The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
JAMES Madison, Washington's floor manager at the Constitutional Convention of 1787 in Philadelphia, stated the main necessity for holding the Convention at all arose from selfish and untrustworthy human nature. The assembly probably understood exactly who he had in mind, although that is a little unfair to residents of Virginia. He really meant everybody. In the theology of the time, mankind was stained with original sin. Particularly in France, many 18th century romanticists responded to the Enlightenment by defiantly declaring human nature is born pure in heart. In their view, current evils grow from the pollution of civilization, without which it might be possible to have no government at all. At its root, such romanticism was an outcry against progress and civilization, blaming the world's troubles on the Industrial Revolution, so to speak. From Madison's skeptical viewpoint, the most awkward feature of the Romantic Period was its adoption by his Francophile friend and neighbor, Thomas Jefferson, the current American ambassador to France. Madison recognized that Jefferson and Patrick Henry were prepared to assail any attempt to add the slightest power to a central government, particularly if it weakened the power of Virginia. As indeed they promptly came forward to do and nearly succeeded.
Treaty of Paris
After fighting an eight-year war for freedom, American belief was wide-spread that it was time to draw back from such anarchy. But there was widespread suspicion in every other direction, too. England seemed to concede, not defeat but only current military overstretch, possibly displaying reluctance to see its former colonies with full sovereignty. George III might wait for America to weaken itself and then try to take them back. Britain almost couldn't do anything right; it was also possibly up to no good when the Treaty of Paris astonishingly conceded land to the Mississippi instead of stopping at the Appalachians. Even our ally France nursed regrets for its somewhat older concessions after the French and Indian War. If even the two mightiest nations of Europe could not maintain order in the vast North American wilderness, perhaps they felt the inexperienced colonies would soon collapse from the effort. Further intra-European wars seemed likely, and could soon spread from Europe to the Western hemisphere. The guillotine was bad enough, Bonaparte would be worse. Our governance as a league of states was in fact, only a league of armies. The Articles of Confederation would not quell inter-state rivalries in peacetime, as only four years (1783-87) experience after the Treaty of Paris were clearly foreshadowing. It was time we listened to Benjamin Franklin, who had been arguing since the Albany Conference of 1745 for unification of the colonies, and to Robert Morris who had been arguing for a written constitution since 1776, a bicameral legislature since 1781, government by professional departments instead of congressional committees, and the ability to levy national taxes -- since at least 1778. Professor Witherspoon of Princeton had provided some ideas about how to make these proposals self-enforcing, Washington was firmly behind a Republican system and opposed to a monarchy. On the other hand, everyone knew that under the Articles of Confederation the thirteen States had often refused to pay their share, abused their ability to deal independently with foreigners, dealt unfairly with their neighbors, and capriciously mistreated their own citizens. It was time to act boldly. With a blue-ribbon convention of national heroes behind these simple ideas, surely it would be possible to convince the sovereign state legislatures to dethrone themselves.
John Marshall
Two men quietly applied even deeper thinking than that; Benjamin Franklin of Pennsylvania, and John Marshall of Virginia. Both of them had served in state legislatures, both were dismayed by the experience. Franklin also had a long period of close-up observation of the British Parliament, suffering personal abuse there, and had reason to reflect on the earlier abuses by that Parliament under Cromwell during the English Civil War. Certain bad tendencies seemed universal in legislative bodies. Although John Marshall was not a member of the Virginia Constitutional delegation in 1787, he was active in the politics of the group it represented back home. Both Marshall and Franklin had reason to be uneasy about misbehavior in representative bodies, whether called legislatures, congresses, or parliaments. When people said states misbehaved under the Confederation arrangement, they really meant legislatures misbehaved. Franklin did what he could within the Convention to curb this observed behavior by enumerating limited powers and endorsing power balanced against power. When he had nudged it as far as he could, he wearily agreed to give the product a try. Franklin did not trust Utopias, but he had lived among Quakers for years, observing one Utopian society which seemed to endure without resorting to tyranny.
The Constitutional provisions in Article I, Section X became the heart of what the 1787 Convention wanted to change about the relationship of the national and state governments.
States are forbidden to ...
"emit bills of credit, make anything but gold or silver a legal tender in payment of debts, pass any bill of attainder, ex post facto law, or law impairing the obligation of contracts."
1787 Convention
This brief clause is almost a presentment of what state legislatures were doing, which serious patriots regarded as wholly unacceptable. Failure of states to abide by the terms of international treaties must be included in such a summary, although the new Constitution went beyond the powers of states by locating treaties beyond the power of even Congress to change, once ratified. Some observers in fact feel that within the First Article clause, protecting the sanctity of contracts was really the nut of the matter. In one way or another, most states seemed to resort to paying their debts with inflation, somehow failing to recognize that borrowing never pays debts, it only postpones them. The great bulk of this new nation's business was to be conducted as voluntary agreements between two contracting parties. The State -- and the states -- were to stay out of the private sector, except as referee, to see that both sides kept their agreements. As a footnote, the matter of government intervention in private affairs was to rise again in the behavior of the Executive branch in the 1937 Court Packing uproar, and in the 2009 health insurance legislation. Some critics, therefore, have discomfort that the heaviest Constitutional weight was placed by the Founding Fathers on protecting private property. Are not other issues more important, they ask, like life, liberty and the pursuit of happiness? The Founders, of course, we're here not ranking benevolences by value; they were stating principal urgencies for convening the meeting. In a strange unintended way, they here stumbled on the right to property as the foundation for all other rights. But John Marshall understood it was true and was to spend thirty years hammering it into place. People broke individual promises by defaulting on debts; they simply did the same as governments, using inflation.
By this point, a patient reader of these reminiscences has probably learned quite enough about the Clinton Health Plan and its immediate aftermath. There is, of course, more to say, but except for political junkies, the topic doesn't warrant protracted dissection. It might be worth knowing the motivations of the insurance industry when they launched that bombardment of "Harry and Louise" television advertisements. Opinion within the insurance industry must certainly have been divided, however, and the main decision makers are probably all now retired. The Harry/Louise ad campaign is often given credit for the political assassination of the Clinton Plan, but that seems unlikely. The decisions about medical care were made without heeding the opinions of providers of medical care, so it would not be surprising to learn that decisions about insurance were made without completely candid discussion with insurance professionals.
In fact, grieving too much for the past may have led to looking too little at the future, which clearly contains a whole new set of facts. When the largest generation in history, the baby boomers, start to retire in 2012, those boomers own children will then be at peak earning power but will be a very small generation, too small to support their more numerous parents. Consequently, the 12.5% tax the current teenagers pay for retirement benefits will be too small to pay for their parents' health costs. It will be uncomfortable to increase that 12.5% by much. Thus, the Ponzi scheme we have run for eighty years will then be unable to conceal its facts with talk of trust funds and lock boxes. For nearly a century, Congress has spent the Social Security and Medicare tax surplus for non-medical purposes. They will have to stop doing that in less than ten years. Consequently, we can confidently expect the boomers to protest loudly: they contributed 12.5% of income during their whole working lives to support medical care, and now learn that nothing was saved for their own health care. Even more exasperating is that the second Bush administration did attempt to introduce legislation in 2006 to set aside some current surplus to reduce the impact of the coming crunch -- and Bush was howled down. It would thus appear to be the nature of current politics that this boomer health cost shortfall will not be seriously addressed until the crisis is actually upon us. Democrats will apparently stonewall the matter to avoid blame for designing and ballyhooing a welfare expedient of the 1930s that was swept under the rug during decades of affluence. Republicans will be determined not to be paymasters for a welfare scheme they had opposed from the beginning. So what will happen?
Government only has two options in funding programs where the money has already been spent; they can raise taxes or they can borrow money. By raising taxes, they risk precipitating an economic depression. By borrowing, they flirt with hyper-inflation of the sort that destroyed Germany and Austria in the 1920s. By adopting a little of both remedies, we wander into "stagflation", a term invented in the 1970s to describe a very unpleasant episode. Whatever the description, there seems a very strong likelihood of economic pain and political uproar. It sounds pretty unlikely the public will be in a mood for expensive additions to health insurance coverage.
All this is a preamble to impending cuts in the health budget. We must anticipate the only approach government ever uses for program reduction, the only arrow in the government quiver. It goes like this: first you cut a program budget by, say, ten percent and watch to see if anything bad happens. If nothing bad happens, cut it again. If something bad does happen during a series of cuts, deny that it did happen, and scramble around to patch up the damage. If possible governments restore some of the cuts when they go too far, but in Medicare whose unfunded deficit is in the trillions of dollars, that may not be possible. Try to get re-elected after you pull off one of these capers, and you begin to sense how dictators get into office. It really isn't comfortable to talk apocalypse this way, and one would certainly hope there is some flaw in the prediction. There could be other unexpected events in the meantime, deus ex machina, but a stock market crash, a thermonuclear war, or violent changes in the environmental temperature are all going to weaken the world economy, not make things better. This doomsday scenario seems almost certain to include some serious cost-cutting in the health financing system. Therefore, it is only common sense to examine what advance changes might be made in the health delivery system to minimize the damage to it.
My proposal amounts to suggesting that we put the doctors in charge of the cost-cutting. In accident rooms, battlefield medical stations, and even television war serials, the person in charge of sorting out the influx of unexpected casualties is said to be in triage. In triage there is one basic rule: put your best man in triage. If the security guard, the admissions clerk, or the night watchman directs the emergency down the wrong corridor, the ensuing blunders will cascade as the system struggles to get things back on track. We can expect objections to what I have to propose which will take the form of warnings about letting foxes watch the henhouse, but in general, the public already supposes the non-physicians will step aside for the doctors in an emergency. So the more open the discussion about command and control, the better, with ultimate faith that the public will support the common-sense approach of putting your best-trained person in charge.
For present purposes, the general proposal is that when drastic cuts in budget get imposed, it should be the physicians of the local community, not the administrators or the insurance executives or the local business leaders -- who should make the painful choices between what is essential and what can be sacrificed. This is most readily achieved by setting aside the Maricopa decision and clarifying the HMO enabling acts to the effect that it is not an antitrust violation for physicians professionally practicing in nominal competition to participate in the shared governance of health maintenance organizations. In other words, that HMOs such as the Maricopa Foundation need not fear antitrust action, using the experience of a dozen other Foundations for Medical Care as proof of the harmlessness
of the approach. It should not be necessary for these organizations to prove positive value, only to demonstrate lack of harmfulness. If they can be established and allowed to compete with insurance-dominated or employer-dominated HMOs, their worth can be established by success in the marketplace. Ultimately, the choice of governance form will thus be made by the patients, and the proposal should be a popular one.
It should also be popular with hospital administrators. They chafed at physician control thirty years ago, but that was before they encountered the far more brutal price negotiations of HMOs dominated by business and insurance. The consequent costly and disruptive wave of hospital mergers is defended by very few, although it would be interesting to examine dispassionate analysis. Probably no one adequately appreciated the threat that employer domination of these practice groups represented to hospital administrations. When hospitals confronted employer groups in serious hard price negotiations, hospitals came to the shocking realization that these people actually had the power to move large groups of people to a competitive hospital, and they certainly talked as though they were capable of doing it. The resulting panic of hospital mergers, consolidation into chains, and the emergence of for-profit competition by hospitals that had no thought of a charitable mission, has created a degree of cost and disorder that was not in the original plan. Hospitals in rural California who told their colleagues of the burdensome power of their staff doctors under doctor-run Foundations would now have to admit that a return to that environment would be a distinct relief.
And there might even be a reconsideration by business leaders. What physicians would bring to the table, what is now new and different, is the undeniable experience that dominating captive HMOs has not proved as useful to employers as they hoped it would be. The cost savings have been disappointing, the exploitation by insurance intermediaries, and the undeniable employee restlessness was not exactly anticipated. Running employee health projects is a large distracting time waster for C.E.O.s who have other goals and mandates to pursue. If employers keep a focus on their reason for involvement in employee health, hardly any of them could defend a posture of resisting the emergence of new choices which make a reasonable claim to reducing employee contentiousness, at a competitively lower cost.
And the government? Among the various unpleasant alternatives that Congress must consider, is the possibility to be discussed next that employers may want to pull out of employee health care entirely. Allowing competitive forms of ownership of existing arrangements might not seem too risky a step, compared with that prospect.
Employer-based health insurance. Although improved health care has added moderately to working years of life, a lot of people hate to work, whereas to other minds, thirty years of improved longevity mostly result in a thirty-year vacation after the end of productive careers. The famous American work ethic is not universally celebrated. Pensions and savings sometimes only partially anticipate the cost of enjoying this health windfall, which unfortunately competes with yet another unexpected cost, the steadily increasing expense of dying. These changes were both rapid and unexpected, so confusion is inevitable.
There is still another way of describing this readjustment to a wonderful scientific windfall: Most sick people are now either too old to work or else too young to work, even before they get sick. Health costs therefore relentlessly concentrate toward the first year of life and the last year of life. The strategy we developed of hiding the health costs of the young and the old within the health costs of the worker class confronts the new reality: middle-aged people have many fewer health costs, themselves. That leaves less room to hide the costs of the sickly young and the sickly old, which all along have been buried within the premiums of workers' health insurance. Let's face a fact: Those who are neither near the first year nor the last year, must somehow pay for those who are -- because there is nobody else.
Hiding the health costs of the young and the old within the health costs of the worker class confronts the new reality: middle-aged people have many fewer health costs, themselves.
What does this have to do with employer-based insurance? In the 1920s a rough acknowledgment was made that healthy working people must obviously support sick people who can't work. So it was devised that basing insurance on employee groups (if their dependents were included) might make a good start toward a national solution. Employer-based health insurance was a brilliant improvisation, but as life expectancy continued to lengthen, the gap between retirement and death also relentlessly widened. In 1943, discriminatory tax deduction slipped in, via Henry Kaiser, badly injuring the atmosphere of fairness for employer-based health insurance. Federal Medicare for the elderly was devised in 1965, and state Medicaid for the poor. They helped but didn't entirely cover the gaps either, and we are coming to learn how much we had to borrow to pay for it.
So now we have the Affordable Health Care Act, commonly called Obamacare. It remains to be seen whether even Obamacare can be made to stretch, because thirty years is a long time between retirement and the last year of life, and fifty years a long time to wait to judge results. With wars, globalization of industry and depressions to contend with, the task is hard, perhaps too hard. Unfortunately, having passed a law containing the Affordable Care Act mandates, we must try to do it in 2014, and do it in a rather utopian way for everybody at once. For what amounts to a level "community" premium for everyone, we must make no allowance for differing costs and pre-existing conditions, economic or medical. Many of these wounds are self-inflicted, costing the program many sympathizers who might have endorsed the same goals at a slower pace.
We Had a Secret Plan. It might as well be mentioned that Americans once nursed a secret plan for all this. We consented to spend incredible amounts of money on medical research for eliminating the disease. In fact, we made a pretty good try, considering we never officially admitted it was our goal. If there is no disease, there will be no medical costs to worry about, right? Directly confronted, eliminating acute disease would unfortunately still leave those first and last years to be paid for. There was just no escaping it, everyone has to be born, everyone has to die. And while substantially eliminating disease among the young and middle-aged is an important economic stimulant, it also lengthened life expectancy by almost thirty years in a single century. Those who managed to prosper were indeed rewarded with a thirty-year vacation, but some of the windfalls had to be set aside for those whose luck was bad, destined to spend thirty years in the shadows. It was a big, bold gamble, and in an American sense, we won it. Never acknowledging it was a goal, no one could say we lost it.
Americans will help others if they can, but first, they must be convinced that others cannot pull them down.
We are now engaged in a great upheaval described as insurance reform, to test whether a great nation which secretly believes it can do anything, can satisfy both those who believe it has attempted too much, and those fearful it will fail by aiming too low. Arguments abound. One description of victory would be this: we must abandon the essentially European idea of rich and poor as permanent classes of society. In its place, we should reaffirm the traditional Whig position that rich and poor are largely two or three, or four, stages of every American's life. In Lincoln's view, we all arrived as poor immigrants, gradually worked our way upward in society, usually taking several generations to reach the top. No more than a handful of born aristocrats ever immigrated to America. In a revised version of the same epic poem, all infants are poor, adolescents are always confused, and gradually we become self-sufficient members of society; eventually, we all die. Whigism refuses to see us as members of tribes, some eternally rich, some eternally poor; Whigs mainly hope that Liberty and personal responsibility will be sufficient to preserve the more perfect union. In Lincoln's case, it was a close call, but we made it, even then.
Obviously, people with income must support the disabled, since there is no one else to do it; equally obviously, the nation has not evolved to the point where it can be done by having one angry tribe tax another. Instead, what is needed is to organize some sort of insurance pool in which younger people contribute for their own individual future, recognizing frankly that people will chiefly fear the system cannot keep its fingers off the money to give it back eighty years later. That's really all that is essential, since many models have tested the insurance market, and watched eyes glaze over with the details.
Young people must subsidize sick old people, all right, but the only old person you surely enjoy subsidizing is yourself. For the moment, forget about the difficult transitions, about which 2500 pages of the law were written and will prove to be too little. The challenge to the country is whether we collectively have the courage to stake our lifetime earnings on the proposition that the average person can save enough of average lifetime earnings to pay for average lifetime medical costs, and still have enough left for a comfortable life. If he can't, this scheme is not going to work, because even if he can, the scheme might still fail. A thousand folksy mottos teach us that Americans will help others if they can, but first, they must be convinced that others cannot pull them down.
The Law of Compounded Interest. There's a seldom mentioned advantage to individually owned and selected insurance-like pooling of lifetime health costs. If insurance premiums are pooled, stored, and invested by professionals, they will gather investment income, or compound interest in quantities which always surprise a newcomer. To wit: money at 10% will double in seven years. Or, stretched over long time periods, the owner can withdraw 4% a year, forever, and still have as much as he started with. Within ages, 25 to 75 exists an opportunity for five doublings at 7% or 3,200%. Hidden in this is another incentive: if you only spend half as much money on healthcare as average, you can eke out another doubling, making it 6,400%. Transforming medical insurance from term insurance to a "whole life" insurance model carries the potential for vastly diminishing the lifetime cost to the average subscriber, but that opportunity probably did not exist a century ago. We may say we sacrifice this new opportunity because we do not quite believe it, but in fact, we mostly do not trust any government to give it back, eighty years later.
"Whole life" insurance model carries a potential for vastly diminishing the lifetime cost to the average subscriber which did not exist a century ago.
This paper, therefore, urges a voluntary approach, individually owned and individually selected, primarily because it seems safer to go a little slower than we could if we just followed a command. Anything which includes the word "mandatory" also forbids the testing of alternatives. At least theoretically, alternative approaches are forbidden forever, with the implication that nothing better will ever be possible. At the barest minimum, the Affordable Care Act must be amended to encourage the testing of new ideas by Congress and by state governments. Another similarly hampering word to avoid, is "perpetual", but it seems more conciliatory to avoid the word "insurance" and to outline the nature of this proposal as a non-insurance savings mechanism limited to lifetime health expenditures. To a framework of five proposals, about a dozen other features are later described but held in reserve, waiting to be added slowly as the system can absorb them. This is neither an Executive Branch initiative nor an insurance company product. It is a national strategy, which starts with individual Health Savings Accounts and builds on that foundation. It adds a high-deductible health insurance policy, preferably without co-payments. It strips down the benefits offered by the HSA to the first and last years of life, to prove the concept safely, and to pay for transition costs. After that, it should expand like an accordion to cover as much as it can afford. Beyond that point, we can argue some more, but we are aiming for maximum elimination of complication and subsidy, not because they are necessarily bad, but because they should in time be unnecessary.
There are two exceptional situations which might also be considered for universal coverage, even mandatory coverage if you insist. They are the first year, and the last year, of life. Some people get Tuberculosis, some people get cancer, some people live to be a hundred. But absolutely everybody is born, and everybody dies. Those are the two most expensive years of most people's lives, they almost always occur in hospitals, and nobody can fake them. The hospitals and Medicare keep careful records, so we know what they cost, both individually and on average. If we reimbursed the average cost to whoever paid it, the administrative expense would be small. The reason for doing this maneuver would be to take these costs out of the catastrophic insurance cost, both smoothing it out, and reducing it by 15%. There would be a transitional cost, because of the differing number of years before death appears. On the other hand, it would take a number of years before the births came up to average. But two major health costs would be universally covered.
During many medical meetings, I developed two generalizations: if one paper in three is excellent, or if the whole meeting produces one shocking discovery, you are having a good meeting. Two thirds of the time, if you let your mind wander, you haven't missed much. So imagine my surprise, when a 6-hour meeting recently related four formerly incurable diseases with new successful treatments, plus a new slant about how rare diseases spread, and disturbing possible insight into the medical economics of pharmaceutical marketing.
Rare Diseases
Another insight about rare diseases was that certain diseases may be rarities in America, but are common in some foreign countries. Perhaps this disparity was due to differences in hygiene or nutrition, but no, DNA testing shows they are inherited. Genghis Kahn or somebody like him seems to have spread a mutation around his neighborhood, and poor transportation kept these diseases local. But recent globalization increased foreign immigration, so these diseases are now commoner in America when we thought they were local mutations. The new cures? They are for biliary cirrhosis, Hepatitis C, hemochromatosis, and Non-alcoholic fatty liver. Having said that, let's narrow our attention to the non-scientific one, the one about drug pricing.
Hepatitis C
First, some background about Hepatitis C. Like HIV (AIDS) in its early stages, it was mostly confined to males, because it was initially spread by a male to male sexual contact in prisons, along with intravenous drug abuse for the same reason. ( Let me tell you, if you weren't a drug abuser when you went into prison, you will very likely be one when you get out. ) The gay community rattled the cage for more research and the result has been a great decline in Hepatitis B and HIV-AIDS, but Hepatitis C proved much more stubborn. For twenty or so years, we had a test which detected the presence of Hep C, but we essentially had no cure, with the possible exception of Interferon, which made people deathly sick for a year and had only a 30% cure rate. Most patients refused to go along with this treatment, and for years I told most patients that in their position, I would take my chances on a better treatment coming along, rather than subject myself to this grief. Well, today I learned the tables had turned. About twenty drugs, in five classes, had more than a 95% chance of cure in three months, with comparatively little toxicity. All on a single projection slide. The speaker said they were contemplating a campaign to eradicate the disease entirely by 2020, while saying there would be a campaign to eradicate it by 2030, just to be conservative.
Drug Prices
Well, I stopped off at one of the drug company booths to help myself to a free lollipop and chatted with the drug representative. The drug was expensive, like $60,000 for a three-month course of treatment, plus MRIs and other tests to monitor it, plus doctor and hospital charges. Let's guess it comes to $100,000 per patient. Wikepedia tells me there are millions and millions of patients with the disease, and the speaker guessed it was 1,600,000 in America. I suppose the drug company thinks no one can multiply because that comes to about $160 billion dollars. The competition was supposed to lower the cost, but the initial reaction was a rush to recover research and development costs before the disease disappeared. Even that wasn't a satisfying answer, because neither prison inmates nor recent prison inmates could possibly afford it. Most of this projected cost would fall on state Medicaid. Whether there is any connection between this set of associations and the Tea Party rebellion against restraining Medicaid is conjectural. But it is certainly strange that a disease which took so long to find a cure would suddenly find twenty cures at one meeting. The drug rep responded that if you just call the drug company -- don't call your hospital or health insurance company -- the drug company will almost always find a way around the problem without substantial cost. That's fine, but $160 billion? Nobody but the federal government has that kind of money, and it's even questionable they have it to spare.
That's all I know. Don't call me, call someone more likely to know the answer. We do know two things: there is a big pool of disease waiting to immigrate, so we have to talk about world-wide eradication, not just about one country. And the treatment of Hep C uses up your resistance to this sort of virus, and likely causes a re-activation of Hepatitis B if you happen to have had it in the past, as many Hep C patients undoubtedly have.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
