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
... William Penn's Quaker Colonies
plus medicine, economics and politics ... nearly 4,000 articles in all
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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.
Everybody knows the old insurance saw, that the big print gives but the small print takes away. If health insurance pays for one sort of thing but not another, there is anxiety that a bewildered patient can be deprived of coverage he thinks he paid for. A patient knows he was sick, that he saw a doctor, or that he went to a hospital; beyond that, it's better not to leave room for arguments. To a certain degree, this is what has made HMOs seem so threatening; complicated assurances can lead to disappointing loopholes. So, for a century it has almost been an article of religious faith that health insurance should cover everything that costs money when you are sick. However, that headlong faith is exactly why the matter needs to be subject to critical review. Not only does monolithic insurance conceal a vast system of cross-subsidies. It has existed for too long when everything else in Medicine has changed for the original premise to be immune to change.
There are health insurance considerations which go beyond mere convenience of administration. Transparency and flexibility, for instance, suffer when everything is under a single blanket. Women pay a share of prostate surgeries they will never have themselves, people who hate abortions have to pay a share of them anyway. The ability to buy what you think you need is taken away, so some people who could afford what they need are unable to afford the whole package because it includes what they feel they would never need. And then there is moral hazard. Some people reach for what they don't need just because it costs nothing extra. Well, this isn't 1930; we don't need to debate the whole issue top to bottom. But there may nevertheless be a few features of global health insurance which could be advantageously teased out separately.
For a first example, look at terminal care. Everybody is going to die, and mostly the cost is picked up by Medicare because most people who die are elderly. Some insight into the issue and a reasonably workable definition of terminal care is provided by the statistic that a third of the expenditures of Medicare is paid for someone in the last year of life. Statistics on the average age at death are known with great precision, so it would be easy to calculate the yearly premium cost at any age or the size of a single-premium policy needed at any age to cover the average cost of the last-year-of-life. If we are ever to fund the unfunded Medicare program, this is the place to start. And if you are wondering how you know in advance when you are going to die, you don't need to know. Just establish an independent "endowment" fund, which reimburses the current Medicare program for any expense incurred during what proves in retrospect to have been the last year. Presumably, the cost of running the unfunded portion of Medicare would then drop by a third, while the cost of the funded third would be diminished by the investment strategy of its manager. The relatively few people who die without Medicare eligibility might be treated in the same way, reimbursing whoever paid the costs, but the risk calculation would be more difficult, and a life insurance policy might be preferable. Once the younger individual with such a designated life insurance policy attained Medicare eligibility, some sort of coordination would be desirable.
Everyone dies once, and no one escapes death. But terminal care benefits are not so terribly different from some other health issues. Nowadays, just about everybody can expect to have two cataract operations, and most people can expect a hernia repair, a gallbladder removal, and if male a prostate removal. Everybody ought to have a pneumonia immunization, and a colonoscopy, by age 66. It would be easy to compile lifetime risks and update them yearly, for the typical male with 1 death, 1 pneumonia vaccination, one colonoscopy, 0.76 prostatectomies, 0.59 cholecystectomies, 0.37 hernia repairs and so on. The cost of this sort of routine care is not really insurance, it is pre-payment. It is not subject to abuse, and need not be challenged or reviewed unless statistical monitoring shows that the incidence of some component was rising in a particular zip code area. In that case, what would be called for would not claim review, it would be provider review.
Perhaps the reader can see where this is going. Having stripped out routine pre-payment as much as is practical, you are left with the unknowable "all other". Insurance which covers this sort of risk becomes true insurance, in an umbrella form. As medical care continues to advance, more things can be moved from "all other" to "routine". Ultimately, and probably sooner than most people would guess, you can achieve a true insurance system, defined as having a trivial insurance premium for a remote risk. From that point forward, you can direct your cost-cutting attention to reducing the cost of routine care. That would include the devising of strategies to pay for luxury versions of routine care, as desired.
Cost-shifting is a necessary accounting evil, without which no large organization could survive. Confusingly large amounts of it, however, undermine trust in the leadership. More specific criticism of current healthcare leadership is its reliance on moralizing rather than an apology. That is a sure sign that oppressors (i.e. insurance and government) made it necessary, and suggests that leadership is toadying to them.
Since managers have no choice but to engage in cost-shifting, it seems better to cost-shift with some hope of repayment. By switching to lifetime health insurance to replace the one-year version, many more opportunities can be developed for repaying the older individual what had been "borrowed" from him as a youth. Even without the notion of paying interest on the loan with investment proceeds, it seems more comfortable to seek loan forgiveness from yourself at a later stage of life, if that proves the necessary insurance metaphor.
The proposal to revise insurance architecture also contains a transfer of the site of cost-shifting from hospitals to the external insurance mechanism, where the underlying problems originated. There is a certain justice to that, but its main attraction is to make it visible and consensual, and therefore more generally accepted. It is one thing to convince a classroom of business students, quite another to convince the whole public, of the regrettable need for cost-shifting that will never seem completely fair.
And finally, there is the investment income. The public is no more likely to forgive its mercenary features than it is to accept that bankers are interested in more than profits from the interest on a loan. After all, interest-bearing loans were forbidden by law for centuries. When it first hears of the fairly astonishing 10% return from a passive investment, and the even more astonishing sums to be derived from ninety years of investing, the public will likely scoff at some sort of trickery. A great many people still prefer managed accounts to passive ones, in spite of Professor Ibbottson's rather convincing data from the immediately preceding century.
Two sources of concern are nevertheless impossible to answer. America may lose its dynamism, as even the Roman Empire eventually did, and nothing can withstand the financial consequences. And secondly, so many people might switch to passive investment that it loses its edge, and eventually pays less than hiding all savings in a mattress. That is to say, high returns imply high risk; without risk, there will be no returns. These considerations are long term and have nothing to do with healthcare. For this reason, I have reluctantly made the suggestion that we establish an independent organization, for all its flaws, to study whatever is happening and continuously make mid-course corrections to adjust for it.
In the light of future developments, we might someday look back on the University of Pittsburgh as the place health insurance stepped over a line and merged group practices with health insurance companies. It's true that was somewhat the way the first Blue Cross in Houston, Texas,
had been organized, although it eventually split into component parts. It's the thought running through closed-panel insurance that this might be an easy way to circumvent antitrust laws because vertical integration is no longer considered a per se violation. Although, as mentioned earlier, it isn't necessarily a good thing either, and it isn't immune to a trial of the facts.
It has certainly aroused violent discomfort among excluded competitors in allied industries, to allow mediation control to fall into the hands of a corporation which could profit from the favoritism. Better to conduct arms-length transactions; the regulator should not profit from its own decisions. No law exactly says this should be so; the customers just like it better. And indeed Pittsburgh was the location of the defining court case, decades ago, where non-profit organizations were declared exempt from antitrust suits, just as Philadelphia had the first case which declared an end to charitable immunity. Until someone re-litigates these cases in a changing environment, these old court decisions retain a particularly large impact on local thinking.
Red tape is always expensive, and right now high costs are a challenging problem. Furthermore, big business is currently paying the bill, and big business would like to be satisfied on the point. That raises another historical point. Henry Kaiser gets credit for inventing the employer-based tax exemption, but the issue was rampant in all of the steel industry, which was often the leader in such innovations. The steel industry has pretty well abandoned America and gone to the Far East except for steel made out of scrap. The health insurance companies traditionally jumped at the command of the big employers, but maybe there is an opportunity for a revision of leadership in the industrial unions, particularly in steel. But while it may well be true this political vacuum has been filled with new leadership, it is likely some old traditions persist. The bitterness of the Molly Maguire era was thought to have ended a century ago, but if your ancestor was hanged or assassinated, the legend lives on. Sounds sort of like the Balkans, doesn't it? Some people in Bosnia are still endorsing genocide in retaliation for Thirteenth-century church burnings.
Red tape is always expensive.
Based on reasonings of this sort, it is fair to conclude that even if the big business (or big government) changes its mind about the ultimate outcome, this kind of behavior may or may not change. Uncertain of the eventual outcome, both providers and vendors of care may think it is better to leave the matter alone. And if someone else pays the bill, someone else may decide to change the system of utilization control. Through a convoluted history in several steps, the University of Pittsburgh has formed a large salaried group practice and merged it with the captive teaching hospital at one end, and the captive health insurance company at the other. Pennsylvania is a large state with rather wide sociological and industrial differences, but it is only natural that the other medical schools, hospitals, physician groups, and insurance companies would worry that this system might migrate into their neighboring territories. At the very least, rearrangements on such a large scale would be expensive and complicated. And not necessarily beneficial to the common good.
In case the reasoning isn't clear, let us restate the argument which was persuasive to the United States Supreme Court in the case of State Oil v. Kahn . As conglomerates acquire new businesses, they find they are not particularly good at managing a few parts of the whole. It is a failure in those defective components, which brings the whole conglomerate enterprise, down.
Companies may merge across traditional occupational boundaries, for a variety of reasons. One of the most questionable reasons to merge is to eliminate an unwelcome constraint on your plans, such as a new invention. Another would be to eliminate a critic whose views thwart you for reasons you do not understand. In the present situation, a medical school which supplies new physicians to a region should not be allowed to favor or control its graduates, or to enhance, protect or destroy their environment, particularly if the public suffers from the effects of it. When a medical conglomerate is allowed to profit in some of its divisions, in spite of losing money in others, the interests of the conglomerate may not be parallel with the interests of the public, in their choices of winners and losers. A mixture of taxable and non-taxable activities offer many opportunities for this to be the result.
Lifetime health care is commonly stated to cost about $350,000, per person, in year 2000 dollars. This figure is based on work of the Michigan Blue Cross, confirmed by two government sources. The underlying formula was supplied by Dale Yamamoto, a Washington actuary, applied to data supplied by insurance companies and intended to give relative cost projections into the future, adjusting for inflation, but not adjusting for scientific advances which might take place. Because the source of the cost was data supplied to insurance companies, the possibility exists that insurance costs are not part of the calculation. Let us assume therefore that $400,000 would be a more accurate estimate for average lifetime costs, setting unknowable scientific advances aside. Doing so allows for potentially omitted insurance costs, and if this surmise is upset, we can transfer $50,000 of the proposed restructuring to retirement benefits.
If we further set aside the costs of working people aged 25-65 until at least the November 2016 presidential elections, we get a rough estimate of $ 300,000-lifetime cost for medical costs, but excluding the costs of employer-based insurance, Medicaid, and the Affordable care act. Unfortunately, even this estimate doesn't include the 42 million people who don't have the ability to pay for themselves, like mentally impaired, illegal aliens, prisoners in custody. Let's estimate that the average American must anticipate $ 400,000-lifetime costs, including the need to pay, somehow, for these medical obligations. When the dust finally settles, we may attempt a more accurate projection of average healthcare costs, but for the moment it seems adequate to state them to be: about $300,000 plus these extras. How much are we spending, right now?
Well, we are spending about $60,000 for Medicare, and we borrow another $60,000 from bondholders--far from enough to cover even roughly estimated costs. Further, we are spending 8%, or $9600, on childbirth and pediatric care to the age of 25, by way of ascribing that cost to the mother and father instead of to the child. That's a total of $60,000 which is visible, and $69,600 invisible..
By contrast, we get more acceptable numbers by doing three things. We could generate 7% interest on the $60,000, by directing prepayments to personal Health Savings Accounts, -- of our present withholding taxes and Medicare premiums. The same amount of money, different post office addresses. And secondly, we relieve the payers for the parents, by paying the costs of the babies and children. Lastly, we generate 7% on a $250 one-time gift at birth
The amount of revenue is complicated. For withholding tax, we generate 7% on $700 yearly additions to withholding, for 40 years. And we generate 7% on $1400 annual Medicare premiums for 20 years.You may need a calculator to verify this, but the interest on withholding is 137,000 + 57,000=$194,000..
And the $1800 escrow gift at birth at 7% equals $137,000 at age 65..
$137,000 +194,000 = $331,000.Commentary: We have postulated a mysterious contribution of $250 at birth which, with a change of postal address, might convert a massive indebtedness into a break-even arrangement. Never mind the rough approximations, the simple reform converts a hopeless deficit into a plausible solution. One more simple step creates a comfortable surplus. Placing both funds into a single investment vehicle (the Health Savings Account) extends the duration of the two pieces to the point where compound interest for a longer span of time, greatly increases the percentage return, as illustrated in Figure 2..
The Health Savings Account, alone among health financing methods, provides for transferring unused healthcare savings to an Individual Retirement Account (IRA), and thus automatically makes a surplus available for retirement spending. There's justice to that, because improved healthcare results in living longer, and hence in rising retirement costs. Of course, ultimately science may help pay for the benefits it has provided, whenever it succeeds in reducing costs by curing some disease. Ultimately it is possible to imagine health costs reducing to the first year and last years of life. Everything in between will have been cured, but only after myriads of untreatable diseases have been extensively treated. Right now, most heavy costs are concentrated in ten diseases. But half of the medical costs are consumed by Medicare, and half of Medicare has concentrated in the last four years of life.
... ....................................................................................................................................................................................
Age....................0....................25....................25-65...............65-85..............85-104...........................Lifetime..........
Childbirth..........XXXXX*.*...........XXXXXXXX**
., Trust Fund.................350.000*........
Dependent Child.........................................
Working Age (omitted)....................................................0.00
Medicare, plus supplementary................................................................$58,000 +(58,000 borrowed)
Lifetime,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,$350,0000(-116,000+(234,000)+Insurance admin=approx 289,000
... ....................................................................................................................................................................................
Up this point, the reader has been exposed to a rather deadpan description of where available data seems to lead us. Experience with discussing the matter with friends at local clubs has been the members of the audience either sit in bewildered silence, or they interrupt with imagined discoveries of flaws in the reasoning. Most of the interruptions are misunderstandings, requiring a lengthy digression to explain the point to someone unfamiliar with the particular topic which upset him. Since readers cannot speak out, but often have the same points of misunderstanding, let me pre-answer some common sources of agitation:
Some Common Misreadings 1) "This is a rich man's plan, which does not focus on the poor man's problems. "No, it accepts the ground rules of Medicare to include everybody, rich or poor, of a certain age; and we follow Medicare's data, so we accept their rules. The data per average beneficiary takes Medicare's data and divides them by the number of beneficiaries. Since Medicare data has age limits, not income limits, including 46 million persons over 65, plus 9 million disabled persons under 65, the average is probably somewhat more conservative (higher) than even the average rich man would actually pay, but the benefits are universal for the age group.
2)"Where is a poor single mother going to get $100 to start a contingency fund?" You mistake the purpose. The $100 is an example, not a mandate. It saves us repeating endless calculations for every year from birth to death. It illustrates the power of compound interest, implies that things which are entirely free are not taken seriously, and provides a point for the subsidy, when a subsidy is needed.
3)"These calculations are preposterous." You may be right if I have occasionally miscalculated or miscopied some numbers. But I tried hard to avoid that. The main purpose of the effort was to point out that increased longevity (caused by medical care) has brought the far end of the curves into an area where the tail of compounding turns upward. We have long since ignored this feature, which greatly bothered the ancient Greeks who discovered it. Since the tail, except for the transition phase, of the curve stretches ahead nearly a century, we mostly haven't adjusted to the practicalities of the proposal, quite yet.
4)"Nobody can earn 7% in the stock market for extended periods of time." I looked over my own and some other accounts, and find I have averaged 6%. A recent article in the Wall Street Journal estimates that switching the stock manager to a fee-only arrangement (instead of participation in the profits) would add one percent to the average investor's final return. If we get serious and exploit computers and other efficiencies, I have no doubt another percent investment return is feasible. Naturally, the finance industry doesn't want to agree, but that's the nature of creative destruction.
5)"What's good to me, to wait nearly a century to get healthcare cheaper? The government or my agent would probably steal it, anyway."
Yes, the problem of the imperfect agency is a real one, and prevention must become part of the design. But the transition might take twenty years, not a century. Medicare itself was created in 1965, and you could have raised the same objection, then. You have to start somewhere, and you have to expect mid-course corrections.
The Real Practical Issues to be Confronted. At my age, I have no desire to start a company and make a fortune, so I leave that to my grandchildren. So I might as well be frank about the matter.
This plan cannot go ahead without some Congressional amendments. Not many, but there would be sufficient to cripple the idea if it provokes opposition which has no motive except political ones. The age and employment requirements of HSA must be eliminated, and other government programs should be modified to adjust to changing life circumstances. Bare-bones catastrophic insurance should be standardized by some mechanism. If there were problems with the ACA, surely there must be flaws in catastrophic insurance companies because they are accustomed to a one-year term format, and this proposal requires a longer horizon. A huge nation-wide system requires local offices and personal advice about how to handle changing investment environments, plus issues like investing for newborns, and for divorces. A totally new approach will require a lot of explaining, and all of this requires investment.
But mainly I have strictly left the working age group (age 25-65) out of the narrative, until the full facts are known after January 2017 and we can learn whether it is to be revenue-neutral or regularly sustains a big loss. When Donald Trump gets control of the department and its books, I worry that deficits will prove to be far worse than even he thought they would be. His temptation to "expose the rascals" will be strong but must be held back for better, more strategic, political uses. One important use would be to punish efforts to stonewall the new program. The Affordable Care Act took two years to emerge with regulations, Medicare in 1965 was an administrative mess for five years -- their computers didn't work, either. So, it might be wise to start modestly, with the program of 1980 to which a few essential parts are added. Just for a taste of what's coming, read Robert Wachter's book, The Digital Doctor to learn how 30 billion dollars was recently taken from the Stimulus Package to finance the Electronic Medical Record, which eventually overwhelms just about every physician who must use it without crippling shortcuts. It often employs MUMPS, an interpreter language, largely given up as obsolete in 1985, so patching it is just about impossible.
At least we don't have to usher in 2017 with a trillion dollar bond issue, after all. Let the program be voluntary, possibly with demonstration projects in various states. The secret of its effectiveness is that savings build up early for expenses which are greatest at the far end. But in a reversed transition, the oldest people must be served first, so you just can't afford to let an unlimited number of the older, expensive ones get in at the beginning. If we must have bond issues, let's start with patching up the cracks as they appear, and keep the bond issue from suddenly looming in the trillions of dollars. The best I can foresee is a twenty-year transition, during which there may be opportunities for wounded ACA supporters to get even. So let's be nice, and not be over-eager with eliminating all of ASA with a single stroke of a pen.
But let's not be timid, either.
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.
