The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
Among the many churches centered in Philadelphia, the Swedenborgian is probably the least typical and most difficult to understand. The church does not actively seek out a new membership, but it welcomes everyone, in the spirit of Emanuel Swedenborg's observation that "All people who live good lives, no matter what their religion, have a place in Heaven." Without attempting to define the teachings of Swedenborg (1699-1772), who was quite able to speak for himself, it can be approximated that Heaven plays a central role in this belief system, and predestination does not. Although the ceremonial features of this religion are very similar to the Episcopal Church, its main emphasis is on good works as a way of attaining the reward of Heaven. In some ways, that is an unexpected position for a noted scientist like Swedenborg to take, since generally scientists lean toward Calvinism, with the mechanistic view that if God is all-powerful, then human free will must be impossible.
cross
There are at least four divisions of the Swedenborgian religion, but the Bryn Athyn branch is most notable in the Philadelphia region. A very wealthy adherent of Swedenborg named John Pitcairn bought a large tract at Bryn Athyn and gathered the local church to live around a perfectly magnificent cathedral and church school. It is hard to think of any church in the Philadelphia region which approaches the magnificence of the Bryn Athyn cathedral. It has a special character that it was conceived and built during the crafts movement of the early twentieth century, with imported European workmen deliberately organized like medieval craft guilds. The central features of this workmanship reflect and then project the belief in personal individuality within the whole religion. No two windows, or doorknobs, or carvings are the same in the cathedral, reflecting the wish for each workman to devise his own unique creation and show the way of personal responsibility to the faithful. This cathedral is one of the things in the Philadelphia region most worth visiting, but to appreciate its quality you have to know what you are looking at.
Everybody in this church is unexpectedly hard to characterize. The Pitcairn Foundation was such a successful investor that it formed a mutual fund for others to share in its good fortune. Its central philosophy is to invest only in corporations which have been dominated by a single family, preferably the founding family, for at least fifteen years. There are about six hundred eligible corporations, and recent management scandals in the newspapers illustrate the Pitcairn's exactly knew the dangers of handing your assets over to a hired manager. This family-centered investing approach consistently yields better than the S & P 500, which in turn beats ninety percent of investment managers. You sort of get the idea you know where this family is coming from when you meet a courtly, meek, retiring but friendly person, who can say, "My mother is the only person I ever met who looked perfectly at home seated under a sixty-foot ceiling."
Helen Keller
Two other famous Swedenborgians illustrate the unusual individualism of this religion. Helen Keller, the deaf-blind girl who overcame her handicap by going to Radcliffe and becoming a successful author and lecturer, for one. The other would be Johnny Appleseed (1774-1845), whose real name was John Chapman. Grammar school legends would have this bearded, barefoot vegetarian adopting a life of poverty like St. Francis, but in fact, he was an extremely shrewd businessman who died rich. He developed the business plan that American settlers would be going West into what was then the Northwest Territory, and having a tough time getting enough to eat the first year or two. So, he anticipated the paths of frontier settlement, and went ahead among the Indian tribes, planting apple trees. When the settlers arrived in the region, he sold them young apple trees and showed them what to do with them. Apples grown from seed are not the tasty morsels we know today but tend to be rather shriveled and bitter. So Johnny showed them how you make cider, and if you let it sit around a while, hard cider. The settlers would use the pulpy squeezing for compost, and he would be back to collect the seeds from them so he could continue his business plan in the next county. In short, he showed them how to drink the apples. He also let the Indians pick the apples, so they liked him and spared him the common troubles of the frontier.
If you are going to boil apples, you need a pot, and Johnny often carried his like a hat. He wasn't a nut, at all, he was a showman. In his backpack, he was also carrying a Bible. And in his head, he carried a motto, "All religion has to do with life, and the life of religion is to do good."
MEETING OF THE SHAKSPERE SOCIETY OF PHILADELPHIA AT THE FRANKLIN INN CLUB, APRIL 2, 2003
Dean emeritus Hopkinson in the chair. Other members present: Bartlett, Bornemann, Cramer, Di Stefano, Dobson, Fallon, Friedman, Griffin, Lehmann, Mabry, Madeira, O'Malley, Peck, Pickering, Schmalzbach, Warden, Wheeler.
Mr. Friedman presented those present with careful directions, in large font, to the Awbury Arboretum in Germantown, where we will
gather at the Francis Cope House for the annual Birthday Dinner on April 23. Our collective thanks again to our industrious hosts, Messrs. Friedman, Madeira and Pope. Members who wish to attend and have not yet responded to Mr. Pope are urged to do so with dispatch and gusto! Spouses and partners are again welcome; there is an additional cost, of course.
We had a vigorous discussion of the last act of The Taming of the Shrew. The Vice Dean reminded us that here the two plots'the wooing of Bianca and the taming of Kate by Petruchio'come together. Disguises again make good theater in these scenes, especially when the real and the false Vincentio confront each other and confound the other characters. Tranio robustly enjoys playing a rich man who is used to issuing orders and being quickly obeyed.
Meanwhile, Kate and Petruchio have ended their war. Has Kate given in? Have the two grown close and abandoned their mutual attempts to dominate? Petruchio insists on a public kiss; Kate demurs but quickly yields. Angry? Ashamed? Pleased? Teasing? Has Petruchio's shock treatment shown Kate that she has been outrageously willful and childish? Or has Kate simply provided good theater, both to the audience and to her family and her intended?
We talked at length about Kate's famous speech of submission, urging wives to yield utterly to their husbands' wishes, the price of happiness in marriage. The Vice Dean asked whether we accept this change in Kate in the theater. How should the speech be spoken? Ironically? Flirtatiously? Comic display to get laughs from her family and from us? Is the speech an example of absurd farcical hyperbole, or is it simply a forceful restatement of Elizabethan received ideas? A mixture? Sexy gamesmanship?
Kate makes this speech after two other new wives have refused to obey their husbands. Members asked whether Kate was continuing her earlier combat with Bianca, so pliable and admired until married! Can we believe Kate will live so submissively in the future? Should we wonder what their marriage will be like? The Vice Dean opined that we do not ordinarily ask such questions about the future at the end of any "comedy of marriage."
A member felt that Kate plays a game here, for Petruchio's enjoyment. She will play the role in an exaggerated way of the traditional Patient Griselda who has no will except her husband's, but she shows the wit and energy and playfulness that can make their marriage a joy, not just acting out of traditionally assigned social roles.
MEMBERS WILL MEET AGAIN ON APRIL 23 FOR THE 152ND ANNUAL SHAKSPERE'S BIRTHDAY DINNER, AT THE FRANCIS COPE HOUSE IN THE ASBURY ARBORETUM, 6:45 PM.
Now that health insurance has been mandated for everyone, it is an unnecessary irritant that some taxpayers will escape income tax for the amount of their premiums, while others will not, all based on what type of employer they have. While this inequity has been present for a long time, it necessarily changes character when the purchase of universal health insurance becomes a legal requirement. It looks as though some self-employed person will have to take this case of unequal justice under the law, all the way to the U.S. Supreme Court; and it is pretty hard to imagine arguments that would defeat the case.
This particular feature of our national health insurance muddle is now nearly seventy-five years old. It shows no sign of improving, although its solution would be very simple. The story of how Henry Kaiser during World War II enticed steelworkers to his California factories by evading wage and price controls is completely documented, widely understood, thoroughly deplored -- and seemingly impossible to change. When a book called The Decline and Fall of the American Empire is eventually written by a new Edward Gibbon, this situation might well be cited as an example of the inability of Americans to govern themselves.
Henry Kaiser
For those too young to remember, Kaiser was given a temporary exception to wartime wage and price controls by the War Production Board. He could buy health insurance for his employees, using his gift to entice East Coast steelworkers to move to his California shipyards. His company naturally took a tax deduction itself for the business expense, but somehow it was considered a forgivable ruse to skip withholding taxes for this virtual salary increase, and ultimately to skip income taxes entirely on this "fringe benefit". The maneuver was quickly copied throughout American industry. Although an attempt was made after the war to bring this legalized tax evasion to a halt, Congress discovered one political party supported Union labor, the other political party supported big business, and both of them urged the government to continue the contrivance against the rest of the public. Meanwhile, the war was over, but self-employed or unemployed citizens who asked to share it were denied the same right. Effectively, wages had been made higher for employees of large corporations than for the rest of the country, labor costs were made lower for their employers, and the arrangement was continued after the War had ended. Over the course of seventy subsequent years, there has never been a successful attempt to correct this inequity, which is turned back by the bellicose stance of organized labor to stand by its principle of never giving up any benefit, once it has achieved it. Management is generally more cheerful in defending this anomaly, but no less grim in its determination to retain it. Each of these combatants is happy to have the other side lead the fight and take the blame, but their positions are identical. Their true feelings are displayed in establishing a threshold limit of 7.5% of gross income for the tax deductibility of health care costs for everybody else. When the matter was last debated in Congress, the threshold was defiantly raised to 10%.
US War Production Board
The importance of the resulting inequity cannot be exaggerated. Subsequent enlargement of this tax beachhead into pensions and related fringe benefits has achieved a rough average of 35% of salaried income in big business, reinforcing the determination to protect it. However, this is probably not the way Big Business primarily looks at it. America has worked itself into a 60% combined state and federal income tax on corporations, consequently driving many corporations to relocate headquarters in countries like Ireland, with 12.5% tax. The Henry Kaiser tax abatement reduces employee costs about 15%, or well over a thousand dollars per employee. Since major employers have thousands of employees, the reduction of their costs brings an aggregate tax abatement to the employer in the many millions. The resistance of large employers to eliminating the Henry Kaiser tax abatement has many sources, but this looks to be the important one, by itself quite sufficient to convince almost any Board of Directors to acquiesce.
And thus, to sustain the employer-based model for health insurance in spite of its Job-lock implications. Congress sees it as too expensive to extend the same tax preference to those who are excluded, and too politically dangerous to take it away from those who have it. In a sense, Congress has a conflict of interest, because it reduces the effective cost of government employees. Two solutions are obviously quite simple: give the deduction to everyone, or else take it away from everyone. Meanwhile, this fraternity of tax-avoiders makes it virtually impossible for big corporations to get out of the employee health insurance business, encourages unhealthy fraternization between Human Resources executives and health insurance salesmen, raises the premiums of health insurance by roughly 30% for those who can least afford that cost, and supports the outlandish incomes of health insurance executives, once they have disposed of their inconvenient non-profit status. It cannot even be said that closing this tax inequity is a side benefit of mandatory insurance since it seems to have survived the enactment of Obamacare.
However, recognition of corporate income tax effects on "inversion", puts the matter as one of national interest in reducing the incentive for major corporations to move abroad, which would be a decisive argument almost anywhere but in a violently divided Congress. One would not blame Congress for studying the other unintended side effects of lowering corporate taxes one way or another, even though they have slid gradually into this situation over seventy years. Nor could one much blame the corporate CEOs from deciding to keep quiet about an issue so much in their present favor. But this is an election-deciding issue under certain circumstances, and it will be no respecter of persons if some candidate decides to make an issue of it.
Since the elimination of tax "loopholes" has become one of the foundations of other proposed tax reforms, there was some hope this parallel reform movement might overlap with healthcare insurance reform, since the "loophole" was really created for circumstances which have long disappeared. Many of the surprising quirks of the health insurance system today can be traced to Henry Kaiser's little scheme of the 1940's. And many quirks would probably inexplicably disappear if this particular tax situation reverted to something equitable. For instance, if you are looking for the explanation for strange behavior by employees, it is called "Job lock", and it is a creature of this tax law. If you lose your job, you lose your health insurance, and if you choose the wrong sort of new employer, you lose the tax deduction. Health insurance remains a one-year term system, and therefore scarcely anyone can envision the potential for permanent lifetime insurance, with internally compounded interest income, such as is seen in whole life insurance. To understand the consequences, just imagine being told you would lose your life insurance if you changed jobs.
Shortly before election last year, the papers were full of agitation about passing laws to require voters to identify themselves. That doesn't sound so burdensome, considering how teenagers pester you to get a driver's license when they reach a certain age. But, oh my goodness, it was a terrible thing to ask of voters who are barely able to crawl to the voting place, much too poor to afford a car, and grossly offended by the suggestion that anyone would dare to have such nasty suspicions. So, being new to the candidate business, I asked a few hardened old pros about it. Is there much voter fraud in Camden County? And if so, how is it accomplished?
For some reason, this innocent question was greeted with gales of laughter. When it settled down, two or three suggestions were offered. In the first place, said the old guy on a park bench, tell the poll watchers to be certain the voting machines have been set to zero before any voter uses them. How would requiring a driver's license prevent that kind of thing? It wouldn't; it depends on having poll watchers.
All right, what else? Well, there's the "old fashioned way". What that refers to is waiting until about an hour before the polls close, and there is nobody watching in the polling place because it's dinnertime. When the coast is clear, just take the list of registered voters who haven't yet voted -- and vote them for your party. Pretty smooth, right?
And if you would be required to write down the driver's license number for every voter, it's pretty easy to spot deficiencies when the results get challenged. So, maybe requiring some sort of ID would be effective, and wouldn't amount to frisking a citizen. And then, there's a law to mention.
In New Jersey, and maybe elsewhere too, a poll watcher is required to be a resident of his district. So, a little old lady with knitting is unlikely to want to watch the polls in some of the tougher districts. For this, both parties employ "flying squads" of some of the party faithful who look like professional football players. One beep on the cell phone and this squad come flying. Well, my Goodness me.
Written several months later:
Judge Richard Posner, whose writings I have come to admire greatly, was interviewed recently on television. Although he said he had written earlier that he saw nothing wrong with asking voters to identify themselves, he now reverses himself and concludes that voter identification laws prevent more people from voting than they prevent fraud. He bases this opinion on what someone tells him is credible evidence, but I'm afraid I neither believe the evidence nor think it is an important way to think about this issue.
I believe the most important issue is to have the public believe the elections were fair, so we don't get more civil disobedience stirred up by political "contractors", or in spite of heated fanaticism heating up in the last few days of an election. There are numerous examples of candidates who supported a fraudulent election of their opponent, rather than have his own supporters injure the reputation of our procedures. Somebody has to win an election, and the election has to be seen as final. In our system, any close election could probably be reversed by a well-managed recount and reversed again on re-recount. To discover large frauds, even if potentially balanced by improved enfranchisement, is to discredit the election process. And since there are many local polling districts near me which have not had dual poll watchers for twenty years, the suspicion of voter fraud in those districts is quite a natural one. I"m not sure what the issues are, surrounding the credibility of absentee ballots.
All I know is a lot of people are increasingly resorting to them because they distrust the conventional polling places. If that's what it takes to convince people the elections are fair, let's try it out wholesale in some districts where obtaining dual poll watchers has been difficult. Like Chicago, for instance?
The present state of healthcare legislation is, to put it delicately, immature. Both Health Savings Accounts and the Affordable Care Act are the law of the land, but the Obama Administration defiantly slipped in some regulations, and quietly slipped in others, which have no precise authorization in the law. Everything may claim to be mandatory, but until enforcement begins, neither enforcement nor appeal to the Supreme Court about constitutionality seems completely feasible. When no one has been injured, no one has "standing" in the eyes of the courts.
Funding the Deductible. For example, every one of the governmental "metal" plans has at least a $1250 front-end deductible, going up to $6300 for full coverage. Meanwhile, non-government health insurance is rapidly replacing copay with high deductibles, too. (Co-pay is the main cause of supplemental insurance, a doubling of administrative burden.) Unless a person is eligible for the subsidy, this mandatory large deductible makes the insurance hard to use unless the individual has saved up some cash for his deductible, somewhere else. So why not provide a tax incentive to have the deductible in escrow? At the moment, Health Savings Accounts are the only feasible approach to this goal, but that does not exactly mean they have been authorized to do so since double coverage is more or less frowned upon. The deductible means nothing until you get sick, so Obamacare gave itself a few years to figure this out, but the public is apparently in jeopardy if it tries to invent a workaround. It begins to look as though the voters may not give the originators of this plan enough time in office to see this as a problem they must address. So, if this is going to be everybody's problem, why not see if the Health Savings Account can offer to do it. By doing so, the individual apparently must drop his existing insurance, so go figure.
By accident or by design,
All Obamacare policy choices have high deductibles.
The Bronze Plan is Cheapest
People who have no illnesses, naturally have little present concern with ambiguities in health insurance. But health insurance will matter as soon as illness appears. Therefore, the present state of limbo will increasingly be of concern to more people. Seemingly, there is a race between the three branches of government to start an action. Either a compromise must be reached between the Executive and Legislative branches, or else the Courts will be forced to intervene by some injured person. Curiously, the only Justice to express displeasure with the present Constitution is Ruth Ginsburg, whose two cancers make her likely to be the next Justice to retire.
A piggy-bank for Millennials. Whatever someone may think of Obamacare, the front-end deductibles provide a pretty substantial incentive to maintain at least $1250 per person cash reserve somewhere, and an HSA would be just a wonderful place to keep it. If that is somehow blocked, an IRA would be almost as satisfactory. If Congress addresses the matter, an IRA could later add a feature to roll over the deductible from such IRAs to HSAs. If the individual avoids spending what is in the HSA, it eventually will revert to an IRA on attaining Medicare eligibility, anyway. Calculating a 10% investment return, age 25, and assuming no medical expenses, it might then have grown to $51,000 taxable, or somewhat less if lower interest rates are assumed. For someone who stays healthy, its minimum distribution as an IRA at age 65 would start paying a taxable retirement income of over $775 a year. That's pretty good for an investment of $1250. Obviously, everybody older than 25 gets less, but in no case does anyone get less than the $1250 he/she put in, just to cover a possible deductible. The issue of the high investment return is taken up in Section Four. As will then be seen, there are two issues: whether such a return can be safe and consistent; and whether hidden fees will undermine the return.
It's true you can't spend the same money twice. If the fund is depleted by spending for a deductible, it must be promptly and fully replaced to keep the fund growing. However, Aetna studied and GAO confirmed, that only 50% of enrollees in employer-sponsored HRAs withdrew any of their funds (which might have been used for outpatient as well as high-deductible purposes). Apparently, these clients were more anxious to preserve the tax shelter, than to protect their health, which is a slant I hadn't considered. This was true, even though the employers' efforts to enhance the compound income were not particularly strenuous. In a sense, it is a flattering sidelight on the frugality of many Americans. But the power of compound interest lies in re-investing the profits, so reasonably prompt restoration of the enhanced principal would not materially reduce the final outcome, just so long as internal profits remained untouched. It would be fairly simple to impose this requirement, creating a distinction between "balance" and "available balance", but doing things for people's own good, is always a questionable adventure.
We mentioned earlier, Roger G. Ibbotson, Professor of Finance at Yale School of Management has published a book with Rex A. Sinquefield called Stocks, Bonds, Bills and Inflation. It's a book of data, displaying the return of each major investment class since 1926, the first year enough data was available. A diversified portfolio of small stocks would have returned 12.5% from 1926 to 2014, about ninety years. A portfolio of large American companies would have returned 10.2% through a period including two major stock market crashes, a dozen small crashes, one or two World Wars hot and cold, and half a dozen smaller wars involving the USA. And even including one nuclear war, except it wasn't dropped on us. The total combined American stock market experience, large, medium and small, is not displayed by Ibbotson but can be estimated as roughly yielding about 11% total return. Past experience is not a guarantee of future performance, but it's the best predictor anyone can use. The supply of small-cap stocks is probably a limiting factor. As we will see, your money earns 11%, but that isn't necessarily how much its owner will earn. But inflation throughout the period remained close to 3%. In this sense, the income net of inflation was never higher than 9%, so we have to presume 9% sets a theoretical limit to what can be achieved by passive investment, even after heroic efforts to reduce middle-man costs. Most of our estimates are based on 6.5%, and most investment managers produce less than that. Nevertheless, very substantial program gains are possible in every tenth of a percentage point which can be further squeezed out. The next candidate for streamlining cost is the Catastrophic insurance premium.
Catastrophic insurance has not been popular for many decades, so presumably, there is room for competition to reduce premiums, marketing costs, profit margins, and other conventional competitive tools. The reimbursement to hospitals has suffered from favoritism directed toward some of its client corporation groups, who indirectly force Catastrophic to absorb some of their costs. And finally, there is likely to be overlapping provision for the same costs in a year-to-year system, which might be wrung out by five-year, ten-year or even lifetime policies. One can see potential economies on every side, but they will not come easily. In the long run, a perfect system might generate the revenue equivalent of 10.5% as a top limit instead of 9%. As everybody came up to speed, the potential is there for easily managing what might now be borderline achievable results. In fifteen years, that is. In the meantime, we will have to be satisfied with less ambitious projections for our present approach of term insurance.
So, in the meantime, we take things in a different direction, based on the whole-life insurance model. But one point may not be so clear: the Savings Account part of HSA is already lifetime, in the sense of rolling over and accumulating after-tax income for the rest of life. So for that matter, Catastrophic high-deductible insurance would be an easy next step, requiring only some adjustment of the present unfortunate tendency to assume an equivalence between "mandatory" and "exclusively mandatory". Money is money, and the courts will have to decide what sort of entirely fungible money is satisfactory for meeting minimum, maximum or any other coverage requirements. Since the "metals" plans all have high deductibles, but also have unduly high premiums, it seems likely the idea was to force insurance premiums to cover the subsidies for the uninsured. Such confusions of language and intent are ordinarily corrected by technical amendments. At age 66, right as it now is, every HSA turns into an IRA for retirement purposes. But up until age 65, it can be used for medical expenses, getting a second tax deduction. We are close enough so that changes to enable a whole-life approach are imaginable, but not yet feasible.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
