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
Philadelphia Reflections now has a companion tour book! Buy it on Amazon
Philadelphia Revelations
Try the search box to the left if you don't see what you're looking for on this page.
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.
There's one good thing about living near the confluence of two big rivers, and one very bad thing about it. The rivers provide transportation in three directions, but about once every twenty-five years the rivers rise astonishingly and threaten to carry everything away. That deposits rich topsoil, making it even more attractive for settlers to locate there. At what we now call Northumberland located on the junction of the North and West Branches of the Susquehanna, there is a monument marking off the flood levels of the past two centuries. Even the least of these floods must have covered a lot of ground, and the highest one is so far above the head of a visitor that it is hard to see how anything could have survived it. Right now, the little town of Northumberland is a burnished little jewel. One hopes the Army Corps of Engineers either has or soon will abate the potential flood danger. It would be interesting to know if flood insurance is available, just as a sign of how experts currently evaluate the risk. The Endless Mountains (that's really their name) stretching almost to Cooperstown, catch a lot of rainwater and snow and occasionally funnel it all down the North Branch to Northumberland. The West Branch is even bigger. Having observed the 1936 flood in Pittsburgh, I can testify it isn't an experience soon forgotten.
Flood Levels
It happens the most prominent resident of the area arrived there in 1794 and lived out the last ten years of his life as a widower. Joseph Priestley, an English dissenting minister had stirred up enough uproar to cause his house to be burned to the ground. No doubt, the English wanted to suppress any repetition of the French Revolution but were willing enough to be rid of a protege of Lord Shelbourne so the government made full restitution of the value of his property when he finally agreed to emigrate. Pennsylvania was chosen on the advice of his good friend Benjamin Franklin. He bought extensive land at the river junction and constructed what most people would describe as a beautiful mansion on reasonably high ground with a river entrance. Although it is built of wood and William Penn's Pennsbury was brick, there is a definite similarity. Priestley's house somehow seems more open and livable, although the outhouse reminds us that plumbing costs were moderate at the time. And furthermore, the original building survives as Pennsbury did not. The original plans for it were later discovered in England, and so it has been possible to make it what it used to be, outbuildings and all. Priestley and Lavoisier did not get along even though they share the honors for discovering Oxygen. Lavoisier was a rich aristocrat, while Priestley was a prominent member of the dissenting class with advanced ideas about democracy. It is said that many of the ideas Thomas Jefferson had about the natural rights of mankind were brought into sharper focus by his association with Priestley. Priestley was primarily a political theorist, acting in the role of a minister. He regarded his chemical experiments as a hobby, motivated by the hope of discovering a bridge between religion and science. The relationship between Priestley and Lavoisier was a strange one, but it had political conjunction as well as a scientific one. Priestley was driven to America by English Tories the same year that Lavoisier was guillotined by French revolutionaries.
Although oxygen had been discovered while Joseph Priestley was still in England, he discovered carbon monoxide in Northumberland, using retorts and scientific instruments he designed and sent to his friend Wedgwood to manufacture. He also devised the idea of carbonated water while he was here. For these as well as chemical methodologies he has been described, at least by Anglo Saxons, as the Father of Chemistry. Following what he considered to be his main occupation he meanwhile founded the Unitarian Church in America. In the little town at the Susquehanna forks, he was unable to establish a viable Unitarian congregation beyond a few followers who came to his home. So, he somehow found the energy to establish the First Unitarian Church in Philadelphia, at 21st and Walnut Streets. (Aside from its historic significance, the present church building is a distinguished work of architecture designed by Frank Furness). Meanwhile, he was very active in national politics; Jefferson's defeat of John Adams' reelection is often ascribed to his efforts.
His wife died of tuberculosis before they could move into the Northumberland plantation, but he lived there with his son and daughter-in-law for ten years, dying in 1804. The son was concerned with founding a utopian colony, but the wealthy daughter-in-law forced a return to England. The grandson generation returned to Northumberland, where the graveyard now has an impressive array of Priestley tombstones.
REFERENCES
The Invention of Air: A Story of Science, Faith, Revolution,and The Birth of America, Steven Johnson ISBN: 978-1-59448-852-8
In this chapter we are discussing health insurance problems which the Affordable Care Act did not create, and for which its only blame is that it neglected to address them. The implication must be that a better health care reform bill would indeed address them, or at least give the public the impression that it considered the problems and for sufficient reason had to pass them by. It highlights one more important reason why this book hopes to generate the creation of a Grand Strategy rather than specific legislation.
The Blunder of Co-payment. Let's state that co-insurance sounds like a deductible but isn't, has shown very little deterrence value at its customary 20% level, creates the market for an extra insurance policy, and would never be missed if eliminated in its traditional form. A deductible, by contrast, is a single lump sum imposed at the beginning of an expense period, a so-called "Front-end deductible", whereas co-insurance imposes a sort of tax on every service, ie. a "20% co-pay". Examples: a deductible would be the first five thousand on a twenty-thousand dollar cost, per episode, or per year, and it does not change with the size of the bill. A 20% co-pay, or co-insurance, takes 20% of every charge. As the Affordable Care Act begins implementation, it is reported that the ACA plans to introduce 30%, 40%, and 60% co-payments through its insurance exchanges, in addition to a $5000 deductible, and in addition to tripling the premium. The matter merits considerable discussion, and it will probably receive it but details are presently very scanty. For example, there is already a flourishing market for 20% copay insurance which pays for nothing else, so the insurance companies will enjoy this feature of Obamacare which stimulates twice as many insurances. Congress would find a large co-payment enjoyable, since a 30% copay means the patient somehow pays at least 30% of its cost, out of his own pocket. These are also the numbers which get the businessman's attention in employer-based insurance. They appeared in a two-line notice in the New York Times, just before the Fourth of July holiday, and only chief financial officers have a lot of information about it. That sounds like a trial balloon which could soon be revised, but possibly not. If this is the final word, it will certainly imply the Administration is desperate to find reductions in the cost of the program. Put it in context: premium prices are doubled, a $5000 front-end deductible is imposed, a minimum of 30% of the program eventually lodges in copayment insurance which the patient must himself pay. On top of that, the only reliable evidence for what is going on comes from Chief Financial Officers, who as a group are the most hostile to the program because it involves them in myriads of complexities having nothing to do with their corporation's core business.
The position of this paper is that copayments should be scheduled to be eliminated entirely, but deductibles raised as high as possible, at least to $5000. This is not a small technical issue. Deductibles have proven effectiveness, while co-pay shows no effect on consumer behavior at the traditional 20% level. It is impractical to extend either approach to patients sick enough to deserve hospitalization as an inpatient because a growing proportion of "patient responsibility" charges reappear as bad debts. Alternatively, to raise office and outpatient price levels much above the minimum cost of hospitalization is not only unrelated but futile. It creates a substantial incentive to admit patients to the hospital in borderline cases, especially from emergency rooms and captive satellite clinics, recently enlarged to take advantage of artificially low-interest rates. Hospital administrators already complain that unpaid co-insurance is their biggest financial drain. The fact is, co-payments have already approached a practical upper limit, without any sign of affecting patient attitudes. Unpaid patient coinsurance is a sensitive indicator of dissatisfaction; there should be more feedback about it between the hospital and accrediting agencies. Since most insurance has a deductible less than $5000, there is probably some room left to increase deductibles, but public outcry can be expected unless something like a Health Savings Account is provided to ease the pain. Insurance companies will rush to be first with a new and improved "supplemental policy", another expensive blot on the landscape, designed to eliminate cost consciousness on the part of those who can afford it. The contradictory message sent by supplemental insurance is that reducing patient cost consciousness is a good thing.
A much better inpatient solution is available in the DRG system, even though it could use some improvement. And there is the potential of using credit cards attached to Health Savings Accounts as a source of data for improving DRG (Diagnosis-Related Groups) by capturing outpatient market costs and using them for market-based hospital cost accounting rather than hospital cost reports, which contain massive distortions from several levels of cost-shifting. Patient cost sharing, in general, is already approaching its limits and cannot be relied upon to produce the order of savings suggested by 50% co-pay. Other, more sophisticated, approaches are needed. To become convinced of this, it helps to understand its history and politics.
The way to cut hospital costs is to cut the indirect overhead costs.
How did we come to this? Because so many industrial workers were quite healthy, young workers have always subsidized older, sicker ones, on the untrustworthy premise that when young ones became old ones, their turn will come (if they still work for the same company.). Trying to maintain "community rates", it was hard to find ways to pacify the young ones, unless you left the old ones stranded. This created pressure to keep deductibles low, even trivial because they would apply to almost everyone no matter how small his annual medical expenses and the young ones were already complaining about how little they were getting. Just how much effect deductibles exerted on premiums was difficult to calculate quickly. By contrast, a co-payment rate of 5% would reduce employer (or government) cost by 5%, while 20% would reduce cost by 20%, etc. To make the immediate point, a 50% co-pay would cut the cost of Medicare to the government by 50%, whereas even an actuary would have trouble producing quickly how much the government would save by raising the deductible by 150%, or to $12,000 annually. Once the negotiators walk away from the table, important consequences for the patients and hospitals will persist and grow, and the long-term trend of costs will be up. One-time convenience for the negotiators should be the least consideration of all, but human nature is human nature. Legislators are implored to hire an actuary to tell them the answers to these numbers (in the form of a table of numbers), so they do not exchange momentary convenience for riots in the streets. And the President must be persuaded not to claim that the "service" benefits are unaffected, or his campaign promises of retaining benefits seemingly satisfied. If you double the premium and double the copayment, you are only providing 25% of the historical benefit, even if an appendectomy is an appendectomy and it's a "covered service". Because of bad debts, raising the copayment from 20% to 50% is only likely to increase revenue by 40% at most. The way to cut costs is to cut the indirect overhead costs, and this insurance talk seldom touches that subject. The place to get more revenue is from people who are healthy or to borrow it. At the moment, 50% of Medicare costs are borrowed, in the sense that they come from tax revenue, which increases the national deficit, which ultimately leads to borrowing.
Doesn't all that make it sound more attractive to look for new sources of revenue? The traditional sources are pretty well exhausted.
There's an old joke about a small town with an ordinance that "Fire hydrants must be painted before each fire." Similarly, it is at first a little confusing about how pre-paid health insurance could pay for the health care costs of someone's last year of life. Necessarily, such a proposal implies the existence of a second mechanism for paying for the costs as they arise, but getting paid back for them later.
Right now, that primary insurer is Medicare. The vast majority of people who die will be covered by Medicare when they do so. So, let Medicare pay the bills, and let the Health Savings Account pay Medicare back. And looking backward, when the Health Savings Account reaches a certain amount, reduce the premiums and payroll deductions for the individual. The overall payment cycle thus means the individual only pays for his care once, with compound investment income contributing the bulk of it. The final intention is to start with the goal of paying for the last year of life, and expanding the number of years like an accordion if you have been lucky and contributed a lot toward the fund, early in life, and not depleted the fund with illness. I'm no actuary, but as a physician, I can tell you that if you have a lot of major illnesses, you will probably have a foreshortened future.
The individual's Health Savings Account is a long-term investor in longevity, paying Medicare back when the last-year costs are known, and receiving a reduction in payroll taxes or Part B premiums in the meantime.
In this example, it is Medicare, universally available for at least Part A (hospital costs), which is imagined as the transfer agent. However, it also ought to work with patient self-insurance, paying for out-of-pocket costs like deductibles and copayments, or with coinsurance, or Major Medical, or any other verifiable source of health payment. Because of such contingencies, it is better to keep track of actual expenses which reimburse individual expenses outside the Health Savings Accounts. Payments through the HSA account should certainly count if they fell within the last year of life, but safeguards would have to be created to discourage gaming the tax deduction. However, we are envisaging transfer payments only at death, so this might not prove to be the problem it seems.
There is no doubt that transferring to Medicare the nationwide average last-year-of life costs as a lump sum (rather than true itemized individual costs), would greatly simplify the accounting, and perhaps Medicare could devise a way to reimburse self-insurance contributions and other participating payers. The trouble with passing it all through Medicare is that it gives the Medicare administration an opportunity to make the rules, which other payers would immediately complain about. Itemizing also has the advantage of putting pressure on the process of billing, which for mysterious reasons now takes six months or more.
In the meantime, the money has to be set aside in some sort of "lockbox" or escrow fund. Individual records must be maintained because it is anticipated the existence of this pre-funded last-year escrow fund provides continuing authorization for reducing payroll taxes and Part B/D premiums by 4%, the amount of the future reduction of Medicare beneficiary costs in our example. Because it is anticipated that the last-year escrow system might eventually accommodate accordion-like extensions of itself, it should be careful not to take early short-cuts which would hamper that evolution. Eventually, the annual Medicare deficit should be reduced by at least 4% fewer costs in our example. Going all the way to 100% of costs is imaginable, but unwise to implement quickly without some experience to act as a guide.
In a way, health insurance suits family plans better than individual ones, because often there is only one responsible working person to foot the bill for everyone. But equally often it is the other way, every ship on its own bottom. Politicians know a no-win situation when they see it, so the matter seldom gets an enduring if arbitrary solution.
So it should be no surprise that responsibility for obstetrical costs has no solution, only expedients in a changing world. It's probably one of the hidden pressures for letting the government pay for it, so we can all forget the issue. Another feature is that it's expensive. The statistic seems high, but 3% of health costs are supposedly derived from the first year of life, and that means $10,000, which really seems quite high. And the report of the first 21 years developing 8% of health costs, also seems high. But something costs that much, and its costs must be paid by someone. As I thought about it, childhood is the reverse of all other health costs, where most people can save money and then spend it. It's impossible to pre-fund newborn costs unless they are paid by some other generation, on the baby's behalf. If that's the case, what would be so bad about grandparents pre-paying a baby's cost?
Furthermore, the grandparents have only recently rejoined the family. In my own case, I had four grandparents like everyone else. But I never met them. I have two great-grandchildren who are almost as tall as I am, and numerous grandchildren who are taller. For decades I have had them to my house for Christmas. All of this seems to relate to my own longevity, and is the destiny of almost everyone else, too.
So this observation is the underlying basis for suggesting we examine generation-skipping for the first year of life. It has the additional advantage of lengthening the period for compound interest to work, especially if the grandparents can save some surplus from Medicare to start the process. If you add that desirable feature to Medicare, you have just about solved a problem where no one else has a clue.
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.
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.
