Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Revisionist Themes
In taking a comprehensive view of a city, an author sometimes makes observations which differ from the common view. Usually with special pride, sometimes a little sullen.

Obamacare Follies, Executive Summary


1. Mandates: Individual vs. employer. Neither one covers the "illegals". a. Individual mandate lays cost on young healthy, subsidizes older, people. b. Employer mandate costs small business, subsidizes large. c. Neither mandate addresses the tax issue which caused the problem. d. The illegals concentrate in five states bordering Mexico -- start there, don't leave it as a left-over. 2. Cost control: the CBO sank this legislation in one sentence. 3. Cost control: the Town Meetings angered people with good health insurance, who don't want to see it injured. That's 85% of voters. 4. Cost control: Taxing providers and suppliers only raise health cost. 5. Cost Control: Home care may no longer be cheaper than hospital care except as a reimbursement quirk. 5. Increasing access is incompatible with cutting costs. Choose, don't dissemble. 6. Health care is a problem but does not create priority over two wars and the worst depression in eighty years -- none of which is now going well. Push the reset button.


1. Required Reading: "The Road to Nowhere" by Jacob Hacker a. "Budget" Reconciliation. b. Cloture: terminating debate. c. Bob Dole: Public Option is a sacrificial feint. 2. Role of Gerrymandering a. Seniority puts extremists in control of Congress b. Gerrymandering puts moderates at greatest political risk. c. 2010 is a redistricting year, especially in New Jersey and Florida. d. Some political party will someday assert national party control over nominations to safe seats. 3. The hidden role of the Governors' Medicaid scam. 4. Small states need regional health insurance regulation; big states hate it. 5. The unconstitutionality (X Amendment) of mandates and the impeachability of presidential macing of political support.


1. Eliminate or modify the tax preference for employer-purchased insurance. 2. Repeal or modify the McCarran Fergusson Act to permit interstate insurance. 3.Restrict patents to those drugs which convince FDA of their unique value. 4. Mandate price/cost ratio to be displayed next to medical prices. 5. Pay hospital claims only after proof of transfer of responsibility after discharge. 6. Similarly, pay for lab charges for last day in hospital only after proof of reporting. 7. Override Maricopa Case of 1982 legislatively. 8. Restore the PSRO system. 9. Federally pre-empt anti-HSA state laws and regulations. 10. Subject Medicare debt to creditor disciplines: a. Suspend COLA and add-ons until proof of solvency. b. Merge Medicare and Medicaid, thus ending the cross subsidy.

Originally published: Friday, September 18, 2009; most-recently modified: Wednesday, May 29, 2019