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Lyndon Johnson
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In 1965, Lyndon Johnson caused the enactment of two amendments to the Social Security Act, Titles 18 and 19. Title 18 is now called Medicare (for the elderly), and Title 19 is called Medicaid (for poor people). These two laws were cobbled together as negotiated compromises; the history of this contraption no longer concerns us. The outcome is that Congress created a Federal program for the elderly, and a state-administered program for the poor, partly financed by the states but mostly financed by federal taxes. The states howl that Medicaid is an unfunded mandate, and the Federal bureaucracy snarls that the states are mismanaging someone else's money. The welfare patients are bitter about second-class treatment, and doctors have as little to do with this system as possible. The focus of this article, however, is on the harmful effect of Medicaid on hospitals. Of all the stakeholders affected by Medicaid, the hospitals have historically been the best treated. Nevertheless, it has brought them to the brink of ruin, most of them acknowledge it, and matters are so hopelessly snarled that it is time to call for a transfer of the medical components of Medicaid to Medicare. In plain language, that means replacing state administration with federal Medicare management.
It may seem peculiar to call for extracting the medical components from a medical program. Forty years of creeping modifications in fifty different state directions have resulted in many state Medicaid programs spending more on nursing homes, home care, and various educational programs -- than on the activities of doctors and hospitals as originally intended. After forty years, this creeping mandate shows no sign of abating. It may never abate, but certain parts of it could rather easily be transferred to federal Medicare program, leaving the innovative fringes to fight their own battles with state legislatures, arguing those merits independently of this issue.
From the hospital point of view, Medicaid pays substantially (20-40%) less than the costs it claims to cover. The chiseling is worse in some states than others, but it is hard to find a single state Medicaid program which clearly pays its costs in full. Medicare is pretty tight-fisted, too, but at least a majority of knowledgeable insiders would admit it comes pretty close to paying its audited costs. Everybody else pays more than costs, but for this discussion that is irrelevant. Government as a whole is not paying its fair share, the state-administered portion is responsible, and there was never any non-political justification for having two programs. So, combine them. Other components of Medicaid, however worthy in intent or effect, are the responsibility of the various states which created them. When the states have got non-hospital, non-doctor issues carved out and audited, the merits of federal funding can be examined.
Two other features of the Medicaid mess can be mentioned, so long as they are not allowed to befuddle the main message of program consolidation. In general, the proportion of elderly or poor clients in rural hospitals does not materially differ from the proportion of such clients in urban hospitals. There is institutional variation, of course, but the principal distinguishing feature is that small rural hospital is necessarily semi-monopolies within fifty-mile districts, whereas urban hospitals face competition more directly. State governments, therefore, are unable to impose discounts on rural hospitals with the same leverage and severity. Seeing this, urban hospitals have often applied political pressure on the legislature to extend comparable relief to them. Since local labor and living costs are lower in rural areas, an excuse is created to word regulations and state laws in a way which recognizes parity in the ratio of audited costs to charges rather than the charges or costs themselves. Quite often, hospital accountants can outwit legislatures in these obscurities, leading to rather obscenely high list prices for hospital services, to shift the ratio. Although it has the temporary advantage of further obscuring public market prices for such services, it constitutes a serious injury to uninsured patients. Other persons, who might perceive no personal need for insurance, are driven to buy it in order to protect themselves from gouging.
Medicare itself is certainly not perfect. The largest remaining issue confounding hospital charges can be traced back to weaknesses of a 1983 Medicare law, the Budget Reconciliation Act. Reimbursement legislation traditionally overpays initially, with every intention of paring prices down later. The providers, hardened to this maneuver, try to stonewall all subsequent amendments as long as they can. In this case, the overpayments have persisted so long they have become basic assumptions, triggering internal re-adjustments which make resolution still more difficult. A number of hospitals have been severely fined for violating the spirit of this law, however close they may come to obey the letter of it. On the other hand, other courts have held that a situation which has been allowed to persist so long can be deemed to be settled law. The result is a predicament which is quite unnecessary, and might be rather readily corrected.
But let's not wander too far from the basic proposal. The corresponding (doctor and hospital) portions of Medicaid should be consolidated into Medicare, with remaining issues settled independently. Consolidating two government programs may not quite be the "single payer" concept that others had in mind, but it resolves most of the legitimate problems which provoked that mysterious slogan.
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Webbed Toes
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It probably took me twenty years to notice that, unlike most people, I had an incomplete separation of my second and third toes. I thought my toes were like everybody else's, but once you start peeking, you see that webbed toes are not normal, although they are not really rare, either. After another thirty years, it became apparent that most of my numerous descendants had the same kind of toe; it was obviously an inherited condition. When the family clan gathered at the beach, it was a source of mild amusement, possibly even a little pride. A few weeks ago, I happened to mention the matter at a party, whereupon another doctor promptly pulled off his shoes and socks, and revealed fused or webbed toes of a much more striking sort than mine; obviously, he was proud of it, too. He is of an old, old Philadelphia family that owns one of the oldest, if not the oldest, a house in Germantown. His family, too, is stigmatized in the same way only more so. In Philadelphia, when you are proud of your family, you are really, really, proud of it.
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Ainhum
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Which brings me back to my days as an intern in the accident room of the Pennsylvania Hospital. When there is a sudden crowd of emergencies in an emergency department, the nurses get all of them undressed, put in a hospital gown, and instructed to wait for the doctor behind a curtain that doesn't quite reach the floor. For some reason, as a medical student, I had been particularly struck by a photograph in a textbook of an inherited disorder said to have been first noted on a slave ship; the disease in the native language was named Ainhum. For reasons obscure, a tight little band appears at the base of the fifth, or little, too. It gets slowly tighter over a period of months, and eventually, the little toe falls off. That's all there is to Aihnum, and all that was known about it. So, imagine my surprise and delight to walk past a row of naked feet sticking out below curtains -- and there was my first and last case of Aihnum.
I summoned my colleagues, and the visiting medical students from both Jefferson and Penn who at that time shared training in our accident room. I raced off to my room to get a camera to record this momentous event. An elderly staff physician, either Tom McMillan or Charles Hatfield, wandered past and was invited to share the excitement. Well, he says, I saw one of those forty years ago, it looked just like that; old Doctor Norris showed it to me when I was an intern. Much murmuring ensued but abruptly stopped when the patient himself rose up and started putting on his clothes. He was going home, but why? "Well," he growled, "I came here because my back hurts, and all you people do is look at my toes!" He said he was going over to the Jefferson Hospital to get proper treatment, and I guess he did.
And finally, there is Morton's Toe. Or perhaps more properly, Mortons' Toes. There were in fact two Doctor Mortons, one of them at Columbia College of Physicians and Surgeons where I went to school, and the other at the Pennsylvania Hospital where I interned. In New York, Morton's Toe refers to a painful callous, or neuroma, that forms on the bottom of the victim's big toe. In Philadelphia, such an answer would get a failing grade, because the Philadelphia Morton had noticed that some people have a big toe that is shorter than the other toes, instead of being bigger as the term would suggest was proper. The tricky thing about this relatively harmless variant is that the big toe is actually not short at all. The foot bone, or metatarsal, is short, so the toe of normal length sits back farther on the foot and just looks shorter. The main significance is for shoe salesmen since the shoe needs to be long enough to avoid crushing the other toes.
So now, you readers who were not lucky enough to go to medical school can get a feeling for what it seems like to be a doctor. The other significant shared bond within the fraternity is a sense of outrage at the way health insurance companies drag their feet paying doctors, but that's not limited to feet..
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Start by looking at what happens if you increase the interest rate from 5% to 12%, or if you lengthen life expectancy from age 65 to age 93. Stretch the limits to see what stress will do. For example, increasing the interest rate to the edge of believable gets your balance to a couple of million dollars amazingly quickly, while lengthening the time period (for that interest rate to work) even further enhances that gain. The combination of the two easily escalates the investment above twenty million. Because we are only trying to get to $350,000, reaching it suddenly seems believable.
The combination of extra time plus extra interest rate holds out a theoretical promise of paying for a lengthening lifetime of medical care, in spite of medical cost inflation. Present realities don't quite stretch that far, but finding some way to reach that level is not hard to imagine. In fact, it gets the calculation to giddy amounts so quickly it engenders suspicion, to which one answer is, we probably don't need anything like twenty million. The actuaries at Michigan Blue Cross, verified by the Medicare agency, estimate average lifetime health costs to be around $350,000 per lifetime. That's just a guess, of course, but increasing interest rates and life expectancy just a little could reach that minimum requirement. How do we go about it, and how far dare we go?
Some very credible theories sometimes disappoint us. Remember, our whole currency is based on the notion of the Federal Reserve "targeting" inflation at 2%, but in spite of spending trillions of dollars, they sometimes seem unable to achieve that target. We had better not count on schemes which require the Federal Reserve to target interest rates, because sometimes, they can't. On the other hand, if a vast army of smart people set about to nibble at various small increases in interest rates and longevity, perhaps they can make serious progress.
One person who does have practical control of the interest rate an investor receives is his own broker. For a full century, Rogen Ibbotson has published the returns on various investments, and they don't vary a great deal. Common stock produces a return of between 10% and 12.7% in spite of wars and depressions; if you stand back a few feet, the graph is pretty close to a straight line. If you search carefully, a number of brokerages offer Health Savings Accounts which produce no interest at all -- to the investor -- for the first ten years. Try earning 2% during inflation of 2%, and see what it gets you. In ten years, that approaches a haircut of nearly 100%, explained by the small size of the accounts, and by the fact that experienced customers who know better, just look for other vendors. Since the number of Health Savings Accounts has quickly grown to be more than ten million, it's time for some consumer protection. The prospective future size of these accounts should command much greater market power, quite soon. After all, passive investment should mainly involve the purchase of blocks of index funds, with annual fees of less than a tenth of a percent. Most of this haircutting is explained by the uncertainties of introducing the Affordable Care Act during a recession, and taking six years to get to the point of a Supreme Court Test to see if its regulations are legal and workable.
That's the Theory. If Necessary, Settle for Less. The rest of this section is devoted to rearranging healthcare payments in ways which could -- regardless of rough predictions -- outdistance guesses about future health costs. When the mind-boggling effects are verified, skeptics are invited to cut them in half, or three quarters, and yet achieve roughly the same result. The purpose is not to construct a formula, but to demonstrate the power of an idea. Like all such proposals, this one has the power to turn us into children, playing with matches. By the way, borrowing money to pay bills will conversely only make the burden worse, as we experience with the current "Pay as you go" method. By reversing the borrowing approach we double the improvement from investment, in the sense we stop doing it one way and also start doing the other. In the days when health insurance started, there was no other way possible. The reversal of this system has only recently become plausible, because life expectancy has recently increased so much, and passive investing has put the innovation within most people's reach. The environment has indeed changed, but don't take matters further than the new situation warrants.
Average life expectancy is now 83 years, was 47 in the year 1900; it would not be surprising if life expectancy reached 93 in another 93 years. The main uncertainty lies in our individual future attainment of average life expectancy, which we will never know, but probably could guess with a 10% error. When the future is thus so uncertain, we can display several examples at different levels, in order to keep reminding the reader that precision is neither possible nor necessary, in order to reach many safe conclusions about the average future. Except for one unusual thing: this particular trick is likely to get even better in the future because people will live longer. Even so, it is better to do a conservative thing with a radical idea.
Reduced to essentials for this purpose, today's average newborn is going to have 9.3 opportunities to double his money at seven percent return and would have 13.3 doublings at ten percent. Notice the double-bump: as the interest rate increases, it doubles more often,
as well as enjoying a higher rate. If you care, that's essentially why compound interest grows so unexpectedly fast. This double widening will account for some very surprising results, and it largely creeps up on us, unawares. Because we don't know the precise longevity ahead, and we don't know the interest rate achievable, there is a widening variance between any two estimates. So wide, in fact, it is pointless to achieve precision. Whatever it is, it's going to be a lot.
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One Dollar: Lifetime Compound Interest, at Different Rates
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Start with a newborn, and give him one dollar. At age 93, he should have between $200 (@7%) and $10,000 (@10%), entirely dependent on the interest rate. That's a big swing. What it suggests is we should work very hard to raise that interest rate, even just a little bit, no matter how we intend to use the money when we are 93, to pay off accumulated lifetime healthcare debts. Don't let anyone tell you it doesn't matter whether interest rates are 7% or 12.7%, because it matters a lot. And by the way, don't kid yourself that a credit card charge doesn't matter if it is 12% or 6%. Call it greed if that pleases you; these small differences are profoundly important.
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If that lesson has been absorbed, here's another:
In the last fifty or so years, American life expectancy has increased by thirty years. That's enough extra time for three extra doublings at seven percent, right? So, 2,4,8. Whatever amount of money the average person would have had when he died in 1900, is now expected to be eight times as much when he now dies thirty years later in life. And even if he loses half of it in some stock market crash, he will still retain four times as much as he formerly would have had, at the earlier death date. The reason increased longevity might rescue us from our own improvidence is the doubling rate starts soaring upward at about the time it gets extended by improved longevity. In particular, look at the family of curves. Its yield turns sharply upward for interest rates between 5% and 10%, and every extra tenth of a percent boosts it appreciably.
Now, hear this. In the past century, inflation has averaged 3%, and small-capitalization common stock averaged 12.7%, give or take 3%, or one standard deviation (One standard deviation includes 2/3 of all the variation in a year.) Some people advocate continuing with 3% inflation, many do not. The bottom line: many things have changed, in health, in longevity, and in stock market transaction costs. Those things may have seemed to change very little, but with the simple multipliers we have pointed out, conclusions become appreciably magnified. Meanwhile, the Federal Reserve Chairman says she is targeting an annual inflation rate of 2% of the money in circulation; the actual increase in the past century was 3%. If you do nothing at 3%, your money will be all gone in thirty-three years. If you stay in cash at 2%, it will take fifty years to be all gone.
But if you work at things just a little, you can take advantage of the progressive widening of two curves: three percent for inflation stays pretty flat, but seven percent for investment income starts to soar. Up to 7%, there is a reasonable choice between stocks and bonds; but if you need more than 7% you must invest in stocks. Future inflation and future stock returns may remain at 3 and 7, forever, or they may get tinkered with. But the 3% and 7% curves are getting further apart with every year of increasing longevity. Some people will get lucky or take inordinate risks, and for them, the 10% investment curve might widen from a 3% inflation curve, a whole lot faster. But every single tenth of a percent net improvement will cast a long shadow.
But never, ever forget the reverse: a 7% investment rate will grow vastly faster than 4% will, but if people allow this windfall to be taxed or swindled, the proposal you are reading will fall far short of its promise. Our economy operates between a relatively flat 3% and a sharply rising 4-5%. In other words, it wouldn't have to rise much above 3% inflation rate to be starting to spiral out of control. Our Federal Reserve is well aware of this, but the public isn't. A sudden international economic tidal wave could easily push inflation out of control, in our country just as much as Greece or Portugal. As developing nations grow more prosperous, our Federal Reserve controls a progressively smaller proportion of international currency. Therefore, we could do less to stem a crisis that we have done in the past.
To summarize, on the revenue side of the ledger, we note the arithmetic that a single deposit of about $55 in a Health Savings Account in 1923 might have grown to about $350,000 by today, in the year 2015, because the stock market did achieve more than 10% return. There is considerable attractiveness to the alternative of extending HSA limits down to the age of birth, and up to the date of death. It's really up to Congress to do it. If the past century's market had grown at merely 6.5% instead of 10%, the $55 would now only be $18,000, so we would already be past the tipping point on rates. In plain language, by using a 10% example, $55 could have reached the sum now presently thought by statisticians -- to be the total health expenditure for a lifetime. But by accepting a 6.5% return, however, the same investment would have fallen short of enough money for the purpose. Like the municipalities that gambled on their pension fund returns, that sort of trap must be avoided. Things are not entirely hopeless, because 6.5% would remain adequate if our hypothetical newborn had started with $100, still within a conceivable range for subsidies. But the point to be made provides only a razor-thin margin between buying a Rolls Royce, and buying a motorbike. If you get it right on interest rates and longevity, the cost of the purchase is relatively insignificant. That's the central point of the first two graphs. For some people, it would inevitably lead to investing nothing at all, for personal reasons. Some of the poor will have to be subsidized, some of the timid will have to be prodded. This is more of a research problem than you would guess: a round-about approach is to eliminate the diseases which cost so much, choosing between research to do it, or rationing to do it. Right now we have a choice; if we delay, the only remaining choice would be rationing.
Commentary.This discussion is, again, mainly to show the reader the enormous power and complexity of compound interest, which most people under-appreciate, as well as the additional power added by extending life expectancy by thirty years this century, and the surprising boost of passive investment income toward 10% by financial transaction technology. Many conclusions can be drawn, including possibly the conclusion that this proposal leaves too narrow a margin of safety to pay for everything. The conclusion I prefer to reach is that this structure is almost good enough, but requires some additional innovation to be safe enough. That line of reasoning will be pursued in Chapter Fxxx.
Revenue growing at 10% will relentlessly grow faster than expenses at 3%. As experience has shown, it is next to impossible to switch health care to the public sector and still expect investment returns at private sector levels. Repayment of overseas debt does not affect actual domestic health expenditures, but it indirectly affects the value of the dollar, greatly. Without all its recognized weaknesses, a fairly safe description of present data would be that enormous savings in the healthcare system are possible, but only to the degree, we contain next century's medical cost inflation closer to 2% than to 10%. The simplest way to retain revenue at 10% growth is by anchoring the price leaders within the private sector. The hardest way to do it would be to try to achieve private sector profits, inside the public sector. This chapter describes a middle way. Better than alternatives, perhaps, but nothing miraculous. For the full whammy, you will have to read chapters Three and Four.
Cost, One of Two Basic Numbers. Blue Cross of Michigan and two federal agencies put their own data through a formula which created a hypothetical average subscriber's cost for a lifetime at today's prices. The agencies produced a lifetime cost estimate of around $300,000. That's not what we actually spent because so much of medical care has changed, but at such a steady rate that it justifies the assumption, it will continue into the next century. So, although the calculation comes closer to approximating the next century, than what was seen in the last century, it really provides no miraculous method to anticipate future changes in diseases or longevity, either. Inflation and investment returns are assumed to be level, and longevity is assumed to level off. So be warned. This proposal, particularly with merely an annual horizon, proposes a method to pay for a lot of otherwise unfunded medical care. The proposal to pay for all of it began to arise when its full revenue potential began to emerge, rather than the other way around. If the more ambitious second proposed project ever works in full, it must expect decades of transition. Perhaps that's just as well, considering the recent examples we have had of being in too big a hurry. Rather surprisingly, the remaining problem appears mainly a matter of 10-15% of revenue, but all such projection is fraught with uncertainty.
Revenue, The Other Problem. The foregoing describes where we got our number for future lifetime medical costs; someone else did it. Our other number is $132,000, which is our figure for average lifetime revenue devoted to healthcare. That's the current limit ($3300 per year of working life) which the Congress itself applied to deposits in Health Savings Accounts. No doubt, the number was envisioned as the absolute limit of what the average person could afford, and as such seems entirely plausible. You'd have to be rich to afford more than that, and if you weren't rich, you would struggle to afford so much. To summarize the process, the number was selected as the limit of what we can afford. If it turns out we can't afford it, this proposal must somehow be supplemented. The provision made for that predicament is we will then have to jettison one or two major expenses, the repayment of our foreign debts for past deficits in healthcare entitlements, or the privatization of Medicare. That would leave us considerably short of paying for lifetime health costs, but it might actually be more politically palatable. It's far better than sacrificing medical care quality, at least, which to me is an unthinkable alternative, just when we were coming within sight of eliminating the diseases which require so much of it.
The Chicago Quartet Volume Two
Four Prescriptions: Proposals or Reform of Health care Financing
Rx. I: PRE-FUNDED HEALTH INSURANCE
INTRO page 1.
Introduction
Benjamin Franklin organized the first American fire insurance company in 1736. Success in the insurance business rests almost unnoticed among the many scientific and political accomplishments of that remarkable man. Even in Philadelphia, few people realize Franklin’s company and several others like it still operate comfortably. Franklin called his company a “Contribution shipâ€, but a more familiar modern term is “mutual†insurance company. Even though mutual life insurance companies have come to predominate, for important reasons fire insurance has been more salable when provided by profit-making companies. The ancient mutual fire insurance companies remain small but reflect some important thinking which this book argues should be applied to health insurance, where ideas are currently badly needed.
What the world already knows about these quaint little companies is almost a hindrance. Occasional articles in the Philadelphia Sunday supplements do sometimes mention them, mostly fascinated with how socially prestigious it is to be a member of their boards of directors, what excellent dinners are served at directors meetings, what priceless antiques are to be found in their headquarters. Franklin to be sure would probably relish the elegance. Unlike the Quakers of Colonial Philadelphia, Poor Richard was not frugal in order to be inoffensive; he was frugal to get rich. Dying the second richest man in the city, he lived the kind of life many Yippies might admire.
Mutual fire insurance companies sell something called "perpetual insurance" which turns out to be perfectly ordinary homeowner's insurance, with one big twist to it. The customer makes one large lump sum deposit in advance, then never pays premiums. During all the time the insurance is in force, perpetually if need be, no further premiums are paid. The deposit earns enough interest to pay the full premium cost of the insurance protection. In that way, the customer has the perfectly astounding experience of having every penny he paid to the company returned when he eventually gives up the insurance. Centuries of experience show that a single deposit of roughly ten years conventional premium will generate enough investment income to cover all anticipated costs from "losses" and administration. The deposits themselves "share the risk", eliminating the cost of paying investors to provide a "contingency reserve". This simple scheme is Perpetual mutual insurance.
As everyone knows, that isn't the way most fire insurance works; the only things perpetual about a more typical policy are the yearly premium notices, which in the aggregate eventually cost much more than making a deposit and giving up the income from it. It is left to the typical stockholder company to worry about getting contingency reserves coming from investors are more popular with homeowners than reserves they have to provide themselves, consequently why perpetual premiums are so much more scalable than perpetual insurance. The young homeowners is typically a debtor, stretching to buy the best house he can afford when he can stump up a down-payment; fire insurance is something his mortgage banker insists he buys. In order to have the American dream a little earlier, the homeowner agrees to pay a little more, later.
Two hundred years after Franklin's death it is possible to gain other insights from "perpetual" insurance because the unfamiliar approach makes us ask basic questions. The next several chapters of this book now set out to argue that health insurance has some serious problems which could be improved by asking those questions. The problems of health insurance are not trivial; many experts question whether we can afford to continue the present system. Whether a breakdown of health insurance would lead to worse care, no access to care or rationed care, the whole subject of health insurance is important to more people than insurance executives. We will return to Franklin's idea after a flyover of current major problems of health insurance, with reflections on how things got to be such a mess. Then, after compounding several insurance remedies based on Franklin's formula, an effort is made to identify potential harmful effects but few are found. The main problem with the prescription is that it has a rather bitter taste.
WHAT'S WRONG WITH HEALTH INSURANCE
There are many things good about the American system of health insurance. Compared with the nationalized health insurance schemes of other countries, our health insurance is a utopia. Indeed, the main reason to criticize the American system of health insurance is to save it from itself, since the foreign alternatives are so much worse. No doctor ever saved a patient by ignoring the symptoms. To be concise, our health insurance system is unfunded, inappropriately linked to employment, adequate for moderate illness but not for catastrophic ones, and incredibly expensive to run. For each of these four disorders, this book offers a prescription. In the first section, keeping Poor Richard in mind, the disorder under examination is that health insurance is unfounded. For the ailment of being unfunded, the prescription offered is the IRA for Health.
Unfunded, Being unfunded does not mean cheap. It costs a typical family about $3500 a year for health insurance premiums. It has become commonplace to read newspaper articles announcing or predicting 15-30% increases. Annual national costs of healthcare are about $500 billion. Those who would like to solve the problem with a national health scheme should remember that $500 billion would be half of the current Federal budget; the $200 billion already federalized are nearly destroying the government. Health care is expensive all right, and unfunded.
Further, because an employee can escape income taxation on a health insurance premium if his employer pays it for him, that's the way health insurance.
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.