After adventures in Congress and the Supreme Court, the Affordable Care Act no longer says it creates mandatory health insurance. It has transformed into addition of Chapter 48 within Subtitle D of the Internal Revenue Code of 1986. As such, it creates a default minimum coverage requirement in Section 1501 (now renamed Section 5000A), recognizing three main exceptions. They are Religious Objectors, Illegal Residents, Incarcerated Persons, (plus a catch-all group of "Hardship Cases".) The total it comprises is about the same thirty million uninsured persons we started with, although they may be different people. This expedient patches over the difficulties created by the Supreme Court decision in XXXX v. Sibelius, but the implication seems to be that since everyone is required to pay taxes, everyone must have health insurance, but that really cannot be so. The largest exception would be those enrolled in Medicare, taxed, but not covered by the Affordable Care Act. Native Americans pose a different problem. The potential for other loopholes to appear is considerable, and further legislative modification is certainly more awkward. Congress will certainly be vexed to find that modification of the immigration laws implies a change in Obamacare eligibility, as well.
In Section 1251 there is an independent exception, which declares everyone who is satisfied with existing coverage is allowed to keep it. Many are surprised to read it there, and no doubt some would wish it would go away. It appears politically impossible to change it. But, when someone gets standing to sue, the Supreme Court will have to choose, and both political parties are fearful of what the Court might then decide. Section 1251 can easily be defended as a necessary step toward gradual transition into a massive new program. It can also be attacked as a Booby Trap, deliberately sabotaging a political victory. And it can be suspected of being one of those raisins deliberately placed in the Senate pudding, with plans that went astray when the death of Senator Kennedy made it impossible to remove it at the House-Senate Conference Committee. When the Supreme Court gets it, it will make little difference who included the provision, or why. With such a gun at its head, the Legislative Branch would be foolish not to seek a quiet resolution.
Let's begin by noticing that exempting some people from the law is exactly the same as allowing them to choose something else. Section 1251 defines a category of exceptions, but it does not affect the number of uninsured. People who do not wish to transfer might as well be added to incarcerated persons, illegal immigrants, and religious objectors, for all the difference it would make in the number of people covered. Since the largest insurance category of all, encompassing employees of large businesses, has been indefinitely postponed independently, it might actually be true that the size of the program could be reduced to more manageable proportions, but it is certainly no larger. For those looking for a workable face-saving way out of the present train wreck, consolidating the exemptions might create a basis for one. While the new coverage might be more comprehensive, it is only that difference in comprehensiveness which changes. As time gets closer to the elections, political damage from administering a failing program certainly gets worse, and "playing for the breaks" has less time to work. The dynamics from the other side of the table are harder to discern, but it is always good politics to rescue the nation from a looming threat.
Although there would certainly be many objections to consolidating the two sections of the APA, it is difficult to imagine other alternatives for this particular issue. Even ending the Cold War took a long time, when the two negotiators agreed on the goal. Perhaps surrendering to Justice Sutherland's historic doctrine that the whole law is "void for vagueness" is best seen as a nuclear option. The practical consequence of totally voiding Obamacare would be a return of health care to regulation by the States but without the benefits of conciliating the change. Beyond that, questions of interstate transfers of health insurance coverage might start with copying useful features from ERISA. To use an old phrase, this isn't rocket science; there aren't many significant differences between states, right now. But it may not be necessary to smash the Affordable Care Act to achieve more than smashing would achieve. We lived with state regulation of healthcare for centuries; we could do it again.
Accordingly, to get the ball rolling, it seems reasonable to Propose: That one or more Houses of Congress should reopen the ACA law for limited technical amendments, chiefly to add Section 1251 as an additional feature of Section 1501, thus making that entire section just one additional category of recognized exemption, from the minimum coverages in the new tax code.
The longer we wait to make drastic changes, the more difficult they become, more proof of benefit will be demanded. In the proposed case of switching health insurance from term insurance to whole-life, a century of insurance development contributed insights. But remember, the past fifty years have seen plenty of dissatisfaction come to the surface, only to be dashed by a (generally correct) opinion that the old system was working better than the proposed one would.
Health Cost Monitor Center. This time, let's start in advance with establishing a monitor center, and locate it near other public data centers. Turf issues are inevitable, but bowling teams can break them down. With attention to the issue, an interagency technical center could develop into a useful employment center, attracting superior people with vastly enhanced opportunities for personal advancement. If the center is large enough and sufficiently diversified, it will resist abuse by tyrants.
By waiting fifty years, we now have big data.
But we could have had answers, fifty years ago.
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Perfect is the Enemy of Good Enough
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Conversely, in a population as large as ours, enough people of younger ages will inquiring minds; the problem is to establish the right leadership, and the right opportunity so we can still estimate in advance what difference our proposals make to costs at almost any age. At least then, the public could judge what is actually happening, instead of relying on the pronouncements of political candidates. Half of hospital cost experience already resides in Medicare data, the last years of life are well documented, and the first years of life are fairly predictable for these purposes. So we start the data with pretty good anchors and a panoramic overview of costs. With at least a stated goal of offering suggested prices for lifetime planning, but not necessarily universal ones, we should be able to cope with a voluntary system.
Footnote: An experience forty years ago makes me quite serious about this monitoring issue. While I was on another mission, I discovered Medicare and Social Security are on the same campus in Baltimore, with their computers a hundred yards apart. So I proposed to the chief statistician, that the Medicare computers already contained the date and coded diagnosis of every Medicare recipient who had, let's say, a particular operation for particular cancer. At the same time and in the same location, the Social Security computers contain the date of everybody's death; the Social Security number links the two. So, why not merge one data set into the other, and produce a running report of how long people seem to be living, on average, after receiving a particular treatment or operation -- and how it seems to be changing, over time. (Length of survival = date of death minus date of the procedure) He merely smiled at the suggestion, and I correctly surmised he had no intention of going any further with it. This time, I resolved to write a book, to see if that might have more effect.
Let's ponder about some of the uncertainties which can only result in guesses at the moment, but which in time can be more precise, and provide the material for mid-course corrections:
Considering the sums involved,
We don't watch public money very carefully.
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You Cannot Have Too Much Data
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Transition Calculations. Let's say we have politicians with the skill to persuade the public to phase out Medicare in order to put an end to the foreign borrowing of half its costs and persuade enough beneficiaries to do so by buying themselves out of the program. It has been our extrapolation that this could be done with a single payment of $80,000 at age 66, having earned an income of 6% since age 30. The cost would compare favorably with present payroll deductions for Medicare, although of course, you can't spend it on two different things; the present premium costs of Medicare provide a roughly equal amount. That provides a price goal, for the beneficiary to make a last-minute decision whether to go ahead with the buy-out. And during the years of accumulating the wherewithal in an escrow fund, it presents a distant steady goal. In addition, we also must recognize that a large foreign debt has been obligated to pay for shortfalls of years now past.
The size of the debt is unclear, but we estimate about an additional $80,000 would pay it off. If the numbers come out wrong, the debt payment could be shrugged off, the way the Chinese Imperial government did a century ago, and the way the Greek government wants to do at present. For argument sake, let us assume that debt to be $80,000, but we are unsure how to pay it. (If I sound like Lyndon Johnson, it is because I am dealing with the same topic.) If these numbers approach any kind of accuracy, the process of buy-out could begin, voluntarily, delaying the choice until the 66th birthday. If there is significant interest in the idea, these numbers could be sharpened, but there would always remain some guesswork. Some additional protection of the gamble could be provided by adding a catastrophic insurance policy. In the long run, this whole buy-out idea would be strengthened by migrating the center of care to a nearby retirement village and using the hospital system only for tertiary care. Obviously, it is intended that the proposed monitoring center would be actively involved, and not merely act passively collecting data without designing some large-scale experiments, also obviously voluntary.
Somehow, a large and well-respected health monitoring system could perform a significant service by participating in more demonstration programs, since so often Congress must resort to trying something because it seems like a good idea. Such an approach needs some discreet professional guidance since obviously, Congress would be reluctant to hand over power, simply because some bureaucrat had gone to graduate school or present the Congressional opposition with an opportunity to get rid of them by assigning unwelcome proposals to a protracted study they did not need. Nevertheless, a few well-designed demonstration programs might be a useful way to make some decisions which are currently only based on hunches. It seems likely the kind of monitoring agency needed, would only have the desired outcome if the first Director of it was a strong and highly talented professional, preferably with a distinguished reputation for an impartial examination of the evidence.
That particular function stresses innovative ideas, starting from their beginning. A limited amount of that is badly needed, but sensitivities must be respected. The main function of a monitoring agency is to provide reliable reports to Congress that a developing program is, or is not, on schedule, or is or is not producing the intended effects at a promised cost. Congress is busy, and it is often in a hurry. It needs to be told that something unexpected is happening, or that something expected is not happening before the news media starts to get excited. And somehow it needs to be a welcome friend to the departmental auditors, who will greatly resent an outside body finding something which has been overlooked. As the saying goes, it needs to have some money in the bank before it opens its mouth.
In 1965, the most fundamental of economic fundamentals reversed itself. America's international trade balance shifted from positive to negative, has remained negative ever since. It's irrelevant that international currency shifted backward to soften the blow; that's what floating currencies are supposed to do. The era of effortless and largely unchallenged American post-war world supremacy was over. From now on, it was to be everyone for himself, in Medicine as in every other trade.
A new triumvirate, consisting of hospitals, health insurance, and medical schools asserted medical leadership, fought against each other for domination, and consequently found themselves a prized destination for opportunists. The new name of the game was to gain control of the payment system, and through it control of hospitals, and through the control of the doctors. But the sponsors of the earlier system, the employer-based one, were still around, and to a large extent, still, dominate. No proposal for running healthcare could omit physicians from the center of control. Most who attempt it, seek to use medical schools as a surrogate for the practicing profession. However, medical schools are in competition with their alumni by owning hospitals, and the rest of the profession see medical school control as favoring a competitor. They resist it bitterly.
Meanwhile, the doctors had experienced entirely different socialization by going away to various wars, and discovering how little they needed hospitals. As shown in episodes of the TV series Mash, new bonds were formed between a medical band of brothers, operating successfully in tents, not medical centers. This experience comes and goes, but unfortunately, there has been such a succession of wars, the experience gets reinforced. One of the great paradoxes of the present medical upheaval is to see government and insurance doing their best to herd doctors back into hospitals so they can be controlled by salaries, rather than by their patients. And while they seem to have largely succeeded, the ACA ambition to control medical care by control of the payment system is appreciably undermined at its interface between institution and profession. It is always an uphill battle, to defend a more expensive, less satisfying, approach; eventually, it is a losing approach. The oppressive cost of everything, the collision between recessions and inflations, seemed to be keeping everybody under control for the time being. But it would be unwise to assume calm will prevail forever, or that a command-and-control arrangement would continue to work through the hospital, without fragmenting somewhere. In a larger sense, a lot of this history was irrelevant. The people really causing commotion were business leaders with an entirely different agenda; their model was Henry J. Kaiser.
Much of the resulting endgame depends on what Washington will be willing to do. Congress will have its own ideas, but Congress is often in a hurry. What isn't complicated, is often politically difficult, and it helps things along if the public has thought about them first. The Supreme Court gives itself more leisure to think, but sometimes that isn't a pure advantage. The President has more staff, but he can't always control it. Medical cost-cutting turns out to be like closing military bases; it has to be gradual, it has to be spread wide and thin, but it must show early benefits quickly. In its first six years, for example, a lot of people must see some benefit, and very few must see their jobs destroyed. All this can be done, but it can't be done repeatedly. The country cannot afford to keep using up its reserves with noble experiments. World affairs and world economics surely present enough distractions, without inventing artificial ones.
On medical affairs, Congress should learn to listen more to doctors and less to our ancillaries. But for this to happen, doctors will have to become more open about their experiences, rather than electing more doctors to Congress, where they become seen as competitors rather than experts. When Congress finally wakes up to the full dimension of what has happened, everybody is going to need some friends he can trust.
In the final section of this book, we will talk a little about some of the thorny transition problems to be expected. It's not a comprehensive discussion, but a wake-up to the healthcare industry and to Congress, about the complexity of some of the implementation problems they are abandoning to the Executive Branch -- at everyone's peril.
So, come along, let's learn a few hidden things. Start with employer-based health insurance. That's what we had for the past century but hardly noticed it. It even helps to know a little of its history.
A Short History of Employer-based Health Insurance. Instead of starting with Bismarck or some other link to a non-American, let's say health insurance in America began as a proposal of Teddy Roosevelt's during the Progressive Era just before the First World War, a century ago. The American Medical Association had a flirtation with Teddy's national health insurance but came to prefer something like the business community's Blue Cross system, as it eventually evolved during the 1920s. Business scarcely recognized it, but large American companies were beginning to shift control from founding families to stockholders, an evolution which advanced during the next three decades, as a way to extract capital gains taxes to float war debts. To a certain degree, growing shareholder control was a step toward meritocracy; in a human relations sense, it may have been a step backward. The shift extends to only about half of corporations even today. But health insurance and stockholder control of the big companies advanced side by side, scarcely realizing how diminished employer benevolence was undermining the process. We glorified the decline of a semi-feudal system, but we lost something in the process.
American health insurance traces back to President Teddy Roosevelt
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It makes a huge difference whether the boss is a paternalistic owner or the manager of someone else's company. In the first instance, he spends his own money, in the other instance, his only absolute mandate is to generate money for the stockholders. That's a measurement applied to every "good" manager. Plenty of owners were tight-fisted, and plenty of managers were benevolent. Even today, small businesses (less than a billion dollars in assets) are mostly "Subchapter S" corporations, and about 15% of really large "Subchapter C" corporations are still dominated by founding families. But in spite of frenzied rhetoric about the "rich owner", the shift in attitudes is clear; as founding generations move away from active involvement in their companies, they become less involved with employees. They themselves become more like their hired managers. Current investment trends, moving into index fund passive investing, further widen the distance between stockholders and owners-by-inheritance. The "silo effect" of specialized departments further isolates the core business from non-revenue support departments.
Cost-shifting was an early development, transferred from the business to the hospital. The concept originally underlying Blue Cross was that private rooms should produce enough profit for the hospital to support the poor folks in open wards, whereas semi-private rooms just break even. At first, only a handful of ministers and school teachers were in the semi-private category. When hospital finances improved, more working-class people moved into the semi-private category, the wards shrank in size, and semi-private -- became the standard clause in employee contracts. For two hundred years, multi-bed open wards were standard, but semi-private became standard in a single decade. Semi-private nevertheless acquired a charity flavor. The "Blue Cross discount" began to apply to semi-private beds, at the same time semi-private became readjusted to become "standard size" for "service benefits". That is, most employees of corporations started to be cared for at less than actual cost, at the Blue Cross discount-to-business rate, because their contract called for being provided certain services, no matter what they cost. In fact, what they appeared to cost was so distorted by cost-shifting, you couldn't tell who was subsidized. It would not take long for a new standard to be demanded: sharing a room with strangers was so low-class. Private rooms were going to be the only decent thing. Spending other people's money is fun.
And because Blue Cross organizations became dominant during the Second World War, their competitors in cash benefits ("indemnity carriers") greatly resented paying more dollars for the same semi-private room than Blue Cross patients did. Some of this was doubtless a response to wage and price controls during World War II, a way of raising wages without expanding the (taxable) "pay packet". The response of commercial indemnity carriers was to price their premiums on "experience rating", which especially cut into the profit margin of Blue Cross private-bed patients. The way that worked was, the insurer waited a year to see what inflation had done, and made a trailing readjustment in the following year's premium. One unexpected outcome of this price warfare was to make the hospital reluctant to reveal its tentative charges, where the employer demanded to be shown the actual costs of his employees, as well as prices to everybody else. When Blue Cross coverage reached government employees, a new power center gained possession of itemized hospital bills. A new employee representative could easily see how much or how little the government was actually subsidizing charity care. Naturally, as the new source of benevolence, they claimed they were paying too much.
When Group practices, or HMOs, started to pay for healthcare, they too demanded to see comparable bills or at least standardized prices. And so it went, with each new wrinkle in payment. Some people paid listed prices, but big groups could afford to send auditors to look at the books. There had long been a three-tier price list, and now there was a six-tier one because of having list prices and actual payments on each of three levels. Soon it began to seem there might be sixty prices for the same thing. Like a stag cornered by barking dogs, the hospital fended off the payers as best it could. Because of the long period of catch-up following the Great Depression and then the Second World War, hospitals usually needed new buildings and improved wage standards for employees. How were they to pay for this, when everybody seemed to be demanding to get backlogged services at the old prices?
For centuries, hospitals had existed on a system of collecting whatever they could, and delivering needed care as best they were able. Their deficits were covered by public subscription, by religions, and by tightening the belts of the charity-minded hospital volunteers. Sometimes the rich guy who lived in a mansion on the hill would donate, sometimes he wouldn't. Surely, the government had a responsibility to rescue such a deserving charity. The student nurses and the young doctors in white worked for no pay at all. That's right, after I graduated from medical school I worked for four years without a dime of pay. If hospitals overcharged a few insurance companies, well, there was nothing else they could do to keep the doors open. Until health insurance made a significant impact, hospitals ruled medical care. They were the only institutions which seemed to work, all new ideas seemed to come from them, and any new idea which came along was somehow centered within hospitals. Although it wasn't described as such, hospitals began to suffer the disease of conglomerates. If an organization takes on too many functions at once, it performs some of them poorly. Usually, one of the subsidiaries fails and drags the rest of the conglomerate down. That's essentially why the Supreme Court, in the State Oil v. Khan case finally decided vertical integration cures itself and usually does not require antitrust judicial action to break it up. That doesn't mean vertical integration is wonderful; it just has to be shown to be bad before you punish it. Unfortunately, high legal fees unbalance the situation. The corporation can usually afford the lawyers, the individual practitioner can't. Threatening to bankrupt the opponent is now a standard procedure in the courts of Justice.
Disregard for the Tenth Amendment in the 1937 Court-packing incident greatly injured the Tenth Amendment's Constitutional requirement that health and health-related activities should be regulated at the state level. But it also heightened public attention on the Constitutional issue, since hospitals, nurses, doctors, pharmacies, and the Blue Cross organizations were all organized along state lines. Only when the Federal government under Harry Truman began to sound serious about central control of medical care, did health insurance begin to cross state lines, and thus weakened hospital and Blue Cross domination of it. By the time Lyndon Johnson began his piecemeal assault in 1965 with Medicare and Medicaid, the insurance industry had broken healthcare into four "markets":
Large-employer groups. The healthiest groups, and hence the cheapest to insure, became the low-hanging fruit. Union pressure combined with the passage of ERISA expanded and somewhat fragmented the groups, but large employers were first and dominant in the planning.
Small-employer groups. Curiously, this often became the most expensive silo of the markets, because of successful pressure to expand -- even mandate -- benefit packages, and the fact that certain expensive cost generators can be selectively insured when the personnel manager knows them by name.
Individuals. Because of adverse self-selection, "non-group" had the highest marketing costs, and often the highest medical costs. It was possible to eliminate the worst abuses, such as figuratively buying insurance while riding to the hospital in an ambulance. But subscribers to non-group insurance move freely between employers and thus can avoid being dropped from the insurance when they change jobs. What is generally touted as a great disadvantage of employer-based insurance, could easily be called the exploitation of being in a position to select only healthy people for jobs. Insurance companies obviously and regularly "prefer to work with groups". Circumvention wears many disguises. When an insurer tells you this is "his company's policy", be sure to kick him in the shins. His company is part of the problem, not part of the solution.
Executive "Cadillac" plans. are mentioned for completeness, although they could also be grouped with steak dinners and baseball tickets, as mere sales promotion kickbacks for the people who make decisions on behalf of members of a large group. They often had "first dollar coverage", essentially paying for everything even faintly describable as medical care, down to the last penny. It should prompt some concern to learn that health insurance for college professors and politicians is often of this variety. In terms of aggregate medical cost, of course, Cadillac plans are negligible. However, as long as they exist, they light the way for those fortunate who can focus on Henry Kaiser gimmicks rather than the treatment of illness and eventually migrate to the rest of the tax-deductible group.
The general purpose of market stratification is to offer much the same product at different prices. Like other concessions which vice makes to virtue, they constrain admiration for the essential, desirable, feature of insurance in the first place: it spreads the risk and lessens the cost of what is supposedly an unpredictable random health catastrophe. If the insurance industry is really serious about this mission, it would start with one outstanding example of it: catastrophic coverage. Remember, the higher the deductible, the lower the premium. Let's repeat that: the higher the deductible, the lower the premium. Are insurance companies really motivated to have lower premiums? That's like saying Insurance Companies want to lower legal costs in order to preserve the impartiality of the courts.
Almost nobody can withstand a million-dollar illness, but almost anybody can afford a hundred dollars a year. Once you have that minimum feature, you can then start to talk about more expensive, more common coverage -- until we eventually reach first-dollar coverage for non-essentials, at wildly unaffordable premiums. By the way, if you would like to know why I didn't acquire catastrophic coverage back in the days when it was widely available, it was because I already had first-dollar coverage given to me by the University where I worked, I couldn't use extra catastrophic coverage even if it was free. This is no longer pre-1965. Everyone should have catastrophic coverage. Only if he can afford it, should anyone have more than that? Since the logic is beyond dispute, has it occurred to anyone to ask why that isn't the usual case? Read on.
A point which cannot be emphasized enough is that a Health Savings Account is just about the best way to invest, if you have given little thought to investing. The deposits are tax-deductible, and the withdrawals are tax-free if they are medical in nature. Even if they aren't medical, they can be anything at all after you reach 66. You probably ought to give a lot of thought and investigation to the particular agent you choose, because they aren't necessarily legal fiduciaries, no matter how friendly they may be. They have no obligation like a doctor or lawyer to put the client's interest ahead of their own, and they can later hire partners you don't care for, so make certain you can terminate the arrangement and switch to someone else without penalty.
Be careful to choose a representative carefully. But whether to choose an HSA, at any age and stage of advancement, always leads to the same answer: Yes, do it. That being the case, a certain number of HSA owners will find themselves with an account they don't know what to do with. There's almost always an exit strategy, although you may need professional advice to judge which one is best for you.
If you started your account near or after retirement, you may have the idea you will never have surplus funds. But if Congress can be persuaded to make it legal, one of your options might be to roll the surplus over to a grandchild or grandchild-like person. If this suits your situation, please notice that a newborn child has some special medical problems. In the first place, the first year of life is unusually expensive; in the aggregate, 3% of all medical expenses are spent on the first year of someone's life. To anticipate a little, 8% of health cost are spent before age 21, which is generally held to be the beginning of the earning period. Children are generally pretty robust, but when a child is sick, he is vulnerable to lasting disabilities of a very expensive sort, so you don't like to see a family cut corners on child care.
But newborns have no earning power, their future is in someone else's hands. The average woman has 2.1 children today, two women thus have 4.2. Four grandparents roughly have one apiece. The way the law of averages is working out, if every grandparent took care of the health costs of one grandchild, things would be close to solved. Things would have to be adjusted for the non-average case, but they would be close to being solved by adding one grandchild's cost to each average Medicare cost for the elderly.
In this case, however, the legal and political problems are greater than the financial ones, so it would suffice for a beginning, just to permit those who want to volunteer, to be permitted to leave unused leftovers in their HSA to children under the age of 21. If there is concern about dynasties and perpetuities, it might be left to the child's HSA, to be exhausted by age 21, or transferred to the HSA of a second child. The sum in question might be around $8000.
The Escrow subaccount within Health Savings Accounts now stands unveiled for what it is -- a transfer system between plans. It pays for health insurance, usually not for current care but designated for underfunded future care. Regular Health insurance sometimes contains similar communication-and -funds transfer channels, but informal ones, patchwork for adding new features to existing ones, as in adding federal funds to state-controlled Medicaid. We here offer the escrowed Health Savings Account as an individually owned policy, specifically incorporating specific finances of a string of pearls to new ones with independent delivery- system regulations. As long as the pearls are careful, they can have a neutral transfer system, like the state-national one for the rest of the economy. Disputes are regulated by the courts under a common Supreme Court. The Court might be a new medical one, or use the one we already have.
This tripartite system not only conforms to the Constitution but restrains mission creep. That's historically why we have a Bill of Rights, although the document doesn't say so.
If the escrow subaccount is purely a transfer system between Pearls on a String, what is the function of the non-escrow portion? It is to permit each Pearl to fund separately and independently, and to make it easier to keep one Pearl from subsidizing another inadvertently. An argument can be made that New York now subsidizes Mississippi within the Federal Reserve monetary system, but that was for facilitating the approval of the various states -- the states which badly wanted a Federal Reserve would be taxed extra to get it -- but it is uncertain whether the same considerations apply to healthcare. The absence of cross-subsidy may be seen as an advantage in Healthcare, and therefore the issue should be decided by Congress. Perhaps decision could be delayed until the public gets a sense of what it wants after some defined period of experience.
When Health Savings Accounts were first discussed, it was assumed they would be funded by employer contributions, so and so many dollars per month or per quarter per employee. Tax deductibility would be decided once, and probably continue indefinitely for a class of employees or a certain type of employer. Actually, that proves to be the most difficult method to determine, because health insurance is given to the employee as a gift, and therefore has already been made tax-exempt. The potential for double tax exemption is raised, and various strategies could be adopted to simplify the tax status.
The double tax exemption might well be re-examined, but much of its unfairness traces to employer's inequitable tax exemption in the first place, which we have repeatedly suggested Congress equalize. It might be compared with using the income from municipal bonds, also tax exempt and tangled up in the minimum tax provision as well. If the amount of questionable deposits is overall fairly small, the matter can be taken up in a general revision of taxation and passed over for the present.
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.