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.
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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.
Allegheny Mountains from which to trade with, and possibly convert the Indians, the French had a rather elegant strategy for controlling the center of the continent. It involved urging their Indian allies to attack and harass the English-speaking settlements along the frontier, admittedly a nasty business. The survivors of General Braddock's defeated army at what is now Pittsburgh reported hearing screams for several days as the prisoners were burned at the stake. Rape, scalping and kidnapping children were standard practice, intended to intimidate the enemy. The combative Scotch-Irish settlers beyond the Susquehanna, which was then the frontier, were never terribly congenial with the pacifism of the Eastern Quaker-dominated legislature. The plain fact is, they rather liked to fight dirty, and gouging of eyes was almost their ultimate goal in any mortal dispute. They had an unattractive habit of inflicting what they called the "fishhook", involving thrusting fingers down an enemy's throat and tearing out his tonsils. As might be imagined, the English Quakers in Philadelphia and the German Quakers in Germantown were instinctively hesitant to take the side of every such white man in every dispute with any redone. For their part, the Scotch-Irish frontiersmen were infuriated at what they believed was an unwillingness of the sappy English Quaker-dominated legislature to come to their defense. Meanwhile, the French pushed Eastward across Pennsylvania, almost coming to the edge of Lancaster County before being repulsed and ultimately defeated by the British.
In December 1763, once the French and Iroquois were safely out of range, a group of settlers from Paxtang Township in Dauphin County attacked the peaceable local Conestoga Indian tribe and totally exterminated them. Fourteen Indian survivors took refuge in the Lancaster jail, but the Paxtang Boys searched them out and killed them, too. Then, they marched to Philadelphia to demand greater protection -- for the settlers. Benjamin Franklin was one of the leaders who came to meet them and promised that he would persuade the legislature to give frontiersmen greater representation, and would pay a bounty on Indian scalps.
Very little is usually mentioned about Franklin's personal role in provoking some of this warfare, especially the massacre of Braddock's troops. The Rosenbach Museum today contains an interesting record of his activities at the Conference of Albany. Isaac Norris wrote a daily diary on the unprinted side of his copy of Poor Richard's Almanac while accompanying Franklin and John Penn to the Albany meeting. He records that Franklin persuaded the Iroquois to sell all of western Pennsylvania to the Penn proprietors for a pittance. The Delaware tribe, who really owned the land, were infuriated and went on the warpath on the side of the French at Fort Duquesne. There may thus have been some justice in 1789 when the Penns were obliged to sell 21 million acres to the Commonwealth of Pennsylvania for a penny an acre.
Subsequently, Franklin became active in raising troops and serving as a soldier. He argued that thirteen divided colonies could not easily maintain a coordinated defense against the unified French strategy, and called upon the colonial meeting in Albany to propose a united confederation. The Albany Convention agreed with Franklin, but not a single suspicious colony ratified the plan, and Franklin was disgusted with them. Out of all this, Franklin emerged strongly anti-French, strongly pro-British, and not a little skeptical of colonial self-rule. Too little has been written about the agonizing self-doubt he must have experienced when all of these viewpoints had to be reversed in 1775, during the nine months between his public humiliation at Whitehall, and his sailing off to meet the Continental Congress. Furthermore, as leader of a political party in the Pennsylvania Legislature, he also became vexed by the tendency of the German Pennsylvanians to vote in harmony with the Philadelphia Quakers, and against the interest of the Scotch-Irish who were eventually the principal supporters of the Revolutionary War. It must here be noticed that Franklin's main competitor in the printing and publishing business was the Sower family in Germantown. Franklin persuaded a number of leading English non-Quakers that the Germans were a coarse and brutish lot, ignorant and illiterate. If they could be sent to English-speaking schools, perhaps they could gradually be won over to a different form of politics.
Since the Germans of Germantown was supremely proud of their intellectual attainments, they were infuriated by Franklin's school proposal. Their response was almost a classic episode of Quaker passive-aggressive warfare. They organized the Union School, just off Market Square. It was eventually to become Germantown Academy. Its instruction and curriculum were so outstanding as to justify the claim that it was the finest school in America at the time. Later on, George Washington would send his adopted son (Parke Custis) to school there. In 1958 the Academy moved to Fort Washington, but needless to say, the offensive idea of forcing the local "ignorant" Germans to go to a proper English school was rapidly shelved. This whole episode and the concept of "steely meekness" which it reflects might be mirrored in the Japanese response, two centuries later, to our nuclear attack. Without the slightest indication of reproach, the Japanese wordlessly achieved the reconstruction of Hiroshima as now the most beautiful city in the modern world.
Settlements for three centuries have clustered along both sides of the Delaware Bay, like beads on two parallel strings.
Dr. Fisher
The Capital of southern New Jersey alternated between Salem and Burlington, and the King's Highway ran between them atop a clay ridge all of fifty feet above sea level. Colonial villages are strung along Kings Highway about ten miles apart, just like villages in the Midwest and for the same reason. That's about the distance a farmer's wagon could travel to market and return in one day. Travel by boat modified that somewhat. One unexpected feature: the marl clay ridge was eventually found to contain the first known dinosaur bones, still proudly on display at the Academy of Natural Sciences. We'll defer until Day Two describing the interesting origins of the coastal route on the Delaware side of the bay below the big river bend at Salem. In New Jersey the counterpart is the Del-Sea Drive, now rapidly fragmenting in response to school crossings and traffic. Although almost everything of interest is along these three roads, for this tour we propose taking President Eisenhower's interstate highway system, with side-trips as needed.
The retreating British Army ferried out of Philadelphia in 1778, went from Camden to Haddonfield and turned north on King's Highway. For this tour, we turn south from Haddonfield, pausing for a glance back at Camden. Poor Camden scarcely exists anymore, but the battleship New Jersey is parked there, the waterfront view is awesome, and Walt Whitman's home is open to tourists. Once the home of shipbuilding, Campbell's Soup, RCA/Victor, and the terminus of railroads at the ferries to Philadelphia, the town was first threatened by isolation by the Pennsylvania Railroad going down the other side of the river in 1839, but ultimately made economically redundant by the construction of the Ben Franklin Bridge in 1926. An interesting sociological study called Camden After the Fall relates how one futile effort after another to restore Camden after 1950 led only to riots and chaos; it's difficult to suggest anything which has not already been tried and abandoned. The present unstated but relentless approach is to tear the obsolete buildings down as they deteriorate, leaving vacant land which will eventually coalesce and become attractive to developers. Toll houses could be found along the turnpike to Haddonfield until 1960, but the automobile made Camden obsolete. What's left begins with the suburbs five miles away.
New Jersey Line
Haddonfield was a plain little Quaker town with undiscovered dinosaurs buried underneath it until the Revolution when the fugitive New Jersey legislature met in the Indian King Tavern and created the State of New Jersey. Because the Pennsylvania/New Jersey fortifications of the Delaware River at Fort Mifflin/Red Bank blocked the British fleet, Hessians were sent to attack New Jersey's Fort Mercer from the rear, staying overnight in Haddonfield. One young Quaker, a famous runner, ran ten miles to alert the defenders of Fort Mercer, who then defeated the Hessian attackers the next day by pretending not to notice the Hessians until they suddenly turned around and ambushed them. Later on, after the British occupied Philadelphia, General "Mad Anthony" Wayne rounded up cattle in Salem County and drove them to Trenton, then over to Valley Forge to relieve Washington's starving troops. The British responded to this with a famous massacre in Salem County by cavalry under Col. John Simcoe. So off we go to National Park, originally called Red Bank because of the reddish color of the clay riverbank at that point on the river, to see Fort Mercer. From here we travel to Salem, seeing its sadly dilapidated Colonial buildings, and the oak tree which was already famous among the Indians for its huge size in 1683. Along King's Highway, we pass through Mickleton, Mullica Hill, and Woodstown, three cute little Quaker villages waiting to be overwhelmed as suburbs.
From here we go to Greenwich, named for Connecticut settlers, where Paul Revere stirred up a tea-burning party in sympathy with the Boston event, on his way to promote even greater agitation in Philadelphia. Greenwich is sometimes referred to as a second Williamsburg, but what's here is original, not reconstructed. In passing, this tour takes us past Hancock's Bridge where Simcoe massacred those farmers who sold cattle to Anthony Wayne. That's biased local history speaking; in fact, Tory-Rebel reprisals were very bitter on both sides. Until ten years ago, this blood-stained site stood alone in the lonely moors, but unfortunately, it's pretty much built up and harder to find in the new suburbs than it was in the reeds.
From Greenwich we go on to Cape May, with a brief detour to Bivalve. The point about this stop is the perfectly gigantic pile of oyster shells left over from the days as a center of oyster harvesting. Notice the roads; they're paved with oyster shells. Oysters eat algae, sewage fertilizes algae. Overfishing the oysters caused rotting algae and bacterial overgrowth in the river. The result was depletion of the dissolved oxygen, dead areas for fish, murky water instead of a clear stream. It's an opportunity for oyster farming, but the vast piles of shells at Bivalve are a warning of how far we have to go before we restore the river.
Cape May was the first Atlantic Ocean beach resort, reached from Philadelphia and Tidewater Virginia by boat long before roads were usable. We are told Cape May was originally a separate barrier island, joined to the rest of South Jersey only later. It was once a whaling port, and the Quakers of the region were more related to Nantucket than to Philadelphia. Whale-watching is popular here, but dolphin sightings are more reliably frequent. As you would expect, this cute little place has many fine restaurants and hotels. The hotels are so authentic that strangers share common bathrooms the way they always used to do, so bed and breakfast places can be preferable for snootier tourists. Those whose great-grandparents once stayed in places like the Chalfonte, however, find it important to rough it in traditional summer places. The ocean currents "tumble" the small stones in the beach so beach-walkers can amuse themselves looking for "Cape May Diamonds". Unfortunately, even the locals often have never heard of them, so you are probably on your own. From here, we take the forty-minute ferry ride to Lewes, Delaware.
Cape Henlopen, on the Delaware side of the entrance to the bay, is south but appreciably to the east of Cape May. That means that a line directly west from Cape May points well inside the mouth of the bay, to Slaughter Beach, or Mispillion Point on the Delaware side. The ocean salt water turns to fresh river water at about this level, making for remarkably good fishing at certain times of the year. Furthermore, horseshoe crabs come ashore here on both sides of the bay to lay eggs. Birds who took off from South America months earlier swoop out of the skies to eat the crab eggs on the appointed day. Hawks pause in the woods to fly together in flocks over the bay, based on their own signals. Mispillion Lighthouse is the greatest place on the Atlantic flyway for bird-watching, crab-watching, fishing and nature loving. But you have to know when to go there and remember the best local hotels do get filled up at those times.
A lot of people are named Turner, probably reflecting some degree of ancestry of wood turners. That's an ancient skill, using wood lathes. In Colonial days, commercial wood turning had a focus on banisters of houses, flag poles, and even toothpicks. At the present time, it is mostly a hobby conducted in garages by people who are mechanically inclined; but when a skilled artist takes it up, the products can be exquisite works of art. Because this is America, there is a national club of artisans and admirers, called the Furniture Society, and a local Philadelphia club called the Wood Turning Center. It's located at 141 North 3rd Street. Because of one-way streets, you are advised to consult a map if you plan to drive there, on the north edge of the Ben Franklin Bridge, rather near the Constitution Center. Ron Humbertson, the curator of the museum, recently visited the Right Angle Club and talked about the subject.
The average skilled amateur takes ten or more hours to produce a wooden bowl on a wood lathe, but the professionals manage to do it in about five hours. If you start with a gnarled tree trunk, the product has many interesting lines and whorls. But then the artisan has to contend with knot holes, unexpected holes of wood rot, and the likelihood of cracking the piece in the process of carving it. By far the majority of a piece of raw wood is then carved away and discarded, something that bothers real tree lovers.
Because of all these unexpected features of the wood, the thinner the final piece, the more likely it is to crack and experience other mishaps, perhaps even leading to discards and starting all over. Even just drying the raw wood can lead to cracks, and sometimes even before the carving begins, so real artists gently dry the wood themselves as part of the whole process of producing art. Even if it doesn't crack, the usual finishing process involves five or more layers of clear epoxy finish, to reduce scratching and to hold it together to prevent those cracks. Those bowls which are intended to hold salads had better be crack-free if salad oil is to be poured on the food. Like any other piece of art, the really outstanding pieces are not intended to go on dining tables.
Having since my return from France demolished the three houses in Market Street, between Third and Fourth Streets, fronting my dwelling-house, and erected two new and larger ones on the ground, and having also erected another house on the lot which formerly was the passage to my dwelling, and also a printing-office between my dwelling and the front houses; now I do give and devise my said dwelling-house, wherein I now live, my said three new houses, my printing- office and the lots of ground thereto belonging; also my small lot and house in Sixth Street, which I bought off the widow Henmarsh; also my pasture-ground which I have in Hickory Lane, with the buildings thereon; also my house and lot on the North side of Market Street, now occupied by Mary Jacobs, together with two houses and lots behind the same, and fronting on Pewter-Platter Alley; also my lot of ground in Arch Street, opposite the church-burying ground, with the buildings thereon erected; also all my silver plate, pictures, and household goods, of every kind, now in my said dwelling-place, to my daughter, Sarah Bache, and to her husband, Richard Bache, to hold to them for and during their natural lives, and the life of the longest liver of them, and from and after the decease of the survivor of them, I do give, devise, and bequeath to all children already born, or to be born of my said daughter, and to their heirs and assigns forever, as tenants in common, and not as joint tenants.
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All the lands near Ohio, and the lots near the center of Philadelphia, which I lately purchased of the State, I give to my son-in-law, Richard Bache, his heirs and assigns forever;
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To my son, William Franklin, late Governor of the Jerseys, I give and devise all the lands I hold or have a right to, in the province of Nova Scotia, to hold to him, his heirs, and assigns forever.
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I give and devise to my dear sister, Jane Mecom, a house and lot I have in Unity Street, Boston, now or late under the care of Mr. Jonathan Williams, to her and to her heirs and assigns forever.
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Since my will was made I have bought some more city lots, near the center part of the estate of Joseph Dean. I would have them go with the other lots, disposed of in my will, and I do give the same to my Son-in-law, Richard Bache, to his heirs and assigns forever.
In earlier sections I said I like computerizing a health insurance exchange. But confessing does not suggest the difficulties are trivial. To enroll by computer implies access to a computer. Since millions of people are still frightened to touch a computer, it implies an army of instructors to guide newcomers through the process. And since the insurance choices confront applicants with a bewildering set of choices, some person they trust must explain the choices to them. Since no insurance system imaginable could satisfy every reluctant hesitater, a considerable complaint and re-assignment process would probably be necessary for years to come. Many people will choose the wrong policy, regret it, and ask to transfer. To continue, you wouldn't expect a person to trust his private data to a system, without a personal password. Fine, but what do you do with seven million passwords? People will forget them, leave them lying around in public, and disremember them. The crooks in the cyber underground will get seven million opportunities to break into the system and steal things. If insurers of older policies undertake passive resistance, things could get tangled for years. So why undertake all these headaches?
There may be other answers to this question, among which is likely to be a set of imperatives contingent on making it mandatory. We will let others make their own arguments since once the vague mandatory feature is dropped, related conjectural problems diminish or disappear. The Affordable Care Act does not proclaim health insurance is mandatory; it only states a tax is required if you don't meet its requirements. The language really does suggest you have a choice between taking the insurance and paying the penalty tax. The Supreme Court mandates the tax must be small, to avoid being coercive to the states. The Constitution forbids the federal government to regulate the business of insurance, a provision heavily emphasized by the McCarran Ferguson Act. If the Health Savings Account with an attached high deductible is allowed to substitute for minimum requirements, any medical requirement is satisfied if someone has the money, and the HSA provides the money. True, it would allow someone with the money to reject the medical requirements, but what objection can there be to that?
There is a legitimate need to facilitate interstate health insurance. That means a minimal set of information exchange items is useful. The person must be confidently identified, and the terms and limitations of one state's policies must be matched with those of a second state. The credit status must be roughly described, and the current premium payments verified. If there is a current illness, its previously related history must be exchanged. Subsequent communication should be conducted between insurance companies, not between 300 million subscribers. Having established the basics, a communications channel(client to-and-from insurance company) must be provided for later use, particularly for expenses, even diagnoses, which might apply. And while this list may not be complete, it is close to adequate and can be expanded a little. It is nearly enough to get travelers, transferees and money exchanges to be organized. It will be sufficient for current needs and can be supplemented between particular states at conferences. And it would satisfy the Constitutional issue without needlessly inflaming it. If the Obama Administration expresses a willingness to compromise, these are the lines it might follow. On the other hand, if the issue is forced to the Supreme Court, the Court might be persuaded to follow these lines. We present three other liberalizing proposals for Electronic Insurance Exchanges:
One. Let a Thousand Flowers Bloom. The Affordable Care Act provides for selling high-cost health insurance products, meeting certain specifications, on the Electronic Health Insurance Exchanges. It's not obvious why the government has a legitimate interest in promoting one kind of health insurance over another, but perhaps a case can be made. Uniform interstate protocols are legitimate between insurance companies, along with standardized codes. And a website is a legitimate means for citizens of one state to communicate with insurance for sale in another state. Beyond setting standardized definitions, the communication between customer and insurer can be left to the individual companies. The case for excluding many existing types of policies has not been made, and this has particularly infuriated the subscribers of such policies, particularly those cheaper than the preferred variety. So why not enable or even facilitate the construction of such exchanges in every state which wants them, privatize the electronic programming and operations, possibly even subsidize them. And then permit every one of them to set its own rules for the products to be sold across state lines, setting its own prices as long as the prices clearly relate to the same products for every state-licensed insurance client who wants to utilize a particular product. Nobody must use the system, but everyone may use it. If no one uses it, it needs improvement. There could be multiple exchanges in each state, but the state may set limits, and no state is required to have any. In return for federal assistance, the federal government is limited in its involvement in setting rules which guarantee access to every system for every insurance company, and every citizen.
Two. Specify That Health Savings Accounts are Acceptable Options. In fact, if Health Savings Accounts (linked to a matching high deductible), were available as an option among many other options in the Electronic Insurance Exchanges, only the worth of the option would be in dispute. The claim of HSAs to being listed, is they are cheaper than any other option. That's a feature which is certainly desirable for a Law which puts emphasis on helping the poor. It could potentially add tax-free investment funds to a pool which helps fund the program or fund its deficit. Such windfall income could provide revenue for the costs of educating and coaxing people into making better choices, and is much less apt to provoke the irritation of mandating people to do unpleasant things for their own good.
Tenth Amendment
Three. Be brief(in requirements), and let who will be clever(in details). The threat of the Tenth Amendment hangs over all federalizing initiatives, not just the Affordable Care Act. If Electronic Health Insurance Exchanges would limit their scope to the flexible enlargement of interstate insurance sales, the insurance would clearly be part of interstate commerce, and thus safe from any revival of the Court-packing disputes of the 1930s. There is almost no justification for interposing the Federal Government into the middle of most communication between subscriber and insurance company. Permitting smaller states to enlarge their markets might by itself relieve many of the indirect pressures now limiting competition as a force to suppress healthcare prices; and could limit the damage to established insurance carriers, who will probably need time to recover from the changes it would force on their marketing.
Proposal 6: Congress should mandate the licensing to sell health insurance to be widely inclusive, including Health Savings Accounts and Catastrophic Coverage, and subject to regulation in the state of corporate domicile, subject to objection by the state of residence of the insured. When there is conflict, an appeal may be federal.
Furthermore, the spread of computers has reached a point where people are sensitive about being commercially manipulated by computers. Fifty years ago, the department store had a computer and the customers didn't. Nowadays, even children have them, and just about everyone is touchy about the way early-adopters try to bamboozle the innocent, putting their own products on the first page, in big letters, and "all others" under a button that doesn't work. Considering all the compromises needed to satisfy a common denominator, it seems very likely some other products would be more suitable for some people. "Hogging the limelight" and forgetting to mention other alternatives have become such common practices, people are on the lookout for them. The term "user-friendly" is now a part of the English language, people immediately bristle at signs of high-handedness, of which there is great plenty in the computer world. It is no secret businesses will tolerate most taxes or indignities, just so all of their competitors are seen to endure the same. It was once a common experience to have one competitor offer to design a computer program for the industry, quietly slanting the terms of entry to favor its own products. Was this just another example of it?
Therefore, allowing privatized insurance exchanges to become available for all variants of health insurance might have allowed time for discovering other features which might require special adjustments. After all, health insurance would remain half-state and half-federal, and undiscovered problems may yet surface. Even if the President planned to run healthcare like an Egyptian Pharoh, a gradual switch to individually owned and selected life insurance would have-- in time -- eliminated the need for pre-existing condition exclusions. It might even have provided an opportunity to reduce premiums for insurance which protects against the cost of appendices, indirect hernias, cataracts, uteri, prostates, and gall bladders --that have already been removed. Not everyone would want such features, but that's a small price to pay for the freedom to want them. A long-term shift to lifetime health insurance might very well require other adjustments, but it would be best to wait to see what they are. Meanwhile, the public will get the idea, teach each other, and get where it wants to be in a few years. That's at least as quick as a mandatory system can respond to industry lobbying, and still, get wherever it wants to go.
However, after all the uproar about the introduction of computerized direct-pay insurance has subsided, a great many opportunities are probably lost for decades, and any suggestions are probably futile. One thing remains, however, in view of the likelihood the issue of the Tenth Amendment will soon arise. How can we preserve the Constitution and still take advantage of our continent-wide marketplace?
The Argument Against National Uniformity of Prices.
It is abundantly clear the Founding Fathers were concerned with unifying a collection of thirteen sovereign states and had to make concessions. Furthermore, it is also clear no other nation in two hundred years has been able to match the achievement, even with massive wars and millions of casualties. So the instinct is strong to leave our Constitution alone. If it was not originally clear, the Civil War made it so. Nevertheless, the nation is laced with successful interstate corporations, for the most part, regulated by the state, not national, law. It seems to have been accomplished by establishing stock exchanges in a few states, operating under a few states' regulations, and otherwise allowing each corporation to choose a state of domicile, where the corporation can be regulated by the laws and courts of that state. The arrangement lasted for two centuries, and only later is starting to bend, under the pressures of electronic innovation. We seldom hear much uproar about the corporate arrangement under the state-federal problem. Why can't health insurance companies accomplish the same thing without federal oversight?
Well, for one thing, some states are still so sparsely settled, they cannot assemble the actuarial minimum numbers to have more than one viable health insurance company, or more than one HMO (Mrs. Clinton please note). Other states are densely populated enough to have several viable insurance companies, so the two-state sizes resist changes made to accommodate each other. The two have a great many dealings with the major corporations in their states, allowing them to pressure state legislatures into favoring state "champions", or else resisting the power of large insurance companies to dominate one state marketplace.
However, this is all pretty small peanuts, and it would seem fairly simple to separate the buying and selling of insurance companies from the buying and selling of insurance. After a while, one or two state exchanges would come to dominate and cluster in one area; while a handful of companies would start to dominate national health insurance business, and therefore migrate their health insurance operations into some different legal climate. In particular, our history of the migrating frontier made local communities restless about the distribution of doctors and hospitals. They could, of course, pass a law if one cabin is built on Pike's Peak, there must be two neurosurgeons within a hundred feet of it. The futility of such laws was soon apparent, and almost all resorted to some sort of incentives to attract medical resources found to be in short supply. State licensing was sometimes a way to create a local monopoly as a reward for a hospital to locate, or some specialist to open an office. But the development of health insurance provided an ideal way to attract specialists in short supply, by the simple expedient of overpaying them. Naturally, such communities resist the proposal to have national uniform fees, as interfering with the laws of supply and demand. Large cities, on the other hand, see national uniform fees as a way to suppress high fees. Our Founding Fathers recognized what was going on, and responded by letting anything commercial be regulated by the local states, flying the flags of states rights or state sovereignty. Franklin Roosevelt, a big-state resident, thought he could accomplish the big-state goal by calling it "court packing", but the nation soon told him his landslide electoral victory had some limits if it had that kind of result. Although Roosevelt largely accomplished his goal by other means, repeated attempts to make medical care nationally uniform has resulted in some kind of Presidential disaster. Things like medical care should become nationally uniform when the country becomes nationally uniform, but not sooner. Actuarial facts change pretty rapidly, as the discovery of gas shale in the Dakotas recently demonstrated. Any fixed but ideal arrangement will eventually fall victim to an agile and geographically flexible competitor.
Two personal examples have emphasized the point to me. In 1947, the Society for the Study of Internal Secretions (later known as the Endocrine Society) held its international meeting in a single lounge in a Chicago hotel. Nowadays, seven thousand national members meet in three concurrent ballrooms, and the shortage of Endocrinologists is over. To my surprise, a gentleman who looked like a Roman Senator approached me after a speech, and invited me, first to dinner, and then to become a paid consultant in his state which had no Endocrinologist. The other example was being approached by a lady in a pink hospital volunteer's uniform, asking me if I would like to become the sole doctor on a resort island of very rich folk, an hour from New York City. I accepted the first offer and declined the second, but the point is, people, protect their own personal needs when national health insurance is under discussion. And they often do not mean to be thwarted by supposed needs for national uniformity.
Congress and the Supreme Court are urged to view the Tenth Amendment as a compromise between big and small states which still enjoys wide support. Big states desire uniformity in order to suppress prices, while sparsely populated states reject uniformity in order to maintain control of local interests.
Proposal 5: Congress is urged to permit the domicile of health insurance corporations to be in one state chosen by the corporation. But all health insurance should be freely sold interstate, subject to regulation by the state of domicile.(2611)
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.
