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
... William Penn's Quaker Colonies
plus medicine, economics and politics ... nearly 4,000 articles in all
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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.
Here's how a discouraging proportion of indigent tax credits go right into the pockets of predators.
Dr. Fisher
If we would only listen, most people have a fascinating story to tell. They usually talk quite freely. Take an illustration from the casual observations of an employee of a tax-preparation service. For him, late February to mid-March is "Tax credit time".
Normal behavior for tax-payers is to wait until the last possible moment before the April 15 deadline, not even thinking about unwelcome income taxes. Commercial tax-preparation services have few if any tax-paying customers in March, but are nevertheless extremely busy. The chairs of their waiting area are occupied by citizens, anxious for the government to pay taxes to them as early in the year as possible.
This startling role-reversal is a result of the tax credit system, which should not be confused with tax deductions. In the case of a tax credit, the government issues a check to make up the difference between what the individual earned during a year, and a certain stated income level. No doubt such benevolence is hedged with innumerable rules, restrictions, limitations, and exceptions, which tax preparation services must know all about and, in effect, certify by countersigning the completed tax form. Following that moment, there is a delay of up to three months before the green government check actually arrives. Since a loan against such pending payments is essentially risk-free, the tax preparation service is more than happy to lend it to the recipient. A fairly representative example would be to charge $200 for the preparation service, plus an additional $200 for the three-month loan of, typically, $7000 in tax credits. Where does that lump-sum payment usually go? Almost invariably, it goes to pay down the unpaid balances of credit cards, otherwise running up 18-30% interest, 23% typical. Since David Swensen of Yale's endowment fund is claimed as the world's best investor for achieving a 17% return, the welfare recipients who effectively get 23% by paying off credit cards -- are making a very good investment decision. Indeed, they aren't being swindled out of anything; they come into the tax preparation services loudly demanding just exactly this product. Although they are mainly unwed mothers in their 20s and 30s, they have obviously been well instructed by their friends about how to make quite a shrewd and entirely legal arrangement.
It's only when you ponder the further implications of this whole process that you begin to wonder if there isn't a more efficient way to handle it. Since the underlying security is the full faith and credit of the United States Government, the loan is essentially risk-free. At a time when commercial mortgages are charging about 6%, these loans imply an extra risk premium of at least 15%. If you regard the welfare client as merely a passive intermediary, a $7000 tax credit payment costs the government $1800 of it to deliver only $5200 to the client, net. That is, about a quarter of the cost of the program is going to loan sharks. Surely, a less costly method could be devised to transmit 12 monthly checks to the clients, or even 52 weekly ones.
Beyond that, there is the uncomfortable question of just where we are going with tax credits. Without begrudging a nickel to the poor unfortunates who are helped by this program, it is alarming to hear that low-income housing and historic rehabilitation of old structures are both rewarded with 20% tax credits, and the idea is spreading that it might be a good idea to pay for health insurance with tax credits. We've opened a door here that we may wish we hadn't opened. Echoing the views of Alexis de Tocqueville, Alexander Fraser Tyler has summed it up: "A democracy...can only exist until the voters discover that they can vote themselves money from the Public Treasury."
Glenn Hubbard, former Chairman of George W. Bush's Council of Economic Advisers, has written his proposals for 2015-2016 as an Op-Ed piece in the New York Times, in January 2015. The choice of newspaper probably has some significance, since the Chairman of a President's Council of Economic advisers sometimes does, and sometimes does not, formulate the economics views of his party and his President. It's possible he seeks to influence the role of his party's Congressional leaders or possibly represents the views of the two former Bush Presidents, or even a variant of them meant to influence Jeb Bush in his run for the 2017 Presidency. Time will probably tell, as the last two years of the Obama second term could be a time of compromise or time of bitter dissent. Hubbard makes ten or eleven points, usually as single-sentence assertions without associated arguments.
Broadened Budget Neutrality. The first point is that Congress has long been working within the boundaries of tax neutrality for any changes in the tax revenue derived from individual social or economic classes, a restriction Hubbard feels is unnecessary. The example he gives is corporate income taxation, which is very likely the area he had in mind. Perhaps, I think he is suggesting, corporate taxes could usefully be lowered without considering the personal benefits to the upper class of corporate stockholders. In effect, Labor Unions are seen to be acting out the attitudes of the Molly Maguires, in which only cigar-smoking plutocrats would be gaining if the corporations they own were taxed less. In the Gilded Age, perhaps family-owned corporations were the norm, but for fifty years American corporations(but strangely, not German corporations) have been stockholder-owned, or even index-fund owned. And if not officially, individual retirement assets are a growing part of every family's savings. There was a time when only rich folk owned stock, but nowadays employee pension assets have become a growing power in the marketplace. Double taxation is much less a class issue than formerly, and perhaps even cigar-smoking union bosses can be persuaded to change their stance and their rhetoric. Lowering corporate taxes might well help the working class more than the top one percent of earners if matters were scored in a balanced way.
Flattening the Steep Step A second point is made that increasing subsidies and tax credits for the poor, leads to a steep step up to employment and a sudden loss of subsidies, as a further hindrance to joining the workforce. Deriding the loss of subsidies as favoring the "trickle down" process, is an unfortunate obstacle to searching for more gradual approaches to general prosperity.
Consolidated Business Tax. An effort to achieve a gradual transition is suggested, of a consolidated business tax rather than industry taxes and exemptions, and very likely a gradual merger of the customary bank loans, versus bonds. There is a sound of general plausibility about this, but no reasoning is offered in the editorial. Depreciation might be loosened somewhat for the general purpose of increased flexibility, but in general, the main area where depreciation ought to be made merely discretionary is in non-profit companies.
Specifying the Top Tax Bracket. It's interesting to read Mr. Hubbard's proposal to make the top bracket for personal income tax the same as the top bracket for business income. The reasoning behind this proposal is not given and is not immediately obvious. However, it does seem to be an improvement to have this issue removed from the class warfare language of "fairness", to be replaced by some other benchmark with a rationale. Hubbard similarly is inclined to replace subsidies to the poor with tax credits, a move which has the additional advantage of smoothing out the "steep step" up to income tax which is more graduated by effectively having more gradations than mere poverty versus no-poverty. Whether this is the underlying reasoning or not, anything which softens the Molly Maguire rhetoric of the 19th Century coal mines would be a step forward.
Health Care It certainly is heartening to see Health Savings Accounts recommended in both of the two alternatives he proposes for paying for healthcare, one with continued employer-based insurance and one with a tax deduction on the personal income tax. And it is certainly time for a way to be found to give equal tax deductions to those who pay for their own health insurance.
Educational Tax Deduction. A truly innovative proposal is made about tax deductions. Mr. Hubbard proposes a personal tax deduction for education and training, similar to the one already given for investment in technology and equipment. There's a question of whether this should be given to the individual or his employer, but that can be worked out in Congress. The idea is excellent, particularly when it is limited to out-of-pocket investments in education since it has the additional potential to address rising tuition costs while encouraging more education.
Block Grants. It is also innovative to consider block grants to the states to replace the tradition of making Federal funds conditional on state "cooperation", which the Supreme Court has begun to disapprove, as an invasion of states rights. This one might even rise to the level of a proposed Constitutional Amendment. There is little doubt the state legislatures are the weakest part of our federalized system, that the Supreme Court recognizes that fact, and leans toward attributing this problem to the system of conditional grants.
Consolidated Entitlements. Unless I am mistaken, there is a welcome proposal to address entitlement programs by consolidating them; and in the process begin to meet the looming issue of underfunded retirement costs. In a sense, the retirement costs are an outgrowth of improved health and longevity, a truly difficult problem created by a desirable effort.
Let's plan to review this program before the end of the year. By that time, it will have been tested in the fire of the adversary process. And since the following year will be disordered by-election campaigns, we can then surmise how much will be passed into legislation, how much will be exposed as impractical, and how much will fail passage but become the lore of long-term party positions in the far future.
It's only a beginning, but the reader now has a summary of where the Classical Health Savings Account stands, with a few suggested amendments to make it better. Remember, with essentially no changes and with minimal marketing effort, C-HSA has acquired fifteen or so million subscribers. Certain features need to be emphasized before it can extend to the rest of life, and harmless modifications made to accommodate the extensions. At the moment, the appeal is mostly to people between the ages of thirty and fifty, while with a few additions it could extend to everyone who wants it. Beyond that, it stumbled onto some features which would make an excellent foundation for wealth creation, for those who don't believe everyone should just invent something and become a billionaire. But to achieve it we have to get past the idea that everything in the public sector must disappear into a black hole, never to return to private hands. Read on, but handle with care.
FLEXIBILITY: Health Insurance, plus Retirement Income if you survive.
Hidden Advantages, Mostly Unexploited. C-HSA has the flexibility to manage the transition between health insurance and retirement income. Health insurance is the primary need of the past, retirement income the primary need of the future. It's a lucky feature that relatively few people have both problems because very few of us could afford to address both of them. At one time, health care was a major concern of employees; nowadays, it is a major concern of retirees. The day will eventually come when so few get seriously ill, other than terminal care, that we can fund retirees for retirement living, and let them dip into the savings if they occasionally get sick. But that's at least a generation away. At every stage, there must be some who generate a surplus, because otherwise, some will remain impoverished.
The C-HSA lets you judge your own needs as they come up, rationing what you think you need less of, in order to pay for what you suppose is your likely future need. That's the 2015 problem, and it has no good solution except flexibility -- and good luck. Because of the fruits of research, the 2050 problem is going to be retirement income, and it will need a source of revenue. The flexibility of C-HSA allows this choice to be made individually and eventually permits Medicare to be liquidated to finance it. C-HSA scarcely needs any changing to make this adjustment; Medicare is the program which needs to face the future, make itself modular, and provide ways for people to buy their way out of it, in pieces. Until changes are made to invite partial buy-outs, there is little HSA can do except buy out of Medicare entirely. It will be a long time before many people will take such a big step, but much sooner, they will surely see parts of it they would like to drop in favor of -- flexibility.
BOUNDARIES: Any surplus belongs to the subscriber.
Substantial Improvements, Without Disturbing the Basic Structure. Much will depend on the early administration of the Affordable Care Act. If it cannot accommodate the needs of big business in their suspended negotiations, or if it proves to be inordinately expensive, it will collapse. Most of the many Republican candidates for President have endorsed HSA as a substitute policy, and Mrs. Clinton has yet to reveal how she will get out of her HMO proposal of ten years ago. By this time, she surely has learned how distasteful the American public finds HMO when run by non-physicians. In coming chapters, we will describe how essentially the same idea was earlier proposed by physicians, and blocked by the Maricopa Decision of a minority of the United States Supreme Court. Physicians never dreamed anyone would direct a medical organization, except physicians, so there is room for revised opinions; but the twists and turns of politics will eventually dictate where physicians will stand. It is amazing how many people want to run medical care, but how few of them want to go to medical school.
Once we all have basics, we can look around for luxuries.
Benefit Package
The present stance of HSA proposals is that the Affordable Care Act would be improved by substituting Catastrophic health insurance, or else First and Last Years of Life Insurance, for the present hodge-podge collection small mandatory benefits. The alternatives, either the employer-based system or the European single-payer system, similarly become unaffordable when made universal. Universal coverage is indeed desirable, but not to the point of defining that nothing is permitted unless it is universal. If we must have mandatory health insurance, let it cover basics alone --either universal experiences like birth and death or universal fears, like a massive expense. Any degree of choice by politicians or bureaucrats is intolerable, and choice by physicians is barely tolerable. Once we all have basics, we can look around for luxuries. Is that too much to ask?
WEALTH CREATION: Tax Exemption, Compound Interest, then Passive Investing.
Future Dreams
The Golden Surprise. In this book, once we have explored some of the Hidden Economics of Healthcare, we will be ready for the big surprise, which is how much money can be created by changing the insurance design. It might take us a decade to perfect, and several chapters to describe. When lifetime coverage seemed to become possible through the pathway of the tax-exempt Savings Account, supported by Catastrophic fail-safe coverage, we made an amazing discovery. As one of the creators of the idea, I can tell you we had no idea the invested income in these accounts could generate so much money.
That came about by our determinedly avoiding government control and seeking new pathways the government could not follow. It may be a delusion on my part, but I believe the temper of the public will never tolerate government ownership of a private business. Although some far Eastern nations have tried it, their present direction is away from it. Even the Indian subcontinent and the more socialist members of the European Union have found it doesn't work. Very few American college students, however liberal, persist in the notion of government running a business, once they emerge from the campus into the real world. The African and South American dictatorships wallow in failures of the oligarchy approach, even when supported by economies based on natural resource discoveries. Consequently, I believe we will emerge from this and future recessions with the cultural belief that collective government ownership of the means of production, is a bad idea. I believe the wide-spread distribution of common stock will make us stronger capitalists, not weaker ones. That's a hint of what follows.
Homer, the blind Greek poet, portrays Odysseus on his voyage home from the Trojan War, mistrustful of his own good intentions about approaching the Sirens, beautiful women with an enticing song. Odysseus lashed himself to the mast of his ship, as a precaution against temptation. The modern version is an escrow account, which protects more useful later expenditures against youthful temptations to spend, or else against hysterical reactions to less serious problems. In an escrow account, the owner specifies legitimate use, deviating only with the consent of some third-party custodian. Escrow has in mind the need for healthy young persons to save for more serious illnesses when tempted to spend on less serious ones, while there does remain an outside possibility for early spending to be more sensible. Buying a red convertible roadster with money set aside for retirement might be one issue best restrained, but not absolutely forbidden.
Escrow subaccounts become necessary when long-term saving is more central to some purposes than others. In a Health Savings Account, the bulk needs to be available for bruises and checkups, but an irreducible amount is set aside for serious distant spending. In the general account, partial escrow meets current needs, but a portion is forced into an untouchable future account. An entire age group may be solvent, while any individual member of it remains in serious deficit. So, insurance spread-the-risk covers some, while escrow protects against others. Both have a cost, kept as small as possible. The depositor must keep in mind, his fears invigorate his counterparty's business plan to make a profit. This whole issue depends upon the J-shaped cost curve of health care. The non-escrowed, general funds are mostly limited by deposits into them, but it must be recalled that health insurance itself adds 17% to medical costs. Escrowed funds depend more on frugal spending habits multiplied by investment and compound interest, boiled down to a few tenths of a percent increment over many decades. Long after bruises and check-ups have been forgotten.
Here's the battlefield. Professor Ibbotson of Yale has shown total stock market returns have averaged 11% for a century, and other investigators using other sources suggest it may have been true for two centuries. Never mind that future predictions may not follow past results -- it's all we have to judge by. Three percent inflation reduces 11% to 8% real return. Serious unexpected recessions ("Black swans") come along every 20 years or so, it has been traditional to protect against them by investing 40% in bonds, reducing the real return to 5%. Our calculation of the present rate of healthcare spending requires 6.7% for the plan we will sketch in later. On the other hand, it will be noticed the finance industry consumes investment returns in a manner which reduces 8% to 5% and meanwhile shifts most of the risk to the customer. Because of computers and productivity, it does not seem unreasonable to hope for 6.7% to the depositor. But it won't come easily since the finance industry is resisting fee-only approaches which the Wall Street Journal estimates would add 1% to the depositor's return. Since bigshot investors refuse to pay more than 0.4% for investing large amounts, and since HSA investors do not have a payroll to meet in recessions, it should be possible to approximate everybody's goals. After a struggle.
Most of our projections assume a 7% investment return for a simple reason. Money at 7% doubles in 10 years; $100 turns into $200 in a decade. Since the life expectancy at birth is now about age 83, eight decades of 7% doubles eight times and $100 at birth turns into (200, 400, 800, 1600, 3200, 6400, 12800, 25600) or more than 250 times as much as you started with. This simple calculation allows you to check data in your head. It is a subset of the "rule of 72", which says any interest rate within reason divided into 72 gives an answer of how long it takes to double. Thus, 7% doubles in 10 years, 6% takes 12 years to double, 8% takes 7 years, 10% takes 7. If you prefer, the Internet supplies many compound interest calculators, but be wary of false answers when a computer cache fails to empty completely. If you use an internet calculator, be sure to use one of the simple formulas for checking answers in your head. That summarizes why we used 7% investment returns instead of 6.7%. No matter what you use, projecting the future contains some uncertainty.
If math of all sorts bothers you, the following chapter may be skipped, since plenty of people with green eyeshades will check it. Ultimately, however, all projections of the future involve some guesswork, and therefore probably some errors. I stand in awe of the life insurance industry, which managed to make a stable business out of almost the same problem. They had to pick a premium decade in advance, invest it in a sea of uncertainty, and return a fixed but attractive guarantee decades later -- and still stay in business. That doesn't mean it will work every time, or that just anyone can succeed. But it does seem to show it is possible.
Let's summarize. The present system is going broke. Unless something changes, the Government will be unable to continue its present level of Medicare spending for more than a decade or so. The public is complaining about how much Medicare costs, but in spite of straining at the limits, 50% of its spending is borrowed by bond issues, and it does not provide any retirement benefits beyond present Social Security. Mrs. Clinton proposed lowering the age limit at a calculated extra cost of $7800 per enrollee per year, eight years ago; probably a third more in today's inflation, which the government protests are too little inflation to erase their deficits. And yet, Medicare covers half of all healthcare costs in the nation. As the Affordable Care Act demonstrated, the healthcare needs of the rest of the country cannot subsidize Medicare, Medicare is more likely to be asked to support other age groups. Medicare is the "third rail of politics, just touch it and you're dead." And yet, additional really sick people are moving into the Medicare age group; eventually, we will reach the point where, except for self-inflicted disorders, there will be no health costs except the first and last years of life. If we are on a pathway toward concentrating all, or mostly all, of healthcare costs into Medicare, it is futile to imagine doing away with Medicare. That's where we are, and it is pretty grim, forget about math to prove it. Please look now at our counter-proposal.
We propose to change the financing, not the delivery system. The total revenue is unchanged, the style and methodology of healthcare delivery are unaffected. Continuing bond issues to cover deficits are not contemplated, although one-time transition costs may have to be. Childhood costs are included, obstetrical and pediatric costs are transferred to Medicare. A moderate retirement benefit (nevertheless larger than sickness costs) is provided. Provision is made to include other programs, like additional pearls on a necklace, but only if they are self-sustaining, every ship on its own bottom. Everything is based on incentives and voluntary enrollment; nothing medical is mandatory. It may take longer than everyone wants, and it may include some approaches that offend some people, but at least they don't have to join if they don't want to. Since mathematical precision is impossible, it may fall short of its goals. In that case, it will only partially cover expenses. In that case, it will require supplementation. But it's hard to see how anyone would be worse off. If you think I am just ranting and raving, read on.
After sixty years as a doctor, it's a little disconcerting to find I have a disease I never heard of. It's better in a way, but in this sense it is worse, to be cured by a treatment I never heard of, either. The disease is mucous membrane pemphigoid, and the cure is Rituxamide. Am I right? Most readers have never heard of either one, but like just about every other patient, I think you all must just be panting to hear about it.
Rituximab
It turns out I had heard about the disease, but someone had changed its name from lichen planus to mucous membrane pemphigoid. The drug, Rituximab, has been around since 1997, treating rheumatoid arthritis, so it's not completely novel, either. It simply hadn't been used for this condition, which was rare. When we got semantic issues straightened out, and I had experienced a second round of treatment, I attended a seminar on lung cancer. That's the sort of thing doctors do for entertainment.
To my puzzlement, I was told a "me, too" variant of this same drug extended the life of lung cancer patients, but only if they were heavy smokers who quit smoking. That sounded peculiar, essentially saying you live longer from lung cancer if you smoke heavily and don't quit. You get a little euphoric when you take a steroid drug to ease the Rituximab, so I was overcome with the audacity to go to the microphone and announce I thought they lived longer, not because it helped the lung cancer, but because they lived longer by having fewer heart attacks and strokes from the smoking they had quit. Of course, I was politely told I didn't know what I was talking about. But an immunologist in the audience rose to say he agreed with me, because he had been giving the drug to practically every patient in his immunology practice, and quite a few of them got better. (To explain, the drug knocks out the T cells, which mediate most autoimmune diseases, so it sounded plausible.) So that's where matters stand. After everybody scrambles to try the drug on various autoimmune patients, some sort of order will probably emerge.)
But before everyone who reads this demands that his doctor gives him this drug for itchy skin, let me tell you the subsequent story. My insurance company sent me what is known as an "EOB" (explanation of benefits) which had two numbers on it. In the upper left-hand corner, it said my bill was $67,000. In the lower right -hand corner, it said the amount owed was $0.00. Somewhere between the two numbers is the amount you would have to pay if you didn't have insurance, the rest is someone's mark-up. I set about to find out how much the drug really costs to manufacture, and it's hard to find out. Someone said $4, but I can scarcely believe it.
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.
