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

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Pearls on a String:Further Extending Health (and Retirement) Savings Accounts
Pearls on a String: Further Extending Health (and Retirement) Savings Accounts. HSAs are the string. Retirement saving, Privatizing Medicare, and Shifting Childhood Costs-- are the Pearls. Other Pearls to follow.

...Authorship of the Constitution
There were seventy invited delegates to the Constitutional Convention. Fifty-five attended the sessions, and thirty-nine signed it. We believe the main contributions were made by seven or eight men. But you can never tell, for certain.

Health Insurance
Clinton Health Plan and its replacements.

(3) Obamacare: Speeches
New topic 2015-09-25 21:48:47 description

Introduction: Surviving Health Costs to Retire: Health (and Retirement) Savings Accounts
New topic 2016-03-08 22:42:53 description

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Pearl #3: Medicare Supplement, Only 20 Percent of a Pearl on the String

Now that we have described Health Savings Accounts as the string linking a string of pearls, we must have a second look at one of the pearls, because in a sense it is two of them. Medicare, it may be recalled, only pays for 80% of its patient's liability, while the other 20% is the patient responsibility. That is, Medicare has a 20% co-payment. Most people who can afford it, will purchase a secondary insurance policy from Blue Cross or a commercial insurer, to cover this 20% liability. Those who cannot afford such policies will often apply to state Medicaid, to become what is known in the trade as a "dual eligible". Those who are not eligible for Medicaid will often just take a chance on their personal resources, often becoming a source of the hospital's or doctors' bad debts. It is thus a curious feature that much of a hospital's bad debts come from the lower middle class.

Co-pay has a long history and a bad reputation. Most textbooks will say it is a form of patient participation in his costs, and a restrainer of abusive claims. But it long ago developed the practical role of adjusting the premium cost during group negotiations. If you don't get sick, you will have no co-pay obligations, but if you do get sick, it extinguishes 20% of the cost. So, although Medicare co-pay secondary insurance responds to the 20% co-pay feature of Medicare, in company negotiations for group policies for younger employees, it can be 30% or 27% or some other number, because the negotiators discovered that doing so reduced the cost of the insurance by 30% or 27% or whatever. It greatly facilitated middle-of-the night negotiations, with calculations on the back of an envelope, and probably had little relationship to restraining medical overuse. Quite obviously, it created the need for a secondary insurance, with a double dose of administrative costs and profits. So an expensive and largely futile feature has persisted for seventy or more years, deeply imbedded in Medicare for fifty. Usually the carrier for the secondary insurance is the administrator for the 80% which the government pays, but nevertheless two confusing reports ("statements of benefits") for two different insurances come trickling in to the patient separately, two or three months after one treatment took place. But it does save the government 20% of its cost, so it persists.

In the case of Medicare, there is another quirk. As mentioned earlier, about 50% of the government's share of the cost, is borrowed. Insurance companies often borrow money, too, but usually not attached to a specific policy. While there may be hidden arrangements between Medicare and its secondary carriers, on the surface it would appear the secondary carrier's 20%, actually represents 33% of Medicare's cash flow. If that's the case, nothing short of a bull in the China shop will dislodge the preposterous dual-insurance system. Furthermore, it seems likely this cash leverage is playing an important hidden role in the ACA negotiations with large group employers. Eventually, this leverage is what might threaten ACA with disruption, but that issue gets us off the topic of Medicare, though the issues sound very similar.

Having earlier reviewed the finances of the 80% of Medicare, and found that financing it is rather precarious, let's look at the more modest goal of financing the 20% co-payment insurance with the available resources. That's a financially more modest goal, but a more achievable one, and one which would remove a large source of public dissatisfaction.

* * * If we were commercial insurance investors dealing with a failing health insurance partner, no additional money infusions would seem sensible until Medicare stopped losing so much money. Because we are talking about a government program however, we must resort to the stance that a new program does not have to accept old debts, only new ones that it had a hand in creating. Therefore, this proposal does not include the repayment of old debts, regarding them as the government's problem to resolve. In many ways, Medicare was a noble achievement, but even the richest country in the world cannot afford to run a 50% deficit indefinitely, in an entitlement program grown so large. Undertaking to correct its mistakes does not imply assuming its debts. Furthermore looking forward, a looming retirement funding crisis, of at least equal size, threatens to replace it as the largest consequence of its heedlessness. Was this lengthening of longevity by thirty years a bad thing? Of course not. The bad thing was to let finances get into their present state before addressing them. The bad thing was to kick the can down the road, for fifty years. Because so few people seem to understand them, let's next review a quick summary of Medicare finances.

The Basic Funding Structure of Medicare. Approximately one quarter of Medicare is paid for by its premiums, often derived from reduced Social Security payments, (a circular solution, if you regard prolonged longevity as a hidden cost of Medicare). Another quarter of Medicare is paid for by a 3% payroll withholding tax on younger, working people. (Unfortunately, this money is immediately spent, in a process quaintly known as "pay as you go"). And finally, half of Medicare expense ($260 billion annually) isn't paid for at all, it's just debt, initially paid for out of general taxation and then floated away by bond issues.

Suggested Solutions:

1. Extract Income From the Float. To attack the problem we would probably need to do many complicated things, but the first step might be pretty simple. We once contemplated a transfer-entrant into this revised program be required to sign an authorization to redirect payments for Medicare cost on his behalf to his own Health Savings Account. From his point of view, nothing changes except the postal address of his payments, which becomes his Health Savings Account. If he is between the age of 25 and 65, his withholding tax is so directed; if he is already on Medicare, it is his Medicare premiums. That's a payment stream which stretches sixty years, overall. Depending on his present age, first it is one, and eventually it is the other. That wasn't so hard, was it?

The money now starts to earn investment income, which is new money for the program, with the surplus eventually going through the Health (and Retirement) Savings Account into retirement funds. One way of looking at this rearrangement is to say the beneficiary has been given the money to pay the bills, but relieved of the obligation to pay old debts. He has also been given latitude to invest the income and use the profit to fund his retirement. What does the government get out of it? It potentially gets an abatement to annual increases in debt, plus the hope the retirement incentive will restrain cost escalation. If you wish, you could say the principal value to the government is creating the incentive at the end of the program. Meanwhile both parties can pray that science will reduce future medical costs, not raise them. But however it turns out, this solution turns out to be too small to make a significant change in the management of Medicare's debt, so we go on to other approaches. However, it raises an interesting point for a brief digression:

Using the shorthand that Health Savings Accounts ought to produce at least a 7% return, and money at 7% doubles in ten years, a quick look at pre-financing present Medicare payments is a little disappointing. In the Secretary's report, Mrs. Sibelius tells us annual Medicare expenses are about $560 billion, and cash revenue aims to be half that, or $280 billion. If the cash revenue resided in the individuals' HSAs, it might add 7% revenue, or 19.6 billion per year. That sounds like a worth-while amount, and it could be approximated it would apply to each yearly age cohort for 65 years (45 years of wage withholding, followed by 20 years of Medicare premiums). Since the system has been in place for many years, it has reached a steady state, net of demographic and economic variations. So an age cohort will collect a lifetime average of 65 x 19.6, or $1,274 billion, or 1274 divided by 500 million individual recipients, or $2548 per lifetime. It certainly sounds as if the maneuver would be worthwhile, because the government would be no worse off, and the subscriber would have $2548 more in his HSA.

But Michigan Blue Cross has estimated the average person spends $350,000 per lifetime for health, half of which is covered by Medicare; and so 25% of that is Medicare revenue. Even by the roughest sort of estimation, this proposed re-direction of revenue would save less than 1% of the cost of Medicare, because revenue is such a small part of cost. To put it another way, this approach might be an important funding device if indebtedness were not such a large part of Medicare's budget. We have not calculated the effect of compounding, which might theoretically reach several times its original size as stated revenue.. On the other hand, neither have we recognized the annual increase in Medicare spending, which its trustees report to be 5.7% per year. Both 7% and 5.7% are fragile projections of the future, one of Medicare spending and the other of the stock market. As long as annual increases in cost are so close to investment revenue from cash revenue, any hope of substantial investment revenue is at the mercy of minor yearly volatility. and cannot be relied on. The best to be reasonably hoped for this proposal is to stop the growth of Medicare deficits. It should be done, nonetheless, but there is no political advantage to be gained from emerging with the problem apparently unchanged.

A second weakness of this approach is variation in proportionality between revenue and expenses among various government programs. Last year, the Social Security budget was $888 billion, while the total Medicare budget was $618. A quick glance at my secretary's pay stub reveals she has five times as much withheld for Social Security as for Medicare. The approach of investing the withholdings until the day they are spent is a good one. But if widely applied, would have drastically unexpected consequences.

Additional Proposals to Supplement Medicare Income. Since Medicare is so underfunded by its revenue, the hope of extracting additional income above 7% is pretty dim. Therefore, the hope of significant cost abatement must come from three other proposals, all of which require the investment of fresh funding. That is, they are investments, not miracles:

2. The Second J-Shaped Curve, Within Medicare. All healthcare costs with the exception of premature birth, genetic disorders and the like, are migrating to older age groups. One of the main sources of disruption is the migration of costs from working people to people on Medicare.

But within Medicare, costs are also migrating into later life. Half of Medicare costs are paid on behalf of the last four years of someone's life. Since Medicare extends about twenty years after retirement, half of total Medicare cost would vanish from its annual budget as a result of placing this burden somewhere else. This might be called the Last Four Years of Life Reinsurance, a component of the First and Last Years of Life reconstruction of healthcare finance, to be described later. The consequence is partly funding forward toward death, partly funding backward toward childbirth, and so reducing the transition time. The present system, it may be recalled, always funds forward toward death, and buries childhood in "family" plans. That's the background.

But death is the end of the line; costs can't get pushed any later, although curiously, revenue just might be. Therefore, the unique features for transitioning Medicare to some other system reside not only in the universality, but also the finality of the cost of terminal care. This entity has a soft lower border, but we know that half of medicare costs are concentrated in the last four years of life, creating a simple surrogate. Paying terminal cost separately allows the remaining cost of Medicare to be cut in half, by spreading it over the remaining sixteen years. Transition time is also halfed. Moreover, smaller pieces are considerably easier to fit into a transition scheme, so the ultimate product fits the cost curve more comfortably. By the way, the last years of life are not the same as the last years of Medicare, and can only be calculated in retrospect, after the death of the individual.. This is the reality which allows one insurance to be paid out as costs are incurred, and a second, re-insurance, to repay the first one after the facts are in. Funding the re-insurance from birth allows compound interest to pay for most of the magic, in a forward direction. And making obstetrics/pediatrics into a gift from parent to child, allows it to fund backward.

3. Contingency Fund. But wherever is this money, half the cost of Medicare, to come from? Terminal care is predictable the day you are born, so you might as well fund it when it is cheap. A separate fund could be imagined, but for simplicity we lump terminal care financing into a general contingency fund. So we next propose to complete the Medicare revenue issue by adding a contingency fund, essentially substituting a subsidy of $1 at birth for a deficit sixty times as large at age 65, and depending on compound interest to make up the difference. (It may well require about $100 up front.) How fast it would actually grow in the intervening 65 years would become evident before then, and appropriate adjustments made, but the person or agency to make the decision should be specified with care. The sixty to one estimate comes from 7% doubling principal every ten years, 2,4,8, 16, 32, 64 doublings in sixty years. How much to begin with is actually the last calculation, adjusted to balance the books as experience gathers to improve the estimate.

4. Extended Contingency Fund. The contingency fund ending when Medicare begins might generate a 64 to one magnification of the initial deposit. However, it could extend to 250-to-one if its boundary were the day of average death (now 84) or 1000 to one if it added 21 years to the date of death and ended where the common law now says a perpetuity begins (one lifetime plus 21 years). Innovations of this sort make many people squirm, but the underfinancing of Medicare in the past leaves little opportunity for conventionality in the future. All of this magic is a function of the mathematics of compound interest; objections to it are sociological, not mathematical. With a leverage of 1000 to one, it is difficult to imagine an inability to pay the front-end $100, when $100,000 is so far in excess of what actually seems needed.

Sweeping proposals of this sort however, do tend to dump their problems at the far end, so the ultimate goal is best stated to be funding part of the individual system backward and still having a contingency fund for safety. That is, the system as a whole may be volatile and require internal borrowing, but each individual HRSA ends up with balanced books. By implication rather than calculation, in ninety or so years, you get rid of the Medicare debt. That's approximately how long it took to create it, too. The system does not "cover" retirement, except perhaps for bare-bones Social Security. It merely closes the individual books after death as described in other sections. Last-Year Coverage is also designed to save money, and thus eventually to generate some funds for retirement, but not likely at first. First and Last Year re-insurance is intended to resemble an accordion, quickly going to the first 25 years of life and the last 4 years of life, then slowly adding other years in the middle. Somewhere along the line, it might even shrink somewhat. At the moment, it appears terminal illness usually lasts four years, a process which might be thought of as "breaking the cocoon of health". Half of Medicare expenditure occurs in the last four years of life, leaving quite a surplus when the other sixteen years of cost are redistributed. In any event, the "accordion" effect is available for use in the transitions.

This completes our proposal for refinancing Medicare. The first step is to eliminaate the supplemental copayment burden by substituting pre-payment for the 20% revenue, and meanwhile letting small front-end investments grow to appreciable size for the remaining 80%. Until we see what must be done to integrate the ACA with the rest of healthcare, it's likely to use up our political capital with the public, just to make that start. Secondly and later, it reduces itself to stabilizing cost increases by first investing the float created by the J-shaped cost curve, combined with cutting forward-financing loose from the debts of the past. Even a program allowed to concentrate on its 50% forward shortfall, must employ some novel approaches to produce annually $250-300 billion in either cost cuts or new revenue. We suggest compound interest is entirely capable of achieving it mathematically by making a total stock market investment starting at birth and continuing to death, or even 21 years after death. All that is necessary to do it on paper is to invest sufficient money at first. Unfortunately, there is an invisible limit to how much the populace is willing to tolerate as an investment, even on such bargain-basement terms, which I postulate to be about $500 per newborn child. Will that suffice for a 65-year investment? Possibly. Will a hundred-year investment cover it? Almost certainly. Do we as a nation have the patience for a hundred-year investment, or the degree of honesty in our agents to leave such huge amounts un-pilfered for a century? That's far less certain.

How Would This Combined Approach Make Medicare Solvent? Medicare has become so over-extended that conventional approaches are soon exhausted. Like any other proposal that might work, this one relies on approaches which are usually best avoided. First of all, it depends on such long time periods that unexpected events would be the rule, not the exception. Many Congresses of many political parties would have to understand it and leave it unharmed for a century. Secondly, such huge amounts of money are involved that tampering, embezzling and fraud are not merely possible, but inevitable. These two problems would confront any reformer. From these two obstacles emerges a third one. Individual Health Accounts would have less risk than gigantic single payers, but some people will be stupid, reckless and venal. If you make up your mind in advance that you will rescue everyone who doesn't succeed, the whole system will be no better than a single gigantic reinsurer overseen by either an idiot or a crook. The opportunities for illegal gains will exceed the opportunities for honest managers. Therefore, smaller is better than bigger, simpler is better than complicated, and success is never guaranteed.

Medicare, possibly yes, retirement income, probably not. To do the quick math in your head, it is useful to remember money at 7% doubles in 10 years. The Medicare deficit doubles every fourteen years. Since Medicare revenue is half of its expenses, its revenue invested at 7% would generate 3.5% of expenses, or just about enough to cancel out the annual rise in the deficit. Current interest rates do not achieve that, but current rates seldom do. During the eight years of the Obama administration, low-cost total market indices averaged 11% gain. Much of this never reached the average stockholder because the finance industry absorbed it, but things seem to be changing quickly. The pharmaceutical industry may possibly be over-represented, but we are proposing to make the average patient become an average stockholder. Let's take the four components:

#1. The Contingency Fund. is designed to be overfunded for contingencies, so it is hard to say how much it should be. The most conservative investment period would terminate at death, but expand to whatever age is necessary, up to age 105. That means the $500 initial deposit never varies. Congress might however decide to vary the initial deposit but keep a shorter time period. It makes no mathematical difference, but its political difference might be considerable.

#2. Delay Liquidating the HRSA at death. Although things get a little threadbare beyond this point, there is no reason to hold back borrowing for a purpose. We are at the point in the compound interest curve where holding the funds for ten years after death would multiply the original subsidy by 128 instead of 64. We are paying the Chinese much less than that for the Treasury bonds, and they would probably be greatly relieved to see a way of recovering their investment. It may not sit very well with some people, but it would surely guarantee repayment. At the moment, repayment looks rather doubtful.

#3. Investing the Pay as You Go. The problems created for others in the payment process have to be reckoned with. We propose the individuals continue pay/go temporarily for half of the withholding tax receipts, effectively unchanged because half the cost has been transferred but the withholding tax revenue remains constant. What is essentially involved is to balance the problems of the current staff against the problems of passing acceptable legislation. But once more, the mathematical "sweet spot" is comparatively easy to calculate, but the political effects are more intangible. It is probably impossible for an outsider to have a firm opinion.

Additional unknowns in this equation are how much nursing home costs from state Medicaid plans would eventually emerge as Medicare deficits. It is common knowledge that although custodial costs are not allowable costs, states have found ways to make them a federal responsibility. We also understand the HRSA owner may get less than 7% income on his deposits. Although the Chinese debt would stop rising, past indebtedness remains unpaid. Current Medicare bills would have to be paid for probably another decade, and may well rise in size. Ultimately, the way to balance the books is to raise the contributions. So, privatizing Medicare might or might not make it costless, but would greatly relieve its present costs. Funding of retirements will have to come from other sources. However, contributions from the two contingency funds could easily be increased.

#4. The Last Four Years of Life Half of Medicare costs appear in the last four years of Life. By reimbursing Medicare for the last four years from other sources, Medicare's average cost is cut in half. but the withholding tax remains the same. Therefore, we come closer to breaking even in several decades, although we probably won't quite make it.

#5. Simplicity, Simplicity. To begin with the opposite of simplicity, two quite unacceptable new ways to manage the medical payment system suggest themselves. One alternative is to consolidate the whole industry, with one corporate administrative arm assuming the payment tasks for everybody, along with the whole delivery system. That scarcely seems appropriate management for a health complex which is already too big to manage. But it seems to generate many current proposals, especially those coming from the bureaucracy itself. Another idea, based on its resemblance to whole-life insurance, proposes a giant company or government department to concentrate on health finance, doing it for everybody. It might seem suitable for an insurance company, a medical school, a computer company, or a medical society. That seems to be what these organizations would like, but it immediately creates additional complexity, because computers only work if you specify some response to every contingency in advance. In a sense, this version of "Single Payer" would be a throw-back to the days when only a big company or a big government could afford to own a computer.

Is medical finance really so complicated most people couldn't handle it by themselves? Let's remember the anguished words of the Tzar: "I don't run Russia. Ten thousand clerks run Russia." What the Tsar was saying, was the problem isn't individual complexity, the problem is the huge volume of simple problems. For example, if we proposed to butter everybody's bread, it wouldn't be hard to do, it would be hard to manage.

{top quote}
Is medical finance really so complicated most people couldn't handle it by themselves? {bottom quote}
Transfer Slips, and Monthly statements, Only. So, yes and no to computers, which what all this amounts to. Abundant cheap computers tempt us to use them for simple tasks, at the risk of making the simple task complex. (In another generation, self-correcting code may correct this problem, at the same time it widens the opportunity for vandals.) The proposal made here instead is a confederation of otherwise free-standing organizations (The Pearls), hiring their own experts, feeding into a common channel of Health Savings Accounts owned by individual patients (The String). Individuals could hire consultants if they pleased but the decisions should be so simple the average high school graduate could cope with them.
One standardized lifetime account form, which serves as a transfer system for a single person's various balances. Sort of like a check-book. It provides a common incentive to be frugal for future retirement, and a common way to multiply such savings.
If that won't suffice for some tasks, we are travelling down the same path as the income tax, and should re-consider such high-handedness.

There might be many networks, as long as their balances are uniformly transferable and they each link ultimately to a transferable retirement fund (The Goal) and a transferable investment fund (The Multiplier). Such networks might grow very large, but still remain quite simple, and decisions which belong to the patient would remain within his control. The only outward purpose of such paperwork would be to transfer credits of the owner to debits of the same owner or vice versa, with the adjusted balance ultimately coming to rest in his retirement account, creating a common incentive to be medically frugal. They would maintain adequate records (which mostly no one ever reads), an information source, and a designated HSA representative, but their outward form and purpose would remain a transfer slip. If you want a simple system, give it to individuals who have an incentive to keep it simple. Don't give it to people who have an incentive to make it complicated.

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If you want a simple system, give it to individuals who have an incentive to keep it simple. {bottom quote}
This particular feature has a political element. The American public now imagines it gets a bargain with Medicare, somehow getting a dollar of healthcare for fifty cents, and therefore a treasure they are unwilling to surrender. In all probability, no organization except the government could participate long with such a deficit, so taking the deficit away from the government necessarily places it in the hands of someone who must balance his books. Somehow, legal protections for the patients against the debts of organizations which participate in the confederation must be established, so they can occasionally provide benefits at a loss, but only within stated limits. Called a "loss leader", the situation is a common one. Two additional savings multipliers must be added, although they will be explained shortly, along with two important investment designs. There are four large sources of new revenue within Medicare:

Investment Mechanisms.We promised to discuss two investment mechanisms which might help matters. The first is the tendency of compound interest to rise with time. We have already shown above that adding another decade to the example will have an exaggerated effect on the outcome. This is an inherant quality of compound interest which crept up on us as science has conquered early death, and should have wide application in the future. As we learn how to avoid borrowing and learn how to be successful creditors, it should become a commonplace to rearrange financing to optimize it.

The second new model is index investing. As international borrowing has vastly increased the money supply, interest rates seem to have settled at a new low. Bonds have always been a zero-sum investment, but recent trends seem to set a new lower boundary. Common stock has more risk and volatility, but John Bogle and others have shown that it is practically useless for an ordinary person to buy anything but total-market common-stock index funds, since the fees charged by intermediaries wipe out any profit from active investing. We recommend a heavy emphasis on this method. Beyond that basic approach, other strategies may be considered as a way to add fractions of a percent to total returns, best avoided by people without experience, or lifetime years to recover from investment misjudgments.

In Final Summary of Privatizing Medicare. Even with considerable twisting, Medicare is so underfunded, no way can be found to self-fund it without adding two to five hundred dollars per person as a pump-primer. That's a great bargain, or course, but it will meet far more resistance than five hundred dollars is worth. Even then, it would require forty or fifty years at the most optimistic. In the Pearls on a String concept, the deficit might be made up by surplus generated by other programs, but it is unlikely to be able to identify such a donor. The Affordable Care Act does not look as though it is going to generate a surplus, for example.


Re-funding Medicare, Pearl #2, Part 3

So we end up funding Medicare mathematically, but with misgivings about both the politics and the economics of it. It would not be the first time America launched an adventure without the money to finance it, as we do almost every time we start a war, or face a depression. However, both the ACA is in doubt, and linked with it is the idea of a single payer with Medicare as a model. Although I have grave misgivings about consolidating delivery systems as a first step, it could be a decision that is beyond the suggestion of a citizen.

Under the present uncertain circumstances -- of wishing to put the ideas forward but lacking the ability to control the environment -- it seems better to hold back on grander designs than just saving a little money. The linkage of Medicare and its secondary insurance is both tight and of long standing. By just eliminating the second insurance policy, we might eliminate a large and useless expense as well as suggest a few ways to save more. Isn't saving several billion dollars worth some effort? The factors which would lead America to embark on a financial crusade as radical as suggested here, are not to be found in mathematics, or even in one-man logic. They are cultural and emotional, mostly evolving out of endless simplification and repetition. The public might be persuaded to try something on 20%, which they would be afraid to try out on a whole program, however floundering it might appear to be.

How Would This Particular Approach Make Medicare Solvent? It wouldn't, but it would help. And it would provide a demonstration of the practicality of some of these ideas for worthy motives, and still leave room to back down if they unexpectedly fail. Most people do not trust their own judgment of complicated math, so we have made it simple. It is surely not the case that every single solution is either too complicated to understand, or too simple to be believable. Every grand proposal, from Otto von Bismarck's social security through the European systems, to Blue Cross/Blue Shield, followed by Harry Truman, Hillary Clinton's foray into HMO, to Barrack Obama's ACA, has proved to be overambitious at the beginning, and woefully inadequate at the end. It seems there ought to be better ways to do things, but this is our way.

Medicare's original design has become so over-extended it has exhausted conventional insolvency approaches. Like any other proposal that might work, our own plan relies on approaches which are usually thought to be best avoided. So the first fundamental is to keep the core of it simple, and be willing to discard the embellishments if circumstances undermine them. The doctors should devise the medical choices, the patients must control the finances, paying only for what pleases them. Government has a limited role in market failures, but very little role in defining them. The goal is to eliminate disease, ultimately reducing its cost to a framework of the first year of life and the last year of life. Anything more must defend itself against efforts to improve, then eliminate it.

And there is another idea which needs testing. Alexander Hamilton persuaded George Washington that "A national debt, if it be not too large, is a national treasure." In 2006, we may have discovered what is a little too large to be sustainable, by permitting banks to convert mortgage debt to stockholder equity and then watching banks topple over from the sudden shift. Up to that time, it was quite legal to rebalance excess debt that way, which is why no one has gone to jail for doing it. And now we have the uncertainty over whether to encourage more of it (as a safety valve), or punish it (as toppling over the entire economy). It does not help matters for the two political parties to take extreme positions without more evidence. Pre-paying for medical care instead of borrowing to pay for it, is an indirect way of testing this thesis.

First of all, our own proposal depends on such long time periods that unexpected events could be the rule, not the exception. Nevertheless, many Congresses of many political parties would have to understand the basics and leave them unharmed for a century. Secondly, such huge amounts of money are involved that tampering, embezzling and fraud are not merely possible, but inevitable. These problems would confront any reformer. From them emerges a third one. Multitudes of individual Health Accounts would have less risk overall than gigantic single payers, because small ones can only be converted into bigger ones, not defeated in a single pitched battle. Inevitably some individuals in charge of any system will prove to be stupid, reckless and venal. The real question is: Compared with What? If you make up your mind in advance that you will rescue everyone who doesn't succeed, the whole system will be no better than a single gigantic reinsurer overseen by either an idiot or a crook, and probably both, from time to time. Index investing is itself a triumph of everyman against the experts, after all. For long periods, single payer systems may be run by saints, but diversity is more resilient in the long run. The more important issue is to define how you will respond when you detect "imperfect agency". The opportunities for illegal gains will inevitably exceed the individual opportunities for honest managers, in size if not in frequency. Therefore, smaller decision units are better than bigger, simpler is better than complicated, and success should never be guaranteed. The irony of the role reversal between the political party of individualism and the party of diversity, is not to be overlooked.

Medicare financing could possibly be eventually covered by this approach, retirement income financing, probably not. To do the quick math in your head, it is useful to remember money at 7% doubles in 10 years. Current interest rates do not achieve that, but then current rates seldom do. During the eight years of the Obama administration, low-cost total market index averaged 11% gain. Most people would never have guessed that outcome in advance. Much of it never reached the average stockholder because the government (taxes and inflation) and the finance industry absorbed it, but public restlessness may change things. The pharmaceutical industry may possibly be over-compensated, but that's not necessarily permanent, either. In this proposal we are proposing to make the average patient become an average stockholder, with little voice in management perhaps, but ultimate ability "to talk with his feet", to buy and sell. Let's take the six components of the proposal:

#1. The co-pay feature. We've offered our opinion that co-pay has little restraining effect on spending, and is only a device for adjusting the amount of insurance to the buyer's budget. So let's take it as that, and use the amount of the copay as, not 20%, but whatever fits our budget. We advocate the accordion principle for predicting future revenue uncertainty. Furthermore, we would abandon the pretense that it is a second insurance policy, and simply pay the carriers a fee for administrative help in running Medicare. That opens it to a bidding process related to work actually performed, eliminates the State insurance commissioner as an actor in this drama, and eliminates a huge source of confusion with the public. Imagine, one statement of benefits instead of two.

#2. The Contingency Fund. is designed to be overfunded for contingencies, so it is hard to say what its upper limit should be. And although on paper no one gets paid off for ninety years, banks are accustomed to rearranging the terms of a loan to shorten the time period for a fee. Dealing with transition periods is an old story for Congressional staff, since otherwise nothing would ever be upgraded. The most conservative investment period would terminate at death, but expand to whatever age is necessary to pay it off, up to age 105. That implies the initial deposit never varies. Congress might, however, decide to vary the initial deposit but devise a shorter fixed time period. It makes no mathematical difference, but its political difference might be considerable and we do not propose to weaken our case by getting into such weedy details.

Eventually, a "sweet spot" should emerge. But let's not drop the argument with a confession of modesty. An officer of a large paycheck company recently declared to me the revenues of essentially all government programs have nothing to do with expenses, and everything to do with politics. True, we operate under a general mandate to balance new appropriations with new revenue sources. But the current payroll deduction for Social Security is five times as high as the deduction for Medicare, with only about 25% difference in expenses between the two programs, for example. The accounting rules for appropriations could be made considerably less political without significant impairment of flexibility. In the long run it is not good politics for the public to discover you have been doing outrageous things. Over and over, you discover the Constitution is a cultural document, intolerant of judges who are obtuse.

#3. Delay Liquidating the HRSA at death. Although things get a little threadbare beyond this point, there is no reason to hold back borrowing for observed volatility. We are at the point in the compound interest curve, where holding the funds for ten years after death would multiply the original subsidy by 128 instead of 64; even 256 is conceivable. We are paying the Chinese much less than that for the Treasury bonds, and they would probably be relieved to see a way of recovering their investment. #2 may not sit very well with some people, but it would surely guarantee repayment, which at the moment, looks rather chancy.

#4. Investing the Pay as You Go. The problems created for others in the payment process have to be reckoned with. We propose the individuals continue pay/go temporarily for half of the withholding tax receipts. That's effectively unchanged because half the cost has been transferred, but the withholding tax revenue remains constant. What is essentially involved is to balance the problems of the current administrative staff against the problems of passing acceptable legislation. But once more, the mathematical "sweet spot" is comparatively easy to calculate, but the political effects are more intangible. It is probably impossible for an outsider to have a firm opinion.

Additional unknowns in this equation are how much nursing home costs from state Medicaid plans would eventually emerge in the form of Medicare deficits. It is common knowledge that although custodial costs are not allowable costs, states have found ways to make them a federal responsibility. We also understand the HRSA owner might get less than 7% income on his deposits. Although the Chinese debt would stop rising, past indebtedness remains unpaid. Current Medicare bills would have to be paid for probably another decade, and may well rise in size. Ultimately, the way to balance the books is to raise the contributions. So, privatizing Medicare might or might not make it costless, but would greatly relieve its present costs. Funding of retirements will have to come from other sources. However, right now contributions from the two contingency funds could easily be increased.

#4. The Last Four Years of Life Half of Medicare costs appear in the last four years of Life. By reimbursing Medicare for the last four years from other sources, Medicare's average cost is cut in half. but the withholding tax remains the same. Therefore, we come closer to breaking even in several decades, although we still probably won't quite make it. The essential feature of carving off terminal care is that it is half the cost of Medicare, and therefore reduces the burden on the other contrivances to reach the final goal of financing it.

#5. Simplicity, Simplicity. To begin with the opposite of simplicity, two quite unacceptable new ways to manage the medical payment system have been suggested by others. One alternative is to consolidate the whole industry, with one corporate administrative arm assuming the payment tasks for everybody, along with the whole delivery system. That scarcely seems appropriate management for a health complex which is already too big to manage. But it seems to generate many current proposals, especially those coming from the bureaucracy itself. Another idea, based on its resemblance to whole-life insurance, proposes a giant company or government department to concentrate on health finance, doing it for everybody. It might seem suitable for an insurance company, a medical school, a computer company, or a medical society. That seems to be what these organizations would like, but it immediately creates additional complexity, because computers only work if you specify some response to every contingency in advance. In a sense, this version of "Single Payer" would be a throw-back in thinking to the days when only a big company or a big government could afford to own a computer.

Is medical finance really so complicated most people couldn't handle it by themselves? Let's remember the anguished words Tzar Nicholas: "I don't run Russia. Ten thousand clerks run Russia." What the Tsar was saying, was the problem isn't individual complexity, the problem is the huge volume of simple problems. For example, if we proposed to butter everybody's bread, it wouldn't be hard to do, it would be hard to manage.

#6. Linking the New Medicare with Health Savings Accounts.. Probably the most important feature of putting pearls on the string, is to avoid tangling the string for the convenience of the pearl. The purposes of the linkage are to acquire a connection to the retirement feature and its incentives to save, and to lengthen the time period of any compound interest. It is not to generate inter-plan borrowings or conveniences, particularly for the early entrants to the string of pearls, at the expense of the later ones.

{top quote}
Is medical finance really so complicated most people couldn't handle it by themselves? {bottom quote}
For Health and Retirement Savings Accounts --- Transfer Slips, and Monthly statements, Only. So, yes and no to computers, which is what all this amounts to. Abundant cheap computers tempt us to use them for simple tasks, at the risk of making the simple task complex and losing the truth in a huge pile of statistics. (In another generation, self-correcting code may conquer this problem, at the same time it will widen the opportunity for vandals.)

The proposal made here instead, is a confederation of otherwise free-standing organizations (The Pearls), each hiring its own experts, feeding into a common channel of Health Savings Accounts owned by individual patients (The String). Individuals could hire consultants if they pleased but the decisions should be so simple the average high school graduate could cope with them.

One consolidated lifetime account form, which serves as a transfer vehicle for a single person's various balances. Sort of like a lifetime check-book. It provides a common incentive to be frugal for future retirement, and a common way to multiply such savings.
If that won't suffice for some tasks, we are travelling down the same path as the income tax, and should re-consider such high-handed laziness.

There might be many networks, as long as their balances are uniformly transferable and they each link ultimately to a transferable retirement fund (The Goal) and a transferable investment fund (The Multiplier). Such networks might grow very large, but still remain quite simple, and decisions which belong to the patient would remain within his control. The only outward purpose of such paperwork would be to transfer credits of the owner, to debits of the same owner or vice versa, with the adjusted balance ultimately coming to rest in his retirement account, creating a common incentive to be medically frugal. This would maintain adequate "records" (which mostly no one ever reads), an information source, and a designated HSA representative, but their outward form and unit would remain a transfer slip. You are striving for a good retrieval system, not a good archive system. If you want a simple system, give it to individuals who have an incentive to keep it simple. Don't give it to people who have a graduate degree an incentive to make it complicated.

{top quote}
If you want a simple system, give it to individuals who have an incentive to keep it simple. {bottom quote}
This particular feature has a political element. The American public now imagines it gets a bargain with Medicare, somehow getting a dollar of healthcare for fifty cents, and therefore a treasure they are unwilling to surrender. In all probability, no organization except the government could function long with such a deficit, so taking the deficit away from the government necessarily places it in the hands of someone who must balance his books. Somehow, legal protections for the patients against the debts of organizations which participate in the confederation must be established, so they can occasionally provide benefits at a loss, but only within stated limits. Called a "loss leader", the situation is a common one, but the effect is quite different from making the government a payer of last resort. Two additional savings multipliers must be added, although they will be explained shortly, along with two important investment designs.

Investment Mechanisms.We promised to discuss two investment mechanisms which might help matters. The first is the tendency of compound interest to rise with time. We have already shown above that adding another decade to the example will have an exaggerated effect on the outcome. This is an inherent quality of compound interest which crept up on us as science has conquered early death, and should have wide application in the future. As we learn how to avoid borrowing and learn how to be successful creditors, it should become a commonplace to rearrange financing to optimize it.

The second new model is index investing. As international borrowing has vastly increased the money supply, interest rates seem to have settled at a new low. Bonds have always been a zero-sum investment, but recent trends seem to set an even lower boundary. Common stock has more risk and volatility, but John Bogle and others have shown that it is practically useless for an ordinary person to buy anything but low cost total-market common-stock index funds ("passive investing"), since the fees charged by intermediaries tend to wipe out the profit from active investing. We recommend a heavy emphasis on this method. Beyond that basic approach, other strategies may be considered as a way to add fractions of a percent to total returns, but best avoided by people without experience, or lifetime years to recover from investment misjudgments.

In Final Summary of Privatizing Medicare. The public sector has been allowed to turn "privatization" into a term of contempt, when in fact it is a goal for the public sector to emulate. Very few people begin their careers in the public sector without spending their whole career there. In that sense, they are natural monopolists and act like them. We should strive for more varied career paths.

Even with considerable twisting, Medicare is so underfunded, no way can be found to self-fund it without adding several hundred dollars per person as a pump-primer. Of course, that's a great bargain compared with a hundred thousand dollars of medical care later on, but it will meet far more resistance than five hundred dollars is worth. Even then, it might require forty or fifty years at the most optimistic, to show a profit. In the Pearls on a String concept, the deficit might be made up by surplus generated by other programs, but Congress is unlikely to be willing to identify such a donor, and indeed it is a slippery path. The Affordable Care Act does not look as though it is going to generate a surplus, for example.


The Segments of Lifetime Healthcare:
Medicare Including Retirement Pearl #1

The Affordable Care Act was announced as mandating health insurance for everyone, but about thirty million people were specifically excluded. The healthcare problems of seven million prison inmates, eight million unemployables, and eleven million illegal immigrants were too specialized to be included in a program which hoped to be one-size fits all. Quite properly, such special outliers would be better handled by special programs designed for their special needs.

The Affordable Care Act (ACA) is now central to Administration attention, and Medicare may be deemed too hot to handle in an election campaign. Nevertheless, we elected here to discuss Medicare but not the ACA. Retirement, childhood, and how to unify complete the list--pretty much all that's left surrounding, but excluding the ACA, election or no election. That emphasizes what had been evaded or neglected, and avoids direct confrontation with the ACA, preparing for the day when that big gorilla is either confirmed or abandoned. It's obviously too expensive, and it remains to be seen whether it can be fixed, or must be abandoned. In our alternative scheme, all of lifetime healthcare would be financially connected to a single lifetime Health Savings Account, one account per person, but the delivery systems would remain semi-autonomous. ACA could surely live in peace with the HRSAs, and could even peacefully adopt the HSA approach. That would save money, but the questions left are whether it would save enough to be worth the trouble, and whether politics will allow it. Like the European Union, it's surely easier to describe than to accomplish.

Retirement as a Medical Issue. The news is precarious for retirement funding. We begin with the far end of life, where most health cost and all retirement cost concentrates. While retirement is parallel in time to Medicare, we begin to recognize increased longevity as an outcome of better health. If one is to help pay for the other, they must, in the Medicare case, draw their funds from the same pool. That's Medicare, which most people don't want to change, but is the first thing which must change. Because unchanged it costs too much to leave anything for retirement.

Although the Industrial Revolution brought many lifestyle improvements in the past two centuries, it also brought turmoil. The idea of leisure time may once have been a reward for the upper 1%, but actually most of the population never dreamed of any leisure time. The novels of the "Lost Generation" after the first World War often revolved around the discovery of unfamiliar leisure pursuits by members of social classes newly learning about such things. The moral, then and now, seems to be that leisure is no bed of roses.

{top quote}
We must assign a reasonable definition to a "decent" retirement, provide for a marginal one, and leave the rest to our own sources of wealth. {bottom quote}
The cultural response seems to be that leisure was best reserved for retirement, although the younger generation sometimes rebelled, wanting some of it sooner. In any event, Medicare surely extended retirement longevity. (Overextended it, if you believe it will be impossible to pay for.) After all, retirement is a continuous cost, while illness is episodic. There are ways of calculating costs which depict retirement as five times as expensive as healthcare. But Medicare cost averages thirteen thousand dollars a year, and rising. That's a pretty meager retirement, and when you discover Medicare is 50% borrowed, you question how many people could retire on $26,000 a year per person, on public sector revenues. If you see retirement as a couple of old folks, you wonder where they would get $52,000 a year, for thirty years. Add Medicare to retirement, and you begin to get absolutely impossible numbers. There seems no possible way to handle this except to provide for subsistence retirement, plus Medicare, and let everyone find some way to get whatever extra he needs, or defines as "decent". And that defines retirement cost as equal to medical costs, when both costs could rise appreciably. The Health Savings Account method of accomplishing this is to put retirement at the end of the financial line, funded by the residuals of the other pearls on the string. You keep what's left. Another way is to retire later, or best of all, find some remunerative way to fill your time and use your experience.

Medicare As a Financial Issue. Medicare is about half paid-for, half borrowed, but it's really totally under water. According to Mrs. Sibelius, about half of Medicare expenditures are supported by the general fund, or general taxation. The general fund is in deficit, however, providing some fairness to the description of Medicare as a fund borrowed from the Chinese, although China and Japan combined only purchase 13% of ten-year Treasury bonds. In the event of Medicare default, the main creditor victims will be U.S. citizens. The purchasers may change, but the deficit looks to be permanent. Until deficits are paid off, it will remain true that Medicare provides a dollar of care for fifty cents. That sounds wonderful, until it suddenly sounds terrible. Medicare is bleeding money. If you want to know how brutal our government can get, read the section later on, about the Diagnosis Related Groups.

{top quote}
About half of the Medicare deficit is pay as you go, about another half is borrowed; only a quarter of the budget is current revenue from the beneficiary age group. {bottom quote}
An accountant might say, Medicare's cash revenue is roughly divided between premiums paid by the beneficiaries, and pre-paid as a payroll tax of 3% on workers not yet old enough for benefits. (About half of this wage tax comes directly from the employee, another half from the employer. We skip over the technicalities that some parts of the program are tied to one fund, other parts to another, and also some are subject to higher income tax). About a quarter of Medicare is paid in advance on a "pay-as-you-go" basis, which is to say some people pay current costs of other people -- they are definitely not saved in anticipation of the contributors becoming beneficiaries, as the term "Trust Fund" implies.

A second quarter is indeed paid and spent by current beneficiaries as Medicare premiums. That is, about half of the deficit is pay as you go, another half is borrowed from foreigners; only half of the deficit is matched by current revenue from the beneficiary age group. Nevertheless, the payers of pay-as-you-go are about thirty years younger than the spenders of it. If we put the youngsters' cash to work for thirty years, what interest rate would it take to grow one dollar into three? The answer is about five to seven percent. For quicker understanding, a few unfamiliar tools are needed:

First and Last Years of Life Re-Insurance By far the best proposal for refinancing Medicare, however, is to anticipate the way science is going to re-design costs. In the long, long, run, there should be very little medical cost left, except the first and last years of life. We have no idea how long it will take, but that's the direction things are almost sure to be going.

So, phase in a re-structuring of funding for both children and elderly first, and then add in the rest of a lifespan, step by step. That way, you first fund an obligation you are always sure to have. Be sure to do it in such a way that maximizes the investment income at compound interest. This might be a project under construction for decades, but its first step would be to begin funding for the Last Four Years of Life, which happens to be an early proposal in refinancing Medicare. Since the reader may be unprepared for the topic, it is considered in a free-standing way, in the next section.

Pay at the time, or pre-pay in advance?> At first, it might seem frugal to have people pay for what they spend; let them pay for what it costs, when you know who ran up the cost. But in the case of birth and death, it's going to be 100%, and the amount of it is a lottery. By far the more important issue is the compound interest you earn by paying in advance. Using the rule of thumb that money at 7% will double in ten years, a life expectancy of 90 should double 9 times from birth to death. That is, a dollar at birth is worth $512 at death.

What's more, 50% of Medicare is reported to be spent in the last four years of someone's life. That's likely to represent terminal care, but it doesn't matter. If you prepay those four years, the rest of Medicare has its cost cut in half. In those two simple statements is found the nut of paying for half of Medicare for $100 -- ninety years from now. It's up to actuaries and accountants to find the "sweet spot", of the most revenue enhancement for the shortest time of investment.


Front Stuff: Pearls on a String: Further Extending Health (and Retirement) Savings Accounts

...Also by the same author:

The Hospital That Ate Chicago, Saunders Press, 1980

Health Savings Accounts: Planning for Prosperity, Ross & Perry, Inc. 2015

Surmounting Health Costs to Retire: Health (and Retirement) Savings Account. 2016

Pearls on a String: Further Extending Health (and Retirement) Savings Accounts (This Volume), 2016

---------------------------------

Ross & Perry Book Publishers

3 South Haddon Avenue

Haddonfield, New Jersey 08033

856-427-6135

----------------------------------

Pearls on a String: Further Extending Health (and Retirement) Savings Accounts Copyright:

ISBN #: (978-1-932080-56-8)

-----------------------------------

Acknowledgements

For advice and support about the thrust of this much revised book, I owe new debts to the many people who read the first versions and commented. The first book was written as ideas developed in my mind, and rather in a hurry. The second revision was written so later thoughts could be introduced earlier in the argument. This one was written and rewritten to rise above the twin possibilities that either, the Affordable Care Act would be completely repealed, or it would essentially survive forever. I still don't know its future, whether it is too big to fail, or too big to survive. Either way, I think it failed to reform some things which should be reformed. The best way to defend that position is to propose an alternative which is much simpler, but more radical.

----------------------------------------------------------------------

Foldback, Front Cover

This book outlines the hidden advantages of Health Savings Accounts, which the author had a hand in creating in 1981, along with John McClaughry of Vermont when John was Senior Policy Advisor in the Reagan White House. HSAs had more advantages than we realized. By turning them into retirement funds at the end, not a word was changed but they created a new incentive to save, by adding a new reason to save. By simplifying reimbursement, they exposed the ineffectiveness of third-party policing, and saved money to be multiplied by investment. They were a vehicle for subsidies to the poor, a Christmas savings fund for the frugal, and interstate mobility for the rich.

Finally, the idea dawned that such simplicity provided an avenue for gradual transition to new programs, as well as an escape hatch if they failed. Beads on a string, as it were, with a common retirement fund at the end, as a universal incentive for savings in each program added. It might take fifty years to implement every step proposed. But then, it took fifty years to get into this situation.

--------------------------------------------------------

Foldback, Back Cover

{Privateers}
George Ross Fisher III M.D.

George Ross Fisher, MD, the author of this book, graduated from the Lawrenceville School in 1942, from Yale University in 1945, and from Columbia University, College of Physicians and Surgeons in 1948. After postgraduate training at Pennsylvania Hospital, Thomas Jefferson University, and the National Institutes of Health, he spent 60 years practicing medicine in Philadelphia, and consulting in New Jersey and Delaware. During that time, he spent 25 years as a delegate to the American Medical Association, and as a trustee of a number of medical organizations.

Following retirement, he formed a publishing company, Ross and Perry, Inc, which has published several hundred books, mostly reprints. He is personally the author of eleven books about Philadelphia history, from William Penn to Grace Kelly. He is the author of the following three books about medical economics:

The Hospital That Ate Chicago; Health Savings Accounts: Planning for Prosperity; Surmounting Health Costs to Retire: Health (and Retirement) Savings Accounts and (the current volume.)

------------------------------------------------------------------------

Dedication Page

To Senator Bill Roth of Delaware, who demonstrated the road between private and public sectors, need not be a one-way street.

-------------------------------------------------------------------------

Bookcover back page, possibly in conjunction with above box and introduction, please discuss:

Health savings account

From Wikipedia, the free encyclopedia

This article is about medical savings accounts in the United States. For international uses, see medical savings account. Health care in the United States

______________________________________________________

A health savings account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP).[1][2] The funds contributed to an account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), HSA funds roll over and accumulate year to year if they are not spent. HSAs are owned by the individual, which differentiates them from company-owned Health Reimbursement Arrangements (HRA) that are an alternate tax-deductible source of funds paired with either HDHPs or standard health plans.

HSA funds may currently be used to pay for qualified medical expenses at any time without federal tax liability or penalty. Beginning in early 2011 over-the-counter medications cannot be paid with an HSA without a doctor's prescription.[3] Withdrawals for non-medical expenses are treated very similarly to those in an individual retirement account (IRA) in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier. The accounts are a component of consumer-driven health care.

-------------------------------------------------------------------


Iterate through a Word document, modifying picture properties(Blog 2300)

(Blog 2300) We have a facility on this website to download books of many chapters (made up of volumes of topics on the site) to Microsoft Word for subsequent editing and eventual publishing. In many cases we download lots of pictures (via an img src= tag). I have not found a way to set the way text flows around the images in Word using HTML or CSS, so I built a Word macro to do it. This should allow you to change the size of images, as well as move them around. Moving the captions requires the use of the captions feature in Word's image menu (right-click).

------------------------------------

Instructions for use of a Macro named Sub ImageFlow():

  1. Open Word

  2. In Word, enter File>Open

  3. enter the URL of the file you want to modify into the File Entry box and press the Enter key to load the document. It may take a minute or two, but a working screen should appear, loaded with the file in a condition ready to move the pictures around.

  4. Press Alt + F11 which will open the VBA screen

  5. Copy the macro found on this page from
    Sub ImageFlow()
    to
    End Sub
  6. In the right-hand panel of the VBA screen press Ctrl+A, Ctrl+V to paste it in

  7. In the VBA screen press F5 to run the macro

If you want to do a lot of these manipulations, save the macro in the Macro Library of Windows Word.

------------------------------------
Sub ImageFlow()
'
'  this Macro goes through an entire Word document and
'  changes the way text flows around each picture
'  ("Tight" in this example but see below for choices)
'
    Dim shpIn As InlineShape, shp As Shape

    For Each shpIn In ActiveDocument.InlineShapes
        If (shpIn.Type = wdInlineShapeLinkedPicture) Then
            Set shp = shpIn.ConvertToShape
            shp.WrapFormat.Type = wdWrapTight
        End If
    Next shpIn

    For Each shp In ActiveDocument.Shapes
        shp.WrapFormat.Type = wdWrapTight
    Next shp

End Sub
----------------------------------------

Change wdWrapTight to any of the following:
wdWrapBehind
wdWrapFront
wdWrapInline
wdWrapNone
wdWrapSquare
wdWrapThrough
wdWrapTight
wdWrapTopBottom

My thanks to http://www.phrebh.com/Jenius/252-center-pictures-in-word-with-vba/ for showing me the essential technique of iterating through the pictures.

What are the InlineShapes' Types? See http://msdn.microsoft.com/en-us/library/microsoft.office.interop.word.inlineshape.type(v=office.11).aspx; it is possible we may also need to select on wdInlineShapePicture (as well as wdInlineShapeLinkedPicture) but for my specific purpose I did not need to.


A most interesting website, thank you. I really hope to visit Philadelphia one day, and I shall definitely consult your website. I came across this website after doing a search on Johannes Kelp / Kelpius. I had just listened to a song written about him called, 'Sighisoara' at ukuleleroadtrips.com. Sighisoara is the place J Kelpius left for Philadelphia with 40 followers. Best Regards
Posted by: Pamela   |   Aug 20, 2015 11:04 AM
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 "...blog/1588.htm" - 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 "...blog/1588.htm" - 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 [http://www.philadelphia-reflections.com/blog/1705.htm] and noticed a ton of great resources. I recently had the honor of becoming a part of a new non promotional project on AlcoholicCirrhosis.com. 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
I FIND THIS VERY INTERESTING, INDEED. I AM HOWEVER, SEARCHING FOR THE ANCESTOR WE HAVE BEEN TOLD WAS JOSEPH M. WILSON OF JORDAN TOWNSHIP IN WHITESIDE CO. IL USA. MY HUSBAND WAS ORPHANED AND WITH LITTLE CONTACT WITH HIS FATHERS SIDE OF THE FAMILY THE 9TH OF 10 SURVIVING CHILDREN SINCE ALL ARE DECEASED BUT, ONE). I HAVE HOPED TO FIND HIS CONNECTION AS TO THE STORIES RELATED BY SEVERAL OF HIS DECEASED RELATIVES THAT WE ARE CONNECTED TO THE WILSON MILL FAMILY HISTORY. OF JOSEPH AND FRANCES. MY HUSBAND WAS ALSO, FAMILY TO: GRANDFATHER RANSOM (ISABELLA)WILSON & HIS BROTHER WILLIAM; OF ELKHORN GROVE CARROLL CO. IL USA AND HIS SON JOSEPH WILSON(NANCY). I?WE( MY SONS AND NEPHEWS NEICES AND GRANDDAUGHTERS IN COLLEGE... WERE HOPING THAT NOW THAT I AM ON THE COMPUTER AND WITH YOUR HELP THRU THE GENELOGICAL SOCIETY TO YOUR ADDRESS WE MAY FIND THE FAMILY WE SEEK. MY LATE HUSBAND AND I DROVE PAST THE SITE OF THE FIELD WHERE JOSEPH AND FAANCES ARE BURIED , THE CEDARS ARE GONE AND IT IS NOW FIELD. I HAVE BEEN HOPING TO FIND THE LINK FOR OVER 30 FAMILY TO PAY TRIBUTE TO THOSE WHO HAVE GONE BEFORE AND PERSEVERED TO BRING US THE LIFE WHICH WE ENJOY AND SERVE, TODAY. I RECEIVED ONLY THIS WEEK BY A FLUKE AN EMAIL WITH PHOTOS FROM A 3RD COUSIN THAT FOUND MY EMAIL ON A COUSINS EMAIL ADDRESS AFTER INQUIRING AND INTRODUCING HIMSLEF: AND HE TOOK THE TIME TO SEND MANY PHOTOS AND HISTORY OF GRANDPARENTS AND FAMILY AS WE HAVE HAD NONE. WE STILL DON'T HAVE A PHOTO OF HIS MOTHER AND FATHER. WHAT I HAVE OF THE TREE, I AM ANXIOUS TO SHARE WITH FAMILY THAT IS SEEKING HISTORY, AS I STILL AM HOPEFUL TO FIND IT IN TIME FOR THE DEADLINE AUG. 30 TYPED AND DELIVERED TO MY MARTIN HOUSE MUSEUM WHERE I AM A MEMBER. MY HUSBAND WAS A MASTER MASON WHILE IN LODGE WITH THE COUPLE THAT DONATED THE HOUSE TO BE A MUSEUM. THANK YOU FOR YOUR TIME AND THE GRAT WORK YOU HAVE ALL DONE ON THIS HISTORY. WE WERE LIFE MEMBERS OF THE LUTHERAN CHURCH BUT , THERE IS NOT ONE IN OUR TOWN, SO I FOUND THE REFORMED CHURCH,OF WHICH, I AM VERY HAPPY TO BE A PART. THANK YOU .
Posted by: SUSAN WILSON   |   Aug 12, 2012 12:49 AM

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