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Dr. Jock Murray
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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 be 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 the 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-shifting 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 unproven but plausible assumption that doing so will eventually bring costs down.
Unthinkingly, many people believe Medicare completely pays all medical costs for 44 million eligible recipients. Not by a long shot. In the first place, many medical costs are ineligible for Medicare reimbursement; the largest is nursing home care. About 5 million recipients are "dual eligible", which means they get both Medicare and Medicaid coverage, and then state Medicaid programs do pay for nursing homes to a variable degree. The federal government excludes "custodial" care, but to some degree does pay for "skilled nursing care" , so the nursing home matter often seems ambiguous, and becomes the source of some resentment.
Beyond that, patients are responsible for annual cash deductibles, hospital daily deductibles and about 20% co-insurance, all of which are really Medicare-related. The 20% coinsurance was allegedly meant to generate cost concern by demanding patients "have some skin in the game", but the great majority of patients promptly took out a second, co-insurance, coverage, so any cost restraint has long been eliminated for them. They have to pay a second insurance administrative cost, plus its profit margin, however. A 20% co-payment isn't enough to influence behavior, while the ability to budget retirement costs is more important to elderly people on a fixed income. They soon see the foolishness of buying a 20% insurance to cover a 20% discount on the first insurance, but the reaction is not that it's stupid, but rather, that Medicare is stupid. Furthermore, if the individual has Major Medical Insurance coverage, some additional odds, ends and outliers are covered, but with with a third insurance layer of cost and profit added. Once it was discovered that insurance profitability was also enhanced by a great many people neglecting to file a Major Medical claim form, the incentive of the insurance industry to protest the situation was effectively smothered. In summary, by addressing the total costs of the elderly rather than Medicare alone, we can claim the elimination of this triple insurance cost, which somehow escaped the attention of the designers of Obamacare for their scheme. In fact, it can be suspected that many advocates of "single payer" are imagining the elimination of this duplication.
In addition, the Medicare patient pays premiums, which amount to a quarter of Medicare cost, and derived from young working person from age 25 to 65, the 2.9% payroll deduction contributes another quarter. We can't both collect it, and still assume it as a cost for the taxpayer to assume. The remaining 50% of the Medicare cost results in a deficit, paid for with debt, largely owed to the Chinese. There's a lot of rounding error and approximation in the reports, but the impression is gained that the U.S. government doesn't pay very much of Medicare costs at all, except for its administrative costs and the debt service. But in fact until those debts are finally settled, no one can say how much the government pays for Medicare.
Since our present purpose is not to pay the costs but to approximate them for discussion of alternatives, rounded-off costs, are perfectly adequate. Approximations only contribute serious errors, if applied in different ways to different payment systems. The individual and his employer are now paying somewhat more than half of Medicare costs, which are perhaps 70% of the total medical costs of the elderly, and the remaining 30-40% is a government obligation whose ultimate settlement is not yet determined. It's not easy (impossible?) to say what we might be paying if these costs were borne by a new financing arrangement. Most economists say the employer contribution is adjusted in fact by lowering wages by an equal amount, and that in turn is recouped in part by income taxes. Furthermore, the Chinese loaned us the money with the expectation of being repaid, so there are outstanding debts from the past which must be figured into the calculation.
Under these circumstances, it seems appropriate to start with a way to pay the total program costs of Medicare. We'll start with that, making a mental note that there's probably 25% (?) more, and try to cope with these other leads and lags, by trying to offset them during the transition, or just by letting the Government Accounting Office figure out the rest. Medicare program costs are a known quantity for use in a program re-design, while other unknowns are for others to conjure with.
Let's be clear about our role. It is to suggest four or five main ways to rearrange health financing, so enormous sums are available to reduce health costs. Once the money is available, only Congress can decide what to do with it. In fact, my prediction is anything else would be brushed aside as an amateur suggestion. Nevertheless, I have given the matter some thought, and offer my ideas. They begin with leaving the practice of medicine alone, on the grounds that the public will not support any major intrusion into what they consider their private affairs. And my suggestions end with the opinion a change such as I propose can only be done once in a century. So please get it right if you do it.
Starting Young, and Playing With Numbers. The power of compounding is brought out by starting really young, possibly even at birth with a gift from parents. At 10%, money doubles in seven years; at 7%, it doubles in ten. In 65 years there are eight doublings at 10%, six doublings at 7%. The real power of compounding comes at the end of the series. The last three doublings were added in the past century. It makes them eight times as valuable to us as to our grandparents. So, something slow, gradual and unnoticed, creeps up on us before opening an entirely new set of possibilities.
Eight times as valuable to us as to our grandparents.
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Three doublings added.
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We divide the roughly 85 years of life into three compartments: (1) Children from birth to age 25, whose health expenses are a debt they owe their parents. (2) Working people, from age 25 to 65, who essentially generate all the wealth of society. (3) And over 65, when working income ceases, and living costs are paid from savings generated earlier in life. There are forty years to earn, preceded by 25 years of being supported, and followed by 20 years of living on savings. That's why so much of this book pivots around ages 25, 65, and 85. If you learn it from your parents, you get a head start. If you must learn it for yourself, mostly it's all gone before you react.
Learn from your elders, get a Head Start.
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If You Learn for Yourself, mostly it's gone.
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Working backward from $80,000 at age 65, you need to start with only $200 at birth with 10% working for you or $1,000 at birth with 7%. What's the significance? If you make a lump-sum payment of $80,000 on your 65th birthday, the lump sum generates what we now assume is the lifetime average cost of Medicare. Translating $200 at birth into $80,000 in 65 years is definitely possible. Figuring out how to translate the money earned into what the average person will spend 65 years later, is too complicated to be precise, but we have learned you always underestimate the change in such a long period. We always underestimate the change, but the cost of it cannot exceed the money we will have. Paradoxically, that may be a little easier. Remember, the stock market averaged 12.7% during the past century, but here we only project a 10% return to an investor, therefore few would dispute results of this financial magnitude are a reasonable goal. I'm not entirely sure what we are predicting, but perhaps it is an invisible limit to the rate of inflation a viable economy can withstand. No gold or silver standard, but perhaps the velocity of money standard. Maintaining a future goal of 3% inflation during the next century, for example, seems entirely within the power of one person, the Chairman of the Federal Reserve. He may fail, and the world economy flies apart, but if it holds together, something like this velocity will have to continue, even if we all are commuting to Jupiter for lunch. The final conclusion would be unchanged: a comparatively minor investment at birth could be fairly comfortably projected to pay for average Medicare costs, half a century from now. You might even get all of Medicare for a single $200 payment; now that's really a bargain. Even $1100 (at 7%) is still a trivial price for retirement with unlimited health care. But remember, we are not promising to pay for it all, just some big chunk that presently isn't paid for. During major inflations such as Germany, Russia and China had, the individual nation disintegrates but eventually catches back up with the rest of the world. Our whole financial system seems to have been stabilized by some such notion for the past four or five centuries.
The Debts of Our Parents. We started by showing it would likely be feasible to assemble $80,000 by the 65th birthday, and that much money on average, would likely pay for Medicare because the relative values will not change unrecognizably in thirty years. Remember, Medicare is spending $11,000 a year on the average Medicare recipient, for roughly 20 years, or roughly $200,000 during a 20-year lifetime after 65. If you start with a nest egg, sickness will slowly wear it down. At the same time, you do make a certain return on your nest egg. The goal is to build the egg up when you are working, so you have something to spare between the interest you make on your nest egg, and the annual cost of the illness. Eventually, the sicknesses win the race, but your task was to stretch things out as long as you can. Eventually, a few people will have to resort to dipping into the last-year-of-life fund (see below), and if things go badly wrong maybe we can only pay fifty cents on the dollar. There is this contingency provision, but it will not be infinite.
Let's examine the concern, which isn't entirely fanciful. Since earning power starts to disappear around age 65, there will inevitably be some people who throw themselves on the mercy of Society with no hope of paying their substantial medical costs. My suggestion is we anticipate this contingency by initially excluding payment for healthcare in the last year of life, which as I have said many times, comes to everyone. Because nearly everyone who dies, is on Medicare, we have pretty good data about the cost of the last year of life. Setting aside the funds to pay for it would allow us to add the cost to our estate or insurance. For those who have somehow escaped pre-payment however, this remains the last final debt and a fairly substantial one. Segregating this debt as the last unpaid one, allows for the people who fall through the cracks, to fall through this one, last. Whether we make this deficit into an unfunded debt of society, or a pre-funded responsibility of a benign society's natural obligations to its citizens, or a debt of society to its medical institutions -- makes only a rhetorical difference. The problem has been concentrated in a single focus, where it can be dealt with as generously (or as tight-fisted), as we choose to appear in the eyes of the world. As envisioned, all other debts are paid before this one, so to some people, it will seem like a contribution to the Community Chest, while others will treat it like highway robbery by welshers and ne'er do wells. But at least we have provided for what we all acknowledge is inevitable.
We estimate compounding will add more revenue, roughly matching the costs of robust stragglers who live from 85 to 91. That is, the growing costs of the elderly are like a longer neck on a giraffe -- rather than a bigger belly on a hippopotamus. Average costs actually go down a little after 85. We assume a fair number of them will be healthy during most of the extra longevity, with heavy terminal care costs merely shifted to 91 instead of 85. We started at age 65, with 65 years of health costs already paid; we paid down the estimated costs of twenty years, and the interest on the remainder pays five more. We get there with money left over, we haven't diverted the premiums from Medicare, and we still have to pay for that last year of life. Except we let Medicare calculate the average cost from the people who decline this gamble, and the fund reimburses the hospital or whatever, for average terminal care costs -- during what is only then recognized to have been the last year of life. If the money from fund surplus isn't enough, the agency can look at raiding the Medicare payroll deduction pool. And there can always be recourse to liberalizing or restricting enrollments, to age groups which experience shows will either enhance or restrict the growth of the fund, as predictions come closer to actual costs. And finally, the last recourse is to have the patient pay for some of his own costs, himself, by re-instituting Medicare premiums. Those who feel, paying for all of the healthcare with investment income was always a pipe-dream, will feel vindicated. But all this book ever claimed was it would reduce these costs by an unknowable amount, which is nevertheless a worthwhile amount.
Whoops, Medicare is Subsidized. A major explanation for the astounding bargain in Medicare funding can be traced to a 50% subsidy of Medicare by the Federal government, which is then borrowed from foreigners with no serious provision forever paying it back. Medicare is: about half paid for by recipients, about a quarter paid for by payroll deductions from younger working people, and about a quarter paid for by premium payments from Medicare beneficiaries, collected by reducing their Social Security checks. A quarter paid in advance, a quarter paid at the time of service, and half of it a subsidy from the taxpayers at large. No wonder Medicare is popular; everybody likes to get a dollar for fifty cents. But the Chinese might be astonished to hear Medicare described as self-funded, sort of ignoring the repayment of their loan.
America's Big Benevolent Gamble.
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Billions for Research
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So I'm sorry but if you want to pay your bills, it might cost more than $80,000 on your 65th birthday, based on the assumption that you do want to notice the nation's huge debts run up by your ancestors. And to go further, it will take at least $200 a year, starting on the average person's 25th birthday, even making what some people would say was an optimistic estimate of 10% return. So you might as well call it $500, just to be safe from other rounding errors, and to allow enough time for hesitation lag about doing such a radical thing. No one says you have to do it my way, but this is how you reach a rough approximation of what it will cost, to do what I think has to be done, including paying off our debts.
That's indeed how much it will cost if you do it all by raising revenue. You can also do some of it by cutting costs, where fortunately we are well along on a uniquely American way to do things. No one else has the money to do it our way, so everyone else tries to cut costs by turning out the light bulbs. But without saying a word, notice how we have united in what the rest of the world thinks is madness.
Americans Unite, Others Think It's Madness.
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Eliminate Costs by Eliminating Disease
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Starting about fifty years ago, we began pouring outlandish amounts of money into medical research. In fifty years, we extended life expectancy thirty years, through eliminating dozens of diseases, along with the cost of caring for them. Just think of the money saved in treating tuberculosis alone, tearing down those TB hospitals seen in every city during my student days. Infectious diseases, particularly typhoid and syphilis, consumed the time of a medical student, and much of the budget of every municipality. One of my professors said we had two challenges left: cancer and arteriosclerosis. He was an optimist because we still have cancer. And the three main mental disorders, schizophrenia, Alzheimer's and manic-depressive disorder. But add five more to that list, and cure them in twenty years. After that, our main problem would no longer be dying too soon. It would be, outliving our incomes. Financially, these are features of the same thing, except one pays for Social Security and the other pays for Medicare.
Consider a moment, how difficult it is to say how much medical care will cost. Remember, a dollar in 1913 is now called a penny, and today's dollar is very likely to be called only a penny in 2114. We long ago went off the gold standard, and money is only a computer notation. Looking back, it is remarkable how smoothly we glided along, deliberately inflating the currency 3% a year, and listening to assurances this was the optimum way to handle monetary aggregates. Even more remarkable still is to hear the Chairman of the Federal Reserve ruminating we don't have enough inflation. It took a thousand years to get used to metal coins, several centuries to get used to paper money, and almost a century to get used to being off the gold standard. The political task of convincing the whole world that inflation is a good thing sounds very close to starting a world-wide civil war.
But we now have more than a million people over the age of 100. They got cough drops as a baby for a penny, and now hardly blink when a bottle of cough medicine costs several dollars. But instead of that, they are likely to get an antibiotic which was not even invented in 1913, retail cost perhaps forty dollars when it was invented, and now can be bought for less than a dollar. If they got pneumonia in 1935, they probably died of it, no matter how much was spent for the 1935 medicine, so how do you figure that? Or someone who got tuberculosis and spent five years in a sanatorium, who today would be given fifty dollars worth of antibiotics. The problems a statistician is faced with are impossibly daunting.
The current practice, which reaches the calculation of $325,000 for lifetime medical costs, is to take today's health costs and today's health predictions, and adjust the average health care experience for it, both backward and forwards. Every step of this process can be defended in detail. But the fact is, average lifetime health cost of someone born today is only the wildest of guesses, no matter what kind of insurance is in force, or who happens to be President of the United States. The cost of drugs and equipment go through a cycle of high at first, then cheaper, then they vanish as useless. But adjusting the overall cost of materials and services when only a faint guess can be made about healthcare and disease content, can be utterly hopeless, or it can be quite precise. Unfortunately, even its probable degree of future precision is a wild guess. It's a wonderful century to be living in unless you are a healthcare analyst. The only safe way to make a prediction is to make a guess that is too high and count on public gratitude that it actually wasn't much higher than you predicted. But to guarantee a particular average outcome, which an insurance actuary is asked to do, will be impossible for quite a few decades.
So, here is a plan for paying for healthcare, which is nothing if not flexible. If we start running out of money too early, we just don't pay our foreign debt, that's all. Doing it overtly is probably to propose a change in our entire culture so it would be done by inflation, a dime on a dollar.
If that isn't enough, we inflate some more until we can stop running up foreign debt.
If that isn't enough, we cut costs, inflate some more, and reduce the quality of health care.
And if that isn't adequate, we put a stop to funding biological research, by letting foreigners try their luck at it. Americans would be particularly loathed to do that because it represents a confession we were wrong about our boast to put an end to the disease.
This four-step process is absolutely mind-boggling to me, absolutely unspeakable, although the Chairman of the Federal Reserve is able to hint around about it. To me, it is so repellant that absolutely no circumstances would allow me to endorse it, and my hope is that just the mention of it will be enough to stir up the newspapers and the Congress. Stir them up, that is, to take some of the harsher measures which are necessary to withstand such suggestions. Meanwhile, we have the satisfaction of generating some compound income on the premiums, which will make the direst eventuality, to be not quite as bad as otherwise.
To keep track of how we are doing, the alternative I propose is to create a semi-permanent agency with adequate resources to oversee the transition and release honest white papers about how it is going, judge how it must be modified. After that, no doubt, a blue-ribbon oversight board must be appointed with power to suggest to Congress what needs to be modified. The blue-ribbon approach is to designate a couple of dozen private institutions to send one representative, and to rotate the appointees among a smaller board than the number of institutions which nominate one. Let's say, twenty positions among thirty institutions, rotating on a three-year cycle, to minimize overlap with Congressional elections. No doubt, that would produce an annual flood of half a dozen books a year by board members, agitating a process which is ultimately decided by elected Congressional representatives.
Insurance companies announce premiums in September or October, giving themselves a few months of constant premium prices while they sell policies with a January renewal date. That provides time for the hesitant buyer to look over the competition but is an unnecessary inefficiency for a lifetime insurance, where it is likely to disappear. During the introductory period, experimentation should be made with charging for the ten-year incidence of certain conditions like appendicitis or gallstones, and allowance made for previous removal of the organ in question. A much larger database would be required to make the same adjustments for annual renewals, and there would be considerably less tendency for the patient to game his own health history. The incidence may be the same, but the risk of shopping behavior is much reduced. The possibility of introducing an elective surgery rider exists.
But a transition can be gradual in more ways than just one, changing annual renewal into once per lifetime marketing. Actuaries calculate the average lifetime healthcare cost to be around $130,000 in the year 2000 dollars. Retirement and Medicare begin at the same time, but retirement is continuous rather than episodic. A comfortable retirement to average age 84 might cost four times as much as the healthcare which created it. We may thus be talking about an average lifetime cost of $650,000 in the year 2000 dollars. At 3%, inflation could increase to nominal average cost of $
Assuming we continue yearly premium adjustments, we should at least make yearly adjustments to the premiums for lifetime coverage. That promotes a yearly decision between the present one-year term insurance and a smoothed-out lifetime price, mostly based on considerations other than price. It probably starts with a variable price band for the company to set, within which the employee is allowed a choice to switch to permanent insurance, or not, with a small price variation depending on the calendar date of switch-over. Age and perhaps other variables would affect the changing price. But the main consideration would be transferability between employers, so several large employers would have to agree on the schedule of prices. If the employer declines to participate, he also declines to pay for it, so he must adjust his pay packet accordingly. It must already be obvious why the employer is inclined to follow industry standards, and why special anti-trust exemptions may be necessary. However, once an employee makes a switch, he is likely to remain with that company for a lifetime, so the incentives are mixed.
To assist that decision, a brief overview of the insurance company position is in order. On the one hand, marketing costs are small for an existing company. The negotiation is with a single personnel office rather than hundreds or even thousands of employees. The concept of permanent insurance is probably unfamiliar to most employees, and most of them would have questions. On the other hand, insurance administration is simpler and cheaper, and some innovative clauses could make it still cheaper to run. It would create a permanent customer for many years of coverage with fewer loopholes. And just look at the money involved.
A lifetime policy, once it gets started, aims to create an individual $2 million reserve at age 65, which is run down to zero in twenty years by payments until average longevity of 85. But half of the clients will live longer than that, so there is a strong probability of payouts from a trust fund for another 21 years. Whether the insurance company services these expenses itself or farms them out to a vendor, this is a very appreciable amount of business. Multiplying such numbers by 350 million Americans, the sums are in the trillions, approaching the total now invested in index funds. What's involved is the destruction of a medium-sized industry, in order to create a mammoth-sized one.
Because just about all medical internships still begin on July 1, I'm pretty sure I first met Bob Gill on July 1, 1948, which I remember was a very hot day in Philadelphia, especially in the old historical library of the Pennsylvania Hospital. That's the first hospital in America, and therefore the site of the first internship in America (Jacob Ehrenzeller). For alphabetic reasons we sat next to each other and were assigned as roommates on the third floor of the original old building. Since Bob's later life was distinguished by quite a bald head, this first meeting with Bob Gill was striking for remembering his original ("cute") widow's peak, which he soon lost forever. All eighteen of us two-year internet wore starchy white uniforms, probably the last time they were all so well ironed at the same time. The hospital laundry did wash them, but we bought our own, so uniforms were far from uniform. We shared the rigors of a two-year internship, without salary, rotating through all the services in preparation for general practice, but ultimately to measure up to the standard that you ought to become a doctor before you became a specialist. Today, an intern is paid about fifty-six thousand dollars a year. But there's a deceptive hook to that comparison.
The days of our 1948 internship followed the stock market crash of 1929 and the commodity crisis of 1930,s, -- years of depression, followed by wars and post wars, eventually finishing with two years of Korean War. We recognize now those were deflationary years, brought on by years of paying off the debts of World Wars I and II. In 1900 Philadelphia was thought to be the richest city in the world, eventually converting family-owned businesses into stockholder businesses, thus allowing industrial ownership to shift to Wall Street in New York. (There was also port-destruction by the maritime union, and wage-depressing migration from the South, suppressing wage levels, of course.) The consequence was protracted recovery from economic deflation, explained by conflicting theories of Maynard Keynes and Milton Friedman. Both were slow to perceive that medical revenues rose more slowly than economic circumstances justified for rapidly improving medical care; while the U.S. simultaneously struggled to pay off its war debts. Part of this was intended to hold down medical costs when corn flakes were substituted for beets and boiled potatoes for the resident medical staff.
Our grandchildren were to enjoy higher dollar income for doing easier work, yes. But grandchildren also accumulated a two hundred thousand dollar matching debt, mostly paid by the federal government, and often repaid later with federally-subsidized resident salaries. My grandson and I were to end up in substantially the same penniless condition, by different routes. Despite nine years after college without income, my generation never regarded itself as poor, because our future was bright. My grandson's generation, by contrast, enjoys a training period he seemingly hadn't earned. The big financial winners were the hospitals, insurance companies, and drug firms. The public may have added thirty years to its life expectancy, but could eventually foresee medical costs rising above what the public could afford. Although this complexity is considerably understated, essentially we had stretched ninety years of progress across forty years of revenue, It's almost too late to compensate the people who made the sacrifices, so we mostly compensate people who had other goals. Future sacrifices will be made by those who will almost surely outlive their retirement savings.
There's a trick to starting the internship on July 1. Without noticing it, the fourth of July quickly follows, and everyone else has arranged the schedule to have the newcomers suddenly in full charge of a hospital after three days of becoming a doctor. Let me tell you it is both a frightening experience and a totally unexpected one, with the fourth of July fireworks echoing three blocks away. Years later, I inventoried the records of the Pennsylvania Hospital for July 4, 1776. Not a great deal different from 1948.
Half a block away from the hospital was the mansion once occupied by Nicholas Biddle, comprising thirty or so rooms, reminding of the days when this was a rich neighborhood. One of Bob Gill's patients ran the Redevelopment Authority and offered the white elephant to Bob for the obvious bargain price of $25,000. It was no bargain because you could buy many similar neighborhood houses for $1500. The Biddle mansion had one condition; it had to be used as a single-family dwelling, so we had to split up our partnership since he had to run a medical office in it to afford it. Today, it posts a for sale sign for three million. Bob gradually filled the house with antiques and built up the Philadelphia equivalent of a Park Avenue practice in it, half a block from the increasingly posh hospital. Although Ben Franklin's own handwriting declares it is to be used for the sick poor, and if there is room, for those who can pay, the neighborhood circumstances gradually forced it into the mode of a fancy teaching hospital. It went from poor to land-poor, and eventually back to posh. In 1948 it was still a public charity, not finding it even worth-while to try to collect a 50-cent fee in the accident room.
Bob who died a few days ago at age 95, was one of three internets who were married, the rest of us stayed in the dormitory and played bridge on weekends. He was three years older than the rest of us because he started his educational career intending to become an engineer. Instead, he became a family doctor to the richest people in the city, as well as a member of the best clubs in town, and a famous historian of colonial Philadelphia. As a curiosity, he became increasingly British in his affections and interests, disappearing to London for long periods, and affiliated with many British organizations who for all I know regarded him as a British ex-patriot. He and I often enjoyed Thursday night roast beef at the Union League, single malt scotch at the St. Andrew Society, and his rehabilitated house gradually came to resemble a house on Wimpole Street. Nicholas Biddle once kept a baby elephant in the back yard, so it's not surprising to learn he had more outside yard space than I did in the suburbs, in retrospect a poor choice of real estate on my part.
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.