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You can almost watch his mind at work. If you give long hard consideration to the topic of inflation, you have to conclude that there seems no reason for it to be a bad thing. It may take a little time, but the price of everything will eventually read just to a new higher level, and relationships will go on undisturbed. At first glance, inflation is just a harmless numbers game. You can understand the power of inflation; everybody likes a little of it for his own personal benefit. If everybody enjoys a little of it in his own sphere, then the whole world is pushed to a higher numerical level.

After long consideration, Hayek came to see that the disruptions of inflation are caused by the uneven speed of penetration throughout an economy or nation. If the price of oil goes up, the price of transportation goes up, then the price of home heating. But those who take the train or who heat their homes with coal are not affected so soon. Mortgages carry a fixed interest rate for thirty years, until the unwisdom of such agreements becomes clear; but it takes time. The process of inflation creates winners and losers, and disruption in the culture of payments. The speed of payment is itself a factor in the virtual size of the monetary pool. In the long run we're all dead and it all settles out, unless we set in motion a universal scramble to get out the door before others get there. Inflation is just as much an evil as collectivism, and somehow the two are usually seen together. The Road to Serfdom sits on the shelf, right next to The Austrian Theory of the Trade Cycle, and Other Essays .

http://www.philadelphia-reflections.com/blog/1262.htm

Preppies of the Future?

Civlization

Modern western civilization had its origin, or revival if you prefer, in the Italian town of Florence six or seven hundred years ago. The rise and fall of Florence is a case example for the two preeminent scholars of civilizations, Peter Hall and Arnold Toynbee. Both of them, for obvious reasons, are British. Toynbee intones the theme that civilizations destroy themselves by overextending their best features. Peter Hall puts that in a larger context. Civilizations flourish in the first place because of competitive tension between two conflicting aspirations; eventual victory by either one starts success on a path of unrestrained decline.

Florence

Florentine civilization grew out of the interaction, conflict, and intermarriage, of pugnacious aristocrats with sly calculating merchants. For a time, an optimum balance was achieved, and Florence dominated the Western world. Centuries later, much the same thing happened to England as feudalism grappled, first with Elizabethan maritime buccaneering and subsequently with the Industrial Revolution. That's where Eton comes in.

Eton

For American purposes, it is enough to focus on two Etonian mottos. Lumping both reckless aristocrats and scheming merchant princes, Eton exists "to exert a civilizing influence upon those who are destined to rule." Eton expresses no pretense about diversity or talent; Eton is not a trade school, a place to make useful contacts, or an elevator for upward social mobility. Labour governments of course do not share such attitudes, enduringly defended by Wellington's proclamation, that "The battle of Waterloo was won on the playing fields of Eton." That school aspires to teach more than Latin or trigonometry; it teaches duty and courage. And, as needed, it works. The graduate of a similar school Winston Churchill, reminding the nation that never have so many owed so much to so few, was delivering a subliminal illustration that leadership grows from education in many different ways.

Derek Bok

So things had not changed much in several hundred years, from Florence to Eton. It became accepted that a nation needs leaders who are smart (no charges of Light Brigades, please), it also needs unflinching bravery, in various combinations at different moments. And then, a research institute very near Lawrenceville, New Jersey, and two Harvard presidents, Conant and Bok, added a new requirement just before the Second World War. By devising multiple choice tests whose results seemed to parallel later academic success in college,

Conant

it became possible to identify myriads of ordinary American children who seemed to have equal or greater potential than the children of wealth and success. If the leadership pool needs to be enlarged, that's where they should come from. Besides, examples have always abounded of the children of famous people who, even with an outstanding education, bitterly disappointed their expectations. Perhaps, by the application of scientific testing combined with judicious financial aid, it might be possible to accelerate the unmentionable social Darwinism long visible in competitive concentrations of hormonally active youth. Without being too obvious about it, perhaps we could create a race of supermen by placing genetically superior candidates together, train them well, and let propinquity do the rest.

Eric Hoffer

The American pragmatic way, and the scientific method, both attempt to make decisions by seeing what works. Eric Hoffer, the San Francisco writer, once visited Lawrenceville and pointed out one thing that definitely works. Rich men, he said, marry beautiful women. And so, their children tend to be unusually handsome. It's a circular system that is undeniably at work. Without any conscious scheming by sociologists, an unnerving pragmatism is already at work getting more of whatever it is we need, into leadership positions. Unfortunately, this fiendishly clever system for influencing the genetic choices of promising candidates cannot unequivocally claim to produce long-term success. Like the British royal family, it seems to some the proportion of failed marriages is too high in our system, the incidence of recreational drugs and alcohol is too great, and the number of graceful drifters too numerous among the alumni. Perhaps that is only invidious opinion, based on contrasting unusual opportunities with the ultimate consequences for a fundamentally normal collection of people. Perhaps, if we were truly objective, we might discern a second-generation production of Nobel Prize winners, Senators, Presidents, Olympic champions that might well justify the opportunities bestowed on the bloodlines. What Lawrenceville may need, to defend itself, is a systematic longitudinal study of outcomes that would demonstrate, let us say to Princeton, that more of our graduates are entitled to admission there. Or, maybe, that's the wrong goal entirely. Perhaps graduates of Lawrenceville, Andover and Exeter don't need Yale, Harvard and Princeton . Perhaps they need a different sort of college. Maybe they should skip college entirely, and go on to graduate schools. Instead of being preparatory schools, perhaps they should be finishing schools.

SAT test

Or, perhaps a longitudinal study would show something even more important, best perceived by ones who passed through the system before there was a SAT. Perhaps the basic premises of the SAT score need to be confronted, along with the cerebral ideals of Presidents Bok and Conant. Perhaps, beyond a certain point, higher SAT scores just lead to more schizophrenia and depression, or other counter-productive products of inbreeding. Perhaps a genetically inbred President, named Bush, is right in his unspoken allegiance to J. P. Morgan's system for identifying leaders. That old walrus-nose swept schoolishness away. "Brains don't make you rich," he snorted. "Character does."

http://www.philadelphia-reflections.com/blog/854.htm

David F. Bradford, 1939-2005

David Bradford

We should take the word of his friend and colleague, Daniel Schaviro, that the core of David Bradford's professional career as an economist was his conviction that a very deep wrong existed when two people could earn exactly the same income over their lifetimes but the one who spent every cent immediately would pay less in taxes than the other who carefully saved for his retirement and heirs. Bradford was offended by this message our society was broadcasting.

Working for a time in the U.S. Treasury Department and later as a member of the President's Council of Economic Advisor's, he was able to explore the mechanical workings of tax law well enough to translate moral conviction into a workable proposal for political reform. In 1977 he published "Blueprints for Tax Reform" , introducing these practical ideas at the highest level of academic rigor. The impact of his ideas in this paper extended through three presidencies, particularly the present one.

Bradford saw the tax injustice which penalized the Protestant ethic could be corrected in two ways. Either the tax code could shelter individual savings from taxes until they are spent (the IRA), or else convert the income tax into a consumption tax (like VAT). In either case, taxation would take place at the same time as consumption, rather than at the time of earning. Notice the person who saves money to spend later will suffer from both inflation and taxes on taxes on the inflation "gains". The political choice between the two proposed solutions was made by Senator William Roth (R, DE) who sponsored the Individual Retirement Account (IRA) and shepherded it through an intensely political Congress. His was a wise decision, since its voluntary nature made it attractive to politicians, while the French experience with a mandatory Value Added Tax (VAT) created political opportunities to favor certain industries, which politicians were quick to understand.

After twenty-five initially slow years, the eventual popularity of the IRA has now encouraged its extension to Social Security. That's what agitates domestic policy debate at the time of David Bradford's unfortunate death. The IRA model is also the basic concept underlying Health Savings Accounts (HRA), which struggled for many years but have reached their own period of growing acceptance. The Blueprints idea has thus dominated domestic politics for nearly three decades, while its originator remained largely unknown. Far from being a sign of weakness of the idea, it is a proof of the revolutionary nature of this simple concept that it initially provokes public resistance, but also inspires relentless tenacity among those who have taken up its challenge.

David Bradford returned to Princeton from his Washington experience, resting for decades at the quiet center of an Economics department that is not known for its quietude. After a most unfortunate fire at his home, he died of the burns in nearby Philadelphia, which hardly knew him.

http://www.philadelphia-reflections.com/blog/907.htm

Bertrand Russell Disturbs the Barnes Foundation Neighbors

Russell

In 1940, the Barnes Foundation disturbed its Philadelphia's Main Line neighborhood in a way that had nothing to do with art. Dr. Barnes was still alive and running the place at that time, so there can be no question about the testamentary intentions of the donor. He hired Bertrand Russell for a five-year contract to teach philosophy at the Foundation, under highly lurid circumstances. By doing so, he put his thumb in the eye of religions generally but especially the Roman Catholic Church, into the eye of a Main Line neighborhood that prized its privacy, and into the eye of the judiciary, although the judiciary found a way to get back at him.

Do not fear to be eccentric in opinion, for every opinion now accepted was once eccentric.

Bertrand Russell

Under the circumstances, hiring anyone at all would have been socially defiant, but Barnes went out of his way to offer a position to a man who was already internationally famous for sticking his own thumb in everybody's eye.

Lord Bertand Russell was the third Earl, the son of a Viscount and the grandson of a British prime minister. He had such a brilliant mathematical mind that no less an observer than Alfred North Whitehead regarded him as the smartest man he ever met. He burned up the academic track at Trinity College, Cambridge, and was made a Fellow of the Royal Society at an early age. There was absolutely no one in the academic world who could look down on him, particularly no one in any American community college. His association with Haverford Quakers was established by marrying Alys Pearsall Smith, a rich thee-and-thou Quakeress then living in England, whose brother was the famous author Logan Pearsall Smith. Many early letters of Bertrand Russell contain instances of what the Quakers call "plain" speech.

If a man is offered a fact which goes against his instincts, he will scrutinize it closely, and unless the evidence is overwhelming, he will refuse to believe it. If, on the other hand, he is offered something which affords a reason for acting in accordance to his instincts, he will accept it even on the slightest evidence.

Bertrand Russell

By the time of World War I, this odd mixture of Quaker pacifism and English aristocratic arrogance seems to have unhinged Russell from social moorings, and he began a lifelong career of defiance mixed with rapier wit that made just about everybody his enemy. He went to jail for pacifism, got divorced three or four times, openly slept with the wives of famous people like T.S. Eliot, and proclaimed that monogamy was not a natural state for anybody. He wrote ninety books, and his denunciation of religion was sweeping. All religious ideas were, in his view, not only false but harmful. Accordingly, everybody in polite society kicked him out, and although he was entitled to a seat in the House of Lords, by 1939 he was nearly impoverished. In desperation, he went to (ugh) America to seek his fortune. He didn't last at the University of Chicago, and even California eased him out. Finally, he was reduced, if you can imagine, to accepting an offer to teach Philosophy at the City College of New York. That proved to be totally unacceptable to Bishop Manning, who led a public outcry against using public funds to support such a radical, known to have held long conversations with Lenin. When a CCNY student was induced to file suit along those lines, an especially hard-nosed judge overturned the College appointment, with the rather gratuitous declaration that Russell's appointment would establish a Chair of Indecency. At that point, Albert Barnes stepped in, and offered Russell a five-year contract to teach philosophy at the Barnes Foundation on Philadelphia's main line.

Bertrand Russell in 1960s regalia.

Bertrand Russell the bomb-thrower accepted the offer and came down to that quiet little lane where the neighbors object to the traffic coming to look at pictures. The five-year contract only lasted three years, when even Barnes got fed up, and summarily dismissed him. The circumstances have not been extensively documented, but they were sufficient to enable Russell to win a lawsuit for redress of grievances. During that three year period on the Main Line, he had produced a book called History of Western Philosophy, which became a best seller and permanently relieved his financial difficulties, and was the basis for his winning the Nobel Prize in Literature. He spent the rest of his ninety-odd years leading demonstrations against the atom bomb, the Vietnam War, monogamy, religion and so on. There are those who regard Bertrand Russell as the role model for the whole Sixties generation, and, unfairly, the 2004 Democrat candidate for President.However all that may be, his activity at the Barnes Foundation undoubtedly was a factor in the firm but unspoken tradition of the Merion Township neighbors that they wanted to get that Art Gallery out of here.

http://www.philadelphia-reflections.com/blog/479.htm

Yale Blue

Yale

When a college applicant recently asked me what was so good about Yale, the question was so unexpected it took a moment to find a graceful answer. What finally occurred to me was the battle cry of New Orleans, before Hurricane Katrina. "It is impossible to find a bad meal in New Orleans." In culinary matters, New Orleans had a deep bench; with everybody in the city interested in good cooking, even the most dilapidated diner would serve you something rather good.

Well, in 1940 at least, it was impossible to take a course in Yale College that wasn't stimulating, taught by a distinguished professor who was charming and likable. At one point, I wandered into a course in early 19th Century English Literature, taught by William DeVane, a courtly and urbane gentleman who happened to be Dean of Yale College. Yale College refers to those who are seeking a B.A. degree; those taking a B.S. degree are said to be part of the Sheffield Scientific School; a few others were going to be engineers. In retrospect, I suppose Bill DeVane was just having fun teaching a course, possibly satisfying himself that Yale College was still working the way he wanted it to. In any event, I certainly didn't take that course because I cared who was Dean, or who DeVane was. I just thought it would be interesting to take a course in Jane Austen, Charles Dickens and some other early Victorian novelists. I'm glad I took that course, but I would have been just as glad if the topic had been the history of the Civil War, or a dozen other things. Except then I would have missed the experience of being close to DeVane, whom I now imagine was the architect of modern Yale College. The essence of this is that a Yale College student could select a course in any subject that caught his fancy, and be confident it would be first-rate. Essentially invisible to me at the time was the absence of certain courses for the main reason there was no one outstanding who was available to teach that subject. If some topic was so central that a course just had to be taught, Shakespeare for example, I suspect the Dean or the President would have found money no obstacle to getting someone outstanding to teach it. Meanwhile, as long as you wandered around inside the printed course catalog, you would need no particular guidance. The faculty obviously enjoyed the students, quite often coming to lunch at student tables in the various residential colleges. For example, William Lyon "Billy" Phelps usually arrived early, and Branford students would fight to sit at his table. At least in those days, the students liked the faculty, and the faculty liked to be with the students.

That sounds like quite a contrast with what is rumored at other colleges today, although it's hard to be sure of comparisons across several decades. Perhaps it was the student rebellions of the sixties, long hair, a fashion of crude speech, and all the other features of the social revolution that started during the summer of love. Perhaps it was the demographic bulge with attendent overcrowding of campus and classroom. And perhaps it was never as idyllic as I remember; my classmate Bill Buckley certainly believed we were at the mercy of godless secularism marching in academic lockstep, although I don't remember anyone else agreeing with him. Today, so many people agree with Buckley's viewpoint that it's hard to assess. But there is little dispute that graduate students never taught undergraduate courses in my day, no lecture that I remember had more than fifty students in the class, no one would have been admitted to class without a tie and jacket, everyone addressed the faculty as "Sir". No one went to Europe in Junior Year, so there was no suspicion that extra tuition for decreased teaching was an administrative goal. Even if there had been a Junior Year Abroad, I wouldn't have taken it because there were so many neat courses in New Haven that seemed more attractive. There were no illicit drugs to worry about, and girls only arrived on the train for special occasions. Yes, there were some beer-drinking playboys, but it was plain to see they would soon flunk out.

http://www.philadelphia-reflections.com/blog/821.htm

Advanced Placement Gains Attackers and Defenders

An abridged extract of what

Naomi Riley

Naomi Schaefer Riley writes in the October 6, 2006 Wall Street Journal, follows:

"... The rat race complaint is that AP courses put a strain on students-too many facts to memorize, too much reading. And teachers complain, too. They say that AP courses force them to teach to test.. .

"Conceived in the early 1950's by educators from three prep schools (Andover, Exeter, Lawrenceville) and three universities (Harvard, Princeton, Yale),

SAT's

the AP curricula demands that students acquire real knowledge. Unlike the SAT's which measure mental aptitude, the AP tests ask students hard questions on the history exam require students to place quotations and documents in their correct context and to identify events, dates, historical figures and ideas....

"Why? Because college increasingly offers a crazed social experience at the expense of rigorous study. But high school does better: It is often the last time that students are forced to learn something...."

Ms. Riley goes on to imply that colleges have deteriorated into little more than binge drinking hide-outs. Since I am 62 years away from personal observation of the college scene, I can't comment, or even know for certain whether things have changed much in this respect.

But on the topic of resistance to Advanced Placement, Ms. Riley explains enough to justify a comment. The SAT revolution, which took place at the same time and much the same place, effectively converts the old college entrance based on genetic probabilities into the new college entrance based on mental aptitude. Since raw mental aptitude seems to be in oversupply, the final decisions are winnowed by extra-curricular success. It would appear to me that the extra-curricular success industry is threatened by proofs of academic achievement. And more importantly, since grade inflation has destroyed the value of high school transcripts, the AP courses serve as a surrogate for effective nerdiness and bookishness. In other words, the AP tests are a threat to the entitlements created by the SAT, one of which is grade inflation.

If grade inflation is under attack, that puts more pressure on high school teachers to teach, school districts to raise their salaries, and taxpayers to pay. Before that happens, there will be pressure to cut the cost of sports and other extracurricular expenses.

Bill Gates

And, come to think of it, if more nerds are admitted to prestige colleges, perhaps their social inadequacies will reduce college socializing that now appears to alarm Ms. Riley. For proof of that trade-off, I enclose a photograph of some overachievers of 1978, two of whom dropped out of Harvard because it was unchallenging. Mr. Gates is lower left, Mr. Allen lower right.

http://www.philadelphia-reflections.com/blog/1142.htm

Unintended Consequences for Advanced Placement

The Nov. 23, 2004 Wall Street Journal writes that "Elite High Schools Drop AP (Advanced Placement) Courses," thus taking me back to 1943, when I guess I started the idea now being dropped.

Allen Heely

The then Head Master of The Lawrenceville School, Allan V. Heely, came around to Yale to visit recent graduates in their college freshman year. For secondary school principals that would, in itself, be quite a novelty today. We certainly considered it a novelty to have him actually buy us a beer, since six months earlier we would have been instantly dismissed from school without hope of appeal, just for one provable beer. The alcohol issue to one side, I can see in retrospect that the Head Master made a serious effort to socialize with his senior students, inviting them to tea every afternoon, and coffee after Sunday chapel. What might sound like quaint Victorian ceremonies to an outsider were in fact conscious efforts to create a role model of the mythical Renaissance Man. He and the school chaplain played piano duets and sang witty songs of their own composition. He brought in famous guests from New York and Philadelphia, and made them perform as conversationalists. Jacques Barzun was a memorable example. I can even see in retrospect he was displaying his elegant talented wife as an example of the sort of woman we were urged to marry. To visit his graduates in their early formative years in college was entirely in keeping with his concept of education as the basis for character development. There was even a quote from J. P. Morgan: "Brains don't make success, character does."

Yale University

Well, for all his effort to be friendly, when the Head Master visits you at college it's a little hard to know what to talk about. So, to be helpful, I pointed out that the science courses were not smoothly integrated between secondary school and college. An example was the contrast between my roommate (Peter Max Schultheiss, now Professor Emeritus of Electrical Engineering at Yale) and me. Pete had scored 100 -- no mistakes on any quiz, all year -- in both Chemistry and Physics, whereas I had not taken either course at Lawrenceville at all. Yet, here were both of us in the same Freshman introductory courses at Yale, required before more advanced courses could be taken. Naturally, Pete had an easier time of it, but at the end of the year we were at the same point, and we both felt he had wasted his time taking the same courses twice. Why couldn't Lawrenceville make an arrangement with Yale to waive the requirement for some introductory courses, saving educational time for something else?

Mr. Heely did a lot better than that. At that time, ninety seniors from Lawrenceville went to Princeton every year, a hundred seniors from Andover went to Yale, and about the same number went from Exeter to Harvard. A pleasant dinner was arranged for the three headmasters and the three University presidents, at the conclusion of which the deal was done. Advanced placement was put into effect. As I understand it, the AP system gradually spread, and last year 14,900 secondary schools offered Advanced Placement courses. You could play around with those numbers and conjecture several million college person-years of education were put to better purposes over the last 62 years. It's a real nice feeling to believe that one twenty minute conversation by two eighteen year old boys could have such a useful effect.

So, now what's the problem with these elite high schools, that want to drop AP courses? It's hard to speak on their behalf, but I'm in a unique position to know the original idea has twisted out of shape a little. The original purpose was to eliminate mandatory repetition of introductory college courses, but nowadays competition for admission is so ferocious that repetition is considered a very smart thing, to beat the system. It works up and down the educational system, awarding a high score for coasting through a course the second time. Advance placement thus becomes a bribe not to do that, and the power of the bribe is prestige for admission to some higher level. With 15,000 high schools (like Garrison Keillor's Lake Wobegon) claiming to provide superiority, there has to be accreditation, and for that there has to be a standardized test. Before long, the curriculum is dominated, not by what the teacher thinks is superior, but by what is likely to be on the accreditation test. In effect, we get a French-like system in which the bureaucracy dictates what is best for the Leaders of Tomorrow. That's quite different from the time when outstanding secondary schools produced an unusually good product, and colleges were asked to recognize it. It's hard to say who's been corrupted here; probably everybody, because it's mass-produced accreditation. If you want to evaluate whether to permit more or fewer waivers for a certain school, you need to evaluate earlier waivees when they reach Junior or Senior level in whatever college had previously done some waiving. Only at that longitudinal point in the process is it possible to conclude whether the waiving of repetitious introductory courses had been useful or harmful.

Underneath all of this is the self-fulfilling prophesy that graduation from a handful of elite colleges will assuredly lead to success in life. If what we need are leaders who are vicious competitors, practiced in circumventing hurdles on the way to getting to the top, credentialism is perhaps a regrettable necessity. But if, as Mr. Morgan said, it's character that matters, gaming the system is not a completely ideal way to promote it.

http://www.philadelphia-reflections.com/blog/474.htm

Charitable Immunity: An Underestimated Revolution

Percent

Until 1939, there was a legal doctrine of Charitable Immunity, which universally shielded hospitals and other charitable institutions from negligence lawsuits. No doubt the underlying reasoning was that charities possess limited funds for unlimited demands, and must be forgiven for imperfect compromises in the face of scarcity. To threaten them in court for falling short of perfection might drive charitable efforts away entirely. Since many professionals donated their services to the common effort, there was some spill-over protection for individual professionals, but this centuries old doctrine applied to institutions more than individuals. There can be little doubt that improved financing of hospitals by health insurance and government programs resulted in both higher standards and lessened public tolerance for imperfection. One might say that twentieth century America decided it could afford better care, supplied the money for it, and expected to see results. It might also be commented that Medicare and Medicaid were significantly over funded at first, but with time have become painfully underfunded, particularly by Medicaid.

The New Hampshire Supreme Court, against all prevailing doctrine of the time, held in 1939 that hospitals in that state should no longer be broadly shielded from liability by the doctrine of charitable immunity. By 1991, this new legal view had extended to the point where the Pennsylvania Supreme Court felt a need to define Corporate Negligence, emphasizing a hospital's duty to ensure a patient's safety while in the hospital. The court specified the duty to provide safe facilities, to select and retain only competent physicians, to oversee all persons who practice medicine within the walls, and to formulate and enforce adequate rules of behavior. Looking back, legal scholars point to two particularly significant intervening court decisions. In 1957, eight years before Medicare, the New York Court of Appeals declared that to say the doctor is the captain of the ship, acting on his own responsibility, no longer fits the facts. The court bore down hard on the existence of salaried physicians, and the illuminating fact that hospitals were openly sending out bills for medical services. In 1973, the Superior Court of Delaware deliberately and consciously extended the New York doctrine from salaried physicians to independent contractors working within the hospital. But independent contractors are still working for pay; the courts have been more hesitant to extend the idea of corporate control to volunteers who work without pay of any sort. But the movement is in that direction, so it is increasingly difficult to find anyone to volunteer. The American instinct to volunteer is still very great, as the response in 2005 to the South Asian tidal wave demonstrated, with relief agencies forced to send out appeals for the flood of volunteers please to stay home. But the central fact remains that the original premise was limited resources for unlimited needs; Medicare and Medicaid temporarily made it seem resources would be infinite, so why should an injured patient forgive a volunteer. As it becomes increasingly evident that the 1965 federal promises of infinite support are unsustainable, the invalidation of charitable immunity deserves to be re-examined.

The 1973 date of the Delaware decision is probably significant, because that was a time of abandonment of malpractice coverage by insurance companies. If you couldn't sue doctors, and you feel you must sue somebody, plaintiffs were in effect told to sue the hospitals. With charitable immunity, hospitals didn't carry insurance, but they immediately searched for it. And thus, a bigger, far juicier deep pocket was created. Physician malpractice premiums, outside of California, were approximately $100 a year. Those rates proved to be far too low. The temporary collapse and disappearance of malpractice insurance companies took place in 1975. It is very hard to blame the actuaries of a malpractice company in say, California, for failing to take fully into account a decision by the Superior Court of Delaware in their premium-setting.

Before this revolutionary upheaval, a volunteer chief of medical staff was (nominally) in charge of every mistake made by any employee, and that was pretty unfair if he got sued. The captain of the ship idea devolved to department heads, or perhaps just the responsible surgeon in the operating room. If the scrub nurse counted sponges wrong and left one behind in the patient, the responsibility passed upward to one of these captains or sub captains. The manifest unfairness of demanding damages from someone six or more steps removed from the incident, particularly one who had a largely honorary title and no real control, exercised a restraint of sorts on lawsuits. Once the blame was shifted to a nebulous legal entity known as the corporation, blameless blame transformed into corporate financial liability. The average size of awards against institutions escalated upward, raising the size of claims for similar injuries against individual physicians. Add to that the growing fact that hospital revenues are almost exclusively derived from insurance third parties, and thus the premiums for hospital insurance could only come from insurance as an automatic pass-through. Disaster looms if the intermediate parties have nothing to lose, and the public pays all the cost through health insurance or taxes. None of this adversary system, including the whole tort system and the whole malpractice insurance system, was designed to cope with a financially pain-free defense posture. One paradox of the situation is that the admirers of the plaintiff viewpoint are typically also sympathizers with universal health insurance. The two are utterly incompatible under any set of proposals, so far offered.

If matters had stopped at that point, well, it's only money. But obviously the counter pressure on health insurers to hold down these costs was inevitable. Hospitals were practically under court order to make rules (the hospital associations would be happy to construct a model set of rules) and enforce them on their attending physicians, to pay professionals salaries wherever possible as a time-tested means of encouraging obedience, and to reorganize themselves as corporations practicing medicine rather than hotels providing space and services. (There are legal barriers, of course. Numerous state constitutions awkwardly state "No person may practice medicine in this state without a license so to do.") Needless to say, physicians resisted this trend toward the corporate practice of medicine, even though its early forms only took the shape of placing the hospital lawyer in charge of conferences about "risk" prevention. Since the lawyer knew very little about the topic, the discussion tends to focus on horror stories of suits that were lost or are in litigation.

This struggle between physicians and administrators for control of the hospital, using malpractice as a debating point, is bad enough. Far worse is the slanting of the system of actual medical organization of the staff. Hospitals now often have thousands of nurses and hundreds of doctors, each reporting upward within two guild structures. You would think the chief of surgery would have a lot to say about the selection of the nursing supervisor in the operating room, but heaven forbid. Nurses are hired and fired through the nursing hierarchy, not the department hierarchy which would cross guild lines. It's sometimes hard to say who is on which side of this issue, and probably everybody is on both sides, sufficient to paralyze rational discussion. Everybody involved wants to diffuse blame for an error through the whole organization, and so resists having responsibility conferred in any consistent way. The chief of surgery, for example, is ambivalent about whether he wants nursing errors legally passed back to him, and thus tends to retreat from asserting himself. It can sometimes be hard to specify the ways this chaos expresses itself in poor quality or higher costs, but it would certainly be remarkable if it didn't.

http://www.philadelphia-reflections.com/blog/812.htm

Main Line School Night

Radnor

There's a lot to learn from the Main Line School Night, and it isn't all taught in the classroom. The basic idea is life-long learning, going to school because it's fun. The idea started five or six decades ago in the Radnor, PA high school, that a lot of educated people wanted to become still more educated in topics of their own selection. No tests, please, and forget about academic credits; most of the students already have an excess of them. Forget about improving your income with advanced degrees; since this is Main Line Philadelphia, quite a few of the students already have all the income they could ever want. As related by the very low-key president of MLSN, David Hastings, the idea was an almost instant success. There were 1200 students enrolled for the second semester. They outgrew the original high school, and now teach courses in seven schools among 40 locations, to 14,000 students a year. There are 400 teachers in any given year, and the tuition charged is aimed at breaking even on the overhead. The academic world is inclined to say the courses lack rigor, by which is partly meant that if the students don't like the course, they walk out. Volley ball, yoga and nutrition certainly do have a California sound, but computers, foreign languages and science can be as difficult as you want to make them. If you get serious about contract bridge, you soon learn that isn't a simple child's game. Courses in wine tasting are given in the local senior citizens retirement communities, but mostly not to the residents. It's not welcome to give that sort of course in a high school. To some extent, this continuing education is an exclusive social occasion, but then so is a course in diplomatic history at Princeton. Mr. Hastings tells of a group of sixteen ladies in a bridge course who have been coming for years, and have learned to close the course rolls by all sending in their checks on the day of registration. This is, after all, the Main Line where exclusionary techniques once learned are hard to forget. There are clouds on the horizon. In the past three years, enrollment has leveled off and declined a little. Almost no major corporation continues to be successful for more than seventy-five years, and many of the people running Main Line School Night are drawn from the Executive Service Corps. In retrospect, for example, the owners and editors of the Saturday Evening Post should have sold out and closed down, as soon as they learned the first million television sets had been sold. Perhaps the decline of enrollment of Main Line School Night reflects the advent of the Internet, or the cell phone, or some other new technological competitor. Or maybe the venture just got too big and successful to maintain its original format; perhaps it's outgrowing its blood supply. But anyway, they have 14,000 students, and can be proud to be in a resting phase, when the rest of the city, or state, or country, hasn't even tried to get started on such a project.

http://www.philadelphia-reflections.com/blog/749.htm

A Woman's Work

Feminism

Whatever the gains and losses of the Industrial Revolution, reproductive need endures. Feminists who proclaim the advice to their sisters, "Have a baby; just don't have two." ignore some pretty simple arithmetic about population growth. What's perhaps worse, they fail to notice conflict with the goal of marrying rich. Rich men can afford a lot of things, but most of them can't afford a working wife. There's a fantasy in soap opera about meeting a fabulously rich man, one who owns motorboats and horses. How glamorous to be swept up by such a paragon; after all, every American hopes to get rich.

Big House

In fact it takes training to run a big house, organize big parties, cope with artisans and servants, facilitate the complicated diplomacy of business and political affairs. A rich man expects his wife to run a big establishment, facilitate a complicated social life with those horses, sailboats and extensive travel. And she better maintain her personal glamor, too, because there are lots of younger women who toy with the idea of grabbing him in a weak moment. So even fun time at the dress shops and hairdressers is obligatory. A man in an exalted position can't afford to have a wife who is employed in some dumb profession; the money she earns is a nuisance.

Finishing School

So that brings us to colleges and Quakers. A handful of elite women's colleges once tried to accommodate the finishing school with career preparation for blue-stocking women. The student could choose which path to follow but until recently finishing school was predominant, and comparatively few chose to be spinsters. Bryn Mawr College quickly grew to be the most prestigious college in the Philadelphia area, since both the finishing school and the bluestocking career had the needs of the upper class in mind. Quakers don't admit to an upper class, but look at their colleges. Haverford was for Quaker males, Bryn Mawr for Quaker women, and Swarthmore for Quakers who fancied co-education. It was a nice arrangement, with Quaker students almost always in the minority, the rest either upper-class (read Katherine Hepburn), or brilliant scholarship students. Bryn Mawr was a little sniffy about the farm-boys at Haverford, and the engineering nerds at Swarthmore. Much of that was an adolescent pose, but it created quite a rearrangement, when Haverford went co-ed.

Haverford College

Almost overnight, women college applicants declared a preference for going to Haverford if there was a choice. Within a few years, Haverford students became 57% female, and Bryn Mawr suffered a decline in average aptitude scores. Why ever would girls prefer Haverford to Bryn Mawr? Indeed, if Haverford was headed in the direction of an all-female student body, Bryn Mawr would seem to be the better woman's college to pick. Somewhere buried in this adolescent stampede is probably some television-inspired confusion between the life of a suburban housewife and the life of a rich man's wife, but there certainly is a big difference in attitude about two-career families. On the other hand, there are lots more opportunities for the upper middle class than the lower upper class, both in the number of available mates, and in the fall-back opportunity to try to make it as a career woman. Rich men are no longer invariably upper class, nudged by their chums to be wary of career girls. Anyway, college freshmen are pretty malleable; Haverford is a little safer bet if you aren't entirely sure of yourself.

http://www.philadelphia-reflections.com/blog/843.htm

Exit, Pursued by a Bear

John Kastor

Everybody ends up getting fired in a recent book by John Kastor about recent events at the University of Pennsylvania just like everybody ending up dead in an Elizabethan play. The vital difference, of course, is that the dramatis personae at Penn can still relate to a bewildered audience their own versions of those grand events. To protect himself, the author peppers his book with more footnotes than a PhD. thesis. And thousands of stakeholders at the University can now realize that during those eventful times they were as clueless as Rosencranz and Guildenstern.

One basic fact about that institution is that the medical school spends three quarters of the entire university budget. That leads to grudges in the little law school, the little engineering school, and the little president's office, as they knuckle under to the Golden Rule. The department chairman with the gold, makes the rules. Since most of that gold comes from research grants, hence ultimately from the federal government, the medical students and the teaching faculty don't have the same power they had during the Vietnam War era, either. Although medical school tuition imposes a crushing burden on the students and their families, leading to debts close to a quarter of a million dollars apiece, the tuition money doesn't amount to much in the university scheme of things, either. In some schools, tuition amounts to two percent of the medical school budget. You could eliminate the students entirely and not see much difference in the "school".

Unfortunately, when you become dependent on government grants, you find they can suddenly be terminated, or awarded without funding, or held up for several months by Congressional bickering. Meanwhile, there are salaries to pay, contracts to fulfill. Even if you can furlough some of the staff, it's not easy to see what you do about a thirty-year mortgage on a research building when there is a lull in its research funding. If you try to save money, the granting agency will try to get it back; they aren't authorized to make grants to be squirreled away. If you shift money to unauthorized uses, you risk going to jail. And yet, if you don't do something along those lines, the whole enterprise can collapse.

Having said that much to be fair, it is still uncomfortable to see the financial transparency of our most valued nonprofit institutions vanish behind a Byzantine fog of secrecy, out of which arise the magnificent towers of new buildings, and in front of which an occasional limousine is to be observed. No wonder the research scientists feel the constant pressure to produce. A Nobel Prize every ten years, or so, would go a long way toward quieting envious remarks from the liberal arts faculty.

Housed in those ivy towers are three institutions, the teaching hospital, the medical school, and the university, with three boards of trustees, and at least three ruling potentates. At irregular intervals, congressional committees do things to the Budget Reconciliation Act which enrich one of the three components of the institution, or suddenly impoverish another, or both. Integration of the three under one governance sounds plausible until you notice how radically different is the mission of each one. You can take a big building away from one component and rent it back to them, and things like that; but you can't do it without starting whispers about Enron. You can gather up surplus funds from one of them during the decade of the eighties, but you have trouble giving it back twenty years later. Officials at Blue Cross come snooping to see if health insurance premiums are passing through this shell game, ultimately paying salaries in the department of English Literature. Everybody distrusts everybody else, somebody sasses somebody, and everybody gets fired.

Nothing unusual about that. It happens at every medical school.

http://www.philadelphia-reflections.com/blog/830.htm

Commercial Academic Think Tank

Stephen P. Mullin

Stephen P. Mullin recently addressed the Right Angle Club of Philadelphia about assorted economic subjects; he is certainly qualified. He was once the only Republican in Mayor Rendell's cabinet, acting first as Finance Director and then as Commerce Director. At first he doesn't appear extroverted enough to be a politician, but quickly demonstrated that he knew the first names of more of the members of the club than the president did, so maybe he does have the innate talents of a politician. Urban political machines don't usually respond cordially to graduates of Exeter and the Wharton School of the University of Pennsylvania. A number of University professors are consultants to the firm, which offers statistical economic advice to the many law firms in town, to philanthropic organizations considering public-interest projects in the region, to government agencies faced with regulating unfamiliar activities, and very likely to anyone else willing to pay for the service of academics, statisticians and analysts. It certainly sounds like a service that governments and philanthropies need, and which the region needs to avail itself of. In a way, it is probably something the University needs, as well. A friend of mine is now retired, but at one time I commuted on the train with an academic administrator of the Wharton School, who was quite obviously disturbed by handing diplomas to students who promptly took jobs which paid those graduates more than he was paid himself. Obviously, such a system cannot persist very long without creating a brain drain, so income supplementation by commercial consulting is a necessary and valuable support for academics. There are, of course, probably some negative features as well.

The Wharton School

It is interesting to hear from Steve how Philadelphia can be variously described. We have, for example, significantly less foreign immigration than other cities. New York, by contrast, has a net immigration of about 700,000 persons a year; such forces can quickly transform a city in a variety of ways. The bombing of West Philadelphia during the Goode Administration was news for a while, then vanished from the papers. But it had a shattering effect on Philadelphia commerce, leading to a period of 8 or 9 years when there was essentially no private investment in the city. Philadelphia indeed now needs to have its municipal bonds issued by the state bonding authority, because our own bond rating is so low the extra cost of municipal debt is a significant one. And there is the cost of invisible shifting of power to Harrisburg. An unexpected result is that sales and real estate transfer taxes escalated to make up for property taxes which then could not possibly be raised as much as inflation. Real estate was in big trouble; whether ingenious strategies like the 10-year tax abatement for new property will be successful in rescuing the real estate industry, remains to be seen. New office towers have been built, but they drain off tenants from older office buildings. We're seeing a massive conversion of older office space into residential apartments, an apparently successful maneuver. But that drains the older residential areas, which leads to -- well, who knows what it will lead to, but it could be slums.

Mayor Michael Nutter

The traditional hostilities between Philadelphia and its neighbors can be defined in a new way, too. For a century, Philadelphia contributed more tax money to the rest of the state than it received in state services. But in the past 20 years, Philadelphia city has become a net importer of an annual billion dollars -- from the rest of the state. Two or three billion go to the schools, which the rest of the state regards as a deplorable waste in view of the quality of the product. And yet, the most hopeful feature of the situation is the vigor and ingenuity of the attempts being made to rescue the situation. In a certain sense, Mayor Nutter is the candidate of the Wharton School. He may well have some innovative ideas, and academic places like the Wharton School will surely suggest others. It remains to be seen whether Nutter can combine idealism with sufficient ruthlessness to make the city function. Cynical oldtimers will grumble that a mayor has to employ a moderate amount of deception and corruption in order to accomplish his mission. Maybe that overstates things, but it is very certain he must be tough. He's dealing with construction unions who will certainly be tough, and whose interest in sacrificing their own agendas in order to help the schools or street crime -- always fairly small -- is even further impaired by the econometrics that 70% of them live in the suburbs. We wish our new mayor all the best, since he seems smart enough to know what needs to be done, and is definitely smart enough not to drop any bombs on houses. He's smart enough to see that extra city revenues derived from gambling might permit the lowering of wage taxes, and hence an urban business recovery. But is he tenacious enough to stay in office long enough to achieve the balanced result; or will the forces of evil simply kick him out of office before wage taxes can be lowered and gambling discontinued? He won't break his promises, but will they break them for him? Beyond being competent, a city mayor needs to be tougher than the convivial but very mean friends he needs to associate with. He must, for example, decline to run for national office, the traditional way that city machines rid themselves of pointy-headed reformers.

WWW.Philadelphia-Reflections.com/blog/1360.htm

http://www.philadelphia-reflections.com/blog/1360.htm

Lumpers In Constant Combat With Splitters

James Boswell's Book

Some colleges produce managers by teaching management theory, but in certain Ivy League colleges it is thought to be more useful to teach how to dominate a committee, eventually perhaps a board of directors, or a board of trustees. The handbook of instruction is James Boswell's Life of Johnson which is a rather large book of verbatim notes that Boswell took of his many lunches at a London club in the 18th Century. Boswell was a quiet mouse privileged to sit in the company of the great Dr. Samuel Johnson, surrounded by the most eminent intellects of the Enlightenment. Boswell carefully manages the background of each episode, describing the issue and the various arguments, and then -- Sam Johnson's booming voice settles the matter. After he speaks, the meeting is over.

Dr. Samuel Johnson

"Why, sir", says Johnson, and then look out for the one-liner to follow. We get the impression that Dr. Johnson used that "Sir" signal to indicate he had enough of these dumb arguments, and soon would come the growled epigram that scatters any token resistance. Boswell may have neglected to record instances where the great Johnson was defeated in debate, who knows. We are left with the distinct impression that if you engaged in lunch table conversation with Sam, you were almost certain to lose. So that's what Ivy League students are being taught: how to win a debate at a committee meeting, in the expectation they would spend much of their lives in committees, boards, and even cabinets. That's how the English-speaking world gets its work done and its decisions made. That's what lunches at the Franklin Inn Club, or the club tables of the Union League, are trying to do for the education of neophytes.

Chauncy Brewster Tinker

As the goggle-eyed student of the great Chauncey Tinker, who gave young Pottle his start in life, it was an awesome performance for me to watch. But the rules of this game never became entirely clear to me, I'm afraid, until the other evening when I listened to Peter Nowell describe in a half-dozen brief paragraphs how he had revolutionized prevailing theories of the cause of cancer. The Franklin Institute then followed the award ceremony by putting on an all-day symposium of notables who run elaborate enterprises in cancer research, essentially funded by the National Institutes of Health, your tax dollars at work again. Last year, the NIH dispensed thirty billion -- you heard me -- dollars in research grants to internationally known research entrepreneurs, and if you can stay awake during their talks, there must be something the matter with you. So far as I could see, they were painstakingly describing every grain of sand on the beach, whereas Peter Nowell made the whole beach electric and clear in ten minutes. Essentially, he was saying that each patient's cancer is caused by a long chain of events, starting with a single mutation within a single cell. All the other cancer cells of a patient are descendants of that first one, which triggered the cascade of chemical events now repeated by the descendants. To stop the process, you probably only have to find a way to break the chain at one vulnerable point. Then you have a cure, without necessarily understanding every other link in the chain.

Peter Nowell

Peter Nowell described himself as a "lumper", admitting that most scientists are "splitters". A splitter quite reasonably attacks a complex problem by isolating one small piece of it at a time; that's really a pretty good way to address overwhelming complexity when you encounter it. But you can be sure that people of that mindset should not be found in a President's cabinet, deciding how to save the world from impending disaster. Whether by their own genetic predisposition or as a result of peer pressure in their profession, they are habitual splitters. And it suddenly occurred to me why Sam Johnson's one-liners always won the argument; he was a lumper. Usually right, sometimes wrong, never in doubt. Witty as a Frenchman, but as quick as a rattlesnake. Cordial, perhaps, unless you disagreed with him.

We need more lumpers. If they get that way from the likes of Chauncey Tinker, we need to print more copies of The Life of Johnson. If they are born that way, maybe we need a breeding farm for lumpers, which is what the Assembly Ball amounts to. But don't get me wrong, we need more splitters, too. They just have to learn their place at the table.

http://www.philadelphia-reflections.com/blog/1810.htm

Volunteerism Needs a Business Plan

Alexis de Tocqueville

The visiting Frenchman Alexis de Tocqueville was struck most by the volunteerism he found everywhere in the young American nation; in his view, the first reaction of 19th Century Americans to a problem was to create a volunteer organization to fix it. Benjamin Franklin, who created dozens of such initiatives, was held up as its great exemplar. But de Toqueville visited us at the beginning of the Industrial Revolution, and we are now well past that into the Information Revolution; voluteerism has noticeably declined. Not only have the great volunteer organizations like the Masons and the Red Cross suffered, but it is far more difficult to enlist the help of others to form a pick-up group to attack some issue or other. It is in that sense the general spirit of volunteerism has declined. The likely difficulty is not selfishness, but helplessness of people to control their own time.

Calling all Volunteers

When volunteer groups do assemble, they are mostly composed of self-employed people like plumbers and dentists, free to be somewhere else during "normal business hours", which although shorter than they once were, seem extended by commuting time and by chores pushed aside during workplace confinement. To some extent longer commuting distances make it physically impossible to do personal chores in the vicinity of the workplace. But constrained personal time is also related to increased control behavior by management. A successful big business has to employ strategies to get employees with cell phones to stick strictly to business while the employer is paying for their time. Now that so many women are going out to work, the family unit needs to struggle to coordinate everyone's work time so there will be some remaining opportunity to conduct family life. When a working couple shares the home tasks and baby sitting, the preempted time now extends to two working partners, and what is left is called "quality time". A probably temporary elaboration of this time competition is the need to chauffeur teenagers to their resume-enhancing activities. For the time being you don't pick a college, the college picks you, and parents desperately labor to assist their children on a career path. Quite obviously, America needs to evolve better ways of trading work at home for more flexibility in the actual workplace, and we also need to build more first-rate colleges, but those issues are not the present topic.To summarize: It's awfully hard to assemble a group of volunteers simultaneously, because employers have so successfully assembled their time. Failing to appreciate the tradeoffs inherent in commuting time is a secondary but still important factor, somehow related to the recent housing/schools mania.

Consequently, volunteer organizations increasingly tend to regard their chores as something you hire someone else to do if it proves impossible to dump them on someone who is retired or unemployed, or too timid to refuse. Even nominal volunteers are reluctant to step forward. This leads to recruitment lectures along the line that naturally you must sacrifice if you really truly believe in the goals of the dear old Whatsis Association, surely just a coercive speech pattern. That claptrap was never heard during the age of universal volunteers; volunteering was just one of those things everyone expected to do to get community activities accomplished. We're losing something important if we continue to endorse this attitude. Sometime during the first twenty-four hours in military service, for example, someone will surely advise the new recruit -- never volunteer.

For a penniless non-profit to adopt the solution of hiring staff when there is no revenue stream to pay them, is the first step toward dissolution of the organization. Essentially, the non-volunteers are ordered to contribute money if they choose to be draft-evaders, and eventually the officers and staff begin to look back at the organization members as cows to be milked. A class of people who are only making a living are substituted for those who understand and promote the goals, and it just goes downhill from there.

Instead, all volunteers really must each do some unpaid work, and the officers and directors must set an example of it. What an organization does next is crucial. Individual members, either anonymous or hoping to remain anonymous, must be approached with the suggestion they accept responsibility for a task. The wild-eyed response to this approach is quite familiar, like the lame excuse that there is no time. A counter response that I'm busier than you are, does not improve the conversation because it suggests the refuser is merely a selfish shirker. Instead, initial requests must take the following form: They should be for a simple, limited task without any obligations stretching to infinity. Almost everyone will be glad to bake a cake for a party, but almost no one will agree to be chairman of the cake-baking department, unless the boundaries of that commitment are more reliably limited than they usually are.

In modern times, any major undefined volunteer responsibility is seen as potentially leading to an unwinable conflict with gainful employment or else its ill-considered outgrowths like commuting. Since that's the basic problem, all volunteer invitations must respect the true issue and devise workable ways to circumvent it. Role models certainly help if you have any.

www.Philadelphia-Reflections.com/blog/1448.htm

http://www.philadelphia-reflections.com/blog/1448.htm

Picking Up the Usual Suspects

The federal government directly controls about half of health care spending, and makes rules affecting most of the rest.

Claude Rain

Every group or business which receives some of this money is alert not to lose it. Many other groups are alert for openings to get more of it. All employ sentries in Washington. False alarms are frequent, stealth attacks are a constant threat, constituents paying the bills demand immediate reassurances. Members of Congress seldom initiate a disturbance unless someone from inside an industry brings it to them. Consequently, when proposals do surface, and seem to be serious, the question to be immediately answered is -- who's behind this? If you know who starts something, you can readily imagine the motive, assess the political strength, decide how to respond. With what little was generally known about the Clinton Health Care Plan of 1993, it was easy to imagine a host of people with some motive, but very hard to say who was actually pushing one. Must be a Democrat, obviously, but not immediately obvious which of several possibilities was the real agitator.

Health insurance companies would always seem likely to have proposals about national health insurance. Blue Cross dominates the market in large geographical markets, mainly East Coast, and would seem fearful to lose that dominance in a major upheaval. But other market areas of the country are dominated by commercial insurance companies who might seek to upend the Blue Cross monopoly, but whose form of business would be even more seriously threatened by health insurance innovations. Most commercial health insurance was written by large life insurance companies who regard health insurance as a small sideline for the convenience of their industrial customers. Blue Cross was somewhat more comfortable with government work, particularly since the 1965 Medicare and Medicaid programs were patterned after them. However, Blue Cross was non-profit, thus lacking in incentives, and historically controlled by health care providers. That is, Blue Cross was formed by and dominated by the hospital associations, and Blue Shield was formed by and dominated by medical societies. Since doctors and hospitals were very prompt in announcing their deep concerns and uncertainties about the Clinton Plan, Blue Organizations seemed unlikely to make daring proposals so likely to provoke trouble at home.

Not that some doctors and some hospitals didn't try to see what might be made of this opportunity. At the American Medical Association, certain leaders known to have Blue Shield involvement offered conciliatory remarks about waiting for further details before taking a stance, but were abruptly halted by a general opinion that things had apparently already gone too far for substantive negotiation. Much the same thing occurred at the Hospital Association; the winners had too much to lose, the losers had too little influence to matter, and nobody stepped up to claim an inside track. Hospital trustees didn't know what was going on, strongly suspected something was going on, and didn't like either situation. If the doctors got mad enough at a hospital, they could ruin it, and if hospitals got mad enough at Blue Cross, it too was ruined. The main strength behind the Blue Cross monopoly position was the secret discount provided to them by hospitals, which was refused to competitor insurance companies, but could easily be extended in the interest of fairness. If need be. The commercial competitors wanted that discount much more than they wanted new insurance models.

There is one subset of doctors and hospitals that might be suspected of generating a sweeping revision of the medical system -- academia. Medical schools think of themselves as the appropriate source of vision about the profession they are training, and they run large prestigious hospitals. Their heavy dependence on government research grants, teaching subsidies, and tuition support programs puts them in constant contact with Washington bureaucracy and politics; propinquity is a great match-maker. Their style of salaried faculty creates estrangement from making a living by being paid fees for specified services, and they are reasonably comfortable with the flaws and techniques of professional promotion within a large organization. So, a slogan which has been attributed to Wilbur Cohen himself does not greatly jar on their ears. The author of the Medicare Act is said to have announced that the entire medical system of America could be accommodated by thirty or forty Mayo Clinics. Twist that just a little, and you are imagining he said forty or fifty medical school teaching hospitals. The briefest contemplation and rebuttal will knock down that proposal, such as pointing out that we have several times that many teaching hospitals at present without achieving anything like the nation-wide coverage envisioned. After absorbing the administrative chaos of readjusting to that model, you would confront the old repeated history of grossly overestimating, and then grossly underestimating, the future manpower needs of a medical system in the process of constant scientific turmoil. Supppose you built the fifty Mayo Clinics and found you needed two hundred? Suppose you built two hundred and found you needed seventy? And then, finally, remember that each big city could expect to contain one of these organizations, but the fewer of them there are, the longer the distance everyone else would have to travel to get to them. No one has even ventured to speculate how you could go about doing such a thing, let alone doing it three or four times to get it right. But, but. The infeasibility of academia at the center of medical care delivery does not eliminate the possibility that the idea underlying the Clinton Health Plan may have originated in academia, or that academia might support some similar proposal with something else at its center.

Since it was soon clear that the traditional "players" in the health policy arena were unlikely to be sponsoring some self-serving policy that might masquerade as the Clinton Health Plan, the search went on. There were a number of professional groups within the medical community who had traditionally chafed at domination of the hierarchy by physician leadership. Nurses, hospital administrators, pharmaceutical companies, druggists, corporate human resources officers, public health officials, social workers, biology teachers all represented groups who derived status with the public by displaying inside knowledge of medicine. But all of them fell silent when a physician entered the room, and tended to shift their emphasis to faults of the "system" or the "industry". Their Washington representatives placed their emphasis on changes in the existing system which might elevate the prestige and income of the members, and were particularly vigilant for system modifications intended for other purposes which might nevertheless create advantageous loopholes for the members. All of this is normal striving in the good ole' American way, a polite variant of the mixture of bellicosity and restraint usually seen in the Union movement. These people wanted to improve their income and working conditions, but were ultimately quite hesitant about radical proposals that might sink the ship. A quick survey showed they were not supporting any particular reform project, even though they could be counted on to support any reform project. Furthermore, they consistently injured their political strength by extending beyond economic goals to issues like radical feminism in the case of nurses, or direct advertising to the public as in the case of the drug companies, or practicing medicine without a license in the case of limited-license practitioners. These people had votes, influence and lobbyists, but they did not have a national project for health care reform of their own devising, and they surely were not the people behind the Clinton Plan.

During the six months before The Plan was presented to Congress and the Public, a White House task force said to consist of five hundred secret members was meeting under the direction of President Clinton's wife Hillary. No doubt part of their purpose was to give Hillary a public platform on which to show her stuff, with the idea of someday succeeding her husband as President sort of in the back of her mind. But most of it was also quite practical; somebody had to figure out what this proposal was going to be, and newly elected Bill had to spend most of his time learning how to run the rest of the country. Buried in here was an efficiency principle too; the staff members of every important congressman and senator were involved in the process, making the deals and surfacing the political angles before things had to come down to votes and filibusters. Meanwhile, the rest of the country had to wait outside closed doors, fed by rumors and spin.

How well I remember one public seminar on the subject during this period of suspense. The audience was filled with people thought to be influential with the public, the usual suspects in that sense, too. Representatives of various interest groups were seated up front at a table, and for some reason I had been picked to represent doctors. Next to me was a druggist who had made a billion dollars starting an HMO; it was intriguing to watch how many well-dressed women with no interest in health care paraded up to the table to show their stuff to the billionaire, while we waited for the meeting to begin. All of the usual suspects of Philadelphia medical care were at the table, each of us wondering what the other was going to say. When some last Very Important Person had wandered in and taken a seat, it was time to begin. The moderator told a funny story or two, and then asked each one of us what we thought of the Clinton Health Plan. One by one, to the utter amazement of us all, we each explained how we were opposed to it.

So obviously this proposal was not coming from the usual agitators. But, remember, somebody was surely behind it. Before we take a stab at that mystery, let's humanize the usual suspects by describing a few of them.

http://www.philadelphia-reflections.com/blog/1265.htm

Pets For all Seasons

Professor James Serpell

People who have had a chance to talk with Queen Elizabeth report she is so fond of her Korgi dog pets that she scarcely talks about anything else. Perhaps because he is British, then, Professor James Serpell has been selected as the chairman of a new department at the University of Pennsylvania Veterinary School, devoted to the study of Human-Animal Interactions. In any event, he made an interesting presentation to the Right Angle Club recently, reviewing the history of acquiring pets. A domesticated animal is not necessarily a pet; chickens and cows raised for food purposes are not considered real pets. A pet is domesticated purely for the purpose of companionship and love. Study of cave paintings and fossils seems to show that pets were maintained for many years before animals were domesticated for food purposes, although hunting dogs might have utility beyond providing love and companionship. The ancient nature of pets does seem to suggest that purposes other than utility have been prized for a very long time, and not necessarily by people who are affluent.

Pets are steadily increasing in number, however, and are estimated as approaching 160 milllion, a number growing faster than the human population of the earth. The human residents of the earth are just about the only species known to make pets of other species, although monkeys will occasionally treat marmosets in a pet-like way. There might still be some utilitarian purposes in keeping pets, however; a goat companion is observed to have a calming effect on wild horses. For something whose utility is marginal, pets are a pretty expensive hobby. It is estimated that $45 billion is annually spent on them. A non-pet lover was once heard to remark that a cat is a domesticated parasite. Apparently, you either love pets or you don't.

Queen Elizabeth II

It probably hasn't much to do with the motives of pet-lovers, but research does seem to show that those who maintain pets live longer than those who do not, whether the pet is a cat, dog, or rabbit. Pet owners have a lower average blood pressure, and score better on tests which reflect the prevailing stress level. In spite of snide remarks sometimes heard about people who love pets better than their neighbors, tests of interpersonal relationships seem to favor pet lovers.

In recent decades, there has been a growing tendency to confer rights, animal rights, on animals in general, and pets in particular. Remarkably, animal rights advocates seem to be more common in urban environments, than in rural ones. Perhaps the experience of wringing a chicken by the neck in order to prepare dinner hardens the heart. Next thing you know, the Tea Party phenomenon will start getting blamed on observations like this, so watch your language, please.

http://www.philadelphia-reflections.com/blog/1794.htm

Avian Footnote

Waldo E. Nelson was a much revered professor of Pediatrics at Temple University School of Medicine for several decades. He was the original source of fame for St. Christopher's Hospital for Children, a powerful and revered teacher, and has recently been mentioned as the "Father of Pediatrics." He died in 1997 at the age of 98.

Saint Christopher Hospital

Everyone admitted he was a demanding task-master, to the point of eccentricity. That's a quality almost essential in any editor of a multi-author textbook, because authors regularly procrastinate in submitting their contributions, while publishers have rigid deadlines and no patience at all with editors who ask to extend them. The central element in Nelson's fame was his 1600-page textbook of Pediatrics, with more authors than it is reasonable to count in the decades it was published and re-published, eventually establishing itself as the standard work in the field. Nelson applied discipline to his resident physicians, too. One former resident recently recalled his forbidding a husband and wife resident pair to eat lunch together in the hospital cafeteria. Not in my hospital, you won't.

What his family life was like is not reported, but it can easily be imagined that he had rebellious children. One day he instructed his daughter to prepare a complete index of the textbook for the next edition. Apparently there was some resistance, eventually quashed. And to emphasize how unlikely it was that anyone would read an index very carefully, the book went through editing and proof-reading, and was in the bookstores for several months before anyone noticed the entry tucked away under "Birds".

BIRDS, For the. page 1-1650.

http://www.philadelphia-reflections.com/blog/1253.htm

Paying for College I

It's almost a platitude that America once changed from a largely agricultural economy to a largely industrial one. And currently, that we are going on from an industrial economy toward a service economy. This latest transformation is one of the main causes of soaring tuition costs; demand for first-class college education exceeds its supply.

College Cost

Tuition costs at the top of the educational pecking order have now reached $52,000 annually, with room and board and other costs sometimes adding another fifteen thousand. This is well in excess of the average after-tax income of working Americans, perhaps even in excess of the average income of college graduates. It clearly often exceeds the income of undergraduates' parents and must be subsidized. It creates a treadmill effect. But after graduating, average incomes of college graduates do exceed the average income of those who only finish high school. That extra income is said to justify the investment in going to college, even after taking into account the loss of 4 years of income, and perhaps a trailing six-figure indebtedness. However, a meaningful judgment can only be made in retrospect, after inflation and taxes work their way into a net-net appraisal. Faith in some postulated answer to this accounting question colors the truth of various belief systems, like: How much should we worry about the widening income gap between the quartiles of income, What is the societal value of income redistribution between those who pay full tuition and those who receive financial aid. And there could be legitimate questions about many other values throughout the whole system. During the Vietnam War, many uncomfortable questions were raised about the educational system, even leading to riots on college campuses. It was often implied that many students were in college merely to escape the military draft. While that may have been precisely what was in many minds, the scramble for elite college admissions has intensified since the end of the draft, seemingly proving a college education has other merits. Steadily rising tuition costs are rapidly narrowing the income advantage, so one supposes the intrinsic merits of higher education can soon be measured by whatever enthusiasm for admission survives the bursar's bite. There are many reasons for doubt.

College Cost Graph

In the first place, these undergraduate tuition charges are not tightly related to the underlying instructional cost. It is natural to expect some markup for any product on sale, and some cushion for the unexpected. However, the difference between the tuition for night school and day school is pretty disconcerting. Comparatively few universities offer the same undergraduate courses as night-school courses, but a number of them do. The tuition for regular undergraduate courses is about average, somewhere around $5000 per course, but the tuition for night school is around $1200 per course -- same teacher, same textbook, same exam. Without access to the accounting data, one is led to suppose the tuition for night school comes pretty close to the true instructional cost of these courses. And therefore led to the supposition that the 300% markup for undergraduates implies that this type of student, blue jeans and all, supports a great deal of unrelated activity throughout the university. This sort of discovery does little to enhance the image of justice in academia.

In the second place, colleges are in a position to have the surplus over non-operating costs flow on into the endowment fund, breaking the linkage to underlying costs entirely. Not flowing directly, of course, but money from the endowment which might have been spent on operations can be conserved by rising tuition income, hence ultimately increasing the size of the endowment. Such forced savings might even be defended as a wise precaution, based on observation of the way Great Britain has made Oxford and Cambridge dependent on government subsidy, and subsequently allowed class warfare antagonisms to degrade the government contributions; these prestigious universities are now much humbled. From the American college president's viewpoint, it might be prudent to put on some fat for the coming winter. Considering merely the economics however, an essentially unlimited ability to divert tuition surpluses reduces the pressure to hold down prices, and may even inhibit incentives to enlarge class size, or to tolerate new institutions. There is thus reason to question whether rising prices will self-correct by expanding supply. The equilibrium of college supply may, or may not, eventually come into balance with nonfinancial reasons for seeking the experience. At the moment however, supply is clearly too small but it is also difficult to envision important restraints on eventual oversupply, except for the nation running out of money. It is a perplexity which to fear more, a construction bubble or an antitrust violation.

America is almost unique in its large proportion of small liberal arts colleges. No doubt, many of them would prefer to remain as they are, but it seems attractive to encourage thirty to fifty of them to become universities. When asked the differences, one college president replied the main difference is the presence of graduate students. Judging from the competitiveness of admission, the demand for graduate students is much closer to supply than at undergraduate levels; some of the tuition distortion may reflect efforts to increase the supply of college teachers. Income prospects after graduation are probably an influence, but since the main occupational opportunity for graduate students is to teach undergraduates, increasing the openings for college graduates in a service economy must also imply increasing the number of people to train them. However, only a minority of university undergraduates go on to become graduate students, so creating fifty universities also rebalances the system at a new level. There are observers who advocate replacing teachers colleges with universities, for various controversial reasons, but that argument leads the conversation into high school education, involving a somewhat different set of issues. It is here worth mentioning that improving the quality of secondary education also enhances the service economy, reducing pressures for enlarged college admission.

Mention of secondary education must be made, however, in order to grapple with the issue of automating education. It must be obvious that one distinguished Shakespearean scholar could replace thousands of lesser teachers of the same subject by issuing video recordings of the distinguished lecturer at work. Face to face interaction is essential at every level of education, but one lecture about Hamlet on DVD could extend the reach of the very best teachers at a cost of a tenth of a cent per student. The extent to which improved lecture quality overbalances reduced face to face interaction is a matter of testing and experience; it probably varies considerably with the situation. Developing experience should concentrate on testing the approach at several levels of education, and adjusting appropriately. The education industry needs to make much more strenuous efforts to reduce its costs through greater adaptation to information technology, if only to improve its ability to teach such adaptations to entrants into other industries. Shortening the school year, wider expansion of the Junior year abroad, and employing graduate students to teach, are debatable methods for reducing the cost of education; but enthusiastic embrace of the computer revolution could improve educational quality before other nations leave us in their dust.

And finally, a caution must be mentioned. Some degree of specialized focus of college courses is inevitable; we cannot develop scientists and engineers without it. But we must not be too quick to eliminate the liberal arts, carelessly calling them a luxury in a busy age. To a probably excessive degree, universities have replaced religions as a place to examine and teach young people how to live and behave. In little more than a generation, universities have determined (long) hair style and (blue jeans) dress style, sexual morals and political belief systems, mostly in a libertarian direction. That is not why we have colleges, or at least not why we must pay a quarter of a million dollars for them. There is another layer of intangible value in a liberal education, perhaps only perceived by personal experience. As I look back on a great many decades, I realize that almost every important step upward in my life was unexpected. Someone came out of the blue and offered it to me. People were watching and judging, themselves unseen. By contrast, almost every advancement that was strived for mightily, perhaps even a little too competitively, was to some degree gratuitously thwarted by others. Unobserved headhunters are watching for many qualities. Spending some extended time learning what our society is all about through liberal education is a technique for self-advancement, too; universities would impair their customers' main chances in life by not imparting it.

http://www.philadelphia-reflections.com/blog/1782.htm

Paying For College - II

Cosmos Club, Washington D.C.

To begin with an anecdote, I belong to a Philadelphia club which reciprocates with the Cosmos Club in Washington DC. It's a handy place to stay overnight on the rather infrequent occasion of visits to Washington on business. It happened I had an early breakfast at the Cosmos, and was the only guest in the dining room. A pleasant well-dressed man came in, and asked if I minded if we sat together. "I'm Bob Goheen. I work at Princeton." Since he was widely known as the President of Princeton University, he was indeed welcome. He could hardly be expected to know my daughter was then a sophomore at his college, so he was of course unprepared for what I had to say.

Empty Pockets

After introductory pleasantries, I told him of my arithmetic problem. My daughter was taking five courses, so the family was paying ten thousand dollars a year, per course. Since most of her courses had over two hundred students in the lecture hall, the University was being paid two million dollars to teach each course. Was it possible I had got the arithmetic wrong? Mr. Goheen neither flushed nor displayed hostility, but his manner did change. Well, of course the tuition pays for far more than direct teaching costs. It's expensive to maintain a first-class library, the University has a responsibility to help the town of Princeton with its problems, the University is proud of its very extensive scholarship program for needy students, there is research to be sponsored. Yes, said I, you have fallen into the trap I prepared for you. My complaint is that if I had donated money for those worthy causes, it would all be tax-deductible; but by having it extracted from me under the name of tuition, I was denied the tax advantage. As expected, he quickly changed the subject. And to his evident relief, I let him do so without resistance.

Since that time, I have had the opportunity to play the same game with several college presidents; not all of them have been suave about it. The only one who took me by complete surprise was the President of Lehigh University, who not only told me he agreed, but added that he had made himself unpopular with his peers by promoting exactly similar ideas. There is a very serious problem, here. Somehow, the higher education industry has got to engage in some statesmanship, because it is only a matter of very short time before someone proposes a government solution.

National Institutes of Health

It is possible to treat this issue as a problem of how to pay for universal college education, which would put it in a category now occupied by health care, and probably reach a political impasse for similar reasons. Or it could be treated as a problem of teasing apart the instructional costs from the research and other scholarly costs. The problem to be solved, viewed from this latter direction, assumes that excellent teaching could occur, isolated from the scholarly activities, in the manner now entirely accepted for secondary and elementary teaching. Conversely, the concept of a research institute with no teaching responsibilities is widely accepted in Europe, for instance, while in America the National Institutes of Health are the most prominent example of its workability. It can be argued that a scholar engaged in research makes a better teacher, it can also be argued that a talent for teaching is not necessarily found in those with talent for research. While it is true that some researchers are productive even in old age, for the most part research is like poetry and sports, a young person's game. A creative scientist can usually look forward to acting as an administrator after reaching a certain age; why not look forward to a career in teaching? There appears to be no serious problem with this suggestion, but a profession comfortable with its present arrangements would probably see no reason for any such contortion, merely to make college education reach universal scale more conveniently. In summary, the question is whether we can afford to put another Harvard in every town of a specified size, or whether we will be forced to transform most existing colleges into enlarged high schools, and build a few more of them. Obviously, the latter is a cheaper method; the question is whether it is a good enough product. Whatever the model to be mass produced, the overall cost would be reduced by stripping out populations who do not need so much education, and getting Google or IBM, or someone similar, to apply massive amounts of information technology to reduce the cost for the rest. In achieving universal health care, by contrast, we can reasonably foresee research reducing most of the delivery costs we now contend with, and even eliminating some of the major diseases. In education for a service economy, the potential of increasing educational need is entirely endless.

Therefore, no matter what pattern we adopt, it must be organized to be in competitive tension with the manpower needs of the economy. If the reason we need a vastly more educated population is to supply better educated graduates to run the economy, a tension must exist between the two or the educational establishment will ruin us with purposeless expansion, just as some elements of the healthcare industry might wish to do with their services, and almost all trial lawyers unashamedly wish for in their area of expertise.

In this area of economic design, lies the answer which President Goheen should have made to me in the Cosmos Club. By asking for massive tax deduction, I was yielding to the idea that education was always a responsibility of government, always paid for by rejiggering the tax code. In that direction lies disaster, since control of the tax code lies in the realm of politics and leads to populist solutions. We must not unbalance power relationships so that economic leaders, asking for a better educated workforce, are not eventually confronted with crippling taxation for the betterment of a bloated academia. A typical college has as many employees as students. We cannot get caught up in an unrestrained process leading to half of the population teaching the other half, except for those who have retired and receive a pension from both activities.

http://www.philadelphia-reflections.com/blog/1785.htm

Starving the Beast of Early Retirement

Inflation-targeting, unless someone is keeping a big secret from us, is the only arrow in the quiver of a nation's central bank, in our case the Federal Reserve. A strong case that the Federal Reserve should acquire no other duties, rests on the fear that any new duty might conflict with holding inflation on target (at present, 2% per year). Inflation targeting rests on Alan Greenspan's simplification of Milton Friedman's "monetary" theory that if you measure the amount of money in circulation, you can combat inflation or deflation by appropriate adjustments of it. Greenspan's further insight was that you needn't measure "monetary aggregates", you just have to measure inflation itself and react like a helmsman with a compass. Until 2008 it looked as though Greenspan had won the argument, by avoiding a deep recession for seventeen years, in the so-called "Great Quieting". Inherent in this helmsman theory is a deeper theory that all episodes of deflation (depression, recession, whatever) are merely over-reactions to inflation; avoid inflation and then forget about deflation. Still further behind this analysis is the observation that all governments at all times are pushing toward inflation, and you can count on that as one of the immutable laws. The blunder of holding interest rates too low in 2001-3, for example, has been blamed as deliberately inflating in order to combat the Dot-Com crash of 2001 for political reasons; by this reasoning, rescue of the DotCom dip led straight to the 2008 Subprime plunge. There is thus reasonable evidence that monetary efforts by the Federal Reserve (adjusting interest rates and the supply of money) is alone powerful enough to control inflation, provided only that the other branches of government abstain from political interference. In the long run, however, the Fed can only smooth out wobbles in the main trajectory. As Rogoff have shown, all crises whether of currency, banking, commodities or securities, are caused by unwise borrowing. Avoiding inflation is thus quite enough to prevent recession, since government pressure to inflate can be surely counted on. Paul Volcker may have proved the issue in another way. During the Carter Administration, the country experienced "stagflation", meaning we had inflation and unemployment at the same time; improving one might make the other worse. But, regarding the whole mess as inflation in disguise, Volcker promptly jacked up interest rates a great deal -- and both inflation and unemployment then seemed to go away. What seems to have been proven is that stagflation is just a variant of inflation and needs to be treated the same way. The same can be said of international currency crises, asset bubbles, bank panics, and securities crashes. That the debtor community always denies this, is the main reason for political parties. When even the creditor community panics and begins to doubt, the result is a much protracted recession.

If inflation targeting is as powerful as that, and as simple as that, what could go wrong? One present worry is that so much American money has fallen into foreign hands that the Federal Reserve could lose control of balance within our borders. There is a second source of danger. Broadly speaking, this concern is that public opinion might demand inflation -- or policies which would surely cause it -- and in a democracy the time might come when the Federal Reserve would have to give people what they demand. You could even observe that James Madison warned us about that two centuries ago.

Government isn't the solution, government is the problem, were words of a California governor. And yet neither Reagan nor the two Bush presidents who followed him made the slightest apology about increasing the federal deficit. It is a Democrat, Governor Corzine of New Jersey, who was thrown to the lions in 2006. We are about to watch one of the most eminent financiers of the country come to the public realization that no accounting trick or delaying strategy is available to help him avoid a public confession of what is wrong, and adopt a correction for that problem rather than an aspirin for its pain. It was pretty subltle of him to place a 4% annual cap on tax increases by local governments; it keeps their tax increases from crowding out the state increases he is planning. You don't get to be chief of the largest investment bank on Wall Street without being fast on your feet, so we were treated to some fancy tap-dancing. The Republicans now have their chance in 2010-2011.

For a number of decades, New Jersey steadily increased the number of state employees and their pension and health benefits. As is so often the case, these state employees and their union became the core voting bloc for the party in power, usually Democrats. Not only are there a remarkable number of employees observable in each of the local offices for the Bureau of Motor Vehicles for example, but New Jersey decided to include the local municipal and school employees (mainly police and school teachers) in the state health and pension system, a decidedly unusual step. These are not trivial costs. As life expectancy gets longer the pensions become more expensive; the health benefits become still more expensive by raising the wages of health workers and by offering more generous home and nursing home care--benefit creep. Just how a ten-mile ambulance ride gets to cost $1700 is a related story, passed over here. And then, a few years ago it seemed like clever bookkeeping to float a bond issue to bring the state pension system up to required full funding. Long term full funding tends to mean a stock portfolio, so buying stocks with the proceeds of a bond issue is the same as buying stock on margin. By a stroke of exceedingly bad timing, the stock market promptly responded to the dot-com boom by crashing, taking the state of New Jersey's margined stocks down even farther, faster. In a sense, not only has the state raised the reimbursement of its workers, it has guaranteed them for life and cannot afford to do so.

New Jersey has always had high real estate taxes, now painfully high. But Jersey residents once could console themselves they had no sales tax and no income tax. Now, NJ sales and income taxes are in the top highest in the country, and just about every other form of state taxation has crept up to unsustainable levels. Doesn't matter, the state is running a $5 billion deficit and will run a greater deficit than that for as long as anyone can predict. Forbidden by the courts to borrow money, it's not easy to see what the Governor can do except raise taxes some more. Well, perhaps there is one thing, if the unions will let him. He can extend the retirement age of state employees from present age 55, to age 75. Having retired at age 81 I have little sympathy, and have even written a long essay praising the joys of late retirement.

But let's see him try to do that without anyone noticing.

http://www.philadelphia-reflections.com/blog/829.htm

Pyramid-Building, Greatly Simplified

Egyptian pyramids were supposed to be built

Everyone who went to Sunday School knows the Egyptian pyramids were supposed to be built by huge numbers of slaves, quarrying stone blocks, transporting them with only crude rollers, and setting them precisely in place under the supervision of slave-drivers with whips. The number of stones has been estimated, a reasonable time estimate made for carving a block, and modern scholars have calculated that every single person in Eqypt must have been either a slave or a slave-driver. In fact, there is a theory among British scholars that such a mobilization of the entire nation could only have been motivated by religious fanaticism, since it's so hard to imagine keeping a nation at work involuntarily in the hot sun for twenty or more years, even with whips.

Michael Barsoum

As recently described to the Right Angle Club by Professor Michael Barsoum of the Ceramics Department of Drexel University, we probably have to revise our views. A "Eureka" moment seems to have first arrived for a French Professor named Joseph Davidovits several years ago, with the thought that perhaps the building blocks of the pyramids may have been cast in place rather than carved. Poured concrete, so to speak, rather than carved out of a quarry and pushed over the desert in some fashion and hauled up into place. Since the blocks seem precisely chiseled to fit together exactly, it has always been hard to imagine how this was done, when the Eqyptians were thought to have no iron tools, only pure copper as a metal ingredient, not even bronze.

Khufu pyramid

The insight was brilliant, although the evidence for it was weak, and it has been pretty easy to pick holes in the proposal. Poured concrete is much easier to reconcile with the remarkable leveling of the stone blocks, where the bottom level of the Khufu pyramid is the size of eight football fields but only varies from true level by one inch overall. Exploratory cuts into the sides of the pyramids reveal the component stones to vary enormously in size and shape in the interior, although the exterior surface is quite smooth. Similarly, the lateral sides of the pyramids vary from true north by only 1/15 of a degree, a remarkable achievement for stone cutting with primitive tools. Broad Street in Philadelphia supposedly runs North and South, for example, but it deviates from true north by six degrees. The pyramid builders, like the architects of ancient Beijing, must have used the Pole Star for orientation, rather than a magnetic compass.

Carved or Cast

While Davidovits got this line of thinking started, Michael Barsoum has considerably advanced the proof of idea by addressing a large number of nitty-gritty questions about just how all this might have been accomplished. For example, the science of ceramics shifted the idea from the Portland Cement model to a recognition that the calcium in the cement came probably from diatomaceous earth, which is to say the crushed skeletons of diatoms on the ocean floor. Microscopic examination of the cement reveals large numbers of intact diatoms, with the cement layer surrounding the limestone aggregates. Furthermore, analysis of the stones shows that the outer shell of the pyramid was cast concrete, but the interior main mass was composed of stone rubble of various sizes and shapes. The apex of the pyramid was pure casting, probably because of the difficulty of fitting exterior and interior stones at the point. So, the Drexel team carried Davidiovits' idea from a general concept to a practical description of how the construction was probably accomplished. Carbon dating was attempted, but this technique stops being accurate for such remote time periods.

To nail down the idea that Philadelphia really explained how to build pyramids, funds are being collected for the construction of a 27 foot model pyramid in Logan Square. Let's hope the community gets behind this effort, which is both scholarly and entertaining, with an element of international competition mixed in. After all, Philadelphia is still smarting from the erection of the Eiffel Tower, six feet higher than Philadelphia City Hall, as the tallest structure in the world at that time. Let's be clear about it: the Eiffel Tower was the tallest structure in the world, while our City Hall remained the tallest building.

http://www.philadelphia-reflections.com/blog/1741.htm

Financing a Research University

Harvard

Fifty years ago, only three American universities, Harvard, Yale and Princeton, were considered world-class. The benchmarks for them were Oxford and Cambridge Universities; both British universities had long history and great prestige. Making allowance for wartime disruption, it was also considered pretty classy to study at the Sorbonne, or Humboldt University in Berlin. Sweden, Vienna, Rome were right up there in prestige.

Oxford

By 2004, a London magazine was offering its view there were thirty American Universities better than anything in the European Community, in particular Oxford and Cambridge. We'll pass over the Economist's anguished analysis of what's wrong in old Europe, and focus here on what American universities are doing right. They certainly do seem to be doing something right, but nevertheless it's still possible to be uneasy about where they are going.

Cambridge

For example, the top three all have more than ten billion dollars apiece in their endowment funds, and thus each perpetually generates roughly half a billion annually in disposable income from passive sources. You can accomplish a lot of worthwhile academic things with that much money. Operating revenue like student tuition, fees, research grants and royalties should support normal running expenses, so endowment income is available for new frontiers of learning, research, and social endeavor. These well-run institutions unquestionably do accomplish many innovative and important advances, to the point where it is simply trivial to point out a few areas of waste or misjudgment. Multiplying their annual discretionary funds by thirty offers an overwhelming force for good in the nation, and in the world.

British

The other twenty-seven premier research universities may not all have ten billion dollars apiece, but they have the Avis, or we-try-harder motivation that may make up for it. The nation really does appreciate their worth. Applications for admission outnumber available places twenty to one, would be even greater if more people thought they had a chance to get in. Outstanding professors are in scant supply, commanding higher and higher salaries. In fact, a patient of mine who is a trust and estate lawyer tells me he gets a little uneasy about the growing number of university professors he sees with million dollar estates. A calm view would be that the nation recognizes the value of superior education, and is forcing the pace for a greater supply of it. Unless our economy experiences a disastrous decline, it is reasonable to expect a hundred universities to migrate up the quality chain in the next generation; most of those eligible for it are grimly determined to see it happen. China can make all the widgets it pleases, but that won't make them catch up with this champion competitor. The French can maybe make better wine, but unless they pep up their schools, they're going to have no shot at glory.

Whew. That's intentionally laying it on thick, because American academic triumphalism has a darker side to give one pause. In the first place, the arrogance of it shows. Even the European aristocrats, formerly world experts in flaunted put-downs, are irritated; and red America is really sore at blue America. Sprinkling a few research universities into Arkansas and Idaho might relieve regional divisiveness somewhat, but lasting social peace can only derive from starting in the third grade of, say, north Philadelphia, Kensington and Norristown . In economic downturns, the country would have big trouble financing universal, bottom up, academic excellence. The tragedy is that money isn't the main problem in the science classes of the thirty research universities we already have; an alarming number of those seats are filled with foreign born students, not even to mention the honors students.

Secondly, the system is already under strain. The families of students are hard pressed by tuitions of twenty or thirty thousand dollars a year, and increasingly ready to complain about the inability, of classes of three hundred taught by non-tenured teachers, to justify to them such breath-taking fees. They may not understand educational financing, but they can count, and then multiply two numbers together. Faculty rewards favor research, not teaching, and teaching is what the students think they are paying for, their parents think they are sacrificing for. If what they are truly paying for are just credentials, they worry that affirmative action will cheapen the credentials. One clear sign of unease is the tendency of children from wealthy families to walk about the campus in torn overalls. This may be more than just a fad, it may be a sign they hope to hide from the university's system of redistributive taxation. Some people pay those high tuitions, but mostly tuitions are discounted for the eager family's ability to pay. Wearing blue jeans won't help, the universities demand to see the family's audited tax returns. In my presence, a university president remarked that the system was designed to extract the last dime from every student. The whole middle class is being asked to give until it hurts, for the unspoken goal of elevating a hundred more research universities to world class. Very few question the premise that unmatchable universities are the key to American world eminence. Quite a few, however, have anxiety that it may not work out for each individual. It may only be a lottery with slightly better odds.

Now, let's get to the research part of the research university. In the past ten years, American universities have collectively received six or seven billion in commercial patent royalties; the aggregate now runs appreciably more than a billion dollars a year and it's growing.

The normal arrangement is to give 20% of royalty income to the professor whose name is on the patent. Since most research is performed by large teams, it is possible to imagine considerable inequity and academic bad feeling in this system. In other walks of life, striving for a bigger share of two hundred million a year would cause differences of opinion about fairness. Here and there, you read articles by participants in this system who are concerned over the message it is sending to the students about personal values. Universities that began with a mission to educate the clergy are now seemingly overpraising the big payoffs.

Many business analysts feel that a successful corporation needs to spend 10% of its revenues on research and development. Behind that is realization that prices and profit margins are largest for new inventions, steadily declining as the new invention attracts competition and eventually becomes a mere commodity. The scientific term entropy is a perfect description of the way world economies seemingly work, like clocks gradually winding down. So businessmen get rid of old products and look for new ones, and the universities are the source of most new ideas and products. Put every last cent into R & D for new products, while the developing countries grind out widgets. If we eventually graduate hundreds of thousands of Americans regularly from unmatchably excellent research universities, the outcome will take care of itself. Even flying airplanes into our tall buildings can't make much difference in this academic arms race. It's essentially how Ronald Reagan defeated the Soviet Union, and it's discouragingly difficult to argue it is totally wrong.

However, you can imagine ways that it might all fall apart. The source of at least half the capital now pouring into the research universities comes from the federal government, particularly the National Institutes of Health, the National Science Foundation and the Department of Defense. It only takes fifty-one votes in the U.S. Senate to change that suddenly, for reasons of national defense, to defend the value of the dollar, to combat inflation, or lots of other reasons. Even now, universities often face annual crises at the end of a funding cycle, when projects have been awarded, people hired, but funding is delayed for uncertain periods of time because of distant political wrangles within the budget process.

That's known as a cash flow problem, and even it is trivial compared with what would happen if federal research funding were delayed a full year. Just look at any university and see all the big tall buildings. They have largely been built to house research activity, and the university would have big difficulty selling them if they were empty. They've usually been paid for with mortgages, and it costs a lot of money to heat, air condition, clean and repair them. Just cut off the cash flow long enough, and you will see how risky it was to get into the research arms race.

http://www.philadelphia-reflections.com/blog/470.htm

New Museum of Chemical Heritage

Eighty percent of the ethical drug industry is located within a hundred miles of Philadelphia, and the whole chemical industry has had its center here for two centuries. The chemical industry is the region's largest manufacturer, now that locomotives and beer brewing have come and gone, but its profile remains low. In fact, chemists personally have a low profile too, and harbor a smoldering annoyance about it. No one has been more determined to change that nerdy image than Arnold Thackray, the recently retired President of the Chemical Heritage Foundation. He's not only a big idea man, but bubbles with energy and persuasiveness. That largely accounts for the fact that CHF has the second largest endowment among public institutions in Philadelphia, the best library of chemical history in the world, and a growing reputation for fine art concentrated in the field. That's not enough for him, so it came about that a new museum was envisioned, funded and created. But not built; building it was assigned to Miriam Schaefer, a famous go-getter who had the unusual qualification of being squeamish about chemistry. It was her assigned task to find a way to make chemistry exciting to people who were not instinctively excited by it, just exactly because she was the world's authority on that point of view. What was vital was that she was the sort of person who can't resist a challenge, and was capable of thinking, well, big.

With the unlimited backing of Arnold and his board, and their almost unlimited financial support, Miriam set about soliciting big ideas from uninhibited people all over the world, and some of their suggestions were even a little too wild to be acceptable. But since the whole idea was to awaken the enthusiasm of anybody, however sullen, who happens to shuffle through the museum, many outlandish suggestions were forced through the filter of a skeptical, conservative, Philadelphia establishment. The result is a series of pleasant surprises, ranging from fine art with a focus on alchemists trying to make gold out of lead, to astonishing computerized graphic displays of the elements of the periodic table fifty feet high, to depictions of Joseph Priestly known as the father of chemistry, a personal friend of Benjamin Franklin, the founder of the Unitarian Church, and a resident of Philadelphia. There's Arnold Beckman's original Beckman spectrophotometer which made hundreds of millions of dollars, was a major factor in the Twentieth century blossoming of biochemistry, and is here shown to be a clever elaboration of a simple idea. Meanwhile, the museum is housed in a massive old bank building, with its interior reamed out and replaced with as much transparent glass as could support the weight. Inga Safron the architectural critic, more than foamed over with praise in her review of just the structure itself. Don't neglect to notice the stunning portrait of Gay-Lussac, the man who discovered that water is H2O. The pigments of his portrait were mixed with bees wax, and with clever lighting have an astonishing luminosity.

The museum is part of an emerging conference center, which should attract audiences of chemists for decades. But that's not entirely the whole idea. The underlying vision is to convince those skeptical, non-chemical bozos that not only are chemists rather richer than the rest of us, and smarter, but clever and fascinating, too. Go visit this museum, before everyone else does.

http://www.philadelphia-reflections.com/blog/1523.htm

Please Don't Lose Any Sleep Over This

Dr. Charles Czeisler

The Institute for Experimental Psychiatry Research Foundation meets alternatively in Boston and Philadelphia, in recognition of its rather complicated historical relationship with Harvard and Penn. The Spring 2005 trustees meeting was held in Boston, with Dr. Charles Czeisler of the Brigham and Women's Hospital making a presentation of his work with sleepy resident physicians. Sleep is now a central focus of the work of the Institute, particularly the effect of lack of sleep on performance. Resident physicians are a group with lots of experience with sleep loss, so much that such experiences as residents are a central imprinting in the lifelong brotherhood of the profession. The public tends to regard the torment of protracted craving for sleep as some kind of dangerous hazing inflicted on professional newcomers by sophomoric seniors. Every once in a while, someone gets hurt by these games. That seems to be general public reaction. For the most part, by contrast, members of the profession who have themselves undergone the experience turn away silently from such unfeeling remarks. As the old contraceptive joke about the Pope has it, if you don't play the game, don't make the rules.

In the first place, it is wrong to suggest that resident physicians are somehow helpless victims of authority, abused slaves of somebody's profit motive, or warped masochists enduring the process in order to inflict it on someone else. Perhaps the example of my classmate Seibert is useful. As a freshman medical student, Seibert was so overwhelmed by the volume of facts he was expected to learn, that he decided to give up sleep entirely. Seibert, by the way, was no moron; he was an honors graduate of a very selective Ivy League university. And he actually did stop sleeping for more than two weeks until he collapsed and had to be stopped. This was his own choice, gamely adopted in spite of general ridicule. And to show that over achieving is not limited to physicians, there was my oriental patient, the daughter of the President of her country. She related that as a graduate student she did not go to bed for three years; during all that time, she sat at her desk, slapping her face to keep awake. What we are talking about here is a self-selected group of committed and dedicated people, perhaps overly shamed by the specter of failure.

The work of our Institute has helped document and understand the injurious effect of sleep loss on performance; no one can go very long without sleep before responses and vigilance begin to deteriorate. A great many vehicle accidents are caused by drowsy drivers; it is a concern that pilots of airplanes on long distance flights are to some provable degree less competent to land the plane. Therefore, it is not completely surprising to find that interns on protracted duty do make 20% more errors in medication orders, and nearly 50% more diagnostic errors. It is jarring to discover a measurable increase in the number of intern auto accidents, particularly when driving home from work. Maybe we ought to pass a law about it.

Commiseration is one thing; proposals to interfere are quite another. For one thing, the time-honored protection against the harm of this problem is redundancy. The complex, fast-paced and dangerous environment of a hospital, like that of an airline cockpit , has very little tolerance for lack of vigilance. Our solution has been to do everything three times, with overlapping responsibilities and repeated opportunity for catching errors before they get through to the patient. Although the malpractice lawyer seeks to pin the whole blame on some person, particularly one who is covered by insurance, the reaction of doctors to adverse events is to presume that at least three people must have cooperated in letting it slip through. At night and on weekends, the reduced staff tends to weaken the defensive network . But by every assessment, the greatest threat to our protective screen of redundancy is cost control. Any manager of managed care can find duplication and overlap in ten minutes of searching for it in a hospital; redundancy is a big factor in the high cost of running a hospital. The law of decreasing returns will dictate that it becomes very expensive to eliminate the last one percent of errors. To state it in reverse: it is very tempting to save a bundle of money in a competitive world, by accepting only a small increase in the errors. Since it is a matter of opinion, physicians are grimly determined that it shall be physicians who strike that balance. Those who press for more punitive treatment of physicians in the matter of errors should reflect that it surely will convince physicians to flee the risk of responsibility for the decision of where to strike the balance.

If you bend metal repeatedly it will crack; if you stretch a rope too hard it will snap. These unfortunate events are not called errors, and it is improper to search for blame in them. The medical profession is aghast that the public does not seem to appreciate that average life expectancy has increased by thirty years in the past century. That's not ancient history; life expectancy has increased by thee years in the past ten. A system that produces a result like that is entitled to a certain amount of tolerance for its errors, if we must call them errors. In other environments, that's known as pushing the envelope. Anyone who thinks it's fun to stand on your feet for thirty-six consecutive hours -- hasn't tried it.

Surgeons are perhaps somewhat more conscious of the need to train young professionals to drive themselves beyond ordinary endurance. After all, if an operation is unexpectedly prolonged, the surgeon can't just quit, he must finish. Neurosurgeons, with their fourteen hour procedures, are particularly vehement on the topic. But it is true of every physician, too. When the telephone rings in the middle of the night, will this young fellow haul himself out of bed, or will he tell the patient to take an aspirin and call again in the morning? Increasingly, we hear complaints from patients that other doctors didn't even take the trouble to examine them; the implication that we are somehow not like that is very flattering. Part of the training is forbearance, too. At three in the morning, it is very easy to feel sorry for yourself, and to reflect that an administrator with four times your income is home in his nice warm bed. The fact is, that if the person who is up and on his feet doesn't do the job, no one will.

Cadwalader

Some incomprehension from bystanders must simply be endured with patience. Beyond that, it could be futile to seek complete understanding. Quite recently, I was explaining to a young lady in a tailored suit who Thomas Cadwalader was. His portrait, beneath which we were standing, hangs in the great hall of the Pennsylvania Hospital. Although he died in 1789, Dr. Cadwalader is still famous for his remarkable, unfailing courtesy. A sailor in a tavern on Eighth Street once waved a gun and announced to the crowd he was going out the swinging doors to shoot the first man he met. The first man happened to be Dr. Cadwalader, who tipped his hat and said, "Good morning, sir." So, the sailor shot the second man he met.

The young lady in the tailored suit brightened up. "The moral of that story, " she said, "Is always wear a hat."

http://www.philadelphia-reflections.com/blog/750.htm

School Tax Seldom Equates to School Spending

Little Red Schoolhouse

As this blog went to press, voters throughout South Jersey had just gone to the polls to vote for school boards and school budgets. Or, at least they had the opportunity to do so, but mostly 15% of eligible voters actually troubled to vote. Meanwhile, school officials chewed their nails in apprehension that many budgets would be disapproved by the taxpayers, and then what? As it turned out, Haddonfield and Moorestown approved their budgets, but over half of the 700 school districts of the state did not. The voters wanted to send a message they were angry about property taxes, and the seemingly related fact that over half of school employees are not teachers. Some of them mistakenly believe county taxes have something to do with schools. If they had really understood the situation, they would have been angry that the size of their local school budget has comparatively little to do with the level of their total tax burden.

Meanwhile, voters with children had been agitating to support the budget or even raise it, even if it raised their taxes; but empty nesters were urging each other to go vote down this budget because their taxes were already excessive. The parents of schoolchildren urged the empty nesters to move somewhere else where they couldn't vote down school budgets. Actually however, if more empty nesters moved in, property taxes would go down without affecting the school budget, because empty-nesters pay taxes without using the schools. Both groups are quite misguided, however, because raising or lowering school budgets would probably have very little effect on overall taxes. Even school officials failed to make their best case to the public, because they misunderstood the tricky way taxes are arranged. They defend every budget by saying it is already cut to the bone. Since it presently makes relatively little difference to overall taxes whether the budget is cut or increased, that's not useful in persuading empty nesters. Budget cutting does make a lot of difference to the quality of education, however, but that's only half of the facts, not a balanced one. The moral of all this is that the voters better get educated about the Jersey political scene, before their children lose the chance to get educated at all.

Since I'm an empty nester, I am pretty familiar with the empty-nest viewpoint. Three of my friends have told me they moved to neighboring suburbs in order to lower their tax burden; they undoubtedly know what they are talking about. But no one I know is able to reconcile that fact with the equally certain fact that Haddonfield has the lowest spending on education, per pupil, in the southern half of the state. In fact they don't care, because they know that local school taxes are significantly lower almost everywhere else, and they don't have to explain why. School officials should be more concerned with explaining their rank in per-pupil spending compared with other districts, but they are driven to make cuts in service where ever they can in order to produce a leaner budget for the voters. They too, seem oblivious to the fact that voter anger won't be soothed for long by their budget cutting, because it won't affect overall taxes. Taxes are what people are mad about, but they must consider all of them, and understand that as one goes down, the other will probably go up. In an another article, we discuss how they mysteriously go up even more. A more sophisticated view would be that in addition to concern about eradicating poverty in the long run, residents of New Jersey are increasingly driven by the need to get their children into the better quality colleges. They would like to improve secondary education to do so, but are hampered by the relative unavailability of high-quality colleges in the state. Some of this has to do with the recent tendency of Princeton and Rutgers to seek a geographical diversity of students. But to be cynical about it, the development officers of those colleges know that major donors are to be found in Texas and California. In New Jersey the majority of income taxes are paid by 1% of the population, and that !% are fleeing the state to avoid its heavy income and estate taxes, just as fast as they can. This is the group that tends to donate most heavily to college improvements, and New Jersey colleges are suffering from their flight. That argument may well be hard to sell in Newark and Camden, but it has a major indirect effect on business creation and employment in the state as a whole.

To return to basics, New Jersey school spending is governed by the Abbott decision, which happens to have been written by a friend of mine, who is a fine, smart, well-intentioned jurist. So-called Abbott districts were found by the courts to have significantly underfunded schools, to the point where it seemed an important public issue that the wealthier parts of the state must help these underprivileged kids get an adequate education. Whether improving the school system in their districts would reduce the crime rate, or welfare rate, among these children in later life was not then known, but subsequent experience does not give it much support. Mainly, it wasn't so much trying to reduce public expenditures in the long run that was behind the Abbott decision, as the feeling it was the duty of a prosperous society to give deprived kids an even break, a sort of penance for success. Accordingly, state school tax revenues were rearranged in an effort to make the per-pupil spending for education approximately equal in all districts, and particularly in the most deprived areas, the Abbott Districts. The first clear sign that something unintended was happening is shown in the accompanying table, indicating that spending in the Abbott districts was in fact now about fifty percent greater than in prosperous nearby suburbs. Equality might be all right, but fifty percent greater was probably not acceptable to the tax paying public. Just how that paradox gets accomplished in Trenton is not yet clear, but the discomfort level about it is heightened by noticing there is generally an inverse relationship between the spending per-pupil and the perceived quality of the educational product. You might compare drop-out rates, crime rates, SAT scores or whatever, but public perception is not likely to overcome data seeming to show that the more you spend, the worse the education. One wag commented that the data also seems to show that the further you get from the Delaware River, the lower the educational spending gets; that relationship is also more or less linear. So, what matters here is opinion, and the prevailing opinion is emphatic that this data is upside down. The Abbott decision that school spending must be equalized but is actually greater accounts for much of this funny data, but in addition there almost has to be some overlooked secondary factor which exaggerates the Abbott effect by as much as 50% beyond equality.

Even the education industry has an incentive to explain at least and possibly to correct, this disparity. Because in politics while you can prove almost anything with statistics, it is quite seductive to imply that this data proves that extra educational spending hurts the quality of education, at least above a certain level. The education industry wouldn't be wise to let that sort of accusation go unanswered, even if it comes as a wisecrack. The real empty-nester accusation, sorry to say, is that "My school taxes are way too high. They not only do me no personal good, but are not helping underprivileged children, either." The consequence is empty-nesters are driven out of town and out of state, making taxes higher for everyone else. It could take decades to undo this damage with an angered public, so everybody better get to work explaining and correcting the problem.

http://www.philadelphia-reflections.com/blog/1805.htm

The Supreme Court Gets Fed Up With Professors

Supreme Court

In March 2006, the Supreme Court, like a sleeping alligator, suddenly clamped its jaws on the Ivy League. Unanimously and without elaborate explanation, the Court told Universities that they could not block the U.S. Armed Forces from recruiting on their campuses. A number of Ivy League Universities, in this case the Yale Law School, had turned away Army recruiters because the Professors were offended by the Army's "don't ask, don't tell" policy on homosexual soldiers. The Supreme Court didn't even consider the reasons for the Universities' policies, although private opinions of the Court conservatives can be readily imagined. The Court would not even dignify the matter with the thunderous phrases about first principles which must have seemed tempting. The Chief Justice signed the order, the Court unanimously agreed, and that's as final as you are going to get.

Lawrence Summers

About a month earlier, things seemed to be going the other way. The Harvard Faculty forced out their president, Lawrence Summers, because he violated their idea of politically correct speech. Quite significantly, two thirds of the students took the side of Summers in the dispute, a warning that the faculty were getting themselves into an isolated position. And if you look back to the way the nation divided when it twice elected the younger George Bush, support for East Coast urban elitism was likely coming to the end of a fifty-year dominance in American life. Not to put too fine a point on it, the country was getting tired of the bitter-end Vietnam War protesters, now entrenched in academic strongholds like Robert the Bruce. It may well be that the country was irked by expensive gasoline, French disloyalty, and Middle East intransigence, while the Legal profession was having a private quarrel. Clever of the Chief Justice to allow people to think what they pleased. The Constitution directs the Armed Forces to defend us; interfering with recruitment is at best impertinent, at worst imperils the nation.

The Supreme Courts of the various states, and the U.S. Supreme Court within the federal court system, retain the power of administration of all the courts which report to them, but they rarely exercise that power actively. As the number of judges has increased significantly in the past thirty years, public oversight of the selection or election of judges has been stretched to the vanishing point. The result has been a strengthening of political control over the courts, a lessening of the quality of the judges themselves, and a growth of the influence of law schools. The same parade of professors keep appearing as friends of the court, the metropolitan newspapers can always count on them for Op-Ed pieces on difficult topics. Their opinions begin to surface as their graduates start to enter law practice. Slowly and relentlessly, the viewpoints of faculty members of the five prestige law schools have come to challenge, and sometimes to upend, the rigidly organized opinions, right or wrong, of judge-made law. When it reaches the point where law schools can blithely block the ability of the armed forces to defend the country from foreign attack, it is past time to do something about it.

Some things never change. But this is going to change, and soon.

http://www.philadelphia-reflections.com/blog/833.htm

Sorting Out Future Winners -- Some Suggestions

It's getting to be time for the country to tell the education industry what is expected of it.

Dr. Fisher

Secondary schools strive to be known for their well-rounded excellence. That's pretty hard to measure, so the prevailing in-a-nutshell scoring system is placement of graduates into highly selective colleges. Secondary school reputation is thus a creature of college admission officers, who mostly rely upon aptitude test scores. To cut all this down to size, what's measured is inborn aptitude of the students more than the quality of teaching. Maybe it's time we acknowledged that, and acted upon it more openly.

One approach would be to give each one of a very large group of college admission officers sole authority to admit a small number of students, and then to make the careers of the admission officers depend on the longitudinal outcome. If the students flunk out of college, you better get a new college admission officer. If a majority are admitted to high prestige graduate schools, however, consider a promotion for the admission officer. If a graduate wins a Nobel prize, the immediate question should be, "Whose admission was this?" Ultimately, there would be another question, "Who's picking these admission officers?"

A second approach would be to devise more dynamic relationships between the SAT testing system, and its long-term results. Good scores on multiple-choice questions may closely predict later success -- as a computer designer or dermatologist. But important leadership professions like politics, business and the military are skeptical that "braininess" is the most important asset for their careers. People in those walks of life regard the aptitude tests as a nuisance, designed mostly to simplify the task of overburdened admission officers. College admission officers, in short, are under suspicion of promoting themselves into a new elite. After fifty years of experience with their tools, it is time their outcomes were evaluated by the public they serve.

Still a third approach, arises out of growing discomfort with recent advances in molecular genetics. After all, if Darwin's theory of evolution is essentially accepted, it brings us close to the old positions of Calvinism. God must surely hate poor people, or he wouldn't have made them poor; or, He must surely love rich people if he made them rich. If Chinese people have 10% higher IQ than Caucasian Americans, you can safely predict what will happen in fifty years if we encourage immigration, or in a hundred years if we don't. But this is too general; let's look at more specific aptitudes.

When remarkable musical talent makes its appearance at the age of three, and follows a noticeable family clustering, there can be little doubt of its genetic source. The Curtis School of Music has long attracted a student body of child prodigies, and the long term results seem to demonstrate lifelong musical excellence is what emerges. A fair amount of artistic temperament also emerges, but its genetic origin is less clear. It's hard to escape the conclusion that inheritance of a small number of genes is responsible for unusual musical ability, and that a blood test for this condition will probably soon be offered us. Whether intermarriage is a good thing or not, throwing these children together in a special school is practically certain to result in intermarriage, with consequent inbreeding of the Arabian racehorse variety. If we decide we want this to happen, we can establish more schools for the musically gifted. But if what else the system produces turns out to resemble side-show freaks, then the matter is less tolerable.

And likewise for the athletes, perhaps subdivided by sport. Football tackles and eighty-pound gymnasts may well be different genetic groups. Speed reading and speed talking seem to run in families. And then, there's an interesting observation about artists and literary figures.

In the past, it has been observed that fine art tends to be produced by the children of the artisan class, while literary celebs are more often the product of professional families. Professionals do tend to live in certain suburbs, artisans in different suburbs; selective intermarriage seems inevitable. Special schools for the artistically talented might be selectively placed in artisan neighborhoods, literary schools in professional districts, mathematics in areas with many engineers. The virtuous circle would soon emerge, as talented people sought these school districts out. It's rather probable that most of the prodigies selected by such eugenic scheming would fail to meet the standard of being well-rounded. Surely there are ways to test this sociology and determine whether we want more Arabian racehorses or whether we don't. Rich men marry beautiful women, and their children therefore tend to be handsome. Few people would challenge the accuracy of the observation. Nobody knows whether it is a good thing. Political correctness is a hindrance to finding out some things of immediate importance.

http://www.philadelphia-reflections.com/blog/850.htm

No Laborer Left Behind

Ivy League

The top thirty American colleges have ten times the applicants they have room for. Demand vastly exceeds supply, prices are essentially fixed; shortages result. Can-do is the American way, so our first reaction is to build a lot more colleges and beat them over the head if they aren't first-rate. To bring this down to a local scale, implications are that Philadelphia has a moral duty to build eighteen more Ivy-League universities.

Cosa Ricians Roofers

Let's think about that, in a back-of-the envelope way. Since the rest of the country is going to be similarly driven, we can't attract Americans to run those universities. Philadelphians who are doing other things must staff those universities; people inclined to become professionals of a different sort are going to have to be trained to be university professors. Students now being rejected will be admitted, since that's the purpose of the thing. Unless we somehow increase academic productivity, every man, woman and child from Trenton to Wilmington is going to be in a college classroom in some capacity or other. We here confront the extrapolation fallacy; a new problem must be addressed in more productive ways than just more of the same.

Curiously, the readjustments to this overall shift from an industrial to a service economy are first making their appearance in things like roof repairs and ironing shirts. When my house needed a new roof, I found I had a choice of workgangs composed of Costa Rican, Puerto Rican, or Polish roofers. The Costa Ricans made the best bid, and went to work immediately. They started pounding on my roof at 6 AM, and were still pounding after I went to bed at night; I have grave doubts that American roofers would approach that work standard. I am told that the entire building industry, on which our current prosperity rests, would collapse if we banned illegal immigration. In a different industry, Philadelphia's convention hall cannot attract visitors unless we build more hotels. But the hotel industry cannot find nearly enough people who speak English to make the beds. For one purpose or another, we have imported 12 million illegal immigrants who mostly remain invisible because they are so hard at work.

We are going too recklessly fast with what is fundamentally a useful transformation of our society. Americans want to go to college because statistics show that will make them prosper. But that's only half of their transformation. The other half is a resulting shortage of labor in the jobs which do not require college. Normally, you would expect wages to rise, but they are suppressed -- deflated -- by substituting immigrant labor, legal and illegal. Impose an effective barrier to immigrants, and you would quickly see inflation like you wouldn't believe. Combat inflation by raising interest rates, and the housing market would quickly collapse. That would prove to be a painful way to make the immigrants decide to go back home, although it would be effective. And so on, and so on, and so on.

Slow down, America. You're going in the right direction, but exceeding the speed limit.

http://www.philadelphia-reflections.com/blog/1251.htm

Future Directions for Colleges

Nicholas Murray Butler

As Columbia University's president for forty-two years, Nicholas Murray Butler officiated at many graduation exercises in front of Columbia's Low Library. In later years, it became a prevailing joke among snickering undergraduates that he would inevitably make reference in his commencement address to the Library behind him, repeating his firm opinion that "A University is a collection of books".

Columbia University

There are other opinions about what universities are, but Butler's famous oration that its library is the heart and soul of any university, is certainly defensible. It's thus plausible for what is happening to libraries to be the text here for what is currently happening to colleges. Librarians following best practices of their profession are engaged in a massive exercise in book-trading with each other, rather like the frenzied teen-age trading of postage stamps and baseball cards. Those books they have but don't much use, are traded off in return for books needed to complete a distinguished collection in whatever topic has been designated their "core mission". With efficient trading, a physical concentration of a thousand books on one topic is more valuable than the same thousand books scattered around the world, and far more valuable than a thousand-book assortment of mixed messages collected in one place, which is how each library begins. Thus, having collected a higher assessment value, and a "distinguished collection" reputation, they are ready to face the threats to librarian existence from the Internet. For convenience if for no better reason, scholars in any particular topic start to congregate at a college which has a complete collection of books in their area of interest. In itself, this congregation of like-minded becomes a further attraction to other scholars. Ultimately, with a strong faculty in a particular topic, students with an interest in a career along such lines are attracted to specific colleges, and become eligible to become graduate students and eventually teachers. Hidden in here somewhere is a means to advance many careers, and let's face it, to enhance faculty salaries. But it's sort of harmless, designed for the good of educational attainment and the intellectual enrichment of the nation.

Since about a quarter of a million students are constantly attending college in the general region of Philadelphia, several hundred institutions around here are continuously sorting themselves out in a gigantic archipelago of college libraries, each linked to variable football success and endowment size, specialized interests, and levels of talent. By the monograms on their sweatshirts, ye shall know them.

It surely goes too far to blame all this on Nick Butler, or a national conspiracy of librarians. We are engaged in a massive national effort to expand the excellence of our colleges and universities, to meet the transformation of our society from the industrial to the information society, and to maintain our leadership among developed nations. Fifty years ago, the Economist tells us, only three American universities could compete with Oxford and Cambridge; nowadays, at least thirty are better than anything in Europe. Judging from the present vicious scramble for admission to prestige colleges, the market could immediately absorb fifty more premier, highly selective, world-beating universities. So, say a thousand college presidents, why not us?

In my opinion, you can see here a main underlying justification for college tuitions of fifty thousand dollars a year, per student. The individual parents say they can't afford such tuitions, and so the nation as a whole may possibly not be able to afford them, either. So far, at least, no one questions that an informal Marshall Plan for colleges is a good thing. Whenever you see a situation universally accepted like that, look out. What everybody knows, is often not worth knowing.

Among other things, American education is also headed for the specialization trap. It's rapidly becoming apparent that employers undervalue a liberal education in the people they hire; it won't take those eager beavers long to figure that out when they apply to college. Here's a tip, kids: a chemical engineer can expect to make a much larger income than a chemist. The Human Resources employees of Walmart and Microsoft were not elected to shape the future of graduate education, but that's who is going to do it if we follow present trends. If it's too strong to heap blame on industry's front men, take a look at the leaders of industry; it's rather easy to assess the academic credentials of, say, the board of directors of any local country club for their ability to shape academic policies. Whoever is making educational policy, let's restrain the growing dominance of pre-employment training in our national goals for a liberal education. Maybe it wasn't so bad when clergymen were in charge of colleges.

Other internal trends collide with external vocational pressure on colleges. The committee chosen to select the concentration areas for a college library soon notice that it is easier to become notable for a rare and obscure subject than an important recognized one. Will that lead to a desirable outcome? Everyone has a dozen editions of Shakespeare, and you can be very certain that Oxford, Cambridge, Harvard and Yale all have distinguished collections of Elizabethan literature, associated with famous scholars. Why in the world would a small struggling college try to collect Shakespeare books, or Shakespeare experts? Furthermore, it is probably possible to buy a tape recording of the most distinguished Shakespeare scholar in the world, giving a breath-taking lecture on the second Act in Hamlet. Could the new Assistant Professor of Literature in a small college compete with that tape recording? On the other hand, should our most struggling colleges specialize in minor obscurities?

In fact, anything the small college teacher could say would seem shabby by comparison with the world-acknowledged master of the subject, holding forth with the lecture that made him famous. And so, one wonders, whether the current fashion to sneer at the Canon of books, written by "dead, old, white men" is not a way of avoiding comparison with performances that have survived much hotter competition. If you carry this a little further, you can see a pressure to avoid offering courses in subject areas which centuries of serious consideration have designated to be the best that civilization offers. The top of the cultural heap has risen to the top because many generations have found what deserves to be there; one would normally suppose those topics, those authors, would be the ones you would want to study if you yourself aspire to be considered an educated person. But if present trends continue very much further, you may find that colleges which have decided to specialize in minutiae are in addition avoiding exposure of the students to what our culture considers to be the best. This is one of those things where a little is probably pretty good, but too much of it is destructive. A well financed, highly talented college applicant can go to a place where the best of our educational product is presented in an outstanding way. Less competitive student applicants may be faced with a choice between bizarre topics, taught very well, or outstanding subjects, taught rather poorly. Or, perhaps worst of all, forced to drop down to a lower rung of the academic ladder, where teaching aspirations are low in every topic, so only Shakespeare, Dante, Plato, Dickens and the like can overcome deficiencies in the way they are taught.

A quick look at the other end of the spectrum gives the same thought a different twist. The universities which can afford to be insanely selective of their entering student class, can also afford to ignore them. Intensely motivated, supremely talented kids, will surely succeed no matter how poorly their courses are taught. They will work hard, mainly to compete with their classmates, who are just as competitive as they are. In fact, it is surely already true that the peer pressure from their classmates has a stronger direct influence on their achievements than the faculty does. Perhaps the faculty has a strong influence indirectly, just as the president of the University is a role model five times removed. If we do not somehow reconsider the processes now underway, the archipelago of colleges will become little more than a postal sorting machine, doing its best to avoid leaving much imprint on the envelopes except a score. As the CEO of America's largest investment banking firm once told the people doing his hiring for him, "Harvard, Yale, Princeton -- Princeton preferred --, 3.6 or better. We don't care what they majored in." With a little more sophistication, displaying just a little more insight into the process, he might have added, "But make certain that what they majored in, was rigorous." If it ever gets to the point where the label you wear is more important than the training you received, the power of universities to set their own prices, select their own customers, and define their own product will have come to the end of the trail. Judging by other industries, that time will probably occur when America finally succeeds in building more first-class university campuses than we can use.

http://www.philadelphia-reflections.com/blog/820.htm

Gardening Survives

Adam Levine, the author of a new book about the Philadelphia public garden scene was recently the featured guest speaker at the Franklin Inn. He's a charming person, and has given us a great book.

He draws to our attention that the Philadelphia region is pre-eminent in the garden world, and has been so for several centuries. While it is true that Philadelphia has a mild enough climate to be suitable to two climate zones, the early settlers came from a region of middle England that has been a garden center since Roman times. And they were Quakers, uncomfortable with outward show in buildings and furnishings, but flowers were innocent instruments of display. Although Chanticleer was created by a Pennsylvania German family, the great centers of public gardens are mostly traceable to the influence of Quakers, and the du Pont family. Since one or two years of neglect will ruin almost any garden, the essence of great gardens lies in the ability to survive.

In fact, the Philadelphia area contains hundreds of gardens which have decayed and virtually disappeared. The Horticultural Society is at the heart of garden preservation, financed in large part by the annual flower show, but even that thriving organization is hard pressed to do justice to the vast areas that need tending. Woodlands would be an example of an area needing tending, and Friends Hospital is an object lesson. When that venerable institution was sold to sharp pencil types from out of town, the Azalea gardens on the grounds were closed to visitors, except for two hours a year. It makes you tremble to imagine how long this famous azalea collection will probably survive. Meanwhile, Germantown's famous gardens are maintained in a minimal way, stretching the resources of the owners who have more urgent demands to meet in their buildings and furniture. Indeed, it is hard to name a really outstanding garden within the city limits, with the exception of the Morris Arboretum, which barely makes it within city boundaries. The area back of the Art Museum along Boathouse Row makes a brave attempt in the spring, but it's a pale reminder of the glory which used to be seen in East Fairmount Park, especially at Lemon Hill, Stenton and Cliveden. Stotesbury is just a relic.

Gardens have moved to the suburbs. Chanticleer, the Morris Arboretum, Longwood Gardens, Nemours, the Scott Arboretum at Swarthmore, West Laurel Hill, The University of Delaware in Newark, Cabrini College in Villanova, Haverford College Arboretum, Temple University's Ambler campus, and the Trenton Sculpture Gardens on the old fairgrounds -- all would demand mention in any list of outstanding gardens in America. But only a few of them aspire to the standards of an outdoor sculpture garden, where the goal was to surround each piece of sculpture with a garden in such a way that only one sculpture could be seen at a time. Now, that was gardening on the grand scale.

Hidden in a regional garden scene are the seed merchants, starting with John Bartram and famous under the Burpees, which make gardens possible. After all, there has to be a place to find these things. Perhaps the catalog stores, like Wayside Gardens, are the hope for the future. Every shrub or tree transported from a nursery takes up a ball of topsoil along with the specimen, and the appearance of nurseries around the periphery of a city is usually the first step in the development of housing projects. If there is an investment of topsoil in every garden, perhaps we ought to think a little bit about the way we let the investment dry up and blow away.

http://www.philadelphia-reflections.com/blog/1297.htm

Why Are Hospital Prices So High?

Aspirin

Cost analysts maintain it really does cost ten dollars to write a simple business letter, so maybe it's no surprise when hospitals charge ten dollars to administer an aspirin tablet.

But there's also another form of hospital overcharging. Mark-ups of prices of several hundred percent over audited costs are routine in hospital bills. These are not hidden cross-subsidies, either; they emerge on the yearly audit as multi-million dollar "losses", neatly balanced by "contractual allowances". Translated, these are discounts to insurance companies.

Why do hospitals raise prices, then turn around and discount them? Why do they overcharge, then call it a loss when they write it off?

It's an important question, because it results in confronting patients without insurance with much larger bills than the effective price to insured ones; patients who can't afford to pay are charged more than those who can.

The old-time system of hospital wards to care for people who couldn't pay have been replaced by collection departments and hospitals are very aggressive in pursuing the the very people who can least afford to pay, and who are grossly overcharged in the first place.

Health savings accounts with high deductibles were conceived as a way for people to self insure but they have been thwarted by hospital overcharges. Since HSA deductibles are guaranteed, hospitals perpetuate their present largest source of loss -- unpaid deductibles. So why do hospitals continue to post abusively-high prices for patients without large-insurance-company coverage?

Until hospital officials come forward with a coherent defense of their practices, outsiders can only guess at motives. Start with the old legal approach of "Cui bono?" (Who might have a motive?) and divide the answers into those with a motive and those with the means. The line-up will then consist of hospitals, insurance companies, limited-license practitioners, and the state government. Limited licensees, acupuncturists and the like, surely must hate high-deductible health insurance because their fees mainly fall below the two or three thousand annual deductible. Old-line health insurance companies also have plenty of motive to keep out competitors, fearing antitrust action if they get too obvious. That leaves the state government.

States have ample power over hospitals. Substantial annual payments are negotiated with hospitals for Medicaid services, charity care, and educational grants and subsidies. Tax exemptions are repeatedly challenged and re-negotiated, and overall non-profit corporations are entirely creations of the state legislature. So, unless it is a violation of federal law, state government has the means to compel hospitals to do anything. Power, yes, but where is the incentive for states to wish for exorbitant hospital prices? Or confer monopoly status on certain insurance vendors by according them sweetheart discounts?

All current plans for "reforming" health care involve providing government-paid insurance to those without. Will the result be to permanently institutionalize the artificially-high public prices to be paid in full by the government? If so, you can well understand why hospitals support these "reforms".

So hospitals are no better than stores that mark up their prices and then loudly proclaim that they will give you a discount. 200% mark-up, 10% off; terrific.

http://www.philadelphia-reflections.com/blog/793.htm

The Blue Cross Discount (6)

Blue Cross Blue Shield

Since I've alluded to the two basic problems in health financing today, perhaps I need to explain them. What's known in hospital circles as the Blue Cross discount refers to the wide disparity between what the hospital will accept from an insurance company and what they will demand in payment from someone who has no insurance. It's often double the price. It's a tragedy that forty million Americans don't have health insurance, all right, because it costs them twice as much. It's a punishment for the terrible crime of not buying insurance, to call a spade a spade.

That sounds like a pretty easy problem to fix, doesn't it? Stop overcharging them, and half of the problem of the uninsured would go away.

Furthermore, most of the people who do have health insurance are effectively able to buy it at seventy cents on the dollar, because they don't pay income tax on the money that goes for "health benefits" which is to say health insurance premiums.

Taken together, most people thus pay seventy cents for health care which will cost uninsured people two dollars. Most people would suppose that we ought to give a break to some poor devil who can't afford insurance, but in fact we skin him alive financially. It's impossible to name any other necessity of life that's treated this way, and it's hard to think of any other problem that would be so easy to solve -- just charge everybody the same amount. If you are really bighearted, charge poor people just a little less,

Now, I refuse to get drawn into a history of the origin of these egregious situations. It has to do with price controls during World War II and the fact that investment capital for the health system was impossible to raise during the depression of the 1930s. But it doesn't matter in the slightest how this came about. What matters is how to make it go away.

http://www.philadelphia-reflections.com/blog/789.htm

Healthcare Reform: Looking Ahead (2)

health care

The Industrial Revolution crowded people together into smoky, draughty unhealthy places to live and work, and thus created ideal conditions for the spread of smallpox, tuberculosis, plague, poliomyelitis and many other infectious diseases. With better sanitation and hygiene, those diseases declined steadily for two centuries. Meanwhile, medical science developed a steady stream of expensive enhancements to health like removing an inflamed appendix, inserting pins into broken bones, utilizing CAT scans and artificial kidneys. These things each made life more comfortable and extended it a little longer, but steadily increased the cost of care. Here and there major leaps forward occurred, like the discovery of antibiotics and the prevention of arteriosclerosis, but it seldom seemed that medical care was stamping out disease, it was just making it more complicated and expensive. But if you stopping plodding forward for a moment and looked backward, the aggregate progress was astounding. Dozens of diseases either disappeared entirely or are well on the way to disappearing, like polio, smallpox, tuberculosis, syphilis, rheumatic fever, and what have you. Life expectancy for Americans at birth, which had been 47 years in 1900, was approaching 80 years in 2000. When I started as an attending physician in 1955, I was in charge of a 40-bed ward continuously full of diabetic amputees; during the last fifteen years of my practice, however, I did not attend a single diabetic amputation. At some point in this amazing medical pilgrimage I can remember realizing that for really important purposes, there were only two diseases left. Arteriosclerosis and cancer; and now arteriosclerosis mortality has declined fifty percent in ten years.

So now it is possible to have the luxury of asking: what will happen when we finally cure cancer? Oh sure, there is Alzheimers Disease, HIV/AIDS, schizophrenia and childbirth, plus an apparently endless variety of ways to produce self-inflicted conditions. Everyone will eventually die of something, so doctors will keep busy. It is not necessary to predict the end of medical care to see that some important social transformations are likely. For example, if we cure cancer around the time of financial chaos caused by the retirement of baby boomers, it is going to be hard to resist the demand that we reduce spending on medical research. Every tedious word of the impending debate on the topic could be written right now to save time, because it is a very strong probability that spending on medical research will decline, once an effective cure for cancer is behind us.

Let's, however, continue our march into the future of healthcare reform. When employers became self-insured for employee health costs, they came into possession of data about what they were buying. It didn't look adequate to them to explain the sums of money they were spending, so they concluded they were being hoodwinked by hospital cost shifting, with consequences summed up as the Clinton Health Plan. Now put yourself in their shoes when the Wall Street Journal tells you cancer has been conquered. Michael De Bakey once pressured Lyndon Johnson to start a crusade against Heart Disease, Stroke and Cancer, and now even cancer is gone. A significant number of C.E.O.s are likely at that point to decide that since Far Eastern competitors don't have this cost to contend with, perhaps it is time to declare that you have been fleeced long enough. Give the employees some money, and tell them to buy their own health insurance.

There are even some more legitimate arguments for doing so. Individually owned and selected health insurance would be portable, putting an end to "job lock", the fear of changing jobs for fear of losing health coverage in the process. Employee divorces create a different twist to job lock, and inequities jump out at you from the tangle of arguments about dual coverage for working couples. Add same-sex marriages to this issue and employers are driven to despair. Individual policies would simplify all of these issues, and open the door to life-long coverages, which we will discuss in a later section.

If medical progress makes just the right progress in the impending time interval before doomsday, it is even possible to start talking about eliminating health insurance in a practical way. If there is no threat of medical expense, why buy insurance against it? Since everybody will die of something, it is hard to envision a time without insurance. But maybe Medicare is enough. Senator Edward Kennedy (D, Massachusetts) will finally have his universal single payer system -- by default.

What we have here are the daydreams of a corporate C.E.O., struggling to make his numbers for the next quarter, and they are pretty strong stuff. But who can doubt the power of these concepts to move the system away from an employer-based formulation?

http://www.philadelphia-reflections.com/blog/1284.htm

The American Health Non-system

Dr. Jock Murray

Dr. Jock Murray has recently been Chairman of the American College of Physicians. He is also a Canadian. Recently, he was invited to address the College of Physicians of Philadelphia on an evaluation of the lessons to be learned from comparing the health systems of the two neighboring nations. It was an excellent, fair, and well-balanced address. The man who introduced him referred jokingly to the American non-system, and Dr. Murray emphasized two epigrams about national systems in general. No nation on earth can afford to fill all of the health demands of all its people. So, all nations confront the three main demands, to deliver everything, to deliver it to everyone, and to do so immediately (ie without waiting lists). Fulfilling any two of these three demands is possible, but to deliver all three is impossible. Comparison of health systems in various countries amounts to identifying which two of the three they have chosen to have, which one they choose to surrender. I hope and believe Dr. Murray would mostly agree to this caricature of his remarks.

As a member of his audience, it does seem to me fair to acknowledge we have a non-system, and probably even fair to go further and observe we fundamentally resist those irksome constraints implicit in having a planned system. No organized system, and proud of it. But we do have something else. Let's call it a vision.

Without formally stating it, or even widely acknowledging it, Americans seem to have embraced a dream that we can indeed have everything for everybody right away. Yes, we can. The method available is to gamble that research can eliminate disease. We hope, although we know it is not certain, that cancer, schizophrenia and Alzheimer's disease will reduce the cost of care. Our model exists in Rheumatic Fever and poliomyelitis, for which there are essentially no remaining treatment costs. We know that everyone ultimately dies of something; we assume we are already paying everybody's terminal costs. Eliminating diseases postpones terminal costs, but surely does not add to them.

We have knowingly and recklessly embarked on a program of pouring huge amounts of money into medical research. I believe the public mostly suspects that much of our present high cost of health insurance eventually finds its way into supporting research, and the public mostly acquiesces in whatever cost-shfting is involved. The people who devote their lives to research in turn vaguely recognize that we might reach a point where the country cannot afford this gamble any longer, and they could have half-wasted a career. We all vaguely understand it's a gamble; major elimination of disease might not be just over the horizon, and might lead us on to indefinite postponement of a foolish dream.

But those are the chances you take; we seem resolved to take them. We are going to give it a go. If we can, we are going to spend whatever it takes to give everything to everybody, right away. We are going to eliminate diseases, on the unproved but plausible assumption that doing so will eventually bring costs down.

http://www.philadelphia-reflections.com/blog/1147.htm

America's New Theater Capital

Gene Terruso

In the Elizabethan era, London experienced a remarkable burst of legitimate theater; Shakespeare was only one part of it. There were fifty-five theaters in London at a time when only two were open in Paris; no one is certain why it happened. Similarly, no one is sure why Philadelphia has decided to have a flourishing theater scene, but if you look around it is true. After 1929, Philadelphia became a "try-out town" for plays hoping to go to New York; we were in a class with New Haven CN and Washington DC. Home-grown talent languishes in competition for audiences who would rather see famous visiting stars. The try-out image must disappear before local talent can develop. Once established however, audiences rather like a theater company with a deep bench; fresh young aspirants at every level, as contrasted with one famous star surrounded by hacks in the lesser roles. The same reaction is seen in minor-league baseball. And no doubt union seniority systems tend to protect the hacks from competing young aspirants. A certain amount of amateurism is forgiven for amateurs; when they get expensive it's better to watch movies. The Right Angle Club was pleased to have it all described if not explained by Gene Terruso, the Professor of Drama at the University of the Arts on Broad Street where the Ritz-Carlton used to be.

The Merriam Theater

As far as inside gossip is concerned, the Merriam Theater is owned by the University of the Arts, but is sort of doomed to shabby prosperity for the next 13 years by a lease which is too lucrative to modify. That's why the seats are a little uncomfortable, the lobby dilapidated, and comparatively few student productions are on the stage. The University would like to have more student presentations, but isn't in a financial position to displace the tenants. The best that can be made of the present arrangement is to encourage the visiting professionals to mingle with the drama students, bedazzling and advising them how to advance in the Big Time. It's a fairly successful compromise.

Until recently, Chicago seemed to have the most successful regional theater experience, but now is thought to be on a par with Los Angeles, Seattle and Cincinnati whereas Philadelphia has supplanted it as the very best place to be. Going backstage, he kids express little interest in going to Broadway, where overpriced theater is just part of the tourist industry. Television is regarded as old-fashioned, so Hollywood is unattractive to them, too. If that's all the future holds, these kids would rather become accountants and computer engineers. And stay right here if they can; that seems to be a central motive. Gene Terruso says there is an "Iceland phenomenon" in Philadelphia, a wonderful hidden place to live, so tell everybody else it is cold and dreary and they will stay away and not ruin it.

The Chicago Theater

The fact seems to be that Chicago is seen to have a great many "hole-in-the-wall" theaters, while Philadelphia has well over thirty flourishing theater troupes. The professor in him prompts Gene Terruso to postulate that the secret of our success is for each repertory troupe to specialize in something, get good at it, and bank on the motto Be clear about your mission; the audiences will follow. Therefore, we have Shakespeare companies, musicals companies, Restoration comedy companies, and so on. Some specialties arel obviously more popular than others. Somewhere in this business school analysis is the likelihood that artsy craftsy people are seldom very good at running a business, so theater success does depend on somebody else who is business-oriented minding the store, and possibly not much good at acting. It's a lesson many idealists and liberals need to learn, and not just in the theater.

University of the Arts

Professor Terruso does ruefully admit that the University of the Arts is a conservatory, by which he means a trade school. Its graduates are more likely to know how Hamlet should run a sword through Polonius without killing the other actor, than to discuss the place of Shakespeare in our cultural heritage. To have a successful theater, however, there has to be an enthusiastic audience. Somewhere, our universities have found it easier to provide a liberal education to one group of people, and impart the tricks of the trade as a specialty. If the two talents merge at all, it is in the profession of Dramaturge, but all in all it would be better if both sides of the footlights understood each other somewhat better. Going to the theater really isn't a specialty, and it isn't a secret society, either. That's part of the response to city leaders who greatly desire a thriving theater, but wish we didn't have to have so many of those artist types walking around town. Both groups need to understand "There's plenty of room at the top, but no room at all at the bottom."

http://www.philadelphia-reflections.com/blog/1988.htm

Copyright © 2004 - 2010 George R. Fisher, MD. All rights reserved.

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