The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
On a pleasant Spring Sunday some time ago, I was at home, doing nothing in particular, when I suddenly experienced severe, crushing pain deep inside my chest. No doubt in my mind what that meant, so I quickly took an aspirin and looked at the clock: 6:50 PM, daylight time. Out the window to my right, my neighbors were having a yard party, so I walked thirty feet over to them. Side-stepping the big Hollywood hello, I told my neighbor I was having a heart attack and would please like a fast trip to the hospital. There was some talk of calling an ambulance, but that was brushed aside. No time.
E-Z Pass Speeds the Trip
Neighbor Charlie took the wheel, a friend got in the back seat, and off we went, fast. About that time, I started to sweat, just like they say in books, but to my surprise only after two or three minutes of the pain. The pain continued unchanged. Luckily, on Sunday evening, traffic was light. Down the main road to Benjamin Franklin Bridge, through the gate with E-Z Pass, over the bridge, turn left. I asked the man in the back to call the Emergency Room on his cell phone to tell them I was coming in, please get the cardiac intervention team to come to meet me at the hospital in a few minutes. We made one wrong turn on a one-way street, adding three blocks to the ride. I knew better but didn't feel equal to protesting. We were soon at the right door, and then into the reception area of the Emergency Department. This area is almost brand new; the first time I had been there. But I had been all over that hospital every day for years at a time, and for two years had been the Physician in charge of the Emergency Room, myself.
Electrocardiogram
I didn't recognize the nice lady at the desk, who wanted to know my next of kin, Medicare number, other insurance coverage, the color of my eyes, the name of my dog. My companions are very large fellows, and I was about to tell them to be polite, but if necessary knock her down, when actually I said the magic words,"Severe chest pain". That was part of her standard protocol, apparently, since I was immediately ushered onto a stretcher through a side door, had an electrocardiogram, watched the resident pick up the phone to call the cardiac team. Then I waved off somebody's informed consent speech to the effect that I didn't just consent to, but in fact, demanded an angioplasty. My clothes were taken away, intravenous lines were placed, ice-cold antiseptics were swabbed around. I was shaved in a business-like way in what the lady cutely called a Mohawk. The surgeon appeared, started his own informed consent speech which was waved off. The locks on the wheels were kicked loose, the stretcher started for the elevator, surrounded by scrambling attendants holding bottles. When we came to rest under a big light in some ceiling, I looked at the large wall clock. It was 7:20 PM. That was exactly thirty minutes after the pain began.
Cardiac Catheter
I was more or less awake during the whole procedure, getting to watch the dark black line of the catheter moving around on the scope beside me. I didn't know this particular surgeon, but it was obvious he was good. Usually, you can watch the catheter tip advance, then pull back, try again, pull back, try again and hit an obstacle. This evening I had the joy of watching a virtuoso performance, with the catheter smoothly advancing to its destination, twist and come to rest. Black dye squirted out, outlining the artery and its branches. The electrocardiogram correctly predicted the obstruction in the right anterior descending artery, and to general relief, the other atrerieswere "clean".
Probably because I got there so fast, plus swallowing an aspirin at home and chewing several in the Emergency Room, no clot had formed around the obstruction, which apparently was caused by a plaque of cholesterol with a split in it occluding the wall of the artery by bulging into the lumen. There seemed to be no clot behind the plaque or in front of it. The catheter had a stent over the balloon tip, which is to say it contained what amounted to braided chicken wire. The whole contraption gets opened up by inflating the balloon, then deflating and withdrawing it, which allows the artery to be held open by the unfolded chicken wire which remains in place. With the early versions of stents, fibrous scar tissue would grow over the chicken wire and block up the artery a few weeks later. Hence, the stent was coated with a chemical which prevents fibrosis. Unfortunately, this chemical also retards the growth of cells which line an artery on the inside, so coated chicken wire provokes clots. While I was still in the operating room, the solemn incantation was begun: I must take an anti-clotting drug every single day for a whole year, and if I missed a single pill, I could immediately die. I was to hear this incantation twenty times, so I guess they really mean it.
On a scale from 1-10, how bad is it?
Well, I was asked to call out a number from one to ten, indicating severity of chest pain. It had been "three" when I got to the operating room, even though it had begun as a "seven", and rose to "seven" several times during the procedure. Seven was my own invention; if I had to ask for pain-killer it was going to be an eight and would get to nine if I had to cry out. It never got worse than seven. When they pulled the catheter out of my groin, it was zero. It has stayed zero ever since.
It was a cause of some interest that my enzymes never rose. When heart muscle is injured, characteristic enzymes leak out and appear in blood tests; you can more or less measure the extent of the damage by the level it reaches. I had reached the emergency room so quickly the enzymes had not had a chance to rise. And the artery was re-opened so soon, they never did rise. For the first time in my life, my blood pressure was 250, so I guess I wasn't as calm as I let on. Somewhere during the procedure, the sweating stopped.
Severe chest pain
So, off to the cardiac care ward, where the custom is for each attendant to write his or her name on a whiteboard, while the date and time are prominently displayed for continuing orientation. They give you a phone so you can call your nurse, but my suggestion is to offer earplugs to drown out the continuous chatter at the desk. A patient of mine once called it the Racket Club. The food is, well, hospital food. Protocol says it should have no salt. I discovered that breakfast arrives on the dot at 9 AM, supper on the dot at 5 PM, lunch somewhere in between. I believe I understand the reasoning. Two days of this, and I'm discharged. Nothing to it, if you get there fast. Let me repeat, if you get there fast.
Since this light-hearted day trip is in sharp contrast with the six weeks of strict bed rest so routine in the days of my internship, not to mention the considerable mortality and disability that prevailed until quite recently, it justifies some reflection. As a medical student, I knew Andre Cournand and Dickenson Richards, who perfected the cardiac catheter. They were awarded Nobel Prizes, as was Michael Brown, who invented the statin drugs to lower cholesterol. Affable and modest men, they have saved millions of lives, now including mine. Or at least they did so, with the assistance of thousands of other doctors who perfected one by one the details of the little minute we danced in the operating room, each adding some little refinement, or eliminating some little hindrance to success. But, doggone it, you have got to get to the hospital fast.
Helicopter Dreams
To do that, you have to give it some thought in advance; some community organization would also be useful. In my case, waiting for an ambulance would have slowed me down. Not everybody can live within a few minutes fast drive of a hospital, and not all hospitals are equipped to handle such cases. The range of effective rescue could be extended with helicopters, but you have to give some thought to where you would have to drive to find a place for a helicopter to land. Philadelphia is almost unique in having the largest evacuation company in the world, headquartered in Trevose, but it would take a lot of negotiation to arrange a system for the whole Philadelphia area. It just happens my oldest son was helicoptered off a mountain in Nepal this year (by an affiliate of this company), but his helicopter almost ran out of gas. These things can be done, and yearly evacuation insurance is about $200 a year, anywhere in the world. But it would take an awful lot of community planning and argue -- and maybe suing -- to make it happen. Is it worth it? Sure, but a little hard thought in advance might offer better solutions for most people.
Byron S. Comati, the Director of Strategic Planning and Analysis for SEPTA (Southeastern Pennsylvania Transportation Authority), kindly gave the Right Angle Club an inside look at the hopes and plans of SEPTA for the near (five-year) future. Students of large organizations favor a five or six-year planning cycle as both short enough to be realistic, and long enough to expect to see tangible response. If plans continuously readjust to fit the five-year horizon, the concept is that the organization will move forward on these stepping stones, even accounting for setbacks, disappointments, and surprises. Furthermore, a serious level of continuous planning puts an organization in a position to react when funding opportunities arise, such as the sudden demand of the Obama Administration that economic stimulus proposals be "shovel ready."
The Silverline V
So, SEPTA is currently promoting five major expansions, based on the emerging success of an earlier plan, the Silverliner V. Silverline is a set of 120 shiny new cars, built in Korea on the model of electrical multiple units, which are expected in Spring 2011 to replace 73 cars or units which were built in 1963. Obviously, 120 are more expensive than 73, but they are more flexible as well. And less wasteful; most commuters are familiar with the model of three seats abreast which unfortunately conflict with the social preferences of the public, tending to make the car seem crowded even though it is a third empty. When a misjudgment like this is made, it takes fifty years to replace it with something better. For example, there's currently a movement toward "Green construction", which is acknowledged to be "a little bit more expensive". The actual costs and savings of green construction have yet to become firmly agreed on, so there's an advantage to being conservative about what's new and trendy in things that take fifty years to wear out.
Septa Regional Map
Four of SEPTA's five major proposed projects are in the Pennsylvania suburbs. New Jersey has its own transportation authority, and Philadelphia is thus left to struggle with the much higher costs of urban reconstruction assigned to its declining industrial population. And left unmentioned is the six hundred pound gorilla of the transportation costs of new casinos. A great many people are violently opposed to legalized gambling, and even more upset by the idea of crime emerging in the neighborhoods of gambling enterprises. Even the politicians who enacted this legislation are uncomfortable to see the rather large expenditures which will eat into the net revenue from this development. Nevertheless, if you are running a transportation system, you have an obligation to plan for every large shift in transportation patterns, no matter what you might think of the wisdom of the venture. The alternative is to face an inevitable storm of criticism if casinos come about, but without any preparation having been made for the transportation consequences. At present, the public transportation plan for the casinos is to organize a light rail line along the Delaware waterfront, connecting to the rest of the city through a spur line west up Market Street; it may go to 30th Street Station, or it may stop at City Hall. That sounds a lot like the present Market-Frankford line, so expect some resistance when the cost estimates are revealed. Because all merchants want to have the station stops near them, and almost no residents want a lot of casino foot-traffic near their homes and schools, expect an outcry from those directions, as well. It would be nice to integrate this activity with something which would revive the river wards, but it seems a long stretch to connect with Wilmington on the south, or Trenton on the north.
The planned expansions in the suburban Pennsylvania counties will probably encounter less controversy, although it is the sorry fate of all transportation officials to endure some hostility and criticism for any changes whatever. Generally speaking, the four extensions follow a similar pattern of building along old or abandoned rail lines, following rather than leading the population migrations of the past. When you are organizing mass transit, there is a need to foresee with some certainty that there will be a net increase in commuters in the region under consideration. The one and two passenger automobile is a much more flexible instrument for adjusting to the growth of new development, schools, retail, and industry. Once the region has become established, there is room for an argument that transportation in larger bulk is cheaper, cleaner or whatever.
The Norristown extension follows the existing but underused rail connections to Reading. Route US 422 opened up the region formerly serving the anthracite industry, but now the clamor is rising that US 422 is impossibly crowded and needs to be supplemented with mass transit.
The Quakertown extension follows the rail route abandoned in 1980 to Bethlehem and Allentown, although the extension is only planned as far as Shelly, PA.
The Norristown high-speed extension responds to the almost total lack of public transportation to the King of Prussia shopping center, and will possibly replace the light rail connection to downtown Philadelphia.
And the Paoli extension follows the mainline Amtrak rails as far as Coatesville.
All of these expansions can expect to be greeted with huzzahs by developers, land speculators, and newsmedia, but resistance will inevitably be as fierce as it always is. Local business always fears an expansion of its competitors; the feeling is stronger in the suburbs than the city, but local business always resists and local politicians always follow their lead. To some extent, the suburbs have a point, since radial extensions are usually much cheaper to build than lateral or circumferential transportation media; bus routes are the favored pioneers in connecting one suburb with another. Therefore, the tendency in these present plans remains typical by threatening the suburbs with a need to travel toward the center hub, then take a reverse branch back in the general direction of where they started, in order to go a short distance to a shopping center or school system. The two main river systems around Philadelphia interfere with the construction of big "X" routes from the far distance in one direction to the far distance in the opposite direction. Euclidian geometry makes the circumferential route elongate as the square of the radius. And jealousies between the politicians in three states create rally foci for the special local interests which feel injured. Since it seems to be an established fact that the proportional contribution to mass transportation by the surrounding suburbs of Philadelphia is traditionally (and considerably) lower than the national average, a political reconciliation might do more for the finances of SEPTA than any federal stimulus package could do. For such reconciliation, a few lateral connections in the net might pacify the suburbs enough to justify the extra cost. Unfortunately, the main source of unjustified cost in regional mass transit is the high wage and benefit levels of the employees, a situation inherited from the old days when commuter rail was part of the stockholder-owned regional railroads. Just as featherbedding was the main cause of the destruction of the mainline railroads, health and pension benefits threaten the life of mass transit. In the old days, local governments acted as a megaphone for union demands. So the railroads just gave the commuter system to the local governments, and let them wrestle with the unions themselves. Since the survival of the urban region depends on conquering this financial drain, the problem must be gradually worn down. But it has been remarkable how long the region has been willing to flirt with bankruptcy rather than bite this bullet.
If anything, this friction threatens to get worse. In 2009, for the first time, a majority of union members in America -- work for the government, the one industry which thinks it cannot be destroyed by losing money. True, SEPTA is not exactly a government function, but it has enough in common with a government department to arouse suburban voters, who regularly refer to it as an arm of the urban political machine. SEPTA isn't too big to fail, but there exists little doubt that government at some level would probably try to bail it out if it did.
On a mud flat of the Susquehanna River called Three Mile Island, a nuclear energy plant had been built around 1970. The mud flat was in front of the entrance of the Swatara Creek, where Middletown the first town in the County had been laid out in 1732. Later on, the town of Harrisburg became the capital city of Pennsylvania, located a few miles north of the Swatara Creek at what had been called Harris's Ferry, later Harrisburg. For quite a while, Middletown and Hummelstown, also on the Swatara Creek, were the two main towns in the area, but the location of the state capital attracted railroads and steel mills to Harrisburg. One of its main claims to fame was that Confederate General Robert E. Lee was thought to have it as his primary objective for invading the North, frustrated in this goal of course by his defeat at the battle of Gettysburg. Meanwhile, Middletown has declined to a small country town and was therefore originally glad to have the industry of electricity generation located next to it. It's true the huge cooling towers loomed ominously, and huge plumes of evaporated water rose in clouds to be seen for miles. But Middletown slowly took on the look of a refurbished 18th Century town, fancy new restaurants and all, prosperous and waiting to be discovered as a tourist attraction. Maybe in time, it would be the next Williamsburg.
The China Syndrome
On March 28, 1979, some valve got stuck within Reactor Number Two. The plant had two reactors, each with a spare cooling tower so it looked as though there were four nuclear plants instead of two. Warning lights and whistles went off, and it is easy to imagine a general panic within the operators of the plant, especially since a popular movie, The China Syndrome had just been issued two weeks earlier, depicting an imaginary implosion of a similar nuclear plant with famous movie actresses running around screaming. It took about five days for the plant operators to make a preliminary assessment of the TMI situation, which did not seem as bad as it might have been. It would take six months to reach a final evaluation of just what had gone wrong, and why. In the meantime, almost anyone could say or imagine almost anything; no one could prove they were wrong. The local citizens held a referendum; they wanted all of the facility to be closed, permanently. Secretary of Health Gordon MacLeod wanted a somewhat more reasonable thing, which was large supplies of sodium iodide pills to be distributed to the populace to prevent the radioactive iodine content of escaped gases from being attracted to the thyroid glands of the population, especially children and child-bearing mothers. Unfortunately, he took the unforgivable step of criticizing the state government for not having stock-piled the pills, and the Governor fired him, thus demonstrating strong decisive action in an emergency. The news media were equally at sea because this was big news. When all was finally said and done, there was no evidence that anyone was injured as a result of the accident. More than thirty years later, there is still no sign that anyone was ever hurt.
Hiroshima Explosion
We might not have been so lucky, of course. When the Russian plant at Chernobyl had a worse accident in 1986, literally thousands of Ukrainians were sickened, and the death rate was appreciable. In Japan, the victims of the Hiroshima explosion were closely followed for many years, and the incidence of cancer of the thyroid among the survivors was truly frightening. However, after more decades elapsed, it was possible to determine that the overall death rate from thyroid cancer was not increased, suggesting these new cancers were not particularly malignant. But in a different set of circumstances, when the Chinese set off their tests of nuclear weapons, it became clear that these tests were followed in a few years by a world-wide epidemic of Hashimoto's Disease of the thyroid. Radioactivity in mushroom clouds is mainly radioactive iodine, with a half-life of seven days. Unfortunately, the clouds sail around the earth, eventually settling into the dirt on the ground. Grass grows there, and cows eat the grass. By this time, the radioactivity is much diminished, but the digestive systems of cows concentrate this weak radioactive iodine, which then gets into milk in a more active form. The kids drink milk and get Hashimoto's disease. Whether they will later get thyroid cancer and die of it remains unknown, but possibly not, in view of the Hiroshima experience. So, amidst a welter of conflicting evidence, it is still possible to say almost anything about nuclear power risks without fear of provable contradiction. It is only safe to repeat that radioactive iodine exposure doesn't do anyone any good.
Unfortunately, thirty years after the accident, we now all understand it would be a good thing to develop energy independence from Middle East sources; but we remain unsure just how unsafe we are willing to become in order to re-adopt nuclear energy. Since the accident at Three Mile Island, our government has made it impossible for a single atomic plant to be built in America. And the politicians are surely right about frightening public opinion on the topic. Just look at pretty little Middletown: it's moving toward becoming a dilapidated ghost town.
Without claiming any expertise in atomic energy production, it is possible to quote others to the effect that the hesitation of the politicians is no longer focused on the danger that a plant will explode. Rather, the real dispute is about the disposal of nuclear waste. No one wants it nearby. The French have built nearly sixty plants in the thirty years we have hesitated; how do the French dispose of nuclear waste? The answer seems to be that waste disposal is not a problem with the French methodology, but a new problem surfaces that the French approach generates a type of waste which is much easier for an undeveloped country to deploy as material for atomic bombs. So, the rumor commonly circulating is that this is really the main practical objection to constructing nuclear energy plants in the French style. As is true for the entire nuclear topic, the rumors outrun the evidence.
Since we propose to fund the end of life with money generated many years earlier, and since the whole structure disintegrates if funds are spent prematurely, it might be a long time before savings amount to much for the people funding them. A long gap between savings and spending generates the income windfall, but failure to distribute the windfall generates restlessness. Saving for one's own later spending does help pacify restless people, and is a major reason for using individual accounts rather than pooling. Minimal amounts of insurance and government redistribution are necessary, but as much as possible should be confined to 5% of the population which generates 40% of the costs. Self-interest thus concentrates transitional revenue as a whole toward individuals who do not live long enough for a full cycle to rescue them. With many contingencies certain to arise in such a long interval, it is difficult to construct a convincing model, except by estimating the upper limit of what it can produce and then guessing at the lower limit of what might satisfy the participants. What follows is an attempt to do that.
The cost of dying is always likely to be greater than the cost of being born. In our estimates, it is taken to be five times as great. Between birth and death, rent-seeking is a formidable competitor to program reduction whenever science produces lower medical costs. Intermediate steps and middle-men should be as few as possible. A reward system should be devised for intermediaries who demonstrate low costs. To be blunt about it, this is one of the strong arguments for individual rather than merged accounts, and private rather than political control; history shows a need for such a bias. It has been Medicare experience that 5% of the clients generate 40% of the costs, so here is another guide for the model. Each year, about 6.6% of Medicare patients die. The number of newborns plus immigrants of various ages are both likely to be capricious and will constantly vex projections. We must do better than we did with the baby boom bulge, where adverse projections were ignored for decades. Scientific advances are likely to mitigate diabetes, Alzheimers, cancer, Parkinsonism, osteoporosis, and a dozen less common degenerative diseases, during the next century. So longevity will increase. Although a dozen, now less common, diseases will take their place, the tendency will be for healthcare costs to decline after age 55 and diffuse more widely after age 75. Since costs will be less affected before age 55 than afterward, there is a potential for investments and compound interest to rescue us in time, since Medicare now covers about half of the costs, and Medicare will continue to expand for increasingly older members. As costs flatten out, there will come a time to take the jump to an entirely new but less expensive system.
The secret of a successful transition is to hold back expenditures but accelerate revenues until the two are close. Then take the jump.
There are such big differences in average health costs between men and women, between regions of the nation, and between employment situations, not to mention income brackets and ethnic groups, the earnest, honest statistics available to the public about its health costs are alarmingly variable. When the recent commotion about the costs of Obamacare are added in, with the delayed changes in the status of employment inclusion, plus unexpected jumps in insurance premiums ranging up to 50%, this seems like a poor time to be talking absolute numbers. Consequently, we prefer to make our transitional projections in terms of relative values. It seems more accurate to say that if women of reproductive age continue to cost 20% more than men, the savings will be 20% greater -- if you follow our plan. Consequently, it is probably more meaningful to project a 50% improvement in both costs, than to make a thousand mistakes in estimating all the numerical variations of the same idea. Only when prices stop changing so rapidly will it be safe to be more specific.
Accordingly, we note that substituting catastrophic insurance for Obamacare ought to reduce costs by 30%. And paying for childhood and last year of life by reinsurance-switching ought to shave off 20% more. Consequently, the addition of $50 per year premium cost (paid into the escrow fund) and substitution of catastrophic insurance, combined ought to reduce costs by about 50%. Since Medicare now consumes about half of health costs, we ought to be ready to complete the transition in about half of the life expectancy, or 42 years. Scientific advances should shorten this time interval, and the many extra suggestions of this book ought to provide additional financial cushions against surprises. Consequently, we project that a transition should take no longer than 42 years, and we fervently hope that luck could improve on that. But 42 years is what we project. Can anybody propose a plan which would improve on that projection? It's, of course, a pity we didn't do this ten years ago, so it would only take 32 more years, but that should be a caution that if we spend ten more years calling each other names, it will take 52 years.
A physician friend of mine was a patient of a famous neurosurgeon who had joined a group and accepted a salary. Quite recently, he visited the neurosurgeon, only to have the interview interrupted by an automated telephone call. The automated message was to the effect that time scheduled for the visit had expired, and he should quickly terminate the office visit. The neurosurgeon remonstrated, to little avail. It seems safe to predict this whole relationship is soon to terminate, although it will be interesting to watch. There are limits to what evasions can be devised, as well as to what controls will be tolerated. I predict this neurosurgeon and this institution will eventually test such limits.
In the same way, I predict a funded pre-payment system will eventually devise enough compromises to keep its system functioning. It produces too much extra revenue to tolerate unlimited abuse. Any system which can produce so much revenue that inflation protectors are necessary, and one which at the same time is so complex it requires actuaries to project revenue--will find the necessary accommodations.
The Hospital That Ate Chicago, Saunders Press, 1980
Health Savings Accounts: Planning for Prosperity, Ross & Perry, Inc. 2015
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Ross & Perry Book Publishers
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Surmounting Health Costs to Retire: Health Savings (and Retirement) Accounts
Copyright: 1-2540412791
ISBN #: 978-1-931839-44-0
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Acknowledgements
For advice and support about the thrust of this much-revised book, I owe new debts to the many people who read the first version and commented. The first book was written as ideas developed in my mind, and rather in a hurry. The present revision was written so later thoughts could be introduced earlier in the argument. It also gave me a chance to distinguish between, what is immediately practical, and grander ideas at the mercy of intervening events. I briefly considered omitting the long-term viewpoint, but include it to suggest alternatives which may or may not be achievable immediately, but would seem like blunders if passed over when there was room for them. Voters want representatives (and authors) who are clear what they hope to achieve, even if events bring them short of it.
This book outlines the hidden advantages of Health Savings Accounts, which the author had a hand in creating in 1981, along with John McClaughry of Vermont when John was Senior Policy Advisor in the Reagan White House. HSAs have achieved 30% savings among early subscribers. The most popular advantage appeared later: to convert the left-over tax-exempt savings to an IRA, at the time of beginning Medicare Coverage. Because of the popularity of this retirement savings feature, this book suggests renaming them to Health and Retirement Savings Accounts, to emphasize the dual possibilities.
In a later section, the book looks ahead to still other features which take advantage of compound interest income during an era of lengthening longevity. Substantial savings appear to become possible from reversing the system, from paying interest, into one of receiving and compounding it. Individual private accounts rather than group insurance contain a number of other hidden advantages, as do high deductibles but absent co-pays. The public currently embraces Medicare but needs to foresee the advantages of gradually shifting its funding whenever research reduces Medicare costs in the future. The mathematics appears to be sound, but resistance might appear, from the political and social disruptions entailed.
George Ross Fisher, MD, the author of this book, graduated from the Lawrenceville School in 1942, from Yale University in 1945, and from Columbia University, College of Physicians and Surgeons in 1948. After postgraduate training at Pennsylvania Hospital, Thomas Jefferson University, and the National Institutes of Health, he spent 60 years practicing medicine in Philadelphia. During that time, he spent 25 years as a delegate to the American Medical Association, and as a trustee of a number of medical organizations.
Following retirement, he formed a publishing company, Ross and Perry, Inc, which has published several hundred books, mostly reprints. He is personally the author of eleven books about Philadelphia history, from William Penn to Grace Kelly. He is the author of the following three books about medical economics:
The Hospital That Ate Chicago;
Health Savings Accounts: Planning for Prosperity;
Surmounting Health Costs to Retire: Health (and Retirement) Savings Accounts,(the current volume.)
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.
