The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
America's two-party system took fifty years to stumble into permanence. Regardless of the happenstances of their eventual emergence, political parties were clearly not designed into the original plan. Those few founding fathers who did think about political parties rejected them as "factionalism", something to be condemned. The true nature and advantages of a two-party system began to be truly venerated when other nations tried something quite different, which we now call Proportional Representation. PR is a fairly natural outgrowth of creating a large democracy from a collection of little tribes -- then creating surrogate political parties for them as part of the design. Guided by historical experience, it is now possible to ignore all minor differences between stable two-party democracy and multi-party democracy, except one. In a two-party system, the political dealing and vote-swapping takes place before the election, with all the players jockeying and sacrificing principle to answer a single candidate question, "Can he win?" By contrast, in a multi-party or proportionally-represented democracy, the election comes first, and only subsequently do vote-swapping and artful promises construct the ticket of candidates and the policy platform. The plain fact is the public doesn't know whom it is voting for and often is disagreeably surprised. Furthermore, important matters remain unsettled by a multi-party election. A cabinet member of a splinter party, potentially one with negligible public support, retains the threat of resigning if things don't go his way, and his resignation may trigger a whole new national election if it breaks up the political margin of the ruling coalition. At least, a two-party system settles things for a while and gives the public a relative rest from factional tensions.
The American system has evolved into a universal conviction, stronger than any Constitution, that two parties are quite enough. Third parties are of course tolerated because they aren't forbidden, but most offer a mechanism in case there is a serious wish to reconstitute one of the two major parties. The strength of third parties is to discipline the leadership of the major parties; the weakness is they threaten the unifying principle of compromise-in-order-to win. Nothing except religious fanaticism would likely induce any ambitious American politician to remain within a third party, fruitlessly frittering away his life's chances. Because of 18th Century history more than wisdom, an "established" religion is constitutionally prohibited in America; observation of the turmoils in other nations, and perhaps wisdom also, keep it that way.
If two parties are then quite enough, is it possible only one would be better? The quickest look abroad, the briefest exposure to history, shows a one-party system is synonymous with dictatorship. Communism and fascism had only this one feature in common; in fact, China seems to be morphing from one to the other, while resolutely retaining its single ruling-party system. The paradox of this situation is that it leads to the American realization that maintaining a two-party system means that neither party must ever achieve total victory. After each national election, the electorate settles back with relief that one side won, but neither side conquered. Even academics are muffled by the system; with much to criticize, there is nothing else worth substituting.
There is one thing left to mention about the two-party system, which is that the interests and affiliations which arouse the club-like loyalties of party members seldom perfectly match the party's current campaign policy issues, and depend in a high degree on habit and a formless sense of group comfort. Any schoolchild can notice, although the party candidates avoid mentioning, that policy issues move back and forth between the two parties. Whether it is tariffs, public schooling, the gold standard or a thousand other matters, the issues repeatedly shift to the other party when lack of progress or apparent betrayal offends them. The special interests seek to use the parties, and the parties regard each special interest as a bargaining chip; the gut feelings of the party membership adjust far more slowly. For maximum effectiveness, a two-party system needs the public to see itself as two warring affinity groups; for a while, polarization seemed to revolve around the rich and the poor. There would always be more poor people than rich ones, as the Founding Fathers feared and the anti-Federalists sought to exploit; but now Populism can only be sustained by continuous massive immigration. The times are growing stale for the Republicans to suggest that only they have an electoral incentive to eliminate poverty, while the Democrats would secretly like to increase it. Or for the Democrats to imply they have a monopoly of sympathy for the poor. Compared with the status of the rest of the world, permanent lifetime poverty in America is growing too infrequent to dominate elections, even supplemented by fear of poverty, a recollection of having once been poor, or guiltiness about never being poor. It is difficult to maintain the firmness of party members with such vague attitudes for abstruse legislative policies like banking reform or compulsory health insurance. Therefore, the search is on for large social affiliations which would more comfortably enlist loyalties for pressing specific legislative actions. At the present time, division of the working populace into the public and private sectors is being promoted as a bedrock political affiliation, but it is questionable whether that will be as successful as the public sector unions seem to hope for. Only twice in our history, during the administrations of George Washington and James Monroe, have Americans overwhelmingly agreed on core issues of religion, foreign policy, and prospects for the future. During both episodes, political parties virtually disappeared.
America's health care crisis may well be solved by curing all disease
Dr. Fisher
America seems determined to invest whatever it may cost to eliminate diseases through medical research. It's pretty hard to know which diseases will experience a miracle cure, and how soon. So it's difficult to make major changes in the system in anticipation of what we all hope for. But it's not so hard to predict what will happen if we are successful.
Health insurance will progressively seem less necessary, and that will prove particularly true for young and middle-aged people. Since our present system of health insurance is largely based on employer-based groups, employers can be expected to become particularly restless about paying for it. Long before all diseases of working people have been completely eliminated, some clumsy political intervention could well cause a stampede among employers -- for the exits.
Even if everyone in the unions and in government is circumspect about alarming the mullets, steady erosion of disease costs among workers will lead to a steady migration of costs to retirees. For practical purposes, that raises the possibility that essentially all medical costs will become the responsibility of Medicare. Since it is universally agreed that demographics will make Medicare expenses unbearable for the national budget in ten or fifteen years, a shift of even more expenses toward the retiree group would be even harder to deal with. It's pretty hard to wish for some particular solution to a problem, when no one has even made a plausible suggestion about it.
So let's focus on the problem which is most likely coming first. Employer-based health insurance, and even health insurance, in general, may well be a thing of the past -- reasonably soon. The main component of it which will not be eliminated is the cost of obstetrics, the cost of perpetuating the human race. The charges being made for this normal and essential process are so burdened with liability risks that it is tempting to blame them all on lawyers. Cost-shifting to other activities and other age groups, however, is also pretty likely. If the concentration of overhead costs on obstetrics goes beyond a certain point, however, I would predict we will see a migration of obstetrics out of the general hospital environment into specialized birthing centers. That's not entirely desirable, because all specialty care is safer when conducted within reach of the whole range of supporting specialties. But if the financial pressure gets great enough, we will surely see a migration back to the specialty hospitals so common in the early 20th Century, then abandoned in the middle of the same century.
Worker's Compensation is another carve-out which will relieve central anxiety of employers, and hence hasten their indifference to general health insurance for their employees. And scandals in the health insurance industry are just going to accelerate the dissolution of support which is inherent in medical progress. Anyone who reads the papers carefully can name at least three billionaires among the ranks of health insurance CEOs.
The pace of coming medical progress is hard to predict, so it is daunting to propose a solution to the problems it will create. That includes proposals which many people would like to advance, like universal health coverage. Patchwork makeshift for uninsured people seems timid and defective. But grandiose proposals for fundamental reform of the whole system are simply foolhardy, at a time when health insurance may well become an obsolete concept, and far greater problems could be made much worse.
This little morality tale was told to me by two unrelated sources, one of whom was a staff aide to Wilbur Cohen, the author of the Medicare law. And the other was a high official of Pennsylvania Blue Shield, the appointed administrative agent for Medicare in Pennsylvania. Its relevance to the more recent SNAFU with Insurance Exchanges introducing the world to Obamacare should be fairly obvious.
After Lyndon Johnson rammed the Medicare amendment to the Social Security Act through Congress in 1965, he wasn't shy about drawing attention to it. The press was present in great numbers, with staff officials who had a role in crafting the document, members of Congress, and anyone else who was standing around. The legislation was laid before him and signed with twenty different pens to be presented as mementos to the in-group. Each pen was only used to inscribe about half of one letter of his name, so it was a slow but joyful process. As intended, it got lots and lots of publicity.
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H. Ross Perot
So, thousands of thankful old folks saw the ceremony on television, though they heard that the law was in effect immediately, and proceeded to dump their medical bills into a shoe box, sending them to Medicare to be paid. Unfortunately, Medicare didn't have an office, a staff, or even a telephone number. These things take time. As fast as they could, the Medicare staff constructed a system of carriers and intermediaries, carriers for part A, and intermediaries for part B. And almost without exception, appointed the local Blue Cross and Blue Shield organizations to be the carriers and intermediaries. Consequently, the organization of Medicare was patterned closely after the organization of the two administrative corporations. Meanwhile, the bills from old folks just kept pouring in through the postal service. It was about all the staff in Washington could do, just to direct the mail out to the local intermediaries and at least get it out of their hair.
Less than a year later, that's how the claims manage to Camp Hill, PA, a little suburban town near Harrisburg. In desperation, Blue Shield had rented a local vacant supermarket and piled the mailbags ten feet high. There were quite a few telephone calls of inquiry, and the old folks were politely told the matter was being looked into. It was beginning to look as though one supermarket wasn't big enough.
Computers were, of course, rented from IBM, who had a policy of renting, not selling, its valuable equipment. Keypunch operators, computer operators were hired, air conditioning was installed, and one team after another of computer programmers was hired -- and fired. Consultants were called, scratched their heads, sent big consultation bills, and turned sadly away. Sorry, but somehow it just doesn't work.
So that's how it happened that one Friday afternoon, a vice-president of Texas Blue Cross named H. Ross Perot came in, accompanied by a fellow with glasses so thick they looked like the bottom of Coca Cola bottles. So far as anyone can remember, the guy with coke-bottle glasses never said one word. The desperate, hopeless mess was explained to Perot, whose salary at that time was rumored to be twenty-five thousand dollars a year, about right for a Blue Cross executive. His background as a kindred Blue Cross person inspired confidence, and the conversation rambled on for an hour or so. Meanwhile, the guy with coke bottles went over to the Penn-Harris Hotel across the street and got to work. By the end of the weekend, he had come back a couple of times, but eventually, would you believe, it really, well it really worked. Contracts were quickly signed, the wheels began to turn, the mailbags in the supermarket began to march through the processing cycle. Blue Shield, the Medicare program, the finances of the nation's elderly, and Lyndon Johnson's reputation -- were all rescued.
As everyone now knows, the Medicare processing contracts made Ross Perot into a billionaire, living on Bermuda in the lap of luxury, eventually upsetting the re-election hopes of George Bush, senior by running for President himself on a third party ticket that had something or other to do with giant sucking sounds. A Congressional investigating committee looked into the outrageous profits Perot had extracted from his homeland's elderly, volleyed and thundered. Whether Perot actually thumbed his nose at them is doubtful, but he certainly was in a position to do so.
Meanwhile, whatever happened to that guy with the coke bottle glasses, no one seems to know.
Times change. The Japanese have been defeated in "the" war. The spirit of sacrificing anything else to survive an external threat has subsided. California has become a blue state, and is fast becoming a minority-dominated one. A new generation has appeared, and unmindful of historic beginnings, has come to accept old expedients as simply the rules of the game. In particular, fringe benefits are no longer a bonus, but just a part of earnings which for some reason are tax-sheltered.
To sum it all up, Chief Financial Officers no longer feel they are cheating when they maximize tax "benefits". It's legal, isn't it? Obviously, an employee receiving a big gift finds it more welcome than paying for it himself, especially since it is tax-free and other people don't get the same treatment. Economists who have examined the matter are fairly unanimous that fringe benefits are all soon merged in the minds of employers and employees alike as "employee cost." Within a few years in a competitive environment, both sides of the gift soon treat fringe benefits as only a tax benefit, with comparable reductions in the pay packet to adjust for them. The cost of the gift soon equilibrates, only the tax deduction is a true transfer.
Nevertheless, there are economic limits, if not legal ones. Issues like Portability, Job-Lock, pre-existing conditions, and individual choice would disappear if health insurance were freed of linkage to employers since these issues are all traceable to the mandatory link between health insurance and losing your job. We really do have an employer-based system, but it has a price. Lifetime healthcare insurance policies would place considerable strain on portability and choice, so employer-basing stands in the road of multi-year insurance. Maybe, just maybe, we should reconsider the advantages and disadvantages of having it remain a gift from employers. The growing suspicion it has been the main impetus for cost escalation is worth testing.
In fact, the shareholders usually get a bigger gift than employees do. State and local corporation taxes vary, but a profitable corporation pays 38% federal corporate tax, and the total corporate tax burden approaches 50% if you include mandated sharing of other fringe benefit costs, the highest in the developed world. By defining fringe benefits as a tax-deductible cost of doing business, some major corporations effectively increase their net income by half.
To understand how that is possible, just look at any payroll tax stub next payday. All these features were intended to redistribute wealth, but the CFOs, turned them into shareholder advantages. Tax deductions from the pay packet total about 15% of net pay. But the employer must match most of that deduction with his own contribution, which brings him to 30%. And furthermore he pays twice as high a tax rate: about 40% tops compared with a blended individual rate of 15%, so it all adds up to 60%. Let's use the imaginary example of a $10,000 health insurance premium, where the employee gets a $1500 tax reduction, but the employer gets $3000. It's after-tax money, so the employee effectively gets $1726 and the employer $4200. For a big employer, multiply that by 10,000 employees and you get a noticeable amount of money. It's so much money you can imagine what the stock market would do, if a proposal to abolish it looked as though it might be enacted. But would you believe it -- that's not the worst of the situation.
The worst is -- the employer has been given a very large financial incentive to raise the cost of healthcare. The higher the better, and shareholders ought to love it. Physicians have the same incentive because we would love to raise our fees, as Adam Smith so tersely put it in The Wealth of Nations. But at least we doctors took the Hippocratic Oath, and most of us are a little ashamed of this conflict of interest. Whereas, a stockholder controlled company has hired a manager with the mandate, to make as much profit as he legally can. Let's summarize: we have engineered a system where it is well known among CFOs that you can often make extra profits by giving a gift of health insurance to the employees. And if that isn't a tax gimmick, I don't know what would be. We have finally reached the point where the health system costs 18% of Gross Domestic Product in spite of closing 500,000 mental health beds, all of the tuberculosis sanatoria, all of the polio beds, and lengthened human longevity by thirty years. Maybe you can blame that paradox on doctors, but I doubt it.
We have simply got to stop telling fairy tales about Henry Kaiser and Liberty ships eighty years ago. This is a tax gimmick and it has to stop. I would be happy to meet with the Business Roundtable to discuss how we could stop it without crashing the stock market, but it has got to stop. My two-part proposal is pretty short, however:
Proposal : Employers should discontinue providing free health benefits to their employees, at the same time corporate income taxes should be capped at the same rates as individual income tax. The speed by which this is to take place might be determined by the Federal Reserve in response to economic conditions, but in no case longer than three years to complete the process.
The competitors deserve a word, here. About half of business is made up of big business, and half is small business. Wall Street and Main Street, if you will. The opportunities which Henry Kaiser stumbled upon in 1943 mostly apply to big business, and probably much of that anomaly can be traced to the fact that bigger businesses are more likely to be profitable, and more likely to be engaged in international trade, where competitors don't get a vote. Some of the tax benefits for small business like Subchapter S, probably represent an effort by Congress to help domestic competitors without helping foreign ones.
But self-employed people, and unemployed ones, are excluded. Very likely, much of the politics of healthcare is intended to help these people, without helping small business or big business, and without helping foreign competitors. Pretty soon, you have a tangle of interests affected by removing the obvious tax inequity which Henry Kaiser is given credit for discovering. Just about everybody has something to gain, something to lose. So it begins to be impossible to say, on net balance, how much the country would be improved by abolishing it. That's particularly true, with the Affordable Care Act on trial.
Just how bad things are, is hard to say. But plenty bad enough. We know about job lock and the other features directly attached to employer-based insurance, and we decided to live with them. But the escalation of healthcare costs, and the soaring international debts used to pay for them, are becoming too much to handle. We can tolerate a lot of things, but it's not clear we can tolerate 18% of GDP devoted to healthcare, particularly if the price keeps rising. It's hard to imagine anything people would prefer to spend their money on, then on longevity. But when serious people, or at least people who take themselves seriously, start talking about euthanasia as a solution to our health cost problem, you know the costs are starting to hurt. So get this: you can only do it once, so euthanasia isn't as useful a solution as tax reform.
What a Tangled Web We Weave.For the most part, only economists are familiar with the rather well-established fact that wages in the pay packet soon decline to recognize the value of other items in the total wage cost. In this case, it is the 15-20% tax reduction as a result of the Henry Kaiser tax dodge. After eighty years, news of this theory has seeped into the minds of labor unions and is slowly becoming common parlance among union membership. So inevitably, bickering about tax subsidies for poor people gradually reached the same point of recognition. Negotiators who have won an economic victory on an esoteric point, often find it difficult to restrain their boasting of it afterward.
In the case of subsidies for the poor to pay for national health insurance, the subsidy was based on whether the individual's income was a certain percent of the poverty level. When the individual's income falls in the border zone, it may make a big difference whether or not to include the tax deduction as wages. A decision on this point affected eligibility for subsidy of millions of low-wage employees of big business. And that in turn affected their personal decision whether to buy health insurance in the exchanges or to continue to get it through the employer -- which way would be cheaper? With millions of dollars at stake, it is small wonder the negotiations apparently broke up and agreed on a two-year postponement of including employees in Obamacare. Since the political makeup of Congress had changed since the law was passed, the law itself could not be adjusted to smooth out this difficulty. The implication (pretense?) has been circulated that somewhere buried in legislation there exists some relief from this situation, but it will not be effective until 2018. It scarcely seems likely a useful compromise could be devised during that time window, or during a Republican administration afterward, so stay tuned.
A related issue might also be involved in the mysterious revival of the minimum wage by union politicians. It seems possible the reasoning is that, since you can't lower the threshold for subsidies, perhaps you could raise wages to meet the threshold. Some pretty sophisticated people are apparently advising these politicians about a pretty obscure economic point. Ordinarily, the market wouldn't tolerate such manipulation, but having gone off the gold standard, perhaps it now seems possible to give it a try. All in all, the arguments for a minimum wage are so tenuous, it seems more likely that inflation is being toyed with, as a possible way to expunge indebtedness.
One secret of success for Classical Health Savings Accounts lies in recognizing a single approach is inadequate; at least two approaches are required. Catastrophic health insurance spreads big risks (mainly hospitalizations), while tax-free accounts promote more frugal spending for small ones (mainly ambulatory care). Combined in an HSA, they do what neither does alone, by covering overlaps. Now I contend, six principles in combination can create even greater savings, when separately they might create more confusion.
1. Redesign Insurance. Health insurance has traditionally been upside down. Starting with "first dollar" coverage, really sick people feared bankruptcy when medical costs outran policy limits for the last dollar. Obviously, it would be better to ensure big catastrophes first, skipping small ones if funds run out. If we must have mandatory health insurance, the thought ran, let it be the high-deductible catastrophic variety, with out-of-pocket limits protecting outliers. To a certain extent, the Affordable Care Act moved in that direction, possibly opening room for compromise. Deductibles should be high, but co-payments are useless and should be eliminated. Subsidies should subsidize people, not specific programs, and should avoid taxing the same program they are supporting.
2. Indirect Transfers Between Age Groups. Working-age people largely finance the health system but most don't get sick themselves, whereas sick people are mostly retired and on Medicare. That makes young people restless, while Medicare breaks the national budget with a 50% subsidy. (It's largely accomplished through bond-loans from foreign countries, like China.) The age-related funds' transfer is desirable but is now largely left to hospital cost-shifting. The cost could be lessened by letting the worker keep health money in his HSA, earn interest, and spend it on himself when he ages. 2b. Furthermore, I propose we shift the cost of the two most expensive medical years of life to individual escrow funds during the period of investment. To be specific, shift the cost of the first and last years of life from coverage by catastrophic health insurance and Medicare -- to repaying average national cost (reported by Medicare) back to the insurers who originally paid the bills. That's technically known as first and last years of life reinsurance.
3. Funds Creation. How might we pay for this transfer? Well, in the first place, living people are assumed to have somehow already paid for their birth year. It will be forty more years before new ones are even half-way phased in. Even terminal care costs will not level out until life expectancy stops lengthening. Revenue, on the other hand, could commence immediately. The hard part of revenue production lies in fixing "agency" failures. That is, avoiding spending it in the meantime, and keeping middle-men from poaching on it. I propose individual escrow accounts are preferable to agency management by either government or private sector financial institutions. Saving for your own rainy day is much more palatable than taxing for transfers between demographic groups. The cost of passive investment in index funds is small, and long-run gross returns approach 11%, or 7% net. But middle-man costs are often too high. Considering the trillions in index fund potential, these inert investments might even be considered for a substitute currency standard. Gold is too rigid, government judgment always proves too inflationary.
4. Compounding. Meanwhile, it helps to recall what the Ancient Greeks knew about compound interest. Money at 7% doubles in ten years, and therefore with life expectancy now at 84, can expect to double more than eight times. 2,4,8,16,32,64,128,256, (512- 1024). Unfortunately, the rounding errors also get compounded. Therefore, although the general concept is unchanged, one dollar at birth actually grows to about $289 at the average time of death by present expectations of it. By that time, life expectancy will likely grow by unpredictable amounts, so it might actually transform one dollar into $500 if inflation is held to no more than 3% -- or to some other value, more or less. The main hope for price stability lies, not so much with the Federal Reserve, as in medical science reducing the burden of disease and increasing the productivity of the delivery system. I feel confident last-year costs can be covered, either by patient contribution or by government subsidy, if -- transition costs are absorbed over the first decade or so, if the Federal Reserve can successfully hold inflation below 3%, and if medical science can cure one or two major diseases inexpensively in the next fifty years. Otherwise, this could merely be a proposal for generating tons of new revenue but would fall short of paying for all the healthcare affected. Even covering by only 10% would produce staggering sums, however.
Let me remind you, those extrapolations are for only one dollar invested. More specifically, the goal of the proposal is to pay for the last year of life by some variant of one-time investing of $150 at birth, possibly even as much as $50 per year. This should be enough to relieve the debt pressure on Medicare and to reduce the cost of catastrophic care for the rest of the population considerably. It's still much less costly than continuing the present approach.
5. Adding a Generation to the Family. To include the cost of children, we propose increasing the $150 at birth to $200 (potentially, $25 a year) and transferring the resulting surplus, from the grandparent's "bequest" to the Health Savings Account of no more than one grandchild at birth, thereby adding 21 years of compounding, broadening the scope to the first 21 years of life, and further reducing the premiums of catastrophic coverage for the rest of the population. Child-care costs are far more significant than they sound, and all health care plans have faltered on them. It is nearly impossible to refund the day you are born, particularly when the responsible parents are young and financially insecure, facing the cost of an automobile, a house, college education, and another child. For a remarkably small dollar cost, compound interest can greatly relieve this social environment, and therefore I advocate the small additional cost of extending the first year of life to the first twenty-one of them. And funding them via the grandpa route.
6. Tax Equity. Additional required regulations are more or less self-evident, but the most important one would be to permit paying for catastrophic insurance premiums by the Health Savings Account itself, thereby creating tax exemption equivalent to employer-based insurance.
(7) The overall result presented here is to shift the costs of children up to age 21, plus the last year of life, to a longer compounding period and to their ultimate source, which is working people from age 22-66. It adds a major source of revenue through extended compounding, and it does this at the reinsurance level, mostly insurance company to an insurance company. By shifting these costs, other programs cost less, and cost-shifting at the hospital level should greatly be reduced. As scientific research reduces costs, Medicare is destined to shrink, so its revenue can gradually be shifted to retirement income. That isn't exactly privatization, although politics may describe it so. In the far, far, future, health care might reduce along with a designated pathway to nothing but the first and last years of life. Or, the concept may be dismantled and pieces of it used in other ways.
(8) The alternative for tax equity is much more drastic -- of reducing corporate tax rates, sufficiently to compensate companies for losing their existing tax preference. For years, reformers have advocated tax equalization by eliminating the tax deduction for employees. It hasn't been successful, so now we advocate equalization first, reduction later. If that is blocked, there is no choice but to lower corporate taxes, paradoxically the source of the problem.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
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