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.
Some things are easier to understand when they start before they get complicated. That's true of banking, where it can now be puzzling to hear there was a strong inclination to forbid banks by law. While we were still a colony, the British discouraged bank formation, fearing strong concentrations of wealth at a great distance could lead to ideas of independence. Anti-bank sentiment was thus a Tory characteristic, although as the Industrial Revolution progressed, Karl Marx and Fredrick Engels stamped it permanently with a proletarian flavor. Large owners of farmland were displeased to see their power weakened by urban concentrations of wealth, while poor recent settlers of America wanted to buy and sell land cheaply, so they favored a currency that steadily declined in value. People with wealth have an incentive to keep money stable, but people with debts have an incentive to pay them off with cheap money. After these battle lines clarified and hardened, the debate has transformed from an original dispute about banks, into catfights about a strong currency. As Rogoff and Reinhart have pointed out, inflation is a way for governments to cheat their citizens, devaluation is a way of cheating foreigners. Naturally, politicians prefer to cheat foreigners, but national tradition curiously seems to favor one style more than another. Essentially, they are the same thing with the same motive, although outcomes may be different. One is restrained by fear of revolution, the other by fear of an international currency war.
Alexander Hamilton
While George Washington was America's first president, Alexander Hamilton was Secretary of the Treasury and Thomas Jefferson was Vice President; the cabinet contained only four members. Although Hamilton was born poor, the bastard brat of a Scottish peddler in the view of John Adams, he had learned about practical finance in a counting-house, and later gained Washington's confidence on the headquarters staff; Washington eventually made him a general. Jefferson was part of the slaveholding Virginia planter elite, elegant in writing style and knowledge of art and architecture, sympathetic to the French Revolution; eventually, he died bankrupt. Early in the Washington presidency, Hamilton produced three long and sophisticated white papers, advocating banks and manufacture. Jefferson was opposed to both, one facilitating the other, which we would today describe as taking a green, or leftish position. Banks were described as instruments for accepting deposits in hard currency, or specie, and lending it out as paper money. The effect of this was a degrading of gold into paper money, or if not, an inflationary doubling of currency. Banks would be able to create money at will, a capriciousness Jefferson felt should be confined to the sovereign government. Just keep this up, and one day some former banker from Goldman Sachs would be able to tell the President of the United States, "The bond market won't let you do that." In this sense, the bank argument became a dispute about public and private power.
Thomas Jefferson
Hamilton, a former clerk of a maritime counting house, could observe that sending paper money on a leaky wooden boat kept the real gold in the counting-house even after the boat was lost at sea. To him, prudent banking transactions enhanced the safety of wealth, reducing risk rather than enlarging it. Later on, he learned from Robert Morris that a bank floating currency values on the private market disciplined the seemingly inevitable tendency of governments to water the currency. Once more, banks should enhance overall safety in spite of being vilified for creating risk. To both Hamilton and Jefferson, all arguments in an opposing direction seemed specious, designed to conceal ulterior motives.
Banks came and went for a century. By the time they almost were a feature of every street corner, banks were taking paper money (instead of gold and silver) as deposits and issuing loans as paper money, too; the gold was kept somewhere else, ultimately in Fort Knox, Kentucky. With experience, deposits could stay with the bank long enough that only a rare run on the bank would require more than 20% of the loans to be supported by physical ownership of gold. By establishing pooling and insurance of various sorts, banks persuaded authorities it was safe enough for them to hold no more than 20% of their loan portfolio in reserves. By this magic, loans at 6% to the customer could now return 30% to the bank. A few loans will default, a reserve for defaults was prudent, so the bank with a 2% default rate could settle for a 20% return rate. A bank which was deemed "too big to permit it to default" was invisibly and costlessly able to trim its reserves, and thus receive a 25% return by relying on the government to bail it out of an occasional bank crisis. With this sort of simple arithmetic, it is easy to see why multi-billion dollar banks were soon arguing that 5:1 leveraging was too small, a reserve of gold and silver was unnecessary, and the efficiencies of large banks were needed to compete with big foreign banks. By the time of the 2007 crash, many banks were leveraged fifty-to-one, which even the man on the street could see was over-reaching. The ideal ratio was uncertain, but 50:1 was certain to collapse, probably starting with the weakest link in the chain.
Alan Greenspan
This brings banking arguments more or less up to date. Except in 1913, an "independent" Federal Reserve Bank was created. It was a private reserve pool balanced by a public partner, the government. In time, the need for gold and silver was eliminated entirely, by the wartime Breton Woods Agreement, and the Nixon termination of it. The predictable inflation which could be expected to result from a world currency without physical backing was prevented by allowing the Federal Reserve to issue, or fail to issue as necessary, the currency in circulation. This substitution was deemed possible by having the Fed monitor inflation, and adjust the flow of currency to maintain a 2% inflation rate. Although 100% paper money was an historic change, it has endured; it has withstood efforts by the politicians to re-define inflation, undermine the indices of its measurement, and brow-beat the vestal virgins appointed to defend the value of the dollar. The old definition of money has changed: it is no longer a store of value, it is only a medium of exchange. The store of value is a nation's total assets. Jubilant politicians have added an additional burden of preventing unemployment, to the original one of defending price stability. In practical terms, the goal is defined as maintaining a 2% inflation rate, while achieving a 6.5% unemployment rate. It remains to be seen whether the two goals can exist at the same time, particularly if the definitions of inflation and unemployment become unrecognizably undermined.
And it even remains to be seen whether the black-box system can be undermined from within. The Federal Reserve is so poorly understood by the public that his enemies now accuse Alan Greenspan of causing the present recession. It is argued that the eighteen years of banking quiet which his chairmanship enjoyed, was only gradual inflation, deeply concealed. It is contended that the unprecedented steady rise of the stock market during those eighteen years was financed by a small but steady loosening of credit by the Federal Reserve. Perhaps what this means is: the definition of inflation must be tightened so its target can be made and adjusted, not to 2%, but to some number slightly less than that, measured to three decimal places. Or that the 6.5% unemployment target must be jettisoned in order to preserve the dollar. With that prospect including international currency wars as its corollary, it will be an interesting debate, and immigration policy is related to it. Because one alternative could become the abandonment of the fight against inflation, in order to sustain the new objective of reducing unemployment, Jefferson would have won the argument.
REFERENCES
The History of the United States: Course 8500, 15 Hamilton's Republic: ISBN: 156585763-1
Recently it was announced that Apple Corp., the largest corporation in the world, enjoys a 50% profit margin. By contrast, an American hospital seldom makes more than a 5% profit, and many lose money. Even at both extremes, individual products have differing ratios of individual prices to individual costs. Only in the aggregate do they produce a company-wide profit of 50% and 5%, respectively. It is on this aggregate profit and loss that the company is judged, its officers promoted, dividends declared for the stockholders, taxes get assessed, and the value of the company measured by the stock market.
A for-profit company is judged by its profitability, and while most hospitals are run as not-for-profit organizations, the accounting convention for nonprofits is to judge "profitability" by the annual increase (or decrease) in its net assets, essentially the same thing as profits and losses. It is not necessary to examine the little quirks introduced by such things as the ownership of fine art. While a not-for-profit corporation is judged by its profitability rather than its profits, that's also really the same thing. It has been said that fewer than a thousand people in America understand nonprofit accounting, and while it is an important subject, it is just not the one we are discussing.
It is also important for even a layman to understand that government accounting while resembling nonprofit accounting, differs in one important feature: departmental accounting regards money from the general taxpayer fund as an asset, not a liability. Therefore, what we would normally regard as a loss for a government department has two components: any reduction in its assets, and any money from general taxpayer funds. The sum of the two is the loss from operations, and in the case of Medicare, it is about $550 billion a year, plus the decline in assets (in the Medicare Reserve Fund) of another $19 billion. Thus, if Medicare were a business, it would be said it lost $569 billion a year, or about half of its expenditures. If a nonprofit hospital were considered with the same numbers, it would be said to have lost $19 billion, because it has no transfers from general tax revenues.
The only present point is that it is difficult to discuss hospital economics in anything but the same aggregate form which is natural to for-profit entities, so you must look to the increase or decrease in its assets instead of profit and loss. If that premise is accepted, it must also be accepted that internal cost-shifting is not merely a permissible but an essential feature of their accounting. There are no dividends to dispose of excess profits; excess profits must be transferred somewhere and justify the costs of something else. Sometimes, just sometimes, a large vaporous cloud called "indirect overhead" floats around justifying expenditures. And weakening price resistance to them, so it's doubly important to concentrate on indirect costs. Triple, because the accountant has very little idea of the relevance of the indirect cost to the main business of the organization, which in this case is medical care. As soon as you start calling it healthcare, its relevance is even more difficult to define.
A large vaporous cloud called "indirect overhead" floats around justifying expenditures. And weakening price resistance to them.
Although a few corporations existed in the Colonial Period, corporations were not considered important enough to be dealt with at the 1787 Constitutional Convention. As the Industrial Revolution proceeded, that indifference was no longer useful, but a special blockade was created by what emerged as the central organizing principle of the new Constitution. That principle of limited federal powers is most clearly stated in the Tenth Amendment, declaring that any power not specifically assigned to the Federal Government belongs to the states and the people themselves. As a practical matter, corporations are created by state legislatures, and the Union would not have been agreed to without that provision. In spite of the current opinions of Justice Ruth Bader Ginsburg, the enduring force of this provision is illustrated by the difficulties the European Union is having over that same issue -- of limited federal sovereignty. It continues to be true that, if the federal union will not agree to limited federal powers, there will be no union. To explain the point, this must continue to be true of any voluntary union of sovereign states which are unequal in size and strength. A peculiarly American twist to this situation is to give corporations a choice of fifty state corporation statutes, and somehow they gravitate to Delaware by choice. It can be argued that a wide choice of governance rules leads to a selection by merit, but the militarily smallest of states does consistently win the prize. Whether that is an oddity or has something to do with it, remains a puzzle.
It is disconcerting to consider that the Affordable Care Act may have upset a minute of healthcare regulations, originally finely balanced on the need to run a hospital with reasonable business latitude. After all, it is impossible to follow society's mission if a hospital cannot itself determine some indirect costs. Once a hospital reaches even moderate size of two hundred beds, almost any product of a hardware store, department store, or supermarket could plausibly be required to run it. Business supplies, school supplies, parking, and building maintenance are required, as are architects, lawyers, and electricians. Once you go down this list, you might constrain approval to buy supplies and equipment that sound as though they belong in a hospital, but one hospital reported its largest single expense was heating oil, closely followed by ice cream. Somehow, every item must be connected in some way to a service which can be charged for, which is an accountant's trick for establishing what is a legitimate expense. Sometimes this is pretty hard to do; a hospital needs a hammer, but how do you assign the cost of the hammer to some item which is legitimately charged for? It soon becomes evident that the assignment of indirect costs is always going to be a little questionable, but always absolutely essential. In the early days of hospital cost accounting, it was reasonable to aggregate the indirect costs of each department and assign them to the direct costs of that department.
From this evolves the concept of a cost-to-charge ratio. Reasonable uniformity in the ratio of charges to costs within departments, or between various departments, assures that cross-subsidy between insurance companies and patient classes is fairly uniform. Without that check, complaints between competitors would be immediate. Essentially, this sort of system depends on equal justice being applied, at least in a general sense. When equal justice is impossible, the accounting department can only rely on intuition and overall balance. Outside regulatory agencies can compare the cost/charge ratio in one hospital's operating room with that of some comparable institution. The first step in such comparisons is to compare the institution-wide ratio with its peer group. If that doesn't produce a reasonable result, the analysis can go down to individual departments to individual tests and procedures, until the source of a wide discrepancy can be isolated. At that point, questions can be asked, and a reasonable conclusion reached. But that was forty years ago. When charges are submitted for an electrocardiogram totaling several hundred dollars, and drugs at several times the retail price in a neighboring pharmacy, this sort of analysis is fruitless because it leads to ridiculous results. It is time to agree that a reasonable pattern of only direct costs can be typically and quickly laid out. On the whole, it can be judged that it is indirect costs which become very hard to follow by the usual step-down process. Therefore, it seems reasonable to pass over direct costs quickly, and go straight to the indirect costs, judging them on their separate merits. Apparently, It really does not matter what charge they have been assigned to; what matters is whether they are legitimate. Outliers can be dealt with individually. What is important is for community representatives to assess, is whether the bulk of general overhead costs can be justified for a community, whether the bulk of CEO salaries suits community expectations, or whether landscaping costs unsettle community opinion.
The main reason for having health insurance is to protect yourself from being fleeced.
Jonathan E. Rhoads, M.D.
This all sounds pretty dry and boring, so let's look at something more exciting. Let's notice that in Medicare's own analysis, the ratio of average charges to average audited costs, or the hundred commonest diagnostic groups, in every section of every region, is four hundred percent greater than the audited cost. In plainer language, the charge reported and billed is 400% greater than the cost, which would be eight times the profit margin of Apple, Inc. if it were paid. It's not paid, but the mystery continues as to why hospitals keep on billing for so much more than they know Medicare will pay. The comparatively small variation in this markup suggests there is a reason unrelated to unreimbursed care since the variation in bad debts is likely to be much greater between hospitals. But the sad consequence is that the poorest people in the country, those without health insurance, get billed -- and vigorously dunned -- for amounts they of all people cannot afford. Another viewpoint was offered by an elderly surgeon, after whom an entire hospital pavilion has been named, that "The main reason to have health insurance is to protect yourself against being fleeced."
Unfortunately, it is just this sort of needed commentary which is most questionable on a constitutional or political science level. It is not at all certain that consumer groups or third-party insurance groups have a right to be dictating salary levels, or whether an institution needs a new HVAC system. It is far from clear that a government of limited federal powers has any right at all to be dictating local hospital indirect expenditures. When Medicare was only one of several dominant payers in a hospital, they did acquire a sort of legitimacy when they insisted on equal treatment with other payers. Now that Federal Laws of uncertain shape, mandate universal coverage of uncertain form, it becomes legitimate to ask whether the format of filling in the coverage gaps can stretch the Constitution into assuming the total administrative control which the Constitution seems to prohibit. As these new regulations get actual implementation, more and more people will acquire "standing" by sustaining a provable personal injury. It remains to be seen, where that will lead.
In a new system involving three hundred million personal situations, some difficulties take time to come to the surface. Other crises can be anticipated in advance. It's like the Salvation Army or the Red Cross: mostly, you get an appeal for donations just before Christmas, but sometimes there's an emergency that comes unexpectedly. Three months before implementation, Obamacare's first crisis seemed somehow steered at small business, since compulsory health insurance for big business was postponed for a year, whereas individuals and small groups were relentlessly ordered to implement on time. Which was it? A rebellion by big business to be pacified, a rebelliousness by small business to be whipped into submission, or a need to have the two separated in time? In 2013 there are only two important elections, for Governor in New Jersey and Virginia, whereas 2014 will have many elections. An administration which seemingly puts politics ahead of every other consideration, undoubtedly takes the calendar into account. The thought suddenly occurs: is this what we can expect in constant succession for the next three years? Are tidbits of information to be timed with current events, while the great mass of information is withheld about the true scope and direction of some new proposal? Even worse, is health insurance regulation to be played off against a similar game in financial regulation, using the issue of Dodd-Frank regulations as a foil? By the way, what happens to our national attention when Syria, China, North Korea or Iran act up? And finally where do we go if the bond market gets fed up with its tormentors, and runs away with interest rates? To be sure, politics ain't beanbag, but does it have to be played like a children's game?
Community rating is a term of art for everybody to pay the same premium, regardless of previous health status. People in bad health get a big bargain, people in good health pay more than their share, and squashing it all together leads to a community rate. Not for everybody in the community, but for every member of an employer group, working for the same company or bargaining unit. By definition, these are healthier people because they were selected for it when they were hired, and for the most part they remained healthier than average just because they were able to work. Inevitably, industries with many women employees had more pregnancies, heavy industry had more accidents than white collar businesses, so community rating worked best in large corporations, while small businesses knew their employees personally and could manipulate the policy benefits to get the best rates for a small minority. Stated broadly, big white collar businesses got the cheapest community rates, heavy industry got higher rates, small businesses got still higher rates, and individual policies had the very highest community rates. When you squash a lot of communities together you might get a real community rate, but competition between insurers soon forced a graded outcome. The Affordable Care Act anticipated that it might at least achieve regional community rates, and still be able to absorb the differences caused by pre-existing condition exclusions, age and gender rate differences, and other purely insurance responses to public demand for truly uniform rates. Actuaries have computers and lots of data at their disposal, so presumably they advised the politicians it was possible to design a system with close-enough-to uniform premiums that any remaining flaws would be excused at the next election. The arithmetic is not so hard, it is the assumptions you have to make.
Whether you are an actuary or a politician, you have to make the assumption that the people who must pay more, will be willing to pay enough more. For that calculation, certain benchmarks are available. There are 42 states which require that the premiums for the subscribers who pay the most, may not exceed five times the premium paid by subscribers who pay the least. State insurance commissioners are charged with protecting the public against insurer bankruptcies, and apparently it is the collective judgment of such officers that companies which allow much greater premium disparities are in risk of consumer rebellion, potentially leading to collapse of the insurance system even for those who are willing to pay more than a 500% premium for it. The term in common use is "unsustainable". Perhaps the nation is fortunate to have had the example of a state which actually attempted to run a system of absolute community premiums.
New York, New York The Mario Cuomo administration of New York attempted such a system in 1992. Premiums rose by more than 30% the first year, enrollment fell by 38% in three years, and among individual subscribers the number fell from 1.2 million to 31,000. For some types of policies, every single insurer in the state abandoned the business.
To return to the present situation, it would appear that individual and small group subscribers were facing premiums much higher than they were willing to pay, and alarming numbers of them indicated they would rather pay the fine than accept the overcharge. At present, these people are being told to take it or leave it, presumably counting on political sympathy plus subsidies to hold them there. They would have to wait at least a year, and very likely longer, to be able to compare their "community rate" with the "community rate" for big business. Even then, there is considerable possibility for creative accounting measures to obscure a fair comparison.
In addition, there is the possibility of U.S. Supreme Court action, questioning the right of the Executive Branch to change a law signed by the Legislative Branch. Even beyond that point, there is a question of equal justice under the law for doing so. In view of the likelihood that it is far easier to implement a few large groups than many small ones, the reasons given for partial postponement seem to require considerable argument to be convincing. The number of instances in which a Constitutional challenge to some feature of the Affordable Care Act is possible, seems to grow regularly. The Court won't hear a case until someone files it, so the Judicial option appears to lie with the opposition.
In recent years, Congress has taken to producing laws of great complexity, sometimes thousands of pages long. This is particularly notable in the Obama administration but can be viewed as a non-partisan tendency throughout the Twentieth century, starting with Teddy Roosevelt and Woodrow Wilson. As part of the phenomenon, the workload of Congress has increased to the point where the Legislative branch is particularly weakened by its traditional procedures. The Executive branch has responded greatly enlarging itself, able to create most of the Law through regulation after the law is passed; and the Legislative branch reacts by creating excessive detail in later laws. This recipe for self-defeat has come to be called "micromanagement" by business theorists, who tend to view "command and control" as a solution. As long as the Constitution stands, that approach will not be allowed to work. It is not the purpose of this book to redesign government, or even to discuss it in detail. However, it is wise to remember that even good proposals are undermined by the change of circumstance. Unwisely freezing details when not truly necessary could defeat the main goal, which is to pay a large share of health costs with compound investment income.
The main goal is to pay a large share of health costs with compound investment income.
The main concern is this: our present or future systems of managing the currency may not permit compound interest to compound faster than inflation. That can't be blamed on the Health Care system, but it would certainly injure health care. At the present moment, long-term U.S. Treasury bonds pay 2%, but inflation reduces the value of the bond by more than that, perhaps 3%. Income tax reduces the value by perhaps 0.5%. The graduated income tax already makes it useless for the top quarter of the population to buy Treasury bonds, to say nothing of the top 1% of the population. Whatever the outlook for bonds, insurance companies must keep a large bond portfolio to pay claims. Whatever the outlook for stocks, a large stock portfolio is necessary to stay ahead of inflation. The public must not force its managers to ignore these rules in order to match the investment results of others.
Congress has responded to unrelated pressures by trying to collect the same taxes from a loophole-less tax code, primarily for the purpose of lowering the rates on the top bracket. Whatever the outcome of this struggle, it dramatizes that the usefulness of investing in bonds can readily be destroyed by modifying the tax code, by the stroke of a pen, as it were. You certainly would not want your lifetime health insurance to be risked by that sort of thing happening, sometime in the next eighty years, so you do not want the government to be too tightly in control of your investment portfolio. You may love your government, but its agenda is not necessarily in harmony with that of an insurance company.
Legislative extremes probably won't happen, because of the historic sensitivity of Americans to taxation. But inflation could be equally destructive, and control of that lies in the hands of an un-elected committee at the Federal Reserve. Much of this power was unintended, created by going off the gold standard, and then replacing it with the power of the Federal Reserve to issue (or, not issue) vast amounts of currency in response to "targeting" inflation at 2%. Since a casual observer has trouble seeing much of a match between 2% and the actual amount of currency issued, the Federal Reserve Chairman has been given wide latitude in adjusting interest rates for his own purposes. The outcome for present purposes is that a fifty-year history of this system would have allowed the following statement: "You could withdraw 4% a year from an investment fund, indefinitely, and still have the same amount remaining in the fund." In the past year, however, the following analysis emerged from David C. Patterson, the CEO of a very large investment fund: "A draw of 3% a year at any time since 1926 would only have resulted in a steady purchasing power 60% of the time." Whether this attack on a fundamental investing maxim was caused by inflation, going off the gold standard, or the actions of the Federal Reserve, it is a lesson that interest rates cannot be predicted eighty years in advance, within the boundaries of what experienced financiers considered safe enough to depend on.
The Bottom Line. The life insurance industry faces exactly the same problem, and if the life insurance industry has a solution, it hasn't made it public. What the life insurance industry surely has, is lobbyists. The solution they would devise doesn't necessarily address someone else's problem, but health insurance for the last year of life comes pretty close to what they do for funeral cost protection, so one could be confident they would be allies in any congressional manipulation of income tax upper brackets, to the disadvantage of investment funds. And the same thing could be said of the financial community. And the banking community, so one could be reasonably confident there would be plenty of allies against any overt congressional assault. That does leave the loopholes created in any plan by the unintended consequences of some other plan.
All in all, it seems the best strategy to begin with an investment fund which has already been authorized and given a tax exemption: the Health Savings Account. Put as much as you can in one and let it grow. Spend it for some health expenditure if you must, but anyone who puts in two thousand dollars at the birth of a grandchild is probably going to be glad he did, even though it might be left undeclared just how it would later be spent or disposed of. Walk a couple of blocks and open a debit card for the fund, and walk a few more blocks to a broker who can sell you a high-deductible health policy. Link these three features together when, and only when, some changed circumstances make it useful to link them in a single integrated system. If this direst of dire circumstances never comes about, you are no worse for leaving them independent. But if something bad does come about, you may possibly be motivated to change the basic arrangement, or even dissolve it and take your money out of it. Under really dire circumstances, your own ability to judge what is sensible is probably the best protection you can reserve for what is, at the best, a very dangerous world we live in. For far distant planning, it is necessary to rely on our form of government to produce leadership which can handle the problems.
The first obstacle for a lawsuit to jump is the right to use the courts. Although failure to demonstrate injury is one of the commonest ways to clear a court's calendar, insisting that the lawsuit must have some utility has become the very foundation for an impartial body of government to be free to settle disputes between citizens. There are other mechanisms, particularly the Courts of Equity of the young Republic, when there were many occasions when something was obviously wrong, but no statute covered the situation. By the Civil War, the Legislative Branch had more than supplied any deficiency of statute. The State of Delaware now has the only surviving Court of Equity, and "standing" now protects the courts from floods of useless lawsuits. However, that leads to the present Court System sometimes blocking a lawsuit, simply because the cause of the complaint is too broad, and requires special strategies to proceed. At the least, it requires a description of how an entire profession has been barred from its customary role, by an accident within the Judicial System.
History of the Matter. In the District Court of Maricopa County, the State of Arizona successfully sued the Maricopa Medical Society as antitrust for its prohibition from Medical Society Membership, any member who charged an indigent patient substantially greater than a fee published by The Society. This action was described as a per se violation of federal antitrust law, and without any trial of the facts was appealed successively to the U.S. Supreme Court. Two Arizona Justices recused themselves, and again without trial of the original summary judgment, was upheld by a 4-3 decision which still stands as National Law.
Subsequent Consequences. In Medical Circles, the Maricopa case is described as "dethronement of the doctors from control of the medical system" and "their replacement by non-physicians". For example, in 1948 the Nation's First Hospital (The Pennsylvania Hospital in Philadelphia) had two administrators, the Administrator and his secretary. Today, the same building which housed 200 patients in 1948 is entirely filled with puzzled administrators. The transition from physician control to something more legal has required insurance redesign which is still an expensive mess. After fifty years of trying, the pharmacy system is still cumbersome, the nursing schools have been upended, and the greatly enlarged billing system is still undecipherable. Meanwhile, physicians are quitting in their fifties because of the welter of unnecessary paperwork which keeps them from doing what they were trained to do, an occasional old nurse still defiantly wears a nursing cap, while cafeteria workers fumble at new-fangled uniforms. Everything has been unnecessarily changed, concealing the fact that it did not need to be changed. Meanwhile, those who took these supervisions in their stride are retiring early. Doctors used to marry their nurses; you now seldom hear of that. Salaries, which used to be zero, are now in six figures. Everybody complains; no one does what he was trained to do, especially the trustees. It once was the function of trustees to oversee funding requests of the doctors and get the money when needed; nowadays they rubberstamp the plans of administrators. There are simply hundreds of computers; no one reads their output. The disappearance of thirty common diseases (tuberculosis, syphilis, polio, rheumatic fever, etc.) is what keeps the system from collapsing. I received a salary of zero for four years, my grandson makes $53,000 a year of what is surely government money for much less medical work, much more red tape. If you don't believe these tales, I will be happy to call these people as witnesses. No doubt, witnesses for the other side will be happy to testify as well, and you can decide for yourself.
Repairing the damage. It took two thousand years to design the old system, but only fifty years to bring many hospitals to mergers, two medical schools to near collapse in Philadelphia alone. The Rs are fighting with the Ds over God knows what. All this mess cannot be repaired quickly, but it wouldn't hurt to get started. The Health Savings Account would be a better place to begin. Since remanding Maricopa for full trial would only be a beginning without much repair, it's little enough to ask as a beginning. The goal, well beyond my own sunset, would be to put the doctors back in charge and then waiting for fifty years. At least, stop getting in their road, since it is only fifty years since they stopped being the most admired profession on earth.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
