The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
... William Penn's Quaker Colonies
plus medicine, economics and politics ... nearly 4,000 articles in all
Philadelphia Reflections now has a companion tour book! Buy it on Amazon
Philadelphia Revelations
Try the search box to the left if you don't see what you're looking for on this page.
George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
JAMES Madison, Washington's floor manager at the Constitutional Convention of 1787 in Philadelphia, stated the main necessity for holding the Convention at all arose from selfish and untrustworthy human nature. The assembly probably understood exactly who he had in mind, although that is a little unfair to residents of Virginia. He really meant everybody. In the theology of the time, mankind was stained with original sin. Particularly in France, many 18th century romanticists responded to the Enlightenment by defiantly declaring human nature is born pure in heart. In their view, current evils grow from the pollution of civilization, without which it might be possible to have no government at all. At its root, such romanticism was an outcry against progress and civilization, blaming the world's troubles on the Industrial Revolution, so to speak. From Madison's skeptical viewpoint, the most awkward feature of the Romantic Period was its adoption by his Francophile friend and neighbor, Thomas Jefferson, the current American ambassador to France. Madison recognized that Jefferson and Patrick Henry were prepared to assail any attempt to add the slightest power to a central government, particularly if it weakened the power of Virginia. As indeed they promptly came forward to do and nearly succeeded.
Treaty of Paris
After fighting an eight-year war for freedom, American belief was wide-spread that it was time to draw back from such anarchy. But there was widespread suspicion in every other direction, too. England seemed to concede, not defeat but only current military overstretch, possibly displaying reluctance to see its former colonies with full sovereignty. George III might wait for America to weaken itself and then try to take them back. Britain almost couldn't do anything right; it was also possibly up to no good when the Treaty of Paris astonishingly conceded land to the Mississippi instead of stopping at the Appalachians. Even our ally France nursed regrets for its somewhat older concessions after the French and Indian War. If even the two mightiest nations of Europe could not maintain order in the vast North American wilderness, perhaps they felt the inexperienced colonies would soon collapse from the effort. Further intra-European wars seemed likely, and could soon spread from Europe to the Western hemisphere. The guillotine was bad enough, Bonaparte would be worse. Our governance as a league of states was in fact, only a league of armies. The Articles of Confederation would not quell inter-state rivalries in peacetime, as only four years (1783-87) experience after the Treaty of Paris were clearly foreshadowing. It was time we listened to Benjamin Franklin, who had been arguing since the Albany Conference of 1745 for unification of the colonies, and to Robert Morris who had been arguing for a written constitution since 1776, a bicameral legislature since 1781, government by professional departments instead of congressional committees, and the ability to levy national taxes -- since at least 1778. Professor Witherspoon of Princeton had provided some ideas about how to make these proposals self-enforcing, Washington was firmly behind a Republican system and opposed to a monarchy. On the other hand, everyone knew that under the Articles of Confederation the thirteen States had often refused to pay their share, abused their ability to deal independently with foreigners, dealt unfairly with their neighbors, and capriciously mistreated their own citizens. It was time to act boldly. With a blue-ribbon convention of national heroes behind these simple ideas, surely it would be possible to convince the sovereign state legislatures to dethrone themselves.
John Marshall
Two men quietly applied even deeper thinking than that; Benjamin Franklin of Pennsylvania, and John Marshall of Virginia. Both of them had served in state legislatures, both were dismayed by the experience. Franklin also had a long period of close-up observation of the British Parliament, suffering personal abuse there, and had reason to reflect on the earlier abuses by that Parliament under Cromwell during the English Civil War. Certain bad tendencies seemed universal in legislative bodies. Although John Marshall was not a member of the Virginia Constitutional delegation in 1787, he was active in the politics of the group it represented back home. Both Marshall and Franklin had reason to be uneasy about misbehavior in representative bodies, whether called legislatures, congresses, or parliaments. When people said states misbehaved under the Confederation arrangement, they really meant legislatures misbehaved. Franklin did what he could within the Convention to curb this observed behavior by enumerating limited powers and endorsing power balanced against power. When he had nudged it as far as he could, he wearily agreed to give the product a try. Franklin did not trust Utopias, but he had lived among Quakers for years, observing one Utopian society which seemed to endure without resorting to tyranny.
The Constitutional provisions in Article I, Section X became the heart of what the 1787 Convention wanted to change about the relationship of the national and state governments.
States are forbidden to ...
"emit bills of credit, make anything but gold or silver a legal tender in payment of debts, pass any bill of attainder, ex post facto law, or law impairing the obligation of contracts."
1787 Convention
This brief clause is almost a presentment of what state legislatures were doing, which serious patriots regarded as wholly unacceptable. Failure of states to abide by the terms of international treaties must be included in such a summary, although the new Constitution went beyond the powers of states by locating treaties beyond the power of even Congress to change, once ratified. Some observers in fact feel that within the First Article clause, protecting the sanctity of contracts was really the nut of the matter. In one way or another, most states seemed to resort to paying their debts with inflation, somehow failing to recognize that borrowing never pays debts, it only postpones them. The great bulk of this new nation's business was to be conducted as voluntary agreements between two contracting parties. The State -- and the states -- were to stay out of the private sector, except as referee, to see that both sides kept their agreements. As a footnote, the matter of government intervention in private affairs was to rise again in the behavior of the Executive branch in the 1937 Court Packing uproar, and in the 2009 health insurance legislation. Some critics, therefore, have discomfort that the heaviest Constitutional weight was placed by the Founding Fathers on protecting private property. Are not other issues more important, they ask, like life, liberty and the pursuit of happiness? The Founders, of course, we're here not ranking benevolences by value; they were stating principal urgencies for convening the meeting. In a strange unintended way, they here stumbled on the right to property as the foundation for all other rights. But John Marshall understood it was true and was to spend thirty years hammering it into place. People broke individual promises by defaulting on debts; they simply did the same as governments, using inflation.
According to Dr. Stephen M. Hahn, Chairman of the Radiation Oncology Center at the Hospital of the University of Pennsylvania, the means of delivering a dose of radiation to cancerous tumors has advanced a remarkable amount since the first linear accelerator was used to zap tumors in the early 1960s. The Right Angle club was host to Dr. Hahn who is overseeing the beginnings of this new technology called proton therapy at Penn where the Perelman Center for Advanced Medicine and the Roberts Proton Therapy Center will come on-line in November of this year. The center will be a state-of-the-art facility laid out in such a fashion that patients will be central to all the treatment areas and have access to every type of cancer treatment in one location.
Radiation Oncology Center at UPENN
Over the years that radiation therapy has been used many advances have been made in delivering radiation using various methods of production of the radiation itself. The magnitude of the beam has been reduced with different sources and the accuracy of delivery has also improved. But one thing that has always been a problem is that images of the tumors were taken with technology that produced flat slices at right angles to the subject, the position vertically was not able to be determined which meant that the radiation could only be directed straight through the surrounding tissues and into the tumor which, of course, ensured that the surroundings got a good dose as well as cancer itself. Intensity modulation (IM) of the beams helped a good deal to ensure that less of the tissue on the far side of the growth was damaged but the collateral damage was still severe and often bad enough to require hospitalization because of the therapy itself.
With the improvement in the past 10 to 15 years in imaging technology it is possible to now create three-dimensional images of the tumors along with precise position data within the patient. This, along with improved beams of radioactive particles which are more finely focused and targetable, has allowed treatment with a good deal less damage to the healthy tissues surrounding the cancers because the beams can be directed from a number of directions thus allowing a full dose of radiation to reach the tumor while spreading out the amount received over the surroundings.
Superconducting Proton Cyclotron
Proton radiation, the technology of the new equipment being readied, further enhances the delivery in that it is possible to focus the beam ever more finely and, best of all, to use a level of radiation that is up to 70% less than even the IM method. Scans showing how the new technology lessens this collateral damage indicated that there was, indeed, still damage to healthy tissue but only to that very small area which was right up against the tumor, not throughout the entire surrounding volume.
It turns out that proton therapy is about two to three times as expensive as traditional therapy. With the lesser danger to the patient and fewer hospitalizations required because of damage caused by the treatment itself however, the cost is mitigated somewhat and this should improve with time. Proton therapy isn't indicated for every case but where it is it appears that cancers are going to have a tougher time than ever before at wreaking their damage and taking lives. The cyclotron which accelerates the protons to the proper level for treatment will operate 16 hours a day, Monday to Friday and 8 hours on Saturdays. Approximately 200 patients a day will be treated.
The Right Angle Club of Philadelphia was recently addressed by Arthur L. Caplan, Director of the Center for Bioethics of the University of Pennsylvania. His topic was Healthcare Rationing. It was interesting to hear the viewpoint of someone who views the 2010 mandatory health insurance system primarily through the lens of its ethics; just like the Tea Party objectors on the other extreme of politics, he sees the new law as merely a rationing system. However, his initial salvo is similar to that of the bill's proponents before it was enacted: "Every system always rations in some way or another." If you expected the outcome to be rationing from the beginning, your focus is naturally fixed on just what sort of rationing you get, perhaps measured by whatever kind of rationing you had formerly hoped for.
Ethics is, after all, a system of constraining native, unconstrained, outcomes into something deemed more suitable. That's a definition which could be equally well applied to the reform of all sorts and repeatedly tends to cast reformers as underdogs fighting the establishment. Since the American healthcare system in 1950 could fairly be described as rationing healthcare with money, and its history from then to now has been one of jumbled similarity to 1950, most discussion accepts a financial rationing description for what Obamacare changed. There is much uneasiness about totally supplanting the marketplace with insurance since universal insurance leaves no room for setting prices -- except by government proclamation, filtered through some sort of insurance bureaucracy. There was a time when many people thought that was better than paying for it yourself, but now that it's here, there are growing doubts.
UPENN
There's surely going to be a last-ditch effort to overturn Obamacare, whether through Congress or the Courts and failing that, through stalling it until the President can be replaced in 2016. Let's assume for the moment that such efforts fail, and are not followed by armed rebellion. If the central issue is how do we find more acceptable methods of rationing, two proposed methods have begun to seem attractive. The first is proposed by Congressman Ryan of Wisconsin, to the general effect of taking what we now spend, chopping it up, and issuing vouchers for the same amount less net middle-man costs. This approach stops the rise of costs right where they are, and thus pleases Congress. But the thing to be rationed is redefined as well. It rations future cost rises, net of any savings wrung out of the system by competition for voucher money. It's fair to claim this system should not deny the present level of care to almost anyone. It has a price, however. If you want future miracles, you have to pay for them.
A second proposal depends on the observation that most healthcare costs are concentrated in the first year of life, and the last year of life. Strip those costs out, and what is left would almost surely be manageable, particularly in view of how the concentration of costs in those two areas steadily increases. Essentially, this system promises to take generous care of the helpless when they are born and when they die. Healthcare costs during the years of school and employment, however, could more confidently be left to people who are sentient and reasonably healthy, so that's where the inevitable rationing would be concentrated. Once more, the payment system has been modified to avoid such third-rail issues as euthanasia for Grandma or for self-inflicted diseases, or even for abortion. Those would be left to the public to manage during stages of life where there is a reasonable likelihood that the patient's own wishes can be paramount. For now, we pass over the technicalities of last-year-of-life insurance, but it could fairly begin with reliance on reimbursing Medicare after the fact, while traditional first-dollar insurance for pregnancy and newborns, or even mandatory government reimbursement, might seem acceptable even to strong conservatives.
So, what's proposed here is a substitute for both the traditional system and the bewildering command and control system of Obamacare. It shifts the subject matter for rationing away from those areas that frighten the public the most, toward either: rationing future unknown scientific advances, or, rationing healthcare during the years when it is comparatively predictable and involves patient cooperation during the years of reason. That's the summary; other proposals are welcome.
Regrettably, after each November election, we first must potentially endure a lame-duck Congress, followed by two years of White House-Congress gridlock. There will, unfortunately, be scant tolerance for ethicists, during those grievous national experiences.
Employer-based Health Insurance. From an employer's viewpoint, a sick employee is an expensive employee, but there are special employer twists to employee illness. The most effective comment a former employer can volunteer in a letter of recommendation is to say that over several years, the employee was "never late and never missed a day of work". It's hard to predict medical costs in advance, but the identification of someone as "accident prone" is the kiss of death for hiring or promotion, because the difference between a devastating injury and a trivial one, is about half an inch. Disabled persons are identified as being unable to do the job, and may include less visible issues, such as being so attached to local health providers they become unwilling to accept a transfer to another city. Some of this affects health insurance premiums, some may not. But the large employers are largely self-insured, so they have more access to individual health cost information, and can longitudinally assess whether their Human Resources departments are doing what is vaguely stated to be a "good job." Some of this is no more than shrewd selection of an agent for administrative services-only. Large self-insured employers almost always have lower health insurance costs, which in the aggregate is likely to mean healthier employees, the cream of the crop.
New or small businesses generally do not have a large enough employee group to justify basing next year's budget on last year's health cost experience. So "small group" insurance tends to reflect the overall higher costs of small-group employees in the whole geographic region, and "individual policies" are the most expensive of all, because they generally have a good idea what they need and want in an insurance policy -- and seek it out. Add to that factor the preferential enjoyment of tax exemption, and the system has gravitated into one which could not have been designed by experts to be so preferential to certain types of business models.
For the sake of economy of effort, let's first see what we can do about portability and privacy, indirectly, by getting rid of the tax preference.
It appears that employers seldom drive their health information advantage to the extremes which would seem within their abilities. Generally, they look for a "Cadillac" plan for important officers and professionals, lower-paid employees generally receiving the "Chevrolet" plan, and that's about as far as it goes. Psychiatrists as a group are much more passionate about patient privacy than other doctors are. Certain employers in Madison Avenue businesses are thus more likely to be dealing with the bills and complaints of psychiatrists, that those who run farmers' co-ops in Nebraska. Probably that reflects some highly charged experiences with a few psychiatric patients, much more likely to give the lurid responses of a trial lawyer than of the tired and bored primary physician. Or of the dressing-room attendants in the fashion business, who are more or less constantly bumping into naked women in a big hurry to change into a new costume. Standards of modesty vary quite a lot across the country, and this probably parallels similar regional variations in the rest of patient privacy concerns. There seems to be a steady trend toward indifference about privacy, however. Even Bill Clinton waited until his last day in office to sign the HIPAA regulations, knowing how unpopular they would be.
Participants in sports where a great deal of betting goes on about game outcomes and career records have good reason to fear careless gossip about injuries, illicit drug use or even cataracts. Aging actresses fear their younger competition; almost everyone is uncomfortable about addictions and deviant behavior. The decline of primogeniture and the rise of antibiotics have even undermined the devastating consequences of suspicions about true paternity. Whether the resulting business models are going to lead to a decline in concern about patient privacy in any forum, could well be argued at length. What's more likely is that most people will tire of the subject.
Nevertheless, no one can dispute that employees in a favorable health insurance arrangement are quite reasonably reluctant to change employment to a situation which loses them a tax deduction on 30% of their salaries. The situation is called "Job lock". Portability is a real problem, while privacy is much less consequential, except to some very vocal groups. Even though it seems unrelated, the manifestly unfair design of this tax preference is one of the reasons American politics have become so restless about seemingly unrelated matters. The freedom to go somewhere else has become impaired. For the sake of economy of effort, let's first see what we can do about portability and privacy, indirectly, by getting rid of the tax preference.
Since we propose a monitoring agency for health insurance, we might as well add a few suggestions for its formative years. Insurance companies with experience in the field should, of course, be represented, and although an actuary might represent a company, actuaries as a profession should be invited to the governing and advisory committees. My own professional experience suggests the President of a large and influential institution will often nominate himself. Then, after a meeting or two, he sends his chief deputy. But scattered through the field are apt to be occasional revered experts, working for obscure institutions with little political clout. These are the ones you want on the brainstorming committees, and they are more likely to be nominated by the professional organization than by the employing ones. For example, let's imagine multi-year catastrophic insurance has been proposed for multi-year pricing.
Catastrophic health insurance is an indemnity plan, and its tradition is to be a one-year renewable one. That is, it's term insurance when we are starting to propose the whole-life model might be cheaper and have some other advantages. What are the pros and cons of multi-year Catastrophic coverage? It's probably cheaper because of lower marketing costs but lacks the flexibility of changing its premium frequently, in rapidly changing marketplaces. And it provides the opportunity to drop a troublesome customer, which is to say it shifts power somewhat in the direction of the insurer. At least in the life insurance market, most of the profit derives from customers who drop their policies, an unfortunate incentive arrangement. A particular hazard is to attract a disproportionate number of clients who have hidden information about impending health problems, leading to "adverse selection" of clients. That leads to requiring physical examinations, which raise costs.
Although some arbitrary time period, let's say five years, may be arbitrarily selected, everybody would recognize that accurate statistics might suggest a better time interval, let's say three or seven years. The management of the company would naturally prefer a shorter period in which to make mistakes, but it might be just as satisfactory (and therefore cheaper) to pick a longer period. Such decisions are often made by a board member with a booming voice, but it would be better to base them on statistics derived from pilot studies. For example, in seven years the client is seven years older at the end of it, and more likely to have serious illnesses intervene.
That may or may not be decisive. With the one-year term, the client is likely to apply for the insurance "on the way to the hospital", that is after he suspects he is sick, but before the insurer can prove it. That leads to waiting periods of variable length, again decided by the booming voice unless you can produce data that he is wrong, and often not even then. Statistics are the timid actuary's friend when he is in conflict with an aggressive executive who came up through sales. The best statistics are derived from pilot studies aimed at the particular question you are asking.
A committee might have better suggestions, but my guess is there are two curves: a slowly increasing one, with age. And a sharply decreasing one with the duration of time since application. My guess is that cheaters will decline in a year, hypochondriacs in three years, and cancer victims in five. The incidence of cancer is age-related, possibly the others are, too. There may be some other factors at work, which will surface in the first study, and have to be examined in a second one. But eventually, it should be possible to prove just what added risk appears at what age, and how much that is attenuated by adverse selection.
Knowing the added risk, it should be possible to set age-related risk adjustments, modified by different surcharges for the first year, the second, etc. And then, it should be possible to judge the best number of years to cover, since the adverse selection should only appear in the first round, not much in the renewals. And finally, it should be possible to see whether lifetime catastrophic rates might be a commercially viable possibility. Once that is established, it becomes like the fable of Columbus and the egg; everyone can do it.
Co-insurance. This seems like a good moment to introduce the subject of co-insurance. Co-insurance is the main reason for supplemental insurance to cover it, resulting in two insurance policies to pay for one illness. One presumes it was the reason Obamacare does not include it. Although it masqueraded as a utilization control, giving the customer some skin in the game, a 20% co-pay feature had very little effect on utilization. It was customary because a 20% co-pay makes the premium 20% smaller, a 30% co-pay would make the premium 30% smaller, etc. It was a handy tool for midnight labor negotiations, but otherwise, it was a burden.
But in the example we are following, it is very handy to have a fixed relationship between the surcharge and the added risk. Therefore, a demonstrated added risk of, let's say, 14.7% in the first year after initial purchase, would be adequately covered by a 14.7% surcharge on the base rate for the age and gender group. In the second year it would be less, and in subsequent years, still less. The insurance design is simple, once you can define the risk. Almost any other risk would be subject to the same rules: tell me the risk, and I'll tell you the premium.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
