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.
Byron S. Comati, the Director of Strategic Planning and Analysis for SEPTA (Southeastern Pennsylvania Transportation Authority), kindly gave the Right Angle Club an inside look at the hopes and plans of SEPTA for the near (five-year) future. Students of large organizations favor a five or six-year planning cycle as both short enough to be realistic, and long enough to expect to see tangible response. If plans continuously readjust to fit the five-year horizon, the concept is that the organization will move forward on these stepping stones, even accounting for setbacks, disappointments, and surprises. Furthermore, a serious level of continuous planning puts an organization in a position to react when funding opportunities arise, such as the sudden demand of the Obama Administration that economic stimulus proposals be "shovel ready."
The Silverline V
So, SEPTA is currently promoting five major expansions, based on the emerging success of an earlier plan, the Silverliner V. Silverline is a set of 120 shiny new cars, built in Korea on the model of electrical multiple units, which are expected in Spring 2011 to replace 73 cars or units which were built in 1963. Obviously, 120 are more expensive than 73, but they are more flexible as well. And less wasteful; most commuters are familiar with the model of three seats abreast which unfortunately conflict with the social preferences of the public, tending to make the car seem crowded even though it is a third empty. When a misjudgment like this is made, it takes fifty years to replace it with something better. For example, there's currently a movement toward "Green construction", which is acknowledged to be "a little bit more expensive". The actual costs and savings of green construction have yet to become firmly agreed on, so there's an advantage to being conservative about what's new and trendy in things that take fifty years to wear out.
Septa Regional Map
Four of SEPTA's five major proposed projects are in the Pennsylvania suburbs. New Jersey has its own transportation authority, and Philadelphia is thus left to struggle with the much higher costs of urban reconstruction assigned to its declining industrial population. And left unmentioned is the six hundred pound gorilla of the transportation costs of new casinos. A great many people are violently opposed to legalized gambling, and even more upset by the idea of crime emerging in the neighborhoods of gambling enterprises. Even the politicians who enacted this legislation are uncomfortable to see the rather large expenditures which will eat into the net revenue from this development. Nevertheless, if you are running a transportation system, you have an obligation to plan for every large shift in transportation patterns, no matter what you might think of the wisdom of the venture. The alternative is to face an inevitable storm of criticism if casinos come about, but without any preparation having been made for the transportation consequences. At present, the public transportation plan for the casinos is to organize a light rail line along the Delaware waterfront, connecting to the rest of the city through a spur line west up Market Street; it may go to 30th Street Station, or it may stop at City Hall. That sounds a lot like the present Market-Frankford line, so expect some resistance when the cost estimates are revealed. Because all merchants want to have the station stops near them, and almost no residents want a lot of casino foot-traffic near their homes and schools, expect an outcry from those directions, as well. It would be nice to integrate this activity with something which would revive the river wards, but it seems a long stretch to connect with Wilmington on the south, or Trenton on the north.
The planned expansions in the suburban Pennsylvania counties will probably encounter less controversy, although it is the sorry fate of all transportation officials to endure some hostility and criticism for any changes whatever. Generally speaking, the four extensions follow a similar pattern of building along old or abandoned rail lines, following rather than leading the population migrations of the past. When you are organizing mass transit, there is a need to foresee with some certainty that there will be a net increase in commuters in the region under consideration. The one and two passenger automobile is a much more flexible instrument for adjusting to the growth of new development, schools, retail, and industry. Once the region has become established, there is room for an argument that transportation in larger bulk is cheaper, cleaner or whatever.
The Norristown extension follows the existing but underused rail connections to Reading. Route US 422 opened up the region formerly serving the anthracite industry, but now the clamor is rising that US 422 is impossibly crowded and needs to be supplemented with mass transit.
The Quakertown extension follows the rail route abandoned in 1980 to Bethlehem and Allentown, although the extension is only planned as far as Shelly, PA.
The Norristown high-speed extension responds to the almost total lack of public transportation to the King of Prussia shopping center, and will possibly replace the light rail connection to downtown Philadelphia.
And the Paoli extension follows the mainline Amtrak rails as far as Coatesville.
All of these expansions can expect to be greeted with huzzahs by developers, land speculators, and newsmedia, but resistance will inevitably be as fierce as it always is. Local business always fears an expansion of its competitors; the feeling is stronger in the suburbs than the city, but local business always resists and local politicians always follow their lead. To some extent, the suburbs have a point, since radial extensions are usually much cheaper to build than lateral or circumferential transportation media; bus routes are the favored pioneers in connecting one suburb with another. Therefore, the tendency in these present plans remains typical by threatening the suburbs with a need to travel toward the center hub, then take a reverse branch back in the general direction of where they started, in order to go a short distance to a shopping center or school system. The two main river systems around Philadelphia interfere with the construction of big "X" routes from the far distance in one direction to the far distance in the opposite direction. Euclidian geometry makes the circumferential route elongate as the square of the radius. And jealousies between the politicians in three states create rally foci for the special local interests which feel injured. Since it seems to be an established fact that the proportional contribution to mass transportation by the surrounding suburbs of Philadelphia is traditionally (and considerably) lower than the national average, a political reconciliation might do more for the finances of SEPTA than any federal stimulus package could do. For such reconciliation, a few lateral connections in the net might pacify the suburbs enough to justify the extra cost. Unfortunately, the main source of unjustified cost in regional mass transit is the high wage and benefit levels of the employees, a situation inherited from the old days when commuter rail was part of the stockholder-owned regional railroads. Just as featherbedding was the main cause of the destruction of the mainline railroads, health and pension benefits threaten the life of mass transit. In the old days, local governments acted as a megaphone for union demands. So the railroads just gave the commuter system to the local governments, and let them wrestle with the unions themselves. Since the survival of the urban region depends on conquering this financial drain, the problem must be gradually worn down. But it has been remarkable how long the region has been willing to flirt with bankruptcy rather than bite this bullet.
If anything, this friction threatens to get worse. In 2009, for the first time, a majority of union members in America -- work for the government, the one industry which thinks it cannot be destroyed by losing money. True, SEPTA is not exactly a government function, but it has enough in common with a government department to arouse suburban voters, who regularly refer to it as an arm of the urban political machine. SEPTA isn't too big to fail, but there exists little doubt that government at some level would probably try to bail it out if it did.
Let's review the logic. Mandatory health insurance was considered to be necessary because we wanted Universal health insurance. And we wanted universal insurance in order to extend health insurance to those who had pre-existing conditions. In a sense, we don't have a mandatory insurance problem, we have a pre-existing condition problem. Is there no other way to solve this?
Perhaps, and perhaps not; but let's take up this critical point at the end of the discussion. Right now, it is pretty clear that 10% is a pretty big price for someone else to pay your bills. Most of us would not pay so much to have someone buy our groceries, pay our utility bills, or put quarters into a parking meter for us. We very definitely would not pay such a fee to someone who proposed to do it with a system of three insurance policies (one for 80%, one for 20% copayment, and the third one for Major Medical policies for gaps in our policy coverage). Nor would we compensate a payment agent to pay for coverage which is riddled with cash demands for escalating deductibles and copayments, every time we go to the drugstore, to the accident room, to the doctor's office. Something surely is wrong when we surrender the convenience of third-party payment, pay heavily for this service anyway, and they are hounded and confused by a myriad of partial payment demands, or bewildered by undecipherable itemized bills with an astonishing total at the bottom -- but nevertheless marked "patient responsibility, zero". Something is very definitely wrong when hardly anyone can explain the payment system to us, and no one is willing to quote a price in advance of service. So, let's start by considering what would happen if we eliminated co-payments entirely, and confined deductibles to out-patient services.
In the past, it might have been theorized that prices would go up because patient participation puts a brake on prices. But now we would have to contend with the question, "How would you be able to tell the difference?" The patient in a hospital bed is incapable of haggling about prices, while the hospital is mostly reimbursed in an approximated lump sum, called the DRG (diagnosis-related group). Even those insurances which are reimbursed by items are subject to secret discount systems, which vary from 40% discounts for state Medicaid to overpayments of 30% of costs for private insurance, and up to 400% for payments by list price. This system led one very famous Philadelphia surgeon to growl, "The main purpose of having health insurance is to keep the hospital from fleecing you." The bad public relations of asking the public to endorse this summary would make the problems of changing the system seem minor. For public relations alone, the system must be made more transparent. Most hospital administrators would make the irrelevant response that, after it all shakes out, hospital inpatient care only generates about a 2% profit margin.
That may be true but fails to emphasize that emergency room services generate a 10-15% profit margin, and hospital out-patient and satellite clinics approach 30%. If you drive past a nearby hospital, you are very likely to see a construction crane in operation. But just take a guess in advance at what type of building is being built.
Since hospitals are obviously responding to prevailing profit margins, they would be wise to agree on negotiations with insurers based on audited profit margins, assigning the margin to individual departments to divide up after internal negotiation. For inpatients, a refined object of negotiation with insurers should be an agreement on the variation of reimbursement to be tolerated between insurers for substantially similar inpatients, essentially some variation of Diagnosis Related Groups. A later chapter discusses improvements needed for DRG determination. The central point is: no attempt should be made to bargain prices with a patient who is sick enough to require inpatient hospitalization.
For emergency room services , it is possible to imagine a sort of DRG, and if the patient subsequently requires hospitalization, that should be the ideal approach. However, most emergency patients are not admitted, and there are usually nearby competitors for them. Therefore, some sort of hybrid should be constructed, partly an Emergency DRG, but also modulated by comparison with neighborhood facilities.
For outpatients, competition should rule, and any insurance accommodation should reflect that fact. Ideally, small outpatient services should be cash transactions, but the trend lately is for increasingly expensive procedures to be performed in the outpatient area. The most suitable outpatient payment would be the option of using a Health Savings Account. Optional, because it is desirable to encourage those who are able to protect their HSAs for other uses, to be described in later chapters.
The ambulatory patient is fully capable of loud and insistent bargaining over prices, ultimately threatening to go elsewhere or just to refuse the pay the bill. In the last extremity of disagreement, the provider will be very glad to accept an HSA, so it serves as sort of a distorted re-insurance, and it is useful to have a central reporting mechanism to determine how the market is faring. Since everyone is now entitled to have an HSA, everyone should sign up for one. The uproar over the Electronic Exchanges has demonstrated that almost everyone is coming to the conclusion that high deductibles are desirable. The reasoning is not so self-apparent, but it is nevertheless also true, co/pay is something to be discouraged.
When a full transition to a new system of personal finance takes ninety years, you might as well say the system is the transition. However, it explains better if you know where you are going, original intent, as it were. Therefore we first present Lifecycle Health Savings Accounts as if everyone is born on the same day, and then explain we understand perfectly well that a lot of people were born on every single other day for the past ninety years. There's going to be a lot of transition, and therefore a lot of calculation. Somebody will have to prepare a big book of tables for computer terminals. In the meantime, the effort seems better spent on describing the theory, which is fairly simple. If you are going to have your ninety-ninth birthday tomorrow, Lifecycle HSAs aren't going to do you much good. We, therefore, pick someone half-way through the transition, which might appear to result in a saving of $175,000 dollars per person per lifetime remaining, if we aren't careful about it. Moreover, we propose phasing in one section of the program at a time, so if the person in the example is financially unable to afford the whole deal, he will "only" save $85,000. The explanation for this "disappointment" lies in the quirks of how Medicare has been financed in the past, but if someone has already lived half his life, he will naturally only cost roughly half as much for the remainder.
Medicare Financing for Dummies.Aside from deductibles and co-insurance, Medicare is financed by three sources. Roughly a quarter comes from payroll deductions for working people in anticipation of later Medicare costs. No interest is currently paid, so one of the sources of financing for this proposal is to earn interest, crediting it to a (voluntary) buy-out escrow fund for the program, within each HSA. By itself, this generates much of the savings we anticipate.
Another quarter of Medicare cost is contributed by premiums paid by the elderly subscribers to the program, generally starting when they reach 66. We propose eliminating such payments, as a way of rewarding those who voluntarily join the transition. Some people will inevitably reach age 66 without generating the necessary buy-out funds, so they alone will have to pay the premium until it replaces their deficiency. They should still save some money by recognition of whatever they did pay in, but it will be less. The design anticipates this particular feature of the program to be a no-lose offer.
And the final 50% of Medicare is currently a subsidy out of general tax receipts. Since we already run a deficit, we borrow the money from foreigners, mostly the Chinese. And if we start paying the full cost, it won't generate actual revenue, it will only stop making the deficit worse. It will also stop paying extra interest to borrow it, which we presume is about 5%, the interest on 10-year Treasury bonds. We presume the government would be willing to pay this interest to the Medicare fund, in return for not borrowing the principal from foreigners. The consequence of such an agreement would be to generate an extra 5% for the transition fund, in addition to the payroll deductions.
This part of the proposal will stop further borrowing on behalf of those who agree to it, but it will not pay off existing debt. Congress will have to decide how rapidly it wishes to rid itself of the principal of this debt. If the two revenue sources already mentioned are deemed insufficient, it can reduce the benefits to those who accept the buy-out, although it will probably slow the transition to do so.
If Congress should feel the incentives need further adjusting, my own suggestion is that it should be effected by adjusting the payroll withholding, either up or down. With an average lifetime calculated healthcare cost of $350,000 per person, there is ample room to do it. To do so would have only minor overhead cost, and it would maintain the system of having working people pay for non-working ones. Or rather, of all persons paying for healthcare while they are earning, including the beginning and end of life, when they cannot work. To do so would preserve the natural way families pay for non-working family members without insurance except catastrophic insurance. We have worked ourselves into the corner of the health insurance industry itself consuming nearly 2% of gross domestic product, mainly because of expanding abusive benefits in response to an unwarranted tax deduction. It is not necessary to criticize the health insurance industry for responding to this incentive.
As a side comment, those people who are given a subsidy are asked to take no risk. Everybody would naturally prefer to avoid risks, so we must create incentives to avoid the implicit adverse incentive. That will usually take the form of avoiding unearned benefits for those who are given risk-free subsidies. The rest of the system is already a balance between risk and cost, offered in the form of less risk, more cost. Stocks are riskier than bonds, long-term bonds are riskier than short-term ones, but the income rewards are reversed. Unfortunately, bonds, money market funds, and Treasury bills pay so little interest, there is little point in exploring HSAs which purely consist of them. In fact, equity financing has only become feasible in the last few decades, as longevity increases. Since the serious risks are infrequently encountered, a young person can afford to take the risks of the stock market, banking on later gains to rescue early mistakes.
So, the time to buy stocks is early, adding bonds later when there might not be time left to recover from a stock crash. Since the full potential of high-quality American stocks is 12%, most young people would start with that, adding a growing proportion of bonds as they approach the end of their longevity. Health risks rise appreciably after age 50, so the balance of stocks and bonds should approach 60/40 at that age, lowering the lifetime income return from 12% toward 6%. Some people will get lucky and be making substantially more than that, and therefore can take the risk of making still more if they delay the dilution of the portfolio with bonds. There will be some who fall short of the benchmark, and who will then have to gamble on the stock market even longer to make the goal of $80,000 lump-sum payment at age 66 to Medicare. That's what it takes to cover half of $175,000 average expenses from age 66 to the end of life -- a half which the government currently subsidizes. By the way, there's another risk, that Congress will not approve of buy-outs, and your Medicare costs will be double, which summarizes the incentive to do it if you are permitted. It's even worse: to spend $175,000 you will have to pay income tax on what you earn before you can spend it on Medicare premiums after age 66, and on Medicare withholdings before that age. That's a pretty strong incentive.
The Presidential campaigns just started, we don't even know the final candidates. We can't, therefore, predict if the election decides the health issue or the health issue decides the election. As one of the originators of Health Savings Accounts, my own position may be a foregone conclusion. But millions of people enrolled in HSAs. They will remain a factor, no matter who gets nominated or elected.
Simplicity is a banner we fly. Instead of a thousand-page law, we offer the simplest of proposals. No matter what the disease, the HSA (Health Savings Account) will probably pay for it. It's only about money, not elastic "service" benefits. It consists of health insurance with a high deductible. That's good, because of the higher the deductible, the lower the premium. Since poor people may be unable to afford a high deductible, it's then linked to a sort of Christmas savings account where you can save up the deductible. After that, coverage is complete.
It's true, a poor person is incompletely covered during the first few years, but it's also true young people have little risk of an expensive bill until they get older. So although millions own these accounts, the majority signed on between the ages of 25 and 45. Simple, simple, simple. It tells you something when forty percent have never made a withdrawal for health, apparently preferring to let the account build up, rather than spend it on small health bills. These people aren't fools, they know heavy expenses lie ahead of them. But they also know interest rates are starting to rise, and they all have experience with paying bills on credit. There are a few who can never accumulate a thousand or so dollars in their whole lives, but subsidies for the poor are a commonplace if America wants to provide them. In an HSA arrangement, subsidies present no steep barrier to later saving, because of an underrecognized feature. If you haven't had a big illness by the age of 66, and then receive Medicare, you get to keep what's left. The incentive seems to work. People with Health Savings Accounts spend 30% less on health than those with other health insurance.
So Health Savings Accounts are not only cheaper, they are the only health coverage which helps your retirement if you don't get sick. They already exist, so if something makes other health coverage collapse, they could immediately substitute. You aren't at the mercy of politics or economic disasters. So, if threatened by loss of insurance, HSAs are as safe as you can get. So the only criticism is lack of tax deductibility for the high-deductible insurance, but that could be remedied by a one-sentence amendment. True, the deposit and age limits haven't been extended in decades, but then we haven't had a Republican president for almost that long, either.
So Health Savings Accounts are already about as good as you can get with divided government, but the present form is far from exhausting their potential. In the first place, we are slowly coming into the era when interest on deposits amounts to something worthwhile. The use of "passive" investment with stock index funds could provide a dizzying reduction in effective costs.
Furthermore, the advance of science hints at more novel uses of unspent health money for retirement purposes. Five or ten diseases account for the majority of health costs, so if somebody cures a disease we could fight the political battle to pay for increased longevity, with reduced health costs. Eventually, the far future contains a vision of constraining serious health costs to the first year of life and the last year of life. Even at present, those two years account for twenty or more percent of health costs, but because they affect 100% of us, they cost so much. By some scientific magic, we can dream of basic costs as only a quarter of present costs, not extended infinitely into the future. It wouldn't be easy to retain such savings as retirement income, because the government always wants to divert savings into battleships. Nevertheless, recasting the image as creating value in retirement, instead of a bleak period of uselessness, sounds like a desirable vision thing, to me.
The first obstacle for a lawsuit to jump is the right to use the courts. Although failure to demonstrate injury is one of the commonest ways to clear a court's calendar, insisting that the lawsuit must have some utility has become the very foundation for an impartial body of government to be free to settle disputes between citizens. There are other mechanisms, particularly the Courts of Equity of the young Republic, when there were many occasions when something was obviously wrong, but no statute covered the situation. By the Civil War, the Legislative Branch had more than supplied any deficiency of statute. The State of Delaware now has the only surviving Court of Equity, and "standing" now protects the courts from floods of useless lawsuits. However, that leads to the present Court System sometimes blocking a lawsuit, simply because the cause of the complaint is too broad, and requires special strategies to proceed. At the least, it requires a description of how an entire profession has been barred from its customary role, by an accident within the Judicial System.
History of the Matter. In the District Court of Maricopa County, the State of Arizona successfully sued the Maricopa Medical Society as antitrust for its prohibition from Medical Society Membership, any member who charged an indigent patient substantially greater than a fee published by The Society. This action was described as a per se violation of federal antitrust law, and without any trial of the facts was appealed successively to the U.S. Supreme Court. Two Arizona Justices recused themselves, and again without trial of the original summary judgment, was upheld by a 4-3 decision which still stands as National Law.
Subsequent Consequences. In Medical Circles, the Maricopa case is described as "dethronement of the doctors from control of the medical system" and "their replacement by non-physicians". For example, in 1948 the Nation's First Hospital (The Pennsylvania Hospital in Philadelphia) had two administrators, the Administrator and his secretary. Today, the same building which housed 200 patients in 1948 is entirely filled with puzzled administrators. The transition from physician control to something more legal has required insurance redesign which is still an expensive mess. After fifty years of trying, the pharmacy system is still cumbersome, the nursing schools have been upended, and the greatly enlarged billing system is still undecipherable. Meanwhile, physicians are quitting in their fifties because of the welter of unnecessary paperwork which keeps them from doing what they were trained to do, an occasional old nurse still defiantly wears a nursing cap, while cafeteria workers fumble at new-fangled uniforms. Everything has been unnecessarily changed, concealing the fact that it did not need to be changed. Meanwhile, those who took these supervisions in their stride are retiring early. Doctors used to marry their nurses; you now seldom hear of that. Salaries, which used to be zero, are now in six figures. Everybody complains; no one does what he was trained to do, especially the trustees. It once was the function of trustees to oversee funding requests of the doctors and get the money when needed; nowadays they rubberstamp the plans of administrators. There are simply hundreds of computers; no one reads their output. The disappearance of thirty common diseases (tuberculosis, syphilis, polio, rheumatic fever, etc.) is what keeps the system from collapsing. I received a salary of zero for four years, my grandson makes $53,000 a year of what is surely government money for much less medical work, much more red tape. If you don't believe these tales, I will be happy to call these people as witnesses. No doubt, witnesses for the other side will be happy to testify as well, and you can decide for yourself.
Repairing the damage. It took two thousand years to design the old system, but only fifty years to bring many hospitals to mergers, two medical schools to near collapse in Philadelphia alone. The Rs are fighting with the Ds over God knows what. All this mess cannot be repaired quickly, but it wouldn't hurt to get started. The Health Savings Account would be a better place to begin. Since remanding Maricopa for full trial would only be a beginning without much repair, it's little enough to ask as a beginning. The goal, well beyond my own sunset, would be to put the doctors back in charge and then waiting for fifty years. At least, stop getting in their road, since it is only fifty years since they stopped being the most admired profession on earth.
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.
