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.
Western civilization now takes One-man, One-vote for granted in any variant of national governance, and a good thing, too. The Romans modified ancient Greek democracy models into a Republic, allowing slightly modified democracy to become practical for larger governments. Citizens elect representatives, and it is possible to imagine groups of representatives electing their own representatives to higher bodies, and so on, up to the line. As long as democracy remains inflexibly the model for a united Europe, other mechanisms must be adjusted for the obvious inequalities of huge population masses. Since money is the main means of exchange in national systems of compromises, it is a handicap for them to freeze a monetary system in place before governance negotiations have even begun. As a reminder of the American experience, remember that in 1787 Virginia was by far the largest and richest state, not at all the case at present. Indeed, the political landscape then consisted of nine small states ranged against four big ones. Virginia, Pennsylvania, and Massachusetts are no longer considered big states, and New York is fast receding from the top tier. Organizing monetary structures around the size can prove crippling to future designs of unified government, particularly if sufficient time elapses between the two steps. At the very least, leisureliness creates an opportunity to cloak opposition to unification within delaying tactics, presenting arguments to "wait and see" how the monetary system works. At worst, it creates an incentive to make certain the monetary system will not work.
Bitting Gold Coin
However, a bridge player must play the cards as they are dealt with him, and Europe has decided on a piecemeal approach to organizing an eventual political union. The first step of monetary union is in its tenth year, and in deep trouble. Therefore, a new alternative to be considered is whether to have a monetary union without a government to oversee it. Since the Spanish doubloon was for centuries the medium of maritime exchange for the whole western world, it can be done. The doubloon was a gold coin worth its weight in gold, the so-called "piece of eight". Since that kind of money proved entirely workable, the issue of feasibility is one of backing for the currency. When gold from the New World ran low, it was hard to support a growing world economy with a shrinking currency; the price of everything went steadily downward, and local shortages were common. So silver was substituted, and then the coinage became fractional. That is to say, paper money was issued in a fixed ratio to the gold in government vaults. Finally, paper money had no metal backing at all and was issued by central banks in response to the prevailing prices of goods. Using an arbitrary figure of 2% to represent population growth, if the consumer price index plus 2% goes down, the Federal Reserve (or equivalent national central bank) prints more money. Conversely, if it goes up, the Federal Reserve bank stops issuing paper money. The currency is thus "inflation indexed" and its worth guaranteed by the government against an international financial panic. World opinion has a lot to do with the value of a national currency, although in theory, the financial reserves are the sum total of all businesses and property available to the government to confiscate. By encumbering its national property, the government monetizes its assets. Even if it were possible to arrive at a tolerably accurate estimate of the total net worth of a nation, much of it is illiquid and has a considerable cost to monetize it. In practice, however, everyone realizes that the government will never sell an island or peninsula, probably going to war to prevent it happening, or simply going bankrupt or defaulting on its debts. The reserves which are listed as backing its money supply are largely frozen in the face of an actual financial panic. Everyone could name a dozen nations which would probably default, should creditors ever trust them, and there are many more who would seriously consider it. However, there are enough "speculators" who take a chance on this scenario for a fee, to keep the system running. If things start looking ugly, these intermediaries quickly disappear and the "markets are frozen". To protect their economies from this sort of chaos, governments look to merging their currencies, or to promising to rescue other member nations in trouble. A big pool of reserves is inherently safer than a small one, so currency unions are attractive to almost everyone.
GooseStepping
Currency unions, however, look like sausage factories when you get inside and look at the details. Some parts of New England are essentially piles of pebbles with a thin layer of topsoil, while the topsoil in Illinois is mostly four feet deep. Some rivers are full of fish, others are full of pollution, and so forth. As long as we are one united country, local differences are largely ignored; if you can't farm the pebbles in Connecticut, you can move to Greenwich and sell Credit Default Swaps. If that doesn't work, you can move to Illinois, and if you don't like big city political machines, you move to Utah. There's a frictional cost to all of this, but it remains a practical alternative. For Europe, it's not so easy to learn a new language, the schools are not so good in Kosovo, and the price of a taxicab in Paris is astonishing. If you are a gypsy, you are very likely to encounter pitchforks after your first night in the campground. No doubt most of this difference between the continents would disappear after fifty years of political unification, but there would be enough problems to make the survival of the E. U. somewhat questionable for two generations, at least. During all of that time, interest rates would reflect the existence of a real risk, and occasionally crises will appear. Madison, Jefferson, and Hamilton were bosom chums in the 18th Century; within five years of the new nation, they were at each other's throats. Founding Father Robert Morris, one of the richest men in America, was denounced and his motives questioned on the floor of the Legislature by a Western Pennsylvania nobody, within weeks of the Constitutional Convention. Vice President Aaron Burr put a bullet through Secretary of the Treasury Alexander Hamilton. Social upheavals are just that: upheavals. The problems associated with piecemeal approaches to the monetary union and the political union have been mentioned. The other side of it may be that many of the unique monetary problems of Europe have been brought to the surface by the current financial panic, and political solutions to monetary difficulties can be devised in advance if anyone has time to do it.
The political side of Europe is becoming plain. The Germanic tribes to the North are rich and have a history of trying to conquer all of Europe; the Latin tribes of the South are poor and nurse a fairly recent memory of defeated military occupation. The Germans are nevertheless the only possible rescuers of the present financial panic. It will not be easy for the Latin component of Europe to humble themselves before a German financial rescue, but they must do so for decades into the future. Although both groups suffer from the debility of a Welfare mentality, the South has it worse and their financial reserves are very questionable. Unless they are ready to do unlikely things like selling real estate sovereignty, they are going to find the ownership of their companies in German hands, and very likely have to endure the sight of the children of Wehrmacht officers managing their local economy. They will have to be tolerant. The Germans are not happy to work long hours so the Greeks may work shorter ones, and must be forgiven for indignation that German funds donated to rescue the Greek Welfare state are diverted for the personal use of corrupt Greek officials. Nevertheless, such affronts eventually become tolerable; a dozen American cities are at least as corrupt, and the California beaches appear to be utterly devoid of the famous American work ethic. Nevertheless, the most likely stark alternative would seem to leave only America, India and China in charge of major viable economies.
Stripped of its mystery and irrelevant details, the Bretton Woods conference agreed that all nations would make their currency convertible into U.S. dollars, and the U.S. would make its currency convertible into gold. Since World War II had left the United States with the only major working economy, it sold goods to the rest of the world and the rest of the world sent us their money to be converted into dollars; we had a "favorable balance of trade." Somewhere in the 1960s the rest of the world got on its feet, and we began to have an unfavorable balance of trade. After a while, foreigners started converting their dollars (the "reserve" currency) into gold. By 1971, the depletion of gold from Fort Knox became alarming, and the United States stopped converting its currency into gold. From that point onward, all currencies became effectively computer notations, whose value as a medium of exchange was what their government said it was.
Paradoxically, it is hard to see how this system would work without a government in charge of it, although private substitutes would probably soon appear if governments relaxed their monopoly on currency. Since a great many people dislike their governments for one reason or another, they chafe at a system which forces them to keep their governments in order to prevent commercial chaos. For those who do not adequately understand this, governments all stand ready to maintain themselves with force, and many other people dislike that feature even more. Since it took place at the same time, the Vietnam protest movement may have had some relation to this major change in the nation, misunderstood perhaps, but viscerally perceived. In view of President Nixon's central role in all of this, one is even tempted to speculate that his electoral promise of a secret means to end the Vietnam conflict, coupled with the subsequent peaceful surge of China and the financial recycling of Chinese money through Treasury bond purchases, may all have been subjects discussed during his historic trip to China.
However that may be, it is a fact that the Vietnam War ended, the Chinese economy flourished with American help, and the deposit of Chinese money in our economy helped fuel a massive economic bubble, and the weakest links in the chain -- mortgage-backed securities -- were the place the bubble burst. Not much of this could have occurred with a gold standard, and in many circles, this was regarded as proof that gold was a barbarous relic. In retrospect, few would deny we had been leveraging our economy to dangerous heights, for nearly fifty years. In 1996, Alan Greenspan denounced our "irrational exuberance", and yet the bubble did not burst for another twelve years. If we succeed in deleveraging our economy until it reaches 1996 levels, it will be regarded as a remarkable success. But the Chairman of the Federal Reserve at that time described it as a dangerous level. And looking back over the centuries, an indescribable number of kings were dethroned or beheaded because they evaded the rather irrational restraints of a scarce, hence precious, barbarous relic. Balanced against that, a billion Asiatics have been raised out of poverty, and the economy of the world overall would seem opulent to our grandfathers. Somehow, we must find the wit and the self-restraint to solve this problem.
REFERENCES
The Battle of Bretton Woods: John Maynard Keynes, Harry Dexter White, and the Making of a New World Order:z Benn Steil: ISBN-13: 978-0691149097
This book was originally based on a notion, on a dream if you will. A whole lifetime of healthcare might be purchased, for what now only covers a quarter of a half -- those scarcely-noticed payroll deductions for Medicare, listed on everybody's payroll stub. But then politics and Supreme Court decisions came along. Turning over each pebble on a new heap, it nevertheless seems that amount might still stretch to cover all of the nation's average lifetime costs, although payroll deductions wouldn't resemble the way to do it. Reducing prices by 28% of $350,000 is a ton of money, particularly when multiplied by 300 million people. Let's lower expectations by saying the new narrower proposal might only reduce prices by 14%. That would be $39,000 times 300 million, or twice the combined fortunes of Bill Gates and Warren Buffett. The $39,000 is a substantial amount for anybody, and $ 11.7 trillion is an astonishing aggregate for the nation. That's once in a lifetime, but it's still $140 billion a year.
I decided to ignore the 42% of historical costs which Obamacare covers (age 21 to 66) until its facts emerge. Just add the cost of the earning segment (21 to 66) to estimate whole lifetime costs. That does leave a gap of one third in the middle of life. If you don't know what the Affordable Care Act will eventually cost, you can't be confident what lifetime healthcare will cost. I'm confident lifetime Health Savings Accounts would cost much less. The Affordable Care Act has not yet convincingly described any cost reductions. But to be fair, neither do Health Savings Accounts. They reduce the price by adding revenue.
The issue is how to transfer $238,000 from individuals in one group, to another group.
Quick calculation now follows. Average lifetime healthcare expenditure (in the year 2001 dollars per person) is in the neighborhood of $350,000. That's the estimate of statisticians at Michigan Blue Cross, confirmed by Medicare. Medicare takes half of the annual cost, from birth to age 21 takes another 8%, and we don't know the cost of the unemployable of working age, but they are 10% of the population. So, the new segment we assigned ourselves, involves at least 68% of national health costs, and probably somewhat more. That represents the basis for saying the working population 21-66 must pay its own costs and somehow transfer at least 68% more to what we will call the dependent sector. At a minimum, that's 68% of $350,000 per lifetime, or $238,000. Don't take it too seriously, but that's the ballpark.
Endowment funds traditionally aim for 8% annual return (3% from inflation, 5% net). The stock market has averaged 12% gain for a century, so 4% isn't exactly missing, but its disappearance requires convoluted explanation, later in the book. Starting with those bits of information and adding a few more, just re-arranging payments would get to the same final result-- by spending one-third as much money. The cost of separating employer-based insurance from all the rest of it exceeds my abilities, so it will have to dangle. How we got to that conclusion isn't rocket science, but it isn't obvious, either. So let's make the conclusion easier: you can make a ton of money doing what is suggested. Don't complain it isn't two tons or only half a ton, it is what it is. You can put this data through a big data computer, or use a slide rule, but you are still dealing with predictions about the future, which will contain lots of uncertainty. Although it will not make healthcare free, it implies savings of about $38,000 per person, per lifetime. View that saving in two ways: it's only about $500 per person, per year. Or, viewed as a nation of 316 million inhabitants, it saves $150 billion per year. Skeptics could attack the math as exaggeration, and still get an answer in billions per year. Tons instead of billions would be even more accurate, just sound less precise.
Next might come nit-pickers. You can't get 8% investment income returns a year, unless this, or unless that. Very well, just say this is the top limit of what is possible as an average, using average investment advice. The Federal Reserve confidently promised to keep inflation at 2%, but actually experienced 3% over the past century. Chairman Bernanke tried his best to "target" inflation up to 2% but inflation just resisted going up that far, and it's pretty hard to get any agreement about why it resisted. Accuracy just isn't possible when you are predicting the economic future. That's why the unit of measurement is in tons. Tons of money. Who will save it and who will steal it, is much harder to predict.
Some doctors, deans, drug companies, financiers and politicians will always try to increase their spending to equal any available revenue. About forty percent of the public will line up at the same trough. All that is beyond my control. You won't find one word in the accompanying book to suggest I endorse such behavior. All I did was write a cookbook. The cooking is up to you.
In the last fifty or so years, American life expectancy has increased by thirty years, enough extra time for three extra doublings at seven percent. So, 2,4,8. Whatever money the average person would have had when he died in 1900, is now expected to be eight times as great, since he dies thirty years later in life. And even if he should lose half of it in some stock market crash, he will still retain four times as much as he formerly would have, at the earlier death date.
The lucky reason increased longevity might rescue us is the doubling rate started soaring upward at about the time it got extended by improved longevity in 1900 (when life expectancy was 47). In particular, look below at the whole family of curves. Its yield turns increasingly upward for interest rates between 5% and 10%, and every extra tenth of a percent boosts it appreciably more. Let's take a small example. Why don't we invest everything in "small" capitalization companies? Because there aren't enough of them to support such a large diversion to a frozen account. We are therefore forced to concentrate in large capitalization corporations, yielding only 11%. A few tenths of a percent extra yield might be squeezed out of this curiosity. Life expectancy is slowly but steadily lengthening. And so on. It's useful for the nation to realize that having everybody live longer is a good thing, just as long as too many extra people don't get sick with something expensive.
In the past century, inflation has averaged 3% per year, and small-capitalization common stock averaged 12.7%. That results in an after-tax growth of 9.7%. Some people consider 3% inflation to be good for the economy, many do not. The bottom line: many things have changed, in health, in longevity, and in stock market transaction costs. Those things may have seemed to have deviated very little, but with the simple multipliers we have pointed out, that upturn in income at the end of life becomes steadily magnified. If you do nothing at 3%, your money will be all gone in thirty-three years. That is if you leave your savings in cash. While it is true there are risks with all choices, the option of being a deer in the headlights is a poor one. There's a small but critical margin, and everyone must collectively struggle for very small improvements in it.
If you work at things just a little, you take advantage of the progressive widening of two curves, also shown on the graph: three percent (for inflation) remains pretty flat, but seven percent (for investment income) starts to soar much earlier. Up to 7%, there is a reasonable choice between stocks and bonds; but if you need more than 7% you must invest in stocks. Future inflation and future stock returns may remain at 3 and 7, forever, or they may get tinkered with. But the 3% and 7% curves right now are getting further apart with every year of increasing longevity. Some people will get lucky or take inordinate risks, and for them, the 10% (large-company stocks) investment curve might widen from a 3% inflation curve a whole lot faster. But except for desperate gamblers, every single tenth of a percent net improvement, will cast a long shadow. That means blue-chip common stocks are best, except during a black swan crash where all bets are off, but bonds are probably least bad.
Save it, or Spend it.
You can't do both.
But never forget the reverse: a 7% investment rate will certainly grow much faster than 4% will, but if people allow this windfall to be taxed, gambled or swindled, the proposal you are reading will fall short of its promise. We are offering a way to minimize taxes, the other two risks are your own problem. Our economy operates between a relatively flat 3% and a sharply rising 4-5%. In other words, it wouldn't have to rise much above 3% inflation rate to be starting to spiral out of control. Our Federal Reserve is well aware of this, but the public isn't. A sudden international economic tidal wave could easily push inflation out of control, in our country just as much as Greece or Portugal if they leave the Euro. Another issue: As developing, nations grow more prosperous, our Federal Reserve controls a progressively smaller proportion of international currency. Therefore, we could do less to stem a crisis that we have done in the past.
To summarize, on the revenue side of the ledger, we note the arithmetic that a single deposit of about $55 in a Health Savings Account in 1923 might have grown to about $350,000 by today, in the year 2015, because the stock market did achieve more than 10% return. It might be more realistic to say $250 at birth rather than $55. but the principle is sound. You can't do it twice, but it ought to work, once. There is therefore considerable attractiveness to the expedient of extending HSA limits down to the age of birth, and up to the date of death. It's really up to Congress to do it.
If the past century's market had grown at merely 6.5% instead of 10%, the $55 would now only be $18,000, so we would already be past the tipping point on rates. You do have to leave some extra room. In plain language, by using a 10% example, $55 could have reached the sum now presently thought by statisticians -- to be the total health expenditure for a lifetime. But by accepting a 6.5% return, the same investment would have fallen well short of enough money for the purpose. Unlike the municipalities that gambled on their pension fund returns, that sort of trap must be anticipated to be avoided.
Things are not entirely hopeless, because 6.5% would remain adequate if our hypothetical newborn had started with $100, still within a conceivable range for subsidies for the poor. But the point to be made provides only a razor-thin margin between buying a Rolls Royce, and buying a motorbike. If you get it right on interest rates and longevity, the cost of the purchase is relatively insignificant. That's the central point of the first two graphs. For some people, it would inevitably lead to investing nothing at all, for personality reasons. Some of the poor will have to be subsidized, some of the timid will have to be prodded.
This is more of a research problem than you would guess: a round-about approach is to eliminate first the diseases which cost so much, choosing between research to do it, or rationing to do it. Right now we have a choice; if we delay, the only remaining choice would be rationing.
Commentary.This discussion is, again, mainly to show the reader the enormous power and complexity of compound interest, which most people under-appreciate, as well as the additional power added through extending life expectancy by thirty years this century, and the surprising boost of passive investment income toward 10% by financial transaction technology. Many conclusions can be drawn, including possibly the conclusion that this proposal leaves too narrow a margin of safety to pay for everything. The conclusion I prefer to reach is that this structure is almost good enough, but requires some additional innovation to be safe enough. That line of reasoning will be pursued in a later chapter.
Revenue growing at 7% will relentlessly grow faster than expenses at 3%. As experience has shown, it is next to impossible to switch health care to the public sector and still expect investment returns at private sector levels. Repayment of overseas debt does not affect actual domestic health expenditures, but it indirectly affects the value of the dollar, greatly. With all its recognized weaknesses, a fairly safe description of present data would be that enormous savings in the healthcare system are possible, but only to the degree, we contain next century's medical cost inflation closer to 2% than to 10%. The simplest way to retain revenue at 7% growth is by anchoring the price leaders within the private sector. The hardest way to do it would be to try to achieve private sector profits, inside the public sector. This chapter describes a middle way. Better than alternatives, perhaps, but nothing miraculous. .
And yet another way to describe Health Savings Accounts, is as a series of places to put money, voluntarily moving from one category to another in response to the age of the owner, but potentially to environmental pressures. If the environment changes, the money might need to migrate, but it never disappears unless the owner spends it. Ideally, the money moves smoothly around in a circle, but it could pile up if some subscriber had unexpected personal situations. It's the subscriber's money, so we wanted to avoid locking him in, except by suggesting the most advantageous way to grow it or spend it. Many voluntary features could have been mandatory, with about the same result, but we wanted subscribers to innovate. The philosophy was that of the college president who built a new college without sidewalks. Only after the students had worn paths of choice in the lawn, did he order the paths to be covered with concrete? Here is a summary of the environmental factors we felt might change enough to warrant new pathways. The same idea applies to repair the lawn after a hard summer.
Demographics. China found it didn't work to limit families to one child, and selective abortions in India caused the same disruptions. The baby boom bulge is a notorious example of a population bulge working its way through the steps, until it finally came to rest in Medicare, threatening the program with bankruptcy when later generations don't bulge enough to support their parents. Some bulges and shortfalls are predictable almost a century ahead, and while the migration of illness and good health is slower, it will pretty surely boil down to two enduring health costs: birth and death. So, the demographics of each generation are basic, and they are often predictable. In our society's view, there is little you could or should do about it, so although we can predict demographic surplus and shortage, we should accommodate the effects, not directly modify the cause.
Wars and Depressions; Inflation and Deflation. Major disasters affect all generations, but sickness concentrates by age. Furthermore, health disabilities from war affect those of military age and their successors, and recessions cast a long shadow over later income potentials. It might be helpful to set aside funds for these disasters since it is possible to estimate the coming economic effects and to start generating income for approaching shortages. There may even be usable information about earlier wars and recessions on which to base such estimates.
Economics is known as the dismal science, reflecting skepticism about the predictions of economists. However, they are getting better at prediction, and should be given a chance to estimate the future effects on health care costs, to the degree they modify the modifiers. The more we do this sort of thing, the more we may find certain predictions cancel each other out. And economists' predictions are likely to reinforce the opinion that the best option is to steer for price stability, rather than resort to violent course reversals, a view not universally held by politicians.
The Nozzle of Transfer Points. It took the Federal Reserve a long period of experimentation to discover its most effective tool for modifying economics in the currency markets was to adjust short-term interest rates. In the economics of health care, I would venture the most effective can be had with the least commotion, by adjusting the transfer limits as money flows between age groups. When the leverage at age 21 approaches over 500-fold, the ranges of power over health spending are enormous. Therefore, regular transfers from the federal Treasury may be quite small, but probably should be prevented from going to zero. Since it is envisioned that grandparents might bequeath a certain portion of their death surplus generated from Medicare without reducing Medicare benefits, the small initial cash deposit is a point which would be noticed least in a panic. Alternatively, adjustments of the amount the grandparent was allowed to bequeath could have a similar multiplier on far larger sums of money. Ultimately, such modifications would have to be reversed when such funds start to accumulate income, but considerable time would pass, between age 21 and 65, to accomplish it. Both government and subscriber must learn the cheapest time to pay bills is while they are small.
A second adjustment tool exists in the ability to require account balances to shrink or go to zero. The money would be given to the account holder, but would simply stop generating income until the required adjustment took place. Opportunities would appear at birth, at age 21, at age 65, and at death. Furthermore, large populations would achieve these ages at different times, so opportunities for adjustment would extend over a range of time. It took the Federal Reserve a long time to learn the sensitivity of adjusting interest rates, and it would take an equally long time to learn how to use these tools as well. It took a particularly long time to learn the most important lesson of all: what the limits were, for accomplishing anything worth-while with these tools, at all. Everything speaks in favor of establishing a monitoring agency, with defined powers and required limits, permanently devoted to this subject alone, periodically reporting its findings to the public.
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.
