Philadelphia Reflections

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

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Create a file within each other for notes about the subject. There is a strong possibility these notes will get mixed up, and if they are filed with the same name, they will overwrite the other file. So, we name each Jot. but we also number the (Jot 1, Jot 2, Jot 77, etc). Then, they are filed in among the text files of the chapter. That is, /quartet/fourrx/hira/spiral/jot6 would be an example of the notes entered for the future inclusion in the Spiral chapter.

The Nature of this sort of thing is that you put things in a general category, and then split them up when you really get to work on the subject. Thus, ideas about the AMA will get put in quartet/revisit/jot for the time being, but as we get closer to it, the contents of the general jot will get lifted out and put in more specific categories, like /quartet/revisit/election /jot and eventually even these will get further split out into chapter, /quartet/revisited/electrons/DOWDA/jot. Because of this shifting around, it becomes important to number the jots.

Since that is the general plan, I have been looking around among various methods of lifting text from one file and placing it in another. One way is to "get" a file into which you are going to transfer information, go to the end of it, "get" the second file from which the information is taken; so both files are in the memory at the same time. Then, the information to be moved is surrounded by block markets, the cursor moved to the place where it is to go, and the ctrl+M command given. Then, the name of the file is changed to the recipient file name (at the top of the screen), and everything deleted from the end of it. Then file it. This will work, but it is cumbersome, and there is a significant danger of erasing a file you want to keep by getting mixed up on what you are doing. There is also the danger that there won't be enough room in memory for both files at once.

Therefore, I have a program called Magic Mirror which does this sort of thing, and there are other programs like Hook-it, which might be satisfactory. We will have to fool around with this until we get a system which we like. On further reflection, it might not be a bad system just to put the jots at the end of the text chapters, since that is where they will get integrated. When we print out the chapters, the jots will follow, and we either use the jots, move them to a different chapter, or erase them.

Meanwhile, here is a Jot for /quartet/fourrx/hira/cheaper/(remember, the MS/Dos computers use a backslash, but I am writing this on a Radio Shack which does not have such a key.

In contrast with an American national saving rate of 4.5%, the Canadians currently save at a 9% rate. Perhaps Canadians save more of their income because they are less adventuresome than we are, or innately more conservative (? they have had socialist governments this century, remember), or because it is colder up there. But their own explanation is that they have a system of tax-exempted savings much like our Individual Retirement Accounts, permitting an annual contribution of $10,000 in contract with the maximum of $2000 our Congress permitted for a short while. The Japanese, for all the talk about work ethic, enjoy comparable tax incentives for the national savings process.

It would be of interest to know what proportion of Canadians utilize this opportunity (the American experience was that only 14% opened IRA accounts), that the great majority of these funds are invested in government securities. /quartet/fourrx/hira/jot:

There must be an important message in the federal incentives we have constructed to make employer-based health insurance the dominant, even sole, form of health financing. A self-employed person can receive a tax deduction (ie treat as a business expense) the premium for his employees, but not the health insurance premium for his own insurance. In order to achieve this fringe benefit, he has to go to the expense of incorporating his business and becoming a salaried employee. At a time when the federal deficit was increased by $50 billion annually through the tax sheltering of employee health insurance benefits, and congressmen knew it would be political suicide to tamper with the process, the 1987 tax law increased from 5 to 7.5% the proportion of income which must be spent on healthcare before further expense become eligible for income tax deduction. Since group Blue Cross subscribers received a 35-50% discount on hospital prices, and Blue Shield group subscribers received a 30% reduction in participating physicians fees, the combination of discount and tax-sheltering easily make health care for employees less than half as expensive as it is for the self-employed or unemployed. That is the public is positively driven to adopt this form or insurance, even if it requires changing the form of incorporation of the business, changing jobs, taking part-time salaried work, or engaging in some sort of prevarication. In an era of interest-group politics, where almost everything which Congress does is at the behest of some pressure group, what group is motivated to defend this logically indefensible system?

Most analyses of issues like this begin with the motto, "Cui bono?" who seems to be profiting from it? The owners, managers, and employees of incorporated business all clearly profit from the tax dodge, and will retaliate against any elected official who tampers with their favored status. Congress, in its desperation to balance the budget, has no hesitation in raising taxes on healthcare. Everyone over age 65 has been made indifferent to the problem by Medicare; liberals lose interest because the poor have Medicaid. Reelection politics come first, the budget comes second, health care comes last. That's the system we have to work with, and politicians in their locker rooms will freely admit it's a bad scene. BUt proposals for reform must yield to the political reality, and find innovative ways to get the system back to rationality, but only within the boundaries of what is politically feasible. It's quite a challenge.


How much would it reduce the % GNP devoted to healthcare, if healthcare were prefunded? (the expenses would be the same, but the income would be partially investment income)



1800 2 (PA and NY)


1988: 7000


Blue SHield mostly doesn't pay for cognitive services: therefore, a realignment of procedural services reimbursement is just a reduction of payout.


1987 Blue Shield (PA) payout:

60% surgeons

9% inpatient internists

25% diagnostic services

6.3% laboratory

Originally published: Tuesday, November 06, 2018; most-recently modified: Thursday, May 16, 2019