Redesigning Old Age

A friend of mine, regarded as a contemporary but probably only sixty years old, was recently speaking of a club picnic which he would not be able to attend. He was now living with his mother, and since she was 84, obviously neither of them could go to a picnic on a sailing vessel. The club committee, listening to this regret, chuckled that of course we shouldn't expect him. My thoughts were somewhat different. Since I'm 84 myself, I was wondering if she was available for a date. And of course I am going on the picnic, why shouldn't I?

Most of the old fatal diseases have been cured, and guess what --People are living longer.

This little encounter is offered as illustration of how realities change faster than attitudes. But attitudes better start catching up with the times, because some grim financial realities are just as safely predictable as the demographics. Biblical prophets declared mankind was destined to live for 70 years, until threescore and ten. But American life expectancy at birth has been extending by three years every ten years, for nearly a century. At birth, the average American male at birth can now expect to live until he is 80, women a little longer. But that will be eight decades from now, so if life spans extend at present rates, average life expectancy will reach 104 by the time today's newborn reaches 80.

Scientific colleagues feel that is an unrealistic example of the extrapolation fallacy. To them, the human genetic apparatus is programmed to wear out at age 100, so advancing life expectancy will taper off between now and then. There's a concept called apoptosis, stating that cells will only divide a certain number of times before they quit. Human protoplasm seems to be programmed to reach apoptosis around age 100. If the scientific articles start mentioning big advances in staving off apoptosis, then of course much of the rest of this article will need to be modified. In the meantime, when a friend or family member dies at the age of 90, it would be appropriate to deplore a regrettable loss of ten years of potential, before that apoptosis thing would have set in.

Six decades of practicing medicine do confirm these statistical inferences. But experience does not at all confirm the present tendency to predict constantly rising costs of medical care. With no difficulty at all, I can recall several dozen diseases which shortened life expectancy in the past, but which have largely disappeared. Tuberculosis comes first to mind; in my student days we saw several new cases every day, and experienced great difficulty finding vacant beds to house them in the several tuberculosis hospitals of Philadelphia. Every single medical student in my class had a positive test for TB, and almost every class had one or two students who dropped out for a year or two to have it treated. Typhoid fever was a similar example from the generation before me. My teachers often pointed out a forty-bed ward at the Pennsylvania Hospital that had been reserved exclusively for typhoid cases. I had been practicing for fifty years when it suddenly became simple to treat duodenal ulcers. Ten percent of the population had ulcers, and they would bleed, or perforate, or penetrate, or stenose and cause thousands of patients to eat disgusting diets, taking handsful of chaulky pills. Rheumatic fever, and the associated bacterial endocarditis, no longer fill our hospitals. Syphilis is gone, poliomyelitis is gone, small pox, and lots of less common conditions. Pneumonia, with a mortality rate of 10%, is now treated with an office visit or two. The death rate from heart attack and stroke is down 50%, with a vast backlog of presently semi-clogged arteries to mature before mortality finally comes to rest at a very low level. Fifty percent of the drugs in use today were unknown seven years ago, so all that education and re-education is unnecessary. In my medical lifetime, I probably discarded two full medical educations.

Looking ahead, I can only see three or four major diseases that still lack a cure. Cancer is number one, and Alzheimer's Disease is number two. Add to that schizophrenia and manic-depressive disorder, and when those four are cured, it becomes difficult to state what will cost Medicare very much, or shorten life expectancy very much below the promised 100 years. So you can't scare me very much about the frightening impending bankruptcy of Medicare. If the problems of foolish borrowing put it out of business, there still won't be much mortal illness worth treating.

What should appall us is the absolutely predictable cost of paying for the protracted healthy retirement of so many people, and the absolute impossibility of paying for it by continuing on our present path. Maybe that's what all this obesity means. Maybe people are trying to store up enough fat when they are forty, so they can go without eating at all from sixty-five to ninety.

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Retire Later

Unions teach their supporters that they must never retreat. Yell, shout, threaten, roll on the floor in simulated agony, denounce and declaim -- but never give back any concession you have previously won. The hall mark of such positions about givebacks, is they are non-negotiable.

Raising average retirement ages to 75 would quickly cure the financial problem.

By having some personal contact with union officials, who are generally decent enough fellows when they are not in negotiating stance, I have learned that retirement age is absolutely not negotiable, unless someone wants to negotiate an earlier age of retirement. Some of this intransigence is fake, having to do with traditional negotiating techniques, and some of it has to do with the pretense that work is a dreadful thing which has been inflicted on the working man by unfeeling employers, or management, or the rich aristocracy or somebody. Reflex belligerence is triggered immediately by suggesting that people are going to have to retire later in life than they expected to. Much as I hate to offend people in their deeply held religious beliefs, I bring the news that retiring later would solve the problem of affording to retire, and that no other proposal under the sun has the slightest chance of solving the problem. When you are dealing with demographics, to declare that something is off the table, or unacceptable, or a giveback -- is just bombast. With present data, we are going to have to set the retirement age to 70. If medical and demographic trends are unexpectedly extreme, we may have to go to 75. If you think someone has promised you can retire at 55, you had better be in an iron lung, drinking your meals through a straw.

It's easy to see that later retirement cuts lifetime costs in two ways: it increases the duration of earning and saving. And it shortens the years of retirement payout. The later you retire, the better it is. So the less you save, and the more lavish your lifestyle, the older you will be when you can afford to retire.

A lot of things can be debated, and a lot of clever ideas can be worked with. But it is going to take an atomic attack or something similar to alter this particular prediction about the future. And even doomsday predictions just make the future look worse, not better.

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Retirement Communities

Prior to the Second World War, old-age homes were a slightly modernized almshouses. Since few people lived very long after they retired, the old-age home took care of a few stranded old folks who could not care for themselves. The places were very depressing and sparse, with a characteristic odor of urine and poorly-ventilated kitchens. But when the time spent in retirement lengthened to twenty or more years, a new dynamic had to be considered. The dingy old single rooms changed into multi-room apartments, the dining room went upscale, and the infirmary changed into a skilled nursing facility. The idea was that you could graduate to more specialized medical care when you needed it, and be visited by your friends in the community who would someday be in the nursing facility themselves, who were paying to keep it up, and who would raise a ruckus if its service began to seem ominous. Whether the community was paying for it collectively or the younger generation was supporting it, it provided a more civilized way to grow old and die.

THe CCRC falls somewhere between a college dormitory and a resort hotel.

People chose these places for a variety of reasons, depending in large part on what they could afford. Widows are often overwhelmed by maintaining a house, widowers are often overwhelmed by cooking. And retired couples are often simply tired of both chores, or sufficiently crippled or befuddled enough to look for a way to give those tasks to younger people. One system grew up of acquiring a second home in a vacation area, and then replacing the main house with an apartment in a retirement community. If you stay in the vacation home for six months and one day each year, certain combinations can lead to appreciable tax savings. Sometimes a married couple is in perfect health and uses a retirement community as a comfortable suburban apartment complex, "just going on living the way we always did". The idea in their mind is the folk wisdom that you need to get used to a place and develop a circle of friends there; to do that, you ought to be less than eighty years old. When that's the general idea, it can be self-defeating to join a group of friends with pooled meal tickets. Thirty friends, or fifteen couples, can give a party for thirty, twice a month. They are quickly sequestered and disliked by everyone else as they make the regular rounds of their nightly parties; but this sort of thing happens in upscale places, the kind of retirement community where some apartments have servants' quarters, and nobody much cares what anything costs. For people in this circle, the most detestable thing about a retirement community is the pressure to have dinner at 5 PM.

For most people, however, having ample funds for retirement is constrained by the uncertainty of how long the retirement will have to be, how much must be held in reserve, even at age 100. The gallows humor continues to repeat some version of trying to plan a way to spend your last dollar on the last day of your life. It isn't just how long you will live, it is how. If you or your spouse becomes blind, or bedfast, or in chronic pain, your level of living is going to change and your daily expenses may rise dramatically. Even if you never gave such gloomy things a moment's thought, the experience of eating in the same dining room with several hundred elderly acquaintances soon teaches the lessons of unexpected illnesses, and weekly funerals. Some people cannot bear the idea of living in such a community, for exactly the reason that it becomes impossible to kid yourself. And one thing no one can kid himself about is the reality that you have to have an awful lot of money before you can ignore the need to watch your pennies. And it isn't just your spending money; it's also the lack of a basement, attic and garage in which to expand or from which to draw reserves, or just to enjoy old books and mementoes buried in dust.

Retirement communities seem to have developed independently in the Quaker suburbs of Philadelphia, and along the California coast. Except for the climate, there isn't much difference. More tennis in California, more trips to the theater on the East Coast. The early communities had a strong focus on finances, which were assumed to create a lifetime retirement fund by selling the family home. The fancier the house, the more elaborate the apartment it would finance. As the duration of retirement grows progressively longer, roughly three years every decade, it is certain that the sale value of the average American family home will get progressively stretched to extend to the average age at death -- especially if you consider the average age of the second of a couple to die, or become blind, or become bedfast.

So, the patterns of financing are changing, at least experimentally. Some retirement communities (the term is CCRC, Continuing Care Retirement Community) are purely rental, partly room and board, extra charge for the nursing facility, or a la carte for all services. People who enter this sort of community are often planning to move to a different one after a period of time, either to adjust to their reduced physical capacities, or changes of location of their families. Some of them actually say they plan to live luxuriously and then move into their children's houses when the money runs out, although it is usually hard to know how seriously to take such comments.

Obviously, what is needed is some sort of insurance mechanism to pool everybody's risks, but there is a fundamental problem. Insurance companies make a big profit on life insurance which underestimated the average age of death. But in this case, unexpected longevity bankrupts any insurance company which underestimates the length of time a person will remain alive in a retirement facility, so such insurance is either overpriced or unobtainable. The same underlying phenomenon affects Medicare and explains its impending insolvency, Those early retirement communities which based their charges on the assumption that Medicare would continue unchanged, are repeatedly stranded when Congress cuts back on Medicare benefits. Some day, these demographic trends will level off and insurance can be restored to practicality, but that time is certainly two or more decades away. Many states, including Pennsylvania, have passed laws that residents of retirement communities may not be evicted if they become impoverished, so the communities are forced to be strict about advance funding. Ultimately, the danger is that the community will be forced out of business, stranding the occupants. With so much time available to discuss such matters in a common dining hall, occupants of these facilities can become obsessed with the need to save for the future, which of course no one can predict.

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Wheels

Camden Auto Shop

A young secretary who once worked for me asked to be excused early, because she had to pick up her car in one of the more blighted districts of Camden. She was welcome to take the time off, but I was a little uneasy about what she was planning to do. "Oh," she said, " My husband taught me to take our old car to the Puerto Ricans. They can fix anything." As indeed they must; Puerto Rico and many other Latin American countries forbid the importation of new cars; they have to get good at fixing old clunkers. The service departments of our new-car dealers, on the other hand, have a noticeable tendency to tell you to replace something rather than repair it. Caveat emptor certainly comes into play at this point, but there's a balancing feature as well; some people should repair, others should replace, exactly the same defective appliance. The viewpoint of the service man is colored as much by knowing how the majority of his customers respond, as by knowing the profit margins which measure his own self-interest.

As far as issues for seniors go, transportation is far more important than greenhouse gases.

Soring Gas Prices

The issue came up for re-examination recently, when I felt peer pressure to buy an environmentally friendly car. My car is big and heavy, accelerates with authority, is over ten years old. It gets thirteen miles to a (now) expensive gallon of gas. Otherwise, there is nothing the matter with it to make me doubt it will last another ten years. On the other hand, the new trendy thing will get more than forty miles to a gallon, accelerate like a jack-rabbit, and bring me admiring glances from young ladies. But just a doggone minute. I currently fill the tank once a month, for thirty dollars. Am I supposed to spend forty thousand dollars for a new car, just to save fifteen dollars a month in gasoline cost? It would take me considerably longer than my present life expectancy to come out even on that transaction, while someone in Puerto Rico or Mexico continues to drive around in my traded-in used car, polluting up a storm. Whether I can afford it is not the issue. I just don't like to be urged to do stupid things. I already do enough stupid things, without having other people invent them for me.

Philly Car Share

Since the matter has come up, maybe we should ask whether elderly people should own a personal car or not. Forget about telling me to take an eye exam or a repeat driver's examination administered by a state policeman; if I stop driving it will be my own decision, not that of the crooked legislature, or the ministers of Plato's Republic. But come to think of it, having my own driver could be very nice. Philadelphia's Mayor Dilworth was driven to work and around by a uniformed driver in what purported to be a Yellow Cab, but looked like a limo to me; his daughter has since confirmed my suspicions with a broad wink. So an idea does come up: there must be many semi-retired folks who own cars but would be happy to make other arrangements for minimal transportation needs. There are those little red cars spread around town for rental at $6 an hour, or even regular rental cars available for weekends and vacation. Come to think of it, there's a fellow who lives in one of Philadelphia's fancier apartment complexes who had a limo and driver of his own. People began to offer to rent his arrangement when he didn't need it, and eventually he wound up with four limosines and drivers just for that big apartment. Anybody who could afford to live in that apartment, with or without a limosine, didn't need a new business venture. The episode therefore carries the discussion in a somewhat different direction.

Retirement Complex

Why didn't the owner of the apartment building install a livery service, without waiting for a retired resident to start it? A variety of answers to that question suggest themselves, chief among which would be that someone in the apartment business would buy a second apartment if he had spare capital, rather than get into a second business he knew nothing about. He would prefer two apartment buildings without limo service, rather than one apartment with a lot of unrelated businesses attached, some of which would probably lose money. We could stop this discussion along the way and reflect on union hostility, uncomprehending tax and license interference, unwillingness to set aside sufficient garage space, and many other man-made obstructions to the idea. But let's jump over all that to suppose what is needed is a multi-apartment corporation which supplies jitney bus service, charter bus service, car-shares, rental car service and livery to a large number of apartments and hotels -- and doesn't own any apartments. Why don't I start such a company myself? Because I'm retired, that's why. The logical place to begin such a venture in a retirement village or big condominium complex is with the concierge. The concierge is in a position to judge demand and build up a string of vendors, eventually forming a company with the successful vendors after the local market has been well explored. Let the business plan emerge from the market exploration.

There's a general observation which applies to all cooperative apartment boards, condominium committees, club memberships, and the like. All such organizations, without fail, divide into two groups: One group describes the present arrangement as a "dump" and demands that everyone pitch in and spend some money fixing up the place. The other group has already stretched its discretionary funds to the limit and beyond, just achieving entry into the place. The latter will resist bitterly any improvements which cost money, even small amounts. Furthermore, they will organize to outnumber and squelch potential members of the other group, because the threat and its underlying motivation, remains permanent. Such political difficulties are best addressed by collecting dues for an improvement fund, which reassures everyone about the limits of what might might some day be demanded. All of that talk about licenses and unions and unneeded expense always boils down to the condominium disease, so progress depends on a realistic appraisal of the chances. First, get a concierge.

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Phillycarshare

Jerry Furgione

Jerry Furgione recently intrigued the Right Angle Club with what those small red cars are all about. A non-profit organization named PhillyCarShare has been able to grow a fleet of 400 autos to rent by the hour -- gas, insurance and washing included. Each car has a home base in some parking lot or garage or other accessible place, from which you take it, and back to which it goes when you are done with it. Reservations are handled by phone or internet, payment by credit card; a platoon of attendants come around at night to refill the gas and check on things.

Philly Car Share Lot

Now that's not quite as convenient as having the car delivered, or picking it up at one place and dropping it off at another, but it's workable. One of the technical secrets is a wireless system working a lock which can be controlled remotely. For a $25 onetime membership fee the customer gets identified with a particular lock, and the car keys are inside the car. That's a little klugey (as trendy people say), because if you forget to lock the car when it's parked it can be stolen. No doubt technology could soon be developed to handle the whole business electronically, emitting signals that the car is parked but unlocked, issuing automated scolding and just-this-once remote locking and unlocking, and perhaps a dozen engineering features. But that takes more volume than 400 cars, and it's early days. Present reliance is made on repeated reminders to lock the car when you aren't using it, backed up with a $100 fine if you forget. It's probably the biggest source of friction.

The rise in oil prices helped the car share business a lot, and enthusiasm among young early-adopters carries things quite a way, so the business is growing. It probably won't be possible to judge the future until competition appears and business levels off, at some stable point. If some of the rough spots can be fixed with gadgetry, this hourly rental system should have a permanent place in our environment. Since it's a non-profit, it will be of interest to see what variants the for-profit sector can provide.

City of Philadelphia

At the moment, the business has the nuisance of an average 6-months delay to get each new parking spot approved by the various ownership and licensing agencies. But the developers of high-rise apartments are learning that having rental cars headquartered at the building entitles the builder to provide fewer off-street parking spaces, so revenue potential starts to appear. Companies, and in particular the City of Philadelphia have taken to using this system to reduce the size of their car fleets; universities are nibbling at the idea of shared memberships. Hard to know where this will lead.

You learn some things the hard way. The cars used to have a plastic card to use for filling up at a gas station, but too many cars were broken into to steal the cards, so this had to be curtailed. If you have an accident the company's insurance takes care of you, but then there are quarrels about renewals of insurance, both theirs and yours. People who are used to jumping into their own cars, and out of them whenever and where ever they please, tend to feel a little constrained by the need to make reservations and be prompt about them (because someone might be waiting for the car).

Which brings you to the ultimate trade-off in this system. People want to have lots of cars sitting around, so they can use spur-of-the-moment planning. The business, on the other hand, wants every car to be in constant motion, every slot in the schedule filled up. Right now the cars average eight users a day and have comparatively little waiting for reservations, only because the typical user at present does not want the car during 9-5, five days a week hours. As business increases, it should emerge just what the break-even points are between too many cars and too few. From the customers' point of view, that means, "How much are you willing to pay to have a car immediately and invariably available?" At the equilibrium point between maximum customer convenience and minimum price, we'll soon see what the public really wants and will pay for.

Meanwhile, the experimentation goes on to explore the tastes and preference of the Philadelphia public, region by region. They have a few pickup trucks if you like, and even a few Lexus's. Although the original idea was developed in Europe, Philadelphia has here the largest hourly rental business in the world, and it's galloping along briskly.

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Books

Books on Tape

Bookishness is not universal, but reading for pleasure is possible for many people whose physical condition limits more athletic activities. Even for those with visual impairment,books are available on tape for auditory reading. Some people seem to have been born with a disinclination to read, possibly because of dyslexia or some other limitation, but in general you read more as you get older. Most people who enter a retirement community will arrive with a personal library, and eventually be dismayed when the communal library tells them it doesn't want their books.

Retirement is finally the time to do some reading.

This seems like an unnecessary waste. Professional librarians, placed in charge of much larger libraries, have long ago met together and decided what to do. Here's what you do. The first step is to appoint a committee to decide on what the core subject material should be. After a number of aimless meetings, the group will ultimately decide that our library should focus on books about, say, airplanes. For gender balance, a second focus on French cooking would do quite nicely. Second, a committee is appointed to inventory the existing library, setting aside the more popular books, and identifying what is already present in the core topics, airplanes and French cooking.

Free Libary of Philadelphia Books

Third step: as new entrants to the community lug in their boxes of books, the books which are outside the core focus are offered to an Internet used book exchange and sold for whatever they will bring. With the money realized from these sales, more books are purchased that fit into the core categories. It will take very little time before your library has a notable collection of books about airplanes and French cooking. People are invited to give lectures and book reviews about these topics, perhaps writing up some articles for the community newsletter. Once in a while, a really noted speaker from outside is invited to a special meeting of the community to listen to an authoritative presentation, and receive the coveted award for noted authorities on airplanes/French cooking. With suitable entries on websites, the local library becomes famous for its collection, and scholars begin to arrive to work on specialized projects and theses.

Nicolas Murray Butler

The idea can be embroidered as desired; you can organize a university if you want to. Field trips and exchanges with similar library clubs are more modest ambitions. To some extent, this idea grows out of an essay called What is a University? which Nicholas Murray Butler wrote and used for a commencement address innumerable times. Columbia Univerity's commencements are still mostly held in front of the steps to Low Library, and may or may not still end with Butler's punch line: A university is a collection of books.

There is no reason why a retirement library should not continue to offer the local and national newspapers, or that huge favorite, the detective murder mystery. Books donated by incoming residents will almost certainly reflect the tastes and interest of the community. But if there is any care taken in the selection of the core collections, the community will develop some amateur scholars in the topics, who will be found working away in the library on some article they are writing. The library becomes a natural focus for the community computer center, or computer training center, or headquarters of the users group. On days when it is raining, some of the golfers may wander in, as well.

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Gardening

Charles Burpee

The late Charles Burpee had a little speech he made everywhere he got a chance. "If you want to be happy for a day," he said, "Get drunk." If you want to be happy for a month, get married. But if you want to be happy for a lifetime -- get a garden." A lot of people who were born and bred in condos think Burpee must have been a little strange, but even they often tend house plants and window boxes.

Gardening not only takes time, it takes time during the day.

Gardening may be fun, but it takes time. It particularly takes time during daylight without rain, which is in much shorter supply during short springtime days, and equally short days in the harvest season. In fact, the most critical part of home gardening is to do your planting and weeding and harvesting at just the right time. It's useful to have neighbors who will tell you what grows well in the neighborhood, and where to buy plants and fertilizers. After that, most amateur gardeners are good to go, once they buy a gardening how-to book. Long ago, one other way to improve your garden was to send some daughters to Shipley School, which always dominated the prizes at the Philadelphia Flower Show. However, Shipley has since gone co-ed, and there may have been many other changes.

So, being retired makes gardening possible for people who like it well enough, but never found time at the right season. It's one of the reasons to be reluctant to sell your house which is now too big for you when you retire. Now at last you can get things mulched and composted and planted and fertilized and pruned. Especially pruning. There is a tendency in suburban living to plant a lot of bushes and groundcover, and then forget them for twenty years. After a while, the house disappears in the bushes and the whole place looks as though it had been abandoned. It can take two years of pruning and fertilizing to get the place salable; and when you get it salable, you start to lose your interest in selling it. You begin to suspect your neighbors have been prodded into competitive gardening; mustn't let them show you up. Real estate agents who have become unexpectedly friendly tell you neighborhood house prices are holding up nicely. Not now, go away.

Gladiolus

A few miles further out from suburbia, in exurbia, notice that farmers seldom bother much with landscaping and flower gardening. A farmer patient of mine once plowed up half an acre and planted gladioli. And then he sold the cut gladioli to a local florist. Houses in the suburbs have foundation planting, azalea usually and rhodedendron right next to the house. Farmers may have just as nice a masonry house, but the lawn grows right up to the foundation wall of the house. Sometimes there is a flowering shrub standing lonesome on the property, usually not even that. If you spend all day every day in the agriculture business, you lose your interest in flower gardens as a hobby. But notice where that has never been true, in Tidewater Virginia and the rest of the deep South. It's not politically correct to say so, but slavery had its advantages for the owners. Once you go beyond having foundation plantings and a kitchen garden, you probably have to have some hired help to garden in a notable way. It's been a help to have power mowers and clippers, fertilizer spreaders and underground sprinkling systems; they just about balance out the loss of gardening assistance from working wives, and the extra time spent commuting extra miles. If a property has been neglected for decades, it's almost a necessity to hire professional help for one or two years to get it into shape. After the work is reduced to maintenance and tinkering, one retired person can handle it with pleasure. If you have kindly friends and neighbors, you will learn about the choicer seed and plant catalogs, especially those who deliver their plants at just the right time in the season.

Some people prefer vegetables and spices. Tomatoes are a favorite place to begin, and cucumbers. Woodruff is nice as a ground cover and turns cheap white wine into May wine. Scallions and basil are nice. But if you are really serious about vegetables you will elevate the beds a foot above ground, and it starts to look a little tacky. A compost heap, on the other hand, is unobtrusive and can be made quite elegant. One neighbor boasted he was going to hold cocktail parties in his compost heap.

John Bartram's farm and garden

Given the chance, it's worthwhile to tour the various show gardens and arboretums in the Philadelphia neighborhoods. John Bartram's farm and garden is right in the center of the city, the way it always has been for the last three hundred years. Bartram hiked all over colonial America, collecting strange plants and flowers for resale. But most of his business was not in Philadelphia or even in America, it was in England. He had a close friend, Peter Collison, who acted as marketing agent if not business partner in Great Britain, where gardening became a major occupation of the great landed estates that American tourists now take such trouble to visit. Obviously, quite obviously, it takes a staff to keep such places up. Retirement communities can do the same in a communal way, if they could only get themselves pulled together.

Farming

The subject of tomatoes is a sad one for the Garden State. Because of its sandy soil, southern New Jersey is especially favorable for tomatoes, and cranberrys, and peas and beans. New Jersey was once a great truck farm state. Fifty years ago, Campbell Soup would bring in vast heaps of tomatoes to the soup factory in Camden, and they were very good tomatoes indeed. The tomato plants would boom continuously all summer, and vast hordes of tomato pickers would continuously harvest the crop until the first hard frost. However, a new breed of tomato plant was developed, which bloomed and ripened all at once. That was very suitable for mechanical tomato-pickers to harvest, human pickers were not longer needed to tell ripe ones from green ones. So the tomato industry picked up and moved to California, where they can grow three crops a year, harvest them with machines, and improve the bottom line for Campbell Soup. Cranberries went the other way, into the pine barrens, and one family the Haines organized a farmers cooperative called Ocean Spray which bought up almost all of the suitable bogs. Even the Journal of the American Medical Association will attest to the merit of cranberry juice for kidney infections, to the point where it has become a little hard to find cranberries in berry form for Thanksgiving and Christmas. Further south in New Jersey, the canneries organized the local farmers into growing a lot of one kind of vegetable for canning purposes. In the 1920's, however one Frank Birdseye learned about the value of quick freezing from the Esquimos, and after applying it first to frozen fish, extended it into the various vegetables formerly organized around canning companies. You can now drive for miles past vegetable farms, without seeing a farmhouse. Quakers catch on quick; the same is true in Chester County, Pennsylvania, where the Brock family holds sway.

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Newspapers

Times Generation X,Y, or Z

Amidst the 2009 depression, newspapers get more expensive but thinner, thus tempting readership into a downward spiral. We hear the generation under thirty scarcely notices newspapers, except for comic pages and sports sections. Kids never were much interested in news, as I discovered at age 15. Time Magazine sponsored prizes for the best score on a current events test at that time; I won it in my school by being the only student who bothered to take the test. Later, I even had to do a lot of arguing to compete with boys clustered around the radio, listening to such timeless music as Amapola , just to find out what had happened at Pearl Harbor. Within two years, several of those boys had been killed in the war that began for us that day. Whether the news is covered by TV, the blogosphere, magazines or newspapers, kids are not now and have never been much interested in news. Those polls and surveys bemoaning the condition of Generation X, Y or Z don't prove very much. In fact, if you want my opinion, all age groups of the American culture have always been astonishingly oblivious to news. When Franklin Roosevelt won landslide election victories in spite of almost universal opposition by newspaper editorials, it astonished the newspaper columnists, but didn't surprise me at all. Americans don't pay much attention to news, never have.

Newspapers are central to the life of retirement.

Toting a hundred morning newspapers in the dark hours before school began, it was painfully obvious to my adolescent muscles that newspapers were thick (and heavy) on Fridays, pathetically thin on Saturdays, and although the weekly cycle persisted, grew unbelievably heavy between Thanksgiving and Christmas, thin and anemic after New Year's. What seems to excite reader interest is advertisement, opening a chest of dreams for the hopeful, plus maybe suggestions to those who are desperate for gift ideas. The generation of my parents read Sears, Roebuck catalogs, my own generation grown adult read the ads back among the brassiere ads. The coming generations get their dream fulfillment -- from electronic gadgets rather than the printed page, but their interest in news is no less, it couldn't be. A major feature in the decline of newspaper revenue was the almost instantaneous transfer of want-ads to the Internet. The shocked newsrooms are discovering that advertisements not only subsidized the news, they generated much of the readership.

For the people in retirement, however, newspapers do provide the news. Retirees read the papers, think about the editorials, begin their conversations with allusions to today's big news stories. Television tells you what is news, but the newspapers make you a current events conversationalist. Every retired person wants to engage in brief banter about some movie star who died, but the retirees mostly male who want to express opinions about the affairs of the world, are accustomed to shaping those opinions by reading the papers. You can't maintain your self-image as a local leader when you don't have a clue. And since retirees have time to read but commuters mostly don't, interpreting the news is a function which maintains generational authority.

Newspapers

Because big papers can afford bigger newsrooms, urban retirees typically maintain dominance over country cousins. People who live in the big city know what's what, while retirees who wander around small towns have to rely on their wits, small-time. The steady disappearance of urban newspaper competition led to the complaint that the press was biased. But disappearance of newspapers entirely is too threatening to social relationships to be tolerated without searches for substitutes.

You would think the newspapers would mount a better self-defense than they have; right now, only 16% of retired males are comfortable using a computer. The rising generation is something else, of course, so there might be a ten year window for the newspapers to regroup and respond. However, it looks as though they waited too long. The New York Times was worth $10 billion six or seven years ago, now is only worth one billion. The Sulzberger family doesn't own it all but have surely lost 90% of their investment, and must be looking to their family security rather than gamble their pittance on saving the paper. The Bancroft family took their billion and ran, leaving it to Mr. Murdoch to worry about new frontiers for the Wall Street Journal. Just about every other family-dominated newspaper has passed into the hands of absentee generations. If a feisty young newspaper heir is going to become Sir Galahad, he better get started soon. The retiree grandparents, out on the golf course, demand no less.

http://www.philadelphia-reflections.com/blog/1683.htm

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The News of Ideas

Harrison Salisbury

Children, if they read a newspaper at all, dive right into the comic pages. Retirees and other older people with time for reflection, go straight to the Op-Ed page. Although columnists and feature writers have occasionally appeared opposite the editorials in the past century, the Op(posite)-Ed(itorial) page as it now has become standardized in metropolitan newspapers, was started in the New York Times in 1970. The leaders of that paper had been wrangling and debating the issue for at least six years, so a great many people now take credit for it. The publisher, Punch Sulzberger, made the final decision to go ahead with it, and Harrison Salisbury as the first editor of the page had a lot to do with shaping it. The most vociferous advocate for the Op-Ed concept was John B. Oakes. The concept would never have succeeded without the enthusiasm of these three men. However, a lot of articulate people sit around the offices of the paper, and the concepts which eventually emerged had a lot to do with the opinions and indirect influence of Scotty Reston and Abe Rosenthal. What in the world was at stake that such a simple idea took so long to emerge?

The Editorial page and the Op-Ed pages are the heart of a newspaper for senior citizens.

Newspapers generally, and the Times in particular, make a great fuss about keeping the editorial and news departments independent of each other. The news department is supposed to report the facts fairly and without coloration by the writer's opinion. It might well be imagined that these well-informed articulate people are constantly itching to express their deeply held beliefs, and convince the world to change its views; that's forbidden. Things are carried to the point where the authors of news stories are not permitted to write their own headlines; sometimes the headlines and the content appear to conflict with each other. The underlying purpose of this isolation is to discourage advertisers from influencing the coverage of their topic. In small-town newspapers it is often true that the paper will not write a story about a business unless it is accompanied by the order for an ad; not so, at the Times. All the News That's Fit to Print, is their claim; all the news that fits, mutter their competitors.

James "Scotty" Reston

The news department is told that opinions are expressed by the Editorial Department. Send them a memo if you want to get our opinion published, but keep it out of your news reports. The Editorial department is held to following the opinions of the newspaper owner in some papers; the Times asserts it excludes even the owner of the paper from its meetings of the editorial boards, This wrangle, some would say hypocrisy, influences a number of publications to a variable degree. Every editorial candidate is expected to demand that his contract include some reference to editorial autonomy, and is expected to resign in a public huff if the owner sticks his nose where it isn't welcome. In turn, the editor has control of hiring the subordinates and making assignments, prerogatives which the owner must not infringe. But it is clear that someone with expressed views repugnant to the owner is not going to get hired, and they all are careful to be well informed about the degree of the owner's interest in matters. For the most part, owners are too busy with other matters to pay much attention to the editorial slant, but they are certainly always at least to be regarded as sleeping tigers.

With this brief summary, it can be seen that both the news and the editorial departments are to some degree just aching to come right out and publish their unvarnished opinion, and from different angles are always under the constraint to tone it down. So, when the idea of an Op-Ed page comes up, both the news and the editorial groups want very much to control it. In this case, the editorial side won the argument, when Punch Sulzburger awarded it to them; and a number of representatives from the news side of the paper, felt their enthusiasm cool. But the mission statement was created by Reston, who convinced people that what was sorely lacking in all newspapers was some discussion of the news of ideas. That's a compromise both sides could live with, and it also happened to be true. Up until that time, there was no established place for discussion of ideas.

Abe Rosenthal

It would have to be admitted that the Wall Street Journal comes closer to fulfilling that mission than the paper which originated it. The reason can be surmised to originate in the hiring policies. As space in the paper becomes constrained by economics, the Times has tended to hang on to its full-time employees, or others who have long-term contracts. No matter how big your payroll or how large your staff, this tends to narrow the range of opinion. In fact, with constrained space but a large staff, it makes things worse. By either intent or financial necessity, other papers have sought out many more occasional opinions from stringers and specialists in the topic of the day. The Wall Street Journal has carried this idea farthest. They appear to hunt up Nobel Prize winners, Presidential cabinet members, corporation chairmen, prominent jurists, and others who would have to be acknowledged as experts in a particular topic. True, there are a couple of regular columnists, and it's also true that the Times is starting to tend in that direction. It would look as though Democrat administrations feed articles to the Times while Republican administrations try to use the voice of the Journal to announce their positions. And from time to time, the parties switch papers, in a bipartisan way, as the expression goes. But the Journal is going further, faster; they now print three pages of editorials, while the Times stays with two. Pages without ads cost money, but that makes them an ideal way to flaunt success with readers.

And back in the 1960s when all this was being debated, very little was expressed in just this way. At that time, the Times had the quaint custom of printing the obituaries opposite the editorials. The two battling contenders to present the news of ideas, spent most of their time refusing to move the obits.

http://www.philadelphia-reflections.com/blog/1685.htm

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What Will Replace Daily Newspapers?

There's much gloomy talk about the newspapers. One of them goes bankrupt often enough to confirm the truth of it. One would suppose a great business opportunity has arisen for someone to devise a replacement for the papers, but as yet no one has claimed the prize. We think we know the grim answer to -- Whither Newspapers?, but no answer at all is offered to -- What's Next?

What could replace a newspaper?

Since the front pages and the editorial pages of the main newspaper in a nearby city find their main readership in the retired males of the region, it may be of some use to speculate on what the old gentlemen will use to maintain their function as local oracles. Television, perhaps, constantly tuned to a news or stock market program. The courthouse hangers-on have always proved to have bits of information that may not be fit to print, but often is useful in winning an election. On a different social level, the golf clubs trade useful tips amidst the sports talk and off-color jokes. Barber shops and tap rooms have their conversational styles. But just about every source of information in common use is reduced to sound bites, sly remarks, and one-liners. Where can we look for future analysis of ideas, of serious thought which needs local application? How about magazines?

Periodicals of all sorts are also feeling the economic pinch of the decline of the Cyrus Curtis rule. The publisher of the Saturday Evening Post built a huge fortune on the general principle that the content of a periodical was just there to attract readers to the advertisements. If you want to know what sort of person reads a magazine, just take a look at the ads. The decline of newspapers is really a technology revolution which precipitated a secondary revolution in how advertisers reach their public. But you can't rescue a newspaper by trying to be a television, or a website, either. The news industry has remained on its plateau longer than might be expected from a monopoly built on the huge investment expense of high-speed printers; the industry had pretty high barriers to entry. Nevertheless, there is the Economist .

Started over a century ago by Walter Bagehot and published in England, this weekly periodical still calls itself a newspaper. Although Englishmen are a little puzzled by its recent success in America, the Economist is fast becoming the trendy source of information for educated Americans. To exploit this success in a talky demographic, the magazine has recently acquired an editor who is noticeably but not damagingly more trendy, himself. If you take all of the news and editorial content of a week's New York Times , it amounts to about the same content bulk as a single weekly Economist . So, from a reader's point of view, you can learn of the latest celebrity fuss from TV, and settle down to either one of these news analysis sources at your leisure. Or Wall Street Journal, Washington Post, etc. The English magazine is more concise but more detailed than the American newspapers, does not have annoying jumps to inside pages in the middle of stories, is organized by topic more handily, and features at least one long in-depth analysis. There are things like movie reviews and useful ads for consumer goods, but if newspapers are going to disappear anyway, the Economist fills the information gap at least as well, at considerably less cost and waste disposal problem. There have been missteps, like its misguided defense of majority rule in subsaharan Africa, and overlong defense of the Vietnam War, but one gets the feeling that Walter Bagehot's paper will absolutely never defend a favorite political party which momentarily preaches economic nonsense. That's a bit of integrity, by the way, which American metropolitan newspapers never seemed to acquire.

The American public-service broadcasting called C-Span is financed on three channels by the cable television industry, and is not only a unique primary source, but has at least one Internet innovation worth considering. C-span seems to send a television crew to every major congressional hearing and public speech or happening; you can almost count on seeing something important on C-span if you hear it's going to happen. True, it concentrates on Washington, but it is rapidly spreading out. It's most notable recent advance is to present a full day of book reviews and author inverviews; if you read a lot of books, it's hard to see how you can avoid watching the weekend book discussions. There are no advertisements, and no editorials, but they can be a little sly. If you suddenly find yourself watching an old speech from a few years back when a politician said something forceful, you can expect this clip to be soon followed by today's interview in which he says exactly the opposite. Today's bombastic incumbent is likely to be followed by a neat rebuttal by his shadow opponent. Not editorializing, mind you, but C-span didn't want you to miss the irony. And topical reviews can be constructed by playing today's speeches pro and con, followed by an author who has a book on the topic, followed by a review of a similar issue twenty, fifty or a hundred years ago. It's very close to primary-source reporting; make up your own mind. A recent innovation has been to play recordings of the House of Parliament at Prime Minister's Question Time, usually on Sunday night. The contrast between their system and ours, their debating skills and ours, and their personal nastiness and ours -- is quite instructive. Without any instructing, of course.

The novel innovation may really turn out to be important. In the past, the most serious criticism of C-Span would have been the seemingly random programming. You never know what to expect, or when, and you can scarcely be expected to watch three channels continuously. The answer has been found in the Internet, with a website called cspan.com. The website carries the program of coming events as soon as they are known, and it also maintains a library of past events in case you missed one. C-Span, in short, is using the Internet to drive traffic to its primary product, not the other way around as the newspapers have (futilely) been doing. And since you have to pay the cable company, directly or indirectly, to watch all cable programs, C-Span even has a revenue source.

http://www.philadelphia-reflections.com/blog/1686.htm

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Pot Belly

T.S. Eliot

In a lovesong written by T.S. Eliot, the character named J. Alfred Prufrock complains that as he grows old, he wears the bottom of his trousers rolled. College freshmen who encounter this line are apt to glide over it, uncomprehending, but the allusion will eventually grow clearer. The old man tends to find his legs have apparently grown shorter, because he has to roll up his pants to keep them from dragging on the ground. Although the cartilages in his knees, hips and lower spine may have compressed a little, the shortened legs are more apparent than real. The pants seem longer because his belt line has dropped. Dropped below his pot belly, that is.

No medical textbook that I know contains much discussion of pot bellies, even though they are almost universal, and universally noticed. The muscles of the belly wall relax, allowing the guts to bulge forward over the pubic bone.

Even doctors don't know enough about this disorder of old age.

The aging lungs tend to enlarge, pushing the guts downward. The spine bends forward, and of course fat tends to increase inside the abdominal cavity. If there has not been too much weight gain, the pot belly tends to flatten out when its owner lies down on his back; if weight has been gained, the pot sticks up like a pregnancy, obscuring the lower edge of the rib cage, bulging out at the sides. Normally, a young person's abdomen is described as "scaphoid", or hollowed out like the inside of a rowboat. A skinny young woman has wider flaring hip bones, exaggerating this scaphoid appearance, and making the waist narrower by allowing the guts to drop down into the larger pelvic cavity. Younger people are more active, with more muscle tone holding things together somewhat better.

Pot Belly

Anyway, when the older person rolls over in bed, the innards of the belly cavity get squashed against the mattress. The old man's prostate leads to a fuller bladder, which means he gets up earlier when he rolls over it, and gets up a lot earlier if he is overweight and has more pot belly. Or it may be the upper stomach that gets squashed, forcing the acid stomach contents up the esophagus and resulting in heartburn, burping, and even cough or hoarseness if the acid gets up into the throat and back down the windpipe. With weight gain, the pressure of lying prone can press against the main leg veins as they cross the brim of the pelvis, resulting in swollen ankles. Since the large intestines are coiled and kinked, external pressure against them causes a minor degree of obstruction which can be experienced as constipation or sometimes bowel urgency. Since the bowels contain a fair amount of gas, pressure on them causes small gas bubbles to merge into larger bubbles, with resulting flatulence which can reach startling proportions in the early morning hours. For all these reasons, people with pot bellies tend to sleep on their backs, causing a lot of snoring. If they snort and waken, they may have night time insomnia, daytime drowsiness. One sure sign of this is that the bed partner flees to a separate bedroom.

Scarlett O'Hara's Wasp-Waist

Victims of this affliction may, if they choose, imitate Scarlett O'Hara in that famous scene in Gone With the Wind with the slave girls pulling a tight corset even more painfully tight, but corsets are currently out of fashion. Or they can take purple pills to correct the heartburn, or regular laxatives for some of the other problems. In general, however, leg-lifting exercises strengthen the belly wall muscles (abs, I believe they are called), and losing weight by eating less does the rest. Losing weight is never easy, but in this case a few pounds can make big differences in belly circumference, as measured by the belt size. Nothing will shrink the enlarged lungs pushing down, however, and arthritis of the spine may maintain the forward stoop. Very few older people are completely without some signs of this common affliction. Even so athletic a person as the ramrod-straight George Washington, developed just a little pot. And Benjamin Franklin, of course, had a hopeless case.

http://www.philadelphia-reflections.com/blog/1687.htm

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Hospitals Shift Costs Three Ways

Safeway Store

The CEO of Safeway Stores recently offered his own company's preventive approaches as an example of what the nation can do to reduce health costs. He's undoubtedly sincere, but he's wrong; he just shifted costs to Medicare. This is only one of three ways, major ways, cost-shifting is misleading us.

Medicare

Average life expectancy is increasing at more than two years per decade, but people always eventually die. Since health care costs are heaviest in the last year or two of life, extending life will soon push nearly all those heavy terminal costs from employer based insurance -- into Medicare. To die at age 64 costs Blue Cross a lot; but to die at 65 just costs Medicare a lot, it doesn't save Society any money. From Safeway's point of view, this effect has the happy outcome that Safeway's health costs are diminished. From the point of view of society, however, lifetime health costs are the same or even greater, because they have been shifted to Medicare. Let's put it another way: dying at age 64 costs the employer and the employees; but dying at 65 costs the taxpayers. Safeway's CEO has definitely improved health care, and accomplished a wonderful result for his employees. But his claim that reduction in his company's premiums reflects a saving of money is at best unproven, and in theory probably incorrect. Increasing longevity is constantly pushing more costs from employers to Medicare, and not just in Safeway; the prospect is that soon substantially all major sickness costs will be assigned to Medicare. (To explain the failure of most employer insurance costs to fall comparably in response to this shift, one must look elsewhere).

But instead of going down that trail, let's look at a second form of cost-shifting. Government payers and monopolists are able to pay hospitals less than actual costs, and get away with it. The worst offenders are state governors administering Medicaid, where the underpayment is roughly 30%, in spite of federal reimbursement to the states for most of it at full price. The resulting profit is used for various state purposes, mainly nursing home reimbursement. For the most part, such diverted funds are used for purposes not easily eliminated, so it is unlikely there will be much cost reduction for government if the scam is acknowledged and eliminated. To avoid bankruptcy, hospitals raise the rates for other health insurance plans -- and the uninsured. Employers are paying for most of it, so they stand to gain from reform, only to face higher state taxes as matters readjust. We have yet to learn where these costs will shift if the federal government takes over the costs of the uninsured. To a major degree, the federal government and its taxpayers are already paying for a lot of this uninsured cost, through the Medicaid shift. So its present dilemma is whether to pay for it twice.

Blue Cross Blue Shield

There's still a third cost-shift. In 1983, Medicare stopped reimbursing hospitals fee-for-service (itemized patient bills are still prepared but are meaningless fictions) and for thirty years has paid by the diagnosis, not the service. Consequently, per beneficiary inpatient costs have only risen 18% in five years, while outpatient costs have risen 47%. Skilled nursing and home care costs are rising even faster.

Not only do these shifts provoke inpatient nursing shortages, they start a war for patients between hospitals and office-based physicians. The difference between a hospital which makes money and one which loses money is based on whether there is enough out-patient revenue to compensate for the hidden tax which the state effectively imposes on hospitals in order to pay for nursing homes. These splashes send off ripples in all directions, enough to fill volumes of commentary.

Just notice, for example, that neither Medicare nor private health insurance pays below costs, if you look at total national balances. Private insurers are paying hospitals 32% more than actual inpatient costs, while Medicare is paying 6% more than national cost. And yet 58% of hospitals are losing money. It could fairly be said we are just looking at a maldistribution of the uninsured, as a cost, and a maldistribution of non-inpatient revenues, as a profit, among the nation's hospitals. To what extent such maldistribution reflects uneven quality, as the losers claim, or inefficiency, as the winners would say, -- merely starts a diversion of attention which could last twenty years while we examine it.

And disruptions enough to take decades to fix. Anyone who believes that ham-fisted reform next month will save money in a situation like this, is dangerous to have around.

http://www.philadelphia-reflections.com/blog/1696.htm

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Cataracts

Cataract Surgery

At a social gathering of older Americans, if someone excitedly announces he has just had successful cataract surgery, the chances are good that every other person in the group will reply they have had it, too. Those who have had two eyes operated have slightly more social clout than those who have had only one, but in general soft lens implants are what everybody has. It's pretty common to meet someone for lunch who had a cataract operation that morning. What a contrast from the olde days. Until about 1970, having a cataract removed was a matter of spending two weeks in a darkened room in the hospital, with your head held in sandbags to keep you from moving. And the result, while better than nothing, was the need to wear glasses so thick they resembled the bottom of cocoa-cola bottles, and narrowed the visual field to the end of a tunnel. Those who had cataract surgery forty years ago had to be blind before the risk was justified.

Everybody gets cataracts, and almost everybody is cured.

There was a reason for this, relating to a blinding eye condition known as sympathetic ophthalmitis. The most harrowing of dangers associated with eye surgery was the tendency for an injured eye to become allergic to itself, and hence also allergic to the opposite eye, soon leading to total blindness in both eyes. Eye surgery was nothing to fool with, and it was particularly dangerous to have a foreign body like a piece of flying glass enter the eyeball. And then, came the Battle of Britain, where so many owe so much to so few.

Spitfire

The British pilots were flying Spitfires, a type of airplane with a large plexiglass canopy over the pilot, allowing him to look in all directions for the enemy. The German Messerschmidt pilots would swoop down on the Spitfires, machine guns blazing. The Spitfires were not necessarily shot down when they were hit, but many of them had shattered chards of plexiglass sprayed into the cockpit, and many of the splinters went into the British pilot's eyes. If they managed to land the planes, the British doctors administered emergency first aid, stopped major bleeding, fixed major broken bones. In the heat of the emergency, no one noticed that bits of plexiglass were being left in the eyeballs.

Eventually, these survivors were being treated for scars and injuries in clinics, long after the war. One British opthalmologist suddenly had a striking insight. These eyes, with buried foreign bodies in them, were working just fine. No sympathetic ophthalmitis; that wasn't supposed to happen. Ultimately, the realization spread that plexiglass could be used as a lens implant, and many patients were successfully treated with a so-called hard lens.

The next advance was the soft lens. Someone realized that soft plastic, like a soft rubber ball, has a memory. Squeeze it out of shape, and it will soon return to its original shape. So, in effect, a soft lens of the proper size and shape can be squeezed into a toothpaste tube, injected into the right place in an eye, and it will pop back into shape. Before this can be done, of course, the rotten old lens has to be removed in any of several ways; pluck it out with eyebrow tweezers, or buzz it into liquid by lasers or other means, suck out the juice, and squeeze the squashed-up soft plastic lens into place. With practice, the whole thing can be done in ten minutes. That's modern cataract surgery, and it's pretty slick, especially if you know what the struggles were, before the Spitfires.

But don't let me overstate matters. This operation still has its risks. The retina behind the lens may turn out to have been defective, so a new lens hardly helps very much. Or there can be a slip, which amounts to one drop of blood getting where it doesn't belong, and the eye or both eyes are ruined. When I had my eye fixed, I seemed to be lying on the stretcher for a lot longer than necessary. Suddenly, I heard operating room doors banging open, and several older physicians in street clothes came in, huddled around, talked with each other for a long time, walked slowly back out into the corridor. I knew exactly what that was all about, and it didn't improve my serenity. Eventually, a nurse asked if I was ready, and I said, Yes, I guess so.

http://www.philadelphia-reflections.com/blog/1697.htm

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Kiddie-Karts

Golf Cart

Back in the days when resort hotels were the place to go for vacations, there was usually at least one old lady in a wheel chair staying at the hotel for protracted periods. She might appear at tea with her silent attendant, and occasionally the evening lecture, and smile at a few passers-by who said hello. Rumor would have it that she owned a Fortune 500 company, or some equivalent mark of distinction. Nowadays, however, the wheelchair attendant has been replaced by the Kiddie-Kart, or go-cart, or golf cart. A rechargeable battery supplies the power, and lots of old folks tootle around most retirement villages, only mildly embarrassed by the notice they receive. Just outside the dining room you can expect to find a go-cart garage, with eight or ten of them parked during dinner. For the most part, polished within an inch of their lives, they look brand-new.

Everybody has shoes, and almost every senior will eventually get an electric cart.

The economics of such go-carts is somewhat skewed. They cost about two thousand dollars, but Medicare will pay half of that. Since everyone who wants to get one is able to get the same Medicare allowance, there's not much of a second-hand market. After all, everybody is able to get a new one worth two thousand for a net one thousand dollars, so why would they pay several hundred for just an old one without a warranty? No doubt, the people who haunt Internet auctions have got something figured out. The owners of these things are glad to volunteer they believe Medicare makes it deliberately difficult to negotiate the paperwork, but in fairness people of this age group quite readily find such things to be an obstacle. No doubt the nice young lady at the go-cart store can suggest work-arounds. The go-carts seem to be quite sturdy. My sister-in-law by marriage went to India in a go-cart, travelling all around the normal tourist sites. She had once lived in India for several years, so she knew the situation and had local friends. Similar trips by other seniors can therefore not be encouraged, but the story does suggest cripples can be much more independent with this sort of transportation than most people would have guessed. There are resort communities in Florida where regular automobiles are prohibited, and everybody tootles around in golf carts redecorated to look like Volkswagens, or even with Rolls Royce radiator fronts. When you see teenagers at a beach resort riding these carts, you know the stigma has disappeared.

http://www.philadelphia-reflections.com/blog/1698.htm

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Investing for Children

Many a Mickle Makes a Muckle

There are three major expenses for an average American lifetime. Paying for college, buying a house, and providing for retirement. Unless there is a substantial inheritance, all three of these expenses must be provided for during the four decades from college graduation to retirement. Even in affluent families during prosperous times, that is almost too much burden to carry. Improved longevity leads to longer retirements, depleting family reserves which might have been transferred to grandchildren for their expensive educations. Even families which can afford it, find the legal climate unhelpful. Money given to a grandchild at birth has twenty years to grow, at least tripling before college entrance, but it proves remarkably difficult to take advantage of this opportunity.

Look Out for the Poorhouse

It is obviously dangerous to allow children to choose how to spend their own money. They will not merely squander money on trinkets, there are automobiles, illegal drugs, and unwise marriages to consider. A law called the uniform gifts to minors act addresses this issue fairly well, placing assets in the hands of a custodian until the child is nineteen. That's the right idea, but nineteen is too young for many who go on to college, and it would be a blessing if the money in these custodial accounts could be frozen until college bills, if any, have been paid.

Trust Funds

A concept known as the Clifford Trust was created, allowing income from a sum of money to go to minor children (at their lower income tax rates) and then after a minimum of ten years the principle reverts to the donor. That was well intended, but it created a mountain of burdensome paperwork, legal and accounting fees. The Internal Revenue Service probably has very good reason to be suspicious of arrangements for children which primarily cloak tax evasions by their relatives. Nevertheless, the great majority of honest parents trying to pay for college are hounded and hassled in order to prevent a smaller number from cheating. Our lawmakers ought to be able to do better than this.

Zero-coupon Bond

It was once possible to buy tax-free municipal bonds without coupons -- so-called zero coupon bonds, or strips -- which could be put in a safe deposit box and forgotten until college admission time. Unfortunately, the law was changed to require yearly taxes on "virtual" income, and much ado was made of the concealment of personal property from the awareness of the infant owners.

Until Death Do Us Part

Trust funds are expensive to construct and maintain, and taxed at a fixed high tax bracket, often higher than the parents are paying. While college tuition bills are crushing, they are not large enough to make it economical to use ordinary trust funds to sustain them for the few years of concern. As the economy grows steadily more prosperous, more people will face these problems, and sympathy may grow to the point of congressional action. Unfortunately, the families who do not have college problems to finance are an envy obstacle in the eyes of elected officials, and the fairness argument is rehearsed.

Warren Buffett

Meanwhile, a single share of Berkshire Hathaway stock would pay for college, would probably triple in value from birth to graduation, generating no taxes in the meantime. The problem obviously is to afford that single share when the baby is born, but possibly a sort of mortgage could be devised. There should be more securities like Berkshire Hathaway; long life to its all-too-mortal master, Warren Buffett.

http://www.philadelphia-reflections.com/blog/1166.htm

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Retirement Communities (CCRC)

Let's confess my meager authority to generalize about trends in retiree convalescence. When I graduated from medical school in 1948, average American longevity was twelve or fifteen years shorter than today, and most assumptions rested on its remaining the same forever. Someone who reached eighty was really old, obviously facing a prompt decline. Today, essentially everybody lives to be eighty. We only half-expect such long life, which is modest of us, and only halfway plan for it, which is foolish.

Picking the right CCRC is as hard as picking the right spouse.

In 1950 a general practitioner in Haddonfield, NJ called for help from the son of one of his patients, a doctor on the staff of the Pennsylvania Hospital. He hadn't had a vacation for twenty years, and wondered if one of the graduating internes might take his practice for a month. I volunteered, and then learned about retirement in a prosperous suburb. My employer had many tasks, among them a schedule of ten or twenty monthly house calls. There may have been some male patients on those rounds, but all I remember were old ladies living on the third floors of big old houses. I wasn't expected to do very much when I visited, at least by Emergency Room standards in the hospital. The families with whom the grandmothers were living wanted to be reassured that nothing was neglected. They wanted to form their own assessment whether the doctor really knew who they were, and would come immediately if needed.

My next insight came a few months later when a doctor on the staff of the hospital had a heart attack; the Chief of Medicine gave me the time off to take care of this practice while the doctor recovered. When I first arrived at the door of the brick Philadelphia row-house where the doctor had his office, I was met by his nurse already wearing a raincoat, handing me an umbrella. We visited ten or fifteen other row houses along the neighboring streets, where to my amazement I found patients with oxygen tents and intravenous infusions. If the patients needed blood tests or electrocardiograms, the nurse arranged for them to be performed at home. Drugs by injection were administered, hospital-like bedside charts were maintained. This was working-class neighborhood substitute for hospital care, but I was astonished to see how adequate it was. By this time, we had many resident physicians at the hospital who had seen service in the war and returned for specialty training; they regaled us at the lunch table about treating major illnesses -- in a tent. This wasn't the Civil War we were talking about, it was 1950.

Fifteen or twenty years later, my personal situation had improved; Medicare had arrived in 1965, but I was in practice as a center-city specialist and hardly noticed the new insurance system. But I did have three patients who insisted on being treated at home, which even by then had become an unusual arrangement. All three lived in condominium apartments in buildings with dining rooms on the main floor which would send up take-out dinners. All three patients had live-in nurses and hospital beds rented from an agency. One spinster lady absolutely refused to be treated in a hospital, because the Queen of England set up a little hospital in her palace when she needed it, and this lady said for practical purposes she had as much money as the Queen. Because she was dying of cancer, I resisted this idea, but if you had seen Katherine Hepburn in The Philadelphia Story you got the helpless feeling this dame was going to have her way. We called in laboratory and x-ray services as needed, administered injections, maintained a hospital chart. In this case, when I made a house call, her chauffeur would pick me up and deliver me, helping to insure my promptness. Her lawyer and I kept careful financial records of the experience, which was new to him, too. After she died, we totalled it up, and discovered with astonishment that the whole thing had been cheaper, a lot cheaper, than going to the hospital. Since she left a sum to the hospital in her will, even the hospital was pleased.

Well, nowadays there are more than fifty retirement communities scattered around the periphery of Philadelphia, many or most of them sponsored by Quakers. It's a national movement, and there are people in California who feel they had the idea first. There are now enough of these organizations to permit some classification of them into types, which mostly follows the sort of community model they resemble. There are some that look and are run like college dormitories, some that resemble convalescent homes, some are very like big-city apartment condos, and some behave like resort hotels. One of them, the Kearsley, sits in the middle of the Bala golf course, attempting to provide first-class service to indigents by using existing government assistance programs, but has lately had to fall back on the Episcopal Church for financial help.

Since a financial shadow hangs over all of them, it should be mentioned first. Every person in a retirement village is eligible for Medicare and Social Security, and with the help of a social worker can fall back on less-known assistance programs. It's impossible to ignore the existence of these funds, but most unwise to depend on them. As the age and number of retirees constantly grows, state and federal governments are starting to draw back from initial generosity. Laws have passed that a CCRC resident may not be evicted for non-payment of debts, so the institutions have had to impose conditions which guarantee them payment from new entrants in the case of later inability to pay. The risk remains that clients who entered before the rules were imposed, can only be extricated by going before Congress and raising a piteous cry on bended knee. Such laws and embarrassments vary from state to state, and from year to year; but unstable finances destabilize any business. When the customers all depend on their savings, and average investment experience is a drop of 30-50% in the past couple of years, no one escapes anxiety.

Although there must be college courses in how to administer a CCRC by now, current administrators are drawn from the environment the place mostly resembles, so the resemblance gets stronger. The former manager of a country club tends to neglect the infirmary; the former directress of a convalescent home doesn't notice institutional food. If the administrator treats customers as complaining nuisances, you get one kind of war; if the board of directors is accustomed to ruling corporations by dictate, you get another. Mainly, these institutions differ from models of other institutions by the degree to which they have active volunteers in charge. The inmates may run the asylum, but only if they become useful volunteers. A curious distinction evolves between those CCRCs which emerge from college alumni associations, and those which are sponsored by churches. University faculties are not accustomed to, nor generally sympathetic with, teamwork. Every faculty member is on his own career path, which he hopes leads straight upward; teamwork to them is a code term used by business executives to imply blind obedience, Charge of the Light Brigade, or worse. Church groups, on the other hand, prize volunteerism. In a church environment, the proposal that Let's Have a Picnic, is supposed to be met with a chorus of Great, I'll be Glad to Bake a Cake. Church-sponsored CCRCs therefore are generally more adaptive to innovation in a formless society. University groups have camaraderie and complaining, but little follow-through. By contrast, business people know what you are supposed to do, you are supposed to make something happen. Church volunteers want to know how they can help. Paradoxically for that reason, the more evidence of golf clubs around the place, the more likely it is to be innovative.

Let's return to the point, succinctly. Life threatening and potentially convalescence-requiring medical conditions are destined to segment increasingly into Medicare, to the point where what remains outside of Medicare is elective, preventive or outpatient. Obstetrics is an exception, remaining more naturally part of the hospital than the CCRC. The rest of medical care thus seems inclined to migrate toward the suburban ring of retirement communities. The more natural transportation flow is for younger people to travel to either a hospital-centered medical cluster or a CCRC-centered cluster, not for frail old folks to leave the convalescent environment except for major surgeries from which they soon return to their infirmary. It doesn't have to be that way, it just seems like the natural arrangement.

Probably the main reason it doesn't work that way today resides in the Medicare law. The 1983 amendments restrained inpatient reimbursement much more than outpatient care or home nursing care, and consequently inpatient costs have risen 18% in five years, compared with 47% for outpatient. Outpatient care is not migrating toward retirement communities because hospitals need the revenue. Somehow, it seems easier to modify these reimbursement rules than to upend suburban CCRCs and relocate them nextdoor to an urban hospital. If the payment rules become reasonable, the system will readjust its geography in a reasonable way, without coaxing.

Surely, non-residents of the CCRCs are destined to wish to convalesce in the spare beds of CCRC infirmaries which should then treat younger people as a much-needed revenue source; any licensing requirements which block this seem unreasonable. Medical hardware,-- x-rays, MRIs and the like,-- is most naturally concentrated in the periphery of CCRCs, as are pharmacies, outpatient labs, doctors' offices. That's going to require a lot of parking space. It's a good thing this will take a couple of decades to happen; many mid-course adjustments will be imperative. But the basic fact is that the whole community's medical need is getting concentrated in CCRCs via Medicare, and so the community's facilities should move closer to that need. The younger community is well able to travel for elective medical services which move away from them. Makes a good chance to visit the grandparents, too.

Nearly every retirement village has four or five retired physicians living there, as well as a dozen retired nurses, lab technicians, and others with a medical experience. Every infirmary has four or five patients whose spouse is a resident of the community, visiting the infirmary regularly, and with sharpened insight. Some other people are natural leaders. If these people could be assembled into a permanent committee of medical oversight, charged with visiting other CCRCs in the region for ideas, and perfecting the interface between the CCRC and nearby hospitals, medical facilities, transportation vendors, and politicians -- things would start to move. Spending twenty percent of our gross domestic product on health is, quite enough.

http://www.philadelphia-reflections.com/blog/1699.htm

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The Whole Town as a Retirement Center

THE automobile changed American living habits. A few suburbs once organized around railroad commuting, and before that a few organized around steamboat commuting. But universal auto ownership triggered wholesale flight to the suburbs, and thus destroyed center city living. As suburbs tumbled into neighboring farmland, they seemed to obey a rule that 30-minute commuting was normal. There are extremes of regular two-hour commutes, but they conflict with a second hidden rule of suburbs, that some adult must be available when the kids get out of school. A third rule is that most young families move from town to distant suburbs when the first child reaches fourth grade. They later will seek a different lifestyle when the last child graduates from high school. Essentially, for American families attracted by the schools, automobile commuting makes suburbs attractive, but empty nests can end the interest.

Remaining in your own home after retirement requires administration.

Although it takes an extra logical step to get there, this insight suggests suburban retirement patterns surprisingly might be changed by working on the inner-city school system. Improve the quality of inner-city schools, and the rush to the suburbs slows down. Reducing urban crime and taxes would also help, of course, but reviving urban school quality is key. It would improve everybody's lifestyle, particularly for suburban retirees because to make suburbs inhabitable for anyone else, the teenager emphasis must subside. Suburbanites themselves drive matters in this direction in other ways, too.

My local suburban school system managed to acquire a reputation for outstanding quality in a couple of decades. It did so by pouring money into the system, bragging about the schools incessantly, but stopping considerably short of demanding the academic rigor found in private boarding schools. The process was driven by the local real estate industry, who shrewdly recognized that the product in demand was high school glamor, not necessarily discipline and homework. This maneuver successfully transformed a town which, fifty years earlier, found two thirds of the houses owned by families without children in public school. By contrast, just about every house in town today houses at least one school child, and the school taxes have been driven uncomfortably high. Meanwhile, four or five neighboring suburbs developed shortages of children, two school districts have even been closed. It seemed clear that families were moving into the "good school" suburb, willingly paying higher taxes while there were children to educate, but moving back to lower-tax neighboring suburbs when school quality no longer mattered to them. All this recirculation was economically rational, although not necessarily the most efficient use of community resources. Part of the lesson of this town may well be that economic recessions negatively affect suburbs, booms make them flourish. Recessions certainly create pressures to lower school taxes.

Retirees currently have difficulty living in this town, because school taxes are prohibitively high for residents without children to send to school. Long-time residents regularly sell their half-empty houses to newcomers with lots of kids, and then the old-timers move a mile or so away to a low-tax suburb, often into a house as large as the one they just left. Others respond to the situation by moving to a CCRC. Is this really a rational way to make rather basic life decisions?

Among the various reasons given to move to a retirement community, a chief one advanced by many people is that it is cheaper. Alternatively moving back into the center of a neighboring city might be more suitable, substituting a richer cultural and educational environment for a monastic one, with fewer bushes. In either case, retirement moves imply making a new set of friends, not particularly easy for old people to do. Commuting is no longer a price the retirees are willing to pay; hardly anyone without children is willing to commute. Safety from crime, and nearness to medical care beat culture most of the time. Although most retirees have forgotten how to enjoy what a city has to offer, center-city life really seems like a more natural place for retirees to congregate. Although the soccer moms seem to be having a fairly good time at the PTA, teenage cultural dominance of suburbs impairs livability for almost everyone else. Taken all together, commuting seems a rather high price to pay for six or seven years of high school excitement, particularly if note is made of the disconsolate loneliness of most adolescents. Inner city schools should improve, dissuading many from moving to the suburbs in the first place; inner city crime and taxes should be controlled to entice a return of the empty-nesters. At the very least, the suburban merchants and real estate agents should be squelched for their constant bad mouthing of neighboring cities.

If it becomes financially and socially possible for retirees to continue living in their lifetime homes, is it wise for them to do so? There is, first, the potential need for making financial provision for nursing, convalescent, or hospice care. Long-term care insurance aims at covering this need, but because these costs are high, the premiums for coverage are also high. It is difficult to know whether these prices are reasonable, because they must contain a margin of error against inflation, risk selection, and moral hazard. The technical insurance terms refer to the fact that the client almost certainly knows more about his impending health risks than the insurance company does, and secondly the mere existence of the insurance presents a temptation to use it. Someone living in the residential area of a retirement village surely has less temptation to move to its nursing facility than some other person still living in a house but potentially able to sell it and cash in his long term care insurance. There is also the danger lurking in the insurance that a client may get tired of paying premiums and drop the insurance shortly before needing it. Some types of insurance, notably term life insurance, actually pay claims to less than ten percent of clients; the rest drop the policies prematurely and receive no benefit. The tentative conclusion has to be reached that entering a CCRC is probably a better concept than buying long term care insurance, at least when both members of a marriage couple are comparatively healthy. Once the first one gets impaired or dies, the plight of the survivor definitely gets more precarious, without a volunteer caregiver or at least an in-house alert system.

One thing is pretty clear. At the present time, almost everyone is strongly advised to get on the waiting list of some CCRC, without hesitating to consider whether that is a final best decision. The deposit is ordinarily rather small, typically around a thousand dollars (returnable if unused). It at least eliminates that dreadful situation of urgently requiring admission, only to find the waiting list is years long. Even paying a deposit on several of these facilities at once can be justified if children move around enough to make a specific choice hard to make. An estate lawyer who was my patient was on the waiting list of five CCRCs for many years before he made a final choice; in his profession, he had many opportunities to see the wisdom of this approach. A less advisable choice made by many people is to enter the community before they need to. Comparatively few of these CCRCs permit you to sell out and move elsewhere without a penalty.

Nevertheless, why should you go, why should you disrupt your life this way? The answer seems to lie in the organization and its administration. When life choices are complex, unforeseeable and largely undesirable, and when your abilities may be slipping away, you may want some help without knowing it, or knowing where it get it. Maybe all you need is a new lawyer or tax accountant, or a different type of doctor, but have a little trouble telling a good one from a bad one. A tightly-knit little town can sometimes supply this service, but somehow it must be supplied. For that purpose, a Quaker organization in Philadelphia called Friends Lifecare at Home will manage an annual reassessment and call in the help necessary to remaining in your own home. It is a noble experiment, steadily growing in success. In a way, it supplies the function of the absent spouse, part caregiver, part watchman, and with a large Rolodex. Its main difficulties have come from Medicare, when seemingly capricious program changes change the assumptions in the yearly premium. Lifecare supplies service when Medicare doesn't; what happens when Medicare stops providing something? Lifecare helps you get a new doctor; what if the old doctor doesn't like that very much? The network of specialists and institutions may be just as important as the doctor, but the network changes when you change doctors. Many nursing care agencies refuse to allow their employees to have a key to the house, on advice of a lawyer who senses liability. Sometimes there is an emergency, no one can get in the door, and the fire department must be summoned to break in. There are problems with any arrangement, and there are problems with any alternative arrangement. This one works best when it is selected, not because it is cheaper, but because living at home is strongly preferred.

There's an architectural problem. Most suburban houses are built for families with children. If you plan to live in that house as a frail old pensioner, you had better fix the stair problem. One-story houses are certainly best, and even one-story houses often have stairs at the front door. Installing a home elevator is often prohibitively expensive, but would not be at the time the house is built. Most of the cost of an elevator lies in the construction of a shaft which has not been anticipated. If an elevator is added to a new house, the shaft is little more than two matching closets on two floors. The cab and motor are surprisingly inexpensive, and need not be added when the house is built. It's the design of closet over closet that makes it inexpensively feasible; what house could not use two extra closets? There are a lot of less defensible requirements in most building codes. While you are at it, be sure the doorways are wide enough to admit a wheelchair, the toilet seats low enough to permit wheelchair use, at least one walk-in shower is available, and handlebars provided near the bathtubs. These are things to think about, before you break your hip. If you don't it may add many thousands of dollars of unwelcome expenses at a rehab center, nursing home, or whatever. And not only expense; your roommate in a semi-private room may enjoy raunchy television channels.

There's also a local government problem, I'm afraid. The local volunteer ambulance service, often but not always run by the police or fire department, has its rules. If you are counting on this service to take you to a hospital or other medical service, you'd do well to check with them to see if they will take you to the place of your choice, if that ever becomes necessary. That's particularly true if you have enrolled in some "medical home" or home care service. If the local ambulance service won't take you there, you better know that in advance. If that's the case, don't argue with them. Either take effective political steps to get them to change their rules, or make other plans to get where you might want to go, at that unknown time in the future when you want to go there. If you live in a little town, drop in and visit with the Mayor or Commissioner, who might be unaware of your problem and easily able to fix it. If you live in a larger town, you may not be able to puzzle out where you could appeal. One easy way to work this particular system is to join the ambulance service as a volunteer, and make inquiries when you are on the inside. As a final last resort, if you live in a big city, go see the local ward leader who can fix things. Some of them will want money, but more likely they will only want your vote at the next election. If you are a member of a very large family, you will get more attention, because there are potentially lots of votes in your family. It's all rather sad, but the fact is that local politics usually control local ambulances, and their allowed destinations. A solution to the problem more directly available, is to talk with some of your neighbors who have cars. All that's needed except for unusual circumstances is transportation. You need not, and in fact usually should not, speed. Whenever I have put someone in an ambulance, my parting words to the driver are, "Don't go through any red lights!" Most of the cumbersome rules hampering ambulance use are imposed by insurance companies because of the high rate of accidents from those sirens and flashing red lights on the roof. If not insurance rules, it's lawyers, watchful for, or against, all the lawsuits which have been induced by Section 1983, a Reconstruction-era statute more recently reinterpreted to encourage citizens to sue local officials for just about anything at all, not just Jim Crow abuse.

And finally, there's a neighbor problem. It was first illustrated to me by my own 90-year old mother, who found everybody in her address book had died, so she threw the book away. One day when she needed a plumber, she just dialed zero and asked for "central", which in this case amazingly called the local police, who took care of it. But don't count on being that lucky. Portable cell phones help a lot with the problem of summoning assistance, providing you know someone to call. In a suburb, a lot of people move away for various reasons, and eventually an elderly pensioner living there is marooned in a neighborhood of strangers, never mind living in the same house for seventy years. The television and the Internet can be a great comfort to a hermit, but when help is needed, some familiar name should be pasted to the refrigerator door. Meals on wheels are nice, but they don't come when your sink is plugged up. A friendly local plumber is nice, but he won't help if the roof leaks. Everybody builds up a local network of friends and vendors, but older people need to watch out that it doesn't get out of date. They badly need what many of them don't think they need, a circle of friends.

http://www.philadelphia-reflections.com/blog/1701.htm

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Rejecting Preventive Health Care for Good Reason

WHILE we debated whether to disregard what could be afforded, and provide sickness care to all, the idea subtly changed to providing health care for all. That is, the proposal was not merely to expand sickness care to everyone, it included an expansion of what anyone would get, and who would provide it. Medical care is provided by physicians, sickness care is provided by doctors, nurses and hospitals, and healthcare is provided by an undefined larger group of providers. No wonder it costs more, and therefore a surprising number of people are unsure they want it. The issue centers on "healthcare" versus sickness care". How's that, again?

Preventive Health Care poses unique issues for seniors.

For example, the notion that preventing disease is superior to treating disease, goes back at least to Benjamin Franklin. Arguing that the Pennsylvania Legislature ought to help build the nation's first hospital, Franklin offered the truism that it saves money in the long run to treat people early and get them back to work. Franklin could hardly have foreseen that it isn't always true. Preventive medicine implies it is cheaper to spend small amounts, possibly every year, for many people, than to spend large amounts for a few. It's a matter of arithmetic, of course, and doesn't always have the same answer. When the math works against a preventive approach, it's usually argued the gain in health is worth it; but that's not invariably the case, either. Once a person ceases to be an , the equation rebalanced. And as an individual approaches end of life, his renunciation of what it takes to prolong life gathers more respect. It's a conflicted opinion, of course. Older people are outraged by any suggestion their lives do not deserve to be prolonged, but still outspokenly prefer to die rather than wear a colostomy bag, or a respirator, or be fed with a spoon. If they are Jehovah's Witnesses and refuse transfusions, that too, commands more respect when they are elderly. This is a familiar problem, not a new one. What's new is more subtle and pervasive.

The public probably does not fully appreciate the disappearance of what might be called capricious diseases, caused by the operation of chance, or God's will. These are fatal illnesses like heart attacks, strokes, epidemics, and other things not anyone's fault. Except for cancer and Alzheimer's Disease, most really common serious illnesses which remain, are to some extent self-inflicted. Smoking causes lung cancer, alcoholism causes accidents and homicides as well as cirrhosis of the liver, taking recreational drugs damages lives, unprotected sex causes HIV. Obesity causes hypertension and diabetes, neglecting your medicine undermines treatment. If this keeps up, we are going to see the day when every obituary will seem too shameful to print. Poor Jud is dead; it's his own fault.

It's maybe even worse than that. The 2000-page Obama care plan was too complicated for even the Congressional committees to understand. But the public was not hostile for technical reasons, the public was irked at the idea. All the President's celebration of saving money through mandatory preventive care provoked the public to tell him, Get off my back. Almost every smoker has tried at least once to quit, absolutely every obese person has repeatedly tried to lose weight unsuccessfully. It's hard, let's see you try it. And now it goes beyond nagging, we are going to take the position that every person with a self-inflicted disease is costing the nation money we can't afford. The country has a right to punish people who drive us to bankruptcy. Let's have some Wellness police, and fair but firm punishments. Is that really what Obama has in mind? Well,sir, you just get off my back.

Even so compliant and dutiful a person as my late wife declared that when she got to be seventy, she was going to try marijuana. The fact that she actually lived thirteen years longer without doing it, did not change her basic attitude. When you get to a certain age, many of the old rules don't apply to you, doggone it.

http://www.philadelphia-reflections.com/blog/1705.htm

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Reforming Health Reform (2009)

Congressman Robert Andrews

A single e-mail to constituents, and no other communication visible to the general public, announced a town hall meeting with our Congressman, Bob Andrews, on the campus of Rowan University, from 6 to 8 PM, August 24, 2009. The subject was to be Health Care Reform Legislation. On arrival, it was hard to find the auditorium in the square mile of new college campus, and only a small sign entitled "Event" indicated the place to park. Lots of cars.

By counting seats in a row and multiplying by the number of rows, the University Auditorium held 3000 people, but at 6PM it was difficult to find a vacant seat. The doors were almost blocked by two lines of people standing to speak at microphones in the center of the hall, snaking all the way out past the television cameras and then out the door. These people were strangely silent, preoccupied but not rude, apparently rehearsing their speeches. In the lobby outside the doors, several workers were distributing posters showing "Thank You!", checking people off on lists of some sort. Many of those who got posters were wearing red T-shirts emblazoned with something or other.

Rowan University

When I finally got a seat inside, it was behind a whole row of such T-shirted poster-holders, mostly but not entirely of the black race. The Congressman was giving a little speech to the effect that he was one of the committee members who wrote the bill, so of course he had to support it. Strange, that as a member of Commerce and Labor he was working on a bill which traditionally is the province of the subcommittee on Health, of the Ways and Means Committee. In any event, that gave him the ability to explain some of the language which was a little too hard to understand. Several in the audience shouted out something unintelligible at that point, but mostly the audience sat in silence, waiting for the questions. He soon opened it up for questions, because he wanted to know what his constituents were thinking.

Although a few inevitably wandered off the point, questioners were confident, moderately deferential, remarkably effective. No matter how it was stated, and no matter how it began ("I have always voted for you, Congressman"), they were at the microphone to run a sword into him. To some extent, posting the entire bill on the Internet has changed politics. One old man, reading from his papers, said that page 343 says, etc; to which the harassed Congressmen blurted out, "That isn't true!" And the old man held his ground, "Oh, yes, and what else isn't true, that's written in the bill?"

Our congressman represents a working-class district, as clearly illustrated by his previously running for Congress without opposition. In searching for the reason this solidly Democrat audience was so antagonized, one gathers they generally have Unionized health benefits, and feel threatened that insuring the "illegals" will be paid for by impairing their own insurance. Somehow they feel that anyone who denies it is lying to them. ("It isn't what's in the bill, it's what will be in the bill ten years from now.") Except for college professors, they have the most luxurious health insurance coverage in America, and are accustomed to boasting of it. Somehow, this privileged position drowns out their envy of rich people. When told that only the top x% of the country would have its taxes raised, one man bore right in on the Congressman. "You never heard anyone asking a poor man to give him a job". (Yeah, right, right on, Yeah.)

Although the people in red shirts holding posters put up a fight for fifteen minutes or so, they soon subsided out of recognition of who owned the room, and the remaining three hours of "questions" were almost uniformly negative. After an hour, the television cameras left the room, and at that signal the people in front of me wearing red shirts, also left. After a succession of speakers praised physicians somewhat excessively, a couple of physicians got up and made a poor showing at the microphone. One of them, a fat woman, had the poor judgment to tell these folks that many diseases like diabetes were self-inflicted, but later heard that it would help if our President would himself stop smoking and leave the rest of us to mind our own business. Two women who proclaimed themselves single mothers were no better treated..

At 9:30, a meeting scheduled to end at 8PM still had a thousand people in the audience, and fifty at the microphones. But I had had enough. They made their point. All that remains is to see how fairly the television editors extract significant clips, and to find out how the rest of the nation feels.

http://www.philadelphia-reflections.com/blog/1714.htm

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Food

In one of those intervals when several casual acquaintances are detained together, awaiting the beginning of some ceremony, there was desultory conversation, jumping from topic to topic. The recently retired President of the University probably had a delayed lunch on his mind. "The older I get, he said with a smile, the more important food seems, and the less important sex does." The considerably younger group knew how to respond to this sally, which was with broad but inaudible smiles, and no comment. This was, after all, the President of the University making a faux pas.

In retrospect, it seems remarkable the rest of us could be so obtuse. During the working years of life, meals are fitted around the workday; the employer defines the day's structure, and meals fit around it. That pattern persists on non-workdays, imposing its schedule even on those who do not go to work. In Haddonfield, the town whistle blows at noon, in Philadelphia the clock opposite City Hall booms twelve. However, in a hospital, nursing home or retirement community the eight-hour day for the cooks sets mealtime. Breakfast comes at 9 AM, dinner comes at 5 PM. The wait staff starts clearing tables ninety minutes later, because they want to go home. To working class families, this sort of schedule is not objectionable. A man who does heavy manual labor wants his dinner ten minutes after he gets home at night. The remarkable docility of his wife contains a faint hint that he can get grouchy or worse if he has to wait a jot for dinner. There are others who respond well to institutional mealtimes; you can see them crowded around the locked entrance of the dining hall, waiting for doors to open. Diabetics, too, have learned the wisdom of regular meal hours. All of these people can be expected to rally around the administration if someone starts to urge more flexible and liesurely meals; they would have trouble understanding the issue. What's lacking, of course, is the deference one comes to expect when dining out. At a restaurant, the diner sets the time he wants the meal to start, and makes the decision when to call for the check and declare the meal is over. If the waiter hustles you, cut his tip. In a restaurant, the meal is a special occasion, caters to your wishes. In an institution, the purpose is to get people fed. In general, people go along with this because they are on a budget, and understand quite well the dining organization wishes to minimize complaints, but only within the constraint of minimizing labor costs.

If that's the system we live by, it really would seem reasonable to contemplate a return to having the big meal of the day at noon, in the style of the Victorian era or the hotter siesta countries like Spain, Greece and southern Italy. Commuting twice a day is probably the problem that switched American custom to having a big meal in the evening. But in retirement, all this is no longer an issue. It takes time for customs to change, but it almost takes a century to change breakfast habits. For half a century, we have denounced high-fat breakfasts, and breakfast still responds slowly. There was a time of my childhood when breaksfast consisted of fruit, cereal with heavy cream, fried or scrambled eggs with bacon, two glasses of rich milk, two pieces of toast and butter. Right now, it has settled on quick foods before train time, orange juice with one slice of toast and coffee; a so-called continental breakfast. But a Frenchman wants a croissant, a German wants a sausage, a Spaniard wants eggs with tomato sauce. An Englishman wants kippered herring with his breakfast tea. And an Australian insists on tomatoes for breakfast, so help me. Now that many women are working late hours, there is more eating supper in restaurants, and lunch is mainly a quick lunch. But most people prepare breakfast for themselves, at home. They buy the ingredients for old favorites at the same place, usually once a week, and once a pattern is established, it seldom changes. So, it would be wise to leave breakfast without tampering. Switching the main meal of the day to noontime, however, could create the opportunity for liesurely dining, even recreational dining. And the staff could get home for their TV program without hustling people to finish their supper. That is, unless golf is a big feature of the place.

One of the major reasons couples enter retirement communities, is that the woman of the pair has become tired of cooking. It's a little hard to know what they mean when they breeze past that comment, because it may really mean that some serious illness has come along, which they would prefer not to discuss with strangers. Or it may reflect early Alzheimer's Disease, usually manifested by repeatedly walking away from a heated frying pan with smoke or even fires above it. Substituting an electric stove lessens this home hazard for a while, but eventually it leads to a demand that something drastic must be done. There are even a few upper crust families who have always had their own cook. That has its limits, however, and in one case I know a former college football hero went to cooking school and learned some special dishes to entertain his guests. Somehow, that always seemed just a little strange, until the subject of kitchen restoration came up with his wife. Not interested in that nonsense, harrumped this lady who could obviously afford to restore a dozen kitchens if she chose. And then she uttered the phrase which unlocked the whole situation. "My mother," she said with finality, "Never set foot in the kitchen."

The sort of food that bachelors and widowers eat is apt to bring tears to your eyes. The only for-sure case of scurvy I ever saw in a long practice of medicine afflicted the Treasurer of my own hospital. It proved easier to give him vitamin pills than to reform his pizza-for-breakfast habits, regardless of how grateful he was to have his teeth stop falling out. Nevertheless, when I became a widower after sixty years of marriage, I was still puzzled by the question, asked twice by two old friends, "Have you been getting any casseroles, lately?" As time goes along, the meaning of this question gets clearer, but the problem got solved in a strange way. I share a cleaning lady with the family next door, where the lady of that house is a truly outstanding French cook. The cleaning lady started bringing me some outstanding dishes, the source of which was soon clarified. She had begged the famous chef lady to teach her how to cook these fancy things, and was quite proud of her new accomplishments. However, the grim fact emerged that her working-class husband absolutely wouldn't touch that stuff, and so she brought it to me rather than stop the cooking lessons. By this route, we get to a dinner conversation held at a table for eight in a nearby retirement village. Three women and five men, far from an average assortment in a predominantly female environment. One extroverted lady, the center of all activities, made an excited proposal. Why don't we set up a table for eight men and go into the kitchen and cook special things for the poor dears? The idea, however, was immediately squelched by another lady at the table. "Why in the world would you want to concentrate what few men we have, all in one place?"

http://www.philadelphia-reflections.com/blog/1718.htm

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Put Down That Lid!

Emily Post

Indoor plumbing, which the British call the loo, has been around for a couple of centuries without stirring up much dissension. Recently, however, attention has been drawn to the outrageousness of the male habit of leaving the lid up. Popular television or something similar has put it about that walking away from the loo requires some statement of etiquette on the point of leaving the lid up or down, depending on knowing the gender of the next person in line for the facility and courteously anticipating the correct up-or-down requirements. Apparently, it's like holding a door open for someone who follows you (rather than letting it slam in their face), except it requires a degree of prediction that some people might think gets a little presumptuous. Furthermore, there is an intimation that only males are now to be required to make the proper gesture. A little thought on the matter would indicate that graceful anticipation might reasonably be suggested to either gender using a common loo. Emily Post is now regarded as fussy and outmoded, but she always offered some commonsense explanation for her rules of behavior, while this seems just a little mixed up.

Toilet

Putting considerable thought into this new discussion topic, one important issue does pop up. If the bathroom owner happens to be a single lady, finding that her lid has been left up would seem to imply that the lady had recently had a visitor. Perhaps we are really on to something, here.

And then, there are the ladies of a certain age, whose habits are firmly fixed. Being occasionally in a great hurry, they might not notice that some ill-mannered brute has left the lid up, and suddenly find they were in cold water. It could indeed happen, but raises the question of just who has failed to develop proper habits or receive sensible training in childhood. Since the consequences might well be getting stuck, or at the least needing to get completely undressed to take a shower, perhaps outrage is somewhat justified. Certainly, one has to sympathize with the need to keep the matter secret from waiting dinner guests. Boiling with rage at the thoughtless person who has done this to her, the frustration of being unable even to mention the matter without being ridiculed -- must be painful indeed. Most brutish males would think it was a pretty stupid situation, possibly a hilarious one. Particularly unfeeling ones might even hint this ought to be heeded as the first sign of Alzheimer's disease.

http://www.philadelphia-reflections.com/blog/1177.htm

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Glutes, Abs and Pects

Union League of Philadelphia

Robert Matsey, the director of Executive Fitness at the Union League, recently entertained the Right Angle Club with a discussion of new trends in muscle building. Which is to say the old theory of Dynamic Tension, as featured in adolescent magazines by Charles Atlas, is being superseded by platform stabilization, a much more popular approach among senior citizens. Since a few members of the club are already in the Medicare age range, and more are approaching it with concern, the talk was greeted with great interest.

Personal Trainer

Bob Matsey has a degree in marketing, so it all comes down to this: the more powder you use in a cannon, the bigger bang it makes. But if said cannon is sitting in a canoe, the extra gunpowder doesn't add much firepower. The new approach stabilizes the platform to magnify the cannon power, without paying so much attention to adding directly to the gunpowder. No one said that weight lifting and pushups don't bulk up your muscles; but if you want to climb stairs and lift things, it will get you farther to stabilize the pelvis and shoulder girdle than to split your seams with muscles that can't do much. Or, worse still, that will lead you to throw out a lumbar disc -- or a cervical one -- struggling to perform a simple task. All of which leads to a complicated discussion of the function of the hamstring muscles of the back of the thigh, which is mainly to overcome the inappropriate architecture we inherited when we became two-legged animals. And, as well, to overcome the tendency of a young straight back to curl up with age and inactivity, and press your nose toward the ground. One of the main causes of back pain can be traced to shortened tight hamstrings, a condition which destabilizes the platform of the pelvis.

Sitting down is the great enemy of posture and bearing; fifty years of it leads straight toward turning a former soldier into a skinny old geezer. Sitting down to a dinner table turns people into fat old geezers, deep inside which is a skinny geezer hidden by the fat.

Muscles

Every medical student is puzzled to learn that most energy expended by muscles is used to lengthen, not shorten, muscles. Without getting into the biochemistry of this issue, it can be taken to explain the tendency of muscles to shorten up when under-used. And, in turn, explains why stretching works a lot better than "body building" against a resistance. It thus may help to understand why it is sometimes easier for skinny old retirees to re-build their muscles into proper balance and coordination, essentially training infantile muscles to work together the right way. Those who have struggled to "work through the pain" may actually reinforce bad coordination, and will require still more sweat on the brow to force things to work the right way all over again. For example, there are two kinds of hamstring muscles, short ones and long ones. The short ones stabilize the pelvis, but if you whip things into obedience, you may be improperly recruiting the long hamstrings to act as stabilizers, making you in effect "uncoordinated" and awkward. RNT stands for reactive neuromuscular training, a process which amounts to improving a muscular coordination flaw by forcibly exaggerating it. The scientific basis for this jargon is a little hard to follow, but it does soon become very clear that RNT is quite uncomfortable. It makes a sort of argument for a compulsory draft into the armed forces at an early age, to beat bad muscle coordination out of the whole public at an early age, before they start sitting themselves to death in front of a computer.

A great deal of emphasis nowadays is placed on gluteal strengthening, a sort of unnatural posture training which can unfortunately be easily dismissed as worthless. In the spirit of defending this particular fitness training, a lady at a nearby table in a fancy restaurant was heard to exclaim to her luncheon partners, "What I mind most about growing old is that I have lost my ass!" Since obviously this disability is greatly to be avoided, get some gluteal training, ladies.

Along the same lines, the economics of fitness centers was recently explained with considerable seriousness, but not by Robert Matsey, who disassociates himself firmly. The trick, explained the outside expert, is to get people to sign up for a whole year of training when they first come in, full of enthusiasm. Since most of them will drop out of attendance after a couple of weeks, it is possible to run quite a profit running a fitness center with hardly anyone showing up.

And finally, Tom Hawes, former president of the Right Angle, rose to link this discussion with the current debate about health care reform Relating how an elderly couple in Florida went to a physician specializing in sex counseling, asked him to obseve their technique and comment on it. He later told them their technique was surprisingly good, and he had no recommendations. The charge for this service was $50, readily agreed to. Nevertheless, they returned with the same request three more weeks in a row, until the doctor asked them what they expected to learn from all this. "Oh, that's not the idea. She's married, and I'm married, so we can't go home. The motel charges $100 and you only charge $50. "

"But the beauty part is that Medicare reimburses us $43."

http://www.philadelphia-reflections.com/blog/1744.htm

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Only Three Things Wrong With American Healthcare

Although Congress is offering several thousand pages of proposals for healthcare "reform", none of them even mentions the three main difficulties, to say nothing of fixing them. Let's be terse about this:

1. Health insurance is fine, but if you make it universal, there is no impartial way to determine fair prices. Somebody must haggle with the vendor in order to introduce the issue of what is the service worth? The customer doesn't care what it costs to make, or whether the vendors are being paid fairly. If everyone is insured, no one cares what it costs. Not only do all costs rise, but they rise without coordination, without a sense of what each component is worth, relative to alternatives.

2. Employer-based insurance is fine, but it ends when employment ends. You just can't stretch employment-based insurance because you can't stretch employment.

3. State Medicaid programs are fine, but just about all fifty states are going broke trying to pay for it. Extending it to more people by raising the income limits just makes things worse. Items 2. and 3. are related. Trying to do both -- expand Medicaid as employment shrinks -- during a recession is incomprehensible. Item 1. (price confusion) gets drawn into this because the States try to pay less than it costs, hoping to shift the deficiency through hospital cost-shifting, utterly confounding the information which prices provide. The doctors have no way to tell which is the cheapest approach to a problem, so they don't try. Without control over prices, we can only control volume.

That's really all there is to this mess. Not one word of the current legislation even mentions these problems, so of course the legislation blunders. Even a child can see that compulsory expansion of benefits to universal coverage will fail if you can't pay for what you already have. No one will make sacrifices for a new system if the sacrifices seem futile. They are futile, so leave me alone.

The current administration has been compared with bank robbers who see they are trapped, and decide to shoot their way out. Let's see them try to shoot their way past the first Tuesday after the first Monday in November.

http://www.philadelphia-reflections.com/blog/1754.htm

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Itch

Dog Itches

If the reader has had itchy, dry skin, or a diagnosis of eczema before the age of say 65, stop reading right now and go see a dermatologist. Most elderly people have skin problems, but what we are talking about is elderly people who have developed skin problems for the first time. We are particularly talking to brisk busy people who are proud to boast they have never had skin problems, but boy they sure have them now. Such people have never been to a dermatologist, wouldn't know where to find one; and therefore don't even know the basics of the subject. Furthermore, what they likely have right now is related to old age, because you mostly can't have diseases of old age until you achieve the status of elderly. So, if you had something like this before, it becomes complicated to distinguish it from the disorders of old age and you better go see a dermatologist.

If that sounds too simple to accept, just think about the following. Dermatitis means a disease of the skin, and eczema is synonymous with dermatitis with the proviso that it oozes, and most dermatitis oozes at least to some degree. Take a quick look at eczema in a computer search engine; the first thing it will tell you is the cause is not understood. The second thing it will say is that eczema is mostly found in children. Perhaps now you get the idea; if you have had this in the past, go away and see a skin doctor.

On the other hand, any group of old folks sitting around the table in a retirement home will immediately brighten up at the mention of skin problems, since most old folks have skin problems. These people itch and itch badly. Everyone at any age has been bitten by mosquitoes and had an occasional run-in with poison ivy, but these produce bearable itches; the itch of senile eczema is unbearable, gets your full attention. It keeps you awake at night, and thus makes you drop off asleep during the day. The things everybody learns will give heavenly quick relief are generally agreed to make you worse, don't do them. Scratching makes things worse, leading to a mysterious thickening of the skin known as lichenification (that's thickening of the skin, in Latin) which is sort of a scarlet letter among dermatologists, you bad person. And the second thing is a habit of deep scratching so bad you cover your shoulders and back with little red ulcers without fully realizing you are doing this yourself, excoriating your skin with your fingernails. Since people do this without realizing it, of course they deny it, and doctors for a long time regarded them as nut cases. However, the current more balanced view is that somehow this kind of excoriation suppresses, depresses or otherwise mysteriously inhibits the unbearable itch. So all of this adds up to saying that elderly eczema drives an old codger to the point of dominating his whole thought process; good manners be damned, he wants to talk about it. And do something about it, right now.

Nummular Eczema

That being the case, helpful friends of a certain age know what to advise: hydrocortisone ointment, or the even more potent fluorinated steroid ointments. This stuff really works, particularly if there is some sort of visible skin eruption to direct your effort, but it's dangerous if you use too much. The skin lesion and the itch will vanish in a couple of days, although of course it is likely to return in a week; keep that up and you will get skin atrophy, and in large quantities will suppress the activity of your adrenal glands. So, if the area of itch is so small there is no danger from the ointment you probably can get along without it, whereas if the affected area is large, you are unwise to paint yourself with a lot of this poison. You could take the same stuff in pills, but that gets you to a dermatologist, so you are already in the pay grade above where you should self-medicate.

The other home remedy which offers instant relief is hot water. Usually administered as a hot shower lasting a good long time, or luxuriating in a warm tub, or best of all a hot whirlpool bath. Unfortunately, this is really bad news for eczema, almost surely making it much worse. Swimming pools and whirlpool baths are used communally, so they are chlorinated; don't do this to yourself. Instead, do the opposite; go for a week or ten days without a bath. You heard me right, go right ahead and stink. You'll find that deodorants take care of the armpits, so a limited amount of perfume-free soap to the groin and perianal area is the limit. For the rest of your carcass, go back to Biblical times and apply oil, preferably one of the many skin-healing cosmetic lotions that are somewhat overpriced but generally quite soothing. So that's it; no bath for a couple of weeks, using oils for reasonable cleanliness. There's a long handled lotion dispenser available for a few dollars, that applies the lotion through plastic balls that act like ball bearings. Since being greasy is part of the problem, this dispenser cleans and soothes with a minimum of oil.

If this suggestion fails to work, you are getting closer to the dermatologist's office every minute, because you have not only stopped scalding your skin in the shower, you have eliminated the perfumes and antiseptics in soaps and detergents. By the way, while going without a bath, go without a shampoo as well; most shampoos are detergents. Drying of the skin by excessive bathing, allergy to soaps and detergents, are the main causes of this condition, so if going without a bath doesn't work, you may well not have the common form of the condition. There are a couple more things to try, however. You can moisturize your skin with alpha keri, take Benadryl to help you sleep, aspirin to relieve the itch. You can consider laundering your sheets with soap, or plain water, or just about anything except sodium laurate, the main detergent which has more familiar trade names. If the itch is localized to identifiable areas, the underwear covering that area should be laundered in plain water, or the mildest form of unperfumed soap.

It should take several weeks to exhaust the potential of all of these ideas, so if things are no better, off to the doctor. Every medical student is trained to look for the most serious possible cause of your complaint, no matter how rare. So if we haven't helped your problem, in a few weeks we probably haven't made it much worse, either. When you are filling out your questionaire at the doctor's office, mention Hodgkins Disease, mycosis fungoides, uremia and biliary cirrhosis, just in case he thinks you were taking advice from a beginner.

http://www.philadelphia-reflections.com/blog/1758.htm

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Rentier Class

To hope to retire, is to hope to be prosperous without working. Those who must work can grow sullen about it.

Dr. Fisher

Rentier income is passive income, such as interest on savings accounts. Lord Keynes gave the definition a noticeable twist by defining the rentier class as "functionless investors" . That suggested Keynes had sentiments about passive investing like those of Karl Marx, who seems to have invented the term; both authors apparently judging the rentier class by the standards of novels by Jane Austen and Edith Wharton, or perhaps the movie stars depicted in the novels of F. Scott Fitzgerald. Not gainfully employed, mainly occupied with debaucheries and expensive luxuries. This envious image dies hard, but may not persist if rentier life becomes everyone's goal. Or it may turn vicious, if a majority of voters see themselves as in the water with the sharks, looking at the lucky few in the lifeboat.

To a certain degree, these attitudes can be managed, as can possibly be illustrated by bankers. After all, bankers most readily extend credit to financially secure borrowers, at lower interest rates, and refuse credit to the penniless clients who need it most. The public is mainly tolerant of the differential cost of taking risks. However, the public is often highly intolerant of the true value of a banker's role: efficient re-distribution of capital between those who have a surplus, and those who have a need. We have come to believe the relief of need requires political majorities, responding to political viewpoints. If votes were all that mattered, however, the growing proportion of the population in retiree status could afford to be complacent.

In the first place, 30-35% of American GDP would now qualify as the spending of passive income, although the varying degree of risk involved in such investment is hard to evaluate. That proportion is sure to rise as we globalize more labor-intensive work. Foreigners begin to notice a paradox that passive income seemingly increases as the labor to achieve it diminishes. Rentiers are never far from the necessity to defend themselves, and our best defense may lie in the two billion Indians and Chinese following our footsteps up the economic ladder.

A greater proportion of our population will be retired persons, living on pensions and rentier income from savings. As it becomes the universal expectation of everyone that thirty years of rentier life awaits in the retirement stage of life, there will be less and less likelihood that Keynes and Marx and Fitzgerald will seem so congenial to the voting class. But take care; young people, particularly unemployed young people, are never far from asking, "And what have you done for us, lately?"

Curiously, another big social implication about rentier income has almost disappeared already. Interest income is paid by a debtor to a creditor; as Marx would have it, the poor workingman is paying the rich rentier. Dividend income represents the profit from a business to its owner, or a farm to its farmer. But emotionally, it no longer does. We have so sterilized the investment process that we seldom think of debtors and creditors, we think of "fixed income" and "fixed income investors". The income from ownership, or "equity", is now thought by economists to bear a definable relation to the "prevailing return from fixed income". It's all, in a sense, the same thing. Future attitudes are hard to predict.

It's also hard to predict where Americans will generally stand, when passive income becomes eighty percent of GDP. Or fifty percent of the population at that time are then rentiers. Eighty percent, if you exclude children. Western Europeans seem willing to sacrifice luxury in order to live as threadbare rentiers, right now. The ancient Romans aspired to more luxury, fewer soldiers; unsympathetic barbarian neighbors then wiped them out. Better do some thinking about this. The Law of Gravity will not save the situation, nor history give much comfort.

http://www.philadelphia-reflections.com/blog/838.htm

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