As I was rushing out of my office one evening, trying not to be late for a rather large gathering of constituents, I was suddenly confronted by a nice young lady holding a piece of paper, closely followed by a young man with a big professional TV camera. I like to think they were lying in wait for me, but more likely they were haunting the Starbucks across the street.
The question was fired at me, what did I think about Governor Christie using the Supreme Court about gay marriage? I had to admit I don't watch TV all day long, so I hadn't heard about it. Well, do you think it is appropriate for the Governor of a state to sue the Supreme Court? Huh, do you? Caught totally by surprise by a question I don't know much about, I answered, or mumbled, that it seemed to be a lawyer's question, and I'm not a lawyer. I do know that the U.S. Supreme Court will refuse to take a case unless the plaintiff can show he has sustained a personal loss of some sort. But I don't know anything about the New Jersey Supreme Court or its rules, and the whole thing seems to me to be above my pay grade. Or something like that.
If I had had more than ten seconds to think about it, I might have said, "What you really are asking me is Don't you think Christie is a bad, insensitive person?" And my answer to that question if put a little more plainly, would be, "No, I like Governor Christie a lot and I trust a former U.S. Attorney to know the fine points of law better than I do, so I support him."
And if I am wrong, and the real question you are asking me is Am I gay? Then, my answer would be, "No, I'm not gay one bit. But I am inclined to let other people do as they please, as long as it is harmless to others."
And if the hidden question is do I approve of people being gay, I would have to answer that if everybody were gay, it's pretty hard to see how the human race would survive. Now could I ask you a question? Who are you, and who is paying you to ask me slanted questions?
Follow-up, written the next day:
The next day's newspaper gave an entirely new slant to this little episode. It seems the decision was made by the Superior Court, not the Supreme Court, and Governor Christie appealed the decision, he did not sue anybody. So the whole interview process was a put-up job, slanting the attention away from a record-breaking court decision to Governor Christie, who was dutifully responding to a Superior Court ruling which overturned a state law. All the rest of it was either intended to shift attention or else to tangle me up in a confused reaction to some events which didn't happen at all.
In that case, let me state my central position. Governor Christie is a great guy, who definitely needs to win re-election next month. And I am running for the role of Assemblyman for the 6th District, prepared to help him in every way I can.
Follow-up, written two weeks later:
Presumably, after a week or two of consultation with experts, and watching for public reaction, Governor Christie withdrew the state's appeal of the Superior Court decision. That would appear to be the end of this phase of the matter, because there is no one else with the "standing" to appeal a state law, and gay marriages will at least go ahead, unrestrained by the State of New Jersey. All sorts of things might or might not happen, like passing a new law that answered the Court's objections. Or someone might feel injured by the present state of affairs and sue for redress of damages. After wracking my brain to think of someone who was injured, let's consider some elderly couple without children. Since state marriage laws are primarily designed to protect mothers and dependent children, gay couples would appear to be in much the same situation as non-gay couples unable to have children. I have never heard of anyone protesting that couples unable to have children are receiving preferences they don't deserve, but it could happen I suppose, and the non-gay couples might lose some legal advantages they had grown accustomed to, feel aggrieved about it, and sue somebody because they lost those advantages. It sounds pretty far-fetched, so in likelihood, no one will sue, and in a few years, the matter will fade away. Some other state might keep the issue alive by its courts deciding differently, of course. But generally speaking, it looks as though the issue of gay marriage is settled in New Jersey, and the legislature can turn its attention to less exciting subjects, like dredging Delaware or building new houses at the shore after Hurricane Sandy. Or, what in the world are we to do about all those people who have been relegated to New Jersey Medicaid by the federal Obamacare legislation. Oh, yes. There's that matter of high state and local taxes.
What Is the Right Shape For a Legislative District?
At first it comes as a surprise, but soon seems natural, that the first question people ask me is, "What's the Sixth District -- do I live in it?" So the answer is: it stretches along the White Horse Pike from Pennsauken to Voorhees, including about fifteen towns, listed at the top of this page. A considerable number of people are uneasy that some of these towns will get consolidated to reduce expenses, but you usually hear that from established residents. The newcomers, mostly younger people, have fewer local loyalties, but the fact is most residents of a town seem to know very little about the other towns in their district, except for high school football rivalries.
Some of that may be caused by rather regular re-arrangements of the districts, which in turn is occasioned by the steady growth of population. Camden County is gradually coming to the end of a transformation of a farm county into a suburban county, and when that settles down the area should become more stabilized. That probably accounts for the rather large number of people who call themselves Independents. There are more Independents registered in this district than people affiliated with a party. Newcomers generally feel uncertain about local issues and uncomfortable about taking a position on them without more information. Judging from the poll results, it looks as though Independents are more likely to vote a straight-party ballot, just the opposite of what might be supposed. Not knowing the local issues, they vote for national ones or just stay home at election time for local issues. Gerrymandering probably is involved in this mix. Local observers say you can predict the politics of the next ten years if you know how to interpret the gerrymandering after each census. In fact, those who have studied the long-term history of the state, say they can see the trends in ten-year waves.
A "Voting District" is itself a local New Jersey phenomenon. There was a time when each county had a state senator, while the Assembly was divided by population. That led to a regular division of urban versus rural, reflected in a rural Senate and an Urban Assembly. That tended to slow down legislation, just as it is now seen to do in Congress, but it gave County politicians more power. A Constitutional revision in New Jersey eventually broke this tradition. We now have "Voting Districts", each one with one Senator and two Assemblymen. Students of political science favor a bicameral legislature, with the two houses elected by different means, deliberately designed to slow down concentrated power plays. Essentially, New Jersey now has what amounts to a unicameral legislature, according to this view of things. So there you are. New Jersey tried it one way and switched to the other. It may not make a great deal of difference, since the real political division is between the Northern end, oriented toward New York, and the Southern end, oriented toward Philadelphia. As Benjamin Franklin once put it, New Jersey is a keg, tapped at both ends.
So, What is so Good About Christie?
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Governor Christie
My daughter lives in Pennsylvania and therefore doesn't know what's what, recently confronted some New Jersey Republican politicians with a question. "Governor Christie is a great politician, and I love his confrontational style. But tell me truthfully, just what has he done that's so great?" Great question, daughter, and I'm going to give you a straight answer.
In the first place, he attacked the 800 or so committees created by the legislature, and cut them down to about 300, by threatening to reveal their existence, and the hundreds of paid stipends they passed along. And then he made great strides toward a balanced budget, protecting New Jersey municipal bonds from the default, in spite of opposition majorities in both houses of the Legislature. Remember, since the biggest item in the New Jersey budget is for pensions for state employees, he's making substantial progress toward converting defined benefit pensions into defined contribution pensions. You don't need a detailed explanation of what that means, beyond knowing it would make a substantial reduction in future pension costs, as would some other reasonable suggestions, like 401(k). The IBM Corporation was the first to start such a change, and believe me the unions fought it, but now are glad they got it because it is portable. The bond markets are heavily influenced by public opinion, and the opinion became, this Christie guy is serious.
And to repeat, all this was accomplished with both houses of the Legislature controlled by the opposite party. Contrast this with the insults and misrepresentations by President Obama of his Congressional opponents. Nobody could expect much cooperation from the loyal opposition after attacks like that. Christie may have implied some threats, but he had the good sense not to project nasty insults, and remains on good terms with his opponents, in forgivably Jersey style. In fact, he gives them certain respectability they lacked before he convinced them the old ways, just couldn't continue.
And then there is the astonishing move toward wedging part of the Union movement from its former perpetual affiliation with the opposite party. Some racial and religious population groups once made the same political mistake: the Republicans wrote them off and the Democrats took them for granted. Either way, they failed to achieve the clout they were entitled to. It just isn't a smart way to behave in a democracy, and the Unions have fallen into the same trap. Or, maybe union leadership is now waking up.
The American union movement is divided into industrial unions in the private sector, and government employee unions in the public sector. The government unions are gaining members, while the industrial unions are steadily losing members, for reasons I'm too polite to mention. Give Christie credit for starting a tectonic shift with a hint to the industrial unions, implying every time the public sector got a raise, the private sector got a tax increase. In New Jersey, that hurts, because government employee unions and industrial unions are not a natural mix. After all, Christie balanced the budget without a tax increase for two successive years.
That's part of the reality in Deptford Township of Gloucester County, where Sunoco decided to get out of the refinery business. Hundreds of union members are out of a job, still facing the second highest taxes in the nation, if they continue to live there.
What Lessons Can We Learn From the Mt. Laurel Decision?
Let's be clear; Mt. Laurel isn't in my district, which is District #6. Nevertheless, the courts have decided in two cases (Mt. Laurel I and Mt. Laurel II) that the little town next to the Turnpike Exit had to provide the area with a certain minimum amount of "affordable" housing, and that decision does considerably agitate District 6, along with most of the rest of the state. That was forty-three years ago, and lawsuits delayed implementation until 13 years ago. Both the legal cost of this episode, and the rancorous discord, were enormous. The New York Times recently published a follow-up story about the improvements that had occurred in the lives of the 140 families in Mt. Laurel, arguably as a result of better homes than they previously could afford, better schools, a safer environment, and maybe, better neighbors. The reporters said they could find no evidence of the increased crime in a peaceful town, or uproar, or major resentments.
The resounding response that I have heard is to the effect that "The Mt. Laurel decision isn't about Mt. Laurel, it's about a lot of other towns." It's hard to know whether that response means to suggest that anticipation is more destructive than the event, or that Mt. Laurel was exceptional. Some of it surely reflects the opinion that the sweeping generalizations of the court are not applicable to some other towns. It is fairly observable that the officials of towns and local real estate interests are far more upset than the general public is, although people are ready enough to agree when someone in the building trade brings the matter up. Some of that is a local issue: the post-war de-industrialization of Philadelphia and Camden City created many scenes of neighborhood abandonment when lower income people moved into a depopulating area. Sometimes in-migration was a cause, sometimes it was an effect, but local people are well aware of what can happen when panic breaks out about falling real estate prices. A house is normally the most valuable property anyone has. The Times article was meant to reassure such people, but it is probably going to leave many unconvinced. For one thing, the Commission established to implement this court decision has not adequately restrained the zealots in their midst. It is clear this is a touchy issue and needs to be treated as one. Haddonfield, for example, does not have a single vacant lot, and feels needlessly hassled when it is criticized for lack of affordable housing./p>
The same needs to be said of the court. It could have made a much narrower ruling, perhaps confined to Mt. Laurel or to growing towns. That surely would have disappointed the individuals who brought the lawsuit, but thirty years of subsequent litigation suggest that a more gradual approach would have been more useful. Perhaps we should not entirely shield our legislative politicians from criticism. They ducked the issue for a long time until the Court finally felt justified in forcing the issue.
Fisher on the Coming Physician Shortage
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Caroline Casagrande
The 11th Assembly District is somewhere to the North, and two Republican ladies, Caroline Casagrande, and Amy Handlin are running for Assembly, the way I am in the 6th District. I don't know them, but I approve of their message in their local newspaper. They feel that Obamacare is going to create a physician shortage, and it certainly does feel as though it's already getting hard to find a doctor. If you think about it, you'd have to agree that giving health insurance to many extra millions of uninsured people would likely put strains on existing supplies of doctors. But there's a related point to make.
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Amy Handlin
I'm quoting Roger Egeberg MD, here, who was General MacArthur's chief medical aide in the Pacific. He later became Assistant Secretary of Health, where I got to know him. He expressed disapproval of salaries for doctors in the strongest possible terms. When I asked why he would say that, he replied, "If you put doctors on salaries, you will get an instant forty-hour week, and after that, you will get an instant doctor shortage." Although I don't know that it would be instant, I think he is probably right about the general idea. Piece work makes you work longer and harder, and for that reason alone a lot of people hate piece work. Doctors call it "Fee for Service", but it's piece work.
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Roger Egeberg MD
In a way I'll explain in another blog, the DRG system of paying hospitals by the diagnosis rather than by itemized services is encouraging hospitals to form satellite clinics and buying up doctors practices to fill them. That's because inpatient patients now lead to a profit of 2%, while the accident room has a profit of 15%, and satellite clinics a profit of 30%. On a national average, of course. Naturally, hospitals see their future in captive doctors on hospital salaries. Meanwhile, if a hospital gets paid by diagnosis, it doesn't matter how long the patient stays, Medicare pays the hospital the same amount. And it doesn't matter how much lab work or x-rays are done, the hospital gets paid the same. Somehow, I don't think you save money with such a system, you just get a more efficient rationing system. And that's the type of system the Affordable Care Act promotes.
Meanwhile, the Medical School deans are responsible for matching supply and demand, and they rather favor the salaried practice. So the hidden cost here is likely to be for an increase in the number of medical schools. Cutting sixty hour weeks to forty hour weeks would require fifty more medical schools. But even then it takes six or seven years for a new medical student to become a new doctor in practice, and you have to figure on taking several years to find the money and to build a new school. So, if it gets done efficiently, it will take ten years at least to recover a balanced supply of doctors. I'm sorry, but you can't just bang your shoe on the desk and demand that something must happen.
Fisher on Representation Size
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Constitutional Convention in 1787
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Constitutional Convention in 1787
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According to the last census, my Legislative district (#6 in New Jersey) has 224,000 residents. If I spent five minutes talking to each one, I wouldn't have time to sleep or eat. Therefore, I get mixed feelings when I hear only 43,000 of them are registered voters, and only 23,000 of them turned out for the last election. I guess I could talk to that many, but it is pretty sad only one resident in ten bothers to vote. The same number of people voted for every R candidate, and the same number of D's voted for almost every D candidate. So, it looks as though a lot of people vote a straight-party ballot.
That's something they surely wouldn't do if they knew each candidate. And that's pretty sad because it is easily managed by party machines. I have to think these things are caused by the steady growth of the population, without comparable growth in the number of representatives, at all levels from township commissioner to President of the United States.
George Washington was bothered by the same problem. In 1787 he had nothing to say about issues during all the time he was the presiding officer of the Constitutional Convention. But on the last day of the convention, he asked for permission to step down and address the group. His conviction was that no congressman should represent more than 30,000 people, and he begged for an amendment providing for it. The delegates meant to oblige him, but somehow it got lost. If they had done what he asked, we would now have about 5000 congressmen, so it doesn't sound workable. As a practical matter, in the early 1920's Congress finally limited the size of its members to 436. So now we have exactly what Washington feared, which is each Congressman represents 700,000 people, nobody knows his congressman, it costs millions of dollars to get elected, party machines dominate what decisions aren't dictated by lobbyists.
Exactly the same thing is true of legislative districts, except the lobbyists are probably less well funded. They seem to search for party machines and spend their time (and money) on unelected party leaders. Unelected is an important word here because many county leaders take care not to hazard their future on an election. I understand the county leader in Mercer county lives on eighteen acres in the center of Princeton. I don't know his name, in fact, almost nobody knows his name, but everybody knows that God himself couldn't afford eighteen acres of Princeton. I got this from a reporter, Bob Ingle, for the Trenton newspaper who wrote a book, called Soprano State. I wish more people would read that book, so I don't have to sound so negative at times. I gather from this book, there is much to talk about.
Anyway, this representation issue is starting to hurt. I go to all kinds of meetings in my district, at least to show my face. Little did I expect I would be sitting in the audience while a professor of history, would explain that Washington's proposal was already part of the Constitution. I woke up slowly and may have got this wrong, but I believe he said it was one of the two (of the twelve original) amendments of the Bill of Rights that Thomas Jefferson recorded as not being ratified. However, Kentucky was a long way away by horseback, and the ratifiers seem to have given up on the messenger who was bringing the duly recorded, on-time, ratification from Kentucky needed to reach the required number. I guess when it got to be dinnertime they decided no messenger meant no ratification.
However, Mr. LaVerne seems to have dug up photocopies of the Kentucky document of ratification, plus the bylaws stating amendments were to be effective as of the date of ratification. Somehow, the War of 1812 got things confused even more and burnt up enough, that Washington's pet idea sort of got lost. If that's really provable, it seems to mean we already have a mandate to have 5000 congressmen (and two or three thousand Assemblymen and women in New Jersey?). The contention seems to be that for two hundred years nobody knew what to do with this bit of history, and sort of decided to ignore it. My view is that even if you knew all about this strange history, you simply can't have it both ways. Either you get stuck with the present inability to represent all those constituents, or else you get stuck with having unworkable thousands of congressmen.
I promise to think about this. And when I get an answer, I'll let you know.
Obamacare and Pre-existing Conditions
Obamacare isn't an issue before the State Assembly right now, but that will soon come when the uninsured find themselves in state Medicaid, which isn't at all ready to take them. But that's for later. Right now the issue that pops right up and assaults you is called pre-existing condition. Those folks are waiting at the door at midnight, waiting for the office to open up, just like Apple Stores before a new model of iPhone. They are desperate to get Obamacare because there is no other solution. And they have been told there is no other way to solve their problem, this is the last chance. Well, that's just not true. Impaired risk is an old, old problem with insurance, and there are standard ways of dealing with it. One is called an "assigned risk pool", and the other is high-risk insurance. In Pennsylvania, there is a fire insurance company known as the Fair Plan, which will only accept you if some regular fire insurer has rejected you. It's owned by the other fire insurance companies and is subsidized by them, although it often surprises itself by making a profit some years.
I've been interested in the Fair Plan for some time, so I'll next attach a blog I wrote several years ago. It's my favorite method of handling pre-existing conditions, and I was pretty disappointed when it wasn't adopted for health insurance. (See below.)
Instead, we have a law forcing everybody to have health insurance whether they want it or not so we can play cops and robbers with people who don't like insurance, such as the Pennsylvania Dutch Amish people. Certain Congressmen have been pushing mandatory coverage for decades, and they always got laughed at. Too grandiose. Too unnecessarily sweeping. Anything with the word "mandatory" in it starts trouble. And anyway there are 30 million people it doesn't fit, like 7 million people in prison, 8 million mentally impaired, 11 million illegal immigrants. That's what you get into when you insist that "one size fits all". There might, there just might be, a trace of trying to succeed with Universal health coverage, when your main primary opponent with initials HC, failed so notably to get it passed when her husband was President.
The issue goes back to the Clinton Health Plan, so let's continue. You may remember it was never brought to a vote because Big Business walked out. The same thing happened this time, except it is stated that big business couldn't get ready for another year. That's a nice way of saying Big Business walked out a second time, but this President was too stubborn to see he was licked. I surmise that Big Business didn't want to pay for the uninsured twice. Particularly when they were being treated to unceasing attack in the Dodd-Frank legislation. Perhaps it wasn't realized that big business was already paying for the uninsured by having hospitals cost-shift the expense to their subscribers, but business knew that was true, and they didn't think it was fair to pay for it twice.
It's hard to know whether the big business will relent if Obamacare can demonstrate success by laying these extra costs on someone else. Or whether the people with pre-existing conditions will push the premiums unbearably high, and the insurance companies will drop out when it results in unsupportable losses for them. A death spiral, indeed.
A former director of Medicare recently said, "Obamacare isn't about healthcare reform. It's about coverage extension." If they had stayed with coverage extension for pre-existing conditions, it would have sailed through. As it stands, we have to have a civil war to get it right, the second time around.
A Fair Plan for Fire Insurance (and Health Insurance, too?)
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Philadelphia Fire Insurance Company
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The Fair Plan (sixth and Chestnut, Philadelphia) is a fire insurance company with unusual features. Someday, it is to be hoped some scholar will write a book about the highly mixed motives of the people who created it, compared with the unexpected ways it did or did not fulfill original expectations, of both its creators and its enemies. The Fair Plan only issues fire insurance on houses, if other insurance companies have turned that house down as a bad risk. But if the clients pass that simple test, they get fire insurance at standard rates. Such risky houses would normally draw higher premiums for fire insurance, but the Fair Plan ensures these risky houses at normal rates. Therefore, it loses money, which is made up by the other regular fire insurance companies in the state in proportion to the business they do, obviously thus raising the price of fire insurance for everybody. But in this way, Pennsylvania guarantees that everybody can get fire insurance at standard rates. Is this a good idea? Might this be a way to give health insurance to all those people who can't get health insurance? Let's talk about the Fair Plan.
We'll set aside discussion of whether the Fair Plan was a product of cynical politicians pandering for votes, or whether it was a noble gesture for fairness and equality for our poorer citizens. It very likely had elements of both motives in it, but that doesn't matter anymore. It's a form of hidden taxation, of course, and it has the result of making Fire Insurance seem more expensive in Pennsylvania than in other places that do their social work with real taxes. Go too far with that, and people will end up buying their insurance in Bermuda instead of boarded-up former fire insurance companies in Pennsylvania.
As the story is now told, the regular insurance companies had a choice of taking the "substandard" applicants in turn ("Assigned Risk") or creating a new company (Joint Underwriting Association). They decided they preferred the JUA. So a company was formed which specializes in nothing but bad risks, including a few arsonists and other unmentionables, but mostly poor people in bad neighborhoods. If we are ever thinking about following the Fair Plan model in health insurance, it would run the risk of being accused of creating a two-class healthcare system. But no one seems to bring up that rhetoric about fire insurance, primarily because there is a comparatively little intrusion of politics in the matter, and anyway they provide standard fire insurance at standard premium rates. This system is given orders to spread the extra cost of universal fire insurance out to the policyholders of all fire insurance, and it does it very efficiently, without extending its mandate into setting firefighter wages, running fire departments or repainting scorched woodwork. The fundamental decision was whether to spend Society's money this way. Once that decision is taken, the task is to do it efficiently. Notice, this is not compulsory fire insurance; it is compulsory availability of fire insurance.
After the Fair Plan had been running for ten or so years, a funny thing emerged. There were years when the Fair Plan made a profit! The fire insurance industry had absorbed the Fair Plan into their scheme of things and felt free to increase the number of applicants they rejected, during years when money was tight or business was bad. If you had compulsory availability of fire insurance, the provision of a company which could not refuse an application made it possible for every other company to refuse when it pleased. When the economy encouraged rejection, a better class of applicant came to the Fair Plan, which made the plan more profitable. When economic conditions reversed, this reversed, and the Fair Plan again lost money. For this reason, the insurance industry is very anxious to prevent the Fair Plan from becoming political or getting tangled up in worthy but extraneous ventures. And that's probably a good model, too, if we are considering adopting a similar system for the health insurance world: stick to your mission.
Since this simple, tested idea never seems to get into the discussion phase of present agonizing over health insurance for the uninsured, it's one clear sign that such discussions at present are not terribly serious.
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Three decades ago, before a lot of New Jersey voters were even born, the so-called Abbott decision ordered the state to distribute money to woefully underperforming school districts to give the kids a fair chance in life. But now, thirty years later, the money routinely goes to ten or twelve school districts, and the other five hundred are suffering from high taxes. The voters in the five hundred districts are angry and want some of their tax money to stay at home. But by any fair appraisal, the schools in the Abbott Districts are still deplorable, and a great many children are growing up without an educational chance in modern life. Both sides have a legitimate point, and neither will budge.
But now there arises an entirely different way of looking at the mess. Maybe money isn't the point, but education is the point. The purpose of the Abbott District money was not to give money fairly or unfairly. The purpose of the money was to educate children, so at least they wouldn't grow up to a life of poverty and crime. In a sense, it doesn't much matter how unfairly the money is distributed, just so the kids get an education. Do they?
Frankly, it doesn't look as though they do. After thirty years, it is not hard-hearted to say the burden of proof is on those who say the money did some good. The very least that everyone ought to agree on is to perform a library search for other ideas, like charter schools, and report to a Legislative committee, followed by taking testimony from places with experience with other ideas. Because the real issue is not, how long we go on spending this money. It is, or ought to be, how long must the kids wait before something better is given a chance?
These are not easy issues. Our forebears didn't do such a wonderful job with assimilating the American Indians, but surely we can do better than that. With this horrible example before us, we cannot really expect the problem to solve itself. Nor is it a purely local problem; plenty of big cities have the same issue in a slightly different form. How are charter schools doing, for example? I have every confidence that if the local Camden County community, or even the whole State of New Jersey, could show some important progress -- money would come pouring in to help a winning project. But to keep on with the same old ideas is going to get you the same old results.
If there is a permanent moral to this vexed affair, here is the one that sticks to me. The Abbott decision seemed to be based on fundamental principles of fairness. But it could also have been described as an educational experiment, and all experiments contain a risk of failure. When courts make such an innovative decision, politics will soon lock it into place for many years longer than it takes to recognize it was a failed experiment -- if indeed it was a failure. Therefore, it is best for such experimental court decisions to set a time limit for later review and revision. Almost anyone would say this time period should be less than thirty years. Otherwise, such matters should be left to the Legislature, which is at least subject to frequent elections and can more easily devise modifications.
Fisher on Proposed Economic Zones
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Governor Christie
There's an idea that politicians are all negative characters, saying nasty things. That's probably because the public only listens to them during the last week of a campaign, when campaign advisors urge them that negative works best. So, here's a positive idea. And it comes from Camden County Republicans.
There's no doubt New Jersey is in a fiscal squeeze. Our property taxes are second-highest in the nation, but our municipal bonds are regarded as risky unless we raise taxes or cut spending. If we raise taxes, people will move to other states. In fact, we mainly haven't lost population because New York City is more heavily taxed, so New Yorkers move to New Jersey. Philadelphia has lost 40% of its population since the peak, and if you ask your neighbors, many of them moved from Philadelphia. Camden City just moved away, period. The people you don't talk to are the ones who have moved from New Jersey. So we are afraid to raise taxes, and we are a little afraid to cut them for fear the municipal bond market will strangle our borrowing power. Here's the proposal.
While we continue with Governor Christie's efforts to cut spending, like getting rid of those 800 paid Committees, and seeing if defined benefit pensions can be converted to defined contribution plans, and the like, let's cut taxes where it would help the most. The Camden County Republican proposal is to cut taxes in defined enterprise zones. If we can attract some new businesses into those zones, they and their employees would pay taxes, and the gamble might pay for itself. It might not, of course, but that's the risk any businessman takes when he makes an investment.
Right now, Exit 4 on the Turnpike is not in Legislative District 6, because the borders get shifted around by gerrymandering. But it's close, and most of the business activity it has created is within District 6, along the route toward Philadelphia. Most of the theory of business clusters suggests that a cluster of business activity is most sustainable when it contains a diversity of industries, but it needs a dominant industry to get started. Tom Booth suggests medical supplies already have a big start in our geographical area, and I can agree that eighty percent of the pharmaceutical industry is located within a hundred miles of us. Burlington County has demonstrated that you can keep everybody happy if you segregate commuters and farmers, which means helping the environmentalists and the businessmen at the same time. It really can be done and is being done by some of our neighbors. Not a bit of doubt you have to be careful about creating winners and losers, because that's where the graft comes from. But there's no doubt if you succeed, you will succeed big.
Cutting (some) taxes and helping the deficit at the same time. Just think of that. And think about 13% of unemployment in Camden County. We have to do something about that or it will destroy us.
Burlington Leads the Way
Somewhere in the past few decades, Burlington became quite activist. Although many tend to think of real estate planning as urban planning, this largely rural county went in for planning in a big way, deciding what it was and what it wanted to be. Generally speaking, its decision was to replace urban sprawl with cluster promotion. The farmers didn't like an invasion by McMansions or industries, while the towns lost their vigor through tax avoidance behavior of the commuter residents. Overall, the decision was to push urban development along the river in clusters surrounding the declining river towns, while pushing exurban development closer to logical commuting centers, leaving the open spaces to farmers. Incentives were preferred to compulsion, with a determination never to use eminent domain except for matters of public safety.
To implement these goals, two referenda were passed with 70% majorities to create special taxes for a development fund, which bought the development rights from the farmers and -- with political magic -- re-clustered them around the river towns. The farmers loved it, the environmentalists loved it, and the towns began to revive. The success of this effort rested on the realization that exurbanites and farmers didn't really want to live near each other, and only did so because developers were looking for cheap land. Many other rural counties near cities -- Chester and Bucks Counties in Pennsylvania, for example -- need to learn this lesson about how to stop local political warfare. Corporation executives don't want to live next to pig farms, but pig farmers are quite right that they were living there, first. When this friction seeps into the local school system, class warfare can get pretty ugly.
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Burlington Bristol Bridge
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In Burlington County, they thought big. The central project was to push through the legislature a billion-dollar project to restore the Riverline light rail to the river towns, along the tracks of the once pre-eminent Camden and Amboy Rail Road. It was an unexpected success. During the first six months of operation, ridership achieved a level twice as large as was projected as a ten-year goal. Along this strip of the Route 206 corridor, the old Roebling Steel Works are becoming the Roebling Superfund Site, now trying to attract industrial developers. The Haines Industrial Site originally envisioned as a food distribution center was sold to private developers who have created 5000 jobs in the area. Commerce Park beside the Burlington Bristol Bridge is coming along, as are the Shoppes of Riverton and Old York Village in Chesterfield Township. As Waste Management cleans up the site of the old Morrisville Steel plant across the Delaware River, a moderate-sized development project is becoming an interstate regional one.
No doubt there will be bumps in these roads; the decline of real estate prices nationally is a threat on the horizon, because it provokes a flight of mortgage credit. It works the other way, too, as banks decide to deleverage by reducing outstanding loans; this is the way downward spirals reinforce themselves. And anyone who knows anything about all state legislatures will be skeptical about political cooperation in a state as tumultuous as New Jersey. The Pennsylvania Railroad destroyed the promise of this state once; some other local interest could do it again. Nevertheless, right now Burlington County looks like a real winner, primarily because of effective leadership.
Harry Kaufman is now long gone, but for decades he represented the volunteer spirit of Haddonfield and the earnest, innocent happy way it contributed the essence of conflicted memories of its Revolutionary origins. The last time anyone counted, there were forty-two direct descendants of Elizabeth Haddon living in the borough, for example, and in a quiet determined manner, they keep alive the Quaker heritage of a non-Quaker town. For example, Harry made his living as a public relations officer for the milk industry. During World War II the Nicholson family who arrived here before William Penn still had a vast dairy farm with its own port on the Cooper River. It was located where Stoy's Landing Road crosses Grove Street, where there used to be something called the Race Track Circle, in honor of the Garden State Race Track which followed the dairy farm, and preceded the big-box shopping center which is still there, without the circle. New Jersey still has over two hundred traffic circles, and those who grew up here remember them as part of the New Jersey heritage, each one characteristically having a diner restaurant, also a Jersey invention and tradition.
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Plays and Players in Haddonfield, NJ
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Harry Kaufman may not have started the Plays and Players of Haddonfield, but he certainly sparked it to a near-professional level in a town of 7000 people. The orchestra and the ballet company are particularly outstanding at the moment, the soloists on the stage quite good, although they never made the grand European tour which is thought to be the prerequisite for getting into the big time. Harry was the life of any party, and particularly good at composing little ditties, never quite getting around to stringing them together into a musical comedy until the 250th anniversary of the town. Even then, it is recalled he was shy and reluctant and had to be pushed a little. Since The King's Road appeared shortly after Oklahoma! transformed, even revolutionized, American musical comedy, it was not only the model but the stimulus for a similar comedy celebrating the beginnings of our little state. The plot was a simple one of a conflicted love affair. The striking innovation of Oklahoma! was to crowd most of the show's songs into the first act, repeating snatches of their themes as sort of Wagnerian background commentary throughout the remainder of the play. The other innovation of what was originally called Green Grow the Lilacs was the addition of Agnes DeMille's ballet company to emphasize the real historical theme with light-hearted music. Since I was one of the original reviewers for Oklahoma! in its New Haven tryouts, I can remember the revolutionary impact of that play, very well.
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Anthony Wayne
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Harry had to go to the Historical Society for authentic details of the conflict between the attraction for Revolutionary aspirations for Liberty, and loyalty to the earlier sufferings of Quakers for their pacifist leanings. Some Quakers deserted their faith to join the Revolution, and other Quakers tried to convert the Hessian soldiers. And still, others were loyal to the King of England. The Revolution was almost won at this moment, as the British occupants of Philadelphia had abandoned their supplies to attack, and had to get to the British fleet, bottled up in the lower Delaware River by fortifications at Fort Mifflin and Fort Mercer on the Jersey side of the river. The Hessians had been sent to attack Fort Mercer from the rear, passing through Haddonfield and stopping one night before going on to what we now call National Park. While the Hessian officers were being entertained by John Gill with discussions of the futility of war, Jonas Cattell slipped out of town and ran to alert Fort Mercer of its danger. The guns of the Fort were turned around, and the defenders pretended not to notice the approach of the Hessians until they were ambushed and largely destroyed. If Fort Mifflin on the Pennsylvania side of the Delaware River could have held out, the starving British might have had to surrender, but that didn't happen. In any event, the New Jersey Militia did its part, and little Quaker Haddonfield helped them in a sort of characteristic Quaker way. With a ratta-tat-tat and a fiddly dee, the rag-tag swallow-tail Jersey Militia got all the credit.
The play does not emphasize that the State of New Jersey was founded at the Indian King Tavern during these commotions, or that General Washington starving at Valley Forge sent Mad Anthony Wayne to circle up and around Trenton to drive a herd of cattle back from Salem County, two hundred miles back to Valley Forge. The British sent Captain Simcoe down to Salem County to massacre the Quaker farmers who provided the cattle. These later developments are only mentioned in its anthem to "Generals Wayne, LaFayette, and Pulaski", and every good resident of Southern New Jersey is supposed to know what that is all about.
The Quaker historian Rufus Jones established the enduring tradition that this split is what ultimately reduced the Quakers from the dominant religious group to a small religious sect in the three states once owned by William Penn, Delaware, Pennsylvania, and New Jersey. Related to such turmoil was the claim that more battles of the Revolution were fought in New Jersey than in any other state; if you include the large privateer navy going to see from the Jersey Pine Barrens, that is probably true. And every twenty-five years or so, we have to put on a revival of "The King's Road", and just show 'em.
Every tennis racquet has a "sweet spot", a place within the stringed area that hits the ball just exactly right with minimum effort, and for that matter, does so with a minimum of noise. If your aim is good, the shot is much improved by whacking it with the sweet spot. In health savings accounts, the sweet spot is that combination of fixed choices over which you have no control, like your age, and independent choices over which you do have some control, like the amount you deposit into the account, or the shrewdness with which you choose your agent. There's a somewhat different sweet spot for males and females, and it will vary with the state of the stock market, or international warfare, during the era in which you had the highest earning potential. In other words, the cost of sickness is the only chance catastrophe we are aiming to protect against. For that narrow purpose, the uncontrollable factor which makes the most difference is
The age at which you started your spending account. Compound interest requires time to work; persons who start their accounts late in life no longer have to pay for their earlier expenses, but they must have some traditional insurance protection during the transition to full dependence on the account, or else some other form of savings. That's why you need catastrophic insurance coverage, but in the early stages of getting established, even that could be inadequate, and nothing can be offered unless the government offers to subsidize it. In order to find a way to capture twenty extra years of compound interest, it is tempting to begin depositing at birth, which is presently prevented by the HSA rule that you must be working to start an HSA. But children have health costs to be managed. In particular, 3% of all health costs are reported to occur in the first year of life. If Congress will allow it, we have a plan in later sections for doing it expeditiously.
Subsidies for the Unemployable, Such as Children. Please do not compare subsidy with lack of subsidy, because the subsidy is always cheaper in the short run. . Furthermore, subsidies are created by the government, and are therefore under pressure to demonstrate equity. Protection in extreme cases must rely on reasoning which placates the "Equal Protection" clause of the Fourteenth Amendment. All forms of insurance contain some incentive not to invest but to squander, and channeling that choice is part of insurance design. Here it attempts to balance a singular opportunity to select the best possible investment opportunity, with the unique ability to spend the proceeds on anything you choose after your health cost has been met. Unfortunately, we have already gone so far with borrowing for health, that many people are of a mind to believe balance can't be achieved. We could go on with this, but a quick summary is there are thousands of possible sweet spots, most of which are partly beyond anyone's control or ability to predict. There are even some circumstances where an individual would be better off putting reliance on Obamacare, trusting the government to bail him out with subsidies; if the nation decided to give equal subsidies for every payment alternative, however, most of these short-term advantages would disappear. The best we can suggest for people who dislike both HSA and Obamacare is, go see your congressman. In this book, we merely suggest that most people would be better off with HSA.
Trying not to be repetitious, there's nothing you can do about your age and sex, or previous state of health. You should have stopped smoking twenty years ago, but you can't help it now if you didn't. Twelve million people already have HSAs; if you aren't one of them, the best you can do is start one now. It's very difficult to imagine a situation in which a late start would inflict harm which subsidy couldn't help. On the other hand, if you make a bad choice of agency, make sure you are allowed to switch to a better one if you can find it. Some brokers charge too much, some of them pick poor investments to get a kickback. Some demand too large a front-end investment, although that may do you a favor in the long run. Essentially, your own choices affect the result, and your main recourse is to invest more than you planned. For the most part, the more you invest the better. If you invest as much as you can and it still isn't enough, you made an investment mistake. It's only a real catastrophe if you then get sick, and Congress didn't provide for those few who inevitably make such a double blunder. In that case, it will have required three misjudgments for a serious mistake to emerge, because even this mishap will be adjusted by aggregate subsidies costing less than the program is able to diminish overall costs -- a very likely outcome.
Interest Rates. Unless you are within a few years of death, or within a few weeks of a stock market crash, in the long run, you are generally better off with stocks than with bonds or money market funds. According to Ibbotson who published the results of all asset classes for a century, the stock market has averaged 11-12% total return for the past century. However, if you maintain internal reserves against a depression, you will probably only receive about 8% as an investor, of which 3% is due to inflation, so figure on a steady 5% after-tax, after-inflation return over the long haul. Use 8% as your shopping guide, resign yourself to 3% inflation loss, and content yourself with complaining about the 4% attrition seemingly imposed by the financial industry. You will find our charts use 5% tax-free as a standard, but show a family of curves up to 12%, just in case someone figures out a better system for harvesting the return. For 3-5 year depressions ("black swans" occur about every thirty years), we show curves of lower returns. Notice endowments and professional investors also figure on 5% overall from a 60/40 mixture of stocks and bonds, because they have a payroll to meet, but you may not. A conservative investor can feel comfortable with a 5% "spending rule", but that assumes a long horizon and the need to make expenditures. Some people have a short horizon and may be able to gamble on a pure stock portfolio because they have some other way to meet medical expenses up to the deductible on their catastrophic high-deductible insurance. But they better know they are gambling, and may, therefore, encounter a black swan they can't cope with. Such people probably need financial advice, because it is also possible to be too conservative if your deductible is comfortably covered. Fear of underfunding may cause the account to become overfunded, but that is scarcely a tragedy because you can withdraw your money without penalty after age 66. In fact, a policy of deliberately overfunding the account at all times never has any great downside, and lets everyone sleep better.
Age at Beginning an Account. If you begin to use an HSA during late working years, you have the consolation that you no longer need to plan for paying for the first forty or fifty years of your own health. However, the years of heavier medical expenses begin around age 45, by which time you have already paid for most of your Medicare payroll deduction, which is about a quarter of Medicare costs. The older you get, the more you have paid with a payroll deduction, but fewer years are left for compound interest to accumulate within the account. Balanced against this is the likelihood you are entering your highest earning years, which carried too far, may tempt you into unwise early retirement. You may need some accounting advice about what is best and still feasible. And you may need legal advice if the laws change.
Younger working people have contributed less to payroll deductions but have longer to earn compound interest in their HSA. People seem to have figured this out, and the largest group of new subscribers are in their twenties and thirties. This is the group with most to gain by proposing a buy-out of Medicare. A quarter of Medicare is paid for with payroll deductions, another quarter by Medicare premiums after you reach 66. If Congress could be persuaded to drop these contributions, what would be left is the half the government pays by borrowing from foreign sources. If you, in turn, agreed to pay off this indebtedness, the government might be tempted to match it by foregoing part or all of your payroll deductions and premiums. Since one about balances the other, the compound interest you earn on your deposits is pure profit. From the government's viewpoint, it might seem a great relief to know the debt would stop growing. Older people are generally so deeply committed to Medicare they would resist, but younger people -- and the Treasury Department -- would find it quite a bargain. Once again, financial advice from somebody good at math is highly advised. When the politics of this matter settle down, it should become possible to state a particular age, below which a Medicare buy-out is safely advisable for anyone. It's almost always in the Government's favor, so independent advice is only prudent. In summary, starting an HSA at almost any age is safe and wise. A Medicare buy-out is wise below a certain age, yet to be determined. In other circumstances, a buy-out is wise if personal finances are comfortable, but right now it would take financial advice to do it. And, of course, a friendly politician to convince Congress to make it legal.
There are two more steps to this transition. But before getting to them, it seems best to run dual systems while you phase one out and phase the other in. It may even prove to be best to run two systems indefinitely. Three principles emerge:
I. It would be pretty hard to run dual systems without also running subsidies for both. This would be part of Equal Justice Under the Law. It's hard to run dual subsidies until you know what the final rules would be. Some subsidies may be difficult to match, and require equivalent subsidies, which are harder to devise.
II. Dual systems and patchwork fixes always provide loopholes for someone seeking to take advantage. Some agency must be designated to keep this in line, using the principle of each system being charged with watching the other one. When you deal with one-seventh of the GDP, tremendous scams are entirely possible. A system of balanced whistle-blowing could effect great savings without the same surveillance costs.
III It isn't necessary to pay for everything. The reader will, of course, have noticed that paying for all of the medical care would save perfectly stupendous amounts of money. But paying for half of it would also save stupendous amounts. And even paying for only a quarter or a third of everything medical would save the economy two or three percent of Gross Domestic Product. That wouldn't be a failure, it would be a tremendous success.
In fact, it might be all the change the economy could withstand for a few years.
The Intergenerational Roll-Over.
The Coming Shift From InPatient to Outpatient Care.
So we end up funding Medicare mathematically, but with misgivings about both the politics and the economics of it. It would not be the first time America launched an adventure without the money to finance it, as we do almost every time we start a war or face a depression. However, both the ACA is in doubt, and linked with it is the idea of a single payer with Medicare as a model. Although I have grave misgivings about consolidating delivery systems as a first step, it could be a decision that is beyond the suggestion of a citizen.
Under the present uncertain circumstances -- of wishing to put the ideas forward but lacking the ability to control the environment -- it seems better to hold back on grander designs than just saving a little money. The linkage of Medicare and its secondary insurance is both tight and of long standing. By just eliminating the second insurance policy, we might eliminate a large and useless expense as well as suggest a few ways to save more. Isn't saving several billion dollars worth some effort? The factors which would lead America to embark on a financial crusade as radical as suggested here, are not to be found in mathematics, or even in one-man logic. They are cultural and emotional, mostly evolving out of endless simplification and repetition. The public might be persuaded to try something on 20%, which they would be afraid to try out on a whole program, however floundering it might appear to be.
How Would This Particular Approach Make Medicare Solvent? It wouldn't, but it would help. And it would provide a demonstration of the practicality of some of these ideas for worthy motives, and still leave room to back down if they unexpectedly fail. Most people do not trust their own judgment of complicated math, so we have made it simple. It is surely not the case that every single solution is either too complicated to understand, or too simple to be believable. Every grand proposal, from Otto von Bismarck's social security through the European systems to Blue Cross/Blue Shield, followed by Harry Truman, Hillary Clinton's foray into HMO, to Barrack Obama's ACA, has proved to be overambitious at the beginning, and woefully inadequate at the end. It seems there ought to be better ways to do things, but this is our way.
Medicare's original design has become so over-extended it has exhausted conventional insolvency approaches. Like any other proposal that might work, our own plan relies on approaches which are usually thought to be best avoided. So the first fundamental is to keep the core of it simple and be willing to discard the embellishments if circumstances undermine them. The doctors should devise the medical choices, the patients must control the finances, paying only for what pleases them. Government has a limited role in market failures, but a very little role in defining them. The goal is to eliminate the disease, ultimately reducing its cost to a framework of the first year of life and the last year of life. Anything more must defend itself against efforts to improve, then eliminate it.
And there is another idea which needs testing. Alexander Hamilton persuaded George Washington that "A national debt if it is not too large, is a national treasure." In 2006, we may have discovered what is a little too large to be sustainable, by permitting banks to convert mortgage debt to stockholder equity and then watching banks topple over from the sudden shift. Up to that time, it was quite legal to rebalance excess debt that way, which is why no one has gone to jail for doing it. And now we have the uncertainty over whether to encourage more of it (as a safety valve) or punish it (as toppling over the entire economy). It does not help matters for the two political parties to take extreme positions without more evidence. Pre-paying for medical care instead of borrowing to pay for it, is an indirect way of testing this thesis.
First of all, our own proposal depends on such long time periods that unexpected events could be the rule, not the exception. Nevertheless, many Congresses of many political parties would have to understand the basics and leave them unharmed for a century. Secondly, such huge amounts of money are involved that tampering, embezzling and fraud are not merely possible, but inevitable. These problems would confront any reformer. From them emerges the third one. Multitudes of individual Health Accounts would have less risk overall than gigantic single payers because small ones can only be converted into bigger ones, not defeated in a single pitched battle. Inevitably some individuals in charge of any system will prove to be stupid, reckless and venal. The real question is: Compared with What? If you make up your mind in advance that you will rescue everyone who doesn't succeed, the whole system will be no better than a single gigantic reinsurer overseen by either an idiot or a crook, and probably both, from time to time. Index investing is itself a triumph of everyman against the experts, after all. For long periods, single payer systems may be run by saints, but diversity is more resilient in the long run. The more important issue is to define how you will respond when you detect the "imperfect agency". The opportunities for illegal gains will inevitably exceed the individual opportunities for honest managers, in size if not in frequency. Therefore, smaller decision units are better than bigger, simpler is better than complicated, and success should never be guaranteed. The irony of the role reversal between the political party of individualism and the party of diversity is not to be overlooked.
Medicare financing could possibly be eventually covered by this approach, retirement income financing, probably not. To do the quick math in your head, it is useful to remember money at 7% doubles in 10 years. Current interest rates do not achieve that, but then current rates seldom do. During the eight years of the Obama administration, the low-cost total market index averaged 11% gain. Most people would never have guessed that outcome in advance. Much of it never reached the average stockholder because the government (taxes and inflation) and the finance industry absorbed it, but public restlessness may change things. The pharmaceutical industry may possibly be over-compensated, but that's not necessarily permanent, either. In this proposal, we are proposing to make the average patient become an average stockholder, with little voice in management perhaps, but ultimate ability "to talk with his feet", to buy and sell. Let's take the six components of the proposal:
#1. The co-pay feature. We've offered our opinion that co-pay has a little restraining effect on spending, and is only a device for adjusting the amount of insurance to the buyer's budget. So let's take it like that, and use the amount of the copay as, not 20%, but whatever fits our budget. We advocate the accordion principle for predicting future revenue uncertainty. Furthermore, we would abandon the pretense that it is a second insurance policy, and simply pay the carriers a fee for administrative help in running Medicare. That opens it to a bidding process related to work actually performed, eliminates the State insurance commissioner as an actor in this drama, and eliminates a huge source of confusion with the public. Imagine, one statement of benefits instead of two.
#2. The Contingency Fund. is designed to be overfunded for contingencies, so it is hard to say what its upper limit should be. And although on paper no one gets paid off for ninety years, banks are accustomed to rearranging the terms of a loan to shorten the time period for a fee. Dealing with transition periods is an old story for Congressional staff since otherwise nothing would ever be upgraded. The most conservative investment period would terminate at death, but expand to whatever age is necessary to pay it off, up to age 105. That implies the initial deposit never varies. Congress might, however, decide to vary the initial deposit but devise a shorter fixed time period. It makes no mathematical difference, but its political difference might be considerable and we do not propose to weaken our case by getting into such weedy details.
Eventually, a "sweet spot" should emerge. But let's not drop the argument with a confession of modesty. An officer of a large paycheck company recently declared to be the revenues of essentially all government programs have nothing to do with expenses, and everything to do with politics. True, we operate under a general mandate to balance new appropriations with new revenue sources. But the current payroll deduction for Social Security is five times as high as the deduction for Medicare, with only about 25% difference in expenses between the two programs, for example. The accounting rules for appropriations could be made considerably less political without significant impairment of flexibility. In the long run, it is not good politics for the public to discover you have been doing outrageous things. Over and over, you discover the Constitution is a cultural document, intolerant of judges who are obtuse.
#3. Delay Liquidating the HRSA at death. Although things get a little threadbare beyond this point, there is no reason to hold back borrowing for observed volatility. We are at the point in the compound interest curve, were holding the funds for ten years after death would multiply the original subsidy by 128 instead of 64; even 256 is conceivable. We are paying the Chinese much less than that for the Treasury bonds, and they would probably be relieved to see a way of recovering their investment. #2 may not sit very well with some people, but it would surely guarantee repayment, which at the moment, looks rather chancy.
#4. Investing the Pay as You Go. The problems created for others in the payment process have to be reckoned with. We propose the individuals continue to pay/go temporarily for half of the withholding tax receipts. That's effectively unchanged because half the cost has been transferred, but the withholding tax revenue remains constant. What is essentially involved is to balance the problems of the current administrative staff against the problems of passing acceptable legislation. But once more, the mathematical "sweet spot" is comparatively easy to calculate, but the political effects are more intangible. It is probably impossible for an outsider to have a firm opinion.
Additional unknowns in this equation are how much nursing home costs from state Medicaid plans would eventually emerge in the form of Medicare deficits. It is common knowledge that although custodial costs are not allowable costs, states have found ways to make them a federal responsibility. We also understand the HRSA owner might get less than 7% income on his deposits. Although the Chinese debt would stop rising, past indebtedness remains unpaid. Current Medicare bills would have to be paid for probably another decade, and may well rise in size. Ultimately, the way to balance the books is to raise the contributions. So, privatizing Medicare might or might not make it cost less, but would greatly relieve its present costs. Funding of retirements will have to come from other sources. However, right now contributions from the two contingency funds could easily be increased.
#4. The Last Four Years of Life Half of Medicare costs appear in the last four years of Life. By reimbursing Medicare for the last four years from other sources, Medicare's average cost is cut in half. but the withholding tax remains the same. Therefore, we come closer to breaking even in several decades, although we still probably won't quite make it. The essential feature of carving off terminal care is that it is half the cost of Medicare, and therefore reduces the burden on the other contrivances to reach the final goal of financing it.
#5. Simplicity, Simplicity. To begin with the opposite of simplicity, two quite unacceptable new ways to manage the medical payment system have been suggested by others. One alternative is to consolidate the whole industry, with one corporate administrative arm assuming the payment tasks for everybody, along with the whole delivery system. That scarcely seems appropriate management for a health complex which is already too big to manage. But it seems to generate many current proposals, especially those coming from the bureaucracy itself. Another idea, based on its resemblance to whole-life insurance, proposes a giant company or government department to concentrate on health finance, doing it for everybody. It might seem suitable for an insurance company, a medical school, a computer company, or a medical society. That seems to be what these organizations would like, but it immediately creates additional complexity, because computers only work if you specify some response to every contingency in advance. In a sense, this version of "Single Payer" would be a throw-back in thinking to the days when only a big company or a big government could afford to own a computer.
Is medical finance really so complicated most people couldn't handle it by themselves? Let's remember the anguished words Tzar Nicholas: "I don't run Russia. Ten thousand clerks run Russia." What the Tsar was saying, was the problem isn't individual complexity, the problem is the huge volume of simple problems. For example, if we proposed to butter everybody's bread, it wouldn't be hard to do, it would be hard to manage.
#6. Linking the New Medicare with Health Savings Accounts.. Probably the most important feature of putting pearls on the string is to avoid tangling the string for the convenience of the pearl. The purposes of the linkage are to acquire a connection to the retirement feature and its incentives to save and to lengthen the time period of any compound interest. It is not to generate inter-plan borrowings or conveniences, particularly for the early entrants to the string of pearls, at the expense of the later ones.
Is medical finance really so complicated most people couldn't handle it by themselves?
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For Health and Retirement Savings Accounts --- Transfer Slips, and Monthly statements, Only. So, yes and no to computers, which is what all this amounts to. Abundant cheap computers tempt us to use them for simple tasks, at the risk of making the simple task complex and losing the truth in a huge pile of statistics. (In another generation, a self-correcting code may conquer this problem, at the same time it will widen the opportunity for vandals.)
The proposal made here instead is a confederation of otherwise free-standing organizations (The Pearls), each hiring its own experts, feeding into a common channel of Health Savings Accounts owned by individual patients (The String). Individuals could hire consultants if they pleased but the decisions should be so simple the average high school graduate could cope with them.
One consolidated lifetime account form, which serves as a transfer vehicle for a single person's various balances. Sort of like a lifetime check-book. It provides a common incentive to be frugal for future retirement, and a common way to multiply such savings.
If that won't suffice for some tasks, we are traveling down the same path as the income tax and should re-consider such high-handed laziness.
There might be many networks, as long as their balances are uniformly transferable and they each link ultimately to a transferable retirement fund (The Goal) and a transferable investment fund (The Multiplier). Such networks might grow very large, but still, remain quite simple, and decisions which belong to the patient would remain within his control. The only outward purpose of such paperwork would be to transfer credits of the owner, to debts of the same owner or vice versa, with the adjusted balance ultimately coming to rest in his retirement account, creating a common incentive to be medically frugal. This would maintain adequate "records" (which mostly no one ever reads), an information source, and a designated HSA representative, but their outward form and unit would remain a transfer slip. You are striving for a good retrieval system, not a good archive system. If you want a simple system, give it to individuals who have an incentive to keep it simple. Don't give it to people who have a graduate degree an incentive to make it complicated.
If you want a simple system, give it to individuals who have an incentive to keep it simple.
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This particular feature has a political element. The American public now imagines it gets a bargain with Medicare, somehow getting a dollar of healthcare for fifty cents, and therefore a treasure they are unwilling to surrender. In all probability, no organization except the government could function long with such a deficit, so taking the deficit away from the government necessarily places it in the hands of someone who must balance his books. Somehow, legal protections for the patients against the debts of organizations which participate in the confederation must be established, so they can occasionally provide benefits at a loss, but only within stated limits. Called a "loss leader", the situation is a common one, but the effect is quite different from making the government a payer of last resort. Two additional savings multipliers must be added, although they will be explained shortly, along with two important investment designs.
Investment Mechanisms.We promised to discuss two investment mechanisms which might help matters. The first is the tendency of compound interest to rise with time. We have already shown above that adding another decade to the example will have an exaggerated effect on the outcome. This is an inherent quality of compound interest which crept up on us as science has conquered early death, and should have wide application in the future. As we learn how to avoid borrowing and learn how to be successful creditors, it should become a commonplace to rearrange financing to optimize it.
The second new model is index investing. As international borrowing has vastly increased the money supply, interest rates seem to have settled at a new low. Bonds have always been a zero-sum investment, but recent trends seem to set an even lower boundary. Common stock has more risk and volatility, but John Bogle and others have shown that it is practically useless for an ordinary person to buy anything but low-cost total-market common-stock index funds ("passive investing") since the fees charged by intermediaries tend to wipe out the profit from active investing. We recommend a heavy emphasis on this method. Beyond that basic approach, other strategies may be considered as a way to add fractions of a percent to total returns, but best avoided by people without experience, or lifetime years to recover from investment misjudgments.
In Final Summary of Privatizing Medicare. The public sector has been allowed to turn "privatization" into a term of contempt, when in fact it is a goal for the public sector to emulate. Very few people begin their careers in the public sector without spending their whole career there. In that sense, they are natural monopolists and act like them. We should strive for more varied career paths.
Even with considerable twisting, Medicare is so underfunded, no way can be found to self-fund it without adding several hundred dollars per person as a pump-primer. Of course, that's a great bargain compared with a hundred thousand dollars of medical care later on, but it will meet far more resistance than five hundred dollars is worth. Even then, it might require forty or fifty years at the most optimistic, to show a profit. In the Pearls on a String concept, the deficit might be made up by surplus generated by other programs, but Congress is unlikely to be willing to identify such a donor, and indeed it is a slippery path. The Affordable Care Act does not look as though it is going to generate a surplus, for example.
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.
