Philadelphia Reflections

The musings of a physician who has served the community for over six decades


Right Angle Club 2016
New volume 2016-10-27 19:24:19 description

Right Angle Club: 2016

In progress.

Reflections on Immortality

Notions of Immortality

When we are children, we have childish notions of immortality. Perhaps we still nourish them for lack of replacement, busying our thoughts with premature death, instead. Most of us forget the dreams of robbing candy stores or marrying a princess, and never bother to replace them. After all, everyone has to die, don't they?

So put it this way: we now have semi-realistic plans to end our lives with a thirty-year paid vacation, but what can be said about a fifty-year paid vacation, or even a hundred? Life itself is degraded by seventy years of loafing, as those who could afford it will tell you. All notions of purpose to life eventually disappear. No longer defining ourselves as soldiers and housewives; we're just cats, dogs and lice. And all our yesteryears have lighted fools the way to welcome death. As that day approaches, it will be marked by waves of awesome but fruitless literature. The Calvinist worship of work gets the last laugh of the comedy.

Subsequent generations of would-be hedonists have certainly given Calvin a hard time. Harder, in a way, than dunkings and pillories. Perhaps harder even than burning at the stake, because Calvinists had the audacity to get rich and comfortable by their effrontery. Perhaps poor and comfortable is better, and comfortable is the real goal, as Quakers were executed for advising. Once you get over the ambition to be King, what else is there?

(Second Edition) Suggested Additions.

Soon after the release date of the first edition of this book, an article appeared in the Wall Street Journal by Lanhee J. Chen and James C. Capretta of Stanford University, entitled "Instead of Obamacare: Giving Healthcare to the People." The authors were in general sympathy with the Health Savings Account approach, and made three other suggestions with which I more-or-less agree. But they add a fourth which makes me unhappy :

1. Continuous Coverage Protection. They rightly notice many recipients of mandatory auto insurance take out the insurance, pay a single month's premium, during which time they get their drivers license. And then no further payments are made for the insurance. The authors propose higher premiums for those who do this, but presumably waive the higher cost if insurance is continued for a full year. There are many people who are suspicious of making anything mandatory, but if it's mandatory, it's unfair to allow obvious loopholes of this sort to persist.

2. Medicaid Reform. The two commenting authors are evidently aware of the unsatisfactory quality of many state Medicaid programs, and propose splitting Medicaid into two parts, one for able-bodied adults and their children, and another for the disabled and elderly. While this division might mesh more easily with existing workers and their families in the event of universal coverage (under a single-payer system), by itself it would not address much else.

A more useful split would be between inpatients and outpatients. That would match Medicare A and B, and it would match the underlying Blue-Cross/Blue Shield organization of paperwork. Moreover, splitting helpless inpatients from ambulatory outpatients would surprisingly allow the marketplace to set inpatient costs. Since a large number of outpatient and inpatient services are identical, it would provide a way to set inpatient prices through the market mechanism. For those inpatient services which have no outpatient match, a relative value system would provide a more logical way to set prices for the remainder of helpless inpatients. Doing this would close a loophole commonly employed to cost-shift inpatient costs to the outpatient area, resulting in vast confusion between two pricing systems for identical procedures, in both Medicaid and Medicare.

3. Medicare Reform. The main reason Medicare is often preferred to Medicaid is, it is funded better. But Medicare itself is 50% subsidized by the general taxpayer. So, effectively Medicare is subsidized more generously than Medicaid, and it is the main source of deficits. You might subsidize Medicaid more generously, or you could apply a 50% subsidy to a single payer system. Either way will cost more, not less. Speaking politically, it is a question of whether you wish to offend the elderly Medicare patients, or the younger indigent ones. Essentially, Congress has already chosen sides once, and is unlikely to change.

Finally, there is one suggestion in the article which does make me uncomfortable, because of what it fails to say. (4.) Retaining Employer Coverage. It costs less to provide health insurance for employees than to pay them wages and let them buy the same health insurance with what is left. Employers are therefore better off giving the health insurance as a gift and taking the same tax deduction, although recent inflation has held back wages more than health costs. Presumably this anomaly would not survive tax reform.

But if it should, it presents an opportunity to rectify the injustice to the other half of (small business) employees whose employers usually do not donate the coverage and make it up at the higher corporate rate. Persisting eighty years after the war which created the pretext, this is an unnecessary reminder of the many irregularities in the tax code. However, a one-line amendment to the HSA Law would suffice to extend the same tax exemption to others. This would permit the premiums of a catastrophic health plan to be paid by the Health Savings Account itself, thereby extending its own tax shelter to HSA owners, at less additional net cost to the Treasury than full exemption. The present inflation distortion should not be missed as an opportunity to restore fairness, which almost everyone now recognizes to be nothing but a lobbying plum.

(Second Edition) Exit Strategy: Medicare

Placing a termination point for Medical Savings Accounts in 1981 was occasioned by recognizing the overlap created in 1965 by Medicare for everyone. It seemed pointless to be covered by Health Savings Accounts as well as Medicare. Pouring remaining HSA surplus into a regular IRA retirement fund seemed like a neat and tidy way to create an incentive to save as much as possible in the accounts. Only in retrospect does the effectiveness of this provision suggest it might have a wider usefulness.

In what follows, we extend the idea to several other medical entitlements without suggesting it should be a universal rule. The time-honored approach was to use a surplus to reduce costs, but there are other things to do. The first would be to imagine a sharp decrease in the cost of Medicare, itself. Since 80% of Medicare is now spent on five or ten diseases, the possibility of a sudden cheap cure of one of those diseases is raised. The almost unimaginable saving in the cost of strokes and heart attacks, created by taking a daily aspirin tablet -- shows what might be possible to imagine as happening again. Not to promise, but to imagine.

On the other hand, it is also possible to imagine other priorities competing for the financial windfall. Suddenly confronted with the issue, the average person would believe such a windfall would more likely pay for aircraft carriers than Medicare deficits. But another opinion would emerge, and should be the default position. The Medicare program and its members experienced the unexpected -- and expensive -- consequence of a more protracted retirement than they planned on. The more just assignment of such windfall would be to pay for the extra retirement cost it provoked. If other emergencies seemed more pressing at the time, they could always be given priority on the money, but the default should first be to pay for consequences.

In a sense, President Obama created a political problem for himself with the original budget for Obamacare. He did not need to make any speeches directing attention to the diversion of Medicare money to help pay for Obamacare costs, because plenty of Republican opponents were studying the budget. And plenty of Republicans remembered Richard Nixon's advice, "Watch what I do, don't listen to what I say." Having spoken to many groups of retirees about healthcare financing, I am acutely aware that retirees are watchful for any move to strip Medicare funds for Obamacare's benefit. It's about their highest priority.

And indeed their anxiety would be heightened to discover that Medicare is already 50% subsidized by general taxation, unsustainably maintained by borrowing money (selling US Treasury bonds) to foreign countries like China. And still more to the point, medical costs have been and will continue to migrate from working age people to retirement age people in the future. Just about everyone who dies, dies at Medicare expense. But even more than that, the effect of medical science has tended to eliminate medical costs for people under 65, shifting them to people who get sick when they are over 65. It can be predicted that a major cause of future Medicare cost increases, compared with the cost of living, is this shift of disease cost to the elderly. Many attempts have been made to shift Medicare costs to the non-sick working population, such as through the payroll tax deduction and hospital internal cost-shifting, but the trend continues. A more sophisticated thing for the retirees to worry about, is the instability of a system which depends on the third of working population -- who are themselves progressively more healthy -- to support the medical finances of the other two thirds of the population, who are sick.

Taken in summary, there exists a great political opportunity for both political parties to put a stop to this "third rail of politics" talk. And to amend the Medicare Law immediately to provide that any declines in Medicare costs should be transferred to Social Security for the purpose of paying for windfall increases in longevity. That provision should not cost much at all, for some time to come. But the incentive it would give to the retirees to reduce their health expenditures would be considerable, just as the comparable provision of Health Savings Accounts has achieved when Medicare coverage is attained. But its real benefit will be deferred until that fateful day in the future. The day you pick up the morning newspaper and find that someone has cured cancer.

(Second Edition)Exit Strategy, Health Savings Account Death Balances

A subscriber with both Medicare coverage and an HSA may die with a balance left in his HSA account. That's what we would like to see, since it suggests ample provision for two universal needs. But what is the most useful re-direction of the surplus? Having died he can no longer use it, and his will may or may not indicate his wishes. True, he originally deposited the money in the account, but escaped income tax, so the government retains some sort of ownership right to the principal and its income.

If the government follows my suggestion, it will have established a first and last-year of life re-insurance program. In that case, a thing likely to result to a surplus at grandpa's death would be to use it to reduce the cost of health insurance for the grandchild. As they say, possession is nine-tenths of the law. Here, it seems a valuable thing to encourage, since it reduces the reluctance to fund the health expenses of a vaguely-related or even unrelated grandchild. Society not only has an incentive to soften the burden of maintaining the population, it probably also has the incentive to diminish its frictions. The less it costs, the more it eases the friction of odd-ball relationships, making it less likely for divorces, gender-changes and unrelated hostilities to end up in court. It thus suggests a welcome candidate for a default use of the money. Everyone who considers these matters deeply should remember, the traditional judge of such matters once was the family unit.

Having considered such a contingency, the next question arises whether all surplus in the HSA of someone who dies should be treated the same way-- that is, adding it to a first and last year-of-life pool. It would thus assist a basic function of everyone, and leave the burden of proof on those who feel a particular family situation has a higher claim on the money than society as a whole. A somewhat different approach might be to recognize newly-deposited money in an HSA is mostly original fully-taxed money, but over time a growing proportion of it comes from investment interest on the tax deduction. That is, the funds of younger people are mostly their own, but toward the end of life the government tax exemption has a growing claim to ownership. It would not seem unreasonable to switch the ownership presumption at the age of retirement, or some other surrogate for advancing age and changing responsibilities. These things change with time; consider how many orphanages there were a century ago, and how few there are, today.

HRSA preferable to 401(k)?

A recent article in the Wall Street Journal announced to the world that Health Savings Accounts were a better bargain for the investor than were 401(k). That's certainly true if you spend the money in an account for approved medical expenses, or if you roll it over into an IRA at the time you receive Medicare. But it's also even arguable if you spend it in any other circumstance.

Let's put it this way: If you had an IRA or 401(k) but not a Health Savings Account how would you justify it? The HSA gives a double tax exemption for health services, but you are no worse off if you remain healthy. Of course you are better off with an HRSA. Of course, that may change, but then the oceans might some day pour over Chicago.

Well, you can't have an HRSA if you are under 21, over 65, or covered by a health insurance policy that doesn't have a high deductible. The Affordable Care Act mandates high deductibles for everybody, but there are still occasional loopholes, probably soon to be closed. If your policy has co-insurance features, that's actually probably an argument to switch out of it. You can't have an HSA if you are also covered by some other government plan. All three plans are sometimes subverted by self-serving intermediary fees, but you just have to shop around for the ability to choose your own investments. That may cause you to pick an inferior health insurance plan, so keep looking. Eventually, some people will reach their limits and need more than one retirement plan, but that's different. Although Health Saving Accounts are spreading nicely, there must be a hundred million people who have no reasonable answer to the question of why they have a 401(k) but not an HRSA, so please read on.

Most of the arguments for having an HSA rather than a 401(k) boil down to saying they are the same thing, but HSA gives you some health options in addition, so why not have them. However, it is possible that your employer has selected a poor 401(k) vendor, one who adds unnecessary fees and requires investments which themselves have poor performance because they are loaded with more fees. So, if you are dissatisfied with 401(k) results through your employer, you may wish to shop around for a better deal, and you might as well pick one with some health benefits attached. After all, the Affordable Care Act mandates high-deductible insurance, so that part of the requirement is likely to be fulfilled already. Since you picked it because of disappointment with your employer's 401(k) investment results, you may encounter some resistance from the Human Relations Department. All in all, there is little value in switching until the employer mandate issue is settled -- except the value of the uproar you create, trying to get treated more fairly. However, there are a few other issues if you have an agreeable employer.

Claims Adjusting for Trivial Claims. In the first place, the HSA wanted to make it possible to skip the middle-man cost and oversight, and simply pay bills with a debit card. So an "allowable" medical expense is more broadly defined than what a health insurer might allow, or at the very least it dispenses with the cost (and delay) of insurance review prior to payment. Since the Account part of the HSA was mainly intended to pay for deductibles, it didn't seem cost-effective to subject extra costs to fruitless but expensive insurance scrutiny. It also eliminated the delay occasioned by remaining on the desk of the hospital billing department for several weeks before someone submits it to the insurer to pay -- when the debit card could just as well have paid it immediately. Just how much these thoughtless design features actually add to the cost is uncertain, because it's used as an excuse for delays which may have other causes.

Skipping Insurance Claims Entirely for Small Claims. As things have turned out, forty percent of HSA accounts have never submitted a claim. Maybe they don't get sick, but more likely the client calculates it is cheaper for him in the long run to pay his small out-patient charges in cash, while letting the Account gather compound interest. Aristotle is said to have complained that most debtors don't realize how compound interest is itself compounded, and rises with time. But maybe debtors are now smarter than Greeks in a toga. A debit card directly adds 2% to the cost, while interest rates vary with the economy. Incurring costs greater than the net is a waste of money, largely growing out of a supposition the employer is paying for this as a gift, and taking a tax deduction at higher corporate rates. That's only true half the time, but the other half haven't marshaled their lobbyists to equalize the tax exemption. Apparently, Congress believes the self-employed don't deserve this tax exemption as much as employees of major corporations do. Or possibly eighty years isn't long enough for Washington to fix the flaw. Let's go on with this, a bit.

Non-trivial Returns From Saving Small Scraps. We were saying HRSAs were a better investment than 401(k). To go forward with the logic, the client is effectively taking out a loan from his 401(k) when he pays his medical bills from it, or in cash, if the purpose is to preserve the preferable interest-bearing account. Assuming both accounts pay the same (you didn't get sick), the result is a wash. But as time goes on, the effective compound interest rate will steadily rise; so the extra profit was made without incurring any extra risk. That may not seem like much, until you employ the old maxim that money at 7% will double in ten years. Two, four, eight, sixteen, thirty-two -- it rises 3200% in fifty years. The stock market may rise or fall during those fifty years, and the client may get any one of a thousand diseases. Inflation may intervene, wars are likely to break out. But the relentless superiority of this riskless choice will persist. And get this: at the conclusion of the exercise, the client who gets sick pays no tax, while the one who was scared to do it, pays the higher progressive tax rate he attains later in life. The hypotheticals have to be carefully chosen to reach any other conclusion. But remember to get started young, because to wait ten years will reduce the multiplier from 32 to 16. The millennial generation complains the tax laws are stacked against them, but I don't see it. They are offered the chance of a lifetime, but they will only get one bite at the apple.

Is that all? Well, no, but there are competitors. The deposits in a Health and Retirement Savings Account, just as surely as the deposits in a 401(k), are occasionally subject to rather extreme middle-man costs. The stock market has steadily risen by 11% for the past century. Never mind that it's true past results can be unsound future predictions, just recall that even the "buy and hold" philosophy has seldom presented the investing customer with more than 5% net-of-inflation return. That's because inflation took away 3%, and hedging against "black swan" crashes (by putting 40% of the portfolio into bonds) has taken away 2% more. That leaves about 1% for the customer and the broker to fight about. More than anything else, this slim working margin has driven the investor to choose "buy and hold" over "market-timing". The evidence continues to accumulate that "buy and hold" is at least as successful as "market-timing", but people continue to market-time when they are desperate for the occasional big winner, never mind that big losers outnumber them. To me, the conclusion is clear the public will increasingly squeeze their friendly advisors for a wider slice of the pie. And in this, our central theme is repeated; the HRSA will out-perform the 401(k). Because the shopper for an HSA manager is the customer, whereas the choice of a 401(k) manager is made by the employer. Pass all the laws you wish about kickbacks; allowing the customer to select the manager will usually beat letting the employer do it for him. There's often nothing so expensive as getting something free.

Washington's Real Motivations

Washington could occasionally display a wicked temper, but in general he was a reserved and dignified man. Physically large and unusually athletic, he tended to dominate by glaring at people rather than debating them. And so, after a lifetime of leadership and distinction, he seldom engaged in arguments. As a consequence of this studied behavior it is possible to have many opinions about his underlying thoughts, except one: he always seems to come out on the winning side. It certainly was effective: he was Commander in Chief, The President and probably the instigator of the Constitutional Convention, and the First President of the United States. To decide whether he got what he wanted means deciding what he wanted, and he hardly ever stated it.

Conrad Black, the newspaperman who went to jail, stated the Canadian point of view, which is perhaps extreme. Black's view was "the Americans" first got the British to help them throw out the French, and then twenty years later got the French to help them throw out the British. These two statements are undoubtedly true if abbreviated. Added to them was the plain history that Washington had personally started the French and Indian War. One has to wonder what was in his mind when the French aristocrat LaFayette came to join him. And later on, what he thought of Thomas Jefferson's love affair with the French Revolution. Or what he thought of the antics of the French ambassador "Citizen Genet".

Washington didn't like the Indians, and he put down the radicals of the Whiskey Rebellion with extreme prejudice. Is it so hard to perceive the barons of Runneymede acting any differently?

H.I.V,, AIDS, and the Law

We had a meeting in March at our new quarters in the Pyramid Club, conventional in all respects except members were urged to bring a female guest. It was extremely well attended, which probably improved the food somewhat. Come to think of it, the jokes were cleaned up a little bit, too. But because the central subject was doubly controversial, covering both the subject of AIDS and the trial bar, I omit all names from this report, in an effort to maintain neutrality on the specific case matter, while discussing the general subject of conflict between the bar and the medical profession.

The case under discussion took place in 1987, so it is important to remember the state of knowledge about A.I.D.S at that moment. Nobody knew for certain what caused the disease, or how to treat it. It was universally fatal, and seemed to be contagious in some way. At least, it seemed to originate in Africa among primates, and when brought to America through Haiti, seemed to concentrate in male homosexuals, although not exclusively. It had a peculiar concentration of brain tumors, and a strange proclivity for yeast infections of the lung. At first, there was no test for this condition, but over the course of fifteen years went from a totally mysterious and ominous condition, to a curable disease. Indeed a largely preventable one, caused by a virus of the retro-virus variety, for which a highly reliable blood test was devised, and a quite effective treatment. Comparatively few Americans now die of AIDS, now called H.I.V. infection, although the disease continues to spread devastation in countries with more primitive medical systems. I hope I have given a fair summary of one of the most rapid investigations into a new complex disease in all of medical history. Enormous amounts of money were poured into research in this condition, probably greatly stimulated by public pressure generated by the gay community, and others.

The lawyer who presented the case to us was called into the matter by a client who had been fired because he had the condition. How much the client, defendant law firm, or plaintiff lawyer knew about the condition at the time was not elaborated. But it surely was incomplete, quite possibly quite rudimentary. Expert witnesses were consulted, although it is not clear how much they could have known at the time. In any event, it was determined the patient was still able to work at the time he was fired. The state of the law on the subject was equally fuzzy in 1987, and the basis of the claim was an infringement of disability fairness, or some legal variation of this language. He wasn't disabled, was the basis for the court's decision, and in a sense that was true.

However, a question was raised from the audience as to whether the issue of contagiousness in the workplace was raised, and the plaintiff lawyer replied it was not; perhaps his impromptu response was somehow inaccurate. However, taking matters at face value, it is possible to imagine the executive of the firm was alarmed by the possibility that other members of the firm would resign rather than subject themselves to the hazard of contracting the disease themselves, thereby destroying the firm. Even so, dismissing the employee seems excessive; he might have been given a medical leave of absence, or some other means of preventing spread of the disease might have been devised. But the point is the firm had a legitimate concern, and probably could not be sure of reassuring the other employees in a scientific way; an unwarranted panic could not be prevented by legitimate scientific arguments available at the time. That the firm chose a cumbersome unfair way of protecting themselves is not completely surprising, any more than a guaranteed way to escape a fire in a theater is even now available, except by not going to the theater.

Until Louis Pasteur discovered the germ theory of disease around 1880, epidemics of contagious disease devastated whole communities for thousands of years. Thucydides described an epidemic in ancient Athens hundreds of years B.C., and even today we are not entirely certain what that disease really was. Since that time, society has developed legal and management techniques of mild utility, since the courts have had to devise some sort of order out of this panic situation. But whether the best scientific approach takes fifteen years to emerge, or centuries, the court decision has to be made on principles which may seem wrong-headed in retrospect. Once the scientific facts are firmly established, the process of undoing unfortunate precedents has to be commenced during which, further blunderings may take place. Finally, the courts and the medical profession may come to agree on the best approach, but it can take a long time. Since presumably there will be future outbreaks of future unknown diseases, I have a suggestion.

Discussions between the two professions ought to be held, to devise a mechanism of appeal to a special scientific court devoted to the problem which arises. The appeals court should refrain from issuing legal opinions until the scientific matter seems to have settled down, but a scientific opinion about the current state of scientific understanding might be quite welcome, anticipating later revisions of the law which undo judicial precedents which were set in an earlier time when only expediency was possible. The precedent already exists of the Courts of Equity, designed to meet situations where injustice obviously exists, but no law exists to address it.

Revolutionary Features of Big Data

The Right Angle Club, now luxuriating in its new quarters in the Pyramid Club, was recently visited by Professor Kenneth Burdett of University of Pennsylvania and Cornell. A charming fellow with a Scottish burr in his accent (he mentioned he had been born in England), he elected to tell us of a new revolution in economics which has slipped by us unnoticed, without textbooks devoted to it, or Nobel Prizes awarded. That is, many of the concepts central to macroeconomics are really net values, or ratios between two more basic facts. The concept of unemployment was offered as a handy example.

We tend to think of 230,000 new jobs this month as a hard fact, but it is actually a ratio of several million people getting new jobs, and several million losing jobs, not to mention a number who simply decide to leave the workforce and retire. We all sort of knew it was a ratio, but most of us had no idea it was the net flow of many-times larger numbers. It is because of the difference in the size of the flows, which are much greater in size than the small net unemployment figure, that this is a revolution rather than a humdrum ratio. We've been accustomed to the much smaller ratio than to the many-times larger flow numbers. What happens is vastly larger numbers of people lose their jobs during a depression, but millions more people re-enter the workforce, too, probably at a lower wage level.

Curiously, a new book by Mark Rank of Washington University, and Thomas A. Hirschl of Cornell (!), called Chasing the American Dream: Understanding What Shapes our Fortunes has just appeared, saying the same thing. Their approach is to develop a figure for the risk of being unemployed for a year in the next 5, 10, or 15, and at the moment the answer for unmarried white persons sometime during the next fifteen years in the future is 32 percent. That seems to be a much more scary projection than to set the present aggregate total unemployment at 4.6%. We'll have to wait 15 years to see if that prediction really is accurate, or if it has the dire consequences we immediately assign to it. But it would appear many assumptions are about to be set on their head, and the quality of our projections is about to shift dramatically. For example, Chairman Bernanke of the Federal Reserve placed great stock on wage inflation being "core" inflation, but these calculations suggest much more can be made of the data than that. Since somehow it is calculated the present recession has eight more years to run, because current oversupply will require eight more years to run down, data recalculated in this new way may give different answers. It would then be useful to see which is the better approach to economic prediction.

Right Angle members who lean both right and left seemed impressed and befuddled by this new view of an old topic, and that's probably a very good thing. There seems no question of the validity of the approach, no question of significance, and little doubt of its ability to change attitudes. We look forward to many more insights from the Dismal Science, of this nature. For instance, this professor of many students of the rentier class remarked at how repeatedly he had been struck by students able to afford red convertibles (and the Princeton tuition cost) were nevertheless willing to throw themselves into the scrum of Wall Street, to make even more money. He regarded that as a strength of the American economy, in stark contrast to that in Europe, where the first sign of prosperity sent his old acquaintances, straight to the pub to relax a bit. In the British aristocracy, "entering trade" is a low-class thing to do, whereas sitting on the sidewalk sipping wine is the mark of really high class.

Getting Started

So it's simple to get started, although any obvious modifications like periodic payroll deductions, are between you and your vendor.

To repeat: you choose a high deductible health insurance plan which conforms to regulations. Since they vary in price and service, you are advised to shop around, probably starting with the Internet, or the personnel department of your employer, or your friends. At the moment, a number of features are fixed by the Affordable Care Act, so price and service are really the main issues.

Then, having identified a (high-deductible) insurer and an HSA vendor (perhaps a bank or investment adviser), you are free to switch later, but in the long run you are looking for more-or-less permanent relationships.

You now presumably have your health insurance policy, with a Christmas saving fund arrangement attached. Don't sign anything until you are satisfied with the answer to this question, "How much income can I expect and how much freedom do I have to invest in total market stock index funds, when and if I choose to?"

If you get evasive answers, you might silently plan to sign up, but plan to keep on looking for a better deal to switch to later. At first, it might not matter, but over time you need to find the best arrangement. A debit card attachment is nice. Big vendors are reassuring, but they tend to be inflexible. Bear in mind, there isn't much in it for your advisor unless you keep renewing for a long time, so if you persist, your will probably get an answer. If persistence doesn't work, the outlook for a favorable answer, however, is dim.

So you might suddenly improve the atmosphere if you offer plans to deposit the maximum allowable immediately, because a lot of obstacles will likely be waived. Keep that up for as long as you can, at least until minimum balance requirements are fulfilled. If you can't manage it, then use the Christmas fund approaches of payroll deductions and income penalties for as long as you have to, but remember your counterparty really must somehow be paid, even though he always remains a counterparty. What about the retirement income features? You probably don't have to worry about retirement for many years, although it is always wise to check occasionally to see how income compares with the competition. As things now stand, you needn't do anything until you become eligible for Medicare, except keep score between your arrangement and others, reacting appropriately to differences. As the time approaches, you will probably find you have lots of choices of retirement plans, so don't be in a rush to freeze that option.

Whether it is explicit or not, let's say you have done everything necessary for both a health insurance plan and, following that, a retirement plan. The retirement plan will have no money in it until you shift it there from the health insurance plan, replaced with Medicare. There are penalties for early withdrawals, but they can be made, if you must. So to summarize, there's a little nuisance when you start, and another bit when Medicare looms. But essentially the Health Savings Account is on auto-pilot if you keep funding it, and events continue to demonstrate you are getting the maximum available return.

That completes the first section of this book. It all may be a little hard to understand, but it's easy to do. The last part of the book is devoted to what else you and Congress might think about, to build additional features on top of this foundation. Most of these extensions would greatly enhance the finances of you and the rest of the country, but all of them must be debated in minute detail before implementation. And all of them require major legislation to be smooth and workable. The Health and Retirement Savings Account as it stands might use a few easy amendments, but it already has most of its kinks worked out. It's already reached the point where the claim can be made it's a whole lot better than any other term insurance plan.

One by one, let's examine the potential multi-year improvements to be debated, so at least you understand where all this might take you.

The Stamp Tax: Highly Innovative, Much Underestimated

One of the great books about Benjamin Franklin has just emerged, and it has an interesting current Philadelphia connection. Benjamin Franklin in London fills in the eighteen years Franklin spent in Europe, with many details and insights not possible to have with three thousand miles of ocean separating his activities from his home base. In fact, it raises the question of what was really his home in his own mind. Boston claims him because he was born there, but it takes a London writer to tell us he moved to Philadelphia because of disputes over vaccination for the small pox epidemic, between his publisher brother and Cotton Mather. XX Goodwin, writer in residence at the Craven Street Ben Franklin Museum, will forever change our views about his subject. We hope he produces much more.

A word about the museum. The Craven Street house is the only Franklin residence still standing, restored with funds from Countess XX, Anthony Biddle's XXX, who unfortunately died this year. Her daughter, Charlotte Petropolis has an apartment in Philadelphia and regularly attends meetings of the Shakspere Society at the Philadelphia Club, which is itself the oldest club in America, and second oldest in the world, according to Matt Dupee, one of the local authorities on such matters, himself a member of a great many clubs around the world. To return to the original point, Goodwin is the beneficiary of this important interest by prominent Philadelphia families in our Founding Father.

Revolutionary Boston Reconsidered

One gathers from the book that Franklin had considered himself a lifelong British subject, and from the Albany Conference of 17XX to his abject public humiliation in the "Cockpit" of Whitehall in 1775, nursed the hope that Great Britain and America would join in an empire as equals. He foresaw the growth of America, and expected the capital of the joint empire to move to America. After he returned to America, of course, the gauntlet had been thrown down, and he made it his task to enlist France on our side, bankrupting France and thus eventually provoking not one, but two national Revolutions. The French stilll think of him as their darling, but the lessons of the French Revolution taught Franklin some things he needed to know at the American Constitutional Convention of 1789. Letting others like Hamilton and Gouverneur Morris do the talking, his influence at dinners and private meetings put a stop to egalitarian babble, and established a firmly Federalist nation. His activity in London would have won him a Nobel prize instead of fairy tales about kites and keys, he was friends with Mozart and Beethoven, plus about five kings. You don't humiliate a man like that without living to regret it, and King George III certainly regretted it in his saner moments.

Which, after three paragraphs, brings us back to the Stamp Tax of 17XX. To begin with, it isn't enough to want to do something, you must figure out a way to get it done. The early 18th Century colonists had learned that smuggling and counterfeiting would frustrate any tax plan for colonies so far away with diversified economies. The oceans were filled with pirates, sometimes described as privateers, and the American coastline was thousands of miles long. Furthermore, maintaining a large British navy from the Spanish Armada to the War of the Austrian Succession required thousands of British sailors, and the Navy had been stripped down to spare expense. So naturally the idea came up to have the colonies pay for their own defense at least, but how were you going to do it, in a way you could afford to continue?

A little digging in history would probably reveal the main author of the Stamp Tax Act, but such things are often the product of staff rather than the parliamentary member who introduced them. But it ingeniously solved the empire taxation problem. You just printed up the stamps and sold them, then required the objects of taxation to have a stamp pasted somewhere on them. You still would have to worry about smuggling and counterfeiting, but the whole thing was an inexpensive way of collecting the money, and enforcing the tax. It even provided some nice patronage jobs for loyal stamp sellers.

Apparently, it was much too clever by half, since the colonists could immediately see what might be ahead of them. An uproar ensued, leading ultimately to repeal of the tax, except for a token tax on tea in order to preserve the principle. But the principle was exactly what bothered the colonists, and a tea tax wouldn't do, either. The rest is history, except I don't happen to know whose idea it really was. But I do know that Franklin was in London at the time, and Franklin's inclinations were strongly in favor of a combined British Empire. Franklin almost lost his job in this uproar, and some of his fellow colonists may have suspected his person position on it.

Looking a Gift Horse in the Mouth

The Progressive Era lasted several decades, some say it still continues. Around 1910, the Progressive Era, reacting to the Gilded Age which preceded it, started doing painful things in the best interest of the individual, like the graduated income tax, the War to End Wars, and employer-based insurance.

Regardless of originator or date, employer based health insurance was imported as an idea from Germany in the nineteen-teens, getting started in the nineteen twenties, and becoming the prevailing standard by World War II. Although control later shifted from employers toward government during this period, Harry Truman was unable to move it further. It was only in 1965 that government control jumped forward, coming to a climax in the 1965 Medicare and Medicaid laws. Curiously, the employer-based format itself reached a peak in the Lyndon Johnson legislation. Since 1965, one president after another has struggled to convert the rest of health insurance to government-based, but always retaining its same general employer-based form. Along the way, two people significantly modified the model: Abraham Flexner, promoting the research-oriented teaching hospital into custodian of the standard of care, replacing the physician guilds; and Henry J. Kaiser, retaining control of a wage cost by calling it a gift, with high corporate income taxes and exempted employee income taxes reducing its effective cost to the employer. In a curious way, high corporate income taxes increased the proportion of healthcare paid for by the Federal Government, by increasing the value of the deduction. Not everyone would agree with this description of history, but I'm convinced of its essence.

Whether the gift comes from business or from government, makes little difference, except to the two contestants. Henry Kaiser seems to have become enlightened that corporate taxation higher than individual rates actually results in important tax advantages for the employer's gift. It allows employers to shift most of the cost to the government, while retaining ultimate control in employers' hands. For many decades the commercial insurance industry tried to break in, but the greatest recent threat to this collusion was accidental. All insurance is a system of cross-subsidies, but the Obama Administration superimposed a subsidy of the poor by the rich, onto an employer system of the young employees subsidizing the older ones. The mismatch between the two seemingly similar subsidies now threatens the coherence of the medical finance system. It also brings out the advantageous warping of the insurance idea by calling it a gift. Furthermore, the gift is ultimately one of money, so how did service benefits get mixed into this? What does the diagnosis have to do with paying hospital bills, except as a mechanism for obscuring the price? The insurance premiums begin with money, and the insurance intermediary ultimately sends money to the provider of care. Money-in, money-out is what the insurance industry calls indemnity insurance. They were using indemnity for centuries before health insurance came along. Why change to a unique and expensive accounting system, if final prices remain unchanged? This device probably started as a way for an insurance intermediary to check the medical validity of a remote claim, but has gradually evolved into an elaborate cost-shifting device. The unfortunate result is to blind the doctors in charge to the true costs of their options. So doctors nowadays totally disregard the posted prices which emerge, when they devise their treatment strategies. The result is very bad, no matter what the original purpose was.

There may be something to the idea that adding diagnoses and services adds enough mystery to the process to keep away competition, but there are business incentives which seem more central. Now that health cost consumes almost 17% of the gross domestic product, corporate taxes are an important part of the federal budget, largely explaining why the President might not want to lower them, even driving international businesses to consider moving abroad, rather than lower corporate tax rates. However, if the tax reduction which results from the gift is considered, the net corporate taxes actually paid are not too different from prevailing international rates. If corporate income taxes were eliminated, at least the employer would have to pay for his own wage costs masquerading as gifts. They might even discontinue them, since employers could get the same tax abatement by calling them what they are, wage costs. Following this scenario, the main benefit appears as the tax exemption in the workers' pay package, and the main victims are the competitors who do not receive the gift. If the government is willing to lose the revenue from the tax-paying half of the workforce, they could permit the Health and Retirement Savings Accounts to pay the premiums, essentially providing tax exemption to everyone. If unwilling to lose revenue, the government could start taxing the large employers, which they are now prevented from doing by the seemingly high rates. It's hard to know whom to blame, except this sort of Byzantine structure creates winners and losers, and is ultimately unhealthy.

Two simple and comparatively painless steps -- equalization of tax preferences, and lowering of corporate income taxes -- might soften the objection to indemnity, so why continue the service benefits concept? For this answer you must return to Abraham Flexner, who brought Bismarck's "der herr Professor" system to America, stimulated much research, and ultimately made teaching hospitals vastly more expensive than community hospitals for routine medical care. And now it is necessary to understand the system of calling all activities which are unrelated to patient care "indirect overhead". Although research is largely funded by outside agencies like the NIH and drug companies, it is described as indirect overhead, and distributed among the patient care bills as additional indirect overhead. Unfortunately, a great deal of bloated administrative cost is classified as indirect overhead, as well. No modern corporation could exist without a certain amount of cross-subsidy, but the present amount of it in hospitals is unreasonable. Beyond a certain level, indirect overhead should be forced out of the hospital cross-subsidy system, funded independently, or at least forced into public view. In short, too much routine care is being reimbursed at a high tertiary care level in the teaching hospitals, and this may well stimulate excessive administrative costs as well, even though it may be hard to trace how it comes about. Their competitors in the community hospitals also probably get a little raise, indirectly, to help suppress their complaints. Wall Street was once lambasted for steak dinners and Superbowl tickets from vendors, but you don't hear much about the hospital administrator version.

To make a long story short, service benefits tend to equalize the cost differences between teaching hospitals and community hospitals, ultimately raising the cost of both, but particularly the cost of routine care in teaching hospitals. Historically, this surplus subsidized the research revolution, to which we owe a thirty-year lengthening of our life expectancy. So, go figure. But nevertheless it now blinds physicians as much as the public to the true cost of their medical decisions until they are unable to respond effectively to rising prices, and don't try. A century of it is long enough to devise a better approach, so apparently some pain is needed. But any way you go about lowering them, if you want to control costs, you must start and end with undiluted true costs, not accounting fictions.

After London, Ben Franklin Revisited

George Goodwin

George Goodwin appears to have written the best book I ever read, in Benjamin Franklin in London, which that writer in residence of the Craven Street Franklin Museum. has just produced. At least I have never read a book which proceeded to explain so much I knew puzzled me. There have been hundreds of books about Benjamin Franklin, but all of them fall back on Franklin's Autobiography which while surely authoritative, often omits significant details. Goodwin, concentrating on the eighteen years Franklin spent abroad, had access to many unnoticed personal papers. It was also written while Franklin was in England, where many things did not appear to need explanation to 18th Century Englishmen. And the autobiography was written for his son, who needed even less explanation. So it's a mistake to ascribe the autobiography's vagueness to deliberate deviousness, to say nothing of basing a whole theory of his personality on deviousness. Its hazy points now seem more attributable to his assuming his intended audience needed little explanation for what to us was seemingly left vague. And so as a first impression, Franklin himself emerges less deserving of his reputation for deceptiveness.

Ben Franklin In London

It occurred to me as I read it, that national opinions will change so quickly, that the transitional opinions of people like me will soon be swept aside. I am no scholar, but have read twenty or so excellent books about Benjamin Franklin, and adopted a number of fixed ideas which I will have to change. Therefore, Goodwin's achievement is in danger of becoming lost in a stampede of permanently revised views. Goodwin himself may be oblivious to his own achievement, which was probably gathered slowly after poring over heaps of primary documents, and living in a London world which needed less explaining to a Londoner. Heaven knows I am no Keats, but my place in all this can possibly aspire to his goals in the poem On First Looking into Chapman's Homer.

Join or Die

In the first place, Franklin appears to have been a staunch British subject, at least from the Albany Conference of 1754 to as late as 1774. His dream, formulated at Albany and expressed in many forms later, was that of a combined British-American empire, with its headquarters eventually to be located in America. For the largest part of his life, his attitude was not that America should be independent of Britain. It was the two nations should unite even more closely, America would inevitably grow larger, and the British Empire would become a British World. After King George III unleashed Wedderburn to excoriate Franklin before the crowned heads of Whitehall, it all changed, of course, but it did so after a personal dispute with the King about lightning rods, where Franklin never doubted he was the world-acknowledged authority. In essence, Franklin was the inventor of electricity, but King George in effect responded, "Who do you think you are, a King?" Those weren't the words they used, but that was the sense of it. Or, considering what was at stake, the nonsense of it. Franklin had been challenged to destroy the British empire if he was so smart, and that is exactly what he set about to do.

King George III

Without editorializing a word, Goodwin allows us to read a line Franklin wrote in 1773, that King George was "perhaps the only Chance America has for obtaining soon the Address she aims at."

Franklin was not without British allies. Lord Chatham, later prime Minister, and Edmund Burke, author of "On Reconciliation With the Colonies" came very close to toppling the government over this issue. Even Lord Howe, Franklin's chess partner and brother of even-more-avid chess partner Lady Carolyn Howe, who was later designated to lead the British repression of the rebellion, is quoted as saying in 17XX, XXXXXXXX. Lord Howe's words are going to require some re-examination of his motives in abandonment of Burgoyne against direct orders, and redirection of the fleet toward Philadelphia. Frankin's response, of course, was to use the victory to sign a treaty of alliance with France.

William Pitt 1st Earl of Chatham

In victorious America, of course, Franklin was celebrated for flying a kite in a rainstorm, something every schoolboy knows is too dangerous to try. It was during his time in England that Franklin performed a series of experiments which invented electricity which every physicist would agree would today win him a Nobel Prize. It made him a friend of Mozart and Beethoven, Joseph Priestley and five kings. Goodwin even restores the tarnished reputation of Peggy Stevenson.

But it isn't all for the better. Goodwin tells us Franklin didn't invent bifocals, some British optometrist did. So he raises a question, for those who are looking for it, about how many of the other American "firsts" for which he is famous, were ideas he picked up in his first trip to London in 17XX, and transported to an America eager to have what was the latest and trendiest. There are probably other innuendoes in this eminently readable but essentially scholarly work. But I missed them, and a hundred graduate students will have to put the record straight.

Innovation and Automation

Innovator Image

The innovator is protected by patents. To some extent, the public is harmed by them, because the public wants the innovation to be cheaper. is reported to have hated patents, because they harmed the public. But less innovation harms the public, too.

Once the inventor invents an innovation, he wants to see it work. Often he employs a craftsman to make one that works, money no object. A few rich people hire artisans to make high-priced versions for various purposes, some of them noble, some just frivolous.

So, some entrepreneur risks a lot of money to build a factory, hire cheap labor if he can find it, and mass-produces a cheaper product. He hates patents, but he loves cheap labor, and he particularly hates automation, which threatens his investment.

But automation is cheaper, so it wins. The automator has to spend a lot of money to accomplish automation, but his cheaper product puts the earlier factories out of work, so they fight automation as long as they are excluded from it, but eventually surrenders. Corporations almost always defeat factories, family businesses, and artisans. Ultimately, automation, corporations and possibly inventors, tend to win. Hand craftsmen, family businesses and cheap labor tend to lose. High volume usually defeats high margins of profit, so the public usually wins, too. If the entire cycle is fast enough, the patent protects the inventor. If it's too slow, the inventor loses. It's easy to see what side each of these participants will take in the political battles, assuming the hope of profit is what motivates each one of them. The public has the votes, so at first they can do almost anything. In the long run, more innovation and cheaper prices will win public approval, but in the short run, patent impairment and job losses may hold things up.

So what is in the public interest? Job retraining and regional movement of labor are two things which come up, their expensiveness probably varies with the particular issue. But one universal good sometimes clashes with another. Is home ownership always a good thing? Are there not times when it would be better to be a renter, and move to a different employment location when your job disappears?

There are certainly times when it is better to own your own home. I finally sold my house after living in it for sixty years. The real estate agent was rueful. He saw it as his losing six sales commissions, over the years, because I did that.

Terrorists: Mafiosa and Nuts?

Dr. Eric A. Zillmer

At a recent meeting of the Right Angle Club, meeting in the Pyramid Club quarters nowadays, a psychology professor from Drexel gave a talk on the psychology of terrorists. He looks as though he played basketball himself, and rather favored the espionage approach to the law enforcement one. Together with the trouble exactly clarifying his role either with Drexel or the government, it all suggested the Yale approach rather than the Notre Dame one, if you understand what I mean. He gave an excellent talk, and questions would have gone on for hours if he had been able to stay longer.

al-Qaeda or ISIS

One interesting distinction he makes, is between organized crime and mental illness. That is, between al-Qaeda or ISIS, and solitary Americans who shoot random schoolchildren in high school cafeterias. Both nationalities tend to end up dead at the end of the episodes, because the swat teams called in, have little patience (or trust) with risking lives to read Miranda Rights to people with smoking machine guns in their hands. But either because there are actually some survivors, or because other members of the criminal network are caught and interrogated, several hundred terrorists have ended up in Guantanamo for further interviews. Somehow, or for some reason, it was arranged for our speaker to interview them on cellphones, with a military interpreter on the line.

Suicide Bombers

Now that the Middle Eastern uprising has gone on for a few years, he said is possible to distinguish two different types of Muslim terrorists, the ones who get blown up in the attack, and others, their handlers whom they have often never met before. These handlers are to pull the triggers on radio devices to set off the suicide vests worn by the "useful idiots", who are sometimes hesitating at the last moment. The ones who get blown up are usually educated young male idealists from the upper classes, quite sane and highly dedicated to the cause they serve. They and their families will be glamorized later for their sacrifice, whereas the gimlet-eyed handlers fade off into the distance through the networks of safe houses. When they do get caught by intelligence agents of various sorts, they generally prove to fit the mold of tough-minded mafiosa, in this tough business for long run power and control. They might be conspirators, but could hardly be called idealists.

Peaceful Domestic

At least, that's what our Drexel professor said he believed to be the case, and in general his prescription for winning this war is to enlist the support of the wavering majority of Muslims who belong to neither one of the activist groups -- yet. Meanwhile, peaceful domestic American citizens can play an important role in distinguishing warrior enemies of several sorts from the occasional young American schizophrenics in cafeterias acting as lone wolves with their mayhem. The American variety needs electroshock therapy more than they need more rights, defense lawyers or longer prison terms. Strengthening or weakening the Second Amendment will have little effect on any of these people, Asian or American, but it might hamper the national survival to mis-characterize the two groups once they are taken into custody. Essentially, the intelligence community doesn't care what is done with the nutcases, as long as you don't hamper their efforts with the Mafiosa. And judging from the Human Rights protectors, they don't much care what happens to the Mafiosa, so long as we protect the rights of nutcases. There are surely a few double-agents mixed in, whose motives for saying what they say, are kept unclear. When the shouting dies down there are nevertheless elements of hope in this controversy. But it could easily get out of control. Because we are outnumbered world-wide, we might just lose.

Franklin and Brexit

Minister David Cameron

In June, 2016, Great Britain voted by a million plurality, to withdraw from the European Union. The plebescite was not binding on Parliament, but Prime Minister David Cameron promptly resigned, and there remains little discussion of anything but going ahead with "Brexit". It will take at least two years to accomplish the matter, and there remains great uncertainty about the terms of separation. The British stock market took a sharp dip. Stock markets always hate uncertainty, and from the start there was little doubt Britain would experience some economic hardship, but still they went ahead with it.

Archbishop of Canterbury

By the greatest stroke of good luck, I happened to be in London for this event. It had been barely noted in the Americana press before I left, and indeed a discussion group hadn't even put it on the agenda after my return. But let me tell you, the British public was talking about nothing else. From the lowest barmaid in a pub to the Archbishop of Canterbury, there was only one topic of conversation, and a very real understanding that Britain might well vote to leave the EU. Once the vote had been taken, of course, even the American public appreciated its significance, and its resemblance to the headlong tumult in our own political parties. Donald Trump might well win the election, and logic or rhetoric had little to do with it. Other countries, Scotland in particular, were teetering in the same direction of demonstrating how far a democracy was from a republic, when each "leader" had a million constituents. And how well the public appreciated the tendency of elected representatives to forget who elected them. Or else, in more rational moments, to appreciate how difficult it is for elected representatives to communicate with constituents.

Ben Franklin London Townhome

To go on with this insight for a moment, my Washington daughter tells me Democrat congressmen are required to spend thirty-six hours every week in a call center, soliciting campaign funds; where do they find time to legislate? But the central background reflection I happened to have about Brexit was how enduring the political split apparently was between the Whigs and the Tories. This thought came to me from one of the real reasons I was in London, to visit Ben Franklin's imposing rowhouse on Craven Street, fifty feet from the National Museum on Piccadilly. Franklin lived there for most of eighteen years, in a style quite different from the two-penny loaf of bread in Philadelphia. He was personal friends with five kings, Voltaire, Mozart and Beethoven, as well as Priestly, Lavoisier, and Hume. Townsend may indeed have passed the Stamp Act, but he invited Franklin to spend the weekend at his hundred-room castle. The neighbors on Craven Street easily recognized the carriage of the Prime Minister when he came to call on Franklin on Craven Street. From the point of view of this social set, the uproar over the colonies was whether England should conquer them and send their raw materials to British factories (the Tory view), or should instead colonize them with Brits, give them the vote, and rule the world as a commonwealth (the Whig view). Naturally, Franklin supported the Whigs, but his loyalty to his good friend George III, never wavered until 1775. And then, lightening struck St. Paul's Cathedral.

King George III

Quite logically, the King asked Franklin's advice. The King however insisted on a brass ball on the top of the church. Franklin resisted, saying a spire was much more effective. We don't have the exact words exchanged, but essentially the King said he was going to have his way, while Franklin in effect asked him who he thought he was talking to. In those days, far less direct wording was needed to give offense on such a central issue of the king having the last word whenever he wanted. It is intimated the King suggested to Weddeburn he should take care of the issue for him, and within a few weeks Franklin was subjected to public humiliation in the cockpit at Whitehall, threatened with arrest, and fled to America to start the war. I had never heard this story, before.

The point it leaves me with is not that Franklin lost his cool and should have known better than to express his opinion. Rather, it is the reflection that never before had a king been challenged on his divine opinion on any subject. Just think of the shock this must have caused him, to have to realize this was the first snowflake in a blizzard. With the Enlightenment and the Industrial Revolution, the world was going to be full of experts, who could make a fool of any king by disagreeing with him in public. This particular king was able to have his way, no matter what, but the day was soon approaching when any science editor, any university professor, and ultimately every barmaid in a pub, could pontificate to the Pontiff.


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