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.

Population Growth: Constitutional Mathematics

Citizens and academics have little appreciation for the intense attention that politicians devote to the rules. By 1787, James Madison had read everything he could get his hands on related to voting procedures, representation, democratic and republican nuances, recent and past. Consider the size of the legislative body, a seemingly inconsequential matter.

Constituents per Congressman

Remember, one way to prevent a particular decision, is to prevent any decision at all. Those who experience blockade by inaction, therefore legitimately argue that improving a committee means reducing its size. That is not invariably the case, because a committee containing inadequate wisdom will seldom be adequately wise. With effective procedures and experienced leaders, a legislative body of two or three hundred can remain productive and efficient. Whatever the limit is, it is safely larger than anything the Constitutional Convention of 1787 had in mind for the United States Congress. The convention concentrated instead on the number of constituents each congressman should have. Divide that number into the population of the nation, and you arrive at the size of the body without specifying it. It would be two centuries before America itself grew to the size where it was necessary to constrain the number of congressmen down to a manageable size. During the earlier years of the republic, there might be a concern that "the body" was too small and thus too easily controlled by personal dominance. But the nation would eventually grow to the point where the size of Congress had to be limited to around 500 members; that would eventually reverse some important considerations. If we ever reach a size where both the size of the body and the number of constituents per congressman are both undesirably large, there could be a lot of squirming.

The House of Representatives has remained frozen at 435 since 1913. A law to remain at that size was passed in 1929. {bottom quote}

The focus the founders chose was the number of constituents each representative should have. Here, the argument was that a congressman representing a small group would likely respond to the narrow parochial interests of that small group, while a representative of a large group would more likely have many narrow interests to consider, thus be more likely to represent the interests of the nation as a whole. Natural conflicts between farmers and fishermen would illustrate this dynamic; small districts or less numerous ones would likely split between those representing fishermen and those representing farmers, large districts or more numerous ones would force the representative to respect the interest of both. Small districts would be more partisan, in this view. However, the founders recognized it becomes more difficult to influence a representative who has too many constituents. An amendment was even proposed to limit a congressional district to thirty thousand voters, but it was never ratified. While the electorate hesitated, the country grew to the point where three hundred million inhabitants would produce a House of Representatives of more than twenty-five thousand Congressmen, far too large to operate in anything resembling its present methods. Forced by population growth to choose between an unworkable legislative body, and the originally intended personal familiarity between Congressmen and constituents, the familiarity was sacrificed and political machines came to dominate the selection process, mainly at the level of the nominating primary election. It was probably unnecessary for political parties to become so partisan so soon, but the ultimate result was inevitable in a growing nation. Since many of the non-democratic nations who might consider adopting our system are already larger than we are, there is little doubt that the size limitations of deliberative bodies are presently inhibiting democratic transformations. Eventually, even we will have to confront the issue, and it is past time for us to be discussing what we would like to do.

It is disconcerting to reflect we have already experienced some examples of the power of the representation issue and seen it can have some major effects. At the time of the Constitutional Convention, the number of members of the House and Senate was probably too small. The House soon grew to be the more powerful of the two because it had enough members to staff a wider variety of committees; in time the Senate grew more slowly and overtook the overpopulated House in influence. At present, the main problem is that both legislative bodies are being overshadowed by the enormous bureaucracy in the Executive Branch, with much longer average tenure and far less responsiveness to manageable electorates. Indeed, the elected representatives are slowly being forced to pander to the voting power of the bureaucracy in Maryland and Virginia, and the rural bias of state legislatures who have retreated to isolated rural villages in order to avoid the press and public scrutiny. Few people could now name their state representatives; in time that will be the destiny of Congressmen and Senators. The representation concern was widespread at the time of the founding of the country; it was accepted during the 18th Century that republics must remain small to remain republics. Madison found this to be one of the most serious obstacles to agreeing to a national republic, and he took considerable trouble to rebut it. This theory was behind the otherwise peculiar concept which Benjamin Franklin had advanced for many decades, which was that England and British America ought to have separate parliaments, united in allegiance to the same king. There seemed little difference between that commonwealth idea and the design of the Articles of Confederation with thirteen colonies reporting to the Continental Congress, so it was fortuitous that the abject failure of the Articles made it unnecessary to argue the merits of this multi-chamber approach at the Constitutional Convention.

Article the first... After the first enumeration required by the first article of the Constitution, there shall be one Representative for every thirty thousand, until the number shall amount to one hundred, after which the proportion shall be so regulated by Congress, that there shall be not less than one hundred Representatives, nor less* than one Representative for every forty thousand persons, until the number of Representatives shall amount to two hundred; after which the proportion shall be so regulated by Congress, that there shall not be less than two hundred Representatives, nor more** than one Representative for every fifty thousand persons. {bottom quote}

Ratified but Never Acted On

Nevertheless, it was a serious concern, based on clear logic. The anti-Federalists were a national group, ultimately a political party of individualists hostile to overbearing top-down authority. Their cause was hampered by the plain failure of the Articles of Confederation, but nevertheless, they were legitimately very restless about a Congress with a weak perception of its duty to represent minorities. The anti-Federalists somehow envisioned each representative as a lawyer defending local interests at court. Indeed, in the days of a strong British monarchy, that was essentially how the British Parliament operated. As the King lost effective power to rule, ministries elected from within the Parliament took over the powers and attitudes of monarchs. In a sense, that was worse, because the districts lost their power to nominate their own representative, who was selected for them by the party leaders -- now acting in the role of substitute King. So that was no good, either, and the anti-Federalists even though collectively a majority, were basically supporters of the Articles of Confederation, and the Articles were a failure. They thus lost the ratification battle, but although soon taking over the government, had no better proposal to make. A few decades later the South seceded and essentially reinstated the Articles of Confederation in their own part of the country; once again the loose confederation idea failed.

In advancing his argument that a large republic was indeed going to be workable, Madison promoted the idea that a large constituency would produce statesmen of distinction. Only a person of great merit, wealth and effectiveness would be well enough known to be elected. Therefore, congressmen with large districts to represent would tend to be rich, well-born and famous. Senators would be even more so because they were selected by legislatures and governors (before the Seventeenth amendment), and thus the entire government would become progressively and permanently made up of the elite. Madison particularly liked this idea, because it seemed to solve what he considered the main flaw of an elected government. Poor people would always outnumber rich ones, and would inevitably use their voting power to enrich themselves at the expense of the upper classes. Constructing an elitist government by enlargement of congressional district size was thus a highly elegant design feature. Unfortunately for Madison, the scheme didn't produce that result.

Much has been written about the most famous about-face in American history when Madison the Federalist founder became Madison the leader of the anti-Federalist faction. Madison, George Washington's trusted Federalist agent, became Jefferson's anti-Federalist agent, and Washington never spoke to him again. Briefly, it has been speculated that the Virginia tobacco plantation culture out of which Madison had emerged, had begun to crumble, undercutting Madison's Virginia base. And it has been speculated that Hamilton's spectacular leadership of the American banking version of the Industrial Revolution unsettled Madison's earlier conviction that the Old Dominion of Virginia could easily rule the new nation. And it has been muttered that Madison, the ever-scheming politician, saw that his own future presidency would be more enhanced by Jefferson's popularity than by Washington's physical leadership in his lame-duck years. There may be still other important considerations in Madison's famous switch which we can only hope historians will be able to uncover. But there seems little doubt that Madison was able to see with his own eyes that the Congress of Merit, Distinction, and Success which he had imagined would result from large congressional districts, had in fact already in Washington's administration begun to deteriorate into the stereotype of professional politician which today's satirists and cartoonists are pleased to pillory in their blogs on the Internet. Madison had feared the poor would outvote the rich, but in fact, the main form this demographic took was that machine politics and special-interest factionalism essentially drove the natural leadership of gentlemen entirely off the stage. The rules changed; winning this game required aggressive power and organization, not just the offer of service.

A committee containing inadequate wisdom will seldom be adequately wise. {bottom quote}

Over time, the relationship between the Senate and the House of Representatives changed, and the size of the membership had much to do with it. At first, the House was more powerful and prestigious. Direct election by constituents had more prestige than appointment by Legislatures. Later on, the Senate was a more suitable size as a deliberative body than the much larger House; running for election every six years was much to be preferred over running every two years. In the past century, the volume of work forced both bodies to develop a standing committee system. With five hundred members, the House could develop specialists in certain areas, and often a senior member in a safe district could remain in a topic area for thirty or more years. The Senate had fewer members, so each Senator is on several committees. Whatever the merits of a smaller deliberative body, the Senators have increasingly found themselves spread too thin, with new members taking too long to become expert, and older members too tired to keep up with everything. The consequences in both chambers have produced a phenomenon that even Madison never envisioned.

The legislative staff has continued to grow and has in general grown increasingly professional and proficient at their jobs. In general, the staff went to better Universities and got better grades there than the member they work for, and need not worry about running for election. Often having spent their lives immersed in a legislative topic, they know it cold. Consequently, we have all the makings of a "Yes, Minister," phenomenon in which the people who were not elected are more expert and more academically serene than the member who was elected, and who has the vote. The member and the staff member desperately need each other to succeed, but nevertheless, the potential for secret resentments and secret contempt is present every day in a highly tense environment of constant overwork. The present code word for this underseas warfare is that the Congress is "dysfunctional", a condition no one who has read much history would worry about. When Ronald Reagan introduced the idea of shrinking the government, and the younger George Bush actually tried to do it, the result was leaked to the newspapers and rumors to the effect that a President who had gone to Yale and had an MBA from Harvard, was a pumpkin. Just how serious all this is, and how exaggerated, is hard to say. But it is a concept that would have dominated the thinking of James Madison for months if it had ever occurred to him. We have entered an era of 1200-page bills, much of which the first surface in conference committees a few hours before the vote. Only a handful of members and a handful of staff know what is in these bills, and it can sometimes be a month after passage before the press discovers many buried features. The members cannot master these masterworks of legislation, so they get bigger by being patched. And by getting bigger, it is harder to master them. If, as someone like Ronald Reagan would genially remark, we just fired all the staff, then the bills would be reduced to one or two pages. In some ways, the legislation would be better, in some ways worse. But it would be different because maybe it should be different.

Delaware Water Gap

Delaware Water Gap

When we think of water gaps, we tend to think of Harrisburg or Pittsburgh, with a wide river turning abruptly to run through a sharp cleft in a single mountain ridge. West Point on the Hudson might be a third well-known example. But the frontal ridge of the Alleghenies, variously called Blue Mountain, Blue Ridge Mountain, South Mountain, or Kennesaw Mountains, is several ridges wide. A gap in that sort of complex mountain range must be crooked and several miles wide to let a river of any size find its way through it. Presumably, this gap at Stroudsburg was formed by some huge volcanic action, because thick sedimentary layers are upended and exposed at the river's edge, with the water winding between the towering formations. To avoid going up and over a thousand feet of the mountain, human travel must follow the same path; a railroad, a little town, and several highways are crowded into the base of the cleft now filling up with gravel eroded from the cliffs. Even the birds need to travel several miles through the winding cleft in the formidable forests, with eagles and occasional turkey vultures coasting overhead, enjoying a ride on windy updrafts, casually on the lookout for lesser prey.

The Gap is a great intersection between New Yorkers and Pennsylvanians, mostly going somewhere else. The dominant Philadelphians got there first and tended to congregate in Stroudsburg where the Waring Blendor was invented within the once-flourishing Pocono region for fishing and getting away from summer fevers. As the jolly guide at the visitor's center chuckled, the New Yorkers tend to arrive eight busloads at a time and head straight for the bathrooms. After that, nowadays most species of city dwellers buzz off for somewhere else, leaving the Water Gap to darkness, and to me.

The Water Gap has at least two other outstanding attractions, however. For fifty or more miles along both New Jersey and Pennsylvania sides of the river, a Federal Game Preservation area stretches through the forests and cliffs to the New York border. You have to be pretty determined to get to it, however, because traffic is traveling in herds at eighty miles per hour past the few entrances. You can be hopelessly beyond the entrances before you recognize you are past the point of no return, or at a point where you can if you wish only make another try for it by finding a place to turn around, pay tolls, and risk your life between the cliffs and eighteen wheelers. If you have enough courage and eye/hand coordination, however, once you do get off into the quiet woods, you pretty much have Shawnee America to yourself. The Appalachian Trail crosses at this point, but hikers should remember you must wade the Delaware River to pick up the trail on the other side.

The other gem of this area is called the Shawnee, a 19th Century resort hotel of genteel note, with outstanding food and a famous golf course that you reach by footbridge to an island. PGA championships have been played here, and Fred Waring probably played some dance music once. At one time, there was a couple of dozen such mountain resort hotels scattered from Maine to Georgia, all of the American Plan, looking as though Scott Fitzgerald and Zelda would come lurching around the next corner. It's anybody's guess whether recessions and gasoline shortages will ruin these places, or whether the people who deserted this summer custom and went to Europe will remember these mountain resorts are here and save them. Right now, there are the golfers and the mountain hikers during the summer and the skiers in the winter. And then there are a few people who want to write or read novels, some conventions, a few tourists if they own a necktie.

This winding, several miles long canyon, once a forest fastness of the Shawnee, was perhaps their main bastion. That most powerful tribe of the Algonquin federation participated in a sixty-year war with the Iroquois and mostly lost. You can certainly imagine what a marvelous fortress this region was, containing protected fertile islands to grow food, interior forests which probably abounded in game, rivers full of fish, sheltering mountains with hidden entrance clefts from which to emerge and dominate the flatlanders in all directions. If you were going to be an Indian, this was surely the best place in the world to be an Indian.

Thomas Say

Thomas Say

When writing to a good friend and fellow naturalist about his exploits in American Conchology, the Philadelphia Entomologist Thomas Say assured his friend that "INSECTS are the great objects of my attention. I hope to be able to renounce everything else and attend to them only." And so he did, writing one of the most important books on the study of North American insects. Say's American Entomology transformed the study of American Natural History from the pastime of science-oriented gentlemen, into a legitimate scientific field.

Thomas Say was born on June 27th, 1787 into a respectable Quaker family, the same summer when men from the newly independent states were meeting for the Constitutional Convention. His father, Benjamin Say, a "fighting Quaker" during the revolutionary war, was a well-established pharmacist and apothecary. His mother was a descendant of the famous naturalist, John Bartram of Bartram Gardens in Kingessing. Say seems to have inherited the naturalist gene, and collected butterflies for his great uncle, William Bartram, as a young boy. Into adulthood, he remained uninterested in all subjects save Natural History.

Say's father, skeptical about his son's obsessive interest in bugs, attempted to set him up in the pharmacy business as a partner with a family friend and fellow naturalist, John Speakman. Unfortunately, both men were more interested in Natural History than business; their partnership failed miserably, leaving Say completely broke but with plenty of time to devote to his passion, Natural History.

This passion contributed to the founding of the Academy of Natural Sciences. Meeting in the houses of local naturalists, and even in Say and Speakman's chemist shop, a small group of young men set out to create an institution where they could collect, share and legitimate the study of Natural History. With Say present at the founding meetings, the Academy of Natural Sciences was established to stop the exportation of scientific research to Europe and establish an American scientific community. Patriotic fervor was particularly notable during the year of the Academy's founding, 1812.

The Academy's progress took a brief hiatus that summer to put a stop to what the new Americans viewed as threats to the young country's independence. Say joined the army and survived its bullets. By the end of the war, and with American economic independence intact, the Naturalists now continued their mission of establishing American intellectual independence. Elected the Conservator of the Academy, Say devoted his life to the maintenance and study of its collections. He is said to have lived in the rooms of the Academy on bread and milk (with an occasional chop or egg) and to have slept under the skeleton of a horse. Notoriously frugal, spending only 6 cents on food every day, Say bemoaned the hassle and expense of dining. He would rather be studying the wings of mosquitoes than wasting time with fancy dining.

During these early days of the United States, Thomas Say was quickly cast as a key member of America's varied and extensive expeditions to discover its largely unknown country. His first was a trip with fellow Academy members to Florida in 1817, a journey cut short by the threat of unfriendly local indigenous tribes. The group did manage to capture a few important species; Thomas Say wrote to a friend that Florida while "not flowing with milk and honey," was "abounding in insects which are unknown."

In 1819, Say was appointed head zoologist for the expedition of Major Long to the Rocky Mountains, where Say discovered and named not only insects, but animals as well, including the Columba fasciata Say, or fan-tailed pigeon. Several years later, in 1823, Say accompanied Long once again, this time on an expedition to the head of the St. Peter's River.

Back in Philadelphia, Thomas Say worked tirelessly to deepen the Academy's intellectual work, publishing many articles for the Academy's Journal on both entomology and conchology. He was also involved with the American Philosophical Society and became professor of Natural Sciences at the University of Pennsylvania. During this busy time, Say also managed to socialize among Philadelphia's upper crust, and is noted as having attended Caspar Wistar's weekly "soirees."

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Papilio Glacus from American Entymology

His urban life did not last, however; Say found himself swept westward in a great tide of social idealism. Robert Owen, a Scottish social reformer, moved to the United States in hopes of establishing a community based on the principles of cooperation, brotherly love, and universal education through the absence of competition, and religious motives. Having purchased the property of the German "Harmonists" in Indiana, Owen persuaded nearly 1,000 people of varying background to help establish a Utopian society. Although Say had a strong democratic spirit, he was perhaps most interested in the move West for what it might offer him in the way of scientific discovery.

In 1826, with both MacClure and Owen, Thomas Say sailed down the Ohio River on what was called the "Boatload of Knowledge," a small ship carrying East Coast intellectuals to their Indiana paradise. Say was put in charge of the operation and named captain of the ship, perhaps due to his experience in the army more than a decade before. It was also on this boat ride to Indiana that Say met his future wife, Lucy Way Sistare, a prospective schoolteacher at New Harmony.

Despite this drastic move, Say remained much more concerned with his study of Natural History than any particular ideological movement, a fortunate enough attitude given the community's short life; after only two years the New Harmony project evaporated because of lack of organization and internal feuds between Owen and his various followers. Say was nevertheless able to use the move out West to his advantage and took part on an expedition to Mexico with William MacClure.

Although voices from the East Coast, and particularly the Academy, called him back, Say stayed in Indiana, publishing his two most famous works, American Entomology and American Conchology. He used illustrations composed over the years by young Titian Peale, son of Say's portraitist, Charles Wilson Peale, as well as Charles Alexandre Lesueur. Lucy Say, his wife, also helped to color the plates for their publication. These two works, and particularly American Entomology were praised abroad as real works of science and as proof the United States had "serious" scientists.

Say experienced relative peace and quiet during his final years in Indiana, a quiet spent in vigorous study of Natural History. However, after years of ill-health, of putting off food for study and his own well-being for that of others, Say died at the young age of 49 in 1834. He was buried at New Harmony, the grave marked with an epitaph capturing his unique passion for the Natural World:

Botany of nature, even from a child,
He saw her presence in the trackless wild;
To him the shell, the insect and the flower,
Were bright and cherished embers of her power.
In her, he saw a spirit life divine,
And worshiped like a Pilgrim at the shrine.

Admonitions: Using the Transition to Lifetime Health Insurance as an Inflation Restraint

Inflation Protection. Let's imagine the typical individual has reached the point where he is writing his will at the age of 90. He has followed our advice, created an HSA, dutifully funded it, and reached the point where his medical expenses are mostly behind him, but -- he has a meaningful amount of money left in the HSA. The existing legislation is pretty relaxed about that, allowing him to convert his HSA into an IRA, and follow its rules for inheritance. That's fine because it has created an incentive all these years, to save just a little extra money in the HSA for contingencies; after paying taxes, he can spend it as he pleases.

The Escrow Fund. It may be fine, but it eventually comes to an end in the face of terminal care costs; at that point, the future is damned. Since most people never know for certain which episode will be the last, indifference to insured costs is fairly general. There needs to be additional restraint against medical cost inflation. We propose that a compartment of Medical Savings Accounts be designated as a single-purpose escrow fund, adhering to the model of buying a life membership in a club, except in this case, it can only buy lifetime health coverage from Medicare. Annually, his fund manager transfers a sum to the individual escrow fund, calculated to reach a buyout price for Medicare coverage at some later age, and assuming the investment income achieves a stated goal. The individual may borrow against the escrow to pay current medical expenses and may need a subsidy to do so, but the escrow may not be spent down. (It continues to generate investment return to the fund which in normal circumstances would exceed the loan interest). At any time he has enough money, our Medicare subscriber can make a voluntary deal with Medicare as follows: If he will turn his escrow fund over to Medicare at his death, then Medicare will no longer collect his full Medicare premiums, starting today. That's a good offer or a bad one, depending on his life expectancy and how much is in the escrow fund; as of today's rules that would typically be several thousand dollars. That's a bad deal for the government if there is inflation. However, for individuals at any age down to age 26, it would seemingly always have made a better deal if he had only made it a year or two earlier. If it had been offered at age 65, it would have made a tremendously better deal than at age 90, because so many more premiums would lie ahead. And before that, if the deal were offered to a working person it could extend to skipping the 6% Medicare payroll tax deductions, which could be a stupendous deal. So let's go back and make a counter-offer using this inflation restraint. It's called the accordion plan, where both the government and the individual must agree on the best year to clinch it, depending on how everything is going. Unfortunately, any system like this requires an unimpeachable monitor.

Buying Out of Medicare. The average person over age 65 is haunted by the possibility that his living expenses will someday exceed his income, so he likes to have as much of his anticipated expenses pre-paid as possible. (He likes to be offered life membership in a club, for example.) So, he proposes to Medicare that they do the arithmetic and tells him at what age they think he could stop paying payroll taxes and/or Medicare premiums to Medicare and pay them into his escrow fund so that he becomes paid-up and no longer cares about medical cost inflation. And if there is no point in time when the two are clearly equal, then how much would he have to supplement the escrow fund from his savings to reach the goal. Since the law of large numbers enables Medicare to predict its average costs with greater precision than the individual can predict his own, a difference between the two prices represents the individual's fear that he might incur substantially higher than average costs. Half of the Medicare beneficiaries will, and half won't, but any individual's actual chances are largely a lottery. So, a substantial number of people would take the deal on terms favorable to Medicare. This isn't exactly the proposal we plan to make, but it illustrates the principle.

Part of the secret of the current proposal is that the individual can have the advantage (and bear the risks) of investing in the equity of private companies, whereas we would squirm if the government owned a big chunk of American private business. Notice for example how quickly the government sold back the stock of General Motors after it had bailed it out. Private individuals might indeed make 10% return on index funds of the entire U.S. stock market, given a 90-year horizon, (and under the discipline that you can't buy high and sell low, because we won't let you sell other than for medical costs). Furthermore, the government can't sell it for you, because you own it independently. This deal would fall apart if inflation unbalanced it, but the value of stocks and the cost of medical care will respond to inflation at about the same rate, providing you wait long enough and use big enough numbers. Nevertheless, it would only seem prudent to appoint an independent agency to monitor and control matters, particularly because stockbrokers are not considered to be fiduciaries, putting the client's interest ahead of their own. In spite of that fact, most people would be astonished at how fast a fund will grow at 10%. Medicare can't get such investment income, because in 1965 it was decided to use the "pay as you go" system, but it is clear that Medicare would sustain much higher debts if we abruptly cut off its payroll tax and premium income. So this process should require each individual to take at least ten years to switch completely, holding each person's "paid up" goal as ransom if he participates in reckless medical spending, and delaying the government's acquiring the escrow if they permit such spending. We are apparently never going back to using gold bars to frustrate government-endorsed inflation of the currency, so we have to devise other self-balancing restraints like this one.

In these days of burdensome health insurance costs, it is useful to consider how health insurance might emulate what is normally done with "whole-life" life insurance. Most life insurance clients to understand that total premiums amount to less than the face value of the policy, while considerably more than the face value is often paid out to the beneficiary. The apparently miraculous appearance of extra money is accounted for, by the ability of the insurance company to invest the premiums until they are needed for benefits. True, life insurance has also prospered from the stretching of longevity by improved healthcare, but that windfall also applies to health insurance. In both cases, improved longevity is hoped-for but not guaranteed, and adds to the safety reserves. The issues to be pondered are how to set final rates so far in advance. Or, if you wait to see how costs actually develop, how to give a useful benefit to someone who by that time is already dead. The life insurance companies have devised their way of managing this awkwardness, which requires public trust in the good faith of their counterparty. Results vary between companies, but in the long run, it doesn't pay to cheat.

The Need for Transparency and the Image of Fair and Square. Transition from an old system to a new one is a familiar problem for legislators. In our case, it may actually facilitate matters by restraining the impulse to take on too much difficulty, all at once. Every citizen is covered for hospital costs in Medicare Part A, and the great majority are covered for physician and outpatient costs by Medicare Part B. Part C is only partial and voluntary, Part D is still on trial. For this discussion, we need not describe the varying ways that Medicare Part A, B, C, and D collect premiums or the historical reasons why they differ. It should be emphasized early, however, that overall direct income falls short of covering overall Medicare benefit costs by 50%, so Medicare is 50% subsidized, and therefore not nearly as stable as the public assumes. It would help a lot, for example, if debt just stops being called an asset on the balance sheets. Everybody enjoys getting a dollar for fifty cents, so the program is more popular than it would be if euphemistic revenue descriptions were discontinued. It is particularly worrisome, that the popular alternative of a "single-payer system" implies simply extending Medicare to persons of all ages. But it also implies extending the 50% hidden tax subsidy to all ages so single-payer consolidation would add an even more unsustainable burden to the national deficit. This apparently irrelevant comment helps explain why the public expected Obamacare to be cheaper than it proved to be, and adds considerably to the urgency to find other revenue sources during a protracted economic recession, for what are proving to be unexpectedly high prices. Hence, the need for more subsidy than was anticipated. The consequent income redistribution is widely resented. Time and again we return to George Washington's central maxim as president: honesty is the best policy.

How To Recycle the Income {bottom quote}

Terminal Care is Mostly Medicare

Go With the Flow. To return to the point, almost everybody now dies with terminal expenses covered by Medicare. The medical industry waits for about six months, and eventually gets paid for its services by Medicare, incompletely perhaps, but for the most part. From this is derived the insurance shorthand concept of the "last year of Life costs" which largely represents terminal illness. Along with the obstetrical costs of being born, these two costs are the only two we can safely assume will continue forever. Everything else is like the Federal Reserve's Quantitative Easing. We can be certain it will stop, but we have no idea how long it will take. While we can perceive that medical progress is largely a matter of removing diseases from the list, the allied perception is that younger people are always going to be somewhat healthier than older ones. There will be exceptions like HIV/AIDS, but the perception is probably permanent. Since progressively older people are supported by savings and wealth transfers, the concept of investing the savings of younger people in order to sustain them when they get older, seems a dependable one. It also seems safe to assume that people will resent it less if it is their own money, rather than drawn from a public pool. That is, savings will be resented less than taxes, incentives will be resented less than coercion, and the final outcome will be the accumulation of more savings within private hands than within national treasuries.

Now add the idealized extra specifics: if subscribers by contribution, gift or subsidy create a Health Savings Account early in life, and Medicare can be induced to reduce its own premiums out of recognition of equivalent reserves in the funds, the future payment of (at least) last-year-of-life costs could be assured -- and current premiums for Medicare could be accordingly reduced, putting the money back in people's pockets. In this way, Medicare and the subscriber would adjust to the benefits of a major new revenue source, the investment proceeds of the Health Savings Accounts. A whole bundle of uncertainties absolutely do remain -- the zig-zag of interest rates, the volatility of the stock market, the elimination of some diseases, the creation of expensive new treatments, the actual longevity of the population, and the constant menace of inflation -- but one certainty survives. To a significant degree, a new source of income would effectively lower the cost of health care, even though it may not have paid for all of it precisely. No rationing, no income redistribution, no great change in how medicine is practiced. The opportunity seems too attractive to dismiss, but it must be continuously and openly monitored.

Income is fairly predictable, Future Costs are not. {bottom quote}

Balancing the Books

Simplify. Since the ultimate outcome is uncertain and will surely vary from predicted, adequate provision must be made for both the possibility of surplus and deficiency. Because of possible surplus, residuals should be allowed to pass through inheritance, or to be spent for non-medical purposes, or both, as incentives to compliance rather than circumvention. Because of potential shortfalls, some process for early detection and freezing of shortfalls should also be created, leading to subsidies, and restitution of subsidies, under defined circumstances. To the maximum degree feasible, the "accordion" principle should be employed, whereby benefits are expanded or contracted to reflect surplus and deficiency in the individual Health Savings Account, and indirectly, the growing success or failure of the scheme. Furthermore, the use of average costs rather than specific ones is encouraged, thus making it easier to deal with average lifetime health costs. In a computer age, it is almost as easy to report 300 million individual accounts as to measure by average performance, but it leads to intolerable public confusion about what is happening to the program. If achievable, a transformation from annual bills to lifetime costs would allow the elimination of pre-existing condition exclusions almost without effort, since lifetime liability would remain unlinked to HSA balances, and even largely unaffected by individual catastrophic illness if pooling is added. It might require considerable research, however, to detect the creation of unforeseen loopholes to game the system. Ultimately, that is a gigantic undertaking. The more we can simplify it with self-enforcing incentives, the more likely we can perform the essentials well, side-stepping all the work and aggravation of playing cops and robbers.

Get Started. The two quickest ways to induce large numbers of people to create Health Savings Accounts would be to add a permanent rollover feature to Flexible Spending Accounts, which currently contain a use-it-or-lose-it feature. Because of the cost to employers, it would be a useful opportunity to remind them of the inequity they have enjoyed from seventy years of Henry Kaiser tax exemption. And the second accelerant would be to eliminate the income tax discrimination against it, by allowing health insurance premiums to qualify for purchase by Health Savings Accounts, and thus to become tax-deductible like almost everybody else's health insurance.

Monitoring the Actions of the Business Coalitions for Health: by Harry Schwarts, PhD

Chicago, Il. Those much discussed and, in some medical circles, much-feared Business Coalitions for Health Action may be a more constructive force on the health scene than doctor pessimists have feared.

No one could have attended the first national meeting of the coalitions, sponsored by the U.S. Coalition for Health Actions at the first of June, without understanding the strength of the commitment of the coalition representatives to more economical resource use in healthcare. But this was no "hate-the-doctor" meeting nor was there any irrational or demagogic posturing such as has come so frequently from some politicians in Washington.

On the contrary, both speakers and participants agreed the United States has a superb health-care system offering patients the best available care. There is a desire to make the system operate more economically by widening the choices of both doctors and patients. But the coalition members seemed much too sophisticated to believe there was any single magic answer such as dragooning all doctors into health maintenance organizations (HMO's) or making them hired hands of the federal government.

Moreover, the stress was on slowing down the rate of future health-care cost increases. It was recognized health-care costs will increase because the country's population is aging and because future medical progress will make it possible for doctors to do more to help their patients than ever before.

Perhaps the most intriguing insight offered to the more than 100 participants came from Stephen Caulfield, of the Government Research Corporation. He suggested that later in the 1980's the greatest of health-care price increases might come from the high cost of the capital.

"There is a desire to make the system operate more economically by widening the choices of both doctors and patients."

Many of the nation's community hospitals, built 20 to 40 years ago, are becoming more decrepit and, in many cases, need rebuilding or complete replacement. Just to replace the community hospitals, with no increase in beds, he estimated, would cost $190 billion, most of which will have to be borrowed. And at the likely rates of interest visible ahead, that interest load may well prove the most inflationary force on health-care.

For physicians pinched by increasing competition and the resulting patient shortage, a possible new rival to HMO's was described in detail by Gary Brukardt, of Denver's Mountain Medical Affiliates, a preferred provider organization (PPO), organizations that may conceivably become as much a part of medical jargon as HMO's.

A PPO is a device for doctors to compete by cutting prices or giving discounts, for third-party payers. Burkhardt's pioneering PPO was organized by Denver's Presbyterian Saint Luke's Medical Center after the hospital began losing more and more of its patients to suburban hospitals and HMO's.

The hospital decided to meet the challenges by organizing itself and its specialist physicians who cared to join into a price-cutting source of tertiary care later expanded to primary care. Mountain Medical Affiliates was organized by the hospital as a complementary physicians organization, now embracing 320 doctors representing 28 specialties.

In effect, the hospital and the PPO offer third-party payers a discounting deal. The arrangement apparently appears mainly to Denver companies that self-insure for medical costs. If their employees go to the hospital, the hospital's bill to the employer is discounted by some undisclosed percentage. If the employees go to one of the 320 participating specialists, their employer is billed at a rate which is between 5 and 20 percent below the prevailing "usual and customary" rates.

For the participating physician, the arrangement has two big advantages. First, it is a source of additional patients, as well as a means of holding on to odd patients. Brukardt estimated that 45 percent of the PPO's patients are new. Second, the companies involved pay promptly, normally within seven to 10 business days on receipt of the physician's bill.

The Hospital itself has expanded its system to include a total of six hospitals including institutions in Estes Park and Vail, Colo., as well as Colby, Kan., two emergency facilities, and eight primary-care centers staffed by employed physicians. Brunkardt emphasized participating PPO physicians control their destiny, decide themselves what the relative values of different procedures shall be and are by no means completely dependent on the PPO. Some physicians g=fet 20 percent of their patients from the PPO, while others get only a few each weeks.

The luncheon speaker was George Ross Fisher, MD, a Philadelphia endocrinologist author of "The Hospital That Ate Chicago" and a veteran member of the American Medical Association's House of Delegates. Dr. Fisher emphasized two points: the need to make patients more conscious of the cost of medical care by introducing more deductibles and percentage payment arrangements into health insurance schemes; and the need to run hospitals in a more businesslike fashion.

To foster the latter objective, he suggests every non-profit hospital set up a subsidiary for -profit organization that would actually operate the hospital. All profits made by the organization running the hospital could be used by the owner, the non-profit corporation, for encouraging teaching and research and to pay for patients who cannot pay for their own care.

There are now 48 full-fledged coalitions for health care operating in the United States, a Peter Ozge, director of the U.S. Chamber of Commerce Clearinghouse on Business Health Coalitions, told the meeting participants. The 48 coalitions enroll 1,870 members 75 percent are employers, 18.5 percent are health-care providers, and the rest is labor, government, and miscellaneous groups.

Most of the coalitions are relatively small, local organizations and only 20 percent of them have more than 50 members, while 9 percent have under 25 members. Most of the coalitions are operated by volunteers or personnel assigned by member companies, but 21 coalitions have only workers employed by those organizations themselves.

About one-third of the coalitions consist exclusively of employers, while only none of the 48 have to labor organizations as members. The interest of the provider organizations in the coalition movement was indicated by the presence of numerous representatives of provider groups such as the Indiana Medical Association, Kaiser-Permanente and the Hospital Corporation of America.

The stress was on slowing down the rate of future health-care cost increases.

The business community's effort to exert pressure for restraint on medical costs is not monolithic. Entirely separate from the coalition movement is the Health Task Force of the Business Roundtable. The Roundtable consists of the chief executive officers of some 200 of the largest corporations of the country, and the latter has encouraged its members to belong to the Washington Business Group on Health, an articulate representative for business views on health issues before Congress.

But apparently relations among the different business groups are cordial. Lindon Saline, Ph.D., a General Electric executive assigned to the Business Roundtable "Health Initiative," spoke to the group. He emphasized the Roundtable is encouraging its member corporations to participate in local coalitions in all of the communities where the member coalitions have significant plants and offices. Willis Goldbeck, the chief executive of the Washington Business Group on Health, acted as moderator at one of the meeting's afternoon discussion sections.

A representative of the Department of Health and Human Services (HHS), medical economist Bruce Steinwald, Ph.D., said the Reagan administration is still interested in the competition strategy but has the regulation strategy in reserve if needed. HHS, Dr. Steinwald said, is collecting a wide variety of information on medical costs and on how costs are affected by different modes of healthcare delivery and by business efforts to restrain costs.

Gerald Gleeson, of the Philadelphia coalition, and government data collection efforts. These efforts aim to make basic data sets available that will permit equivalent comparisons between medical care given and medical costs incurred for similar conditions in different communities and different parts of the county.

However, few stressed that the collections of fully comparable and uniform data for all parts of the country will permit government and other third-party payers to press for greater uniformity throughout the country. It is known, for example, that the length of stay in a California hospital is relatively short while relatively long in the Northeast. With the passage of time, availability of better data may create the basis for pressure to make the length of stay in a hospital and other cost elements more uniform across the country.

Gleeson, other speakers, and various coalition members and staff personnel attending the meeting expressed concern that the Reagan administration may try to put more of a load on the coalitions that they are capable of bearing. "We cannot be the nation's health planners, utilization reviewers and 'what have you' as some in Washington would like us to be." one veteran coalition official said.

Nevertheless, the coalitions hope to expand their activities and help get all providers both doctors and hospitals to adopt more economical modes of health-care delivery. Doctors and their organizations are apparently welcome to cooperate as are hospitals and their organizations. But nobody at this Chicago meeting doubted there would be conflicts as well as cooperation in the months ahead.

Philadelphia Reflections

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

Obituary

George R. Fisher, III, M.D.

Population Growth: Constitutional Mathematics

Delaware Water Gap

Thomas Say

Admonitions: Using the Transition to Lifetime Health Insurance as an Inflation Restraint

Monitoring the Actions of the Business Coalitions for Health: by Harry Schwarts, PhD