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.
In the 1954 case of Brown v. Board of Public Education, Chief Justice Warren wrote an opinion for the U.S. Supreme Court (347 U.S. 483), overturning the 1896 doctrine of "separate but equal" in public school systems which the Supreme Court had laid down in Plessy v. Ferguson, 163 U.S. 537. Warren famously declared that separate was inherently not equal. The Brown decision did not extend to all public accommodations, or even to all schools. It was limited to public schools. Furthermore, in explaining why it took half a century for the Court to discover this principle, Warren pointed out the schools in the South were largely private schools at the time of the Plessy opinion, since the movement toward free common schools, supported by general taxation, had not yet taken hold. The central point in all this was that Brown desegregated public schools and nothing else. Therefore, when the case of Stephen Girard's will ("poor, white, orphan boys") came back before the Court, the issue was whether Girard College was a public school because Girard's will designate the City and State to appoint the trustees.
Girard College
The first black plaintiffs to seek admission to Girard College, at least in response to the Brown v. Board decision, were represented by Raymond Pace Alexander, a black member of Philadelphia City Council. Alexander maintained that the College's racial discrimination, employing the supervision of City and State governments, was unconstitutional. Since Alexander was plainly interested in the education of black students generally, it was important to stress the public school issue. Otherwise, invalidating many wills, and the policies of many private schools, would have been harmful to black students. For example, the Annenberg Foundation has donated $52 million to the United Negro College Fund, the W.K. Kellogg Foundation: $58 million for higher education for Hispanic and Native Americans, the Lilly Endowment: $92 million for the Hispanic Scholarship Fund and United Negro College Fund. The largest such private racially segregated donation is from Bill and Melinda Gates: $1 billion annually for 20 years for full scholarships for black, Hispanic, Native American and Asian students, seeking degrees in engineering, mathematics, science, and education. In the course of protracted litigation, it became clear that the Supreme Court's Brown decision could not be completely reconciled with its 1844 decision (Vidal v Girard Executors, 43 U.S. 127, upsetting the arguments of Daniel Webster) reaffirming all the language of the Girard Will. Girard made Girard College an essentially private school financed by private money. But the choice of the City and State to appoint trustees did create a degree of public involvement. Faced with challenging litigation, the courts would have to invalidate some feature or other of the will to maintain strict conformity with Brown v. Board of Public Education. Which choice -- admit black boys and girls, or find a different way to appoint trustees? Since the trustees selected by other means would very likely be exactly the same people, the choice seemed an easy legal one. The political choice was more difficult.
Raymond Pace Alexander
At first, the Supreme Court seemed to be taking the approach of changing the method of selection of trustees. They deflected (remanded) the matter to the Pennsylvania Supreme Court, which in turn remanded it to the Orphans Court in parallel with a newly-legislated power of the Orphans Court to appoint substitute trustees. The Girard case was headed for the conclusion that Orphans Court should either appoint new trustees or define a way to appoint them. Without the political appointment of trustees, Girard College was a fully private institution, unconcerned with the constitutionality of the Plessy decision, or with the Brown repeal of it.
However, further litigation ensued, with a new focus for the U. S. Supreme Court to ponder. The contention was made that Girard had two purposes in mind when he wrote the will. He wished to help the poor, white, orphan boys. But he also stated that he truly had the welfare of Philadelphia at heart, wishing to foster the prosperity of the City and the health and comfort of its inhabitants. Were these two distinct goals, or was the education of certain orphans a mechanism to enhance the welfare of the City? Involving the leading men of the city in the governance of the College, and acquiring the power and influence of its leading politicians might strengthen Girard College in many important ways. Could it be that the words about the general welfare were more than merely lawyer's boiler-plate? While the general public at that time and subsequently may well have regarded these pleadings as pretty specious, the critical audience for this case was made up of lawyers and judges, politicians and officials. The sitting judge had once volunteered to defend officers of the Communist Party against the charge that they advocated the overthrow of the government by force, so he was not afraid to adopt unpopular opinions. There has been no claim he was himself a Communist. But the viewpoints of immensely rich merchants were likely of secondary importance to him, especially by comparison with City Councilmen.
Judge Joseph S. Lord, in what turned out to be the final judicial opinion, seemed to emphasize a slightly different slant. If Girard had to make the choice now facing the court, between poor, white, orphan boys, and retaining the City as his surrogate trustee, Girard would have made the choice to retain the politician trustees. If that seems unlikely to a great many people, let's help him out a little. Let's suppose Girard the financial wizard could have the benefit of reviewing the first century of actual experience with his will. Is it not defensible to contend that the remarkable investment administration of the Board of City Trusts -- arguably just as effective as his own would have been -- would hold great appeal for this star of American investing? Would it not have been persuasive to this notorious micro-manager, that the quality of schools eventually depends more on who runs them, than on who is in attendance?
In any event, by 1968 after a long and complicated legal battle, the first black students were admitted. The case had reached the US Supreme Court, which declared the provisions of Girard's will were superseded by the Brown decision, and therefore the Trustees were permanently enjoined from denying admission of poor black orphans on the sole ground that they were not white, provided they are otherwise qualified for admission". In a second decision, the Court later added a second prohibition against the trustees denying admission to females.
The U.S. Supreme Court carefully specified that the trustees were the objects of its ruling since they were appointees of the State and Municipal government. In part, this precision had the effect of preserving the 1844 decision of the Supreme Court, upholding the provisions of the Girard will against Daniel Webster's assault, on behalf of Girard's other relatives and potential heirs. By taking a strict focus on the governmental appointment of the trustees, the Supreme Court was able to skirt the awkwardness of continuing the unhampered existence of a considerable number of estates and foundations devoted exclusively to the benefit of minorities.
In the reign of the young one who has succeeded his father in the kingship, lord of diadems, most glorious, who has established Egypt and is pious towards the gods, triumphant over his enemies, who has restored the civilized life of men, lord of the Thirty Years Festivals, even as Ptah the Great, a king like Ra, great king of the Upper and Lower countries, offspring of the Gods Philopatores, one whom Ptah has approved, to whom Ra has given victory, the living image of Amun, son of Ra, PTOLEMY, LIVING FOR EVER, BELOVED OF PTAH, in the ninth year, when Aetos son of Aetos was priest of Alexander, and the Gods Soteres, and the Gods Adelphoi, and the Gods Euergetai, and the Gods Philopatores and the God Epiphanes Eucharistos; Pyrrha daughter of Philinos being Athlophoros of Berenike Euergetis, Areia daughter of Diogenes being Kanephoros of Arsinoe Philadelphos; Irene daughter of Ptolemy being Priestess of Arsinoe Philopator; the fourth of the month of Xandikos, according to the Egyptians the 18th Mekhir.
DECREE. There were assembled the Chief Priests and Prophets and those who enter the inner shrine for the robing of the gods, and the Fan-bearers and the Sacred Scribes and all the other priests from the temples throughout the land who have come to meet the king at Memphis, for the feast of the assumption by PTOLEMY, THE EVER-LIVING, THE BELOVED OF PTAH, THE GOD EPIPHANES EUCHARISTOS, of the kingship in which he succeeded his father, they were assembled in the temple in Memphis on this day declared:
WhereasKing PTOLEMY, THE EVER-LIVING, THE BELOVED OF PTAH, THE GOD EPIPHANES EUCHARISTOS, the son of King Ptolemy and Queen Arsinoe, the Gods Philopatores, has been a benefactor both to the temple and to those who dwell in them, as well as all those who are his subjects, being a god sprung from a god and goddess like Horus the son of Isis and Osiris, who avenged his father Osiris, being benevolently disposed towards the gods, has dedicated to the temples revenues of money and corn and has undertaken much outlay to bring Egypt into prosperity, and to establish the temples, and has been generous with all his own means; and of the revenues and taxes levied in Egypt some he has wholly remitted and others has lightened, in order that the people and all the others might be in prosperity during his reign; and
whereas he has remitted the debts to the crown being many in number which they in Egypt and the rest of the kingdom owed; and
whereas those who were in prison and those who were under accusation for a long time, he has freed of the charges against them; and
whereas he has directed that the goods shall continue to enjoy the revenues of the temples and the yearly allowances given to them, both of corn and money, likewise also the revenue assigned to the gods from the vine land and from gardens and the other properties which belonged to the gods in his father's time; and
whereas he directed also, with regard to the priests, that they should pay no more as the tax for admission to the priesthood than what was appointed them throughout his father's reign and until the first year of his own reign; and has relieved the members of the priestly orders from the yearly journey to Alexandria; and
whereas he has directed that impressment for the navy shall no longer be employed; and of the tax on fine linen cloth paid by the temples to the crown he has remitted two-thirds; and whatever things were neglected in former times he has restored to their proper condition, having a care how the traditional duties shall be fittingly paid to the gods; and likewise has apportioned justice to all, like Thoth the great and great; and has ordained that those who return of the warrior class, and of others who were unfavorably disposed in the days of the disturbances, should, on their return be allowed to occupy their old possessions; and
whereas he provided that cavalry and infantry forces and ships should be sent out against those who invaded Egypt by sea and by land, laying out great sums in money and corn in order that the temples and all those who are in the land might be in safety; and having gone to Lycopolis in the Busirite nome, which had been occupied and fortified against a siege with an abundant store of weapons and all other supplies seeing that disaffection was now of long standing among the impious men gathered into it, who had perpetrated much damage to the temples and to all the inhabitants of Egypt, and having encamped against it, he surrounded it with mounds and trenches and elaborate fortifications; when the Nile made a great rise in the eighth year of his reign, which usually floods the plains, he prevented it, by damming at many points the outlets of the channels spending upon this no small amount of money, and setting cavalry and infantry to guard them, in a short time he took the town by storm and destroyed all the impious men in it, even as Thoth and Horus, the son of Isis and Osiris, formerly subdued the rebels in the same district; and as to those who had led the rebels in the time of his father and who had disturbed the land and done wrong to the temples, he came to Memphis to avenge his father and his own kingship, and punished them all as they deserved, at the time that he came there to perform the proper ceremonies for the assumption of the crown; and
whereas he remitted what was due to the crown in the temples up to his eighth year, is no small amount of corn and money; so also the fines for the fine linen cloth not delivered to the crown, and of those delivered, the several fees for their verification, for the same period; and he also freed the temples of the tax of the measure1 of grain for every measure2 of sacred land and likewise the jar of wine for each measure2 of vine land; and
whereas he bestowed many gifts upon Apis and Mnevis and upon the other sacred animals in Egypt, because he was much more considerate than the kings before him of all that belonged to them; and for their burials he gave what was suitable lavishly and splendidly, and what was regularly paid to their special shrines, with sacrifices and festivals and other customary observances, and he maintained the honors of the temples and of Egypt according to the laws; and he adorned the temple of Apis with rich work, spending upon it gold and silver and precious stones, no small amount; and
whereas he has funded temples and shrines and altars, and has repaired those requiring it, having the spirit of a beneficent god in matters pertaining to religion; and
whereas after enquiry he has been renewing the most honorable of the temples during his reign, as is becoming; in requital of which things the gods have given him health, victory and power, and all other good things, and he and his children shall retain the kingship for all time.
WITH PROPITIOUS FORTUNE: It was resolved by the priests of all the temples in the land to increase greatly the existing honors of King PTOLEMY, THE EVER-LIVING, THE BELOVED OF PTAH, THE GOD EPIPHANES EUCHARISTOS, likewise those of his parents the Gods Philopatores, and of his ancestors, the Great Euergatai and the Gods Adelphoi and the Gods Soteres and to set up in the most prominent place of every temple an image of the EVER-LIVING KING PTOLEMY, THE BELOVED OF PTAH, THE GOD EPIPHANES EUCHARISTOS, which shall be called that of 'PTOLEMY, the defender of Egypt,' beside which shall stand the principal god of the temple, handing him the scimitar of victory, all of which shall be manufactured in the Egyptian fashion; and that the priests shall pay homage to the images three times a day, and put upon them the sacred garments, and perform the other usual honours such as are given to the other gods in the Egyptian festivals; and to establish for King PTOLEMY, THE GOD EPIPHANES EUCHARISTOS, sprung of King Ptolemy and Queen Arsinoe, the Gods Philopatores, a statue and golden shrine in each of the temples, and to set it up in the inner chamber with the other shrines; and in the great festivals in which the shrines are carried in procession the shrine of the GOD EPIPHANES EUCHARISTOS shall be carried in procession with them. And in order that it may be easily distinguishable now and for all time, there shall be set upon the shrine ten gold crowns of the king, to which shall be added a cobra exactly as on all the crowns adorned with cobras which are upon the other shrines, in the center of them shall be the double crown which he put on when he went into the temple at Memphis to perform therein the ceremonies for assuming the kingship; and there shall be placed on the square surface round about the crowns, beside the aforementioned crown, golden symbols eight in number signifying that it is the shrine of the king who makes manifest the Upper and the Lower countries. And since it is the 30th of Mesore on which the birthday of the king is celebrated, and likewise the 17th of Paophi on which he succeeded his father in the kingship, they have held these days in honor as name-days in the temples, since they are sources of great blessings for all;
it was further decreed that a festival shall be kept in the temples throughout Egypt on these days in every month, on which there shall be sacrifices and libations and all the ceremonies customary at the other festivals and the offerings shall be given to the priests who serve in the temples. And a festival shall be kept for King PTOLEMY, THE EVER-LIVING, THE BELOVED OF PTAH, THE GOD EPIPHANES EUCHARISTOS, yearly in the temples throughout the land from the 1st of Thoth for five days, in which they shall wear garlands and perform sacrifices and libations and the other usual honors, and the priests in each temple shall be called priests of the GOD EPIPHANES EUCHARISTOS in addition to the names of the other gods whom they serve; and his priesthood shall be entered upon all formal documents and engraved upon the rings which they wear; and private individuals shall also be allowed to keep the festival and set up the aforementioned shrine and have it in their homes; performing the aforementioned celebrations yearly, in order that it may be known to all that the men of Egypt magnify and honor the GOD EPIPHANES EUCHARISTOS the king, according to the law.
This decree shall be inscribed on a stela of hard stone in sacred and native and Greek characters and set up in each of the first, second and third rank temples beside the image of the ever-living king.
1artabe, a Greek or Persian measure of 52 liters (1.48 bushel). 2aroura, a Greek measure of 2,735 square meters (0.67 acre). This page was derived from an English translation of the Greek text of the Rosetta Stone, published in a booklet by the British Museum. this derivation the Egyptian names of the gods appear where the Greek names appeared originally. The Greek measures in the text may have had no Egyptian equivalent, as the Greeks had already ruled Egypt for 136 years. No doubt the size of the jar of wine was also standardized.
Grandfathers tell their wide-eyed offspring that a thing, anything, is only worth what you can sell it for. Not necessarily what you paid for it, or what it cost to make, or what it may be worth in the future. That thing whatever it is worth what you and someone else agree to exchange it for, right now. Our economy depends on the idea that one person would rather have the object, the other person would rather have the money, and when they agree on the exchange of the money for the object, both parties walk away feeling better off. Multiply these little improvements millions of times, and the economy constantly grows richer, just by exchanging.
Fire Sale
Now, any seller has an option to refuse an offer, waiting for a higher price. This time option is essential to the wealth idea underlying trade; if you simply must have the money before a satisfactory offer appears, you will surely sacrifice some money on the trade. Maybe your counterparty makes a little more money but between you two, wealth is generally not created by fire sales. By definition, you sold before you got a fair offer, so wealth may even have been destroyed and at best the other person's gain just equals your loss. So, everyone is enjoined to conduct business and affairs in a way that makes it possible to wait to trade until a fair offer does appear, but even that maneuver is not as satisfactory as an immediate fair trade.
In the frozen markets of 2008, trade is coming to a halt because so many people are holding off on sales; wealth is definitely being destroyed in the process. Government intervention is proposed as a method to assign a fair price and make trades. The process is generally that the government will offer to buy these frozen securities, hoping to hit fair value precisely and hoping both sellers and buyers will accept that price. Since the government agents are spending other people's money, they will likely overpay and must lean against that tendency.
If the government pays too little, buys the securities and then resells them at a higher more nearly fair value, the government will make a profit, but the seller suffers. That's really not the intention at all. Skinning the seller is not desirable because wealth is destroyed in the process; keep it up and a recession will result. On the other hand, if the government pays too much, it will eventually lose money. The world economy will suffer from any outcome other than striking just the right price. Therefore, the government insists on receiving a warrant against the common stock of the seller who made an unearned profit, so the profit returns to the government. If there is no profit, the warrants are worthless, so they can be seen as a harmless disincentive against overpayment. In 1991, a similar credit bubble overtook Scandinavia after the fall of the Soviet Union and the unification of Germany. When it all shook out, the Swedish and Finnish governments lost 2-3% of their GDP on the interventional sales, Norway's made a profit of 0.2% of GDP. During the bubble preceding intervention, Scandinavian real estate, and the stock markets went up roughly 200% before they crashed; four years later, both real estate and stocks were up over a thousand percent.
It seems churlish to mention it, but this plan is only a stop-gap. It may get markets unfrozen, but when trading resumes they may thaw down to lower prices. In fact, prices are almost certain to fall if we face up to a realization that prices were too high, to begin with. House prices were just too high, oil prices were too high, and maybe a lot of other things were overpriced. As a nation, we borrowed too much, bought too much, forced prices too high. Leveraging, borrowing and prices all must, therefore, come down. But slowly and gradually, please. We will eventually grow our way out of this housing glut; floods, fires, and population growth will eventually use up the housing surplus.
Credit Bubble
Meanwhile, we have a short-term and long-term problem with determining fair value without ongoing transactions to verify them. In the short term, some government employee must judge the fair value of securities locked in frozen markets. When the crisis is over, that job is done. In the longer run, it will be necessary to maintain a continuing estimate of the value of the securities held by banks and corporations, so the proportion of debt can be calculated. Recent debts of investment banks were often 33 times the value of their stockholder equity. That seems to be too risky, and perhaps the regulators should insist on ratios of 10 to one, such as most commercial banks maintain. The best ratio is one problem, but a greater one is that no one can be sure what the underlying equity is worth unless an active market provides a precise comparison. There has been a tendency to turn to accountants to calculate an answer to this uncertainty.
In November 2007, FAS 157 was issued, declaring that fair value will be whatever the owner can sell a security for. In frozen markets, that sometimes proved to be nothing at all and obviously caused problems. This Financial Accounting Standard replaced Statement 125, which declared that fair value was whatever an informed buyer would be willing to pay. These two standards, in the absence of active real transactions, can differ so widely in a frozen market that statutory measurements of corporate riskiness are sometimes highly inappropriate. No amount of splitting the difference will satisfy the participants when serious issues are at stake since their resolution depends on the time available to find a willing counterparty, and during that interval whether alternative resources are available to satisfy creditors. Many traders have misperceived the signal when perfectly healthy securities had to be dumped in frozen markets. When the store of healthy securities runs out however, distressed debts must be liquidated at a loss. The qualifiers -- trading volumes, available reserves, illiquid reserves, historical volatility -- of a more accurate estimation of riskiness are evident, but it is not clear that a unified scoring could describe them.
Dear reader, please bear with the next three paragraphs. There's nothing entirely new. All of these ideas have been around for a long time, but are reshuffled into somewhat surprising recombination. We assume the reader has accepted our brief excursions into compound interest, escrow accounts, the J-shaped lifetime health expenses, and the complexities of pre-paying the cost of newborns. Our whole economy is built on debt and its extension called credit. However, everyone guiltily knows is it better to be paid interest than to pay it. Everyone knows life expectancy has lengthened, but not everyone realizes the cost implications. And even Aristotle despaired of the way we ignore the way compound interest sharply increases at the far end; it's J-shaped, too. Let's start by re-emphasizing what everyone supposedly knows already.
The Cushion. The first hypothetical graph illustrates a tax-free escrow account, into which only $400 is deposited at birth, and terminates at death 90 years later, accumulating wealth until age 65 but then spending it down for retirement. The numbers are arbitrary. That is, it begins with a manageable sum but eventually produces a modest retirement, just by sitting still. This is the "accordion" we employ to substitute for our obvious inability to project costs and revenue for a century ahead. It assumes an average income of 6.5%, which is justified by the history of the past fifty years, which show a high of 8.6% and a low of 4.5% in successive thirty-year slices. Actually, as my son shows in the appendix, it is the more conservative modal value rather than the average, to satisfy actuaries who will be asked about it. We have only partial data for fifty years before then, and even sketchier data for a century before that. But the data seem to justify the same conclusion for a long time, in spite of countless wars and recessions. This isn't the plan, it is the cushion which would support the plan if it failed, intended to show our proposals remain within the limit of what is conceivable. No one, of course, can claim to predict the future with precision.
Measurement Inaccuracies. According to accountants, revenue always equals costs, accountants then stretch things a bit to make it happen. But in projecting the future we sometimes substitute one for the other because data is more available. When you dig into how these numbers are produced, you see their premises, hence their inaccuracies, are sometimes quite different. That's a fact which misleads the reader when the two curves are superimposed, allegedly displaying profits and deficits as the difference between cost and revenue. Sometimes it also misleads executives, who have to scramble to keep the company (or the nation) afloat in a mismatch. Without going into boring details, this explains much of the empiricism of the planning process. Sometimes, just sometimes, the Board of Directors acting on logic, knows better than the CEO, acting on data. In healthcare, the central actor is the dismaying alacrity with which costs react to reimbursement.
A Harpoon for Leviathan. And having long experience with the conflict between the welfare of the individual patient and the welfare of the organization, doctors instinctively resist the efficiencies which allegedly result from placing centralized control more and more remotely. Remote, that is, from the patient, who then suffers from the choices being made. Therefore, the "disintermediation" which is implied by individual health accounts immediately appeals to physicians and should appeal to patients, even though it is easily shown that running a tight ship is best for the organization. Therefore, while using Abraham Flexner's ideas as a model ultimately added thirty years to life expectancy, it could not stop its own momentum to adjust to the retirement consequences of improved longevity. People instinctively sense some control must be restored to the patient. Even if they were not so much cheaper, giving patients individual control of their own Health Account balances is the least disruptive place to give patients a harpoon for Leviathan. Prices have wandered too far from costs, and that's a fact.
The Plan in Outline. We assume many things will remain unchanged. Health costs will remain J-shaped, low at the beginning, high at the end. We assume life will continue in three stages: dependent children for thirty years, working and earning for thirty years, and retirement for thirty years, all more or less. We assume some transfer system must exist, so the one-third in the middle can support the two-thirds at the ends. And we assume that research efforts (now $33 billion yearly) will continue until there are essentially only two costs left: the first year of life and the last year of life. Diseases will first concentrate on Medicare, and then gradually fade away. There will be many ups and downs before it takes place, but eventually, that will be the final configuration. Since there are many programs for health, broken up and overlapping, eventually most of the existing structures will change, merge, or disappear. We started with health costs paramount but will end with retirement costs dominant, birth and death continuing as appreciable costs. Finally, most of the next century will be spent in the transition from what we have now, to birth, education, retirement, and death, with education, perhaps going its own way.
The Plan. Technically, the plan revolves around birth and death re-insurance, possibly renamed First and Last-year of Life Re-insurance. Assuming this is the final configuration toward which we are working, our new plan should deliberately aim for it, meanwhile coping with the individual changes science forces on us. One lucky thing is that everybody alive has already been born, so it is not so urgent to cope with that transition quite so urgently. That's good because the transition to the last year-of-life will be complicated enough. Re-imbursing Medicare for terminal care costs should reduce the Medicare withholding tax for working people, allowing that amount to be directly transferred to escrowed partitions of individual HRSAs, instead of indirectly through intermediaries. Growth of this money in the escrow would be the new money for the system, so the individual must negotiate an income rate with his HSA vendor, at least matching the Medicare inflation rate, before he would be able to accept the system of transfers. However, the amount needed is astonishingly small, since it multiplies many times in the process. The transfer, or whatever it is eventually called, of $100 from the withholding tax to the escrow fund at age 25, would generate (at 6.5%) $100,000 at the person's death at age 84. The cost of the last year of life, currently, is said to be $25,000. Paying for the rest of Medicare at current prices might require $300 more. Paying for all of Medicare plus a retirement income from 65 to 84 would depend on what you think is a moderate retirement. But paying an additional retirement of $20,000 a year (amounting to $40,000 per couple) would cost an additional $4000. That's a lot of money, but remember the present total contribution to the withholding tax is $227 billion, or roughly $6800 per worker per year. There's no need for precision in such numbers, but beneficiaries and benefits get added so quickly it is silly to be more precise. The conclusion is obvious that there is plenty of money in this approach. The potential difficulty lies in the transition.
Don't turn your head to spit. Please remember that the secret of this approach is to use two funds gathering income simultaneously from opposite directions. Since 7% of income doubles the fund in approximately ten years, using two funds in opposite directions results in doubling the doublings. The success of the venture thus lies in maintaining a reasonable income in competition with your own intermediaries throughout, either through excessive fees or confiscation by the sovereign. Whether the danger is called default, inflation, or outright confiscation, the expression for this is "imperfect agency", and it has endured as long as governments. The only nation with a Constitution to last 200 years can be the only nation to resist imperfect agency, as well. But it won't happen without vigilance. Since some of the religious divines in my own family tarnished their record, the advice they give in Texas is, "Don't turn your head to spit."
There's a deficit in this system, occasioned in 1965 when generations of new Medicare recipients (like my own mother) were given Medicare without contributing to its costs. Congress will have to decide how to cope with this, possibly by absorbing it, possibly by taxing heirs of the beneficiary (like me), who will probably protest about ex post facto. If that approach is blocked, the new investment money will have to be taxed for it, somewhat delaying its benefits. However, transition costs are nothing new to Congress, and a variety of methods have historically been applied. This proposal eventually envisions enlargement to include the second-to-last year of life, etc, while the first year of life might even start from birth to age 25. Working from both ends, the transitions should eventually be complete, and Medicare should gradually shrink. So long as the excesses in the system eventually go to support retirement income, it should be possible to grow our way out of the Entitlement squeeze. Its long term hopes probably rests on research discovering cures for expensive diseases, diminishing the costs of Medicare, but longevity will also increase, so increased retirement costs must be considered as well. This proposal must be considered a long-term transition plan of uncertain length. Present beneficiaries of Medicare can rest assured that dual systems are practically inevitable for quite some time.
It is the present intent to regard the Affordable Care Act as revenue-neutral since it is not possible to predict what it will actually be. So the problem of the first-year-of-life may not need to be addressed immediately, but ultimately the plan is to over-fund the last-year costs by about $400 (sound familiar?) and distribute $100 to funding newborns by inheritance at the death of what would be their grandparent, reserving the remaining $300 for the last year of their parents. To make all of this come out right, the present 2.1 births per mother would translate into $200 per child generation and $400 per grandchild generation. But there are four grandparents, so it remains $100 apiece per grandchild.
Let's now turn to health insurance for newborns, which pose new difficulties.
Let's see what we have to work with, in Medicare. The first step is to set the boundaries. Aside from the add-on programs for disabilities and End-stage kidney programs, the public first encounters Medicare at around age twenty, when the working population begins to have 3% of its payroll check deducted. From that point to retirement at age 60-65, Medicare is invisibly taxing payroll checks and paying as it goes, but the beneficiaries hardly know they have it. At age 65, let's say for the sake of tradition, payroll deductions trickle off and Medicare payments trickle in. The serious illness starts to play an important role in life beginning at age 55, but half of Medicare expenditures take place in the last four years of life.
Of course, people who are healthy live longer than people who get deathly ill, so although the average age at death is about 73, medical progress is pushing the average death age steadily older. Some day it will approach 84, the average age of longevity at birth, which is itself predicted to be 90 in a relatively few decades. In short, people are dying older and seemingly can be predicted to die even older in the future.
The problem, however, is whether new treatments or even new diseases will fill in the gap between retirement and the last four years of life. Or, whether increasing longevity will just push the terminal four years older, like the cap on the end of a mushroom. My own personal observation is that diseases which were once thought unworthy of attention are now getting a lot more of it. Skin cancers would be an example. When the average seventy-five-year-old got skin cancer, it was possible to surmise some other life-threatening issue would interrupt the need to worry about skin cancer. Nowadays, there is an increasing tendency to treat skin cancer in the nineties. On the other hand, if we are talking about one of those people who never see a doctor except by looking up from an ambulance stretcher, the trend will be different. In all likelihood, both trends will continue, and it will eventually be possible to say half of the somewhat greater expenses will take place in the last five years of life, even though the average age at death is then approaching 90, Both the ages and the costs will have to be adjusted as we go. These are guesses of course, which should get more accurate as time goes by. From the financial point of view, compound interest will be working in our favor, while biology is probably going to increase costs. If more pessimistic biologic predictions prevail, we will be very lucky to have explored some revenue enhancement.
We have dug ourselves quite a deep financial hole. Suppose, by some combination of revenue enhancement, good luck in the market, and compound interest, the revenue is sufficient to pay for half of Medicare. Very likely what would then happen is the deficit would disappear, foreign borrowing would stop, and Medicare would become self-sustaining (between the payroll deductions and the Medicare premiums). The citizenry would hardly see any difference; the improvement would take the form of reduced foreign borrowing, avoiding catastrophes we didn't expect in the first place. After a few years, we would be back where we started.
Now suppose we doubled our success and paid out the bonus in extra retirement money. Since our present notions of a decent retirement are five times the healthcare benefit, we could expect nothing but complaints about a retirement system which approximately doubled the present Social Security benefits. Otto Bismarck, whose National Healthcare goal was to keep people quiet so he could conquer Europe, would never stand for such a failure. And yet the first of these two approaches would require payroll deductions of 6%, and the second would require 9%, even assuming the Affordable Care Act budget would prove to be revenue-neutral. The burden could be lightened by dipping into the contingency fund, but a much better approach would be to use the strategy of the Last Years of Life -- Reinsurance.
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.
