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.
We should take the word of his friend and colleague, Daniel Schaviro, that the core of David Bradford's professional career as an economist was his conviction that a very deep wrong existed when two people could earn exactly the same income over their lifetimes but the one who spent every cent immediately would pay less in taxes than the other who carefully saved for his retirement and heirs. Bradford was offended by this message our society was broadcasting.
Working for a time in the U.S. Treasury Department and later as a member of the President's Council of Economic Advisor's, he was able to explore the mechanical workings of tax law well enough to translate moral conviction into a workable proposal for political reform. In 1977 he published "Blueprints for Tax Reform", introducing these practical ideas at the highest level of academic rigor. The impact of his ideas in this paper extended through three presidencies, particularly the present one.
Bradford saw the tax injustice which penalized the Protestant ethic could be corrected in two ways. Either the tax code could shelter individual savings from taxes until they are spent (the IRA), or else convert the income tax into a consumption tax (like VAT). In either case, taxation would take place at the same time as consumption, rather than at the time of earning. Notice the person who saves money to spend later will suffer from both inflation and taxes on taxes on the inflation "gains". The political choice between the two proposed solutions was made by Senator William Roth (R, DE) who sponsored the Individual Retirement Account (IRA) and shepherded it through an intensely political Congress. His was a wise decision, since its voluntary nature made it attractive to politicians, while the French experience with a mandatory Value Added Tax (VAT) created political opportunities to favor certain industries, which politicians were quick to understand.
After twenty-five initially slow years, the eventual popularity of the IRA has now encouraged its extension to Social Security. That's what agitates domestic policy debate at the time of David Bradford's unfortunate death. The IRA model is also the basic concept underlying Health Savings Accounts (HRA), which struggled for many years but have reached their own period of growing acceptance. The Blueprints idea has thus dominated domestic politics for nearly three decades, while its originator remained largely unknown. Far from being a sign of weakness of the idea, it is a proof of the revolutionary nature of this simple concept that it initially provokes public resistance, but also inspires relentless tenacity among those who have taken up its challenge.
David Bradford returned to Princeton from his Washington experience, resting for decades at the quiet center of an Economics department that is not known for its quietude. After a most unfortunate fire at his home, he died of the burns in nearby Philadelphia, which hardly knew him.
The Industrial Revolution crowded people together into smoky, draughty unhealthy places to live and work, and thus created ideal conditions for the spread of smallpox, tuberculosis, plague, poliomyelitis and many other infectious diseases. With better sanitation and hygiene, those diseases declined steadily for two centuries. Meanwhile, medical science developed a steady stream of expensive enhancements to health like removing an inflamed appendix, inserting pins into broken bones, utilizing CAT scans and artificial kidneys. These things each made life more comfortable and extended it a little longer, but steadily increased the cost of care. Here and there major leaps forward occurred, like the discovery of antibiotics and the prevention of arteriosclerosis, but it seldom seemed that medical care was stamping out disease, it was just making it more complicated and expensive. But if you stopping plodding forward for a moment and looked backward, the aggregate progress was astounding. Dozens of diseases either disappeared entirely or are well on the way to disappearing, like polio, smallpox, tuberculosis, syphilis, rheumatic fever, and what have you. Life expectancy for Americans at birth, which had been 47 years in 1900, was approaching 80 years in 2000. When I started as an attending physician in 1955, I was in charge of a 40-bed ward continuously full of diabetic amputees; during the last fifteen years of my practice, however, I did not attend a single diabetic amputation. At some point in this amazing medical pilgrimage I can remember realizing that for really important purposes, there were only two diseases left. Arteriosclerosis and cancer; and now arteriosclerosis mortality has declined fifty percent in ten years.
So now it is possible to have the luxury of asking: what will happen when we finally cure cancer? Oh sure, there is Alzheimers Disease, HIV/AIDS, schizophrenia and childbirth, plus an apparently endless variety of ways to produce self-inflicted conditions. Everyone will eventually die of something, so doctors will keep busy. It is not necessary to predict the end of medical care to see that some important social transformations are likely. For example, if we cure cancer around the time of financial chaos caused by the retirement of baby boomers, it is going to be hard to resist the demand that we reduce spending on medical research. Every tedious word of the impending debate on the topic could be written right now to save time because it is a very strong probability that spending on medical research will decline, once an effective cure for cancer is behind us.
Let's, however, continue our march into the future of healthcare reform. When employers became self-insured for employee health costs, they came into possession of data about what they were buying. It didn't look adequate to them to explain the sums of money they were spending, so they concluded they were being hoodwinked by hospital cost shifting, with consequences summed up as the Clinton Health Plan. Now put yourself in their shoes when the Wall Street Journal tells you cancer has been conquered. Michael De Bakey once pressured Lyndon Johnson to start a crusade against Heart Disease, Stroke, and Cancer, and now even cancer is gone. A significant number of C.E.O.s are likely at that point to decide that since Far Eastern competitors don't have this cost to contend with, perhaps it is time to declare that you have been fleeced long enough. Give the employees some money, and tell them to buy their own health insurance.
There are even some more legitimate arguments for doing so. Individually owned and selected health insurance would be portable, putting an end to "job lock", the fear of changing jobs for fear of losing health coverage in the process. Employee divorces create a different twist to job lock, and inequities jump out at you from the tangle of arguments about dual coverage for working couples. Add same-sex marriages to this issue and employers are driven to despair. Individual policies would simplify all of these issues, and open the door to life-long coverages, which we will discuss in a later section.
If medical progress makes just the right progress in the impending time interval before doomsday, it is even possible to start talking about eliminating health insurance in a practical way. If there is no threat of medical expense, why buy insurance against it? Since everybody will die of something, it is hard to envision a time without insurance. But maybe Medicare is enough. Senator Edward Kennedy (D, Massachusetts) will finally have his universal single-payer system -- by default.
What we have here are the daydreams of a corporate C.E.O., struggling to make his numbers for the next quarter, and they are pretty strong stuff. But who can doubt the power of these concepts to move the system away from an employer-based formulation?
Extensive premium changes in health insurance followed the introduction of the Affordable Care Act. Most changes involved an increase in patient participation in the costs, either deductibles or coinsurance, coupled with a "cap" on total patient payments. Almost all insurance seemed to grasp the futility of co-payment as a purchasing restraint, substituting fairly high deductibles for the old 20% co-pay. As election day nears, we are seeing a rash of articles about the hardships of front-end deductibles, during the first year of their introduction, and the largest patient group with this kind of experience are holders of Health Savings Accounts. A sudden media clamor about one point generally suggests some political stirring-up is taking place, but perhaps it is fast-breaking news that someone with a torn fingernail decided to bandage it herself rather than go to the accident room, all because of the shocking discovery that the days of first-dollar coverage are fast receding. The lady in the article didn't mention any other medical debts, but that is surely coming in the news.
After Medicare was introduced in 1965, I had already been in practice for fifteen years, and it did not surprise me how many patients, indigent and otherwise, had snaggly teeth, perforated eardrums, amazingly big hernias, gall stones, extensive varicose veins, and gigantic prostate glands. It was just the way things were, and doctors set about treating 'em as they appeared. What amazed me, six or seven years later, was the supply of these things had greatly diminished. Only then did I realize that people had been holding back on elective surgery because of finances. This backlog was a reasonably good measure of the benefit which Medicare was having, by giving elective surgery away free.
But that was only true if you consider every single remediable condition to be a disgrace of some sort. The people who had these conditions had weighed the costs against the benefits and had often simply declined. You could argue if you must, that poor folks just couldn't afford to get essential treatment, and that anyone who denied them this essential human right was an ogre; but that didn't appear to be the case in large measure. What was true was that the threshold for offering charity care was set to match the judgment of the decliners, rather than the level of physical perfection of an ancient Greek god. Folks just didn't think the surgery was worth the money, but when it became free, a new standard was set and they might as well get it fixed like a dent in an auto fender. Nevertheless, there's a strange fact about surgical scarcity and abundance. If you are planning on having any of these procedures, I would advise getting a surgeon with training during that catch-up period of the nineteen-seventies, because he had a lot of practice. In fact, my granddaughter flew to Nashville to have a perforated eardrum repaired by a famous expert during that period. When she recently needed a second operation after forty years, she had trouble finding a surgeon who could do it, even with half a dozen doctors in her family.
Surely a front-end deductible won't get us back to the same state of affairs, even if deductibles continue another forty years. But to some degree, it will happen, and what we once called a backlog will resurface as a debt from one time period to the next, with the threshold reset. Since we definitely need deductibles, it seems we apparently also need a small backlog of untreated elective (non-fatal) conditions, whether they do better than that in France or Sweden, or not. Since it can be safely predicted this will happen, we need to devise a way of managing the issue without provoking unsustainable costs. In the meantime, known but untreated, treatable conditions will become an accounting entry, which can fairly be attributed to the solving of our health cost issues. It's a debt, but I'm not sure total bodily perfection is the best standard of it.
Foreign debts for Medicare. For some time, Medicare has been 50% subsidized by federal borrowing. At the very beginning in 1965, it was 100% federally subsidized, and gradually payroll deductions, premiums and new programs with better funding arrangements took over. So far as is easily determinable, no one has dug out all of the subsidies and repayments, to be able to tell us what the accumulated unpaid debt for the Lyndon Johnson entitlement programs has been. What it has accomplished is harder to measure, since it must include a share of the improved longevity during the interval. Nevertheless, we could make an effort to see what the book cost has been. Surely it has been greater than just the cost of elective surgeries. At first, the creditors were all American citizens, most taxpayers, but at least it kept the money within the domestic budget. Since we started to borrow the money from the Chinese government, it assumes a different character, one which any creditor would feel entitled to evaluate. To know what to do about this debt is above my pay grade, as they say, but at least it would seem to be responsible stewardship to make a formal accounting of where we stand, and what we plan to do about it.
Domestic Healthcare Debts. Without getting into a wrangle about the Tenth Amendment, it is fair to say that health care has long been thought to be a responsibility of the several states, so at the least, the fifty state budgets would have to be examined and aggregated, perhaps the municipal budgets as well. In Philadelphia, the deficit of PGH (Philadelphia General Hospital) was running eleven million dollars a year, when it closed in 1977. The nation's first hospital, the Pennsylvania Hospital, was created by a grant from the state legislature in 1755, at a time when Ben Franklin was active. Perhaps it is not necessary to go quite so far back to see how the books balance, but any adjustment for inflation would bring out the considerable taxpayer expenditure for health, ever since the nation was founded.
Sustainable Growth Factor. Every year since 1997, Congress has calculated the rate at which health costs should be growing, and when it exceeded that, has planned to reduce physician reimbursement to compensate. Every year Congress has relented at the last moment, but never put an end to the threat. Since the accumulation has reached a point where almost every physician in practice would have to stop the practice if Congress honored its threat, something must be done about it. Paying it all off at once would trigger a 26% drop in physician income since every physician carries a 50% gross overhead, collecting an additional 26% would be a disaster. Perhaps the two political parties each hope the other will get the blame and pay the bill. But the bill remains part of the debt hanging over the Federal Government for health entitlements, and like most of this debt, it is a question how to treat all of its inflation in the interval.
Healthcare Mortgages. Bill Dunkelberger the Philadelphia economist, recently remarked that real estate is where the rubber hits the road, the place where interest rates really matter, the place where equities collide with fixed income. For eight years past, our long term interest rates, net of inflation, have been close to zero. That allows the government to borrow free of charge, and in effect allows hospitals and universities to build buildings without much or any cost.
Unfortunately, our businessmen have not responded with a comparable spree of interest-free borrowing, because they see nothing worth borrowing to build for. Their unwillingness to spend leads to the appearance of growing earnings, which artificially supports the stock market. It's hard to imagine a stock crash just because prosperity returns, so it's hard to know what will happen if it does. Hospitals and universities think they have something to build which will generate a healthy return for them, so one builds out-patient facilities, and the other builds lavish dormitories. When interest rates return to normal (they haven't, in Japan, done so for seventeen years), it's a puzzle to know whether the economy and the stock market will tank, or will celebrate. In any event, there is a great deal of new real estate debt which must be added to the level of government indebtedness, due to health. Since nothing much could be done with such single-purpose structures, their disposal is also part of the consideration. When Jefferson University received a gift of a basic science building to house the first two years of its classes, they got a maintenance jolt. Just to heat, air condition and clean the building consumed the entire tuition of the first two years of classes.
Student Loans, broadly defined. To judge by Nineteenth-century plays and novels, medical students were traditionally impoverished. Today, students of all descriptions are carrying six-figure indebtedness, but medical students are a special case. They run up debts in order to stay in school, and the schools prosper. Then, they take jobs for several years as house officers in hospitals, who are paid by the government from Medicare funds which are used in large part to pay off their loans. And then, they go into practice, often reimbursed by salaries provided by government entitlement programs like Medicare and Medicaid. It's more than I am able to say whether these successive loans add to each other, or cancel each other out. In any event, a huge amount of money is being paid for what is described as medical education, but a certain amount of it is diverted to other university uses.
Future Entitlements. In many ways, the largest indebtedness to account for, are entitlements which have been conferred on future generations, many of whom are not yet American citizens. This is the problem most pension funds are now encountering, of whether such a future promise is a contract which must be honored, that is, whether it counts as a debt. Congress certainly acts as though it must say it is a contract, or else be dis-elected. But the rest of us would not regard that as much of a tragedy, so perhaps it isn't a debt. Whatever we end up calling it, it would surely be an improvement if we could hear it accounted for as if it were the debt of a corporation. Perhaps that wouldn't lead to improving the situation, but it would certainly feel a little better.
A bank account earning interest will contain more money than a bank account earning no interest. How much the interest will be, depends on circumstances, but earning interest beats no-interest every time. In the case under discussion, the account is a Health Savings Account, and the alternatives for spending are healthy alternatives. Because the volume of money passing through the system is estimated to be huge ($325,000 per lifetime), the interest to be earned on 316 million Americans is staggeringly huge. In the following discussion, it is assumed the comparatively easy decision has been made to accept the money, but the highly contentious decision remains: how to spend it. The following choices immediately come to mind:
Pay off the health entitlement debts of the past.The U.S. Treasury reports our foreign debt to be $4.5 trillion, of which one trillion is owed to China, and one trillion to Japan. The Treasury does not issue data any more detailed than the national total, for the interesting stated reason that all Treasury bonds are general obligations. Some of this debt originated as Medicare subsidy, but it is not easy to learn more than that. In addition, it would only seem fair to devote some of a windfall for health to paying off its past obligations. For these two reasons, it would be possible to run an appreciable surplus without seeming to affect current balances.
Universal Entitlement. Obamacare was enacted on the proposition of universal entitlement to health insurance. Implicit in that claim was the idea that many Americans did not have and could not afford health insurance, and that insurance coverage represented some minimum level of healthcare entitlement, even if it had to be subsidized. Persons who did not have health insurance were regarded as jeopardized, even if they were in perfect health, and even if they did not regard health insurance as worth its cost. This uninsured risk within the population was covered by providers absorbing the cost, along with traditional health charities, and other levels of government. Somehow the idea was included that it was superior to have the federal government cover these costs, or perhaps it was superior to cover these costs with a graduated income tax. Although in the early stages there was some talk of reducing healthcare costs by federalizing them, it was eventually acknowledged, extra insurance coverage implied higher costs for everyone, except those who received government subsidies, derived from graduated income taxes, and identified as entitled by government regulation. It is a great curiosity of this campaign that employers were never pointed to as having a burden lifted when the existing system was still described as employer-based. As proposing to devote a huge windfall to the purpose tends to bring out, the cost of healthcare was being shifted from employer tax-deductions to individual taxation of the upper-bracket sort.
After three years of Obamacare, the two clear beneficiaries are health insurance companies and employers who donate the insurance to their employees. It is not clear either of these two groups was particularly suffering, so it is not obvious why a windfall should benefit them.
A point which cannot be emphasized enough is that a Health Savings Account is just about the best way to invest, if you have given little thought to investing. The deposits are tax-deductible, and the withdrawals are tax-free if they are medical in nature. Even if they aren't medical, they can be anything at all after you reach 66. You probably ought to give a lot of thought and investigation to the particular agent you choose, because they aren't necessarily legal fiduciaries, no matter how friendly they may be. They have no obligation like a doctor or lawyer to put the client's interest ahead of their own, and they can later hire partners you don't care for, so make certain you can terminate the arrangement and switch to someone else without penalty.
Be careful to choose a representative carefully. But whether to choose an HSA, at any age and stage of advancement, always leads to the same answer: Yes, do it. That being the case, a certain number of HSA owners will find themselves with an account they don't know what to do with. There's almost always an exit strategy, although you may need professional advice to judge which one is best for you.
If you started your account near or after retirement, you may have the idea you will never have surplus funds. But if Congress can be persuaded to make it legal, one of your options might be to roll the surplus over to a grandchild or grandchild-like person. If this suits your situation, please notice that a newborn child has some special medical problems. In the first place, the first year of life is unusually expensive; in the aggregate, 3% of all medical expenses are spent on the first year of someone's life. To anticipate a little, 8% of health cost are spent before age 21, which is generally held to be the beginning of the earning period. Children are generally pretty robust, but when a child is sick, he is vulnerable to lasting disabilities of a very expensive sort, so you don't like to see a family cut corners on child care.
But newborns have no earning power, their future is in someone else's hands. The average woman has 2.1 children today, two women thus have 4.2. Four grandparents roughly have one apiece. The way the law of averages is working out, if every grandparent took care of the health costs of one grandchild, things would be close to solved. Things would have to be adjusted for the non-average case, but they would be close to being solved by adding one grandchild's cost to each average Medicare cost for the elderly.
In this case, however, the legal and political problems are greater than the financial ones, so it would suffice for a beginning, just to permit those who want to volunteer, to be permitted to leave unused leftovers in their HSA to children under the age of 21. If there is concern about dynasties and perpetuities, it might be left to the child's HSA, to be exhausted by age 21, or transferred to the HSA of a second child. The sum in question might be around $8000.
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.
