The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
... William Penn's Quaker Colonies
plus medicine, economics and politics ... nearly 4,000 articles in all
Philadelphia Reflections now has a companion tour book! Buy it on Amazon
Philadelphia Revelations
Try the search box to the left if you don't see what you're looking for on this page.
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.
Recently, Jason Duckworth of Arcadia Land Company entertained the Right Angle Club with a description of his business. Most people who build a house engage an architect and builder, never giving a thought to who might have designed the streets, laid the sewers, strung out the power and telephone lines, arranged the zoning and otherwise designed the town their house is in. But evidently it is a very common practice for a different sort of builder to do that sort of wholesale infrastructure work -- privatizing municipal government, so to speak. A great deal of what such a wholesale builder does involves wrestling with existing local government in one way or another, getting permits and all that. In a sense, the existing power structure is giving away some of its authority and does so very cautiously. Sometimes that involves suing somebody or getting sued by somebody. Perhaps even greater braking-power on unwelcome change is that the wholesale builder is in debt until the last few plots are sold, and realizes his profit on stragglers. Since it often happens that the last few plots are the least desirable ones, this is a risky business. Big risks must be balanced by big profit potential, and one of the risks of this sort of privatization is that too much consideration may be given to the players at the front end, the farmer who sells the land and the builder who must keep costs down, at the expense of the long-range interests of the people who eventually live in the new town. Top-down decision making is much more efficient, but its price is decreased responsiveness to citizen preferences.
For Sale
As it happens, Arcadia specializes in towns designed to look like those built in the late 19th Century. Close together, a front door near the sidewalks, front porches for summer evenings. To enhance the feeling of being in an older village, Arcadia specifies certain rules for the architecture, to make it seem like Narberth or, well, Haddonfield. Until recently, suburban design emphasized larger plots of land, and few sidewalks, with streets often ending in cul-de-sacs instead of perpendicular cross-streets in the form of squares. The "new urbanism" appealed to those who were seeking greater privacy, revolving around the idea that if you wanted anything you drove your car to get it. Three-car garages were common, groceries came from distant shopping centers. There are still plenty of new towns built like that today, but Arcadia appeals to those who want to be close to their neighbors, want to meet them at the local small stores scattered among the houses. In the 19th Century, this sort of town design was oriented around a factory or market-place; since now there are seldom factories to orient around, the appeal is to two-income families who want to live in an environment of similar-minded contemporaries. The whole community is much more pedestrian-oriented, much less attached to multiple automobiles.
Since Mr. Duckworth mentioned Haddonfield, where I live, I have to comment that the success of living in a town with older houses depends a great deal on the existence of a willing, capable yeomanry. Older houses, constantly at risk of needing emergency maintenance, need available plumbers, roofers, carpenters, and handy-men of all sorts. Because it is hard to tell a good one from a bad one until too late, this yeomanry has to be linked together invisibly in a network of pride in the quality of each other's work and willingness to refer customers within a network that sustains that pride. A tradesman who is a newcomer to the community has to prove himself, first to his customers, and almost more importantly to his fellow tradesmen. If you happen to pick a bad one, good workmen in other trades are apt to seem mysteriously reluctant to deal with you as a customer, because you too are somewhat on trial. Maybe you don't pay your bills, or maybe you are picky and quarrelsome. In this way, the whole community is linked together in a hidden community of trust. Over time, the whole town develops certain recognizable social characteristics that a brand-new town doesn't yet need. If that time arrives without a network of reliable tradesmen, the town soon deteriorates, house prices fall, people move away.
Fannie Mae
It's curious that the residents of such a town are a breed apart from the merchants in the nearby merchant strip. If the merchants of town life in that same town, there is much less conflict. More commonly, however, the merchants rent their commercial space and commute from distant places. That disenfranchises them from voting on school taxes and local ordinances and creates a merchantile mentality as contrasted with a resident community, dominated by high school students. One group wants lower taxes, the other group wants to get their kids into Harvard. One group wants space for customer parking, the other group is opposed to asphalt lots. And in particular, the residents want to avoid garish storefronts and abandoned strip malls. Since the only group which has an influence on both sides of this friction are the local real estate agents and landlords, their behavior is critical to the image of the town. When real estate interests are not residents of the town it is ominous, and they are well advised to remember that the sellers of houses are the ones who choose a real estate agent for a house turn-over. There's more to this dynamic than just that, but it's a good place to begin your analysis. Suburban real estate interests are constantly tempted to get into local politics, but politicians are the umpires in this game, and it soon becomes bad for their business if real estate agents potentially put their thumb on the scales.
FHA Seal
All politics is local, but all real estate is not entirely local. The present intrusion of the Federal Government into what is normally a purely local issue has become more pointed in the present real estate recession. Almost all mortgages are packaged and sensitized by "Fannie Mae and Freddy Mac". By overpaying for the mortgages they package, these two federal agencies are subsidizing the banks they buy the mortgages from. Or, that is half of the subsidy. The other half is the Federal Reserve, which presently lends money to banks at essentially zero interest. Acquiring free money from the "Fed", while selling mortgages to Fannie Mae at above-market rates, the federal government supports the banks at both ends. And that's not quite all; there is something called the FHA, Federal Housing Authority, which guarantees mortgages. Essentially an insurance policy, the FHA guarantee is issued for a cost to home buyers who meet standards set by Congress (for which, read Barney Frank and Chris Dodd). Although houses during the boom were selling for 18 times the estimated rental value, they are now selling for 15 times rental. FHA will insure such risks, but the banks won't lend more than the normal proportion, which is 12 times rental. Consequently, almost all mortgages are FHA insured, while the federal administration storms with a fury that the banks "won't lend". And indeed it begins to look as though banks will never issue uninsured mortgages until home prices fall another 25%. If home real estate prices do decline to a normal 12 times rental, a lot of people (i.e. voters) will be unhappy, and not just homeowners who bought at higher prices. The market is fairly screaming that you should sell your house and rent, but so far at least, these federal subsidies seem to be holding prices up. When normal pricing arrives, the recession is just about over, but it certainly won't feel that way if you are a seller.
An entirely new concept like reconstructing health insurance on the "whole life" model can be expected to provoke concerns. Here are a few of what surely is not yet a complete list:
Inflation. It is true that rampant inflation would be injurious to the whole idea of permanent health insurance. However, it is the job of the Federal Reserve to maintain price stability, and many changes have taken place in the Federal Reserve's methods of operation since 1913. The most notable one was the abandonment of the gold standard by President Nixon in 1972 as a late consequence of flaws first introduced at the Breton Woods Conference in 1945. Observers may be of the opinion that the gold standard was stronger protection against inflation than the present inflation-targeting one, but the latter is nevertheless the system under which we operate. It should be recalled that in 1945, America had two-thirds of all the gold in the world, and international trade was being stifled by the unbalanced distribution of any common means of exchange. The correction of this gold maldistribution finally came to an end when a correction was no longer necessary, and indeed in 1972, it was possible to foresee an American gold shortage if trends continued. The American currency is no longer supported by a link to gold or any other commodity. In its place, the Federal Reserve issues or withdraws currency from circulation in response to inflation, attempting to maintain a steady inflation rate of 2% to match the growth of the economy. There are disputes about exactly which inflation rate would be ideal, but the ability of the Federal Reserve to maintain its stated targets has been reassuring. While there is room for argument among economists about the precisely optimum inflation target, the variation has been less than 1/2 %, even in times of economic disorder as severe at the present one. The projected finances of funded health insurance can safely sustain much greater miscalculation than this. If a threat is present, it comes from other directions.
Inflation
The suggested choice of an index fund composed of the entire list of domestic American common stocks was intentional and may be vital. The Affordable Care Act's provision for mandatory universal coverage makes it official that the full faith and credit of the American taxpayer stands behind the funding, so the American stock market is a close surrogate of that pledge. Anything which could destroy the stock market would constitute a threat to America much greater than a collapse of its health insurance, and enormous efforts would surely be invoked to prevent such a disaster. The wisdom of ransoming the whole economy to a comparatively small component of itself can be questioned, but it is nonetheless difficult to imagine a default when such heavier consequences would follow it. The same can be said of a permanent stock market decline, a devaluation of the currency, or a bond market default. These things can happen, but injuring health financing would scarcely enter the discussion.
The Changing Mix of Disease. Most of the rest of the world still concentrates its medical attention on the treatment of contagious diseases. In America, contagious disease scarcely makes the top ten concerns. No one would have predicted this a century ago, and no one can predict the mix of diseases, or their cost, a century from now. We do know that people will continue to be born and invariably to die, but we do not know what will kill them or what it will cost. It is even possible that an epidemic will unexpectedly sweep the globe, or an asteroid will hit the earth, but in general, big changes occur over more than a decade and give some time for readjustment. We tend to feel confident that our longevity will continue to lengthen, although in Russia it has lately shortened. Generally, new treatments have patent and development costs at first, and then become cheaper. But even healthcare workers enjoy raising their own salaries. It is difficult to predict population costs for healthcare eighty years from now, or whether they will be distributed evenly throughout the population. Unfortunately, this uncertainty will bedevil any system of financing that can likely be devised, but that does not mean reimbursement systems cannot be designed to cope with it.
Therefore, it is essential that any long-term plan, not just this one, build an accordion system into its initial design, and assign the task of watching over this problem to a permanent oversight body, particularly one which is able to resist the general economic pressures bearing down on the Federal Reserve. Inevitably, there will be times when the two bodies are adversaries. The easiest approach is, to begin with, the first and last years of life as anchors, and extend the reimbursement to intervening years as needs can be projected. This is one of several reasons why it is advisable to anticipate two parallel systems, one paying the bills as they appear and raising premiums if need be, while the other reimburses the first one as its fund permit. If a cure for cancer or Alzheimer's disease should appear, there might be funds to reimburse the other system for eight, ten or more years, readjusting premiums as it goes. If those miracle cures prove to be astonishingly expensive, the accordion would contract the other way, or its premiums would readjust in the other direction. Let us be clear what we are attempting: to reduce the annual premium of health insurance for the working years of life as much as we can. We must resign ourselves to remaining uncertain how much the premium can be reduced in the far future. No one spends public money as carefully as he spends his own. Complexity is therefore useful in areas where moral hazard is an important issue. Otherwise, grown-ups will behave like children at someone else's picnic.
Fluctuating Interest Rates.
At the time of this writing, the Federal Reserve has forced American short-term interest rates almost to zero, and held them there for three years. Japan did the same thing two decades ago, and they have had the unprecedented experience of remaining near zero for nearly twenty years, held there against the will of the Ministry of Finance by what is known as a "liquidity trap". Meanwhile, by the Fed buying long-term bonds in what it calls QE3, long-term interest rates have been forced in the opposite direction to a higher level than normal by the Federal Reserve. It is not necessary to explain here how this was accomplished, or why.
What it is important to see is that the value of bonds, both short and long-term, can be manipulated by the Federal Reserve at the will of the Chairman or at most a handful of committee members. Therefore, predicting future prices or rates is nearly futile for everyone else, and investing in bonds is much riskier than it seems. However, there are economic consequences to interfering with markets, so over long periods of time, there are limits to what the Federal Reserve can do without destroying the economy. In a sense, this is one of the prices we pay for controlling inflation by inflation-targeting. There are boundaries within which the Federal Reserve can operate, and eventually, interest rates will revert to their long-term averages. In the very long run things will average out, and in the present context, we are imagining investment horizons of eighty or more years. This is why insurance companies can buy bonds with serenity, and just wait long enough for interest rates to normalize. But there must be an organization with some feature of immortality to intervene if the counterparty (The Federal Open Market Committee) is immortal and has unlimited funds at its disposal.
However, the Federal Reserve is not independent, no matter how hard we try to make it so. We are here discussing money which belongs to individuals who can vote, and who will surely be concerned about the investment policies of 17% of the Gross Domestic Product. The Federal Reserve can thus be easily imagined to develop an occasional severe conflict of interest between what is good for healthcare financing and what is good for the economy as a whole. The pressures which the public might decide to exert are not predictable, except that they would be hard to resist. The public has long proven itself to be a poor investor, buying high and selling low, even when it knows better. It almost seems better to avoid bonds in the portfolio of investments entirely rather than take the political risks, until it is recognized that this fund would soon develop the need to pay its claims every year, even if the stock market is at a low or stock dividends are zero. Therefore, it becomes clear enough that when bonds start paying 4% or more, the fund ought to buy some of them and hold them to maturity, just as life insurance companies do. Perhaps it becomes clearer why insurance companies hold a portfolio of 60% stocks and 40% bonds, but it is not exactly clear what to do when a fund of this size proposes to start when interest rates are at their present extreme. This sort of technical issue just has to be left to bond market professionals, since it involves short selling and other arcane issues that the public ought to know enough to stay away from.
The Investment Fund Becomes a Gorilla. Any insurance company must segregate a claims reserve fund, to assure it always has money available to pay its claims. In the system we envision here, the potential claims are too far in the future to be confident how much they will eventually become for a newborn baby, etc., but for the cohort just beginning that last year of life, the average cost of the previous year's Medicare claims will be abundantly clear in Baltimore, where they keep such records; it will probably be close to 20% of Medicare's budget. It certainly will be clear contributions to the pool of Health Savings Accounts cannot possibly match the claim cost of the first year in operation, and should try to do no more than reducing the initial end-of-life claims by whatever is available.
Adverse selection of beneficiary composition. Since the actual beneficiary would be the Medicare Trust Fund (and not the subscribers, who would then be dead) the impact of the news of this program would focus on the reduced Medicare premiums for younger subscribers. Medicare premiums would be reduced by no more than 20%, which would nevertheless probably be greeted as a windfall. The true beneficiaries would mainly be successor cohorts already in retirement, although paying off some of the Medicare debts dating back to 1965 would be a splendid idea. The fund will gradually level out, but it will likely take at least ten years to do so. Social Security and Medicare had the same problem at the time of their beginnings and elected merely to borrow the money, essentially never repaying it to the "pay as you go" system.
Eventually, Medicare will be put to the expense of developing premium billing systems of some complexity. At least, this new system has a source of revenue in the investment of its cash accumulations, with an estimated time of twenty years for it to catch up with itself. Much would depend on the medical costs of the twenty years prior to the individual last year of life; at the moment, they are might even be sufficiently lower to make this approach workable. But if some new treatments, for cancer let us say, are more expensive than the years they would add to longevity, this mixed blessing would have to be treated as an independent problem. Other solutions are available; the ability of the government to borrow at lower than prevailing rates are based on the assumption that it is a sovereign debtor. While this advantage is not guaranteed, it does exist and probably would be difficult to change. Furthermore, whether pre-funding would initially appeal more to younger or older people is hard to predict, calculating the potential source of revenue or losses from various mixtures would have to account for any difference in costs among various ages. Creating enrollment quotas for various ages in the early years of an accordion expansion might be workable.
And then, there are some macroeconomic perplexities. As mutual fund and index fund usage expand, fewer stockholders vote their proxies; the present proposal would make this problem worse so there would be even less resistance to lavish management salaries. The influence of family controlled stock within the portfolio, and of hedge-fund control would increase; possibly, foreign control would be easier. While true enough, these issues are not for this paper to deal with, only to mention.
The success of a pre-funded program would probably be judged by the extent of voluntary acceptance of it, and success would mean the endowment fund grows to be vast and well-distributed. Success would entail huge sums of money, potentially disruptive of the existing financial system. At peak capacity, the financial markets would have to absorb weekly inflows of about 1/4% of GNP, and eventually liquidations of double that size. Success might also entail a significant shrinkage of our oversized medical complex. Background churnings of that size would soon underlie every calculation in the markets, with uncertain consequences for what would probably be a steadily growing world financial marketplace, perhaps a disruptively international one. Not everything can be predicted so far in advance, but it is safe to say it would be tested for flaws until the markets conclude it is flawless, a very long time indeed. Such a Leviathan cannot be set on automatic pilot, but neither dare it relies on having the wisdom to make unblemished mid-course corrections. There are risks in attempting a middle approach, which must just be accepted as being less than the potential rewards of taking the risk.
The purpose of healthcare financing is to redistribute the pain of paying for it. Otherwise, the patient doesn't want to be sick or die; illness itself is a disincentive to abuse. The concern about abuse mainly arises when someone else pays for it. The indigent patient doesn't want to be sick, either, but somehow that's different. Not only does the public resent the cost, but the public also resents the need for the cost, as well.
Two of the central figures in devising Obamacare -- supposedly free healthcare for everyone -- have framed the issue as to whether it is better to die in America or somewhere else. Just about no one wants to die anywhere, at any time I notice. The mortality figures are too fuzzy to judge whether the extra cost is worth the money, but essentially there isn't enough provable difference among developed nations to assert most care lengthens the lifespan of the patients. Especially for cancer patients. Apparently, the diffusion speed of new knowledge makes it impossible to tell how much it helped. Or else the amount of new knowledge isn't sufficient to show up in such crude data. By that standard, medical care is just as "good", one place or another, one insurance system or another. It just costs more, that's all. When some research laboratory finds a cure for cancer, health care still won't seem to have proved it helped.
But life expectancy will increase; in the long run, costs will come down. It can be very confidently assumed that those who invest their savings early in life will enjoy a more prosperous retirement than those who depend on entitlements.
A central feature of compound interest is the quirk that the longer you invest, the higher the interest rate becomes. That's not going to change, no matter who votes against it. What did change, after thousands of years of staying the same, was longevity. The Biblical guess for potential longevity was three score and ten, but most people died in their twenties and thirties, far from the theoretical longevity of the human condition. By the year 1900, actual longevity was 47 years, and three-score and ten still seemed about right. But today longevity at birth is thought to be around 82, and what with heart transplants and all, it may level off at 90 in a few decades. The Sunday supplements are already speculating the average person may someday reach the age of 110, or more.
It's probable that civilization developed a number of conventions to adjust to shorter longevity, based on the notion that if things don't change for a century, we can make do with short-term expedients for national currencies, life insurance, mortgages and similar long-term arrangements. Stories are told of Bismarck, or was it Franklin Roosevelt, who based retirement schemes on the assumption most people would be dead at the age of 65 or 67, so there would be plenty of money to pay their pensions. But insurance companies gradually learned how to get rich on premiums based on old assumptions, but pay-outs based on a longer reality. Other long-term financiers played the same game, and governments switched from a gold standard to inflation-targeting. A fixed amount of gold drives prices steadily downward in an expanding economy; a floating currency gradually floats prices upward, but creates innumerable adjustment headaches. With periodic crashes, we manage. The present book proposes we use the quirk of rising interest rates in compound interest as a way to cope with unstable currencies, but it's only an expedient, and it may not last forever.
At the moment, it looks as though longevity will level off at around age 90, but that projects a progressively longer retirement vacation to pay for. For the time being, we appear to be leveling off at equal thirds, childhood and education until 30, earning from 30 to 60, and retiring from 60 to 90. That's pushing things a bit; no one can be sure a third of the population can, or will, support the other two thirds. It's particularly dubious when you consider about 30 million people in America will always have some degree of dependence. That's roughly seven million incarcerated in jail, eight million handicapped, and 11 million illegal immigrants. Going to work at age 25 and retiring at age 75 would provide much safer numbers, particularly if 5% of the population is normally between jobs in a mobile society, and we propose to spend 18% of national income (GDP) on healthcare for the rest. Americans like to grumble a lot, but compare how much better off we are, than the other four fifths of the world, living on something approaching a dollar a day. We like to think it is possible to get rich without making anyone else poor, but the rest of the world has been taught to make money by taking it from someone else.
So, without further illustration, Americans should adjust themselves to a century of working longer and harder, perhaps age 25 to 75, recognizing the rest of the world will out-vote us if they can, and trusting in our own resources whenever there is a choice. That's the reality underlying a preference for individual savings accounts, it really isn't safe to trust the currency forever because even our leadership occasionally disappoints us for whatever motive. And it's the reality of extending the working years, even if income falls, because the longer you are self-supporting, the shorter the time you must depend on others. And there's one other simple peasant teaching: start saving as young as you can, on the day of your birth if your family is organized that way. It was pretty useless when people lived to be 40, because compound interest scarcely had time to begin work. But the rule of thumb is that money at 7% interest doubles in ten years. If you live to be 90, that could be nine doublings (2,4,8,16,32,64,128,256,and 512) or five hundred dollars per dollar. Since you only need a trustworthy custodian to do it, it is probably the basic unit of currency, slowly changing over time. But you don't need to take it so literally, understanding the principle is more important.
The rule for health insurance (which is what we are mainly describing)is to organize the insurance to begin saving as young as possible, and to spend the money as late as possible. Health insurance is one big transfer mechanism. You earn money from 30 to 60 and you spend it from 0 to 90, but you spend the greatest amount in the first year of life and the last four years of life. Therefore, it is poor design to assign the cost of childbirth to age 30, it's mostly borrowed money, and it's spent the day you were born. You could argue before a judge the cost is partly the mother's cost, partly the father's, partly the infant's; the judge will probably assign the cost to the person with the deepest pocket. In this particular case, the deepest pocket is probably the grandparent, having six or seven doublings intervene. In fact, in a situation torn with divorce and dissension, the grandparent may be the person -- not only most able, but -- most willing to pay the bill. Skipping the process of inheritance, the donation of the money by grandparent to the baby's individual account eliminates cost and controversy, and potentially reduces the cost by 32 to 64-fold.
Overview. To be brief about it, spending for healthcare now crowds toward the end of life, mostly after age 65, while the money to pay for it is generated well before 65. Disregarding the complicated history of how we got here, in effect, we borrow from an interest-free account at Medicare to pay Medicare for Medicare, without earning interest on the money idled in the meantime, sometimes for as long as forty years. Potentially, the two age groups could unify their finances and get more or less dual savings. That's the dream advanced by the single-payer advocates, but on examination, the cost, politics, and complexities of actually unifying entire delivery systems would soon overwhelm total- merger enthusiasts. Unfortunately, the revenue has fallen too far behind the costs to make this completely possible. It is nevertheless contended here, only the financial transfers need to be unified, using Health Savings Accounts as a transfer vehicle, and allowing compound interest to extend beyond the boundaries of insurance programs. Such simplification, while not easy, would achieve most of the savings of unifying whole insurance programs, particularly the incentive to keep what you don't use, for your retirement. Among other things, it would solve most of the Constitutional problems, and avoids most of the delivery system obstacles. Indeed, a financial network is about all we could manage, but it is adequate for the need. Because of its towering cost components, even integrating the financial transfers might take longer than we anticipate.
But massive numbers are only part of the health financing problem. At the beginning of life, medical expenses concentrate forward, toward the very first day, leaving absolutely no way for the child's own income to pre-pay his expenses. No matter how it is rearranged, someone must give children some money. Indeed, this second issue seems so unsolvable, everyone has stopped trying to notice it. It only makes people uncomfortable to suggest that adding children to a new HSA system might add twenty-some years to the compound interest in Health Savings Accounts if they only had some money. They don't, so be quiet.
But on the contrary, if someone always gives children the money for their healthcare, why not acknowledge it? Frank acknowledgment seems pre-destined if you aspire to serve lifetime financing. You require two systems, roughly the opposite of each other. One delivery system faces toward the beginning and the other faces toward the end of life. (Even this conception finds the working class in the middle, largely funded by employers who change frequently and have other concerns foremost in their minds.) If the realities of life will never change, then it is the payment system which must adjust, with the finances of each system facing in opposite ways. The reader is therefore urged to toy with the eventual outline of a circular system, far down the line. For now, existing programs would alter their interface to accommodate a new funds flow, while changing their program as little as possible. There's still a big gap left unfilled: Those working people aged 25-65 who largely support the whole system, unfortunately already have so many constraints on their financing it is not feasible even to discuss their needs until the politics subside a little. Connecting, yes; unifying, only as much as you can. Therefore, this book passes over single payer as fundamentally over-reaching and concentrates on lower-hanging fruit.
Essentially, it is proposed: The Health Savings Account to expand to be a unifying financial bridge between programs, one account per individual lifetime, serving many disparate programs. Designed to be implemented in phased-in pieces, it continues to aspire to minimize changes in the delivery system itself. The reader will probably be surprised at how simple some dilemmas are likely to become, once it is conceded the individual patient ought to decide what others now decide for him.
Extended retirement costs are a predictable outcome cost of Medicare.
Prepare yourself for one big rearrangement of thinking, however. Extended retirement costs are a direct consequence of superior healthcare. They could become five times as expensive as healthcare itself, and still be fairly described as a predictable outcome cost of Medicare. The only way budget shifts could be avoided is if science cures a few expensive diseases, quickly. That's not impossible, but it's unwise to depend on. It's also conceivable Medicare beneficiaries could be persuaded to allow HSAs to borrow from Medicare, but only after a titanic struggle, and only after Medicare revenues improve appreciably. New revenues for retirement must nevertheless be found, sooner rather than later, because of the ever-growing retirement crunch. It's a devastating realization, but the seed of solving the problem is contained in it. Where are the new revenues to come from?
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.
