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.
At a recent meeting of the Right Angle Club, Stephen C. Bennett an administrator, and Alix Esposito a social worker, kindly addressed the club about the Veterans Hospital where they work. The federal government pushes its mass produced products into every city, but gradually a local flavor starts to creep in; how this process works is illustrated by the fact that Steve's grandfather Claude was once the manager of the Bellevue Stratford Hotel. The VA hospital may be a piece of Washington D.C. planted on Philadelphia soil, but Philadelphia will surely absorb it with the passage of enough time. The VA was once a part of the Veterans Administration, but now it is a part of Department of Veterans Affairs, run by a Cabinet Secretary, no less. It's the second largest department of the federal government, and since the only bigger department is the Department of Defense, the combination of the two shows you how far we have come from the nation's original opposition to "standing armies". The fact that these two components of our war machine are separate, on the other hand, surely symbolizes some hidden tensions between our regular armed forces and the American Legion, or the hidden frictions between two congressional committees, or else some other mystery of bureaucratic politics.
The Veterans Administration was founded in 1930, the Philadelphia VA Hospital was built in 1950. Originally, it was designated as a Deans Hospital, signifying the intention to confer prestige and lessen friction with the medical schools. Originally, Philadelphia's VA was affiliated with several medical schools, but in time its proximity to the University of Pennsylvania led to the elimination of ties with other schools. Although the bed capacity is growing in reaction to America's successive wars, its open wards converted after 1960 to more semi-private style, and its focus of medical activity shifting with changes in medical science, the VA remains isolated from the rest of the city and the rest of Philadelphia medicine. Part of this is physical; the hospital is confined by the University of Pennsylvania, the parking complex next to the Amtrak line, and the Woodland Cemetery, so there is little room to grow. And comparatively little commonality with the neighbors. There are 2000 employees and a $30 million budget, marooned in a sea of automobile traffic going elsewhere in a big hurry, too big to ignore but too small to influence the local culture.
Vietnam War
The patients are distinctly different from those you find in other hospitals. There is a great deal of chronic mental disorder a heavy influence of alcohol and substance abuse and rehabilitation, and even some residential apartments for patients. On a national level, between a third and a half of homeless people are veterans, but for some reason in Philadelphia, only a tenth of the homeless are veterans. During the Vietnam War, the system of draft avoidance through educational exemptions resulted in that generation of veterans coming from an unusual concentration of low income and low educational subgroups. The system of government pensions and promotions tend to retain employees in the system for a lifetime. It's true that informal transfer arrangements allow a certain amount of migration to Florida (in the winter), or Maine (in the summer), or California (to see what LaLa land is all about), but those who do this stay within the VA system. Consequently, the interchange of ideas and techniques that professionals carry with them between hospitals is curtailed, confined somewhat to variations within the VA system, conforming to its social norms. An archipelago, although not exactly a gulag archipelago.
Veteran
But by far the greatest source of distinctiveness in the VA hospitals comes from the byzantine eligibility standards for the patients. The reimbursement systems of Medicare, private insurance -- which more or less copy each other -- changed around 1988 in a way that more or less eliminated psychiatric inpatient care in the community, especially if it lasts more than a month. The VA, on the other hand, was forced by circumstances to increase its attention to this area. Consequently, all social workers everywhere inquire immediately whether an addict or a schizophrenic might be a veteran. A differential sorting process quickly gets underway, with the VA as the preferred place to send such patients if at all possible. Non-veteran victims of the same conditions tend to have a worsened time of it, because the pressure on state and local governments to make some provision, has been relieved.
Walter Reed Hospital
At the other extreme, the social elite of the armed forces are not admitted, either. President Eisenhower was unquestionably a veteran, but he had his famous hospitalizations at >Walter Reed Hospital. There's an income limit for VA admission, which automatically cuts off 20-year veterans above a certain rank, possibly major. And there are overlapping disability classifications for military hospitals and veterans facilities, with considerable latitude available to uniformed boards of three serving officers, only one of whom is a physician. The result is a general perception that if you have any influence at all, you can generally avoid the VA and be treated in a military hospital, probably in a VIP unit. Good for them; I'd take advantage of it if I had a chance, too. But by siphoning off the top brass, a lot of pressure to improve quality is removed as well. If a VA hospital had eight or ten Admirals and Generals as patients, with academy classmates coming to visit, it's safe to assume that courtesy, orderliness, and cleanliness would instantly improve. And take it from me, the quality of care would improve, as well.
If we propose to adopt the whole-life model for Health Savings Accounts, then why don't we just add it as a new product for the companies who are already in the whole-life business? It's a good question, and most of the answer is I don't happen to own an insurance company. Somebody has to invest a pile of money to own one. You almost never hear of corporate pirates attempting a take-over, and many insurance companies make their profits on subscribers who drop their policies, although that's mostly term insurance. Come to think of it, these are mostly 19th Century organizations who sort of had the good luck to encounter windfall profits when subscribers lived longer than was necessary to break even, and then even kept living on some more. It isn't exactly the background of people who start new businesses with new ideas. Nevertheless, they do sell their products to young people, invest the premiums for many years, and eventually pay their bills to old folks, on time and cheerfully. And there would seem to be plenty of incentive. Aggregate retirement income fifty years from now will probably be many times as large as the present face value of insurance, and probably include a larger proportion of the population. They already have actuaries on their payroll who could do the math, and who yearn for the day a new product would give them a shot at being CEO. Like me, they have already had a look at the C-suite offices, and like me, compare them favorably with the Temple of Karmac.
Who will run L-HSA, once it is legal?
However, I don't know any of them personally, so the assumption must be made that L-HSA will grow out of companies that package C-HSA at present and sort of have a term insurance point of view. Elements of it have been around for almost two centuries, but even the life insurance industry might become dubious to hear whole-life coverage of health insurance presented as an investment. As the level of income taxation rises, tax-free internal transfers assume new value, but resistance to higher taxes will grow. Extending life expectancy gives compound interest much longer to grow, it thus transforms what it can do. In addition, if you desire intergenerational cost shifting for health costs, you probably must incorporate some form of insurance as a pooled transfer vehicle. This combination also enables funds to shift within the account to a later time in life. It's a more attractive individual incentive for savings, than threateningly proposing your generation must support mine.
As a final feature, Catastrophic high-deductible is here added, providing stop-loss protection. Call it re-insurance if you prefer. It's single-purpose coverage, based on the idea that the higher the deductible, the lower the premium. So it follows that the longer you are a customer, the more catastrophic insurance you can afford. Cost saving runs through all multi-year ideas, but lifetime coverage is a cost-saving whopper, because of the way Aristotle discovered compound interest turns up at the far end. (By the way, that's why I suspect we have rules against perpetuities of inheritance.) It transforms Health Savings Accounts into a transfer vehicle for funds, from one end of life to the other, and must add debit-card health insurance for current expenses. Forward from the surplus of the present. And backward from the compound interest of the future. The last-year-of life could be chosen as an example because the last year comes to 100% of us, and is usually the most expensive year in healthcare, not greatly different from the face value of life insurance. But needs differ, and a ton of money sounds pretty good at any age. A Health Savings Account can also be used as a substitute for day to day health insurance. Another synonym might be Whole-life Health Insurance, although multi-year health insurance is probably more precise. The idea behind presenting this concept piecemeal is to provide flexibility for both overfunding and underfunding, since the time periods for coverage can be so long (and the transitions so variable) that both eventualities would occur simultaneously to different individuals.
The simple idea is to generate compound investment income -- not presently being collected -- on currently unconsumed health insurance premiums. And eventually, to apply the profit to reducing the same individual's future premiums. Even I was then startled, to realize how much money it could save. It's a scaled-up version of what whole-life life insurance does for death benefits. Since lessened premiums generate greater investment income, the math is complicated even when the theory is simple, but every whole-life insurer has experience with smoothing it out. For example, if someone had deposited $20 in an HSA total market Index fund ninety years ago, it would now be worth $10,000, roughly the average present healthcare cost of the last year of life. Neither HSAs nor Index funds existed ninety years ago, and of course, we cannot predict medical costs ninety years from now. This is only an example of the power of the concept, which we can be pretty certain would save a great deal of money, but skirts the guarantees about just how much.
There's one other advantage to using HSAs within the whole-life insurance model. It has always bothered me that life insurance tends to gravitate toward bond investments, matching fixed-income revenue with fixed-outgo expenses. But insurance companies largely support the bond market, which is many times as large as the stock market. In effect, their situation encourages them to increase the amount of leverage in the economic system, thereby increasing its volatility, and its tendency to experience black swans.
Furthermore, the insurance industry has accumulated a great many special tax preferences, based on the notion its social value is a good one. Placing life insurance in competition with non-insurance providers of the same services would justify extending the tax preferences to the others as well. The resulting competition would invigorate what has become a pretty stolid plodding citizen, with somewhat unique power over state legislatures. State legislatures, in turn, would benefit from increased competitive points of view among their lobbyists.
People would be expected to join at different ages, so the ones who join at birth in a given year have accumulated funds which would be matched by late-comers. In our example, if a person waited until age twenty (and most people would wait at least that long), he would need to deposit $78 -- not $20 -- to reach $10,000 at age 90. It's still within the means of almost anyone, but the train is pulling out of the station. Participation is voluntary, but no one saves any money by delaying and learns a bitter lesson when he tries. Notice, however, no one pays extra for a pre-existing condition, either; it costs more to wait, but it does not cost more to get sick while you wait. If the government wants to pay a subsidy to someone, let the government do it. But nothing about the whole-life retirement system compels increased premiums for bad health or justifies lower premiums for good health.
Whole-life health insurance takes advantage of the quirk that the biggest medical costs arise as people get older, and similarly, health insurance premiums are collected early in life when there is considerably less spending on health. The essence of this system is to reform the "pay as you go" flaw present in almost all health insurance. Like most Ponzi schemes, the new joiners do not pay for themselves, they pay for the costs of still-earlier subscribers, a system that will only work if the population grows steadily and/or prices rise. When the baby boomers bulge a generation, they bankrupt the system, but only when they themselves start to collect. Everybody knows that. What is less generally known is that "pay as you go" systems fail to collect interest on idle premium money; the HSA system does that, and it turns out to be a huge saving unless the Industrial Revolution stops. Medicare and similar systems don't collect interest during the many-year time gap between earlier premiums and later rendered service; potential compound interest is therefore lost because payroll deductions are used for other purposes. "Pay as you go" is only half of a cycle; adding a Health Savings Account converts it into a full cycle like whole life insurance, and furthermore returns the savings to the individual, rather than using them for insurance company purposes. Whole-life life insurance is more than a century old, but health insurance somehow got started without half of it, the half which could lower the premiums. Nobody stole those savings, they just weren't part of the gift.
All this creates an incentive to overfund the Health Savings Account. The surplus which remains after death is a contingency fund, probably useful for estate taxes or other purposes; but on the other hand, the uncertainty of estate taxes creates an incentive not to overfund by much. Most people would watch this pretty carefully, and soon recognize the most advantageous approach of all would be to pay a lump sum at the beginning, at birth if possible. Before someone roars in outrage about the uninsured, let me say this would work for poor people with a subsidy, and it begins to look as though the Affordable Care Act won't work unless it is subsidized. In that case, a downward adjustment doesn't reduce premiums, it reduces the subsidy.
Investment It seems best to confine the investments of a nation-wide scheme to index funds of a weighted average of the stocks of all U.S. companies above a certain size, and thus offering to pool for those who are (rightly) afraid of investing. This will disappoint the brokerage industry and the financial advisors, but it certainly is diversified, fluctuates with the United States economy, and has low management costs. In a sense, the individual gets a share in nation-wide whole-life health insurance which substitutes long-run equities for conventional fixed income securities. It removes the temptation to speculate on what is certain to occur, but on dates which are uncertain. Treasury bonds might be added to the mix, but almost anything else is too politically vulnerable to political temptations. Even so, it will have downs as well as ups, and therefore participation must be voluntary to protect the index manager from political uproar when stocks go down, as from time to time they certainly will.
One danger seems almost certainly predictable. This book has chosen 6.5 percent assumed return, mostly because it happens to make examples easy to calculate. The actually required return is probably closer to 4% plus inflation. Supposing for example that 7 % is the right number, there is little doubt a steady investment return is only achieved on an average of constant volatility, sometimes returning 20% in some years, and sometimes declining as much or more in other years. Judging from past experience, there will be a temptation for some people to make withdrawals in years of bull markets, which could reduce average returns to 3 or 4 percent in bear market years, and fall short of the 7% average at the moment it is needed. In addition, the officers of Medicare are likely to be tempted to pay Medicare more than a 7% average in windfall years, leaving the running annual average to decline below 7%, just as the trust officers of pension funds once deluded themselves by temporary runs of bull markets. Ultimately this issue reduces itself to a question whether a temporary surplus is really temporary, and if not, whether the subscribers should benefit, or the insurance company. After that is decided, extending or contracting the accordion would get consideration. It seems much better to negotiate these philosophical questions of equity in advance, and establish firm rules before sharp temporary fluctuations are upon us.
Ensuring the Uninsured. Because universal coverage has great appeal, I have gone through the exercise of calculating whether the impoverished uninsured might be included by using subsidy money to provide a lump sum advance premium on their behalf. It would work, in the sense, it would be less costly, but I do not recommend beginning by including it. Reliable government sources have calculated that even after full implementation, the Affordable Care Act will leave 31 million people uninsured. That is, there are 11 million undocumented aliens, 7 million people in jail, and about 8 million people so mentally retarded or impaired, that it is unrealistic ever to expect them to be self-supporting. In my opinion, it is better to design four or five targeted special programs for these people and keep their vicissitudes out of conventional insurance. Better, that is, than to include them in any universal scheme which the mind of man can devise. But to repeat, the mathematics are adequate to justify the opinion that it would save money to include them in this plan with a front-end subsidy of about five thousand dollars, adjusted backward for fund growth since birth. I refuse to quibble about investment size since no one can be certain what either investments or medical science will do in the future. It seems much better to make annual recalculations for inflation and medical discoveries, and then make adjustments through an accordion approach for coverage. There seems to be no need to make precise predictions since any benefit at all is an improvement over relying on taxpayer subsidies, which now run 50% for Medicare itself. This plan will help somewhat, no matter what the future brings, and as far as I can see, it would make the presently unmanageable financial difficulties, more manageable.
We begin this second edition with a shortened description of the Classical variety of Health Savings Accounts. There had been over fifteen million subscribers to this idea by the time of writing the First Edition, and since then many more people have joined. HSAs are no longer a novelty, requiring a great deal of explanation.
However, newcomers may need some basic information, and after all, there are three hundred million other people who remain to be enlisted. For them, we probably need to explain that the classical Health Savings Account was first conceived by John McClaury and me in 1981, endorsed by the American Medical Association a year or two later (I was a member of their House of Delegates at the time), widely publicized by John Goodman in his book, Patient Power, and taken up by the Cato Foundation, among many other friends. It was enacted as a pilot program under the title of Medical Savings Accounts in 1996 and finally enacted permanently as Health Savings Accounts in 2003. Bill Archer, Chairman of the House Ways and Means Committee's Subcommittee on Health is generally given credit for maneuvering the law through Congress, but a great many others helped a lot.
The actual content of the law is very simple, containing only two main parts. The first of these is a tax-exempt saving fund, and the second is a linkage to a high-deductible indemnity health insurance. Anyone between the ages of 21 and 66 is entitled to join, and after age 66 any remaining balance of the HSA changes into an IRA (Individual Retirement Account). The distinction is, expenditures from the HSA are entitled to a second tax deduction, provided they are spent on legitimate medical expenses. For the whole duration of the period of eligibility, HSA is the only "qualified "retirement account entitled to two tax deductions, the first when money is deposited, and a second if it is spent on medical care. This configuration of double-deduction is common in Canada, but in the US it is unique. The underlying reasoning was that Medicare would replace it at that age, and in addition, there were laws prohibiting payments between two federal programs for the same purpose. It later turned out these age limitations interfered with suggested expansions of the program described later in this book, so one of the modifications now suggested is some appropriate amendment of them.
It is useful however to remind people that Health Savings Accounts are quite different from Health Spending Accounts, which are entirely different. These other accounts contain a "use it, or lose it" spending limitation to the current year, leading to surges of unnecessary spending on prescription sunglasses, etc. at year-end. These spending accounts are definitely not the same thing as savings accounts, but they would come close if the "use it or lose it "feature was removed.
Furthermore, the various vendors of Health Savings Accounts have proved to be ingenious in providing alternatives within the rules. There is even a website displaying five examples of typical variations, and no doubt more will appear. Generally, those variations respond to changes in the economic scene, since many investors remember the high-interest rates of a decade ago, whereas others focus on the negligible rates currently available, but look ahead to a return of high ones. No doubt short sales against anticipated falls in short-term funds rates will appear, and all of the complexities of Wall Street may eventually make an appearance. Investors in small towns are particularly warned to consult a wider range of vendors by reviewing the choices on the internet, reading some national journals devoted to the subject, and similar means of looking beyond limited choices. The original idea was certainly to permit the subscriber to shop around for what suited him best
We, therefore, venture a recommendation, with the usual warning that past performance does not guarantee future results: we favor the purchase of low-cost index funds mirroring the entire American stock market. For a price of fewer than ten dollars a trade, widespread diversification can be obtained and maintained in what John Bogle calls "passive investing". That market has maintained a gross return of 11-12% for a century, and even after inflation is very likely to net 6% or 7% to the investor who adopts a "buy and hold" strategy. Few brokers will assume any risk for small investments unless the customer commits for long periods of time. One available strategy is to over-deposit when the account is opened, but even there the law currently limits deposits to $3300 a year, and many brokers have a $10,000 minimum. These limits, like the age limits, are becoming obsolete, and in any case, should be expanded to a lifetime limit rather than an annual one. Furthermore, it seems useful if some impartial body were given the authority to re-examine all such issues annually, particularly emphasizing the customer's ability to change agents when dissatisfied. Remember that investment agents are not required to put the customer's interest ahead of their own; they are not "fiduciaries". So be cordial, but act with care.
Although they seem to have the same design, employer groups don't fit the ACA plan very well. You will notice in current reports of 20% boosts in the individual health insurance contracts because of the Affordable Care Act, there was scant mention of employer groups. Their rates are negotiated privately, and usually at lower rates. They usually pay a different share of subsidies, too. In fact, it can be easier to deal with a plan with no subsidy at all, than with one which requires fitting several partial pieces together. Employer groups are often further subsidized by state and federal income tax deductions, with puzzling circular dependence. Employers make young employees subsidize older ones, while the ACA emphasizes rich ones subsidizing poor ones. (Young employees are seldom richer than older ones, so there's a mismatch, somewhere.) Young employees think of buying protection against unexpected illness, while older employees think of buying necessities at what they hope is a discount.
Some employed subscribers then find they are better off switching to Medicaid, which has historically been quite substandard. Others conclude their health risks cost less than the penalties for having no insurance at all. Some genius may be able to reconcile these issues, but at some point, it seems better to start over. An important fact to remember: many poor persons are eligible for Medicaid, but haven't applied for it. That's a job the hospital social worker usually supplied in the Accident Room as they were being admitted. When it was decided to give ACA insurance to poor people, this awkwardness suddenly surfaced, in the form of implicit subscribers who were sicker than was planned for.
Mixing the subsidy with the service package usually causes trouble, lumping too many sick people with too few well ones.
In the case of the Affordable Care Act, a fear is raised, a migration away of either subsidized or low-cost clients would raise the premiums of those who remain. The suggested compromise emerges that if government subsidies are resorted to, they should be unwrapped from the service delivery package, and funded independently. So long as the subsidy is distributed by the same criteria for everybody, it might pass muster. To emphasize: mixing the subsidy with the service package usually causes trouble; confusing too many sick people with too few well ones, has often proved to be a disaster.
Since Health Savings Accounts were begun independently of subsidies, they sometimes face the unjustified taunt they "do nothing for the poor man." If equal subsidies were distributed, the subsidy issue could become independent of the type of health care someone happens to have. It's too bad this wasn't examined from the beginning since it definitely hampers the Affordable Care Act more than it helps it. Competition paradoxically does the opposite, no matter how hard that is to accept.
If you want to extend the same health subsidy to the HSA as is extended to ACA, go ahead, but stop using the addition of subsidy as a reason to prefer one payment system to the other, or one proposal to another.
Our culture is reluctant to subsidize poverty, for fear of encouraging it. We are somewhat more willing to subsidize poverty caused by addiction, but prefer to subsidize it less than poverty caused by other diseases, like blindness -- once again, because we are afraid we might encourage self-inflicted conditions. But hierarchy doesn't always stop with different diseases; we might prefer to subsidize one race, one region, or a whole host of other conflicting preferences. Nevertheless, it seems definitely better to subsidize individual poverty -- as such -- than to get into quarrels about the relative shamefulness of causes for health poverty, or the politics of their funding. My present conclusion is: if you want to extend the same health subsidy to the HSA as is extended to ACA, go ahead, but stop using the addition of subsidy as a reason to prefer one payment system to the other, or one political party's proposal to another. Hidden in that preference is the delusion it is easier to control politics than the marketplace.
Perhaps, poverty should be treated as economists treat unemployment -- a net absence of affluence, imitating unemployment as a net absence of employment. That says it might be temporary, which is not implied by saying it's a class of people or a particular form of thinking. The Biblical description once implied both unemployment and poverty were two classes of society, quite likely permanent ones. But that was hundreds of years ago and in a foreign land. A small demonstration program in several states might clarify whether this difference of viewpoint might actually lead to an improved subsidy approach. For a long while, I thought eliminating poverty would eliminate the sense of being poor. But it doesn't. Somehow we must get over the idea that the way we were born is the way we must remain, overlooking the plain fact that just about everybody is going to live thirty years longer, and that's generally a good thing. In fact, it's hard to think of anything most people would rather spend money on, than longevity.
The electronic medical record had a great flurry of excitement about 1980, and I was one of its earliest proponents. I wrote my own program in the Basic language to produce bills and insurance claims forms, and to serve as the basis for adding diagnoses, lab work, and prescriptions. It took about a year of my spare time, worked very well in my office, and is available for anyone who wants it. It had two flaws, and it still has two flaws. After a fruitless effort to simplify physician input, I abandoned that particular effort as taking too much of my time.
That's still the case, thirty years later. Programmers have a habit of telling the boss something can't be done when it is merely inconvenient to do it, and doctors absolutely will not tolerate doing something some lesser-paid person can do for them. Some variant of the Google search engine might suffice for coping with physician input, particularly if combined with Dragonfly voice recognition. Eventually, someone will conquer this beast, but it turns out to be harder than it looks, and nerdy doctors have turned their attention from data entry to Big Data. Meanwhile, programmers have avoided the task of simplifying something which could be simplified, just because it requires acknowledging that somebody else's time is worth more than their own. The time for excitement about data entry has passed, while the problem remains incompletely solved. If you were going to win a Nobel prize, it wasn't going to be for data entry perfection.
The second physician obstacle is that computers generate far more information than anyone has time to read. The white blood count is vital when appendicitis is being considered, but it just bulks up the chart thirty years later. So what is needed is an automatic summarization system, with hooks back to the original data in the rare instance where retrieval is needed. Since medical care is constantly changing, the summarization algorithm must change with it. It's a big job, and somehow billions of dollars have been expended trying to do something else the doctor never asked for. The new danger is that some malpractice lawyer will discover a point vital to his case has been omitted from the summarization (but not the bulk record) without the doctor's knowledge, even though it seems no longer vital to the treatment of the patient in the future. For a long time, I merely smiled when people told me the EMR was more trouble than it was worth. But recently I have read of the astounding amounts of money (thirty billion dollars have been mentioned) which have been devoted to this mess, much of which is pretty cute but nobody asked for it. Apparently, the doctors who advised the program let the big-shot millennials who actually wrote the code do the real directing because it seemed worthwhile to spend billions to accomplish their personal goal of payment by diagnosis instead of by procedure. Maybe that's how you subdue a bucking broncho, but the doctors work around you until you seem to be winning. And then they quit.
If someone had the bad judgment to put me in charge of this circus, I would immediately limit the archiving to data which can be automatically generated, and rest content with reports of lab and x-ray reports from this source. And then I would advertise for someone to produce workable physician data entry, as well as generate periodic automatic summarization. Until these two features pass approval by seasoned physicians, we would just have to get along with paper records. This is essentially what I told some meetings of 1980 enthusiasts. But it hasn't happened, yet, so the system progressively antagonizes a group they cannot command and cannot do without. Herding cats, I believe it is called.
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.
