, start talking about euthanasia as a solution to our health cost problem, you know the costs are starting to hurt. In my opinion, we have reached the point where a lot of unthinkable cost reductions, must be taken out and reviewed. My own solution is to switch from a debt-based system to a savings-based system, with savings of immense size which have to be stretched a little to suffice. But get this: you can only do it once.
Caution About Averaging. Remember, it does you no good at all to have $10 in your account and receive a bill for a $1000. That is just as true if the national average of HSAs contain $50,000, which unfortunately isn't yours. Money to pay your bill is in the system, but you can't get at it. The first thing to point out, is that the national curve of health accounts shows most expensive illness takes place after the age of 60, when chronic diseases and terminal disease makes an appearance, and where funds in HSAs ought to be ample. Therefore, you are cautioned to pay medical bills from any source of money you have, in order to avoid depletion of the HSA later in life, when it really ought to have money to spare. And within reason, even borrowing (short-term, and at low interest rates) is usually better than depleting the account for diseases that won't kill you soon. Since most high medical bills are caused by hospital care, the catastrophic insurance requirement was added. Ordinarily, that feature has been fortuitous, but the migration to outpatient surgery caused by DRG payment is threatening, and the inflation of normal outpatient prices, as well as monopoly new-drug pricing, threaten to upset the payment system before it can adjust. Short-term loans from a premium pool, or else a new layer of semi-catastrophic insurance inserted between the two existing classes appear to be a coming necessity. In the meantime, short-term borrowing at what we hope are bearable rates, seems to be the only available expedient.

Investment Control.As the reader will discover in Chapter Four, it becomes necessary to take the risk of provoking the whole financial industry, rich, powerful and resentful though they may be. As the immensity of our financial difficulties became apparent, there was no hope of solving the health financing problem without increasing investor returns. And that could probably only be accomplished at the expense of the retail broker. We are asking big business to give up half of its net income, but that's not enough. We are asking the life insurance industry to take on a whole new role, and either they or the health insurance industry will probably experience wrenching changes. But it's not enough. We must ask the public to take on some responsibility for its own finances, when most of them can't balance their own checkbook.

If you surrender control of investments, there is considerable danger the broker could select an investment that gives him a kickback. Although they should be, stock brokers are not fiduciaries. A common overcharge is excessive commission for liquidating withdrawals, which ought to cost no more than $7.50 per trade. If your goal must be 10% annual return, safely, you must be prepared to fight for it. before making withdrawals to pay medical expenses, which will be discussed separately. (Unless you control fees, or deal with a fiduciary, you will be lucky to net 1%) Even during an economic recession with negligible interest rates common stock total return is 5%, and a recession is an especially good time to buy stock and hold it, where 30-50% becomes conceivable. In a tax-exempt fund, ignore dividends. Buy and hold, is the thing, with no commissions above $10 a trade (either buy or especially on sell), highly diversified for safety, index funds of common stock. Either hold back a little cash for medical issues, or pay small medical bills with other funds. At least until you are sixty, try not to spend HSA money unless you have no other source of funds.No advice is absolute, but the reasoning behind this little homily appears in other sections of the book.

(Proposal 7c) The subscriber must be permitted complete freedom of choice among managers of his HSA account, managers of his Catastrophic Health Insurance policy, and management of his investment account. No element of kick-back arrangement is permitted, and written assurances should be on file.(2720) A provision to this effect has proven necessary in the past. Whether this provision remains necessary will largely depend on passing Provisions 7b. and 7d.

(Proposal 7d) Limit eligible investment agents who handle HSAs to legally defined fiduciaries. Needless to say, the brokerage industry will oppose this, and they should be asked if they can suggest alternatives.(2720)

Pooling of funds. Pooling is what you only partially get with the present H.S.A as provided by present law. The Catastrophic fund is pooled, and the Savings Account is individually owned and controlled.That is both a good and a necessary arrangement. The law requires that an H.S.A. be accompanied by a high-deductible or "catastrophic" health insurance, which is expected to pool the experience of subscribers. High expenses, which characterize hospital inpatient care, require the pooling of major expenses. Outpatient care, on the other hand, is conducted by a rational ambulatory patient, who can argue and bargain -- and shift to another provider if necessary. It has been the intention since the start of the HSA program that the market pressure on outpatient costs would spill over to the same items in the inpatient area. However, the DRG system has proved to be such an effective price-control mechanism, that its main defect is the crudeness of the code it employs. The crudeness produces severe unfairness between teaching hospitals and non-teaching ones, between urban and rural hospitals, and warps the admissions to specialty hospitals. All of this is unnecessary, reflecting the relative lobbying power of the winners and losers. The dual-system has produced satisfaction for millions of subscribers, and approximately 30% savings in cost. It is a pity that a technicality like a diagnostic coding system should cripple it.

But a second problem has been created: really suitable low-cost high-deductible policies are not provided by Obamacare. For cost comparisons, we do the math based on the hypothesis that the reader does not have Catastrophic re-insurance, although in real life and for the present, the best available alternative is the Bronze plan. For outpatient expenses, you are expected to pay out of your own funds, or else draw on the H.S.A. to cover them. When the law was written, the big expenses were hospital expenses, but the prepayment system enacted in 1983 limited their profitability, so hospitals have tended to shift from inpatient toward outpatient care where profits are more unconstrained. There was a time when fixing hernias and removing gall bladders as an outpatient was unheard of, but that has changed, so a pooling system for outpatient costs would be a desirable addition. There might be plenty of money in this approach which could be pooled, but a comfortable average will still be disrupted by an occasional high-cost outlier. For example, major auto accidents might run up a very high accident room cost which would not be covered, even though the average was well in surplus. A credit card would cover such eventualities, but their interest rates are high, and it might be better if investment houses provided loan funds for this purpose at lower cost. If you must borrow, liquidate the loan at the earliest possible moment.

(Proposal 7e) Congress should set a reasonable time goal, and then mandate that the DRG be rewritten based on SNOmed, and reduced to a DRG which is much larger than at present, and capable of easy expansion. As mentioned, the hospitals which are winners under the old system will identify themselves by opposing this, and they should be asked if they can suggest alternatives.(2720)

(Proposal 7f) Congress should periodically investigate whether an intermediate insurance category of high-priced outpatient services has been created. If so, hearing should be held with an eye to creating one. It must be recognized that the nature of medical care is continually evolving, and this is one direction which may be emerging.(2720)

(Proposal 7g) Congress should hold hearings to devise a truly bare-bones indemnity catastrophic policy for adoption by HSA subscribers. It is time to reconsider the whole concept of first-dollar coverage, with service benefits, and to find ways to allow it to continue as an option, while preventing it from imposing itself on those who would be better served without it.(2720)

Compound Investment Income. Here, we have the heart of the whole arrangement. It's not a bonus, but rather the source of the new revenue to pay for burdensome health care expenses. Call it the Ben Franklin approach, that allowed him to retire at the age of 41 and live comfortably for another forty years. John Bogle's discovery of buy-and-hold index fund investing is safe and effortless. It makes it unnecessary to rely on a high-commission stock picker to achieve first-class results. In fact, the results of passive investing have recently been so superior that you wonder why anyone does anything else. Unfortunately, there is evidence that the financial industry has been so stressed that it has resorted to taking a majority of total returns, to itself. Therefore, the novice investor must be warned that stock market trades are widely available for less than $10, but are frequently charged $300. The investment returns should be, but seldom are, displayed, so it is often impossible to compare different brokerages, and even harder to compare a company's gross returns with its net, returned to the investor. So trust, but verify. If you are prudent, a cash deposit of $132,000 spread over 40 years, can pay for $325,000 of lifetime health care, the present national average. That's not exactly free, but it represents an average saving of $192,000, multiplied by 350 million people, which seems to mean $68 trillion in health revenue released for medical use. These back-of-the-envelope calculations are so dizzying that, pick all the nits you please, and the same conclusion would emerge. We'll return to that after going into more description of how the proposal should work.

(Proposal 7h) Congress should require all managers of Health Savings Accounts to display to the customer, and publish to the world, quarterly, their average total returns, as compared with average net total returns to HSA subscribers,and to the individual subscriber if there is meaningful variation. If the difference between net and gross exceeds 1%, the manager should be required to complete a form explaining it. There are several trillion-dollar funds who would find this proposal no hardship.

(Proposal 7i) Managers of HSA investments should be qualified as fiduciaries under standard definitions, or make it clear to the customer that they are not. It must be recognized that the nature of medical care is continually evolving, and this is one direction which may be emerging.(2720)

(Proposal 7j) A cost comparison and returns comparison of all managers of HSA, by location, should be annually published, at least on the Internet, or in some other way made available to the public. Those who are wise in the ways of investing have no idea, of how innocent many people are.(2720)

Commentary: Agency for Mid-Course Corrections

Among the many things we don't know about the future, is the average longevity eighty years from now. The whole life insurance industry prospered when they sold policies assuming American longevity of 47 years in year 1900, and it turns out to be 83 today, still growing fast. If longevity should get shorter, as it recently has in Russia, life insurance would go out of business. Since we can't rely on projections, we have to rely on observations, and make mid-course corrections. If Lyndon Johnson had known, he probably had the temperament to take the chance on Medicare. But the American people might not have taken that chance, so he really had little choice.

President Johnson both underestimated how much Medicare would cost, and how successful it would be. He was therefore in no position to multiply 50 million Americans times $11,600 per year per person, times 22 years per person. Nor could he know how fast longevity would grow, or how fast the cost would rise. But Medicare was a medical success, which has to be paid for; and we forgive him. Similarly we guess the average life expectancy where things will flatten out will be about age 91. (Be careful, most life expectancy figures are for life expectancy at birth.) But to be right, the guesser would have to be lucky in everything: a favorable investment climate for the right ten-year period, plus a favorable health situation which avoids expensive illnesses just at the right age. Using a lower goal of $60,000 single premium for Medicare by assuming a higher interest rate of 7% is easier to achieve, but the limitation for HSAs which might actually be reached first, is the $3300 yearly cap on contribution rate. If costs go up but that deposits remain the same, then everyone might be forced to pay medical expenses out of pocket in order to cope. Congress can change that limit, whereas the longevity is whatever it is. Therefore, it's considerably safer to over-deposit more than you believe you will need, planning to return the excess. As a practical matter, the real danger is overoptimistic revenue projection. Someone who sells his business at age 63 might have enough cash, but still encounter trouble because of the $3300 per year limit. It seems pointless to squeeze through such a narrow window, and much better if the window were enlarged to permit lump-sum deposits up to a $132,000 lifetime limit. With that sort of cushion, plus a stretch of reasonably good health at the right time of life, it would become considerably safer to take the risks. At age 65, a lifetime of health costs is already in the past, but the curve of health expenses starts to bend upward at age 50, at a time when college expenses for children may be persisting, and the house isn't quite paid for. It seems a pity to cripple a good idea with pointless contribution limits that almost stretch far enough, but leave people fearful. If Congress develops a serious interest in lifetime insurance, the yearly contribution limit should be revisited.

Revisited by whom? A simplified goal is therefore to accumulate $80,000 in savings by the 65th birthday, remembering that savings get a lot harder when earned income stops. With current law, you would have to wake up and start maximum annual depositing of $3300 by your 50th birthday, to reach $80,000 by age 65, and you would need generous internal compounding to make it. But notice how easily $100-200 a year would also get you there, starting at age 25 (see below), even justifying somewhat less optimistic investment income returns until age 65. Many more frugal people might skin by with looser rules; It even could rather easily be subsidized for poor people and hardship cases. If you are going to cover lifetime health costs instead of just Medicare, many more will need $80,000 to do it, and have something left to share with the less fortunate. But to repeat once again, that still compares favorably with the $325,000 often cited as a lifetime cost. That's all we care to promise in public, but secretly we know it may not be enough. The plain fact is, if longevity or inflation get out of hand, someone must have the courage to raise the contribution limits. If people simply cannot pay that much, we become insolvent debtors. But at least we can recognize a political squeeze we could afford to pay, and designate someone who is sufficiently thick-skinned, or sufficiently isolated, to enable us to pay it. There's one other expedient. We could abandon the idea of an $80,000 single premium Medicare, revert to the present Medicare system, and eventually pay $788,000. Where did that number come from? It comes as a gentle reminder that Medicare's foreign debt will continue to rise and be serviced if we don't pay it off. It's probably futile to estimate the interest rate an insolvent nation would be forced to pay, but it would certainly rise as the end game approached. About the best to say about it is, it's cheaper than provoking an atom war.

Proposa 13a: Instead of the present annual limit of contributions to Health Savings Accounts of $3300 per year, Congress should permit a lifetime limit of $132,000, with annual deposit limits adjustable to bring accounts at their present age, up to what they would have been if $3300 annually had been deposited since age 25.(2718)

Proposal 13b: Congress should reserve decisions to itself for changing the lifetime contribution level, and review final appeals from contract terms which seem to threaten imminent major adjustment to the general public lifestyle.(2718)

Starting with the Medicare example. Notice that forty years of maximum contributions, would amount to far more than the necessary $40-80,000 by age 65. We haven't forgotten that the individual is at risk for other illnesses in the meantime, so in effect what we need is an individual escrow fund for lifetime funding intended (at first) only to replace Medicare coverage. (We are examining lifetime coverage, piece by piece, trying to accommodate an extended transition period.) Depending on a lot of factors, that goal could cost as little as $100 a year deposited for forty years, or as much as the full $1000 per year. It all depends on what income you receive on the deposits in the interval. In a moment, we will show that 10% return is not impossible, but it is also true that a contribution of $1000 per year would not seem tragic, compared with the present cost of health insurance (now averaging over $6000 a year). I have unrelated doubts about the current $325,000 estimate of average lifetime health costs, but that is what is commonly stated. For the moment, consider these numbers as providing a ballpark worksheet for multi-year funding, using an example familiar to everyone, but not necessarily easy to understand after one quick reading.

The Cost of Pre-funding Medicare. Rates of 10% compound income return would reduce the required contribution to $100 per year from age 25 to 65, but if the income were only 2% would require $700 contributed per year, and at 5% would require $300 per year. Remember, we are here only talking of funding Medicare, as a tangible national example, Obviously, a higher return would provide affordability to many more people than lesser returns. Let's take the issues separately, but don't take these preliminary numbers too literally. They are mainly intended to alert the reader to the enormous power of compound interest. Let's go forward with some equally amazing investment discoveries which are more recent, and vindicated less by logic than empirical results.

If someone makes a single deposit of $80,000 on his/her 65th birthday, there will accumulate $190,000 in the account over 18 years, the present life expectancy if he spends nothing for health and invests at 5%; assuming $190,000 is what the average person costs Medicare in a lifetime. Since the average person spends $190,000 during 18 years on Medicare, enough money will accumulate in Medicare to pay its expenses, and after some shifting-around, this should make Medicare solvent, in the sense that at least the debt isn't getting bigger because of the individual. Furthermore, index funds should be returning 10-12% over the long haul, so there should be some firm discussions with the intermediaries about some degree of dis-intermediation. Please don't do the arithmetic and discover that only $40,000 is needed. That seems plausible, but that's wrong, because the costs remain the same , and previously the government has been borrowing half the money from foreigners. In effect, the subscribers have been paying the government in fifty-cent dollars. There has been an exchange of one form of revenue for another, so the required revenue actually does demand $80,000 for a single deposit stripped of payroll deductions and perhaps premiums. An end would put to further borrowing, but the previous debt remains to be paid. I have no way of knowing how much that amounts to, but it is lots. All government bonds are general obligations, mixed together, and access to Medicare reports back to 1965 is not easily available. What we can more confidently predict is the limit that young working people can afford to put aside for the sole purpose of paying off the Medicare debts of earlier generation. If there are other proposals for paying off this foreign debt, they have not been widely voiced. And the debt is still rapidly growing.

They would have to set aside an average of $850 per year (from age 25 to 64) to achieve $247,000 on the 65th birthday, assuming a 5% compound investment income and relatively little sickness. This might seem like an adequate average, but occasional individuals with chronic illnesses would easily exceed it in health expenditures. It is not easy to estimate the size and frequency of such occurrence in the future, so someone must be designated to watch this balance and institute mid-course adjustments. As an example, simple heart transplants costing $200,000 are already being discussed. To some unknown extent, the cap on out-of-pocket expenses would have to be adjusted to pass these cost over-runs indirectly through the Catastrophic insurance. Insurance does greatly facilitate sharing of outlier expenses, but usually requires a time lag whenever new ones appear.

It does not require much political experience to know that taxpayers greatly resent paying debts that benefitted earlier generations. They complain, but complaining does not pay off the debts of the past. To double required deposits in order to pay off past debts, as well as using forgiveness of payroll deductions and premiums, would require an additional $120,000 per year escrow, for each year's debt accumulation. At present, roughly $ 5300 per beneficiary, per year, is being borrowed, and there are roughly twice as many current beneficiaries as people in the tax-paying group, but only 18 years, as compared with 40 years as a prospective beneficiary. So that comes to liquidating roughly $1300 a year of debt to balance the two populations, or $2600 a year to gain a year. That's for whatever the debt happens to be, which surely someone can calculate. To accomplish it, one would have to project an average of % income return. That's definitely the outer limit of what is possible, and it probably over-reaches a little. Therefore, to be safe, one would have to assume some other sources of income, a change in the demographic patterns, or an adjustment with the creditor. Assuming inflation will increase expenses equally with inflation seems possible. And it also seems about as likely that medical expenses will go down, as that they go up. You would have to be pretty lucky for all these factors to fall in line over an 80-year lifetime. So, although Medical

It is this calculation, however rough, which has made me change my mind. It was my original supposition that multi-year premium investments would only apply up to age 65, and that would be followed by Medicare. In other words, HSA should only be implemented as a less expensive substitute for the Affordable Care Act. It seemed to me the average politician would be very reluctant to agitate retirees by proposing a plan to eliminate Medicare. They would feel threatened, the opposing party would then fan the flames of their fears, and the result would be a high likelihood of undermining the whole idea for any age group, for many years. Better, I thought, to take the safer route of avoiding Medicare, and confining the proposal to working people, where its economics are overwhelmingly favorable.

But when the calculations show how close this proposal under cautious revenue projections could come to failure, and when nothing else remotely close to it has been proposed by anyone, the opportunity runs the risk of passing us by. So, I have changed my mind. The moment of opportunity is too fleeting, and the consequences of missing it entirely are too close, to worry about the political disadvantage of doing the right thing. The transition to a pre-funded lifetime system will take a long time to get mature, and the political obstacle course preceding it is a daunting one. At least we should allow it as a demonstration option, where some fears will prove unwarranted, and others can be corrected.

So we make the guess of the average life expectancy where things will eventually flatten out, will then be about 91. (Be careful, most census figures are for life expectancy-at-birth.) But many people would have to be lucky in everything: a favorable investment climate for the right ten-year periods, plus a favorable health situation which avoids expensive illnesses just at the age when they begin to threaten. Some life-saving scientific advances would be a big help, too. Using a lower goal of $80,000 and an interest rate of 7% is considerably easier to conjure, but the barrier which might be reached first is the $3300 yearly contribution limit. Some unfortunate individuals might be forced to pay all medical expenses out of pocket in order to make the investment fund stretch, even before the average becomes affected. The individual who came up short might still remain considerably ahead of where he would be without an HSA, but we are using a precise match of revenue and expense, to simplify the examples. Someone who sells his house or business at age 63 might have the cash, but still have trouble because of the $3300 per year deposit limit. It seems pointless to squeeze through a narrow window, and much better if the window were enlarged to permit lump-sum deposits up to a $132,000 lifetime limit, adjusted for inflation and compound income returns. With that sort of cushion, plus a stretch of reasonably good health at the right time of life, it would become considerably safer to take the risks. At age 65, a lifetime of health costs is nearly in the past, but the curve of health expenses starts to curve up at age 50, at a time when college expenses for children may be persisting, and the house isn't quite paid for. It seems a pity to cripple a good idea with pointless contribution limits that almost stretch far enough, but leave people fearful. If Congress develops a serious interest in lifetime insurance, the yearly contribution limit should be revisited.

The simplified goal is therefore to accumulate $80,000 in savings by the 65th birthday, remembering that savings get a lot harder when earned income stops. With current law, you would have to start maximum annual depositing of $3300 by your 50th birthday, to reach $80,000 by age 65, and you would still need generous internal compounding to make it. But notice how easily $100-200 a year would also get you there, starting at age 25 (see below) and less optimistic investment income returns until age 65. Many more frugal people might skin by with looser rules; poor people and hardship cases could more easily be subsidized. If you are going to cover lifetime health costs instead of just Medicare, many more will need $80,000 to do it, and have something left to share with the less fortunate. But to repeat once again, that still compares very favorably with the full $325,000 which is often cited as a lifetime cost. We have already imposed an extra $80,000 internal savings requirement in order to include Medicare; here is the place it would be a hardship.

Starting with the Medicare example. Notice that forty years of maximum contributions, would amount to far more than the necessary $40-80,000 by age 65. We haven't forgotten the individual is at risk for other illnesses in the meantime, so in effect what we need is an individual escrow fund for lifetime funding intended (at first) only to replace Medicare coverage. (We are examining lifetime coverage, piece by piece, trying to accommodate an extended transition period.) Because of the extended period for income compounding, the addition of Medicare will eventually subsidize the costs of pre-Medicare younger people. But for a while, the exactions for Medicare will seem a strain for younger people. Depending on many factors, that goal could cost as little as $100 a year deposited for forty years, or as much as the full $1000 per year. It all depends on what income you receive on the deposits in the interval and the varying age of entering the program. In a moment, we will argue that 10% returns are not impossible, but long periods of 5% are possible. It is also true that a contribution of $1000 per year would not seem tragic, compared with the present cost of health insurance (now averaging over $6000 a year). But for some, it will be greeted sullenly. I have unrelated doubts about the calculation of $325,000 estimates of average lifetime health costs, but that amount is what is commonly stated. For the moment, consider these numbers as providing a ballpark worksheet for multi-year funding, using an example familiar to everyone, but not necessarily easy to understand after one quick reading.

The Cost of Pre-funding Medicare. Rates of 10% compound income return would reduce the required contribution to $100 per year from age 25 to 65, but if the investment income were only 2% would require $700 contributed per year, and at 5% would require $300 per year. Remember, we are here only talking of funding Medicare, as a well-understood national example, Obviously, a higher return would provide affordability to many more people than lesser returns. When $100 competes for the investment income from 10%, it's much easier than $300 competing for 5% income. Let's take the issues separately, but don't take preliminary numbers too literally. They are primarily intended to alert the reader to the enormous power of compound interest, and the big difference made by relatively small changes in it. Let's go forward with some equally amazing investment discoveries which are more recent, and vindicated less by logic than empirical results.

A transition from term insurance to pre-payment of Medicare is greatly eased by forgiving the premiums and payroll deductions, which are roughly age-distributed, and can therefore be forgiven in a graduated manner for late-comers to the program. Most cost-redistribution of high-cost outlier cases should be handled through the catastrophic insurance, which is well suited for invisible and tax-free redistribution. Because of hospital cost-shifting, inpatients are temporarily overpriced, but are quickly becoming underpriced as a result of gaming the DRG to shift costs to outpatients. This will in time affect the relative costs of Catastrophic and Health Savings Accounts, and must be carefully monitored for mid-course adjustments. This changing horizon of cost shifting almost demands the creation of a special agency to keep track of it.

Proposal 13c: Congress should create and fund a permanent Health Savings Account Agency. It should have members representing subscribers and providers of these instruments, with power to hold hearings and make recommendations about technical changes. It should meet jointly with the Senate Finance Committee and the Health Subcomittee of Ways and Means periodically. It should have extensive access to the appropriate Executive Branch department, to review current activity, detect changing trends, and recommend changes in regulations and laws related to the subject. On a temporary basis, it should oversee inter-cohort and outlier loans, leading to recommendations about the size and scope of inter-subscriber loan activity. At first, it might conduct the loan activity itself, with an eye toward eventually overseeing a commercial vendor.(2718)

Cost Sharing with Frugality.At present costs, statisticians estimate future healthcare costs of about $325,000 (in year 2000 dollars) for the average lifetime. We could discuss the weaknesses of that estimate, but even though it's breathtaking, it's the best guess available. Women experience about 10% higher lifetime health costs than men. Roughly speaking, how much the average individual somehow has to accumulate, eventually must equal what he spends by the time of death. The dying individual himself has little interest in what is left unpaid at his death, so Society must do it for him, in order to survive as a Society. At this point, we unfortunately must also work around one of the great advantages of having separate accounts.

On the one hand, individual accounts do create an incentive to spend wisely, but it is also true that pooled insurance accounts make cost-sharing easier, almost invisible, and tax-free. Cost sharing induces reckless spending of other people's money however, while individual accounts induce frugality with your own money. Therefore, linking Health Savings Accounts with Catastrophic insurance provides a way to pool heavy outlier expenses, while the incentive for careful money management remains in the outpatient costs most commonly employed (together with a special bank debit card) to pay outpatient costs. Such expenses are much more suitable for bargain-hunting anyway, because dreadfully sick people in a hospital are in no position to argue or resist.

But a cautionary reminder: linking individual accounts to frugality through outpatients, as well as linking heedless spending to insurance through inpatients -- induces hospital administration to game the system you have devised. There's no doubt we have created a system which can be gamed by shifting medical care to the outpatient area, but we must expect the DRG to be attacked, in order to reverse the incentives, which run in the hundreds of billions of dollars. A well-informed monitoring system simply must be created and funded, if we ever expect the decision to hospitalize patients to rest on whether the patient needs to lie down, instead of on what kind of payment system we happen to fancy. At the same time, the present DRG coding system must be considerably improved to withstand being subverted.

Standard Deviation within and between age cohorts.Furthermore, there is an important distinction between a mismatch of revenue to expenses caused by chance within one age group, and a revenue mismatch between two age cohorts. To put it another way, somebody has to pay off these debts, and we must have a plan about who should pay them when revenue is not present in the account. Borrowing between subscribers within the same age cohort should pay modest interest rates to forestall gaming, but borrowing between different cohorts for things characteristic of their age level (pregnancy, for example) should pay no interest if at all feasible. Unfortunately, people sometimes abuse such opportunities, and interest must then be charged. Until the frequency of such things becomes better established, this function of loan banking policy should be part of the function of the oversight body. When its limits become clearer, it might be delegated to a bank, or even privatized, but the policy must be monitored by specialists who understand what is happening "on the ground". While it is unnecessary to predict the last dime to be spent on the last day of life, incentives should be understood by the managing organization, separating routine cash shortages from likely abusive ones. And looking at all such activity as potentially having been caused by payment design. Much of this sort of thing can be minimized by encouraging people to over-deposit in their accounts, possibly paying some medical bills with after-tax money in order to build the fund up. Such incentives must be contrived, if they do not appear spontaneously. User groups can be very helpful in such situations. People over 65 (that is, those on Medicare) spend at least half of that $325,000 lifetime cash turnover, but just what should be counted as careless overspending, can be a matter of argument.

Proposal 13d: Current law permits an individual to deposit $3300 per year in a Health Savings Account, starting at age 25, and ending when Medicare coverage appears. Probably that amount is more than many young people can afford, so it would help if the rules were relaxed to roll-over leftover entitlements to later years, spreading the entire $132,000 over the forty-year time period at the discretion of the subscriber.(2718)

Some Brief Examples of HSAs .


Obamacare does not include Medicare recipients. However, it is a familiar topic, and its data are fairly accurately available in a unified form. So future Obamacare costs are readily understood by subtraction of Medicare costs from lifetime totals, and future changes can be more readily integrated. The average lifetime medical costs are roughly $325,000, as calculated by Michigan Blue Cross, who devised a system for adjusting costs to year 2000. The results have been verified by several Federal agencies, although the method includes diseases and treatment which we no longer see, and adjusts for inflation to a degree that is startling. Medicare data are more precise, but have the same trouble adjusting for the changes of half a century. By this method, we get the approximation of $209,000 for Medicare. By subtraction we get the data approximating what Obamacare would cover, slightly confounded by including the small costs of children. That is estimated by subtraction to be $116,000. The revenue to pay for these costs is assumed to come entirely from the working years of 25 to 65. In the examples which follow, the Health Savings Account data are the maximum annual allowable ($3350) multiplied by 40, representing the working years, so they represent the maximum contribution, adjusted for compound investment income at 6.5%, and paying for lifetime costs.The aggregate cash contribution is thus $134,000, which without being disturbed by withdrawals, at 6.5% would hypothetically grow to the astonishing figure of $3.2 million by age 93. A more conservative interest rate of 4% would reach nearly a million dollars. The conclusion immediately jumps out that there is plenty of money in the approach, with the main problem remaining, somehow to devise a way to get it out in adequate amounts when the average is adequate but an occasional outlier cost is extreme. In these examples, inflation in revenue is assumed to be equal to inflation in costs, an assumption which is admittedly arguable.

HSA and ACA BRONZE PLAN: A FIRST LOOK. Although a catastrophic high-deductible plan must be attached to a Health Savings Account, and the Affordable Care Act provides a catastrophic category, those plans are not available after age 30 except in hardship cases. Therefore, at the present writing it is necessary to select the plan with the highest deductible and the lowest premium, which happens to be the Bronze plan. "Lifetime" coverage with this, the cheapest ACA plan, would amount to $170,000, or $38,000 more than the most expensive HSA allowed by law. That's about a 22% difference. And furthermore, the bronze plan does not allow for internal investment income accumulation, which could amount to five times the actual premium revenue if held untouched until the end of projected life expectancy.

A more conservative analysis would end at age 65, because that is where the Affordable Care Act presently ends. Stopping the investment calculation at age 65 would lead to the same $170,000 for the bronze plan, compared with an adjusted price of HSA of $132,000, less a 6.5% gain of $xxxx, or $xxxx. To be fair about it, the gain would have to be adjusted for inflation, which at 2% would amount to $xxxx, a xx% difference. Let's make a more dramatic assertion: The difference between the most expensive HSA and the cheapest Bronze plan, would be $xxxx. In a minute we will discuss the reasoning applied to Medicare, but it will show that a deposit of $80,000 at the 65th birthday would pay for the entire average lifetime of twenty years as a Medicare recipient. In a manner of fast talking, you get a lifetime of Medicare coverage free, somehow buried within the HSA approach. That's an exaggeration, of course, but at a quick glance it could look that way. We haven't accounted for Medicare payroll deductions or premiums. Or government subsidies. And we haven't depleted the fund for the medical expenses it was designed to pay.

HSA AND MEDICARE. Medicare Part A (the hospital component) is free, and the system while generous, is pretty ramshackle. Furthermore, it isn't free, since it collects a payroll tax from working people, and collects premiums from the beneficiaries. Almost no one understands government accounting, but it has the unique feature that its debts are often described as assets. That is, transfers from another department are assets, so money which is borrowed, from the Chinese let's say, is placed in the general fund and transferred internally, so such debts are assets. And the annual report (available from CMS on the Internet) shows that 50% --half-- of the Medicare budget is such a transfer asset, otherwise known as a subsidy. Medicare is a popular program, because a fifty percent discount is always popular; everybody likes a fifty-cent dollar. Unfortunately, the elderly Medicare recipients perceived the Obamacare costs were underestimated, and became suspicious Medicare would be raided to pay for it. Therefore, every elected representative regards Medicare as the "third rail of politics" -- just touch it, and you're dead.

THE OUT-OF-POCKET CAP FUND. The Affordable Care Act contains two innovative insurance ideas for which it should be given full credit: the electronic health insurance exchanges which unfortunately caused such havoc from poor implementation, nevertheless have great potential for reducing marketing costs with direct marketing, and should be given full credit. And secondly, the cap on out-of-pocket payments is really a form of re-insurance without the cost of creating a re-insurance middleman. It is this which is the present focus. Three of the "metal" plans have deductibles of about $6000, and two of the plans have $6000 caps on out-of pocket cash expenses by the beneficiary. How these two features will be co-ordinated is not yet clear, and does not concern the present discussion.

The point which emerges is the original Health Savings Account was based on the concept of a high deductible, matched with enough money in the fund to pay it. Effectively, it provided first-dollar coverage without the cost-stimulating effect, and experience in the field showed it worked out that way. However, the forced match of HSA with one of the metal plans interfered to some unknown degree with the comfort of virtual first-dollar, and the cost reduction of a psychological high deductible. The premium is higher, because an increased volume of small claims is covered, and may be exploited. And an increased pay-out means less cash is available for investment. The result could be either higher costs or lower ones. And therefore, the idea arises of a single-payment fund of initially $6000, deposited at age 25 (Since that might well be a hardship for many young people, an additional feature is required). But the power of compound interest is such that this reserve would eventually become seriously overfunded. If the hypothetical client deposited $6000 at age 25, he would have accumulated $80,000 from this source alone. That's enough so that if it were paid to Medicare on the 65th birthday, it would pay for Medicare for the rest of the individual's life. But since it would not be needed from age 50 to age 65, further compounding (at the arbitrary rate of 6.5%) to $320,000 or some such amount, at age 65. Therefore, the following uses can be envisioned: ( 1.) Lifetime health insurance without premiums after 65. (2.) Since Medicare premiums would not be required, the Medicare premiums would not be required and should be waived. Money which flows in from earlier payroll deductions could be diverted to paying off the Chinese Medicare debt. (3.) We have glossed over this matter, but everyone was born at someone else's expense, and should pay off his debt for the first 25 years of his own life. (4.) If circumstances permit, the client should be able to transfer $6000 to other members of his family for the same funding as he got it. (5.) Surpluses might persist in exceptional circumstances, and the option to supplement his own retirement funds might be offered. Eventually, it seems inevitable that the premiums for "metal" plans would be reduced.

At the very least, one would hope that this dramatic example of the power of compound investment income would encourage wider use of the principle.

How Certain Numbers Were Derived

These are important numbers to know, but difficult for most people to understand what they mean. That will of course depend on how they are derived, a subject of much less interest to many people. Therefore, the more controversial numbers are discussed in this chapter, which the reader may skip if he chooses.


Most people in the past did not live as long as they do today, so the "average person" is a composite of older people who had illnesses as children which we seldom see today, plus some who may well live beyond recent expectations, but who live beyond the age of death of their parents. One surmises this tends to include among "average" some or many hypothetical people who had both more illnesses as children, and who will have more illnesses as retirees. This would lead to an average with more illness content than the future likely contains.

Prices in the calculation have been adjusted to 2000 prices, slightly less than 2014. Furthermore, there has been a 2% inflation adjustment, which reflects that a dollar in 1913 is now worth a penny, so we expect the penny to be worth 0.0001 cents in 2114. It is hard for most people to wrap their heads around such calculations. There is a $25,000 lifetime difference between the sexes, but the highly hypothetical result is this statement: The Average Person Can Expect Lifetime Health Costs of $325,000. Since most assumptions lead to an overestimate of future real costs, this number is conservatively on the high side. Comparatively few people would think they can afford that much. That is, plenty of people are going to feel stretched to adjust their savings to that level of inflation. It's the best estimate anyone can make, but by itself alone it seems to justify organizing a government agency office to match average income with average expenses, and to make the ingredient data widely available to many others outside the government on the Internet, to maximize the recognition of serious errors, unexpected financial turmoil, the development of new treatments, and changes in disease patterns. Inevitably, these calculations will be applied to other nations for comparison, but that is a highly uncertain adventure.


Like Archimedes announcing he could move the World, if he had a long enough lever and a place to stand, accomplishing this little trick could arrive at impossible assumptions. Our basic assumption is that paying for your grandchildren is equivalent to having your parents pay for you, even though the dollar amounts are different. It's an intergenerational obligation, not a business contract, and you are just as entitled to share good luck as bad luck when the calculation is shaky at best. Since children's costs are relatively small, little damage is anticipated from taking present costs, adjusted for inflation, for both past and future.

Is it reasonable and/or politically possible to lump males and females together, when females include all the reproductive costs, and have a longer life expectancy? How do we apportion the pregnancy costs between mother and child, with or without including the father? What is fair to those who have no children? What costs do we include as truly medical? Sunglasses? Plastic Surgery? Toothpaste? Dentistry? The recent hubub about bioflavinoids threatens to convert what was mainly regarded as a fad, into a respectable therapy for allergy. When allergists and immunologists agree it is a fad, you don't pay for it; if substantially all of them think it is medically sound, pay for it. The opinion of the FDA informs the profession, it does not substitute for that opinion. Quite aside from cost issues, all of these issues affect the statistical ground rules, and may not have been treated identically among investigators. Unverifiable 90-year projections must be thoroughly standardized to be useful, and that's one committee I shall be glad to avoid, because I do not believe the improved accuracy is worth the dissention. When somebody discovers a cure for cancer or Alzheimers, rules may have to be revised, net of the cost of the treatment, and net of the increased longevity. Government accounting, private accounting, and non-profit accounting are three different schools of thought for three different goals; when a government borrows outside of its accounting environment to reimburse providers of care, misunderstandings of the "cost" consequences result, in the three definitions of medical costs. In short, only broad qualitative trends can be credible at the moment.


Some of the foregoing examples are lurid, and perhaps a little dramatized for effect. But the effect of compound investment income is so impressive, that there really is little question there is plenty of money to do just about everything which needs to be done in health financing. The problem, however, is how to get enough money to pay the right bills, at the right time. The temptation to steer the money into the wrong places has been present since Isaac and Esau, and while the pooling principle of insurance (and government) solves that problem, excessive use of that flexibility is what mainly got us into the present mess. The intrusion of government can be traced to the "pay as you go" system, which amounts to paying long-term debts with current cash flow. This money has been present right along, but political considerations created pressure to begin the government system, right away, and for everyone right away. The citizens are partly responsible, since they have taught politicians they must respond to people taking off their shoes and pounding the table with them. So, yes it's true that compound interest gives an advantage to frugal people, and to some extent to people who are already prosperous. But egalitarianism doesn't justify refusing to do what is in the general interest of everyone. We are currently in a pickle because we took egalitarian short-cuts in 1965, and have preferred to borrow money for healthcare, ending up paying many times what we need to pay, rather than yield to mathematical principles discovered by Euclid, or perhaps it was Archimedes.

But while Health Savings Accounts, individually owned and selected, have more investment flexibility to take advantage of the necessarily higher returns of the private sector, and the flexibility to choose superior investment techniques as they are invented, and the flexibility to adjust to personal circumstances rather than universal absolutes,-- they lack the flexibility to pool resources between different persons and times. Perhaps this flexibility could be extended to whole families, since there are shared perplexities of pregnancy, age group and divorce which must be addressed in a communal forum, and perhaps churches or clubs could fill that role. But in our system sooner or later you get mixed up with a lawyer, judge or investment advisor. And therefore must contend with moral hazard, and disloyal agents. By this time, I hope we have learned the weaknesses of that new branch of government, the government agencies. As Adlai Stevenson quipped, "It used to be said, that a fool and his money are soon parted. But nowadays -- it could happen to anyone."

So I recognize that although some people in a Health Savings Account system will have barrels of money, while others will be desperately in need, the fact that on average there is plenty of money to fund everybody isn't quite good enough. Somewhere a pooling arrangement must be created, and the fact that the people running it will be overcompensated must be shrugged off as inevitable. But since the people who trust it will be fleeced, they might as well be the ones to create or select it.


This book was intended as part of a larger volume about the Affordable Care Act of 2010, commonly called Obamacare. However, that whole episode is still vexed with unexpected developments, so I set the longer version aside lest it get still longer. This slimmer one concentrates on what I would offer in place of the ACA. I fully expect any criticism of an American President's plan to be greeted with, "OK, wise guy, what would you suggest that's better? " So, here it is.

It's the Health Savings Account, in two forms. The 1981 version works pretty well, but the passage of time shows the need for a dozen or more tweaks, which are explained individually. The original version has demonstrated a 30% cost reduction among several million early-adopters. So perhaps if we polish a few rough spots, the 30% savings will spread the idea further. Whether it spreads any faster will unfortunately depend on national politics.

Meanwhile, in searching for a way to cut cost, I discovered much less expensive variations of Health Savings Accounts can be developed on a lifetime model. Lifetime insurance makes it possible to eliminate costs like covering gall bladder removal in people whose gall bladder has already been removed. Even more important, it provides a framework for combining several advances like: whole-life insurance, passive investing, direct-pay insurance, and possibly even some Constitutional reconsiderations. Extra complexity worries me somewhat, because although some people will quit trying to understand it, and just adopt it because it works, other people will reject it because it sounds confusing. As it gets more complicated, it just has to get more paternalistic, and opinions differ on whether that is an advantage. There are enough Americans who won't accept anything unless they understand every word of it, so their carefulness will keep it slowed down. Even that has some advantage: a careful approach will upset fewer apple carts.

No doubt the two versions of Health Savings Accounts could be described in fewer pages. But greater density often hinders comprehension, seldom helps it. Furthermore, presenting an alternative without a critique would leave the reader uncertain whether I believe the Affordable Care Reform presently goes too far, or not far enough. (In fact, both things are true, because it seems so likely both government and business employers will abandon the patient in pursuit of other agendas.) At the same time, the present system seems unsustainable. It needs more balance between benevolence and fiscal prudence, and it needs more restraint to both sides protesting the other will ruin us. Of course we must do what we can for the poor. But we also need to stop promising more than we can deliver. In the very long run, it won't be politicians, it will be scientists who seriously reduce the cost of disease for everyone, by eliminating diseases. Until that happy day arrives, we need to maintain a lowered tension of attitudes. When government and business operate as partners, that's nice, but somehow it doesn't sound like a level playing field for the rest of us.

The Affordable Care Act contains at least two innovative ideas which I certainly endorse. The idea of direct payment of insurance from client to insurance company (replacing employers as absentee brokers), is good, since it reduces the temptation for financial intermediaries to abuse the role of umpires. Rent-seeking is the technical term for this, I believe. Most office and outpatient claims could be paid by a bank credit card, streamlining the slow and expensive claims processing approach. Sadly, we may never know the full benefits of direct payment, because public dismay at the fumbling introduction of computerized insurance exchanges could poison direct-pay indefinitely. And secondly, to go on with my diplomatic message, the ACA use of a "cap" on out-of pocket payment seems like a simple, clever way to avoid adding another costly layer of re-insurance. The system already requires three levels of insurance (basic, supplementary, and major medical) to pay simple claims completely; it doesn't need more layers. These two features, translated as -- more business efficiency, and less mission-creep -- could easily be allied with Health Savings Accounts, which already bring financial pragmatism to several million Americans, voluntarily. Remember, this country responds poorly to almost anything with the word "mandatory" in it.

However, two points of agreement are not enough innovation to balance the remaining unevenness. I regret how the Affordable Care Act continues to push the square peg of "service benefits" into the round hole of casualty insurance. That sort of incompatible mixture befuddled things for a century, and I look for little good to come of it. Except for helpless hospital inpatients with a tube in their nose, service benefits generate rent-seeking, because service benefits blur the boundaries and create loopholes. Later on, we describe the confusion and exploitation created by service benefits (renamed Diagnosis-Related Groups) as a method of reimbursement. If sharpened and refocused, they ease the problem of negotiating prices with people too sick to cope with finances. But wide implementation of that approach without thoughtful pilot testing, has resulted in bewildering chaos in outpatient pricing. Even dropping DRG and returning to the old system would now pose a daunting risk, for one main reason. The DRG system has made hospital outpatient prices -- totally meaningless. As a goal, the role of service benefits should be revised for inpatients, but eliminated for outpatients, who are generally alert for better bargains. Two systems of payments, for two entirely different requirements. As it happens, this is neither the fault of Obamacare nor inherent in Health Savings Accounts. So we must break off with the essential moral: one size fits all is a poor approach, and mixing two fairly good approaches into one approach for everyone, leads into the wilderness.

The Health Savings Account is a mixture of two approaches which leaves the choice flexible enough, for the patient to go either way. It's a mixture of cash payments with insurance coverage. It can be viewed as cash with insurance standing behind it, or it can be viewed as insurance with cash to fill in the gaps. That may be a problem for Congress to decide which committee has jurisdiction, but in practice it is a useful incentive to be frugal. The tendency should be resisted to specify that one is to be used for inpatients, and the other for outpatients. That's the way it mainly works out, but there are plenty of exceptions. My friends in administrative positions will have to forgive me for saying no one really likes uniformity -- except administrators. What has evolved is to make a hybrid of the two approaches and apply the hybrid to everyone. Admittedly, individually owned accounts create some technical difficulty for tax-free cross-subsidy, and I thoroughly understand the nation's attachment to pooled insurance as a way to subsidize the poor and helpless. But technical difficulties can be overcome, whereas pooled insurance, totally under political control, will usually impoverish a good-hearted nation; and that's where we are heading. I'm not going to explain further, because it's not the main topic of the book. The main topic is how to save money. No matter how complicated it sounds, at least it's easy to measure the result.

Regardless of chapter markings, there are only two topics: regular Health Savings Accounts, as they exist today. And Lifetime Health Savings Accounts, as I hope they will evolve, tomorrow.

George Ross Fisher, MD


November, 2014

SECOND FOREWORD (Whole-life Health Insurance)

Reader, switch your mental gears. This second Foreword is a summary of a radically modified proposal. The Health Savings Account idea was originally created in 1981 by John McClaughry of Vermont, jointly with me, as a form of health insurance and now has subscribers numbered in the millions. While its progress has been fairly slow, it's jarring to have it portrayed as a spoiler when it's been around for thirty years longer than the President's plan. His plan was probably rushed too fast, and mine hasn't been pushed hard enough. On the other hand, the revised proposal, called Lifetime Health Savings Accounts, really is brand-new.

Elements of it have been around for a century, but even the life insurance industry might be dubious to hear whole-life coverage presented as an investment. After all, life insurance makes little real difference to the donor, after he is dead; it's primarily for transferring benefits to someone else. That's why the concept of "cash value" was added. As the level of income taxation rose, tax-free internal transfers assumed new value. No doubt, life insurance didn't generate as much money a century ago as it does today, mostly because longevity is so much increased. Extended life expectancy gives compound interest so much longer to grow, it transforms the practical uses of the vehicle. If you desire intergenerational cost shifting for health costs, you probably must incorporate some form of insurance as a pooled transfer vehicle. This newer variation also enables shifting funds within the account, to a later time in life. That adds up to a much stronger individual incentive for savings than proposing your generation might support mine.

As a final feature, Catastrophic high-deductible is here added, providing stop-loss protection. It's single-purpose coverage, based on the idea that the higher the deductible, the lower the premium. Cost saving runs through all these multi-year ideas, but lifetime coverage is a cost-saving whopper. It transforms Health Savings Accounts into a transfer vehicle for funds, from one end of life to the other, forward from the present. And backwards from the future in the form of reduced Medicare premiums and/or payroll deductions. The last-year-of life could be chosen as an example because it comes to 100% of us, and is usually the most expensive year for healthcare. But needs differ, and a ton of money sounds pretty good at any age. A Health Savings Account can also be used as a substitute for day to day health insurance; so to distinguish the two, this particular variation has been called Lifetime Health Savings Accounts. Another term might be Whole-life Health Insurance, although multi-year health insurance is probably more precise. The idea behind presenting this concept piecemeal it to provide flexibility for both overfunding and underfunding, since the time periods for coverage can be so long (and the transitions so variable) that both eventualities might occur at some point.

The simple idea is to generate compound investment income -- not presently being collected -- on currently unconsumed health insurance premiums. And eventually, to apply the profit to reducing the same individual's future premiums. Even I was startled to realize how much money it could save. It's essentially a scaled-up version of what whole-life life insurance does. Since lessened premiums generate lessened investment income, the math is complicated even when the theory is simple, but every whole-life insurer has experience with it. For example, if someone had deposited $20 in an HSA total market Index fund ninety years ago, it would now be worth $10,000, the average present healthcare cost of the last year of life. Neither HSAs nor Index funds existed ninety years ago, and of course we cannot predict medical costs ninety years from now. This is therefore only an example of the power of the concept, which we can be pretty certain would save a great deal of money, but skips the guarantees about how much. Investment problems are discussed in Chapter Four.

Furthermore, people would be expected to join at different ages, so the ones who join at birth in a given year have accumulated funds which must be matched by late-comers. In our example, if a person waited until age twenty (and most people would wait at least that long), he would need to deposit $78 to reach $10,000 at age 90. It's still within the means of almost anyone, but the train is pulling out of the station. Participation is voluntary, but no one saves any money by delaying subscription, and learns a bitter lesson when he tries. Notice, however, that no one pays extra for a pre-existing condition; it costs more to wait, but it does not cost more to get sick while you wait. If the government wants to pay a subsidy to someone, let the government do it. But nothing about the whole-life system compels increased premiums for bad health, or justifies lower premiums for good health.

Whole-life health insurance takes advantage of the quirk that the biggest medical costs arise as people get older, whereas health insurance premiums are collected early in life, when there is considerably less spending for health. The essence of this system is to reform the "pay as you go" flaw present in almost all health insurance. Like most Ponzi schemes, the new joiners do not pay for themselves, they pay for the costs of still-earlier subscribers, a system that will only work if the population grows steadily. When the baby boomers bulge a generation, they bankrupt the system when they themselves start to collect. Everybody knows that. What is less generally known is that "pay as you go" systems fail to collect interest on idle premium money; this system does that, and it turns out to be a huge saving unless the world collapses. Medicare and similar systems necessarily can't collect interest during the many-year time gap between earlier premiums and later rendered service; potential compound interest is therefore lost. "Pay as you go" is only half of a cycle; adding a Health Savings Account converts it into a full cycle like whole life insurance, and furthermore restores the savings to the individual, not the insurance company. Allow me to point out that a subscriber doesn't even lose money if he drops the policy, thus avoiding one of the regularly uncomfortable features of life insurance. Whole-life life insurance is more than a century old, but health insurance somehow got started without half of it, the half which could lower the premiums. Nobody stole those savings, they just never appeared, because unused premiums in Pay-as-you go are immediately spent for someone else and therefore, never invested. Adding one feature already enabled by Congress, the Health Savings Account effectively permits tax-free saving, and passes it back as reduced premiums (but only if your health insurer agrees to it.)

Individuals own their own Health Savings Accounts, but most people would probably be wise to pool the funds in a general custodian account. We propose an index fund as a way of solving the investment issue. If government sponsorship is expected, the index fund would be wise to include the stock of every American company above a certain size. An apparently paradoxical transfer backwards in time is made possible: by matching it with Medicare's already reverse process of paying for current terminal-year costs with some other subscriber's currently collected "premiums" (usually payroll deductions). Both the individual subscriber and Medicare then benefit from completing the cycle and harvesting the income. To the extent that investment income has been generated by the passage of time, the subscriber gets cheaper insurance and the insurer gets lower costs. For the most part, this system would be almost invisible (once the agreements are established): by using Medicare regional average costs, instead of individually itemized costs. Notice it make no difference which health insurance actually covers the bills, although the presumption is that for most people it would be Medicare. At the most, it is about as simple as buying life insurance to pay for your coffin.

In the meantime, something or somebody must pay those last year of life expenses as they occur, never knowing whether this is a final year or not. That will probably be Medicare, but it could be anybody, so the Health Savings Account could also reimburse other payers, including secondary payers. Please notice that an enlarged or "accordion" plan starts paying out at the far end of lifetime expenses. It could then work forward to paying the second or third or more years before the last one, if there is excess money in the fund -- just the reverse of what you might expect. It could then also reduce coverage if contributions don't match the average. Current healthcare insurance is nicknamed "pay as you go"; I suppose I must resign myself to "die as you go" describing this proposal to round it out.

At first there must be transition costs, but nothing approaching what appeared in 1965. When Medicare began, the taxpayers just wrote off the costs of those who were already aged 65 or older, and by skipping withholding taxes for part of the woking lifetimes of everybody up to forty years younger, must have run a very sizeable deficit for a very long time. This proposal should have no such burden, since (by working in reverse) it needn't pay twice for all of the costs which have already been paid once. This peculiar surplus might be applied to the huge unfunded debt obligation which Medicare has already incurred, in part because of free-riders who were born before 1900 and are all dead, and partly because in 1965 we had a positive international trade balance and thought we could afford anything. Although it has the potential to become a political football, no one seriously expects such windfall profits to go entirely to the subscribers.

Some people say 60% of Medicare costs are now paid out for health expenditures of someone during the last year of his/her life; thirty percent sounds more plausible, even taking co-insurance and self-insurance into account. Nor can anyone predict what such costs will be, fifty or sixty years into the future, so someone has to calculate continuously what they actually are, from ongoing Medicare statistics. But let's say they really are 60%, which I rather doubt. That would mean premiums and taxes could be reduced by 60% in the meantime. The idea is to make certain to pay for the last year of life, making annual adjustments for what the costs are actually proving to be. Extending the idea is probably best delayed until some experience accumulates.Someone must calculate the annual inflation in average healthcare expenses, matching it with investment returns, and possibly adjusting the contribution levels if things do not point to a good outcome. If life expectancy continues to lengthen, the amount of investment income could be larger than anticipated. On the other hand, if an expensive cure for cancer makes a dramatic appearance, perhaps the individuals haven't put enough money into the investment fund. Someone will have to be empowered to respond to circumstances, in either case.

All this creates an incentive to overfund the Health Savings Account. Surplus which remains after death is a contingency fund, probably useful for estate taxes or other purposes; but on the other hand the uncertainty of estate taxes creates an incentive not to overfund by much. Most people would watch this pretty carefully, and soon recognize the most advantageous approach of all would be to pay a lump sum at the beginning, at birth if possible. Before someone roars in outrage about the uninsured, let me say this would work for poor people with a subsidy, and it begins to look as though the Affordable Care Act won't work unless it is subsidized. In that case, a downward adjustment doesn't reduce premiums, it reduces the subsidy.

This proposal envisions starting with last-year-of life coverage, making provision for two accordion-like extensions: at the beginning for early, late or skipped payments. And at the other end for more, or fewer, years before the last year of life. There is no doubt that dual accordion-like flexibility creates an arithmetic problem, but most of this could be reduced to look-up tables. In this way, most of the initial complexities become surprisingly manageable because: the expectation of death is 100%, almost all deaths are covered by Medicare, and the bulk of Medicare revenue comes from payroll deductions earlier in a working life, rather than premiums from current recipients. Maybe these advantages are overestimated, but over and over again it has to be repeated: this plan may not save as much as I hope, but it will save a lot. In the meantime, the quirks of Obamacare will become clear enough to see what can be done with the same concept for people now under the age of 65. Meanwhile, I feel this book will never get published if I wait to find out.

Investment It seems best to confine the investments of a nation-wide scheme to index funds of a weighted average of the stocks of all U.S. companies above a certain size, and thus offering pooling for those who are (rightly) afraid of investing. This will disappoint the brokerage industry and the financial advisors, but it certainly is diversified, fluctuates with the United States economy, and has low management costs. In a sense, the individual gets a share in a nation-wide whole-life health insurance which substitutes long-run equities for conventional fixed income securities. It removes the temptation to speculate on what is certain to occur, but on dates which are uncertain. Treasury bonds might be added to the mix, but almost anything else is too politically vulnerable to political temptations. Even so, it will have downs as well as ups, and therefore participation must be voluntary to protect the index manager from political uproar when stocks go down, as from time to time they certainly will.

One danger seems almost certainly predictable. This book has chosen 7 percent assumed return, mostly because it happens to make examples easy to calculate. The actual required return is probably closer to 4% plus inflation. Supposing for example that 7 % is the right number, there is little doubt a steady investment return is only achieved on an average of constant volatility, sometimes returning 20% in some years, and sometimes declining as much or more in other years. Judging from past experience, there will be a temptation for some people to make withdrawals in years of bull markets, which could reduce average returns to 3 or 4 percent in bear market years, and fall short of the 7% average at the moment it is needed. In addition, the officers of Medicare are likely to be tempted to pay Medicare more than a 7% average in windfall years, leaving the running annual average to decline below 7%, just as the trust officers of pension funds once deluded themselves by temporary runs of bull markets. Ultimately this issue reduces itself to a question whether a temporary surplus is really temporary, and if not, whether the subscribers should benefit, or the insurance company. After that is decided, extending or contracting the accordion would get consideration. It seems much better to negotiate these philosophical questions of equity in advance, and establish firm rules before sharp temporary fluctuations are upon us.

Insuring the Uninsured. Because universal coverage has great appeal, I have gone through the exercise of calculating whether the impoverished uninsured might be included by using subsidy money to provide a lump sum advance premium on their behalf. It would work, in the sense that it would be less costly, but I do not recommend beginning by including it. Reliable government sources have calculated that even after full implementation, the Affordable Care Act will leave 31 million people uninsured. That is, there are 11 million undocumented aliens, 7 million people in jail, and about 8 million people so mentally retarded or impaired, that it is unrealistic ever to expect them to be self-supporting. In my opinion, it is better to design four or five targeted special programs for these people. Better, that is, than to include them in any universal scheme that the mind of man can devise. But to repeat, the mathematics are adequate to justify the opinion that it would save money to include them in this plan with a front-end subsidy of about five thousand dollars, adjusted backward for fund growth since birth. I refuse to quibble about investment size, since no one can be certain what either investments or medical science will do in the future. It seems much better to make annual recalculations for inflation and medical discoveries, and then make adjustments through an accordion approach for coverage . There seems no need to make precise predictions, since any benefit at all is an improvement over relying on taxpayer subsidies, which now run 50% for Medicare itself. This plan will help somewhat, no matter what the future brings, and as far as I can see, it would make the presently unmanageable financial difficulties, more manageable.

George Ross Fisher, M.D.

I'm overwhelmed. I'm thinking of a one-line poem by William Blake: "Enough or too much" " stragglers who live from 85 to 91." Sorry to be a burden, but soon to be 91 I can still go a couple of rounds without huffing and puffing. You remind me of Dr. Melvin Konner.... professor.... anthropologist..... physician.
Posted by: Martin   |   Sep 27, 2014 5:16 AM
I want to thank you for this wonderful resource. I find it fascinating. May I offer one correction? In the section "Rittenhouse Square Area" there is reference to the Van Rensselaer home at 18th and Walnut Streets and its having a brief fling as a club. I believe in 1942 to about 1974/5 the Penn Athletic Club was located in the mansion. The Penn AC was a good club, a good neighbor and a very good steward of the building - especially the interior. It's my understanding that very unfortunately later occupants gutted much of the very well-preserved original, or close to original, interiors. I suppose by today's standards the Van Rensselaer-Penn Athletic Club relationship could be described as a fairly long marriage. The City of Philadelphia played a large role in my life and that of my family, and your splendid website brings back many happy memories. For me and many others, however, there is also deep sadness concerning the decline of so much of the once great city and the loss of most of its once innumerable commercial institutions. Please keep-up your fine work. Your's is a first-class work.
Posted by: John D. Mealmaker   |   Aug 14, 2014 2:24 AM
Dr. Fisher, The name Philadelphia University was adopted in 1999, as you write, but the institution dates to 1884 and has been on School House Lane since the 1940s. It acquired the former properties of the Lankenau School and Ravenhill Academy, but it did not "merge" with either of them. I hope this helps when you update your site.
Posted by: David Breiner   |   Jun 11, 2014 10:05 PM
Hello Dr. Fisher, I was looking for an e-mail address and this is what I could find. I must tell you my Mother who you treated for years passed away last May. She was so ill with so many problems. I am sure you remember Peggy Marchesani. We often spoke of you and how much we missed you as our Dr. You also treated my daughter Michele who will be 40. I am living in the Doylestown area and have been seeing the Dr's there.. I just had my thyroid removed do to cancer. I have my fingers crossed they get the medicine right. I am not happy with my Endochronologist she refuses to give me Amour. I spoke with my Family Dr who said he will take care of it. I also discovered I have Hemachromatosisand two genetic components. I have a good Hematologist who is monitoring me closely. I must say you would find all of this challenging. Take care and I just wanted to convey this to you . You were way ahead of your time. Thank you, Joyce Gross
Posted by: Joyce Gross   |   Apr 4, 2014 2:06 AM
I come upon these articles from time to time and I always love them. Is the author still alive and available to talk with high school students? Larry Lawrence F. Filippone History Dept. The Lawrenceville School
Posted by: Lawrence Filippone   |   Mar 18, 2014 6:33 PM
Thank you for your articles, with a utilitarian interest, honestly, in your writing on the Wagner Free Institute of Science [partly at "" - with being happy to post that url but the software here not allowing for the full address:)!] I am researching the Institute, partly for an upcoming (and non-paid) presentation and wanted to ask if I might use your article's reproduction for the Thomas Sully portrait of William Wagner, with full credit. Thanks very much for any assistance you can offer here. Josh Silver Philadelphia
Posted by: Josh Silver   |   Jun 2, 2013 1:39 PM
Thank you for your articles, with a utilitarian interest, honestly, in your writing on the Wagner Free Institute of Science [partly at "" - with being happy to post that url but the software here not allowing for the full address:)!] I am researching the Institute, partly for an upcoming (and non-paid) presentation and wanted to ask if I might use your article's reproduction for the Thomas Sully portrait of William Wagner, with full credit. Thanks very much for any assistance you can offer here. Josh Silver Philadelphia
Posted by: Josh Silver   |   Jun 2, 2013 1:39 PM
George, Mary Laney passed away last November. I was one of her pall bearers. She had a bad last year. However, I am glad that you remembered her and her great work. I will post your report at St Christopher's and pass this along to her husband Earl. Best wishes Peter Hunt
Posted by: Peter Hunt   |   Mar 28, 2013 7:12 PM
Hello, my name is Martin. I came across [] and noticed a ton of great resources. I recently had the honor of becoming a part of a new non promotional project on We decided to put together a brief guide about cirrhosis, and the dangers of drinking. We have received a lot of positive feedback and I wanted to suggest that we get listed on the above mentioned page under The National Institutes of Health. Let me know what you think and if you have any further requirements or suggestions.
Posted by: Martin   |   Jan 1, 2013 8:51 AM
Posted by: SUSAN WILSON   |   Aug 12, 2012 12:49 AM

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