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James Madison
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JAMES Madison was born (1751) a rich Virginia planter, was a major factor in the composition of the U.S. Constitution, became secretary of State and President of the United States for two terms (1812-20), and died (1836) impoverished at the age of 85. Because the Constitutional Convention was conducted in secrecy, we cannot be entirely certain which parts to attribute to him, or even what his personal position had been on many issues. He was Chairman of the Committee of the First Congress and the dominant figure writing the Bill of Rights, which he had declared were unnecessary. These early Amendments to the Constitution were therefore sparsely confined to those rights which met universal approval and excluded the many proposals of rights which were controversial. The surprising outcome is that the Bill of Rights survives as a bedrock summary of the nation's belief system. There is a tendency to review the actions of all Presidents after they leave office, searching for remarks or behavior which clarifies their official actions while President, and in Madison's case his positions on the dominant Constitutional issues of our Republic. However, that later period of his life was marked by many abrupt reversals of inexplicably contradictory positions that often lessen his stature, and embarrass his earlier achievements. Gouverneur Morris, for example, had the lowest possible opinion of Madison, summarizing him as merely a drunkard. Morris was so contemptuous of Madison that during the War of 1812 that aristocratic main editor of the Constitutional document denounced the whole effort in disgust, mainly devoting his own efforts to making money from the Erie Canal, and later going to France in the Bonaparte era. Other close observers refrained from comment about Madison's drinking habits, and we must presently remain uncertain whether the comment explains Madison's erratic behavior, or whether it was merely an emotional exaggeration by Morris who spent most of his own later life, acting entertainingly at social gatherings.
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William Penn
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On the one hand, and on the other; there is scarcely an episode in Madison's life which could not begin with the same words. Madison had tuberculosis and was sent North to go to college at Princeton, where he was much taken with Quaker beliefs in a state still controlled by William Penn's proprietors, but in a College whose campus thoughts were dominated by refugees from the Scottish Enlightenment. He was a good student and stayed an extra year to study Greek under the famous John Witherspoon. He was soon involved in politics, catching the eye of General Washington with his active promotion of the cause of the unpaid Revolutionary Army. Washington soon enlisted the efforts of this neighboring Virginia planter in organizing a new Constitutional Convention, primarily intended to strengthen central government against the intransigent state legislatures, with a particular effort to enable the central government to levy taxes to service war debts. Neither Washington nor Madison knew much about finance; the ideas about leveraging sovereign debt through a central bank evidently came from Robert Morris, who was a close friend of Washington's and in many ways the acting President of the United States during the Revolution. The young Alexander Hamilton bore the same sort of relationship to Morris as the young Madison bore to the General who was a generation older; in both cases, they supplied their own ideas, but mainly applied time, youth and energy to the concepts of their seniors. Hamilton and Madison became fast friends in a great cause, notably collaborating in the writing of the Federalist Papers to promote the new Constitution. Madison was the great scholar of the Roman Republic, a Washington favorite, and displayed a remarkable innate talent for politics in the finest sense, explaining complicated logic and persuading the unpersuaded. Washington nursed a passionate hatred for partisan politics and collaborated with the daily assistance of Madison in defining the traditions of the American presidency. Washington wanted to avoid the appearance of being a King, which was another Washington hatred but was badly in need of some models for an entirely new concept, the executive branch of a deliberately divided government. In one famous episode, Madison wrote Washington's speech, then wrote the reply to Washington by Congress, then wrote Washington's thank-you note back to Congress. Madison was devoted to his work; he only married Dolley Madison when he was 37 years old. Madison would seem to qualify for the category now called nerd.
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John Adams
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Hamilton, on the other hand, had many children, legitimate and otherwise, many girlfriends, at least two duels, and flamboyant behavior on the parapets of Yorktown during the final battle. Unlike the aristocratic Madison, he was described by John Adams as the "bastard brat of a Scottish peddler". Although both men seemed to be driven by their short stature, Hamilton never let it get the better of him. Even Martha Washington was amused by his rambunctious behavior, naming her tomcat after him. Both men seemed unduly influenced by their new friends, Hamilton by his rich New York wife's rich friends, and Madison by Thomas Jefferson and Patrick Henry, the big men on campus so to speak, of the Virginia scene. When Hamilton began to favor banks, bankers and obscure financial wizardry -- and particularly after Madison's hero George Washington took Hamilton's side in the establishment of a central bank-- Madison was ready to be courted by his childhood heroes in Tidewater Virginia, particularly Thomas Jefferson, who always wrote prose as if writing poetry. That's about all we really know about the episode, and there is probably more we don't know, but Madison in an instant became Hamilton's mortal enemy, Jefferson's fast friend, an enemy of the bank, and -- the founder of America's first political party. George Washington never spoke to him, again. It seems possible to suspect that Jefferson was jealous of Washington, although he always was very careful not to confront him directly. When Hamilton persuaded Congress to enact a whiskey tax, Albert Gallatin and other friends of Jefferson's party stirred up the Whiskey Rebellion in Western Pennsylvania, and Washington personally led fifteen hundred Federal troops across the mountains to put down the rebellion. General Alexander Hamilton was at his side. James Madison was somewhere else, probably reading a book. Madison was the sort of person who always knew when his enemies had the votes. He was often lost without the assistance of Gallatin, who somehow knew when the enemy had the better argument.
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Bladensburg races
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Eventually, America split between those who sympathized with the French and their land domination of Europe and those who began to seek a repair of the trade relationship
with Brittania which ruled the waves. The Adams presidency was ruined by fallout from this international warfare, an embargo was imposed, and both France and England did their bit to make things worse. At one point, it was uncertain whether America would be going to war with France or with England. Eventually, it was with England in the War of 1812. Jefferson and Madison had become successive presidents dedicated to saving money by disarmament, but in spite of our having no navy and nothing but militia for an army, we blithely set about to conquer Canada, with the plan of trading it for trade concessions from the British Empire. Unfortunately, the War was a several-year series of overwhelming defeats for the Madison administration, culminating in the burning of Washington D.C. and the "Bladensburg races" (for the exits), but celebrated as Dolley Madison rescuing the portrait of George Washington, and Francis Scott Key writing the "Star Spangled Banner" about the bombardment of Baltimore. Indian massacres in Michigan and other western defeats complimented the litany of disaster, which was finally ended when Gallatin negotiated the Treaty of Ghent as status quo pro antebellum with the preoccupied British, and then celebrated Andrew Jackson's defeat of the British army at New Orleans, after the Treaty had been signed but before news of it reached home. As Madison's last acts at the end of his term, he promoted Adam Smith economics, the reconstitution of the Bank, a general rearmament campaign -- and then vetoed the bill when it passed. To say that Henry Clay in Congress was embarrassed is to stretch the limits of language. After he left office, Madison became a senior statesman, making all sorts of pronouncements about current events and the true meaning of some Constitutional point involved, quite regularly reversing his positions and encouraging secession by talking about it so much.
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Marbury v. Madison
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This sorry tale is too long to present fairly and accurately, while its point can be most simply made by reference to Madison's first involvement as Secretary of State, in the famous Supreme Court case of Marbury v. Madison . When the departing Adams administration made some last-minute inconsequential appointments, one of them was to Marbury. At the beginning of the Jefferson Presidency, John Marshall was the departing Secretary of State, James Madison the incoming one. The appointment to Marbury was duly made and ratified, its certificate lying on the desk of the Secretary of State. Marshall (outgoing) neglected to send the certificate to Marbury, and Madison (incoming) refused to do so, on the advice of Jefferson the President; none of them ends up looking, adult. Instead of recusing himself, Marshall as Chief Justice further entangled himself in a dispute where he was the referee, by devising the concept that the Supreme Court could declare acts of Congress unconstitutional, and trapping Jefferson into a position where he had to agree with it. All in all, it certainly would seem simpler for Madison to have sent over the certificate. The authors of the three most famous documents in the American icon were inaugurating what a recent biographer Kevin R.C. Gutzman, described as the Presidencies of Chicanery.
James Madison deserves the highest praise for his achievements in three documents: the Virginia Plan, which was the forerunner of the Articles portion of the Constitution, that is to say, the basic structural components of our present government. Secondly, the bulk of the Federalist Papers leading to the Ratification of the Constitution. And third, the Bill of Rights, which he saw no need for, and therefore personally rewrote to be miraculously sparing of language, limited to bedrock essentials, and celestial as a statement of American national purpose.
Madison lived a long life, but it is difficult to find anything in the last forty years which justifies his early promise. Or which could be called a disgrace to it, either, if he had only made a more ordinary beginning.
REFERENCES
| James Madison and the Making of America: Kevin R. C. Gutzman: ISBN-13: 978-0312625009 |
Amazon |
As I was rushing out of my office one evening, trying not to be late for a rather large gathering of constituents, I was suddenly confronted by a nice young lady holding a piece of paper, closely followed by a young man with a big professional TV camera. I like to think they were lying in wait for me, but more likely they were haunting the Starbucks across the street.
The question was fired at me, what did I think about Governor Christie using the Supreme Court about gay marriage? I had to admit I don't watch TV all day long, so I hadn't heard about it. Well, do you think it is appropriate for the Governor of a state to sue the Supreme Court? Huh, do you? Caught totally by surprise by a question I don't know much about, I answered, or mumbled, that it seemed to be a lawyer's question, and I'm not a lawyer. I do know that the U.S. Supreme Court will refuse to take a case unless the plaintiff can show he has sustained a personal loss of some sort. But I don't know anything about the New Jersey Supreme Court or its rules, and the whole thing seems to me to be above my pay grade. Or something like that.
If I had had more than ten seconds to think about it, I might have said, "What you really are asking me is Don't you think Christie is a bad, insensitive person?" And my answer to that question if put a little more plainly, would be, "No, I like Governor Christie a lot and I trust a former U.S. Attorney to know the fine points of law better than I do, so I support him."
And if I am wrong, and the real question you are asking me is Am I gay? Then, my answer would be, "No, I'm not gay one bit. But I am inclined to let other people do as they please, as long as it is harmless to others."
And if the hidden question is do I approve of people being gay, I would have to answer that if everybody were gay, it's pretty hard to see how the human race would survive. Now could I ask you a question? Who are you, and who is paying you to ask me slanted questions?
Follow-up, written the next day:
The next day's newspaper gave an entirely new slant to this little episode. It seems the decision was made by the Superior Court, not the Supreme Court, and Governor Christie appealed the decision, he did not sue anybody. So the whole interview process was a put-up job, slanting the attention away from a record-breaking court decision to Governor Christie, who was dutifully responding to a Superior Court ruling which overturned a state law. All the rest of it was either intended to shift attention or else to tangle me up in a confused reaction to some events which didn't happen at all.
In that case, let me state my central position. Governor Christie is a great guy, who definitely needs to win re-election next month. And I am running for the role of Assemblyman for the 6th District, prepared to help him in every way I can.
Follow-up, written two weeks later:
Presumably, after a week or two of consultation with experts, and watching for public reaction, Governor Christie withdrew the state's appeal of the Superior Court decision. That would appear to be the end of this phase of the matter, because there is no one else with the "standing" to appeal a state law, and gay marriages will at least go ahead, unrestrained by the State of New Jersey. All sorts of things might or might not happen, like passing a new law that answered the Court's objections. Or someone might feel injured by the present state of affairs and sue for redress of damages. After wracking my brain to think of someone who was injured, let's consider some elderly couple without children. Since state marriage laws are primarily designed to protect mothers and dependent children, gay couples would appear to be in much the same situation as non-gay couples unable to have children. I have never heard of anyone protesting that couples unable to have children are receiving preferences they don't deserve, but it could happen I suppose, and the non-gay couples might lose some legal advantages they had grown accustomed to, feel aggrieved about it, and sue somebody because they lost those advantages. It sounds pretty far-fetched, so in likelihood, no one will sue, and in a few years, the matter will fade away. Some other state might keep the issue alive by its courts deciding differently, of course. But generally speaking, it looks as though the issue of gay marriage is settled in New Jersey, and the legislature can turn its attention to less exciting subjects, like dredging Delaware or building new houses at the shore after Hurricane Sandy. Or, what in the world are we to do about all those people who have been relegated to New Jersey Medicaid by the federal Obamacare legislation. Oh, yes. There's that matter of high state and local taxes.
What Is the Right Shape For a Legislative District?
At first it comes as a surprise, but soon seems natural, that the first question people ask me is, "What's the Sixth District -- do I live in it?" So the answer is: it stretches along the White Horse Pike from Pennsauken to Voorhees, including about fifteen towns, listed at the top of this page. A considerable number of people are uneasy that some of these towns will get consolidated to reduce expenses, but you usually hear that from established residents. The newcomers, mostly younger people, have fewer local loyalties, but the fact is most residents of a town seem to know very little about the other towns in their district, except for high school football rivalries.
Some of that may be caused by rather regular re-arrangements of the districts, which in turn is occasioned by the steady growth of population. Camden County is gradually coming to the end of a transformation of a farm county into a suburban county, and when that settles down the area should become more stabilized. That probably accounts for the rather large number of people who call themselves Independents. There are more Independents registered in this district than people affiliated with a party. Newcomers generally feel uncertain about local issues and uncomfortable about taking a position on them without more information. Judging from the poll results, it looks as though Independents are more likely to vote a straight-party ballot, just the opposite of what might be supposed. Not knowing the local issues, they vote for national ones or just stay home at election time for local issues. Gerrymandering probably is involved in this mix. Local observers say you can predict the politics of the next ten years if you know how to interpret the gerrymandering after each census. In fact, those who have studied the long-term history of the state, say they can see the trends in ten-year waves.
A "Voting District" is itself a local New Jersey phenomenon. There was a time when each county had a state senator, while the Assembly was divided by population. That led to a regular division of urban versus rural, reflected in a rural Senate and an Urban Assembly. That tended to slow down legislation, just as it is now seen to do in Congress, but it gave County politicians more power. A Constitutional revision in New Jersey eventually broke this tradition. We now have "Voting Districts", each one with one Senator and two Assemblymen. Students of political science favor a bicameral legislature, with the two houses elected by different means, deliberately designed to slow down concentrated power plays. Essentially, New Jersey now has what amounts to a unicameral legislature, according to this view of things. So there you are. New Jersey tried it one way and switched to the other. It may not make a great deal of difference, since the real political division is between the Northern end, oriented toward New York, and the Southern end, oriented toward Philadelphia. As Benjamin Franklin once put it, New Jersey is a keg, tapped at both ends.
So, What is so Good About Christie?
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Governor Christie
My daughter lives in Pennsylvania and therefore doesn't know what's what, recently confronted some New Jersey Republican politicians with a question. "Governor Christie is a great politician, and I love his confrontational style. But tell me truthfully, just what has he done that's so great?" Great question, daughter, and I'm going to give you a straight answer.
In the first place, he attacked the 800 or so committees created by the legislature, and cut them down to about 300, by threatening to reveal their existence, and the hundreds of paid stipends they passed along. And then he made great strides toward a balanced budget, protecting New Jersey municipal bonds from the default, in spite of opposition majorities in both houses of the Legislature. Remember, since the biggest item in the New Jersey budget is for pensions for state employees, he's making substantial progress toward converting defined benefit pensions into defined contribution pensions. You don't need a detailed explanation of what that means, beyond knowing it would make a substantial reduction in future pension costs, as would some other reasonable suggestions, like 401(k). The IBM Corporation was the first to start such a change, and believe me the unions fought it, but now are glad they got it because it is portable. The bond markets are heavily influenced by public opinion, and the opinion became, this Christie guy is serious.
And to repeat, all this was accomplished with both houses of the Legislature controlled by the opposite party. Contrast this with the insults and misrepresentations by President Obama of his Congressional opponents. Nobody could expect much cooperation from the loyal opposition after attacks like that. Christie may have implied some threats, but he had the good sense not to project nasty insults, and remains on good terms with his opponents, in forgivably Jersey style. In fact, he gives them certain respectability they lacked before he convinced them the old ways, just couldn't continue.
And then there is the astonishing move toward wedging part of the Union movement from its former perpetual affiliation with the opposite party. Some racial and religious population groups once made the same political mistake: the Republicans wrote them off and the Democrats took them for granted. Either way, they failed to achieve the clout they were entitled to. It just isn't a smart way to behave in a democracy, and the Unions have fallen into the same trap. Or, maybe union leadership is now waking up.
The American union movement is divided into industrial unions in the private sector, and government employee unions in the public sector. The government unions are gaining members, while the industrial unions are steadily losing members, for reasons I'm too polite to mention. Give Christie credit for starting a tectonic shift with a hint to the industrial unions, implying every time the public sector got a raise, the private sector got a tax increase. In New Jersey, that hurts, because government employee unions and industrial unions are not a natural mix. After all, Christie balanced the budget without a tax increase for two successive years.
That's part of the reality in Deptford Township of Gloucester County, where Sunoco decided to get out of the refinery business. Hundreds of union members are out of a job, still facing the second highest taxes in the nation, if they continue to live there.
What Lessons Can We Learn From the Mt. Laurel Decision?
Let's be clear; Mt. Laurel isn't in my district, which is District #6. Nevertheless, the courts have decided in two cases (Mt. Laurel I and Mt. Laurel II) that the little town next to the Turnpike Exit had to provide the area with a certain minimum amount of "affordable" housing, and that decision does considerably agitate District 6, along with most of the rest of the state. That was forty-three years ago, and lawsuits delayed implementation until 13 years ago. Both the legal cost of this episode, and the rancorous discord, were enormous. The New York Times recently published a follow-up story about the improvements that had occurred in the lives of the 140 families in Mt. Laurel, arguably as a result of better homes than they previously could afford, better schools, a safer environment, and maybe, better neighbors. The reporters said they could find no evidence of the increased crime in a peaceful town, or uproar, or major resentments.
The resounding response that I have heard is to the effect that "The Mt. Laurel decision isn't about Mt. Laurel, it's about a lot of other towns." It's hard to know whether that response means to suggest that anticipation is more destructive than the event, or that Mt. Laurel was exceptional. Some of it surely reflects the opinion that the sweeping generalizations of the court are not applicable to some other towns. It is fairly observable that the officials of towns and local real estate interests are far more upset than the general public is, although people are ready enough to agree when someone in the building trade brings the matter up. Some of that is a local issue: the post-war de-industrialization of Philadelphia and Camden City created many scenes of neighborhood abandonment when lower income people moved into a depopulating area. Sometimes in-migration was a cause, sometimes it was an effect, but local people are well aware of what can happen when panic breaks out about falling real estate prices. A house is normally the most valuable property anyone has. The Times article was meant to reassure such people, but it is probably going to leave many unconvinced. For one thing, the Commission established to implement this court decision has not adequately restrained the zealots in their midst. It is clear this is a touchy issue and needs to be treated as one. Haddonfield, for example, does not have a single vacant lot, and feels needlessly hassled when it is criticized for lack of affordable housing./p>
The same needs to be said of the court. It could have made a much narrower ruling, perhaps confined to Mt. Laurel or to growing towns. That surely would have disappointed the individuals who brought the lawsuit, but thirty years of subsequent litigation suggest that a more gradual approach would have been more useful. Perhaps we should not entirely shield our legislative politicians from criticism. They ducked the issue for a long time until the Court finally felt justified in forcing the issue.
Fisher on the Coming Physician Shortage
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Caroline Casagrande
The 11th Assembly District is somewhere to the North, and two Republican ladies, Caroline Casagrande, and Amy Handlin are running for Assembly, the way I am in the 6th District. I don't know them, but I approve of their message in their local newspaper. They feel that Obamacare is going to create a physician shortage, and it certainly does feel as though it's already getting hard to find a doctor. If you think about it, you'd have to agree that giving health insurance to many extra millions of uninsured people would likely put strains on existing supplies of doctors. But there's a related point to make.
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Amy Handlin
I'm quoting Roger Egeberg MD, here, who was General MacArthur's chief medical aide in the Pacific. He later became Assistant Secretary of Health, where I got to know him. He expressed disapproval of salaries for doctors in the strongest possible terms. When I asked why he would say that, he replied, "If you put doctors on salaries, you will get an instant forty-hour week, and after that, you will get an instant doctor shortage." Although I don't know that it would be instant, I think he is probably right about the general idea. Piece work makes you work longer and harder, and for that reason alone a lot of people hate piece work. Doctors call it "Fee for Service", but it's piece work.
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Roger Egeberg MD
In a way I'll explain in another blog, the DRG system of paying hospitals by the diagnosis rather than by itemized services is encouraging hospitals to form satellite clinics and buying up doctors practices to fill them. That's because inpatient patients now lead to a profit of 2%, while the accident room has a profit of 15%, and satellite clinics a profit of 30%. On a national average, of course. Naturally, hospitals see their future in captive doctors on hospital salaries. Meanwhile, if a hospital gets paid by diagnosis, it doesn't matter how long the patient stays, Medicare pays the hospital the same amount. And it doesn't matter how much lab work or x-rays are done, the hospital gets paid the same. Somehow, I don't think you save money with such a system, you just get a more efficient rationing system. And that's the type of system the Affordable Care Act promotes.
Meanwhile, the Medical School deans are responsible for matching supply and demand, and they rather favor the salaried practice. So the hidden cost here is likely to be for an increase in the number of medical schools. Cutting sixty hour weeks to forty hour weeks would require fifty more medical schools. But even then it takes six or seven years for a new medical student to become a new doctor in practice, and you have to figure on taking several years to find the money and to build a new school. So, if it gets done efficiently, it will take ten years at least to recover a balanced supply of doctors. I'm sorry, but you can't just bang your shoe on the desk and demand that something must happen.
Fisher on Representation Size
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Constitutional Convention in 1787
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Constitutional Convention in 1787
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According to the last census, my Legislative district (#6 in New Jersey) has 224,000 residents. If I spent five minutes talking to each one, I wouldn't have time to sleep or eat. Therefore, I get mixed feelings when I hear only 43,000 of them are registered voters, and only 23,000 of them turned out for the last election. I guess I could talk to that many, but it is pretty sad only one resident in ten bothers to vote. The same number of people voted for every R candidate, and the same number of D's voted for almost every D candidate. So, it looks as though a lot of people vote a straight-party ballot.
That's something they surely wouldn't do if they knew each candidate. And that's pretty sad because it is easily managed by party machines. I have to think these things are caused by the steady growth of the population, without comparable growth in the number of representatives, at all levels from township commissioner to President of the United States.
George Washington was bothered by the same problem. In 1787 he had nothing to say about issues during all the time he was the presiding officer of the Constitutional Convention. But on the last day of the convention, he asked for permission to step down and address the group. His conviction was that no congressman should represent more than 30,000 people, and he begged for an amendment providing for it. The delegates meant to oblige him, but somehow it got lost. If they had done what he asked, we would now have about 5000 congressmen, so it doesn't sound workable. As a practical matter, in the early 1920's Congress finally limited the size of its members to 436. So now we have exactly what Washington feared, which is each Congressman represents 700,000 people, nobody knows his congressman, it costs millions of dollars to get elected, party machines dominate what decisions aren't dictated by lobbyists.
Exactly the same thing is true of legislative districts, except the lobbyists are probably less well funded. They seem to search for party machines and spend their time (and money) on unelected party leaders. Unelected is an important word here because many county leaders take care not to hazard their future on an election. I understand the county leader in Mercer county lives on eighteen acres in the center of Princeton. I don't know his name, in fact, almost nobody knows his name, but everybody knows that God himself couldn't afford eighteen acres of Princeton. I got this from a reporter, Bob Ingle, for the Trenton newspaper who wrote a book, called Soprano State. I wish more people would read that book, so I don't have to sound so negative at times. I gather from this book, there is much to talk about.
Anyway, this representation issue is starting to hurt. I go to all kinds of meetings in my district, at least to show my face. Little did I expect I would be sitting in the audience while a professor of history, would explain that Washington's proposal was already part of the Constitution. I woke up slowly and may have got this wrong, but I believe he said it was one of the two (of the twelve original) amendments of the Bill of Rights that Thomas Jefferson recorded as not being ratified. However, Kentucky was a long way away by horseback, and the ratifiers seem to have given up on the messenger who was bringing the duly recorded, on-time, ratification from Kentucky needed to reach the required number. I guess when it got to be dinnertime they decided no messenger meant no ratification.
However, Mr. LaVerne seems to have dug up photocopies of the Kentucky document of ratification, plus the bylaws stating amendments were to be effective as of the date of ratification. Somehow, the War of 1812 got things confused even more and burnt up enough, that Washington's pet idea sort of got lost. If that's really provable, it seems to mean we already have a mandate to have 5000 congressmen (and two or three thousand Assemblymen and women in New Jersey?). The contention seems to be that for two hundred years nobody knew what to do with this bit of history, and sort of decided to ignore it. My view is that even if you knew all about this strange history, you simply can't have it both ways. Either you get stuck with the present inability to represent all those constituents, or else you get stuck with having unworkable thousands of congressmen.
I promise to think about this. And when I get an answer, I'll let you know.
Obamacare and Pre-existing Conditions
Obamacare isn't an issue before the State Assembly right now, but that will soon come when the uninsured find themselves in state Medicaid, which isn't at all ready to take them. But that's for later. Right now the issue that pops right up and assaults you is called pre-existing condition. Those folks are waiting at the door at midnight, waiting for the office to open up, just like Apple Stores before a new model of iPhone. They are desperate to get Obamacare because there is no other solution. And they have been told there is no other way to solve their problem, this is the last chance. Well, that's just not true. Impaired risk is an old, old problem with insurance, and there are standard ways of dealing with it. One is called an "assigned risk pool", and the other is high-risk insurance. In Pennsylvania, there is a fire insurance company known as the Fair Plan, which will only accept you if some regular fire insurer has rejected you. It's owned by the other fire insurance companies and is subsidized by them, although it often surprises itself by making a profit some years.
I've been interested in the Fair Plan for some time, so I'll next attach a blog I wrote several years ago. It's my favorite method of handling pre-existing conditions, and I was pretty disappointed when it wasn't adopted for health insurance. (See below.)
Instead, we have a law forcing everybody to have health insurance whether they want it or not so we can play cops and robbers with people who don't like insurance, such as the Pennsylvania Dutch Amish people. Certain Congressmen have been pushing mandatory coverage for decades, and they always got laughed at. Too grandiose. Too unnecessarily sweeping. Anything with the word "mandatory" in it starts trouble. And anyway there are 30 million people it doesn't fit, like 7 million people in prison, 8 million mentally impaired, 11 million illegal immigrants. That's what you get into when you insist that "one size fits all". There might, there just might be, a trace of trying to succeed with Universal health coverage, when your main primary opponent with initials HC, failed so notably to get it passed when her husband was President.
The issue goes back to the Clinton Health Plan, so let's continue. You may remember it was never brought to a vote because Big Business walked out. The same thing happened this time, except it is stated that big business couldn't get ready for another year. That's a nice way of saying Big Business walked out a second time, but this President was too stubborn to see he was licked. I surmise that Big Business didn't want to pay for the uninsured twice. Particularly when they were being treated to unceasing attack in the Dodd-Frank legislation. Perhaps it wasn't realized that big business was already paying for the uninsured by having hospitals cost-shift the expense to their subscribers, but business knew that was true, and they didn't think it was fair to pay for it twice.
It's hard to know whether the big business will relent if Obamacare can demonstrate success by laying these extra costs on someone else. Or whether the people with pre-existing conditions will push the premiums unbearably high, and the insurance companies will drop out when it results in unsupportable losses for them. A death spiral, indeed.
A former director of Medicare recently said, "Obamacare isn't about healthcare reform. It's about coverage extension." If they had stayed with coverage extension for pre-existing conditions, it would have sailed through. As it stands, we have to have a civil war to get it right, the second time around.
A Fair Plan for Fire Insurance (and Health Insurance, too?)
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Philadelphia Fire Insurance Company
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The Fair Plan (sixth and Chestnut, Philadelphia) is a fire insurance company with unusual features. Someday, it is to be hoped some scholar will write a book about the highly mixed motives of the people who created it, compared with the unexpected ways it did or did not fulfill original expectations, of both its creators and its enemies. The Fair Plan only issues fire insurance on houses, if other insurance companies have turned that house down as a bad risk. But if the clients pass that simple test, they get fire insurance at standard rates. Such risky houses would normally draw higher premiums for fire insurance, but the Fair Plan ensures these risky houses at normal rates. Therefore, it loses money, which is made up by the other regular fire insurance companies in the state in proportion to the business they do, obviously thus raising the price of fire insurance for everybody. But in this way, Pennsylvania guarantees that everybody can get fire insurance at standard rates. Is this a good idea? Might this be a way to give health insurance to all those people who can't get health insurance? Let's talk about the Fair Plan.
We'll set aside discussion of whether the Fair Plan was a product of cynical politicians pandering for votes, or whether it was a noble gesture for fairness and equality for our poorer citizens. It very likely had elements of both motives in it, but that doesn't matter anymore. It's a form of hidden taxation, of course, and it has the result of making Fire Insurance seem more expensive in Pennsylvania than in other places that do their social work with real taxes. Go too far with that, and people will end up buying their insurance in Bermuda instead of boarded-up former fire insurance companies in Pennsylvania.
As the story is now told, the regular insurance companies had a choice of taking the "substandard" applicants in turn ("Assigned Risk") or creating a new company (Joint Underwriting Association). They decided they preferred the JUA. So a company was formed which specializes in nothing but bad risks, including a few arsonists and other unmentionables, but mostly poor people in bad neighborhoods. If we are ever thinking about following the Fair Plan model in health insurance, it would run the risk of being accused of creating a two-class healthcare system. But no one seems to bring up that rhetoric about fire insurance, primarily because there is a comparatively little intrusion of politics in the matter, and anyway they provide standard fire insurance at standard premium rates. This system is given orders to spread the extra cost of universal fire insurance out to the policyholders of all fire insurance, and it does it very efficiently, without extending its mandate into setting firefighter wages, running fire departments or repainting scorched woodwork. The fundamental decision was whether to spend Society's money this way. Once that decision is taken, the task is to do it efficiently. Notice, this is not compulsory fire insurance; it is compulsory availability of fire insurance.
After the Fair Plan had been running for ten or so years, a funny thing emerged. There were years when the Fair Plan made a profit! The fire insurance industry had absorbed the Fair Plan into their scheme of things and felt free to increase the number of applicants they rejected, during years when money was tight or business was bad. If you had compulsory availability of fire insurance, the provision of a company which could not refuse an application made it possible for every other company to refuse when it pleased. When the economy encouraged rejection, a better class of applicant came to the Fair Plan, which made the plan more profitable. When economic conditions reversed, this reversed, and the Fair Plan again lost money. For this reason, the insurance industry is very anxious to prevent the Fair Plan from becoming political or getting tangled up in worthy but extraneous ventures. And that's probably a good model, too, if we are considering adopting a similar system for the health insurance world: stick to your mission.
Since this simple, tested idea never seems to get into the discussion phase of present agonizing over health insurance for the uninsured, it's one clear sign that such discussions at present are not terribly serious.
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Three decades ago, before a lot of New Jersey voters were even born, the so-called Abbott decision ordered the state to distribute money to woefully underperforming school districts to give the kids a fair chance in life. But now, thirty years later, the money routinely goes to ten or twelve school districts, and the other five hundred are suffering from high taxes. The voters in the five hundred districts are angry and want some of their tax money to stay at home. But by any fair appraisal, the schools in the Abbott Districts are still deplorable, and a great many children are growing up without an educational chance in modern life. Both sides have a legitimate point, and neither will budge.
But now there arises an entirely different way of looking at the mess. Maybe money isn't the point, but education is the point. The purpose of the Abbott District money was not to give money fairly or unfairly. The purpose of the money was to educate children, so at least they wouldn't grow up to a life of poverty and crime. In a sense, it doesn't much matter how unfairly the money is distributed, just so the kids get an education. Do they?
Frankly, it doesn't look as though they do. After thirty years, it is not hard-hearted to say the burden of proof is on those who say the money did some good. The very least that everyone ought to agree on is to perform a library search for other ideas, like charter schools, and report to a Legislative committee, followed by taking testimony from places with experience with other ideas. Because the real issue is not, how long we go on spending this money. It is, or ought to be, how long must the kids wait before something better is given a chance?
These are not easy issues. Our forebears didn't do such a wonderful job with assimilating the American Indians, but surely we can do better than that. With this horrible example before us, we cannot really expect the problem to solve itself. Nor is it a purely local problem; plenty of big cities have the same issue in a slightly different form. How are charter schools doing, for example? I have every confidence that if the local Camden County community, or even the whole State of New Jersey, could show some important progress -- money would come pouring in to help a winning project. But to keep on with the same old ideas is going to get you the same old results.
If there is a permanent moral to this vexed affair, here is the one that sticks to me. The Abbott decision seemed to be based on fundamental principles of fairness. But it could also have been described as an educational experiment, and all experiments contain a risk of failure. When courts make such an innovative decision, politics will soon lock it into place for many years longer than it takes to recognize it was a failed experiment -- if indeed it was a failure. Therefore, it is best for such experimental court decisions to set a time limit for later review and revision. Almost anyone would say this time period should be less than thirty years. Otherwise, such matters should be left to the Legislature, which is at least subject to frequent elections and can more easily devise modifications.
Fisher on Proposed Economic Zones
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Governor Christie
There's an idea that politicians are all negative characters, saying nasty things. That's probably because the public only listens to them during the last week of a campaign, when campaign advisors urge them that negative works best. So, here's a positive idea. And it comes from Camden County Republicans.
There's no doubt New Jersey is in a fiscal squeeze. Our property taxes are second-highest in the nation, but our municipal bonds are regarded as risky unless we raise taxes or cut spending. If we raise taxes, people will move to other states. In fact, we mainly haven't lost population because New York City is more heavily taxed, so New Yorkers move to New Jersey. Philadelphia has lost 40% of its population since the peak, and if you ask your neighbors, many of them moved from Philadelphia. Camden City just moved away, period. The people you don't talk to are the ones who have moved from New Jersey. So we are afraid to raise taxes, and we are a little afraid to cut them for fear the municipal bond market will strangle our borrowing power. Here's the proposal.
While we continue with Governor Christie's efforts to cut spending, like getting rid of those 800 paid Committees, and seeing if defined benefit pensions can be converted to defined contribution plans, and the like, let's cut taxes where it would help the most. The Camden County Republican proposal is to cut taxes in defined enterprise zones. If we can attract some new businesses into those zones, they and their employees would pay taxes, and the gamble might pay for itself. It might not, of course, but that's the risk any businessman takes when he makes an investment.
Right now, Exit 4 on the Turnpike is not in Legislative District 6, because the borders get shifted around by gerrymandering. But it's close, and most of the business activity it has created is within District 6, along the route toward Philadelphia. Most of the theory of business clusters suggests that a cluster of business activity is most sustainable when it contains a diversity of industries, but it needs a dominant industry to get started. Tom Booth suggests medical supplies already have a big start in our geographical area, and I can agree that eighty percent of the pharmaceutical industry is located within a hundred miles of us. Burlington County has demonstrated that you can keep everybody happy if you segregate commuters and farmers, which means helping the environmentalists and the businessmen at the same time. It really can be done and is being done by some of our neighbors. Not a bit of doubt you have to be careful about creating winners and losers, because that's where the graft comes from. But there's no doubt if you succeed, you will succeed big.
Cutting (some) taxes and helping the deficit at the same time. Just think of that. And think about 13% of unemployment in Camden County. We have to do something about that or it will destroy us.
Burlington Leads the Way
Somewhere in the past few decades, Burlington became quite activist. Although many tend to think of real estate planning as urban planning, this largely rural county went in for planning in a big way, deciding what it was and what it wanted to be. Generally speaking, its decision was to replace urban sprawl with cluster promotion. The farmers didn't like an invasion by McMansions or industries, while the towns lost their vigor through tax avoidance behavior of the commuter residents. Overall, the decision was to push urban development along the river in clusters surrounding the declining river towns, while pushing exurban development closer to logical commuting centers, leaving the open spaces to farmers. Incentives were preferred to compulsion, with a determination never to use eminent domain except for matters of public safety.
To implement these goals, two referenda were passed with 70% majorities to create special taxes for a development fund, which bought the development rights from the farmers and -- with political magic -- re-clustered them around the river towns. The farmers loved it, the environmentalists loved it, and the towns began to revive. The success of this effort rested on the realization that exurbanites and farmers didn't really want to live near each other, and only did so because developers were looking for cheap land. Many other rural counties near cities -- Chester and Bucks Counties in Pennsylvania, for example -- need to learn this lesson about how to stop local political warfare. Corporation executives don't want to live next to pig farms, but pig farmers are quite right that they were living there, first. When this friction seeps into the local school system, class warfare can get pretty ugly.
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Burlington Bristol Bridge
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In Burlington County, they thought big. The central project was to push through the legislature a billion-dollar project to restore the Riverline light rail to the river towns, along the tracks of the once pre-eminent Camden and Amboy Rail Road. It was an unexpected success. During the first six months of operation, ridership achieved a level twice as large as was projected as a ten-year goal. Along this strip of the Route 206 corridor, the old Roebling Steel Works are becoming the Roebling Superfund Site, now trying to attract industrial developers. The Haines Industrial Site originally envisioned as a food distribution center was sold to private developers who have created 5000 jobs in the area. Commerce Park beside the Burlington Bristol Bridge is coming along, as are the Shoppes of Riverton and Old York Village in Chesterfield Township. As Waste Management cleans up the site of the old Morrisville Steel plant across the Delaware River, a moderate-sized development project is becoming an interstate regional one.
No doubt there will be bumps in these roads; the decline of real estate prices nationally is a threat on the horizon, because it provokes a flight of mortgage credit. It works the other way, too, as banks decide to deleverage by reducing outstanding loans; this is the way downward spirals reinforce themselves. And anyone who knows anything about all state legislatures will be skeptical about political cooperation in a state as tumultuous as New Jersey. The Pennsylvania Railroad destroyed the promise of this state once; some other local interest could do it again. Nevertheless, right now Burlington County looks like a real winner, primarily because of effective leadership.
Harry Kaufman is now long gone, but for decades he represented the volunteer spirit of Haddonfield and the earnest, innocent happy way it contributed the essence of conflicted memories of its Revolutionary origins. The last time anyone counted, there were forty-two direct descendants of Elizabeth Haddon living in the borough, for example, and in a quiet determined manner, they keep alive the Quaker heritage of a non-Quaker town. For example, Harry made his living as a public relations officer for the milk industry. During World War II the Nicholson family who arrived here before William Penn still had a vast dairy farm with its own port on the Cooper River. It was located where Stoy's Landing Road crosses Grove Street, where there used to be something called the Race Track Circle, in honor of the Garden State Race Track which followed the dairy farm, and preceded the big-box shopping center which is still there, without the circle. New Jersey still has over two hundred traffic circles, and those who grew up here remember them as part of the New Jersey heritage, each one characteristically having a diner restaurant, also a Jersey invention and tradition.
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Plays and Players in Haddonfield, NJ
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Harry Kaufman may not have started the Plays and Players of Haddonfield, but he certainly sparked it to a near-professional level in a town of 7000 people. The orchestra and the ballet company are particularly outstanding at the moment, the soloists on the stage quite good, although they never made the grand European tour which is thought to be the prerequisite for getting into the big time. Harry was the life of any party, and particularly good at composing little ditties, never quite getting around to stringing them together into a musical comedy until the 250th anniversary of the town. Even then, it is recalled he was shy and reluctant and had to be pushed a little. Since The King's Road appeared shortly after Oklahoma! transformed, even revolutionized, American musical comedy, it was not only the model but the stimulus for a similar comedy celebrating the beginnings of our little state. The plot was a simple one of a conflicted love affair. The striking innovation of Oklahoma! was to crowd most of the show's songs into the first act, repeating snatches of their themes as sort of Wagnerian background commentary throughout the remainder of the play. The other innovation of what was originally called Green Grow the Lilacs was the addition of Agnes DeMille's ballet company to emphasize the real historical theme with light-hearted music. Since I was one of the original reviewers for Oklahoma! in its New Haven tryouts, I can remember the revolutionary impact of that play, very well.
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Anthony Wayne
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Harry had to go to the Historical Society for authentic details of the conflict between the attraction for Revolutionary aspirations for Liberty, and loyalty to the earlier sufferings of Quakers for their pacifist leanings. Some Quakers deserted their faith to join the Revolution, and other Quakers tried to convert the Hessian soldiers. And still, others were loyal to the King of England. The Revolution was almost won at this moment, as the British occupants of Philadelphia had abandoned their supplies to attack, and had to get to the British fleet, bottled up in the lower Delaware River by fortifications at Fort Mifflin and Fort Mercer on the Jersey side of the river. The Hessians had been sent to attack Fort Mercer from the rear, passing through Haddonfield and stopping one night before going on to what we now call National Park. While the Hessian officers were being entertained by John Gill with discussions of the futility of war, Jonas Cattell slipped out of town and ran to alert Fort Mercer of its danger. The guns of the Fort were turned around, and the defenders pretended not to notice the approach of the Hessians until they were ambushed and largely destroyed. If Fort Mifflin on the Pennsylvania side of the Delaware River could have held out, the starving British might have had to surrender, but that didn't happen. In any event, the New Jersey Militia did its part, and little Quaker Haddonfield helped them in a sort of characteristic Quaker way. With a ratta-tat-tat and a fiddly dee, the rag-tag swallow-tail Jersey Militia got all the credit.
The play does not emphasize that the State of New Jersey was founded at the Indian King Tavern during these commotions, or that General Washington starving at Valley Forge sent Mad Anthony Wayne to circle up and around Trenton to drive a herd of cattle back from Salem County, two hundred miles back to Valley Forge. The British sent Captain Simcoe down to Salem County to massacre the Quaker farmers who provided the cattle. These later developments are only mentioned in its anthem to "Generals Wayne, LaFayette, and Pulaski", and every good resident of Southern New Jersey is supposed to know what that is all about.
The Quaker historian Rufus Jones established the enduring tradition that this split is what ultimately reduced the Quakers from the dominant religious group to a small religious sect in the three states once owned by William Penn, Delaware, Pennsylvania, and New Jersey. Related to such turmoil was the claim that more battles of the Revolution were fought in New Jersey than in any other state; if you include the large privateer navy going to see from the Jersey Pine Barrens, that is probably true. And every twenty-five years or so, we have to put on a revival of "The King's Road", and just show 'em.
State and Federal Powers: Historical Review
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John Dickinson of Delaware
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It was expedient to leave certain phrases in the Constitution intentionally vague, but the overall design is clear enough. Just as twenty-eight sovereign European nations now struggle to form a European Union, thirteen formerly sovereign American colonies once struggled to unify for the stronger defense at a reduced cost. Intentionally or not, that created a new and unique culture, reliant on the constant shifting of power among friendly rivals. Everybody was a recent frontiersman, trusting, but suspicious. It still takes newcomers a while to get used to it.
So the primary reason for uniting thirteen colonies was for a stronger defense. As even the three Quaker colonies of New Jersey, Pennsylvania and Delaware could see, if you are strong, others will leave you alone. In time, the unification of many inconsequential behaviors created a common culture of important ones; and in time that common culture strengthened defense. At first, it seemingly made little practical difference locally whether construction standards, legal standards, language and education standards and the like were unified or not. Except, that in the aggregate, it forged a common culture.
The practice of Medicine was certainly one of those occupations where it mattered very little whether we were a unified nation. Unification of medical care offered a few benefits, but mostly it didn't matter much, right up to 1920 or so. Even then I would offer the opinion, that unification of the several states (with consequent Free Trade) only made a big difference to health insurance, and still made little difference to the rest of medical care. In fact, there are still about fifteen states with too little population density to provide comfortable actuarial soundness for health insurance, as can readily be observed in the political behavior of their U.S. Senators. Although the number of low-population states gets smaller as the population grows, there are even so perhaps only ten big states where multiple health insurance companies can effectively compete within a single state border. Quite naturally the big-state insurers expect one day to eat up the small ones. By contrast, the nation as a whole, the gigantic population entity which Obamacare seeks to address, has far too many people spread out over far too large an area, to be confident we could unify them into one single program. Dividing the country into six or seven regions would be a much safer bet. That's the real message of the failure of the Computerized Insurance Exchanges -- far too much volume. And the coming failure of the Computerized Medical Record -- with too much complexity. With unlimited money, it can be done, because diseases are disappearing and computers are improving. But why struggle so hard?
It is at least fifteen years too early, and mostly serves the interest of insurance companies, if they can survive the experience. At the same time, we are at least fifteen years away from growing the smallest states to the point where we could decentralize. It's really a situation very similar to the one John Dickinson identified, James Madison briefly acknowledged, and where Benjamin Franklin improvised a solution. In their case, it was a bicameral legislature. In the case of medical care, it could be an administrative division of revenue from the expenditure. It could be the cure of a half-dozen chronic diseases. It could be six regional Obamacare. But creating one big national insurance company during a severe financial recession is something we will be lucky to survive.
Returning to the Constitutional Convention, an additional feature was added to the tentative 1787 document to respond to protests from small component states. They objected that whatever the big-state motives might be, small states would always be dominated by populous ones with more congressmen if a unicameral Legislature is made up of congressmen elected by the population. Pennsylvania had recently had a bad experience with a unicameral legislature. So a compromise bicameral legislature (with differing electoral composition in the two houses) was added to protect small-state freedoms from big domineering neighbors. Even after the Constitution was agreed to and signed, the states in ratifying it still insisted on a Bill of Rights, especially the Tenth Amendment, elevating certain citizen prerogatives above any form of political infringement, by any kind of a majority. These particular points were "rights"; individuals were even to be insulated from their own local state government. The larger the power of government, the less they trusted it.
John Dickinson of Delaware, the smallest state, soon made the essential point abundantly clear to a startled James Madison, when he pulled him aside in a corridor of Independence Hall, and uttered words to the effect of, "Do you want a Union, or don't you?", speaking on behalf of a coalition of small states. It was probably galling to Dickinson that Madison had never really considered the matter, and went about the Constitutional Convention airing the opinion that, of course, the big states would run things. Dickinson, who had been Governor of two states at once, had observed the effect of this attitude and wasn't going to have more of it.
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Delegates
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Benjamin Franklin, who for over 40 years had been working on a plan for a union of thirteen colonies (since 1745, long ago producing the first American political cartoon for the Albany Conference), devised the compromise. It was essentially a bicameral legislature -- with undiminished relative power in the Senate for small states. In this backroom negotiation, it was pretty clear Franklin held the support of two powerful but mostly silent big-state delegates, Robert Morris and George Washington. These were the three men of whom it could be said, the Revolution would never have been won without each of them. In 1787 they were still the dominant figures in diplomacy, finance, and the military. All three were deeply committed to a workable Union, each for somewhat different reasons. Now that a workable Union was finally within sight, parochial squabbles about states rights were not going to be allowed to destroy their dream of unity.
And so it comes about, they gave us a Federal government with a few enumerated powers, ruling a collection of state governments with regional power over everything else. And since big-state/small-state squabbles are unending, almost any other solution to some problem repeatedly, seemed preferable to disturbing what holds it all together. On the other hand, the Industrial Revolution was beginning at about the same time, and people who recognized the power of larger markets almost immediately set about attacking state-dominated arrangements, systematically weakening them for a century, and redoubling the attack during the Progressive era at the end of the 19th Century. Attacks on what seemed like an abuse of state power, the power to retain slavery, and later the power to perpetuate white racism, were claimed to justify this attrition of states rights. The ghost of the Civil War hung over all these arguments, restraining those who pushed them too far.
However, the driving force was industrialization, with enlarged businesses pushing back against the confinement of single-state regulation within a market that was larger than that. This restlessness with confining boundaries was in turn driven by railroads and the telegraph, improving communication and enlarging markets, which offered new opportunities to dominate state governments, and when necessary the political power weakens them. One by one, industries found ways to escape state regulation, although the insurance industry was the most resistant, whereas local tradesmen like physicians found it more congenial to side with state and local governments. The 1929 crash and the Franklin Roosevelt New Deal greatly accelerated this dichotomy, as did the two World Wars and the Progressive movement from Teddy Roosevelt to Woodrow Wilson. The Founding Fathers were said to have got what they wanted, which was a continuous tension between two forces, supporting both large and small governments; with neither of them completely winning the battle.
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Insurance Monopoly
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The medical profession further evolved from a small town trade into a prosperous profession during the 20th century, but the practice of medicine remained comfortably local. Even junior faculty members who move between medical schools quickly come to realize their national attitudes are somewhat out of touch with local realities. For doctors, state licensure and state regulation remained quite adequate, and state-regulated health insurance companies paid generously. State-limited health insurance companies had a somewhat less comfortable time of it, but the ferocity of state-limited insurance lobbying, as exemplified by the McCarran Ferguson Act, perpetuated it. The medical profession watched uneasily as the growth of employer-paid insurance extended the power of large employers over health insurance companies beyond state boundaries, and thus in turn over what had been medical profession's kingdom, the hospitals. And the medical profession also had to watch increasing congeniality with big government extend through businesses, unions and universities, fueled by overhead allowances of federal research grants and finally in 1965, federal health insurance programs. Nobody likes his regulator, but national organizations inevitably prefer a single regulator to fifty different ones. Furthermore, everybody could see that health care suddenly had lots of money, and naturally, everybody wanted some.
There is nothing naturally inter-state about medical care -- except health insurance.
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It was all very well to pretend that health care was out-growing local-state regulation, but those on the inside could uneasily watch the federal/state competition for control, with the federal government repeatedly stacking the deck more in its own favor. Aside from federal program interventions, there is still nothing naturally inter-state about medical care -- except health insurance. Doctors, hospitals, and patients all tend to remain local, but insurance can easily cross state lines if regulation permits. Even in insurance, small states have difficulty maintaining actuarial stability, driving health insurance toward one-state monopolies. With a few big-state exceptions, even most health insurance companies prefer single-state monopoly status to federal regulation because it facilitates marketing. To praise the virtues of insurance competition is fine, but if sharing the local market means struggling for adequate risk reserves, nationwide regulation will inevitably lead to domination by a few big-state insurance companies. Small-state insurers would enjoy access to a national market; but blocked from it, they need to retain a local monopoly to survive. Fleeting thought might be given to Constitutional Amendment, but there are probably always going to be enough states which consider themselves small, to block the two-thirds requirement for Amendment. Imposing nationwide uniformity by force would possibly improve standards, but uniformity is increasing rather than decreasing, so the argument is not a strong one.
To be fair about it, there was not a strong case for state regulation, either. It could have been argued that uniformity and reduced administrative costs favored central regulation over-dispersed control, because of improved efficiency; and few would have argued about it. Until the ACA insurance exchanges crashed of their own weight around the ears of hapless creators, that is, unable to do what Amazon seems to do every day, and raising quite a few embarrassing recollections. Recollections of the mess the Sherman Antitrust Act inflicted on local medical charity in Maricopa County, Arizona. Recollections of the "Spruce Goose" airplane that Howard Hughes made so big it couldn't fly. Recollections of the gigantic traffic jam strangling the District of Columbia every weekend. And, reminders that 2500 pages of legislation remain to be converted into 20,000 pages of regulations which it would take a lifetime to understand. Suddenly, let's face it, retaining state regulation of health care, or not rocking the boat, gets a lot better press. It might even work better than the national kind, especially in an environment where no one expected a perfect solution, and just about everyone had heard of the Curse of Bigness. When we first discovered that use of health insurance added 10% to the cost of health care, it had seemed like an easy place to extract 2% of the Gross Domestic Product for better things, just by streamlining administration. But after the health exchange fiasco, some people begin to wonder if 10% is just what it costs to use insurance to pay for healthcare. If that is the case, perhaps we should look at other ways of paying our bills, not just a different regulator. Nobody would pay 10% just to have his bills paid, if he understood what he was doing.
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.
