Philadelphia Reflections

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

Related Topics

Obamacare: Examination and Response
An appraisal of the Affordable Care Act and-- with some guesswork-- its tricky politics. Then, a way to capture major new revenue, even paying down existing Medicare debt, without raising premiums or harming quality care. Then, an offering of reforms even more basic, but more incremental. Finally, the briefest of statements about the basic premise.

Health Savings Accounts, Regular, and Lifetime
We explain the distinction between Health Savings Accounts, Flexible Spending Accounts, and Lifetime Health Savings Accounts. Sometimes abbreviated as HSA, FSA, and L-HSA. Congress should make it easier to switch between them. All three are superior to "pay as you go", health insurance now in common use, only slightly modified by Obamacare. It's like term life insurance compared to whole-life. (

Annotated Table of Contents

CHAPTER ONE: Where Are We, And How Did We Get There?

--- Teddy Roosevelt started it, but politicians have shorter memories than historians. For practical purposes, Obamacare 2012 is an extension of the Clinton health proposal of 1991, with HMOs deleted, and computers added. It is useful to conjecture Bill Clinton's strategy, which would explain much of the present muddle. If Hillary runs, we could even see it tried for the third time.

2589 Clintoncare and Obamacare: Historical Foreword

1729 Picking Out the Raisins From the Pudding

2670 Welcome to Welfare

1714 Reforming Health Reform, New Jersey Style

2622 Children, Playing With Matches

2602 Text of AFFORDABLE CARE ACT, PL 111-148, March 23, 2010, Renamed HR 3590

2594 The Real Obamacare, Unveiled

2672 Text of Section 1501, renamed Section 5000A: MINIMUM COVERAGE

2639 Text of Section 1251 (H.R. 3590):PRESERVATION OF RIGHT

TO MAINTAIN EXISTING COVERAGE 2673 Proposal: Coordinate Sections 1501 and 1251

2676 Health Care and Education Reconciliation Act of 2010

CHAPTER TWO: The Supreme Court Has Its Say

--- The U.S. Supreme Court had nursed certain Constitutional issues since Franklin Roosevelt's court-packing days, but it was state Attorney Generals who propelled States' Rights into the central Constitutional issue of the first few days of Obamacare. Liberal academics have long flirted with remaking the whole Constitution, and President Obama once taught Constitutional Law. While extreme Liberals nurse Constitutional revision, most Liberal politicians would prefer to split Republican voters with a third party. It is too early to predict which party would suffer.

2624 State and Federal Powers: Historical Review 2250 Obamacare's Constitutionality

2289 Roberts the Second

2592 More Work for the U.S. Supreme Court: Revisit Maricopa

2625 What Can Supreme Court(s) Do About Tort Reform?

2613 ERISA Is Thrust Into the Battle

CHAPTER THREE: Sudden Fiasco Of Electronic Insurance

----At first, it seemed a minor programming problem had temporarily inconvenienced the Electronic Insurance Exchanges. The realization soon emerged that the whole program was sloppy and untested, requiring months of repair, if not the abandonment of Obamacare. If direct marketing gets discredited, it would be a pity. The underlying idea was good and achievable. But this implementation was a disaster.

1288 Money Bags

2603 Electronic Insurance Exchanges

2626 Streamline Health Insurance?

2604 Redesigning Electronic Insurance Exchanges

2611 Phasing In A Direct Premium Payment

2615 Creative Destruction for Health Insurance Companies

CHAPTER FOUR: Small, Quick Proposals to Extend Health Savings Accounts

----Here's our alternative proposal, first devised by John McClaughry and George Ross Fisher in 1980, enacted into Law in 19xx by Bill Archer, and now numbers more clients than Obamacare. It requires publicity more than legislation, but six small technical amendments could rapidly turn an experiment into a national program. It seems to save as much as 30% of premiums, without much disturbance of the healthcare delivery system.

2637 FIRST PROPOSAL, Amending HSAs To Include Tax Sheltering

2573 SECOND PROPOSAL:Spending Accounts into Savings Accounts

2611 THIRD : Phasing In Direct Premium Payments

2584 FOURTH: Investments Pay the Bill: Obstetrics Lengthens Duration, Deductible Reserve is the Kernel.

2607 FIFTH: Having Invested, How Do You Reimburse the Providers of Care?

2630 SIXTH: Indemnity and Service Benefits

2585 Foreword: Children Playing With Matches: Investigating and Debating the Healthcare System 09 2636 2606

CHAPTER FIVE: HSAs, Backwards and Forwards

----The above describes the HSA and how it might be more useful if tweaked a little. This next chapter is a much more grandiose version, expanding the simple idea into a proposal for lifetime health insurance and describing the enormous unsuspected potential. Ninety-year projections are never accurate and require many mid-course corrections. We propose a new institution to monitor and steer it and attempt to describe what might be encountered. The power of compound interest could well pay for most of healthcare, but it is unnecessary to over-reach. Paying for a third of our costs would be accomplishment enough.

2590 Health Insurance Design.

2638 Pay As You Go

2587 Predictions of Future Healthcare Costs: Quis Custodiat Ipsos Custodes?

2628 Average Lifetime Medicare Balance Sheet

2627 Shifting Money Backward in Time: Managing the Transition

2593 Economics of Chronic Disease and Catastrophic Illness

2634 Comments on Diagnosis Related Groups (DRG)

2635 Admonitions: Using the Transition to Lifetime Health Insurance as an Inflation Restraint

2473 An Unending Capacity to Generate New Problems

1734 Healthcare Reform for Lobbyists

2485 Cost Shifting, Reconsidered

2571 Proposed: A Republican and/or Conservative Healthcare Solution


CHAPTER SIX; Reforms More Basic Than Obamacare

----Obamacare is just coverage extension by subsidies. The biggest flaws in our payment system are fifty years old and are the cause of most of the delivery system flaws. Meanwhile, Science is reducing disease costs by reducing disease, for all income brackets. By switching "medical" care into "health" care we keep authorizing new carpetbaggers to bill the insurance. Physicians received 20% of payments in 1980; now it is 7%, half of which is spent on overhead. Nevertheless, compound interest income could reduce costs greatly without changing healthcare. Lifetime insurance (above) could pay for about a third of future costs; direct cost efficiencies could probably save another third, leaving a third to be paid in cash. But don't make it entirely free, unless you want to make it entirely ruined.

2633 Stepping out of the Obamacare Frame

1730 What Obamacare Should Say But Doesn't

2616 The Coonskin Hat

2404 "They Don't Make That, Anymore"

2564 Last Cow in Philadelphia

2112 Paying for Assisted Living

1431 July 4, 1776: Patients in the Pennsylvania Hospital on Independence Day

1733 Obamacare And Its Repair, Executive Summary

2453 What's The Matter With a Conservative Answer?

Originally published: Friday, December 13, 2013; most-recently modified: Sunday, July 21, 2019