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

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Reminiscences
"The past is never dead. It's not even past." -- William Faulkner, Requiem for a Nun

Growing Legs

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A good idea is usually better than its originator thought it was. After arguing for nearly three decades that the Medical Savings Account would reduce the cost of medical care without injuring its quality, some other advantages began to appear. For example, if the owner of the policy bought it young and didn't get sick, the accumulated funds would probably grow to considerable size. After a while, income from the investments would be enough to pay the premium on the catastrophic (high-deductible) policy. It would thus permit the individual to skip any contributions or premiums during a couple of years of sickness or unemployment. As they say in the life insurance world, it would effectively contain a "waiver of premium clause", something heretofore unknown in health insurance. What's more, if things went particularly well, the interest income would sustain the policy without further contribution for the rest of the individual's life, or at least until Medicare appeared. Think of that. Paid-up health insurance. It probably would be safer not to promise such benefits because who knows what might happen in the dim future. But just let it happen once, and it would be front-page news.

Because everybody can one day expect to have Medicare, the unspent balances in the accounts might well be diverted to things which Medicare can't afford to cover, like nursing home care, or plastic surgery.

Because a lot of small claims would be paid for out of the account rather than with claim forms, administrative costs would decline. Doubled administrative costs from 20% copayment insurance would disappear. You could use special credit cards for this medical purpose; maybe there is something like frequent-flier discounts which could be devised. And so on. The ideas just sort of tumble out when you get to thinking about it.

So a good idea has more to it than its originators realized, and the idea grows legs. That is to say, it starts to spread by itself as different people make different discoveries. Not only do faithful disciples spring up unbidden, the originator of the idea can sometimes have the amusing experience of being button-holed by a total stranger, who starts to advocate his new idea, which turns out to be, you know what. There was once a time when I felt the need to submit an occasional resolution to the AMÅ, just to keep the subject alive. In time, I began to worry about other people jumping up and boring the AMA to death.

But the opposition grew legs, too. When Chairman Archer of the House Ways and Means Committee --bless him-- finally forced through a MSA law, the Senate (always the Senate) stuck in a limitation that no business might provide MSAs as employee health benefits if they had more than fifty employees. Large insurance companies lost interest in promoting a policy with such necessarily uncompetitive marketing expenses, and the Archer MSAs were very slow to be adopted because it was so hard to find someone to sell them to you. Many other subtle but crippling provisions appeared in what was known as the Kennedy-Kassebaum Law. When I later had occasion to ask Senator Kassebaum why she helped cripple the MSA, she did not bother to deny the amendments were crippling, simply shrugging her shoulders and saying, "Blue Cross".

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