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.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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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.
Helen of Troy had launched a thousand ships. Lord Howe only launched four hundred and thirty, but they were bigger. It is estimated a thousand oak trees were cut down to build just one man o' war. To repeat what happened next, this flotilla was parked in lower New York harbor while forty thousand redcoats conquered Brooklyn Heights, Manhattan, Washington Heights, Perth Amboy, New Brunswick, Princeton, Trenton -- and then Washington promptly made fools of Howe and Cornwallis, at Trenton, Princeton, New Brunswick. Howe, and Cornwallis, in particular, were raging mad. The first year of the two-year siege of Philadelphia was over, and at half-time, the British team was popped up.
Lord George Germaine
The grand plan laid out in London by Lord Germaine was for Howe to capture New York, and maybe Philadelphia if it would be useful, while Gentleman Johnny Burgoyne took an army from Canada along that giant cleft in the earth which starts at the St. Lawrence River, down Lake Champlain, then down the Hudson from Albany to New York. The Hudson is very wide, and the British Navy would have no trouble sailing upriver to Albany, landing an army to meet Burgoyne coming south, with the effect of cutting New England off from the rest of the Colonies. Burgoyne got his orders in London shortly after Howe's January disaster in Trenton arrived in Quebec in May and started on his campaign June 20. Nothing dilatory about him. Howe, however, had six months to get to Albany before that, and several months more before Burgoyne would get to Saratoga, tromping through the woods and black flies. From Staten Island, it might have taken Howe ten days to sail to Albany in plenty of time.
Chesapeake Bay
Instead of that, Howe solitary and without advice, decided to take Philadelphia. Although the British never dwelt much on the fine points, the actual rebellion was only taking place in New England at the time the fleet set sail. It was the arrival of the fleet which triggered the Declaration of Independence, not the other way around. Lord Howe therefore probably felt some justification in revising the agreed plans and orders under which he set sail. As has been described already, the initial foray to Trenton ended embarrassingly. So, the capture of the enemy capital would now help people forget Princeton, and it would be sweet to whip Washington.
Unfortunately, they wasted a lot of time doing it. Finding Delaware too well fortified, and almost as snaggy as Henry Hudson had found it more than a century earlier, he sailed all the way to Norfolk, came up the Chesapeake and landed at the head of Elk, and marched for Philadelphia. The Brandywine Valley has deep sharp cliffs off to the right, so Cornwallis was sent off to the left as a flanker past Dilworthtown while Howe attacked Washington head on at Chadd's Ford. It was to be the largest battle of the whole Revolutionary War. When Washington found himself facing encirclement, he had to order a withdrawal. To skip a few events now memorable to the Main Line suburbs, Philadelphia was essentially then occupied without a further fight, with the British set up their defenses at Germantown, seven miles from the center of town. Three weeks later, Washington attacked Germantown in a three-pronged assault that mainly failed because two of his formations attacked each other in the fog. That was October 4, 1777. The news soon reached them that Burgoyne had surrendered the other British army --starving in the woods -- at Saratoga, New York on October 17. Howe had in effect abandoned Burgoyne in order to take Philadelphia, but it was probably as much a result of getting drawn into a tangle, as a single decision to disregard the grand plan.
In retrospect, it was quite a bad choice. All the world -- and the King of France in particular -- could see that Washington had beaten Howe at Trenton and then Gates and Benedict Arnold had soon beaten Burgoyne at Saratoga. General Gates, of course, was in charge at Saratoga, but Arnold was the flamboyant hero. Adding to his earlier exploits in Quebec and later providing the captured cannon of Ticonderoga for General Knox to drag over the mountains to Boston, thereby allowing Washington to drive the British fleet to safer distances, Arnold now essentially won two more battles at Saratoga. The first was to defeat Leger, who had been sent down Lake Ontario to come back up the Mohawk Valley to Albany. Then, turning his troops through the woods, Arnold joined Gates at Saratoga and defiantly led the charge that smashed the British line, when Gates would have been satisfied with containment. Arnold, like Alexander Hamilton, was a flamboyant man after Washington's heart.
Meanwhile, Howe settled down to enjoy winter at Philadelphia. His court jester and chief entertainer were Major Andre, who took wicked pleasure in using Ben Franklin's Market Street home as his own. There was additional satisfaction in knowing that Washington was freezing at Valley Forge.
There had been rumors for some time that the Please Touch Museum was planning to move from 21st Street to larger quarters, but recently its Executive Director Laura Foster appeared at a luncheon at the Franklin Inn Club to announce definite plans. The Museum moved into Memorial Hall in West Fairmount Park in the fall of 2008.
Memorial Hall Fairmount Park
There are over 400 children's museums in the world, and the first one was started in Brooklyn in 1899. Just why Philadelphia waited until the Bicentennial Celebration in 1976 to start one, is not clear. It's particularly unclear when you hear of its explosive success. Growing rapidly during an era when museums of all sorts are seeing declining attendance, the Please Touch Museum will be making its fourth move in thirty years, each time to larger quarters because they needed more room. Sooner or later, expansionism will get its comeuppance of course, and Memorial Hall is one awfully large building to fill. And to heat, and to paint, and to air condition. The price is right, however. The City Administration, which approached the museum with a proposal, has offered an 80-year lease for a dollar. When you hear that they have occasionally had 1500 visitors in a single day, however, and annual attendances approaching 200,000, almost anything seems possible.
Liberty Torch
There are certain limits. Nothing frightens a 4-year-old like a herd of 10-year-old boys racketing about, so there are segregations necessary. In other situations, these little kids not only can't touch, but they also can't see and they want to see badly. And the sociology is interesting. The kids may well clamor to come when they hear other kids talking, but in general, it is the parents who get the idea that a museum trip would be fun. And the parents seem motivated by theories of upward mobility, of giving their child a "leg up" on the competition. The museum is certainly filling a need, but you have to wonder where our society is headed if a picnic in the park is mainly a good idea if it gives junior a leg up.
Meanwhile, keep tuned. To fill up that monstrous Memorial Hall will take publicity, and these gals sound as though they mean to have a lot of it.
Monday Sepr. 17, 1787. In Convention (6th and Chestnut, Philadelphia).
The Engrossed Constitution being read, Doctor. Franklin rose with a Speech in his hand, which he had reduced to writing for his own convenience, and which Mr. Wilson read in the words following:
I confess that there are several parts of this constitution which I do not at present approve, but I am not sure I shall never approve them: For having lived long, I have experienced many instances of being obliged by better information or fuller consideration, to change opinions even on important subjects, which I once thought right, but found to be otherwise. It is therefore that the older I grow, then after I am to doubt my own judgment and to pay more respect to the judgment of others. Most men indeed as well as most sects in Religion, think themselves in possession of all truth, and that wherever others differ from them it is so far error. Steele, a Protestant in a Dedication tells the Pope, that the only difference between our Churches in their opinions of the certainty of their doctrines is, the Church of Rome is infallible and the Church of England is never in the wrong. But though many private persons think almost as highly of their own infallibility as of that of their sect, few express it so naturally as a certain French lady, who in a dispute with her sister, said, "I don't know how it happens, Sister, but I meet with nobody but myself, that's always in the right"- "Il n'y a que moi quia Toujours reason."
The signing of the Constitution
In these sentiments, Sir, I agree to this Constitution with all its faults, if they are such; because I think a general Government necessary for us, and there is no form of Government but what may be a blessing to the people if well administered, and believe farther that this is likely to be well administered for a course of years, and can only end in Despotism, as other forms have done before it, when the people shall become so corrupted as to need despotic Government, being incapable of any other. I doubt too whether any other Convention we can obtain may be able to make a better Constitution. For when you assemble a number of men to have the advantage of their joint wisdom, you inevitably assemble with those men, all their prejudices, their passions, their errors of opinion, their local interests, and their selfish views. From such an Assembly can a perfect production be expected? It, therefore, astonishes me, Sir, to find this system approaching so near to perfection as it does; and I think it will astonish our enemies, who are waiting with confidence to hear that our councils are confounded like those of the Builders of Babel; and that our States are on the point of separation, only to meet hereafter for the purpose of cutting one another's throats. Thus I consent, Sir, to this Constitution because I expect no better, and because I am not sure, that it is not the best. The opinions I have had of its error, I sacrifice to the public good--I have never whispered a syllable of them abroad-- Within these walls they were born, and here they shall die--If every one of us in returning to our Constituents were to report the objections he has had to it, and endeavor to gain partisans in support of them, we might prevent it is being generally received, and thereby lose all the salutary effects and great advantages resulting naturally in our favor among foreign Nations as well as among ourselves, from our real or apparent unanimity. Much of the strength and efficiency of any Government in procuring and securing happiness to the people, depends, on opinion, on the general opinion of the goodness of the Government, as well as of the wisdom and integrity of its Governors. I hope therefore that for our own sakes as a part of the people and for the sake of our posterity, we shall act heartily and unanimously in recommending this Constitution (if approved by Congress and confirmed by the Conventions) wherever our influence may extend, and turn our future thoughts and endeavors to the means of having it well administered.
On the whole, Sir, I cannot help expressing a wish that every member of the Convention who may still have objections to it, would with me, on this occasion doubt a little of his own infallibility--and to make manifest our unanimity, put his name to this instrument.
He then moved that the Constitution be signed.
When the last members were signing it, Doctor Franklin looking towards the President's Chair, at the back of which a rising sun happened to be painted, observed to a few members near him, that Painters had found it difficult to distinguish in their art a rising from a setting sun. I have, said he, often and often in the course of the Session, and the vicissitudes of my hopes and fears as to its issues, looked at that behind the President without being able to tell whether it was rising or setting: But now at length I have the happiness to know that it is a rising and not a setting Sun.
THE Revolutionary War ended militarily with the Battle of Yorktown in 1781, and diplomatically with the Treaty of Paris in 1783. The careers of Washington and Franklin appeared to be complete, while the economic and financial career of Robert Morris seemed likely to stretch for decades into the future. But as matters actually turned out for these three fast friends, it was Washington who was propelled into a new political career, Franklin soon died, and Morris got himself into a career-ending mess. The financial complexity and economic power of the United States did grow massively in the next several decades, but unfortunately, Robert Morris was soon unable to exert any leadership. At the end of Washington's eight years as President, the power of the Federalists, and particularly the three men most central to it, was coming to a close. John Adams had a tempestuous single term, and then Federalism was all over.
Robert Morris
The end of the Eighteenth century marked the end of The Enlightenment and the beginning of the Industrial Revolution, accompanied by many national revolutions, not just the American one. This was a major turning point for world history. The momentum of these upheavals still continues, but it is clear that the Industrial Revolution of which the Morris banking revolution was an essential part swept the world far faster than the social and political revolution, in which he also played a pivotal role. In the banking and industrial revolution, it is universally agreed that Morris was almost always right. In the social and political world, it is conversely agreed he was quite wrong. Essentially, Morris assumed that a small minority, an aristocracy of some sort, would rule any country. Within weeks of the ratification of the new Constitution, or even somewhat in anticipation of it, America made it clear that replacing an aristocracy of inheritance with an aristocracy of merit would not satisfy the need. Morris, born illegitimate and soon an orphan, was obviously in favor of promotion based on merit. John Adams defined leadership even more narrowly; he said a gentleman was a man who went to college, and he probably meant Harvard. Nobody extended the leadership class to include Indians and slaves, but the backwoodsmen of Appalachia made it clear that power and leadership at least included them. Thomas Jefferson was the visible leader of this expansion of the franchise, but changed his mind several times. James Madison switched sides; Thomas Paine switched in the opposite direction. The leaders of Shay's Rebellion and the Whiskey Rebellion lacked coherence and consistency on this point; instead of agitating for a refined goal, they mostly seemed to be running around looking for a leader. William Findlay, on the other hand, knew what he wanted. The issue might be defined as follows: it was obvious that hereditary aristocracy was too small and too inflexible to suffice, but it was also obvious that every man a king was too inclusive. An expanded leadership class was needed, but its boundaries were indistinct and contentious. But to return to Findlay, who at least had a clear idea of what he wanted.
William Findlay
William Findlay was a member representing Western Pennsylvania in the State Legislature, in 1785. It would be difficult to claim any notable accomplishment in his life; he was largely uneducated. The new leadership class must, therefore, include both the uneducated and the mediocre. The Legislature at that time met in the State House, Independence Hall, in Philadelphia, where no doubt the unconventional dress and manners of backwoodsmen did not pass without audible comment. Findlay made his own political goals quite explicit; he was for paper money to facilitate land speculation which could make him rich. Wealth was a goal, but it did not confer distinction. The rights of the Indians, the rights of the descendants of William Penn, the rights of the educated class and the preservation of property were all just obstacles in the way of an ambitious man who had carefully studied the rules. Everybody's vote was as good as everybody else's, and if you shrewdly controlled a majority of them, you could do as you please. If this meat-ax approach had any rational justification, it lay in the essential selfishness of every single member of the Legislature, working as hard as he could to further his own interest. If someone controlled a majority of such votes, then the majority of the public were declaring in favor of the outcome. Those who believed in good government and the public interest were saps; the refinements of education mostly just created hypocritical liars. There was a strain of Calvinism in all this and a very large dose of Adam Smith's hidden hand of the marketplace. If you were rich, it was proof that God loved you, if you were poor, God must not think much of you, or He wouldn't have made you poor. Findlay had the votes and meant to become rich; if his opponents didn't have the votes, they could expect soon to be poor. In this particular case, the vote coming up was a motion to renew the charter of the Bank of North America. Findlay wanted it to die.
America's first bank, the Bank of Pennsylvania
It came down to a personal debate between Findlay, and Robert Morris. Morris had conceived and created America's first bank, the Bank of Pennsylvania. Today it would be called a bond fund, with Morris and a few of his friends put up their own money to act as leverage for loans to run the Revolutionary War. After a short time, it occurred to Morris that the money in a bank could be expanded by accepting interest-bearing public deposits and making small loans at a higher interest rate, which is the way most banks operate today. Accordingly, a new bank called the Bank of North America was chartered to serve this function, which greatly assisted in winning the Revolutionary War. There was no banking act or general law of corporations; each corporation had its individual charter, specifying what it could do and how it would be supervised. When the charter came up for renewal, Findlay saw his chance to kill it. Morris, of course, defended it, pointing out the great value to the nation of promoting commerce and maintaining a stable currency. The reply was immediate. Morris had his own money invested in the bank and only wanted to profit from it at the public expense. His protests about the good of commerce and the public interest in stable money were simply cloaking for this rich man's greed to make more money. Findlay made no secret of his interest in reverting to state-authorized paper money, which could then be used by the well-connected to buy vast lands in Ohio for speculation. There were enough other legislators present who could see welcome advantages, and by a small majority the charter was defeated.
John Hancock
At this point, Morris made a staggering mistake. After all, he was a simple man of no great background, largely uneducated but fortified by his ascent in society from waterfront apprentice to the highest of social positions, a friend of George Washington and Benjamin Franklin, acclaimed as a financial genius, the man who saved the Revolution, very likely the richest man in America. For many years, he had harbored not the slightest doubt of his personal genius, his absolute honesty, and total dedication to the welfare of his country. To have this reputation and accomplishment sneered at by a worthless backwoodsman, a man who would stoop to using the votes of other backwoodsmen to accomplish self-enrichment, was intolerable. Morris announced and actually did sell out his entire business interest as a merchant, at a moment when he fully understood the new nation was about to enjoy an unprecedented post-war boom. So much for his self-interest. It helps to understand that John Hancock and Henry Laurens had done the same thing in Boston and Charleston, against what we now see as a strange aristocratic tradition of prejudice against bankers and businessmen. In even the few shreds of aristocracy now surviving in Britain and Europe, the tradition persists that a true aristocrat is so independently wealthy that no self-interested temptations can attract him away from purest attention to the public good. The original source of this wealth was the King, who conferred high favor on those who served the nation well. A curious exception was made for wealth in the form of land, the only dependable store of tangible wealth, and transactions in land. Wealth was something which came from God and the King in return for public service. Land ownership was its tangible storage and transfer medium. Otherwise, grubbing around with trade and manufacture was beneath the dignity of a true gentleman.
Henry Laurens
We now know what was coming. Wealth was soon to be the reward of skill and merit, recognized by fellow citizens in the marketplace, by consensus. Findlay and his friends wholly accepted this conclusion, unfortunately skipping the merit part of it for several decades. In their view, you were entitled to the money if you had the votes. As the nation gradually recognized that rewards must be durable, and once granted were yours to have and to hold, the new nation gradually came to see the need for durable ownership of property. Unless or until the owner places it out at risk in the marketplace, legislative votes may not affect its ownership. Our system ever since has rested on the three pillars of meritorious effort, assessment of value by the free market, and respect for pre-existing property. That's quite a change from the Divine Right of Kings, and therefore quite enough material to keep two political parties agitated for a couple of centuries. And quite enough change to bewilder even so brilliant a victim as Robert Morris.
Extensive premium changes in health insurance followed the introduction of the Affordable Care Act. Most changes involved an increase in patient participation in the costs, either deductibles or coinsurance, coupled with a "cap" on total patient payments. Almost all insurance seemed to grasp the futility of co-payment as a purchasing restraint, substituting fairly high deductibles for the old 20% co-pay. As election day nears, we are seeing a rash of articles about the hardships of front-end deductibles, during the first year of their introduction, and the largest patient group with this kind of experience are holders of Health Savings Accounts. A sudden media clamor about one point generally suggests some political stirring-up is taking place, but perhaps it is fast-breaking news that someone with a torn fingernail decided to bandage it herself rather than go to the accident room, all because of the shocking discovery that the days of first-dollar coverage are fast receding. The lady in the article didn't mention any other medical debts, but that is surely coming in the news.
After Medicare was introduced in 1965, I had already been in practice for fifteen years, and it did not surprise me how many patients, indigent and otherwise, had snaggly teeth, perforated eardrums, amazingly big hernias, gall stones, extensive varicose veins, and gigantic prostate glands. It was just the way things were, and doctors set about treating 'em as they appeared. What amazed me, six or seven years later, was the supply of these things had greatly diminished. Only then did I realize that people had been holding back on elective surgery because of finances. This backlog was a reasonably good measure of the benefit which Medicare was having, by giving elective surgery away free.
But that was only true if you consider every single remediable condition to be a disgrace of some sort. The people who had these conditions had weighed the costs against the benefits and had often simply declined. You could argue if you must, that poor folks just couldn't afford to get essential treatment, and that anyone who denied them this essential human right was an ogre; but that didn't appear to be the case in large measure. What was true was that the threshold for offering charity care was set to match the judgment of the decliners, rather than the level of physical perfection of an ancient Greek god. Folks just didn't think the surgery was worth the money, but when it became free, a new standard was set and they might as well get it fixed like a dent in an auto fender. Nevertheless, there's a strange fact about surgical scarcity and abundance. If you are planning on having any of these procedures, I would advise getting a surgeon with training during that catch-up period of the nineteen-seventies, because he had a lot of practice. In fact, my granddaughter flew to Nashville to have a perforated eardrum repaired by a famous expert during that period. When she recently needed a second operation after forty years, she had trouble finding a surgeon who could do it, even with half a dozen doctors in her family.
Surely a front-end deductible won't get us back to the same state of affairs, even if deductibles continue another forty years. But to some degree, it will happen, and what we once called a backlog will resurface as a debt from one time period to the next, with the threshold reset. Since we definitely need deductibles, it seems we apparently also need a small backlog of untreated elective (non-fatal) conditions, whether they do better than that in France or Sweden, or not. Since it can be safely predicted this will happen, we need to devise a way of managing the issue without provoking unsustainable costs. In the meantime, known but untreated, treatable conditions will become an accounting entry, which can fairly be attributed to the solving of our health cost issues. It's a debt, but I'm not sure total bodily perfection is the best standard of it.
Foreign debts for Medicare. For some time, Medicare has been 50% subsidized by federal borrowing. At the very beginning in 1965, it was 100% federally subsidized, and gradually payroll deductions, premiums and new programs with better funding arrangements took over. So far as is easily determinable, no one has dug out all of the subsidies and repayments, to be able to tell us what the accumulated unpaid debt for the Lyndon Johnson entitlement programs has been. What it has accomplished is harder to measure, since it must include a share of the improved longevity during the interval. Nevertheless, we could make an effort to see what the book cost has been. Surely it has been greater than just the cost of elective surgeries. At first, the creditors were all American citizens, most taxpayers, but at least it kept the money within the domestic budget. Since we started to borrow the money from the Chinese government, it assumes a different character, one which any creditor would feel entitled to evaluate. To know what to do about this debt is above my pay grade, as they say, but at least it would seem to be responsible stewardship to make a formal accounting of where we stand, and what we plan to do about it.
Domestic Healthcare Debts. Without getting into a wrangle about the Tenth Amendment, it is fair to say that health care has long been thought to be a responsibility of the several states, so at the least, the fifty state budgets would have to be examined and aggregated, perhaps the municipal budgets as well. In Philadelphia, the deficit of PGH (Philadelphia General Hospital) was running eleven million dollars a year, when it closed in 1977. The nation's first hospital, the Pennsylvania Hospital, was created by a grant from the state legislature in 1755, at a time when Ben Franklin was active. Perhaps it is not necessary to go quite so far back to see how the books balance, but any adjustment for inflation would bring out the considerable taxpayer expenditure for health, ever since the nation was founded.
Sustainable Growth Factor. Every year since 1997, Congress has calculated the rate at which health costs should be growing, and when it exceeded that, has planned to reduce physician reimbursement to compensate. Every year Congress has relented at the last moment, but never put an end to the threat. Since the accumulation has reached a point where almost every physician in practice would have to stop the practice if Congress honored its threat, something must be done about it. Paying it all off at once would trigger a 26% drop in physician income since every physician carries a 50% gross overhead, collecting an additional 26% would be a disaster. Perhaps the two political parties each hope the other will get the blame and pay the bill. But the bill remains part of the debt hanging over the Federal Government for health entitlements, and like most of this debt, it is a question how to treat all of its inflation in the interval.
Healthcare Mortgages. Bill Dunkelberger the Philadelphia economist, recently remarked that real estate is where the rubber hits the road, the place where interest rates really matter, the place where equities collide with fixed income. For eight years past, our long term interest rates, net of inflation, have been close to zero. That allows the government to borrow free of charge, and in effect allows hospitals and universities to build buildings without much or any cost.
Unfortunately, our businessmen have not responded with a comparable spree of interest-free borrowing, because they see nothing worth borrowing to build for. Their unwillingness to spend leads to the appearance of growing earnings, which artificially supports the stock market. It's hard to imagine a stock crash just because prosperity returns, so it's hard to know what will happen if it does. Hospitals and universities think they have something to build which will generate a healthy return for them, so one builds out-patient facilities, and the other builds lavish dormitories. When interest rates return to normal (they haven't, in Japan, done so for seventeen years), it's a puzzle to know whether the economy and the stock market will tank, or will celebrate. In any event, there is a great deal of new real estate debt which must be added to the level of government indebtedness, due to health. Since nothing much could be done with such single-purpose structures, their disposal is also part of the consideration. When Jefferson University received a gift of a basic science building to house the first two years of its classes, they got a maintenance jolt. Just to heat, air condition and clean the building consumed the entire tuition of the first two years of classes.
Student Loans, broadly defined. To judge by Nineteenth-century plays and novels, medical students were traditionally impoverished. Today, students of all descriptions are carrying six-figure indebtedness, but medical students are a special case. They run up debts in order to stay in school, and the schools prosper. Then, they take jobs for several years as house officers in hospitals, who are paid by the government from Medicare funds which are used in large part to pay off their loans. And then, they go into practice, often reimbursed by salaries provided by government entitlement programs like Medicare and Medicaid. It's more than I am able to say whether these successive loans add to each other, or cancel each other out. In any event, a huge amount of money is being paid for what is described as medical education, but a certain amount of it is diverted to other university uses.
Future Entitlements. In many ways, the largest indebtedness to account for, are entitlements which have been conferred on future generations, many of whom are not yet American citizens. This is the problem most pension funds are now encountering, of whether such a future promise is a contract which must be honored, that is, whether it counts as a debt. Congress certainly acts as though it must say it is a contract, or else be dis-elected. But the rest of us would not regard that as much of a tragedy, so perhaps it isn't a debt. Whatever we end up calling it, it would surely be an improvement if we could hear it accounted for as if it were the debt of a corporation. Perhaps that wouldn't lead to improving the situation, but it would certainly feel a little better.
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.
