George R. Fisher, III, M.D.

Obituary

George R. Fisher, III, M.D.

Age: 97 of Philadelphia, formerly of Haddonfield Dr George Fisher III

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.

The Corinthos Disaster

Oil Tanker on Fire

Fire, huge fire. The Corinthos disaster of January 30, 1975, was the biggest fire in Philadelphia history, and one hopes the biggest forevermore. Its immensity has possibly lessened attention for some associated issues which are nevertheless quite important, too. Like the issue of punitive damages in a lawsuit, or the need to balance environmental damage with a national need for energy independence. And the changing ways that law firms charge their clients. We hope the relatives of the victims will not be offended if the tragedy is used to illustrate these other important issues.

On that cold winter day, two big tanker ships were tied up alongside the opposite banks of the Delaware River at Marcus Hook. The Corinthos was a 754-foot tanker with a capacity of 400,000 barrels of crude oil, tied up on the Pennsylvania side at the British Petroleum dock with perhaps 300,000 barrels still in its tanks at the time of the disaster. At the same time, the 660-foot tanker Edgar M. Queen

Edgar M. Queeny

with roughly 250,000 barrels of specialty chemicals in its hold, let go its moorings to the Monsanto Chemical dock directly across the river in New Jersey, intending to turn around and head upstream to discharge the rest of its cargo at the Mantua Creek Terminal near Paulsboro. Curiously, a tanker is more likely to explode when it is half empty because there is more opportunity for mixing oxygen with the combustible liquid sloshing around. A tug stood by to assist the turn, but the master of the Queeny felt there was ample room to make the turn under her own power. With no one paying particular attention to this routine maneuver, the Queeny seemed (to only casual observers) to head directly across the river, ramming straight into the side of the Corinthos. Actually, the Queeny had engaged in a number of backing and filling maneuvers, and the sailors aboard were appalled that it seemed to lack enough backing power to stop its headlong lunge at the Corinthos. There was an almost immediate explosion on the Corinthos, and luckily the Queeny broke free with only its bow badly damaged. Otherwise, the fire might have been twice as large as it proved to be with only the Corinthos burning. The explosion and fire killed twenty-five sailors and dockworkers, burned for days, devastated the neighborhood and occupied the efforts of three dozen fire companies. A graphic account of the fire and fire fighting was written by none other than Curt Weldon who was later to become Congressman from the district, but was then a volunteer fireman active in the Corinthos tragedy.

There were surprising water shortages in this fire on the river because the falling tides would take the water's edge too far away from the suction devices for the fire hoses on the shore. The tide would also rise above a gash in the side of the burning ship, floating water in and then oil up to the point where it would flow out of the ship onto the surface of the river. Oil floated two miles upstream from the burning ship and ignited a U.S. Navy destroyer which was tied up at that point. Observers in airplanes estimated the oil spill was eventually fifty miles long. All of these factors played a role in the decision whether to try to put the fire out at the dock or let it burn out; experts continue to argue which would have been better. There were always dangers the burning ship would break loose and float in unexpected directions, that the oil slick would ignite for its full length, and that storage tanks on shore would be ignited. The initial explosion had blown huge pieces of iron half a mile away, and the ground near the ship was littered with charred, dismembered pieces of flesh from the victims.

, Of course, there was a big lawsuit. When a ship is tied up at a dock it certainly feels aggrieved when another ship crosses a river and rams it. The time-honored principle of admiralty law holds that the owner of an offending ship is not liable for damages greater than the salvage value of its own hulk, which in this case might have been about $3 million. The underlying assumption is that the owner has no way of knowing what is going on thousands of miles away, no control over it, no power to respond in a useful way. Enter Richard Palmer, counsel for the Corinthos. Palmer was aware that the National Transportation Safety Board collects information about ship maintenance inspections in order to share useful information for the benefit of everyone. His inquiry revealed that the inspections of the Queeny for four years before the crash had repeatedly demonstrated that the stern engine had a damaged turbine, and was only able to drive the ship at 50% of its rated power. Why this turbine had not been repaired was now irrelevant; the owners of the ship did have relevant information and had failed to act in a timely safe fashion. The limitation of liability to the salvage value of the hulk now no longer applied if the negligence was judged relevant. The defendants, the owners of the Queeny, decided to settle. While the size of the settlement is a secret of the court, it is fair to guess that it approached the full value of the suit, which was $11 million. Mr. Palmer, by using his experience to surmise that maintenance records might be available at the Transportation Agency, and recognizing that the awareness of the owner might switch the basis for the compensation award from hulk value (of the defendant's ship) to the extent of the damage (to the plaintiff's ship), probably tripled the damage settlement.

Reflections on the extraordinary benefit to the client from a comparatively short period of work by the lawyer leads to a discussion about the proper basis for lawyers fees. Senior lawyers feel that the computer has revolutionized lawyer billing practices, and not for the better. Because it is now possible to produce itemized billing which summarizes conversations of less than a minute in duration, services for the settlement of estates can be many pages long, mostly for rather routine business. Matrimonial lawyers are entitled to charge for hours of listening to inconsequential recriminations; lawyers can bill for hours of time spent reading documents into a recording machine, or sitting wordlessly at depositions. Since the time expended can now be flawlessly measured and recorded on computers, there is little room for a client to remonstrate about their fairness. Discomfort about this system underlies much sympathy for billing for contingent fees, where the lawyer is gambling all of his expenses and effort against a generous proportion of the award if he wins the case, nothing at all if he loses. This latter system, customary in slip and fall cases and justified as permitting the poor client to have proper representation, undoubtedly promotes questionable class action suits and often leads to accepting personal liability suits which should be rejected for lack of merit. The thinking underlying personal injury firms is widely said to be: most insurance companies will settle for modest awards in cases without merit because the defense costs would be no less than that amount, and occasionally a personal liability case gets lucky and extracts a huge award.

Listen to one old-time lawyer describe how legal billing used to be. After the case was over, the lawyer and the client sat down to a discussion of what was involved in the legal work, and what it accomplished for the client. A winning case has more evident value than a losing one, provided the lawyer can effectively describe the professional skills that helped bring it about. The whole discussion is aimed at having both parties leave the discussion satisfied. To the extent that both parties actually are satisfied with the value of the services, the esteem and reputation of the legal profession are enhanced. And the lawyer is a happy and contented member of a grateful community. If he can occasionally claim a staggering fee for a brief but brilliant performance, as in the case of the explosive fire on the Corinthos -- well, more power to him.

It does not take much familiarity with oil refineries to make you realize that cargoes of crude oil are a very dangerous business. We are accustomed to hearing jeers at those who protest, "Not in my backyard", and we deplore those who would jeopardize our national security to protect a few fish and trees in the neighborhood of potential oil spills. Since we do have to import oil and we do therefore have to jeopardize a few selected neighborhoods to accomplish this vital service, the opponents are sadly destined to lose their protests. But that doesn't mean their concerns are trivial. The shipping and refining of oil are dangerous. We just have to live with it and be ready to pay for its associated costs.

Basic Coverage: Three Big Problems, No Little Ones

Columbus and the Egg

Let's summarize. We started with the classical Health Saving Account (C-HSA), which may need a little updating, but appeals to millions of frugal people as a simple way to avoid the tangles of present-day healthcare financing. The law hasn't changed much, but used by millions of subscribers has turned up many surprising features, all good ones. Deliberately overfunding them has unexpectedly useful results, for example, in providing retirement income if you have been lucky with your health.

On that foundation then was devised New Health Savings Accounts (N-HSA), combining six more innovations, each of which is easy to explain, but in combination utterly transform the basic design. The extended longevity of the 21st Century makes compound interest in passive investing into a powerful investment tool and is used to reduce healthcare costs to the consumer, markedly. Secondly, improved healthcare for the working years has unbalanced the employer-based model, so sickness costs are getting crowded into retirement years. For this, the accounts permit extraction of the first year and last years of life, transferring their heavy costs to the working generation where employment-basing still makes sense. And so on. With very little new legislation, most of this package is ready to go.

Lifetime Health Savings Accounts (L-HSA), patterned on a whole-life model. L-HSA won't work without some new legislation to edge around recent regulations and some outmoded premises. Multi-year coverage is cheaper but requires a longer commitment, so it needs to be precisely designed. Starting fresh, it directly addresses a host of problems hiding behind a century of habit. Its flexibility accepts a range of designs, stretching from self-insurance out of a bank's safe deposit box, stretching all the way to letting life insurance companies run everything.

We conclude insurance of every sort "shares the risk" for expensive problems but generates extra expense when little problems get insured that don't need to be. Little medical problems swamp the fixed overhead of insurance unnecessarily. When you only insure essentials -- as true catastrophic insurance does -- it costs far less than insuring everything. So, here's an outline of a major variation, adding features, one by one. It's a Health Savings Account, on steroids.

Proposal 25A: Let's combine the high cost of the first year of life with the really high-cost last year of life, as a basic foundation of minimum health insurance.

The dual combination could surely include everyone. What I am technically trying to achieve, I admit it, is to combine one life situation, which sometimes generates a surplus it can't use, with another situation, where every baby creates a difficult debt for someone else to pay. And whereas 100% of the population experiences birth and life at the two ends of life, there is ancient uneasiness about sharing liabilities outside of families, and even, how far the boundaries of families will stretch. Ancient fear of violating obsolete family boundaries sometimes hinders useful proposals. Because of increased longevity, grandparents are now real people, not just a picture on the wall. And by no means are they all senile.

A sly feature of all this is, people still alive are willing enough to overfund the costs of the terminal care lying ahead of them, but few still alive have their own birth costs on their minds, even if they were never paid. That lopsided initial generation might generate sizeable reserves for a circular program, if we imaginatively link accounting between generations, carrying those birth costs forward. Another unrecognized feature is the costs of these first and last years of every life are in fact both paid in retrospect, and often not by the patient.

Furthermore, most of the heavy expenses of both ends of life are created within a hospital, which often delays final billing until the issue of responsibility is settled, creating blind spots in which final responsibility is unclear. Nevertheless, the hospital aggregates many services in a total hospital bill, so bulk payments by diagnosis or even by age, are tempting but as yet crudely perfected. When all these matters finally get standardized, reimbursement from one insurance entity to another should become commonplace. The final transaction in both end-of-life insurance as well as the beginning of- life insurance easily and more naturally evolves into who reimburses some other entity who (temporarily) paid the bills.That's about all, there is to say about the funds' flow, which should become very simple, but come in larger lumps. At such esoteric levels, no one cares whose money it is, so long as it gets paid. At the local patient level, family transfer issues can be troublesome. It can be recalled we have gone into detail about grandparent/grandchild transfers in the section on New Health Savings Accounts, and indeed it emerges as the main innovation of that effort. Still earlier, we described the compound interest hidden in the background, paying for a great deal of it. As an aside, most people will eventually find it is desirable to use overfunded accounts as a basis for tax-sheltered retirement costs, and will therefore often die with a small surplus, which is the basis for closing the loop between generations. That may take time to evolve.

Proposal 25B: And then, add catastrophic coverage regardless of age, less the cost of overlaps. Title: Tri-Challenge Basic Coverage.

Here's the universal catastrophic coverage we promised in the first chapter, minus the first and last years of life overlaps.

Overlaps. One passing word about overlaps. Reducing overlaps is one of the main mechanisms for reducing costs, but the insurance entities will fight fiercely over who gets the reductions. For example, what about a six months old child who dies with an expensive hospital bill? My suggestion is that the beginning of life insurance pays first, the end of life insurer pays second, and then the catastrophic insurer pays for the balance. This gives the savings to the catastrophic carrier, but most of the cost is given to grandpa, who is dead, and anyway, most of it is investment income, leading to fewer complaints.

We thus design the basic coverage to include two universally-unavoidable costs, plus the universally-inescapable risk of unpayable health costs at all ages in-between. It is clearly superior to less universal, and more unaffordable, coverages.

Proposal 25C: Require the unused birth coverage to be transferred, either at the time of death or optionally at other times, to either a designated grandchild by inheritance or to a designated pool of unassigned third-generation recipients. The grandchild's Health Savings Account would begin at birth, capturing 21 extra years of compound interest, compared with employer-based insurance.

The purpose of beginning an HSA at birth is to add 21 years to the compounding while staying within the laws of perpetuities.

A 1:1 ratio of national grandparents to national grandchildren do exist, but so do multi-children families, no-children families, unmarried families, divorces, etc. There is definitely a need for a pool within which, mis-matched funds are administered.

The childhood transfer feature adds about $28,000 to the coverage, but it would only require $42 a year (added to the last year of life premiums, at 6.5% interest compounded from one year of age). Because catch-up transition at age 40 would require $200 annual contribution to catch up with newborns, rising to $28,000 for someone aged 65, it might be better to add $25, or so, at birth to reduce the even greater cost of late joiners (over age 40) to the plan. They must be enticed, however, because they are the ones closest to activating the transfers, and hence are the most important support to enlist to an innovation.

Proposal 25D: This is voluntary Tri-Challenge Basic Coverage. Whether to make it mandatory, whether to subsidize it for the poor, and whether to replace Obamacare with it -- are political decisions, not questions of insurance design.

This coverage probably approaches half of the entire health costs of the nation, depending on how you treat the cost of prison inmates, the unemployable and illegal immigrants. If science should ever succeed in eliminating every major disease and therefore every other cost of healthcare, 18% of present costs would very likely persist. And in fact, the cost of prisoners, mentally retarded and illegals show no signs of changing much, either.

They are costs most likely to be permanent, but what we spend on the rest will depend on where we place the limits on "Catastrophic" care insurance. That cost depends on the size of the deductible, and the upper limit of coverage. You can readily predict the debate: the higher the deductible, the lower the premium, so the out of pocket cost depends on the deductible, too. But while controversy would remain, the great beauty of this design is the lessened political resistance from every voter who would likely benefit, which is 100%.

There is no escaping these realities, and in the meantime, the rest of health costs will dwindle down to the cost of birth and death, which change their nature very slowly. Therefore, although it is not traditional in the health insurance field, I propose it has long seemed an entirely natural thing, for the costs of childbirth to be an obligation of some other generation, usually but not always of the same family.

The problem is indeed complicated by the unusual concentration of malpractice claims in obstetrics, as well as the marginal finances of parents at this stage of their careers. But the hidden effect is to create more, or less, valuable babies, depending on how you judge the impact of emotions versus supply and demand. It was almost an unknown issue a century ago.

Any resistance to this proposal is thus likely to be more instinctive than rational since we have had so many generations of channeling such issues within the family unit. The relatively trivial cost of funding children's health care through 104 years of compound interest does generate a temptation to overfund the program, which if necessary can be frustrated by requiring one or more zero balances per lifetime. That is particularly true in this particular instance when compound interest could generate almost any amount of leveraged money at the death of a grandparent, simply by increasing the modest amount impounded at the grandparent's birth, and waiting long enough for it to grow. People in charge of managing the currency are then drawn into the discussion. Indeed, the relatively confiscatory level of estate taxes (60-70%) is a sign our society is not comfortable with perpetuities, although available remedies are fairly simple. Indeed some states also levy inheritance taxes on the recipients as well as the donor's estate taxes.

Whatever the traditional resistance, it's permanently true that the costs of the first year of life will always greatly exceed what a newborn is able to pay. And therefore it surely follows that this obstacle has hindered health financing for a very long time. There must be some mechanism for inter-generational transfer of funds, or life cannot continue. At present, it's called a family, and families are under strain. Conditions of modern life have evolved to the point where interference with some generational transfers will cause more suffering than the relaxation of such attitudes. There will be resistance, but it must be persuaded to reconsider its position and bilateral compromise must result.

Warning: Start Saving While You are Young. Health Costs for the first year of life are reportedly 3% of the total, and while the last year of life (15%) is worse, those costs laid on young families are particularly disruptive because of still higher costs later if neglected. At best they compete with college, housing, and automobile costs, and probably reduce the birth rate of the middle class. The enclosed graph shows a family of curves based on subsequent investment income from different invested external-contribution levels at birth, to help readers judge how much surplus might likely be generated at the end of a lifetime of average costs. Our goal is to estimate the cost of overfunding grandpa's health costs at birth, so there would remain an incentive for him to spend wisely, but still generate enough surplus to fund a grandchild's juvenile health costs. That is, to estimate the cost of transferring the obligation of grandchild costs from parents to grandparents. But it must ultimately be recognized that the full consequences of such a basic change, are unpredictable.

First, however, we must determine the size of grandchildren's costs. 3% of all costs ($10,500) for the first year of the child's life sounds plausible. But 5% of costs from the first birthday cake to the 21st birthday ($17,200) sounds surprisingly high and needs to be challenged if only to defend it properly from rapidly escalating educational costs. That's one of the great advantages of starting with a demonstration project; you can see where the bills are coming from. But that's mostly a quibble, because even $17,000 is manageable, and the legal boundary of age 21 is strongly defended.

Let's take just a moment to examine the laws of perpetuities, which mostly focus on intergenerational inheritance. Established about three hundred years ago as common law, they permit transfers for 21 years after the birth of the last person to be alive at the time of the bequest. I'm not a lawyer, but those do not seem like a handicap for what is proposed.

The pool would also pay for multiple children in a family or those newborns who do not have a willing grandparent. I never met any of my four grandparents, so I don't know if they would have been willing or not. As the father of fourteen living children, one of my two grandfathers would surely have wanted some adjustments. If it becomes an issue, the government could easily afford to donate the $7 yearly required to avoid the issue. During the early transition phase, it might possibly be necessary to have government backup if temporary mismatches appear, eventually repaid by adjusting the initial cash deposits. It happens the birthrate is 2.1 per mother, which easily matches one-half per grandparent, greatly relieving but not eliminating the occasional mismatches. It would seem a fairly simple task to charge 1:1 (grandparent to child) for the first three or four years, and gradually re-adjust if more precise data becomes available. It could even be possible to pay for the child-generation completely, but this is not entirely desirable. It should not require dynamic scoring to understand that making healthcare free would increase its cost.

Not everything which is desirable to do is desirable to do in a big hurry. {bottom quote}

The political advantages are wide-spread. Much tax resistance to paying for healthcare would be deflated by knowing that almost all cost was absolutely essential, and for the most part universal. The parent generation would be relieved of the cost of the healthcare of children. During transitions, there probably will be problems with overlapping coverage. Not only is Medicare reducible for overlapping costs, but the U.S. government is relieved of some of the embarrassment of borrowing 50% of Medicare from foreign countries in order to pay for it. But, sorry, we're getting down into the weeds.

If desired, the 1.6% salary withholding for Medicare can be reduced, relieving working people and their employers of about one-quarter of Medicare costs. The tax inequity between employees and self-employed should be eliminated anyway, but this somewhat reduces the disparity. The doughnut hole was a good idea, but it is part of copayments which are a bad idea. It should be self-evident that making hospital insurance free but doctor payment subject to Part B premium, creates unmanageable distortions. Many healthcare financing problems are like the fable of Columbus and the egg -- once explained, anybody can do it. Nevertheless, it would seem much better to proceed slowly according to a defined plan, using demonstration projects and experimental trials, mid-course adjustments, and careful monitoring. Because not everything which is desirable to do is desirable to do in a big hurry.

Finally, someone does need to calculate the cost of adding catastrophic stop-loss insurance to birth-and-death insurance. It isn't possible for an insurance outsider to calculate the overlaps between the two types of insurance, which are probably considerable. But, particularly if there is a lot of overlap making it relatively cheap, that combination would constitute the kind of basic insurance which covers what everyone needs, and very few would be able to fabricate. If you linked it to a more sensible diagnosis related code, as a basis for DRG for inpatients, and firm association with market-based outpatient costs, you might get a firm basic package. It then only requires a relative value index for items which do not overlap, and a firm rule that the same items be charged the same amount, for helpless inpatients and not-so-helpless outpatients.

What are vital but uncovered by this basic package are new scientific discoveries, so self-evidently essential they create temptations to exact extortionate prices. I'd say it would be shooting yourself in the foot to go hard on such discoveries for their first few years. Overall, that which is left uncovered by this hybrid tri-insurance may be hated for its commercial motives, but nevertheless remains something we clearly want to encourage. Managing costs of that sort ought to be left to the Food and Drug Administration, the Patent Office and competition. And silently endured by insurance.

Paying for Medicare Transition with Trust Funds.

Since its finance isn't much affected by the Affordable Care Act, there's a temptation to skip over Medicare. But ACA deficits and design flaws frequently grew out of Medicare's initial design decisions. Furthermore, the scientific tendency has been to cure acute diseases of younger people first, so the trend predicts still more high expense (chronic disease) patients will migrate toward Medicare. The ultimate prediction is for little to be left uncured at some distant time, except in the first year of life and the last year of life.

Changed Circumstances. There have been three main changes since some wag called Medicare the third rail of politics -- "just touch it and you're dead". The first change since 1965 is much-increased longevity as a consequence of much-better healthcare. Someone must have seen this coming, but apparently, no one spoke up. Although prolonged retirement is expensive, notice also how it prolongs the period of time available for compound interest to work, so the income curve starts to bend upward after thirty or forty years, regardless of the economy.

Secondly, passive, or index, investing has greatly simplified and strengthened amateur investing. Finally, the Health Savings Accounts appeared, often producing savings of 20-30%. It's time to re-examine the assumptions of 1965, with these three lights shining on them: longevity, passive investing, and payment design. We are not recommending that HSA be entirely funded by index funds, but merely recoiling from too much debt backed by government guarantees. (see below)

Proposed. In "Ye Olde" Medicare, the average beneficiary pays $56,000 per lifetime (in payroll withholding tax and premiums), but it actually costs the government at least $112,000 per person -- the remaining $50,000 or so per person is secondarily borrowed, so there are no left-overs for retirement. But prolonged longevity and longer retirement, hence more borrowing, are inevitable consequences of better healthcare with the present design. Viewed in that light, Medicare is broke. But viewed as a transition problem, it paradoxically addresses half of it; since half, the Medicare transition is already covered by bond issues. Put that together with the halving provided by Last Year of Life re-insurance, and you have made big progress toward transition. We also offer several other proposals for transition.

Our "New" Medicare, by contrast, seemingly could pay for all its present medical care, plus appreciable retirement cost, with the same revenue. Minimal extra government debt, no rationing or curtailment of service. It does it without changing major program elements; this is a financial change, not a medical one. It really does let you keep your own doctor, and doesn't tell him how to treat you, because it doesn't concern such things. Half of all medical expense is covered by Medicare. And we propose to fund half of that, plus all of the obstetrical/pediatric care, with First and Last Years of Life Re-Insurance. Transition begins to look feasible if we can convince old folks with a fixed income to take a chance on it.

Tools Seemingly Available for Transition to the New System, But Presently Not Provided For in Law: (See below) 1) Scientific break-through cures which significantly reduce the cost of Medicare. 2) Gradual buy-ins for latecomers, which significantly reduce the buy-in cost for people well past 65 at the start. 3) Special Trust Fund Extension eligibilities after death or before childbirth. Compound interest doesn't need the owner to be alive. 4) Delaying the Start of a Childhood Roll-Over. 5) Graduated Retirement as funding develops. All of these will be explained later, and the news is not all bad.
Extra Tools, Needed From Congress: "Change the destination" of Medicare's Withholding Tax, and Premiums, so the same money, plus interest, end up in the individual's Health Savings Account, instead of Medicare. That's in return for the subscriber agreeing to buy out Medicare at its mandatory onset, plus any other imposed conditions. There is one technicality: the tax exemption is currently distributed through the income tax system, while it should be added to the HSA, instead. Furthermore, if a considerable surplus (more than $100, say) from compound interest persists after withdrawals, the choice of buying out Medicare can be offered at its beginning age up to the perpetuity limit (on average, age 104), disregarding whether the depositor is still alive or covered by a special successor trust fund. Re-depositing in an HSA should make such contributions tax-exempt and earn compound interest (we hope, at 7%) in an escrowed sub-account which bypasses current medical costs until it is time to use them for Medicare. At least, escrowed in a way which cannot be diverted from Medicare use. Therefore, average payroll-withholding transforms from $28,000 ($700 yearly for forty years, taxable) into health care worth on average 18% more than that, or $825, because it's before-tax, and at 7% grows to $138,000 at age 65 (Try that out on your Internet compound interest calculator). That's what folks are paying right now, but including the tax exemption isn't as smooth as it could be. Don't forget the escrow feature, which keeps people from being their own worst enemies when other purchases compete for the single-purpose savings escrow.
Starting at any age before 66, it could then transform $1400 yearly Medicare premiums, before tax, and thus really $1650 into 18% more for twenty more years, and also pays tax-exempt interest. (Most people will find they have to read this several times because Health Savings Accounts are the only plan enjoying these particular features.) The net effect of augmented income tax augmentation, compounded, is to transform $56,000 before tax, into $534,000 before-tax at age 84, the present life expectancy, not counting $112,000 borrowed by the government, which we hope they can eventually stop borrowing. That doesn't sound like good arithmetic, but If you don't believe it is possible, just try it on one of the Internet's free compound interest calculators. (Furthermore, if an afterdeath trust fund is created to the limit of a legal perpetuity [one lifetime plus 21 years], the present expenditure would be subsequently transformed by compound interest into whatever $2,066,000 is worth at the time, we should hope amply providing for all of Medicare, plus some generous retirement without government borrowing. You won't be surprised to find others think this is more than you will need. We will later suggest better ways to rearrange the same facts, but this summary contains the general idea in highly condensed form.
Although an accumulation of over $2 million per subscriber seems adequate for any normal purpose, it should be recognized that this figure only applies to someone who started saving from birth and waited 104 years to collect. Therefore it would only be a theoretical issue for a long time. A far more generous sum is possible earlier if the original purposes of payments are ignored, and the principle adopted that the largest contribution should begin earliest. That maneuver results in payments age 104 of $30,165,195.00 which would make most people giggle. The obstacle to overcome is the resistance stirred up by matching Medicare premiums to newborn children's HSAs. However, if the system needs more money, this is the place to get it. By adopting this principle, a $2 million fund is achieved at age 60 instead of 104, which eliminates the need to consider several other strategies, expenses and objections thereto, subsequent to a Medicare buyout. It would make an $18,000 grandchild gift seem trivial, and last year of life strategy unnecessary, for example.

Transition costs dominate the replacement of almost any health insurance, so let's restate the theory. A J-shaped cost curve forces a J-shaped revenue stream. When you switch systems, you must reverse the order, paying expensive existing ones first; and funding proves inadequate unless you can double it. If you could just manage, it would be possible to make partial cost savings you could boast of, but except for the Postmortem Trust Fund way you must pay double for all of it, or give up the attempt. By contrast, if you have at your disposal a large new source of credit like a postmortem Trust Fund, with an elastic retirement fund absorbing embarrassing surpluses, you can survive early misjudgments. Medicare could pay for its entire cost with compound interest on what subscribers now contribute, save for the fact it will have inadequate cash flow from people on their deathbeds. But if the death of the subscriber is ignored, the inflow of funds from surviving depositors could continue into postmortem trust funds of the decedents. At 7% return, extending the payments to the length of perpetuity (21 years) would multiply its amount four times, reducing the problem to a quarter of where it started. The transition time is thereby considerable shortened. For transition purposes, it might be wise to create a contingency fund, of up to $250 at birth. But remember, the size of the gap in a life plan can only be finally addressed after we see what is to become of the ACA (Obamacare). For the purposes of this book, we simply treat the ACA as if it were revenue-neutral, a somewhat unlikely forecast, but a completely understandable assumption.

It's Time for a Grand Summary

This book will appear in print around the time of the November 2016 presidential election, and therefore have little effect on its outcome. I expect the election to polarize both political parties still further on the Affordable Care Act, sucking all the oxygen out of the room, as the expression goes. It is likely to create a sort of lame-duck situation during November and December, no matter who wins. Therefore, I decided to present a book which superficially seems to have little to say about the Affordable Care Act, in order to grasp the microphone first, about health issues which got ignored by the Affordable Care uproar. Even when discussion seems to focus on the A.C.A., trade-offs are blithely apt to ignore "germane-ness". And thus get to issues which have been debated very little, and pass very quickly. This book primarily attempts to do two things to re-focus attention:

1. To draw attention to the Health Savings Account legislation as a fall-back from almost any deadlock. HSA is already enacted, tested, and distributed. If Congress reaches a deadlock, the HSA is existing law, and anybody in a jam can simply go down the street and buy one. It's simple and cheap to get started, is approximately as inexpensive as any other health insurance, and you can discard it whenever you like. (Naturally, I hope people will keep it.)

It does have a few flaws, which I hope Congress might correct. It unnecessarily limits buyers to people who are employed. That seems purposeless to me, while it prevents minor children from being enrolled, limits the deposit of funds to a fixed amount of their own money, and forces people out of the HSA at age 65. Forcing people to drop it as they acquire Medicare, impairs one of its most important virtues, the incentive to apply unspent money to retirement living, just at the time they are likely to retire. Some people will have other retirement sources and time-tables, and wish to defer use of some or all of them. Getting back to children, permitting deposits at birth would add at least twenty years to the compound interest period available preceding retirement, allowing the retirement fund to grow four times as large. Dropping the age and employment limits would not require more than a few sentences of an amendment, and provide maximum flexibility.

2. We also portray universal Health Savings (and Retirement) funds as potentially "a string holding together a necklace of pearls". To do that requires major legislation, going far beyond emergency stop-gaps for deadlocks. It's potentially a program for health, phased in over a century, and including the possibility of even including ACA. Since one Congress cannot bind a successor, it provides a road map through ten or more changes of political control in Washington, adding or subtracting individual programs which sometimes have little relation with each other. As a matter of fact, if an attachment is voluntary, you can have other parallel programs without attaching them, if you prefer.

By happenstance, reform could start with one "pearl" already in place. By the legislation's automatic transfer to an Individual Retirement Account at the onset of Medicare coverage, every subscriber in effect would immediately possess one of the essential ingredients of a lifetime health and retirement funding system. That even generates coherence, symbolizing prolonged longevity as a result of earlier health care. On the other hand, it implies the present configuration of Medicare is perpetual when it already has a number of features which should be changed. Therefore, it is essential to state at the outset that the string, the HRSA, intends to be kept as simple as possible so that amendment complexity is concentrated into the "pearls" themselves. After doing so, the HSA can remain versatile enough to suffice for newborns, mentally handicapped and billionaires, alike. It might provide healthcare for prisoners in custody as well as the marooned Medicare copayment supplements. Some things wouldn't work and can be dropped without upsetting the whole system. The expression is KISS -- which they tell me means keep it simple, stupid.

The basic structure is to divide health finance into two parts, one for everyday routine expenditures, and the other for bare-bones, cheap, insurance -- for people who are too sick in bed to be bothered with haggling over finances. If there is anything left over at age 65, it can be spent for retirement and serves as a life-long incentive to be frugal about health expenses. It's for everybody, not just some demographic group. If the government chooses to subsidize certain groups, then that becomes an independent topic, sharing a common framework, hanging separately from the necklace as it were. At the moment, it's one serious technical flaw is to imply total control over investment policy lies in the hands of any corporation which manages it, leading eventually to suboptimal investment performance for customers. Also, limiting management to visible fees rather than invisible profit-competition should allow plenty of room for shopping between managers.

Having established the basic framework and pointed out its present main -- but correctable -- flaws (management control of investment, and mandatory management participation in profits), we added two potential pearls to the necklace. One is the two parts (80/20) of Medicare with its finances unified, and the other is to provide health coverage for children up to the age of 25. These are both sensitive topics and may take the protracted debate to get the mechanics right. When these two programs have finally got their books balanced by deciding who pays for what, they are ready for voluntary acceptance into HSAs, and they remain eligible to be tossed out if unexpected problems surface, once we get over any notion of infallibility. Balancing the books may include subsidies, but the subsidies for poor or the handicapped must reasonably result in balanced books. It is intended to be an insurance design, not a subsidy originator. A design, not a budget; the government may subsidize as it pleases without changing the design. The government has a right, even a duty, to provide for those who cannot provide for themselves. But deficit financing is not wise: if you are going to subsidize, subsidize the pearls, not the string. This wouldn't eliminate politics, it merely shifts politics to a less dangerous level.

At that point, we now stop detailed planning and merely list seven more "pearls" which might be added on the same terms. They would be special programs for difficult situations, like prisoners in custody, physically or mentally handicapped to the point of not being self-sufficient, and aliens within our borders. We are told the aggregate of these three groups alone is thirty million people.

When it comes time to negotiate the Affordable Care Act, between twenty and forty million more are eligible to become self-financed "pearls" after the ACA finds a way to balance its books. It is not intended to subsidize other subsidies linked to programs. That's the government's job. Unfortunately, the government has tended to raise prices for people struggling to pay their bills by subsidizing other people who cannot. The consequence is even more people cannot afford their own care, threatening to sink the lifeboat for everybody. If we are to subsidize the health care of some part of the population, let the money come from defense, or agriculture, or infrastructure, not from the quality of healthcare of some other person.

To continue the list, additional pearls for the future are the accumulated debts of fifty years of deficits, and the tax deduction-supported gifts of health insurance from employers to employees. I'd like to see some resolution of the mess left behind by Maricopa Medical Society v. Arizona decision of the Supreme Court. As these problems get worked out to be self-sufficient, they become eligible to become "pearls" as long as it remains clear this proposal is not a cross-subsidy vehicle. At the moment, the ACA shows no signs of adding anything to the HRSAs except more deficits, making solutions more difficult to find. Just because we see no end to problems, shouldn't keep us from getting started. In particular, when the ACA is addressed, out goes the oxygen from the room, diverting attention from anything except expedients. That should not be necessary. All of these problems can be worked on simultaneously.

* * * *

It is now time to identify the financial maneuvers which promise partial success. It isn't true there is only one principle involved, but there is certainly one main one. Almost all of the magic of money creation in this proposal is provided by stretching out the time for income earning. A longer earning period takes advantage of the rock-solid principle of compound interest rising at the end of its investment period. To return to our oft-repeated formula, money earning 7% will double in 10 years, so 2,4, 8, 16 reaches 512x magnification in 90 years. From age 80 to 90 the money grows 128-fold., so an original investment of $100 grows from $25,600 to $51,200 between the ages of 80 and 90 or $2,560 per year for a $100 investment. That is, it's not growing at 7%; during those last 10 years, it's growing at 256%. And it's not magic, it's just math. Furthermore, it's not new. The ancient Greek Aristotle complained about the unfairness of it because he was seeing it as a debtor. So that suggests a related strategy: wherever possible, position citizens as creditors, not as debtors.

What's new about this whole thing is the extension of longevity. In Aristotle's day, it was considered remarkable to live to be forty years old. In our era, life expectancy at birth is moving from 80 toward 90. So today it's not a pipe dream, it's a realistic strategy. But stretching it out automatically comes with problems, too. There's a greater risk, fifty years of extra opportunity for someone to chisel it from you. History is replete with examples of kings who shaved gold coins, financiers who took more profit for themselves than for their investors, central banks who give you back a penny when you invested a dollar a century earlier. If you win a war, you might emerge better off; but if you lose a war you may be more like the seventy million people who died from wars in the past century, an experience which strongly favors having no wars, but otherwise doesn't seem to change things much. This risk/reward ratio strongly suggests we have neglected the necessary precautions required. So the proposals of earlier pages to balance the Medicare budget, etc., carry the risk that something or someone will come along and divert the money to other purposes. And without planning to forestall that, you have not got a workable plan.

That's the thinking underneath the dispersion of control to individual Health Savings Accounts, just as it is the reasoning behind resistance to consolidated systems of control, such as "single payer" systems as presently described by their proponents. They all just make it easier for your trusted agent to steal bigger amounts of money at one time. William Penn, the richest private landholder in recorded Western history, spent his days in debtor's prison because his steward falsely accused him of stealing the money from him. Robert Morris, the financial savior of our nation, likewise went to debtor's prison while the Governor of his state nearly sprained his hand signing over property deeds to himself. When the Federal Reserve was created in 1913, a dollar was a dollar; now it is a penny. Nobody needs to explain what "pay to play" means. So, although we need much more ingenuity in devising safeguards for savers, we need to grit our teeth and allow some people to fail to take their opportunities. Countless teenagers who might have had a comfortable retirement will instead have the opportunity to smash up their red convertible on the way home from college. We absolutely must not deprive them of this risk, out of sympathy for its consequences. There will be plenty of Huns, Goths and Vandals watching what Rome does with its advantages.

* * * *

Suffice it to say a billion dollars will turn anyone's head; Health Savings Accounts are already many times that size in aggregate. Although ownership is dispersed widely, it is only a matter of time before some stockholders organization is formed, ostensibly to protect the interests of HSA owners. There will be an eternal need to suggest tweaks in the law to adjust to new circumstances. There will be a need to monitor the performance of managers, and even to counter the power of regulators. Sneaky little laws will get thrown in the hopper, requiring alarms in the night. Someone who lost money will sue to recover it; someone will have to decide whether to settle or resist in court, ever mindful of precedents being set. Executives will demand extraordinary life-styles; someone will have to decide if their production warrants the rewards. Someone else will have to be fired for incompetence or venality, but he will find many friends to defend him. The methods of selection of the board of directors are vital issues, now and forever in the future. As much as anything, continuous publication of results ("sunlight") is vital to oversight. The directors of the oversight body should have a deep suspicion of the directors of the "pearls" and only limited pathways for promotion between the two. Every time, every single time a dereliction is discovered, the results should be published and morals are drawn. Mr. Giuliani made a name for himself by policing broken windows, and it's still a very sound principle.

There is a financial success, and then there is product quality, which is different. Organizations will undoubtedly be formed to monitor quality, and these will produce measurable monitoring results. An effort should be made to make a meaningful match between these two report cards, with comparable groups having access to each other's data. There should be observers from each discipline on the other's board, and possibly a few voting overlaps. Disparities between rankings in the two evaluations should be explored and evaluated, and at least one annual meeting should be composed of both kinds of boards, devoted to the interaction of cost and quality. This may prove particularly fruitful at moments when scientific advances cause major changes in underlying premises. On another level, dialog should be frequent between research groups like the NIH, to see if research parallels needs..

A particularly interesting comparison might result from contrasting the regions with their 20% copayment partner's performance. They should be very similar, but may not prove to be.

Albany Conference 1754

State and Federal Powers: Historical Review

John Dickinson of Delaware

It was expedient to leave certain phrases in the Constitution intentionally vague, but the overall design is clear enough. Just as twenty-eight sovereign European nations now struggle to form a European Union, thirteen formerly sovereign American colonies once struggled to unify for the stronger defense at a reduced cost. Intentionally or not, that created a new and unique culture, reliant on the constant shifting of power among friendly rivals. Everybody was a recent frontiersman, trusting, but suspicious. It still takes newcomers a while to get used to it.

So the primary reason for uniting thirteen colonies was for a stronger defense. As even the three Quaker colonies of New Jersey, Pennsylvania and Delaware could see, if you are strong, others will leave you alone. In time, the unification of many inconsequential behaviors created a common culture of important ones; and in time that common culture strengthened defense. At first, it seemingly made little practical difference locally whether construction standards, legal standards, language and education standards and the like were unified or not. Except, that in the aggregate, it forged a common culture.
The practice of Medicine was certainly one of those occupations where it mattered very little whether we were a unified nation. Unification of medical care offered a few benefits, but mostly it didn't matter much, right up to 1920 or so. Even then I would offer the opinion, that unification of the several states (with consequent Free Trade) only made a big difference to health insurance, and still made little difference to the rest of medical care. In fact, there are still about fifteen states with too little population density to provide comfortable actuarial soundness for health insurance, as can readily be observed in the political behavior of their U.S. Senators. Although the number of low-population states gets smaller as the population grows, there are even so perhaps only ten big states where multiple health insurance companies can effectively compete within a single state border. Quite naturally the big-state insurers expect one day to eat up the small ones. By contrast, the nation as a whole, the gigantic population entity which Obamacare seeks to address, has far too many people spread out over far too large an area, to be confident we could unify them into one single program. Dividing the country into six or seven regions would be a much safer bet. That's the real message of the failure of the Computerized Insurance Exchanges -- far too much volume. And the coming failure of the Computerized Medical Record -- with too much complexity. With unlimited money, it can be done, because diseases are disappearing and computers are improving. But why struggle so hard?
It is at least fifteen years too early, and mostly serves the interest of insurance companies, if they can survive the experience. At the same time, we are at least fifteen years away from growing the smallest states to the point where we could decentralize. It's really a situation very similar to the one John Dickinson identified, James Madison briefly acknowledged, and where Benjamin Franklin improvised a solution. In their case, it was a bicameral legislature. In the case of medical care, it could be an administrative division of revenue from the expenditure. It could be the cure of a half-dozen chronic diseases. It could be six regional Obamacare. But creating one big national insurance company during a severe financial recession is something we will be lucky to survive.

Returning to the Constitutional Convention, an additional feature was added to the tentative 1787 document to respond to protests from small component states. They objected that whatever the big-state motives might be, small states would always be dominated by populous ones with more congressmen if a unicameral Legislature is made up of congressmen elected by the population. Pennsylvania had recently had a bad experience with a unicameral legislature. So a compromise bicameral legislature (with differing electoral composition in the two houses) was added to protect small-state freedoms from big domineering neighbors. Even after the Constitution was agreed to and signed, the states in ratifying it still insisted on a Bill of Rights, especially the Tenth Amendment, elevating certain citizen prerogatives above any form of political infringement, by any kind of a majority. These particular points were "rights"; individuals were even to be insulated from their own local state government. The larger the power of government, the less they trusted it.

John Dickinson of Delaware, the smallest state, soon made the essential point abundantly clear to a startled James Madison, when he pulled him aside in a corridor of Independence Hall, and uttered words to the effect of, "Do you want a Union, or don't you?", speaking on behalf of a coalition of small states. It was probably galling to Dickinson that Madison had never really considered the matter, and went about the Constitutional Convention airing the opinion that, of course, the big states would run things. Dickinson, who had been Governor of two states at once, had observed the effect of this attitude and wasn't going to have more of it.

Delegates

Benjamin Franklin, who for over 40 years had been working on a plan for a union of thirteen colonies (since 1745, long ago producing the first American political cartoon for the Albany Conference), devised the compromise. It was essentially a bicameral legislature -- with undiminished relative power in the Senate for small states. In this backroom negotiation, it was pretty clear Franklin held the support of two powerful but mostly silent big-state delegates, Robert Morris and George Washington. These were the three men of whom it could be said, the Revolution would never have been won without each of them. In 1787 they were still the dominant figures in diplomacy, finance, and the military. All three were deeply committed to a workable Union, each for somewhat different reasons. Now that a workable Union was finally within sight, parochial squabbles about states rights were not going to be allowed to destroy their dream of unity.

And so it comes about, they gave us a Federal government with a few enumerated powers, ruling a collection of state governments with regional power over everything else. And since big-state/small-state squabbles are unending, almost any other solution to some problem repeatedly, seemed preferable to disturbing what holds it all together. On the other hand, the Industrial Revolution was beginning at about the same time, and people who recognized the power of larger markets almost immediately set about attacking state-dominated arrangements, systematically weakening them for a century, and redoubling the attack during the Progressive era at the end of the 19th Century. Attacks on what seemed like an abuse of state power, the power to retain slavery, and later the power to perpetuate white racism, were claimed to justify this attrition of states rights. The ghost of the Civil War hung over all these arguments, restraining those who pushed them too far.

However, the driving force was industrialization, with enlarged businesses pushing back against the confinement of single-state regulation within a market that was larger than that. This restlessness with confining boundaries was in turn driven by railroads and the telegraph, improving communication and enlarging markets, which offered new opportunities to dominate state governments, and when necessary the political power weakens them. One by one, industries found ways to escape state regulation, although the insurance industry was the most resistant, whereas local tradesmen like physicians found it more congenial to side with state and local governments. The 1929 crash and the Franklin Roosevelt New Deal greatly accelerated this dichotomy, as did the two World Wars and the Progressive movement from Teddy Roosevelt to Woodrow Wilson. The Founding Fathers were said to have got what they wanted, which was a continuous tension between two forces, supporting both large and small governments; with neither of them completely winning the battle.

Insurance Monopoly

The medical profession further evolved from a small town trade into a prosperous profession during the 20th century, but the practice of medicine remained comfortably local. Even junior faculty members who move between medical schools quickly come to realize their national attitudes are somewhat out of touch with local realities. For doctors, state licensure and state regulation remained quite adequate, and state-regulated health insurance companies paid generously. State-limited health insurance companies had a somewhat less comfortable time of it, but the ferocity of state-limited insurance lobbying, as exemplified by the McCarran Ferguson Act, perpetuated it. The medical profession watched uneasily as the growth of employer-paid insurance extended the power of large employers over health insurance companies beyond state boundaries, and thus in turn over what had been medical profession's kingdom, the hospitals. And the medical profession also had to watch increasing congeniality with big government extend through businesses, unions and universities, fueled by overhead allowances of federal research grants and finally in 1965, federal health insurance programs. Nobody likes his regulator, but national organizations inevitably prefer a single regulator to fifty different ones. Furthermore, everybody could see that health care suddenly had lots of money, and naturally, everybody wanted some.

There is nothing naturally inter-state about medical care -- except health insurance. {bottom quote}

It was all very well to pretend that health care was out-growing local-state regulation, but those on the inside could uneasily watch the federal/state competition for control, with the federal government repeatedly stacking the deck more in its own favor. Aside from federal program interventions, there is still nothing naturally inter-state about medical care -- except health insurance. Doctors, hospitals, and patients all tend to remain local, but insurance can easily cross state lines if regulation permits. Even in insurance, small states have difficulty maintaining actuarial stability, driving health insurance toward one-state monopolies. With a few big-state exceptions, even most health insurance companies prefer single-state monopoly status to federal regulation because it facilitates marketing. To praise the virtues of insurance competition is fine, but if sharing the local market means struggling for adequate risk reserves, nationwide regulation will inevitably lead to domination by a few big-state insurance companies. Small-state insurers would enjoy access to a national market; but blocked from it, they need to retain a local monopoly to survive. Fleeting thought might be given to Constitutional Amendment, but there are probably always going to be enough states which consider themselves small, to block the two-thirds requirement for Amendment. Imposing nationwide uniformity by force would possibly improve standards, but uniformity is increasing rather than decreasing, so the argument is not a strong one.

To be fair about it, there was not a strong case for state regulation, either. It could have been argued that uniformity and reduced administrative costs favored central regulation over-dispersed control, because of improved efficiency; and few would have argued about it. Until the ACA insurance exchanges crashed of their own weight around the ears of hapless creators, that is, unable to do what Amazon seems to do every day, and raising quite a few embarrassing recollections. Recollections of the mess the Sherman Antitrust Act inflicted on local medical charity in Maricopa County, Arizona. Recollections of the "Spruce Goose" airplane that Howard Hughes made so big it couldn't fly. Recollections of the gigantic traffic jam strangling the District of Columbia every weekend. And, reminders that 2500 pages of legislation remain to be converted into 20,000 pages of regulations which it would take a lifetime to understand. Suddenly, let's face it, retaining state regulation of health care, or not rocking the boat, gets a lot better press. It might even work better than the national kind, especially in an environment where no one expected a perfect solution, and just about everyone had heard of the Curse of Bigness. When we first discovered that use of health insurance added 10% to the cost of health care, it had seemed like an easy place to extract 2% of the Gross Domestic Product for better things, just by streamlining administration. But after the health exchange fiasco, some people begin to wonder if 10% is just what it costs to use insurance to pay for healthcare. If that is the case, perhaps we should look at other ways of paying our bills, not just a different regulator. Nobody would pay 10% just to have his bills paid, if he understood what he was doing.

Philadelphia Reflections

The musings of a physician who served the community for over six decades

Obituary

George R. Fisher, III, M.D.

The Corinthos Disaster

Basic Coverage: Three Big Problems, No Little Ones

Paying for Medicare Transition with Trust Funds.

It's Time for a Grand Summary

Albany Conference 1754