As the nation's health steadily improves, it's going to cause some problems of a social nature.
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The most astoundingly good news about health is frightening, precisely because it is so astoundingly good. The average life expectancy of Americans has increased by three years during the last decade. That's right, we got thirteen years for the price of ten. Most of that improvement has come from taking daily aspirin tablets, or from taking the anti-cholesterol "statin" drugs, with a resulting decrease in the death rate from heart attacks and strokes by roughly 30%. It seems possible to hope for another three-year extension of lifespan in the next decade; when statin drugs lose their patent protection they will become a lot cheaper, and many more people will take them regularly. It seems churlish to emphasize the negatives of such a miracle, but unfortunately, it's questionable if our political and financial mechanisms can readjust to such an unprecedented commotion.
It could get much worse. The improvements in cancer treatment have lately been much slower and more expensive. If someone invented a treatment for malignancy which proved to be safe and cheap, we could get another five years, followed by still another five years as the patents run out and doctors get the hang of using it. Everybody could then reasonably expect to live to be ninety. What the Social Security and Medicare budgets would look like under those circumstances, must simply boggle the mind. If people mostly lived to be ninety, comparatively few of them would have much serious illness before they were sixty-five. The vast bulk of medical expense, for practical purposes almost all of it except obstetrics and psychiatry, would become Medicare expense. People would of course eventually die of something, and all of those terminal care costs would be Medicare costs. The government would, of course, begin to see what is happening and attempt to change the political arrangements for financing it, but that would be resisted bitterly, and it would be slow. What would not be slow would be the decision by employers that there is no sense in accepting financial responsibility for health costs which no longer have much impact on working people. Right now, health insurance amounts to forcing employees under the age of forty to subsidize the costs of other employees between the ages of forty to sixty-five. If that curve shifts to the point where everybody under sixty-five is essentially subsidizing people on Medicare, well, say goodbye to employer-based health insurance. Not later, right now. At the end of whatever calendar year, employers all wake up together and start a stampede out the door.
The first issue, of course, is not how to shift around the costs of medical care, but how to pay for staying alive. We can raise the age for beginning Social Security benefits, but that doesn't create money, it just shifts retirement cost from the government to the individual. What matters is that people must keep working longer, earning at least enough to support themselves; and that implies greater competition with younger people for available work. It may mean greater resistance to immigration, particularly illegal immigration, and a greater appreciation for frugal living. But shifts of twenty or thirty percent in the workforce within a decade probably cannot be accomplished, any more than they could be accomplished in Africa after the elimination of epidemic diarrhea and other tropical diseases. Genocide as an avocation does not seem very appealing, either. One suspects something similar happened to India with British colonial rule, better water and drains, and all that. And one has to speculate that something like that is being concealed in China, for all its vaunted growth in Gross Domestic Product. Selectively killing all girl babies at birth, and all boy babies after the first one seems more drastic than we would accept. But we must eventually do something, with the first step being a general appreciation of the problem. Overpopulation may or may not be the problem; the problem is too many healthy people past the traditional age of employment.
Somewhere in the writings of Aristotle is the maxim that all culture comes out of the wealthy classes because only the wealthy have time for it. Aristotle is obviously now out of date on that topic, because we can easily foresee a population of healthy old folks with time on their hands. Our cultural institutions seem painfully slow to recognize, not just their new customer base, but the potential creative base. Surely, Grandma Moses is not the only artistic self-promoter in her age group. And surely, adolescent love affairs are not the only topic capable of attracting a mass audience. Improved cataract extractions, better hearing aides, and outstanding dentistry will surely make it possible to foresee more grown-up tastes in music, the visual arts, and culinary skills. Once these old folks stop predicting their own impending deaths and face a twenty-five-year future on the golf course, a flowering transformation of the arts is safely predictable.
But that's not enough. Most people were not born with the talent to carry a musical tune or draw a straight line, and many of those who do have some talent feel the arts are trivial. For most people, the way to fill up a quarter of a century is to go back to work. I didn't say it was easy. There is just no feasible alternative.
In 1965, the originators of Medicare made two mistakes, both of which seemed perfectly understandable at the time. To get the program rolling, they enrolled my parents' generation to enjoy the benefits without charge, if they were already over age 65 (my mother lived to be 103). And for the same reason, they used current revenues to pay for such older people, who had never contributed to their own costs. The system was called "pay as you go" to justify taking current revenues to pay for benefits unsupported by previous contributions. Money flowed out as fast as it was received, but Medicare never made a serious effort to catch up.
Consequently, there was no interest paid for the use of the money, but the program did get started, years before it would otherwise seem feasible. The program is now over fifty years old however, and it still isn't gathering interest on cash which doesn't get spent for decades. Furthermore, the health of the population invisibly improved so rapidly that decades were added to the lifespan of Americans, and the interest income being lost steadily increased, as well. Since everyone likes to live thirty years longer, pay as you go was considered a reasonable price to pay for it.
However, the possibility has apparently been overlooked that a transition to pre-paid insurance might only be mildly painful. And even if the transition proved to be very painful, eventually the cost savings of Medicare passed on to the subscriber, might be reduced by millions and millions. It is now time to examine whether biting this bullet could really be relatively painless any longer and whether it would save much money. The answer appears to be Yes to both questions. To begin, the arithmetic will be skipped, and the reasoning explained. Following that, the arithmetic is concentrated for those who wish to reassure themselves; it may be skipped by those who don't. If you get the reasoning straight, the math is easily checked by compound interest calculators on the Internet. If you do that, you may find the Internet calculators sometimes create some errors themselves, however, so check your fact-checking.
Medicare is partially prepaid by withholding roughly 3% of a subscriber's wages in advance, as can be seen on any pay stub. From age 25 to age 65, the money aggregates to equal about a quarter of Medicare's actual cost. Another quarter is repaid by premiums, from people actually receiving Medicare. Although the data is overwhelmingly voluminous, it can be found among the Internet reports of CMS, the Center for Medicare and Medicaid. Since patient payment revenues thus aggregate to only half of the total Medicare expenditures, the residual half is paid out of the general fund of taxes, and later borrowed to restore the fund. (Partisans might say it is laundered through the general fund before it is borrowed.) About 13% of our bonds are held by oriental foreigners, and most of the rest is loaned to American citizens. This is how Mrs. Sibelius explained things in her report on the Internet when she was in charge of it. The accumulating debt is now becoming serious, even accounting for the slang phrases used in Congress, suggesting this debt can never be repaid. Stick it to the Chinese, except 87% of it is ultimately owed to U.S. citizens. And U.S. citizens would take most of the haircut, as another saying goes if the debt were dishonored.
Now, focus on an important feature of the average Medicare cost. As a total departmental cost, it includes every person who becomes eligible for Medicare by attaining age 65. It is not exactly what the average person pays, rather, it includes the whole program including those who pay nothing. Therefore, privatizing Medicare with the same funds would not deprive the indigent of anything at all; present funding already includes them. That's one of the main attractivenesses of "single payer", defined as Medicare for everyone at any age-- it's essentially all-inclusive. Unfortunately, its deficit is all-inclusive, too. For present analysis it's a rhetorical advantage to say, any new system using the old money would be all-inclusive as well. Except for half of the increased cost causes a correspondingly increased deficit. At present, the annual deficit is about $200 billion.
It's also important to acknowledge that extended retirement benefits are an innate obligation of Medicare, and right now retirement costs aren't provided at all, except for the (older) Social Security program. Good care leads to a longer life, and we should be grateful. But longer life is expensive, and most people will find they have not saved nearly enough to make it comfortable. For this, there should be more sympathetic. Nothing like this had ever happened before, so some skeptical people cannot be entirely blamed for wanting to see some hardship before they believe the government cannot borrow its way out of it. The financial crunch of some sort is surely coming in the near future because we are recovering from a recession, a political party deadlock, and the threat of both domestic uproar and international discord, both at once. But the health care arithmetic remains pretty clear, as we will see in the next section.
At present, about half the cost of Medicare is recovered by the U.S. Treasury. Without paying any interest, the revenue immediately gets spent, and an equal amount is borrowed -- that's what we just said. So to speak, we only propose to change the mailing address of the checks, that's what we also said. Just deposit that same money (in the same amount) into your Health Savings Account, get a tax deduction for doing so, and earn compound interest on the combined amount. With a tax deduction adding 18% in value and transferring the money at age 65, it will in fact be more money than you appear to need, and it would certainly be less debt.
For the first time, it provides some retirement money "to compensate" for the extra longevity Medicare has provided. If you earn enough investment income (say, 7%), it will be enough to pay for the whole program, including indigents and disabled, so long as they are over 65 or entitled to a special Medicare disabled program, as 9 million already are. Remember, that promise includes a retirement fund. If you don't earn enough investment income, it won't cover it all but it will surely cover more than it would have, without any compound interest and tax shelter. And the investment return would probably be increased at the expense of the financial community, who will resist. Fee-only advice, rather than commissions, would add about one percent to investor returns, according to the Wall Street Journal, although lobbyists for Wall Street vigorously deny it. The proposal here is to insist both systems operate side-by-side until the difference is clear.
Although the arithmetic seems to be pretty evident, we do advise creating a contingency fund in addition, just to be safe. The contingency fund would have to be at least a hundred dollars at birth and might be as much as two hundred-fifty. That's the only extra expense for a lifetime of healthcare and retirement which actuaries estimate to cost an average of $350,000 per average lifetime, plus an equal amount for retirement, to say nothing about the hidden elimination of the government's deficit for Medicare. That's a pretty good bargain, so we suggest consideration of paying some of the resulting surpluses to a children's fund, rather than just letting it appear in estates. You can tell yourself you've helped little children while protecting yourself against contingencies. The Medicare crisis goes away, the Retirement crisis is abated, the national debt stops expanding, and a start is made on the childhood problem -- all with money you're already spending, plus a hundred or so dollars, just for safety and dignity. Read on, just in case you are good at math, and you don't believe in miracles.
By the way, it has been implied this release of money is due to inflation, and it is true the inflation assumption (for income and general expenses alike) remains about 3%. But the real success secret beyond any person's control is inherent in the mathematics of compound interest. When an investment goes much beyond thirty years in duration, the effective interest rate rises spectacularly; you can thank Medicare for that, if you wish, or perhaps Aristotle. Inflation raises your retirement cost, that is true. But it also raises your income, so at present, it's a short-term wash except for scientific advances, which are surely a long-term net improvement.
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The Escrow subaccount within Health Savings Accounts now stands unveiled for what it is -- a transfer system between plans. It pays for health insurance, usually not for current care but designated for underfunded future care. Regular Health insurance sometimes contains similar communication-and -funds transfer channels, but informal ones, patchwork for adding new features to existing ones, as in adding federal funds to state-controlled Medicaid. We here offer the escrowed Health Savings Account as an individually owned policy, specifically incorporating specific finances of a string of pearls to new ones with independent delivery- system regulations. As long as the pearls are careful, they can have a neutral transfer system, like the state-national one for the rest of the economy. Disputes are regulated by the courts under a common Supreme Court. The Court might be a new medical one, or use the one we already have.
This tripartite system not only conforms to the Constitution but restrains mission creep. That's historically why we have a Bill of Rights, although the document doesn't say so.
If the escrow subaccount is purely a transfer system between Pearls on a String, what is the function of the non-escrow portion? It is to permit each Pearl to fund separately and independently, and to make it easier to keep one Pearl from subsidizing another inadvertently. An argument can be made that New York now subsidizes Mississippi within the Federal Reserve monetary system, but that was for facilitating the approval of the various states -- the states which badly wanted a Federal Reserve would be taxed extra to get it -- but it is uncertain whether the same considerations apply to healthcare. The absence of cross-subsidy may be seen as an advantage in Healthcare, and therefore the issue should be decided by Congress. Perhaps decision could be delayed until the public gets a sense of what it wants after some defined period of experience.
When Health Savings Accounts were first discussed, it was assumed they would be funded by employer contributions, so and so many dollars per month or per quarter per employee. Tax deductibility would be decided once, and probably continue indefinitely for a class of employees or a certain type of employer. Actually, that proves to be the most difficult method to determine, because health insurance is given to the employee as a gift, and therefore has already been made tax-exempt. The potential for double tax exemption is raised, and various strategies could be adopted to simplify the tax status.
The double tax exemption might well be re-examined, but much of its unfairness traces to employer's inequitable tax exemption in the first place, which we have repeatedly suggested Congress equalize. It might be compared with using the income from municipal bonds, also tax exempt and tangled up in the minimum tax provision as well. If the amount of questionable deposits is overall fairly small, the matter can be taken up in a general revision of taxation and passed over for the present.
Last year of life insurance is life insurance, retrospectively paid after the death of the subscribers to his health insurance company. Although theoretically reimbursement could be made for actual individual expenditures, it is a more powerful idea to reimburse in the amount of the calculated average last-year costs of the community. It could loosely be said this approach constitutes 100% reinsurance of a selected peril, in order to suggest possible variations, such as 105% reinsurance (to transfer administration costs), 80% reinsurance (to encourage case management ), etc.
The last-year-of-life concept should be regarded as a tool for coping with certain problems inherent in the system of basing health insurance on employer groups. Employer-related health insurance is tax-favored, reduces marketing costs, and almost eliminates risk to the insurers; it is far easier to modify such a system than to reform it. However:
Non-random perils like AIDS may cause insurers to withdraw from ensuring particular companies or even whole industries.
Employees who retire early for reasons of health may find themselves unable to obtain health insurance after the COBRA protection period.
There is presently no method available for young people to guarantee their insurability before they enter permanent employment, or for employees of any age to guarantee their insurability in the event of company insolvency.
The risk of losing insurability is present in every change of employment; job immobility is created when fear of health insurance problems is on the employee's mind. Early retirement may be rejected for fear of exposure to loss of health coverage between the time of retirement and the onset of Medicare coverage.
Serious dilemmas for corporate funding of post-retirement health benefits have been created by a fear that voluntary pre-funding such obligations may create cash targets for corporate raiders. An employee has no legal rights to the prefunded reserve even though he may have legal claims for the eventual benefit obligations
Consequently, the most conservative present estimate of unfunded post-retirement health insurance obligation is $100 billion, and it may be four times that.
Since last-year-of-life insurance is life insurance, it might be provided as either term insurance or cash-value insurance. Although cash-value insurance has obvious advantages for the problems listed above, it would not enjoy the same tax-sheltering which term insurance would have, and consequently would require legislative relief to be fully effective. However, term insurance might well offer some relief for the AIDS problem.
Insurers are leaving the Washington DC area because of prohibitions against screening for AIDS, and Massachusetts also has a law against testing. The obvious first resort of an insurer is to withdraw from covering companies involved in the arts, design, theater, etc, and this tendency is paralleled by rapidly increasing detox and rehab costs for cocaine abuse, which have led to harsh exclusions for psychiatric care. The point is that employer-based insurance seldom includes a premium provision for risk, and if a particular peril cannot be excluded then a general class of service or a particular sort of employer is excluded as a proxy for it.
In this particular instance, it is proposed that insurers explore the willingness of their group markets to shift coverage of last-year costs from company-specific to community-rated premiums while continuing to be experience-rated for all other perils. If the various trade-offs were favorable, then insurers might be willing to discontinue offering last-year coverage except through the community-rated life insurance route. At present, the experience is probably insufficient to judge whether a market-driven voluntary approach would be effective. In the event, most companies proved willing to adopt the approach but insurers feared non-compliant competitors who saw an opportunity to steal business, then the public-interest need for legislation to protect the health insurance industry from disruption by the AIDS problem would have to be debated. For those who dislike compulsory solutions, it is exasperating to discover that the insurance industry generally prefers to be compelled by law since to move ahead in a cooperative manner is to invite anti-trust action.
In this particular instance, it is proposed that insurers explore the willingness of their group markets to shift coverage of last-year costs from company-specific to community-rated premiums while continuing to be experience-rated for all other perils. If the various trade-offs were favorable, then insurers might be willing to discontinue offering last-year coverage except through the community-rated life insurance route. At present, the experience is probably insufficient to judge whether a market-driven voluntary approach would be effective. In the event, most companies proved willing to adopt the approach but insurers feared non-compliant competitors who saw an opportunity to steal business, then the public-interest need for legislation to protect the health insurance industry from disruption by the AIDS problem would have to be debated. For those who dislike compulsory solutions, it is exasperating to discover that the insurance industry generally prefers to be compelled by law since to move ahead in a cooperative manner is to invite anti-trust action.
The preceding, or "term-insurance" approach has the advantage of gathering useful information about the last-year concept without requiring extra tax sheltering or even the formality of separate policies or insurance subsidiaries. It could be retrospectively tested on paper without much cost or any risk, and it might be held ready as a potentially useful tool for the eventuality of the AIDS epidemic provoking serious disruption of health insurance. However, much more important benefits might grow out of the cash-value life insurance or refunded, approach to last-year-of-life coss. Since last-year expenses come at the end of a 70+ year life expectancy, the opportunity for compound interest to work is at a maximum.
Under this approach, the initiative would lie with life insurers, who would be induced to include a standard beneficiary clause in their policies. That clause would assign the community-average last-year health cost reimbursement to any health insurance company which had assumed those costs and had previously provided the beneficiary with appropriate consideration for making the assignments. (At the moment, the various secondary adjustments between employer, employee, health insurer, and tax collector can be left to the marketplace to work out. If no one makes an adequate offer, the beneficiary simply has some life insurance).
The cost of such insurance might turn out to be fairly modest. Although average last year-of-life health costs might be guessed to approach $20,000 per death, the comparatively low death rate before the age of 65 means that an average life insurance policy of less than $5000 (with proceeds exhausted at 65) could conservatively be guessed to cover that need. After age 65, every person can reasonably expect Medicare to have a last-year obligation. Using a 65 investment assumption, the present value of such policy would be $250 at birth; a 3% assumption would only be $500 and would allow general inflation the economy to be ignored. (The $5000 figure would seem to allow generous room for potential innate health-care cost inflation, inasmuch as last-year coverage does not require any provision for recovery from one formerly-fatal condition only to die later of a second fatal condition, which is the main cause of "innate" health cost inflation.) Presumably, the best protection against future health cost escalation is to purchase more insurance than is thought to be needed, expecting any surplus to flow into the estate. Even taking a conservative view of the health-cost escalation problem, its possible to imagine premium costs of $100 per year during thirty years of working life.
Although the marketplace could be expected to determine how much reduction in health insurance premium would be accorded for the lifting of last-year risks, the main value of this coverage would appear in the case of someone who was uninsurable (? ie unemployable?) without it, or who would have been afraid to switch jobs without it. When individuals sustain periods of loss of income, the possession of this insurance might be regarded as a form of catastrophic health coverage, which for the temporarily unemployed might be an absolute minimum coverage. The reasoning is that this type of coverage can be switched on or off; a treaty of assignment need only be signed if the individual finds it advantageous to use it, and is later revocable at will. The policy, in short, is his not his employer's but can be made to coordinate with employer benefits.
Medicaid programs are rather dubious candidates for this approach but even they might be induced to be more generous with last-year coverage (probably under either a term-insurance or waiver-of-premium approach) than they have typically been with full health insurance, the becaused potential for abuse is eliminated.
Finally, the relationship with Medicare needs to be explored with HCFA. After all, Medicare is the main health insurers of fetal illness costs. Far from ever escaping these costs, Medicare has a major concern that it may also have to assume long-term custodial and nursing home costs. Far from ever escaping these costs, Medicare has a major concern that it may also have to assume long-term custodial and nursing home costs. In this matter, Nature provides a certain trade-off. Dying young and outliving your income are both tragedies, but few people have both of them. There is a need to consider ways of transferring costs between the two largely-exclusive problems. The aggregate community cost of fatal illness after age 65 is much heavier than it is up to age 65; possibly $20,000 average coverage would be necessary. Since compound interest would have longer to operate, however, the premiums or present-value costs would not necessarily be proportionately larger. A premium of $40 (1988 dollars) could be imagined; there is no reason why premiums could not be inflation-adjusted on a yearly basis as an alternative to making overly conservative interest-rate assumptions.
The proposal is to explore with HCFA he attractiveness to them of providing some degree of long-term care coverage in return for surrender to them at age 65 of paid-up life insurance adequate to cover fatal-illness costs.
QUESTION: If the health insurer agrees to lower his premium, and subsequently pays the last year costs for the subscriber, how can he be assured the life insurance will eventually reimburse him?
Since health insurance is mostly in employer groups, covering only expenses n the current year, the health insurer can limit his concern to the current year. The health insurance annually needs a slip of paper guaranteeing payment by a life insurer, in the event of client death. Three main methods are available, each with implications about who owns and controls the process:
One method is to follow the reinsurance model strictly; the employer pays the health insurer, who then pays a life insurer for "reinsurance". In this case, the health insurer controls the process, which is almost invisible to the employer an employee.
Where the employer already has a group life insurance benefit, he might well wish to send the check directly to the life company for a somewhat larger benefit(simultaneously reducing the payments to health insurer). While this approach gives control to the employer, it also gives him the headache of negotiating the premium adjustments.
Both of two foregoing approaches would be administratively very convenient, but neither one provides the employee with portability between employers, bridging of episodic gaps in employment, etc. For the employee to take advantage of portability, carriers other than the company carrier must be utilized. The employer's health carrier would then need yearly slips of paper from a number of life carriers, most easily obtainable as part of the yearly premium billing process for the life insurance. Such a paper would amount to a rebate coupon, issued by the life insurers, honored by the health insurer.
It is essential to keep paperwork simple for an estimated premium of about $100 a year for a term an $400 a year for cash-value life insurance (of course, only$100 of either would be transferred to the health insurer). Consequently, insurance management would want to look into bulk communication: "Dear Health Insurer, Our records show the following clients have exclusively assigned the average last-year health benefit to your company for deaths which might occur during the period between A and B. Yours Truly, Life Insuror"
Because of the problem of differing premium dates, the insurance industry might further wish to agree on a calendar or other standardized year definition for this type of coverage. The administrative issue can be stated in the plainest possible term: the extra administrative cost of this approach is the price of portability.
QUESTION: No underlying health insurance.
Although an individual with cash-value life coverage could borrow against it to pay health costs, terminal or otherwise, the issue has been raised as to how someone would employ the life insurance mechanism if he did not have any underlying health insurance, but did have term life insurance. Alternatives would be:
He could purchase health insurance with a front-end deductible equal to the face value of the life insurance. MONY sells a $25,000 deductible policy for about $200 a year family premium, with a $1,000 top limit. Such a combination would protect for more than just terminal illness, but it would not protect against more than one heavy cost. For what would presumably be a very low extra premium, he would need another reinsurance policy to cover multiple illnesses. Such reinsurance might have two parts: one part to cover the remote possibility of exceeding the deductible more than once, and another part to cover the deductible on what proved to have been a non-fatal illness. This degree of coverage goes considerably beyond the last illness concept and would naturally cost more.
The main problem with this life-insurance-to-pay-off-the-high-deductible approach is that it presumes the beneficiary would pay his bills in cash and contains no way to spread the risk. Therefore, everyone ends up either overinsured or underinsured. A smaller issue is that he would pay full charges without a way to negotiate volume discounts at hospitals. Taken together, this approach would be unnecessarily expensive.
An approach more narrowly related to the cost of terminal illness would be for the life insurer to pay last-year costs, large and small, but only reduce the net death benefit to the estate by the average community terminal illness cost rather than the actual case-by-case expense. Once the average rate had been established, it would become possible to tailor the insurance coverage, leaving a suitable margin for year-to-year inflation and other contingencies.
The degree to which carriers could pool claims data in arriving at the average cost is an anti-trust question; the definition of a covered expense is purely a question of practicality within claims administration. However, differences of opinion about the feasibility of different coverages might make data sharing less practical.
QUESTION: What if there are multiple carriers involved?
On examination, this question relates mainly to carelessness, misunderstanding or incompetence on the part of the subscriber. Even if the individual has multiple life insurance carriers, he would be foolish to execute a last-year beneficiary clause with more than one of them. Consequently, no such clause should be permitted unless it defines the primary carrier for last-year purposes as that carrier with the earliest date of execution of such a clause which is still valid at the time of death.
With regard to multiple health carriers, the life carrier would generally take the position that he is only going to pay so much, and the health carriers can work it out among themselves. The reasonable division of the award would be in proportion to the degree the health insurers had paid out the actual health costs. No doubt there would be instances of multiple health insurance coverages of someone who dropped dead with no medical costs at all. If the reimbursement were on the basis of average community costs, lawyers for the health companies would no doubt exercise their imaginations in court, but the life insurer would be serene, and the situation would soon clarify itself with case law.
It is somewhat more difficult to contend with the possibility that the life insurance clause would authorize payment of actual individual costs, only to discover that the beneficiary had over insured himself with multiple health carriers, without coordination of benefits clauses. The life carrier would thus be in a poor position to know just what the actual payments by the two contending health insurers had been, and how much overlap or legitimacy there was to them. It follows that the subscriber who requests that individual actual reimbursements rather than average community ones be made, must also be required to specify whether he wants all carriers reimbursed, or only the primary, or only the largest, payor. With the life carrier thus immunized, it becomes the responsibility of health carriers not to reduce their premiums or make other concessions to the subscriber in return for a last-year treaty unless the subscriber can satisfy them that their agreement meshes with the life clauses, or that the subscriber agrees to the coordination of benefits.
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.