Philadelphia Reflections

The musings of a physician who has 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)
DelawareOriginally 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.

Tourist Walk in Olde Philadelphia
Colonial Philadelphia can be seen in a hard day's walk, if you stick to the center of town.

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

Independence HallMillions 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.

Benjamin Franklin Parkway
Benjamin Franklin Parkway

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
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The Founding of The Franklin Inn Club

An address by Arthur Hobson Quinn at the J. William White Dinner on January 17,1952, commemorating the Fiftieth Anniversary of the founding of the Franklin Inn Club.

The Founders:

Edward W. Bok, Cyrus Townsend Brady,

Edward Brooks, Charles Heber Clark,

Henry T. Coates, John Hornor Coates,

John Habberton, Alfred C. Lambdin,

Craige Lippincott, J. Bertram Lippincott,

John Luther Long, Lisle De Vaux Matthewman,

John K. Mitchell, S. Weir Mitchell,

Harrison S. Morris, Ellis Paxson Oberholtzer,

Arthur Hobson Quinn, Joseph G. Rosengarten,

Charles C. Shoemaker, Solomon Solis-Cohen,

Frederick William Unger, Francis Chruchhill Willams,

Francis Howard Williams

It is a somewhat lonely eminence in which I find myself. That I am the only living founder of the Inn is due simply to the accolade of chronology -I have been able to survive the others! May I take this opportunity to thank the Inn for creating me the first honorary member? My association with it has been purely one of enjoyment; I have never held an Office, and except for membership on Entertainment Committee, I have done little to serve the Inn. It has not been because of any lack of affection.

The founding of the Inn was due to some intangible and some concrete impulses. The turn of the century was responsible for many new movements and it is heartbreaking now, to those of us who were young at the time, to remember how we welcomed the dawn of what we were sure would be better days.

Centering in Philadelphia, there were at that time an unusual number of men of distinction as creators of literature. Weir Mitchell had written in Hugh Wynnethe greatest novel of the Revolution, and in his Characteristics had created the novel of psychology. Horace Howard Furness, Senior, had won eminence with his Variorum Shakespeare. Henry Charles Lea was producing his histories of the institutions of the Middle Ages. John Bach McMaster had just published the fifth volume of his great History of the People of the United States. John Luther Long had just created the Character of Madame Butterfly, to become a world figure. Langdon Mitchell had won a triumph with his play of Becky Sharp. Owen Wister had scored a popular success with The Virginian, a romance with a theatrical flavor appropriate to the grandson of Fanny Kemble, and while Charles Heber Clark was trying to forget that as Max Adeler he had delighted thousands with his humor, Out of the Hurly-Burly was not forgotten . I can still remember the day when he remarked dryly, "I can not bring myself to read these books written by other people."

It should be a matter of pride to us that it was in this creative atmosphere that the Inn was born. All the writers I have mentioned were members of the Inn, and although their participation in our activities varied, their fellowship was an inspiration. I owe to Karl Miller's great statistical ability and keen interest in the Inn some figures which show that of the fifty-one members who joined in 1902, forty-four were then of later listed in Who's Who in America. It was a noteworthy group.

As long as I have been selected as the "authority" on the foundation, here is the result of my memories and my research, aided greatly by the labors of the Secretary, William Shepard.

For the record, then, the concrete sources were follows:

On February 19, 1902, ten men meet at the University Club, drew up a preliminary draft of a constitution and signed a Call for the formation of an "Authors' Club." In our printed booklet of 1950, the statement is made that Dr. Mitchell was present. I see no evidence that he was there, for he did not sign the Call. The account is in the handwriting of Francis Churchill Williams, the first secretary, and it is clear that Dr. Mitchell was elected President in his absence. It is interesting that of the ten signers of the call, J. Bertram Lippincott, John Luther Long, William J. Nicolls, Harrison Morris, and Craige Lippincott remained members of the Inn until their death; that Francis Howard Williams became Vice-President and Churchill Williams was the most active force in the actual organization of the Inn.

While Weir Mitchell was not the actual founder, he became the inspiration, the creator of the spirit of the Inn. While he did not belong to any organized preliminary group, his home was the center of gatherings which met there on Saturday evenings after nine o'clock to listen to what he truly described as "the best talk in Philadelphia," and these gatherings were certainly one of the indirect sources of the Inn. Many of his guests joined the Inn, and while I was a guest only after the Inn was founded, I am sure there must have been discussion of such a club.

Another concrete source was the Write about Club, a small group of men founded in 1897 and still in existence, who met weekly and read stories and verse for the criticism of their fellows. Among this group were Churchy Williams, who joined it with the idea of turning it into a club such as the Inn became, but found this impracticable; Charles C. Shoemaker, a publisher, for thirty-four years Treasurer of the Inn, needed the money ; Edward Robins, a short story writer; Edward W. Mumford, who became president of the Inn and did great service at the time of temporary low water; Rupert Holland, a director, and still a member of the Inn, and Lawrence Dudley, for many years the active chairman of the Entertainment Committee. The relations of these two clubs were mutual, Dudley and John Haney were first members of the Inn and later joined the Write about Club. Robins, Williams, Shoemaker, and I were first members of the Write about Club and were elected members of the Inn at its foundations.

To return to actual meetings of the Inn. Dr. Mitchell did preside at the meeting held at the Art Club on March 4, 1902, when the scope and purpose of the Club were definitely settled. Thirty-two or Thirty-three men were present. The Name of the Club was the subject of heated discussion. Dr. Mitchell objected to the proposed name "Authors' Club." He remarked that the "Authors' Club." in New York was one of the dullest place he has ever visited, and some years later, I was able to confirm his opinion. Another heated discussion as to qualifications was crystallized by the decision that the Club should be founded upon "the book, its creator, its illustrators and its publisher," who made the book available. The undated minutes of the next meeting tells us that the name "Franklin Head" and three for "Authors' Club." I have among my own memorabilia a notice which reads, "A first meeting of the Franklin Inn Club will be held at the Club House, 1218 Chancellor St., at eight, Wednesday evening June 4, 1902." I also find in my scrapbook an invitation reading, "The President of the Franklin Inn Club desires to say that the dinner you have done him the honor to accept will be at the Club House at seven, punctually, on January 6, 1903."

It will be noticed that although some of us have made it a point to say "Franklin Inn" without the "Club," the earliest notices were inclusive of that word. The names of the diners are recorded in a framed manuscript, hung on the wall in an inconspicuous place; it should have a more dignified position, for it was the first of these dinners, of which this is the fiftieth. Thirty-six names are immortalized there, signifying the Club's willingness to accept an invitation to good dinner. Dr. Mitchell's presiding was, of course, the feature of any dinner. When he died in 1914 it was impossible to replace him, the resulting election for president tore the Inn in two.

I wish to take this opportunity to pay a tribute not only to the first president of the Inn but to the man himself and to the great novelist. He was always willing to help younger writers and great novelist. He was willing to help younger writers, and I owe to his friendship introductions to men like William Dean Howells and others which aided me greatly in my work in American Literature. He was a patrician, as George Meredith recognized when he, in commenting on Dr. Mitchell's Roland Blake, Which he had read three times said, "It has a kind of nobility about it." He imparted this quality to his characters from Hugh Wynne down to Francois, the thief of the French Revolution they too are patricians. They do not argue about caste like the people in the novels of Henry James, who saw his countrymen through a haze of social hopeless. From whatever time or place they come, they are natural gentlefolk, who have seen the best of other civilization, and remained content with their own inheritances of culture.

Like all men of spirit, Weir Mitchell had a large capacity for scorn. In his fiction and poetry, this revealed itself in his artistic reticence, springing from the innate refinement of his soul. He knew death in its most horrible forms; he knew life in its most terrible aspects. He had read human minds in the grim emptiness of decay or the frantic activity of the possessed. With his great descriptive power, he could have painted marvelous portraits of the human race in its moments of disgrace. But with a restraint which puts to shame those who today in the name of realism are prostituting their art and exploiting the base or the banal in our national life, the first great neurologist knew the difference between pathology and literature. The scientist knew how bitter life would be for in Roland Blake he said, "if memory were perfect, life unendurable. " But the artist knew that the highest function of literature is to record those lofty moments which make endurable the rest of life.

May I appeal with a message from the founders to keep our ideals clear; they would wish me, I know, to remind you that it is not just another club of gentlemen interested in literature. Our Constitution provides for a limited number of distinguished public citizens. But unless the Inn is built around the "Book," it has not kept the spirit and intention of the founders. I realized this is not always easy. Great writers and painters come in clusters. They have come three times to Philadelphia first in the late eighteenth century, when Franklin, Francis Hopkinson, Thomas Godfrey, and Benjamin West established in America the art of the essay, poetry, drama, and painting; second, in the middle of the nineteenth century, when Robert Montgomery Bird and George Henry Baker for the first time challenged the playwrights of England with The Gladiator and Francesca da Rimini, and when Poe spent his six greatest years in Philadelphia; Third, in other group of our founders. Another cluster will arise in Philadelphia and, when that day dawns, may the Franklin Inn keep the light burning to attract them to its fellowship. I believe that ed can be helped by celebrations of the pioneers. I have tried to pay a tribute to them in a bit of verse-.

Those days are done. Around the hall

You see the portraits on the wall

Of those who played the founder's part

In this, our friendly home of art,

Whose triumphs we tonight recall.

Time runs-He never stoops to crawl-

The veil of memory partly pall

The splendors which the years impart-

Those days are done!

Yet when across this evening fall

Clear voices from the past call

The quick blood back along the heart,

We know, by every pulse's start,

That Never, Till the end of all,

Those days are done!

-- by: Arthur Hobson Quinn, January 17, 1952

Pipe Organs, and Similar

The Franklin Inn Club was pleased to hear a talk about pipe organs the other evening, by one of its members, Wesley Parrott. Wesley has degrees in the subject from the Curtis Institute and Eastman and was accompanied by Riyehee Hong, who has a Ph.D. degree on the subject from the Moore College. Wesley is now the organist at St. Mary's Church on Cathedral Avenue.

{Privateers}
l'Orge de Valere

The flute is just about the oldest musical instrument if you regard a pipe organ to be essentially a large collection of flutes with a single mechanical air blower, controlled by a console. Bagpipes almost fit that description, too, except a bagpiper first fills the bag with air he blows in by himself, and fingers the holes in the pipes for individual notes, whereas the pipe organist has mechanical assistance to supply the air and control the pipes.

It seems to have been Emperor Charlemagne who decreed the pipe organ would contribute the main music of churches, and to fit this role, pipe organs in France and Italy evolved in the direction of elaborating the overtones and color characteristics of the organ as sort of a soloist in a church. Organs from this distant era are still playable but seem tiny in comparison with later examples. German music, in general, has always emphasized melody over elaborate overtones, and German organs evolved in the direction of distinctive notes in counterpoint. That has been true for centuries, but it was the missionary surgeon Albert Schweitzer who most recently made great steps away from French influences back toward melody and counterpoint, both in musical composition and in mechanical modifications of the instrument to suit that baroque goal. The mechanical underpinning of this distinction lies in the immediacy of response and shortening of tone decay, making the notes crisper. The older French version tends to smear the notes together, like a young person who talks too fast. The whole French language shares that characteristic of slurring words together, and speakers thus seem to be talking a little too fast to be understood. The German language is more staccato, with distinct separate words. In general, pipe organs tend to be either of the French or the German style, but there is a great deal of individual variation, resulting in subtle distinctions lost on most audiences. The design and construction of organs remained essentially unchanged from 1390 when l' Orge de Valere" was published by Guy Bovet, until 1876, when the great modern innovation of the electric organ was displayed in Philadelphia.

{Privateers}
Pipe Organ Sketch

In fact, two modern changes were heavily American-influenced. The most important change in the mechanics after five hundred years was introduced at the 1876 Centennial Exposition in Philadelphia, by Hilborne L. Roosevelt, a cousin of Teddy, and son of S. Weir Roosevelt. The organ on display was the main organ of the main exposition building and created a sensation. Although he was only 37 years old when he died ten years later, Roosevelt became one of the largest organ manufacturers in America, a friend of Thomas Edison, and was recognized for a number of electrical inventions. Electrical control of the blower and valves greatly expanded the potential for size and complexity of the keyboard console. Up until that time, the keys were pounded with the organist's fists, and organists therefore somewhat resembled blacksmiths, both in musculature and temperament. The application of electricity greatly expanded the complexity and artistic potential of both the German and French styles. Meanwhile, the symphony orchestra was evolving throughout the 19th Century, and now the organ was able to imitate the whole orchestra. This evolution soon developed a mass market in the huge silent movie theaters of the early 20th Century, which in turn generated a pressure to evolve orchestra-like characteristics in the organs installed in the theaters, adding extra pipes and tones to suit that taste, which was exuberant. The advent of sound movies would soon eliminate the need for pipe organs in movie houses, but the instruments were durable and built into the walls. A few of them therefore still remain, largely unused, and probably unusable. The Philadelphia region is unusually rich in pipe organs of various sizes and complexity; students of the subject come here to tour them.

Philadelphia's Kimmel Center has a new pipe organ, with two consoles to suit the two main styles of organ music, solo of the Charlemagne sort, and orchestral music. Wesley feels too much emphasis was placed on maximizing the seating capacity of the Kimmel auditorium, causing the organ to be fitted into a narrow tunnel-like enclosure. The resulting sound of the organ has a uni-directional quality which is unrelated to the organ itself; some people criticize the overall result as "assaulting" the audience, but whether for better or worse the Kimmel Center distinctively has a Kimmel sound.

The electronic organ, as distinguished from the electric organ, doesn't use pipes, it synthesizes sound. It is far cheaper to manufacture, but is undergoing such rapid change in so many directions nowadays that it resembles the home computer; you have to go to the expense of getting a new one every few years. The electronic organ is clearly catching up with the range and quality of pipe organs but has not yet reached parity except in specialized situations. But its rapid and relatively inexpensive adaptability gives it a great advantage when musical tastes are changing. Modern music places much more emphasis on percussion, and modern society is much less attracted to great big hollow churches. Electronic organs thus change direction faster than multimillion dollar organs of the traditional sort, and slowly, slowly, the quality is catching up, too.

Adrift With The Living Constitution

{Senator Joe Setak}
Senator Joe Sestak

Former Congressman Joe Sestak visited the Franklin Inn Club recently, describing his experiences with the Tea Party movement. Since Senator Patrick Toomey, the man who defeated him in the 2010 election, is mostly a Libertarian, and Senator Arlen Specter who also lost has switched parties twice, all three candidates in the Pennsylvania senatorial election displayed major independence from party dominance, although in different ways. Ordinarily, gerrymandering and political machine politics result in a great many "safe" seats, where a representative or a Senator has more to fear from rivals in his own party than from his opposition in the other party; this year, things seem to be changing in our area. Pennsylvania is somehow in the vanguard of a major national shift in party politics, although it is unclear whether a third party is about to emerge, or whether the nature of the two party system is about to change in some other way.

For his part, Joe Sestak (formerly D. Representative from Delaware County) had won the Democratic senatorial nomination against the wishes of the party leaders, who had previously promised the nomination to incumbent Senator Specter in reward for Specter's switching from the Republican to Democratic party. For Vice-Admiral Sestak, USN (Ret.) it naturally stings a little that he won the nomination without leadership support, but still came reasonably close to winning the general election without much enthusiasm within his party. He clearly believes he would have beaten Toomey if the party leaders had supported him. It rather looks as though the Democratic party leadership would rather lose the election to the Republicans than lose control of nominations, which are their real source of power. Controlling nominations is largely a process of persuading unwelcome contenders to drop out of the contest. Sestak is, therefore, making a large number of thank-you visits after the election, and clearly has his ears open for signs of what the wandering electorate might think of his future candidacy.

America clearly prefers a two-party system to both the dictatorial tendencies of a one-party system, as well as to European multi-party arrangements, such as run-offs or coalitions. A two-party system blunts the edges of extreme partisanship, eventually moving toward moderate candidates in the middle, in order to win a winner-take-all election. Therefore, our winner-take-all rules are the enforcement mechanism for a two-party system. Our deals and bargains are made in advance of the election, where the public can express an opinion. In multi-party systems, the deals are made after the election where the public can't see what's going on, and such arrangements are historically unstable, sometimes resulting in a victory by a minority fringe with violently unpopular policies. In our system, a new third-party mainly serves as a mechanism for breaking up one of the major parties, to reformulate it as a two-party system with different composition. Proportional representation is defended by European politicians as something which promotes "fairness". Unfortunately, it's pretty hard to find anything in politics anywhere which is sincerely devoted to fairness.

Going far back in history one of the great theorists of legislative politics was the Roman Senator Pliny the Younger, who wrote books in Latin about how to manipulate a voting system. For him, parties were only temporary working arrangements about individual issues, a situation where he recommended: "insincere voting" as a method for winning a vote even if you lacked a majority in favor of it. Over the centuries, other forms of party coalitions have emerged in nations attempting to make democracy workable. Indeed, a "republic" itself can be seen as a mechanism devised for retaining popular control in an electorate grown too large for the chaos and unworkability of pure town hall democracy. A republic is a democracy which has been somewhat modified to make it workable. Our founding fathers knew this from personal experience, and never really considered pure democracy even in the Eighteenth century.

{Senator Specter}
Senator Specter

The two main actors in shaping the American Republic were George Washington and James Madison. Madison was young, scholarly and largely unknown; Washington was old, famous, and insecure about his lack of academic political education. Both of them knew very well that if Washington really wanted something he was going to have it; what mainly restrained him was fear of looking foolish. But he hated partisanship and conniving, partly as a result of having been the victim of General Mifflin and the Conway Cabal. Washington hated political parties and anything resembling them; Madison was young and uncertain, and briefly surrendered the point. It took about two years of real-life governing for Madison to conclude that political parties were absolutely essential to getting something accomplished. In this, he experienced for the first time those unwelcome "pressures from the home state", with Thomas Jefferson determined to thwart Alexander Hamilton, and Patrick Henry thundering and denouncing any hesitation in going for the jugular vein of opponents. Madison was deeply concerned with making his new nation success and eventually joined Jefferson in the Virginia policy of opposing banks, cities and manufacturing. When Washington saw that Madison was committed to this course, he never spoke to him again. For Washington, honesty was always the best policy, and personal honor is never regained once it is lost. The compromise of 1790 was particularly vexing to their relationship, when Washington's honor and personal finances were used as bargaining chips for moving the nation's capital opposite Mount Vernon on the Potomac River, in return for placating Hamilton and Robert Morris with the assumption of state revolutionary war debts.

Henry Clay 1811

Legislative partisan politics took a violent turn in 1811 when 34-year old Henry Clay was elected to his first term as a member of the House of Representatives. The Senate was less prestigious than the House in those days, and Clay had spent his time as a senator studying the landscape of the House before he made his big move upward. Up until that moment, the role of Speaker was that of mediator and administrator of the rules, partisanship was considered a shameful thing in a Speaker. Young Clay was elected Speaker on the first day of the first session after he moved to the House as a member. Seniority was brushed aside, and this newcomer took over. It takes only a moment's reflection to surmise that a lot of politics had taken place before the House convened. Not only that, but Clay immediately added the power of the Speaker to appoint committee chairmen, to the invisible powers of majority leader. The office of majority leader had not yet been created, but it was not long in emerging that anyone who could assemble enough votes for Speaker was also able to make highly partisan choices for Committee Chairs. Eventually, the seniority system was imposed in part as a reaction to perceived abuses of Speaker power. It is worth a digression to reflect on the role of any seniority system, which as it is clearly seen in labor-management industrial relations, serves to deprive management of promotion power, usually substituting seniority for selection by merit. In the case of the Speaker, the seniority system catapults the power of the Speaker over that of every member of his caucus. To rise in a seniority system for committee chairmen, a member must first be appointed to a desirable committee -- by the Speaker, or by his instructed favorites on the appointment committee. It puts in the hands of the Speaker or his agents the power to humiliate a member by ignoring his seniority; the other members know immediately what that means. To understand the power of this threat, reflect on Woodrow Wilson's famous observation that "Congress in committee, is Congress at work."

Soon after Henry Clay made his dramatic moves, Martin van Buren extended the idea of partisan party politics to the actual election of Congressmen. Much of the hoopla and deceptiveness of subsequent campaigns was invented by Andrew Jackson's vice president. And that included their own deal, in which van Buren worked for Jackson's election in return for a promise that he would be the successor, President. After that came the election of 1848, in which William Henry Harrison was elected as a man born in a log cabin. When, in fact, he had been born in one of the largest mansions in Virginia. That had been approximately George Washington's residence description, too, but it is hard to see Old Stone Face lowering himself to accept any office unless it was offered unanimously.

Compare that with the campaign financing episode which created the urban political machine. The Philadelphia traction king Wm. L. Elkins was narrowly concerned with building streetcar lines along with his business associate P.A.B. Widener; Widener had been a city politician before he got into street cars. One or the other of these two approached the Mayor of Philadelphia with the complaint that it interfered with building streetcar lines to have to bribe every bartender on every street corner. So he made a proposal. It wasn't the money that bothered him, because he could just raise trolley fares to cover it, it was the protracted delays. So, how would it be if the trolley company just delivered a big lump-sum bribe to the mayor? That would give enormous political power to the party boss through the power to distribute or withhold the boodle to party workers. And it would save the trolley company lots of time, while not costing any more than the "retail graft" system. Since then, just about every urban political machine in the country has been largely financed through the macing of utilities.

The downward trend of serial modifications to the Philadelphia Constitution of 1787, should be clear enough without further illustration. If the Tea Parties aren't mad about it, they should be. More likely, however, they are mainly mad about the modern pinnacle of sly tinkerings, plainly displayed on TV during the enactment of the Obama Health Bill. The point was repeated for emphasis in the Dodd-Frank financial bill, in case it is ever claimed to have been accidental. In both cases, 2000 page bills were prepared out of sight and thrust before the Congress with orders to enact them in four hours. If that's a representative government, perhaps we ought to go back to having a King.

State and Federal Powers: Historical Review

John Dickinson of Delaware

It was expedient to leave certain phrases in the Constitution intentionally vague, but the overall design is clear enough. Just as twenty-eight sovereign European nations now struggle to form a European Union, thirteen formerly sovereign American colonies once struggled to unify for the stronger defense at a reduced cost. Intentionally or not, that created a new and unique culture, reliant on the constant shifting of power among friendly rivals. Everybody was a recent frontiersman, trusting, but suspicious. It still takes newcomers a while to get used to it.

So the primary reason for uniting thirteen colonies was for a stronger defense. As even the three Quaker colonies of New Jersey, Pennsylvania and Delaware could see, if you are strong, others will leave you alone. In time, the unification of many inconsequential behaviors created a common culture of important ones; and in time that common culture strengthened defense. At first, it seemingly made little practical difference locally whether construction standards, legal standards, language and education standards and the like were unified or not. Except, that in the aggregate, it forged a common culture.

The practice of Medicine was certainly one of those occupations where it mattered very little whether we were a unified nation. Unification of medical care offered a few benefits, but mostly it didn't matter much, right up to 1920 or so. Even then I would offer the opinion, that unification of the several states (with consequent Free Trade) only made a big difference to health insurance, and still made little difference to the rest of medical care. In fact, there are still about fifteen states with too little population density to provide comfortable actuarial soundness for health insurance, as can readily be observed in the political behavior of their U.S. Senators. Although the number of low-population states gets smaller as the population grows, there are even so perhaps only ten big states where multiple health insurance companies can effectively compete within a single state border. Quite naturally the big-state insurers expect one day to eat up the small ones. By contrast, the nation as a whole, the gigantic population entity which Obamacare seeks to address, has far too many people spread out over far too large an area, to be confident we could unify them into one single program. Dividing the country into six or seven regions would be a much safer bet. That's the real message of the failure of the Computerized Insurance Exchanges -- far too much volume. And the coming failure of the Computerized Medical Record -- with too much complexity. With unlimited money, it can be done, because diseases are disappearing and computers are improving. But why struggle so hard?

It is at least fifteen years too early, and mostly serves the interest of insurance companies, if they can survive the experience. At the same time, we are at least fifteen years away from growing the smallest states to the point where we could decentralize. It's really a situation very similar to the one John Dickinson identified, James Madison briefly acknowledged, and where Benjamin Franklin improvised a solution. In their case, it was a bicameral legislature. In the case of medical care, it could be an administrative division of revenue from the expenditure. It could be the cure of a half-dozen chronic diseases. It could be six regional Obamacare. But creating one big national insurance company during a severe financial recession is something we will be lucky to survive.

Returning to the Constitutional Convention, an additional feature was added to the tentative 1787 document to respond to protests from small component states. They objected that whatever the big-state motives might be, small states would always be dominated by populous ones with more congressmen if a unicameral Legislature is made up of congressmen elected by the population. Pennsylvania had recently had a bad experience with a unicameral legislature. So a compromise bicameral legislature (with differing electoral composition in the two houses) was added to protect small-state freedoms from big domineering neighbors. Even after the Constitution was agreed to and signed, the states in ratifying it still insisted on a Bill of Rights, especially the Tenth Amendment, elevating certain citizen prerogatives above any form of political infringement, by any kind of a majority. These particular points were "rights"; individuals were even to be insulated from their own local state government. The larger the power of government, the less they trusted it.

John Dickinson of Delaware, the smallest state, soon made the essential point abundantly clear to a startled James Madison, when he pulled him aside in a corridor of Independence Hall, and uttered words to the effect of, "Do you want a Union, or don't you?", speaking on behalf of a coalition of small states. It was probably galling to Dickinson that Madison had never really considered the matter, and went about the Constitutional Convention airing the opinion that, of course, the big states would run things. Dickinson, who had been Governor of two states at once, had observed the effect of this attitude and wasn't going to have more of it.

{William Bingham class=}
Delegates

Benjamin Franklin, who for over 40 years had been working on a plan for a union of thirteen colonies (since 1745, long ago producing the first American political cartoon for the Albany Conference), devised the compromise. It was essentially a bicameral legislature -- with undiminished relative power in the Senate for small states. In this backroom negotiation, it was pretty clear Franklin held the support of two powerful but mostly silent big-state delegates, Robert Morris and George Washington. These were the three men of whom it could be said, the Revolution would never have been won without each of them. In 1787 they were still the dominant figures in diplomacy, finance, and the military. All three were deeply committed to a workable Union, each for somewhat different reasons. Now that a workable Union was finally within sight, parochial squabbles about states rights were not going to be allowed to destroy their dream of unity.

And so it comes about, they gave us a Federal government with a few enumerated powers, ruling a collection of state governments with regional power over everything else. And since big-state/small-state squabbles are unending, almost any other solution to some problem repeatedly, seemed preferable to disturbing what holds it all together. On the other hand, the Industrial Revolution was beginning at about the same time, and people who recognized the power of larger markets almost immediately set about attacking state-dominated arrangements, systematically weakening them for a century, and redoubling the attack during the Progressive era at the end of the 19th Century. Attacks on what seemed like an abuse of state power, the power to retain slavery, and later the power to perpetuate white racism, were claimed to justify this attrition of states rights. The ghost of the Civil War hung over all these arguments, restraining those who pushed them too far.

However, the driving force was industrialization, with enlarged businesses pushing back against the confinement of single-state regulation within a market that was larger than that. This restlessness with confining boundaries was in turn driven by railroads and the telegraph, improving communication and enlarging markets, which offered new opportunities to dominate state governments, and when necessary the political power weakens them. One by one, industries found ways to escape state regulation, although the insurance industry was the most resistant, whereas local tradesmen like physicians found it more congenial to side with state and local governments. The 1929 crash and the Franklin Roosevelt New Deal greatly accelerated this dichotomy, as did the two World Wars and the Progressive movement from Teddy Roosevelt to Woodrow Wilson. The Founding Fathers were said to have got what they wanted, which was a continuous tension between two forces, supporting both large and small governments; with neither of them completely winning the battle.

Insurance Monopoly

The medical profession further evolved from a small town trade into a prosperous profession during the 20th century, but the practice of medicine remained comfortably local. Even junior faculty members who move between medical schools quickly come to realize their national attitudes are somewhat out of touch with local realities. For doctors, state licensure and state regulation remained quite adequate, and state-regulated health insurance companies paid generously. State-limited health insurance companies had a somewhat less comfortable time of it, but the ferocity of state-limited insurance lobbying, as exemplified by the McCarran Ferguson Act, perpetuated it. The medical profession watched uneasily as the growth of employer-paid insurance extended the power of large employers over health insurance companies beyond state boundaries, and thus in turn over what had been medical profession's kingdom, the hospitals. And the medical profession also had to watch increasing congeniality with big government extend through businesses, unions and universities, fueled by overhead allowances of federal research grants and finally in 1965, federal health insurance programs. Nobody likes his regulator, but national organizations inevitably prefer a single regulator to fifty different ones. Furthermore, everybody could see that health care suddenly had lots of money, and naturally, everybody wanted some.

{top quote}
There is nothing naturally inter-state about medical care -- except health insurance. {bottom quote}
It was all very well to pretend that health care was out-growing local-state regulation, but those on the inside could uneasily watch the federal/state competition for control, with the federal government repeatedly stacking the deck more in its own favor. Aside from federal program interventions, there is still nothing naturally inter-state about medical care -- except health insurance. Doctors, hospitals, and patients all tend to remain local, but insurance can easily cross state lines if regulation permits. Even in insurance, small states have difficulty maintaining actuarial stability, driving health insurance toward one-state monopolies. With a few big-state exceptions, even most health insurance companies prefer single-state monopoly status to federal regulation because it facilitates marketing. To praise the virtues of insurance competition is fine, but if sharing the local market means struggling for adequate risk reserves, nationwide regulation will inevitably lead to domination by a few big-state insurance companies. Small-state insurers would enjoy access to a national market; but blocked from it, they need to retain a local monopoly to survive. Fleeting thought might be given to Constitutional Amendment, but there are probably always going to be enough states which consider themselves small, to block the two-thirds requirement for Amendment. Imposing nationwide uniformity by force would possibly improve standards, but uniformity is increasing rather than decreasing, so the argument is not a strong one.

To be fair about it, there was not a strong case for state regulation, either. It could have been argued that uniformity and reduced administrative costs favored central regulation over-dispersed control, because of improved efficiency; and few would have argued about it. Until the ACA insurance exchanges crashed of their own weight around the ears of hapless creators, that is, unable to do what Amazon seems to do every day, and raising quite a few embarrassing recollections. Recollections of the mess the Sherman Antitrust Act inflicted on local medical charity in Maricopa County, Arizona. Recollections of the "Spruce Goose" airplane that Howard Hughes made so big it couldn't fly. Recollections of the gigantic traffic jam strangling the District of Columbia every weekend. And, reminders that 2500 pages of legislation remain to be converted into 20,000 pages of regulations which it would take a lifetime to understand. Suddenly, let's face it, retaining state regulation of health care, or not rocking the boat, gets a lot better press. It might even work better than the national kind, especially in an environment where no one expected a perfect solution, and just about everyone had heard of the Curse of Bigness. When we first discovered that use of health insurance added 10% to the cost of health care, it had seemed like an easy place to extract 2% of the Gross Domestic Product for better things, just by streamlining administration. But after the health exchange fiasco, some people begin to wonder if 10% is just what it costs to use insurance to pay for healthcare. If that is the case, perhaps we should look at other ways of paying our bills, not just a different regulator. Nobody would pay 10% just to have his bills paid, if he understood what he was doing.

Reducing Health Care Costs, by Reorganizing Them (Lifetime Health Savings Accounts)

Lifetime Insurance: Deriving National Health Costs Indirectly.

It's traditional to estimate future health costs by listing the ingredients of cost, then adding them up. How many physicians do we need? How many hospitals? What diseases will have expensive cures, which ones will disappear entirely? And so on. For a century these questions have produced a single answer: It is impossible to foresee the volume or price of ingredients, so it must be impossible to predict overall costs.

Footnote:That isn't quite the case however. Since third-party payers were placed in the middle of the transaction, and particularly after electronic computers arrived, piles of payment data made analysis irresistible. That approach was soon discredited when everyone with a computer found the increased volume of the wrong data never compensates for its lack of relevance. The watchword became GIGO, garbage in, garbage out. Expanding the dataset with large volumes of medical data is a dream lingering on, but eventually runs up against a new stone wall. It makes no sense to shift the clerical data-entry burden to a physician, the most expensive employee in the system. Although the Affordable Care Act mandates something close to that, it is safely predicted it will restrain the impulse when the cost is fully appreciated. Meanwhile, the utility of just applying more advanced mathematics to simple data opened up a vista of revising the health insurance system. In a sense, this book is a product of that sort of thinking. Its difficulty is a radical idea can be developed in six months, but it may take decades to judge if it had the predicted effect.

Let's start with the final answer to the test. In the year 2000 dollars, the average American spends an average of $325,000 on health care in a lifetime. Women spend about 10% more than men. To ensure the whole lives of 340 million Americans, the cost would be trillions of dollars. That's 110,500 trillion, in fact, give or take a few trillion, or 110 or whatever is one thousand times bigger than a trillion. These mind-boggling figures were developed by Michigan Blue Cross from its own data and confirmed by several federal agencies. By the end of this book, we will have suggested it should be possible -- to cut that figure in half. It is entirely legitimate to be skeptical, since a ninety year lifetime involves a great many diseases we don't see anymore, afflicting many people who would have been readily cured with present medications except they weren't yet invented. It would involve predictions about the health costs of people who are still alive, destined to be treated with drugs we don't yet have. It is roughly estimated that fifty percent of the drugs now in use, were not available seven years ago. Since we have to go back ninety years to get the data about the childhood illnesses of our presently oldest citizens, the unreliability of looking ninety years forward from 2014 is pretty clear. But some things change slowly, so the problem is how to select.

The value of these calculations is considerable, nonetheless. They give us a technique which the statistical community agrees is reasonable, which tells us lifetime insurance would require something like $300,000 per person. Future trends can be calculated, indicating whether costs are going up or down, and roughly by how much. When you consider they had to account for inflation, you begin to appreciate the achievement. A penny in 1913 money is worth a dollar today, just for illustration. Naturally, we then assume a dollar today will be worth 100 dollars, a century from now. Regardless of numbers games, we have an accepted tool to estimate the general magnitude of health costs, and by how much they will likely change. It's useful, even if its answers are appalling.

Indeed, at first, the health insurance industry skipped the computer details and invented "Risk Adjustment", essentially just basing next year's premium on last year's results. If future medical care changes direction drastically, its payment system might be forced to change. But if health care doesn't change much, the payment system won't need to predict the future. That reasoning reflected the insurance industry's own history, where the marketing department eventually asserted dominance over the actuaries, by declaring it was more important to predict usefully, than with precision. With increasing longevity, all life insurance has to be like that.

The approach has its limits. Insurance did underestimate how much the payment system could warp the medical one over long periods because it gradually misjudged who its customers were. Payment methodology was relentless in affecting its true customers, who were businessmen in the human relations departments of large corporations. Looking back over an expedient system designed for short-term goals, a shocking realization dawns: most current "reform" thinking is about how to twist the medical system to fit some unrelated budget. Even more shocking is that the business customers discovered how modified tax laws could let them buy health insurance with a sixty-cent business dollar. When passed to the employees, another 15 or 20 cents could be clipped off.

Gradually we reach the point of rebellion; if it is legitimate for insurance executives to tell physicians how to practice medicine, it must be equally legitimate for physicians to re-design the payment system. So let's have a go at it.

Footnote: In the thirty years since I wrote The Hospital That Ate Chicago about medical costs, the newspapers report physician reimbursement has progressively diminished from 19%, to 7% of total "healthcare" costs, so perhaps now it's legitimate for some other professions to answer a few cost questions, too.

As patient readers will gradually see, considerable extra money is already in the financial system, leaving difficult problems of how to get it out and spread it around. This isn't snake oil or a mirage. The beneficiaries would scarcely see any difference in medical care if Health Savings Accounts fulfilled their promise. But frankly, the insurance providers would have to make some wrenching changes. Since millions make their living from the present system, it is undoubtedly harder to design a new system which would please them.

Medical care now costs 18% of Gross Domestic Product (GDP) and 18% is pretty surely crowding out other things we might prefer to buy. In a sense, the political beauty of the premium-investment proposal we are about to unfold lies in its primary aim of only cutting net costs by adding new revenue.

Lifetime Health Insurance: General Idea Behind the Proposal.

Let's get more specific than GDP, which is a pretty vague concept. A new primary goal of the Lifetime Health Savings Account proposal is to collect interest on idle insurance premiums, as has been done for decades whenever whole-life insurance replaces one-year "term" life insurance. If the recovered money flows to the management, it increases profits. If it goes to lower prices, the recovered money flows to the consumer. Since this tension always exists between the two counterparties, the final direction of funds-flow begins with subtle differences in the whole design of the insurance, made right at the beginning of the program.

The longer we wait to make drastic changes, the more difficult they become, and more proof of benefit will be demanded. In the proposed case of switching health insurance from term insurance to whole-life, almost a century of health insurance development is threatened. But remember, the past fifty years have seen plenty of dissatisfaction come to the surface, only to be dashed by a (generally correct) opinion that the gain was not worth the pain; the old system was working better than the proposed one. So this time, let's start in advance with establishing a monitor center where our control data is extensive -- the cost of terminal illness in the last year of life. It happens that every American has Medicare, and every American must some day die. It also happens that nearly everybody who dies does so as a Medicare recipient. Not quite, but in a population of 350 million people, it's close enough for information needs. Conversely, in a population this large, enough people of younger ages will also die; so we could still extrapolate what difference our proposals are making to costs, for the beneficiary to have attained almost any age. At least then, the public could base its opinion on what is currently happening, and actually happening, instead of having to rely on the anguished pronouncements of political candidates.

Footnote: An experience forty years ago makes me quite serious about this monitoring issue. While I was on another mission, I discovered that Medicare and Social Security are on the same campus in Baltimore, with their computers a hundred yards apart. So I proposed to the chief statistician that the Medicare computers contained the date and coded diagnosis of every Medicare recipient who had, let's say, a particular operation for particular cancer. Meanwhile, the Social Security computer contains the date of everybody's death, with the Social Security number linking the two data sets. So, why not shuffle one data set against the other, and produce a running report of how long people are living, on average, after receiving a particular treatment or operation. He merely smiled at the suggestion, and I correctly surmised he had no intention of following up on it. This time, I resolved to write a book about it, and see if that has more effect.

SOME BASIC QUESTIONS

No matter what payment system we use, the accounting system has to be clear on a few facts. For example, who produces revenue, who gets subsidized? At least in the healthcare system, it is unwise to assume that everyone pays for what he spends. Even if he does, he may well pay at one age and receive subsidies at other ages.

Answering the revenue question starts out pretty easy, but quickly gets harder. Children under roughly age 25 are subsidized by their parents, and retirees over 65 are living on their pensions and savings. Working people, roughly between the age of 25 and 65, are paying for the entire medical system, directly or indirectly, even though the money comes from the employer, who controls the terms through health insurance family plans. Legally speaking, parents are making an untaxed gift to their children when they pay for the child's healthcare bills. But it often gets further muddled by divorce and orphaning, and divorce at least is getting pretty common. For our purposes here, it is unnecessary to get into biological and legal complexities, to make a broad statement: the whole medical system is in some way supported by people with a paycheck, who are therefore aged 25 to 65. That's the healthiest component of society, so it can be increasingly unstable to base healthcare costs on family values, in a divorce-prone society, further clouded by payment of insurance by employers. Because of the tax laws, employers intrude their wishes, and may sometimes act as pawns for labor unions. But even with all this intrusion, society seems to feel the parent or parents are the best overseers of the kind of healthcare to use for all three living generations, even though effective employer and government control is perilously close to the surface. To some extent, this may reflect the fact that every sick person could become dependent on the assistance of others, and to that extent needs their consent. An employer-based health insurance system may not be the best, so the looser the family control, the more unstable employer-basing may become. Nevertheless, it is also reasonably accurate to say the upper limit of healthy revenue is ultimately traceable to people 25 to 65 and is probably going to remain that way.

Footnote: For children, medical costs can usually be traced to some sort of gift or loan from the pool of working people. And in a general sense, the revenue which pays for Medicare beneficiaries is also indirectly derived from the pool of working people, in this case, themselves at a younger age. In the case of divorce, should the new father or the actual father be assigned these costs? It might simplify things if childhood costs were assigned to the mother. This is the sort of issue we assign to judges in the Orphan's Court, but there is an even more perplexing issue: what do we do with the costs of a pregnancy, share it one way, two ways, or three? If there is a reimbursement, who should get it? Is that a cost to the child, leading to a debt to the mother, or is pregnancy a cost to the mother, unshared by the child? It was not so long ago that all pregnancy costs would have been legally assigned to the father. From the way things are going, it looks as though the insurance ought to regard pregnancy costs as a cost of the child, with a loan or gift coming from one or both natural parents. But in reality, the legislature or the Congress will make the best decision it can, and tell the insurance company what they decided. In considering it, the Congress or Legislature might remember that insurance companies have generally preferred to use family-plan insurance, reimbursing whoever paid for the family insurance at the workplace; and thus it gets back to the employer, even though that is not a socially useful outcome.

Since we confess we are here trying to demonstrate how universal lifetime Health Savings Accounts might support the whole system, let's skip over the sensitive issues and temporarily agree to impose the revenue limits of the maximum HSA deposits permitted under present law. Anyone 25 to 65 are permitted to contribute $3300 a year to a Health Savings Account. They are also permitted not to contribute that much or even anything but suppose for present purposes that everybody did. Ignoring any periods of illness or hardship, the average person is therefore permitted to contribute a maximum of $132,000 in a lifetime. Suppose for further example sake, there is no other source of medical revenue. Would that amount of money suffice to carry the entire nation's health costs, from cradle to grave? To that, the astounding but gratifying answer is a qualified Yes. So with that mildly reassuring news, let's look at the issues related to selecting a new HSA account.

Tax Exemption First of all, every bit of HSA deposits, both contributions, and compound income. is tax-exempt to the individual owner. That immediately makes it possible for anyone to claim the discriminatory tax exemption for health costs which Henry Kaiser devised for employees of profitable corporations. True, unless it is contributed by an employer, employer deductions are still omitted, although that is a separate issue. Big solvent business employers can take a 60% corporate tax deduction in addition to what the rest of us non-employees have been denied for seventy years, by purchasing HSAs for employees. If the employer is already struggling to meet the payroll, of course, he won't do it. Extending this deduction to HSAs makes employers more likely to offer them, although the present confused state of the employer mandate under the ACA makes it uncertain. To a certain extent, it continues to be unfair to confer such a huge tax advantage to a corporation based on the number of employees it has, although even this feature can be overlooked during periods of high unemployment.

A related mathematical issue is that a deposit when you are young is much more valuable than the same deposit later. Since young people are relatively healthy, while older ones are relatively sick, a deposit by a young person has many decades to grow before it is used for health care. True, young people have colleges and cars and houses to compete for their savings but just listen to this: If it were allowed by the fund managers, you could pay for a 90-year lifetime with a deposit of less than $100 at birth. The contrast is so staggering, that even raging hormones cannot compete with it in any rational analysis. Therefore, pay for administration and trivial medical expenses from some other account (in order to build this tax-sheltered one up), whenever you can do so without running up high-interest charges. By the same reasoning, discounted tax-exempt bonds might lock it up until an investment manager would charge reasonable fees to manage it as a fair-sized HSA. But let's not exaggerate. The main financial differences between an HSA and an IRA, are that an HSA is tax-exempt when you withdraw it for health purposes, whereas the IRA has a top limit of $6000 (for persons over age 50, $5000 below that age), not $3300, for annual contributions. The big obstacle is that IRA contributions are limited by the amount of money paid by an employer in that year, something a newborn obviously cannot match. Therefore:

(Proposal 7a) Waive the limit to annual HSA contributions for underaged subscribers, for single-premium contributions of less than a thousand dollars. While resistance to this provision might focus on class distinctions, the subsequent benefit to Medicare and/or Medicaid might ultimately be so large as to overcome it.

Portable, without Job-lock. No matter where you move, or where you work, this fund moves with you. Or leave it where it is, and communicate by mail.

Individually owned and selected. If you don't like one advisor or his results, choose another.

Investment Control. Here, we advise caution. If you surrender control of investments, there is some danger the broker could select an investment that gives him a kickback. Although they should be, stockbrokers are not fiduciaries. A common overcharge is an excessive commission for liquidating withdrawals, which ought to be no more than $7.50 per trade. Your goal should be to get a 10% annual return, safely, before making withdrawals to pay medical expenses, which will be discussed separately. (Unless you control fees, or deal with a fiduciary, you will be lucky to get 1%) Even during an economic recession with negligible interest rates common stock total return is 5%, and a recession is an especially good time to buy stock and hold it, where 30-50% becomes conceivable. In a tax-exempt fund, ignore dividends. Buy and hold, is the thing, with no commissions above $10 a trade (either buy or especially on sale), highly diversified for safety, index funds of common stock. Either hold back a little cash for medical issues or pay small medical bills with other funds. At least until you are sixty, try not to spend HSA money unless you have no other source of funds.No advice is absolute, but the reasoning behind this little homily appears in other sections of the book.

(Proposal 7b) Limit eligible investment agents who handle HSAs to legally defined fiduciaries. Needless to say, the brokerage industry will oppose this, and should be asked if they can suggest alternatives.

Pooling of funds. Pooling is what you only partially get with the present H.S.A as provided by present law. The law requires that an H.S.A. be accompanied by a high-deductible or "catastrophic" health insurance, which is expected to pool the experience of subscribers. But really suitable low-cost high-deductible policies are not provided by Obamacare. For cost comparisons, we initially pretend that you do not have Catastrophic re-insurance, although in real life and for the present, the best available alternative is the Bronze plan. For outpatient expenses, you are expected to pay out of your own funds, or else draw on the H.S.A. to cover them. When the law was written, the big expenses were hospital expenses, but the prepayment system enacted in 1983 limited their profitability, so hospitals have tended to shift from inpatient toward outpatient care where profits are more unconstrained. There was a time when fixing hernias and removing gall bladders as an outpatient was unheard of, but that has changed, so a pooling system for outpatient costs would be a desirable addition. There might be plenty of money in this approach which could be pooled, but a comfortable average will still be disrupted by an occasional high-cost outlier. For example, major auto accidents might run up a very high accident room cost which would not be covered, even though the average was well in surplus. A credit card would cover such eventualities, but their interest rates are high, and it might be better if investment houses provided loan funds for this purpose at a lower cost. If you must borrow, liquidate the loan at the earliest possible moment.

Compound Investment Income. Here, we have the heart of the whole arrangement. It's not a bonus, it is the source of the new revenue to pay for burdensome health care expenses. Call it the Ben Franklin approach, that allowed him to retire at the age of 41 and live comfortably for another forty years. John Bogle's discovery of buy-and-hold index fund investing is safe and effortless. It makes it unnecessary to rely on a high-commission stock picker to achieve first-class results. So trust, but verify. If you are prudent, a cash deposit of $132,000 spread over 40 years, can pay for $325,000 of lifetime health care, the present national average. That's not exactly free, but it represents an average saving of $192,000, multiplied by 350 million people, which seems to mean $68 trillion in health revenue released for medical use. These back-of-the-envelope calculations are so dizzying that, pick all the nits you please, and the same conclusion would emerge. We'll return to that after going into more description of how the proposal should work.

Caution About Averaging. Remember, it does you no good at all to have $10 in your account and receive a bill for a $1000. That is just as true if the national average of HSAs contains $50,000, which unfortunately isn't yours. Money to pay your bill is in the system, but you can't get at it. The first thing to point out is that the national curve of health accounts shows most expensive illness takes place after the age of 60, when chronic diseases and terminal disease makes an appearance, and where funds in HSAs ought to be ample. Therefore, you are cautioned to pay medical bills from any source of money you have, in order to avoid depletion of the HSA later in life, when it really ought to have money to spare. And within reason, even borrowing (short-term, and at low-interest rates) is usually better than depleting the account for diseases that won't kill you soon. Since most high medical bills are caused by hospital care, the catastrophic insurance requirement was added. Ordinarily, that feature has been fortuitous, but the migration to outpatient surgery caused by DRG payment is threatening, and the inflation of normal outpatient prices, as well as monopoly new-drug pricing, threaten to upset the payment system before it can adjust. Short-term loans from a premium pool, or else a new layer of semi-catastrophic insurance inserted between the two existing classes appear to be a coming necessity. In the meantime, short-term borrowing at what we hope are bearable rates, seems to be the only available expedient.

SOME BRIEF EXAMPLES, EXPLAINING LIFETIME HSAs .

Obamacare does not include Medicare recipients. However, it is a familiar topic, and its data are fairly accurately available in a unified form. So future Obamacare costs are readily understood by subtraction of Medicare costs from lifetime totals, and future changes can be more readily integrated. The average lifetime medical costs are roughly $325,000, as calculated by Michigan Blue Cross, who devised a system for adjusting costs to the year 2000. The results have been verified by several Federal agencies, although the method includes diseases and treatment which we no longer see, and adjusts for inflation to a degree that is startling. Medicare data are more precise but have the same trouble adjusting for the changes of half a century. By this method, we get the approximation of $209,000 for Medicare. By subtraction, we get the data approximating what Obamacare would cover, slightly confounded by including the small costs of children. That is estimated by subtraction to be $116,000. The revenue to pay for these costs is assumed to come entirely from the working years of 25 to 65. In the examples which follow, the Health Savings Account data are the maximum annual allowable ($3350) multiplied by 40, representing the working years, so they represent the maximum contribution, adjusted for compound investment income at 6.5%, and paying for lifetime costs. The aggregate cash contribution is thus $134,000, which without being disturbed by withdrawals, at 6.5% would hypothetically grow to the astonishing figure of $3.2 million by age 93. A more conservative interest rate of 4% would reach nearly a million dollars. The conclusion immediately jumps out that there is plenty of money in the approach, with the main problem remaining, somehow to devise a way to get it out in adequate amounts when the average is adequate but an occasional outlier cost is extreme. In these examples, inflation in revenue is assumed to be equal to inflation in costs, an assumption which is admittedly arguable.

HSA and ACA BRONZE PLAN: A FIRST LOOK. Although a catastrophic high-deductible plan must be attached to a Health Savings Account, and the Affordable Care Act provides a catastrophic category, those plans are not available after age 30 except in hardship cases. Therefore, at the present writing, it is necessary to select the plan with the highest deductible and the lowest premium, which happens to be the Bronze plan. "Lifetime" coverage with this, the cheapest ACA plan, would amount to $170,000, or $38,000 more than the most expensive HSA allowed by law. That's about a 22% difference. And furthermore, the bronze plan does not allow for internal investment income accumulation, which could amount to five times the actual premium revenue if held untouched until the end of projected life expectancy.

A more conservative analysis would end at age 65 because that is where the Affordable Care Act presently ends. Stopping the investment calculation at age 65 would lead to the same $170,000 for the bronze plan, compared with an adjusted price of HSA of $132,000, less a 6.5% gain of $xxxx, or $xxxx. To be fair about it, the gain would have to be adjusted for inflation, which at 2% would amount to $xxxx, an xx% difference. Let's make a more dramatic assertion: The difference between the most expensive HSA and the cheapest Bronze plan would be $xxxx. In a minute we will discuss the reasoning applied to Medicare, but it will show that a deposit of $80,000 at the 65th birthday would pay for the entire average lifetime of twenty years as a Medicare recipient. In a manner of fast talking, you get a lifetime of Medicare coverage free, somehow buried within the HSA approach. That's an exaggeration, of course, but at a quick glance, it could look that way. We haven't accounted for Medicare payroll deductions or premiums. Or government subsidies. And we haven't depleted the fund for the medical expenses it was designed to pay.

HSA AND MEDICARE. Medicare Part A (the hospital component) is free, and the system while generous, is pretty ramshackle. Furthermore, it isn't free, since it collects a payroll tax from working people, and collects premiums from the beneficiaries. Almost no one understands government accounting, but it has the unique feature that its debts are often described as assets. That is, transfers from another department are assets, so money which is borrowed, from the Chinese, let's say, is placed in the general fund and transferred internally, so such debts are assets. And the annual report (available from CMS on the Internet) shows that 50% --half-- of the Medicare budget is such a transfer asset, otherwise known as a subsidy. Medicare is a popular program because a fifty percent discount is always popular; everybody likes a fifty-cent dollar. Unfortunately, the elderly Medicare recipients perceived the Obamacare costs were underestimated and became suspicious Medicare would be raided to pay for it. Therefore, every elected representative regards Medicare as the "third rail of politics" -- just touch it, and you're dead.

THE OUT-OF-POCKET CAP FUND. The Affordable Care Act contains two innovative insurance ideas for which it should be given full credit: the electronic health insurance exchanges which unfortunately caused such havoc from poor implementation, nevertheless have great potential for reducing marketing costs with direct marketing, and should be given full credit. And secondly, the cap on out-of-pocket payments is really a form of reinsurance without the cost of creating a re-insurance middleman. It is this which is the present focus. Three of the "metal" plans have deductibles of about $6000, and two of the plans have $6000 caps on out-of-pocket cash expenses by the beneficiary. How these two features will be co-ordinated is not yet clear, and does not concern the present discussion.

The point which emerges is the original Health Savings Account was based on the concept of a high deductible, matched with enough money in the fund to pay it. Effectively, it provided first-dollar coverage without the cost-stimulating effect, and experience in the field showed it worked out that way. However, the forced match of HSA with one of the metal plans interfered to some unknown degree with the comfort of virtual first-dollar and the cost reduction of a psychological high deductible. The premium is higher, because an increased volume of small claims is covered, and may be exploited. And an increased pay-out means less cash is available for investment. The result could be either higher costs or lower ones. And therefore, the idea arises of a single-payment fund of initially $6000, deposited at age 25 (Since that might well be a hardship for many young people, an additional feature is required). But the power of compound interest is such that this reserve would eventually become seriously overfunded. If the hypothetical client deposited $6000 at age 25, he would have accumulated $80,000 from this source alone. That's enough so that if it were paid to Medicare on the 65th birthday, it would pay for Medicare for the rest of the individual's life. But since it would not be needed from age 50 to age 65, further compounding (at the arbitrary rate of 6.5%) to $320,000 or some such amount, at age 65. Therefore, the following uses can be envisioned: ( 1.) Lifetime health insurance without premiums after 65. (2.) Since Medicare premiums would not be required, the Medicare premiums would not be required and should be waived. Money which flows in from earlier payroll deductions could be diverted to paying off the Chinese Medicare debt. (3.) We have glossed over this matter, but everyone was born at someone else's expense and should pay off his debt for the first 25 years of his own life. (4.) If circumstances permit, the client should be able to transfer $6000 to other members of his family for the same funding as he got it. (5.) Surpluses might persist in exceptional circumstances, and the option to supplement his own retirement funds might be offered. Eventually, it seems inevitable that the premiums for "metal" plans would be reduced.

At the very least, one would hope that this dramatic example of the power of compound investment income would encourage wider use of the principle.

How Certain Numbers Were Derived

These are important numbers to know, but difficult for most people to understand what they mean. That will, of course, depend on how they are derived, a subject of much less interest to many people. Therefore, the more controversial numbers are discussed in this chapter, which the reader may skip if he chooses.

WHAT IS THE AVERAGE LIFETIME HEALTH CARE COST, PER PERSON, AT PRESENT RATES?

Most people in the past did not live as long as they do today, so the "average person" is a composite of older people who had illnesses as children which we seldom see today, plus some who may well live beyond recent expectations, but who live beyond the age of death of their parents. One surmises this tends to include among "average" some or many hypothetical people who had both more illnesses as children, and who will have more illnesses as retirees. This would lead to an average with more illness content than the future likely contains.

Prices in the calculation have been adjusted to 2000 prices, slightly less than in 2014. Furthermore, there has been a 2% inflation adjustment, which reflects that a dollar in 1913 is now worth a penny, so we expect the penny to be worth 0.0001 cents in 2114. It is hard for most people to wrap their heads around such calculations. There is a $ 25,000-lifetime difference between the sexes, but the highly hypothetical result is this statement: The Average Person Can Expect Lifetime Health Costs of $325,000. Since most assumptions lead to an overestimate of future real costs, this number is conservatively on the high side. Comparatively few people would think they can afford that much. That is, plenty of people are going to feel stretched to adjust their savings to that level of inflation. It's the best estimate anyone can make, but by itself alone it seems to justify organizing a government agency office to match average income with average expenses, and to make the ingredient data widely available to many others outside the government on the Internet, to maximize the recognition of serious errors, unexpected financial turmoil, the development of new treatments, and changes in disease patterns. Inevitably, these calculations will be applied to other nations for comparison, but that is a highly uncertain adventure.

HOW DO YOU CALCULATE CHILDREN'S HEALTH COSTS?

Like Archimedes announcing he could move the World if he had a long enough lever and a place to stand, accomplishing this little trick could arrive at impossible assumptions. Our basic assumption is that paying for your grandchildren is equivalent to having your parents pay for you, even though the dollar amounts are different. It's an intergenerational obligation, not a business contract, and you are just as entitled to share good luck as bad luck when the calculation is shaky at best. Since children's costs are relatively small, little damage is anticipated from taking present costs, adjusted for inflation, for both past and future.

Is it reasonable and/or politically possible to lump males and females together, when females include all the reproductive costs, and have a longer life expectancy? How do we apportion the pregnancy costs between mother and child, with or without including the father? What is fair to those who have no children? What costs do we include as truly medical? Sunglasses? Plastic Surgery? Toothpaste? Dentistry? The recent hubbub about bioflavonoids threatens to convert what was mainly regarded as a fad, into a respectable therapy for allergy. When allergists and immunologists agree it is a fad, you don't pay for it; if substantially all of them think it is medically sound, pay for it. The opinion of the FDA informs the profession, it does not substitute for that opinion. Quite aside from cost issues, all of these issues affect the statistical ground rules, and may not have been treated identically among investigators. Unverifiable 90-year projections must be thoroughly standardized to be useful, and that's one committee I shall be glad to avoid because I do not believe the improved accuracy is worth the dissention. When somebody discovers a cure for cancer or Alzheimers, rules may have to be revised, net of the cost of the treatment, and net of the increased longevity. Government accounting, private accounting, and non-profit accounting are three different schools of thought for three different goals; when a government borrows outside of its accounting environment to reimburse providers of care, misunderstandings of the "cost" consequences result, in the three definitions of medical costs. In short, only broad qualitative trends can be credible at the moment.

CRUCIAL FINAL QUESTION: FUNGIBILITY (Shifting money around)

Some of the foregoing examples are lurid, and perhaps a little dramatized for effect. But the effect of compound investment income is so impressive, that there really is a little question there is plenty of money to do just about everything which needs to be done in health financing. The problem, however, is how to get enough money to pay the right bills, at the right time. The temptation to steer the money into the wrong places has been present since Isaac and Esau, and while the pooling principle of insurance (and government) solves that problem, excessive use of that flexibility is what mainly got us into the present mess. The intrusion of government can be traced to the "pay as you go" system, which amounts to paying long-term debts with current cash flow. This money has been present right along, but political considerations created pressure to begin the government system, right away, and for everyone right away. The citizens are partly responsible since they have taught politicians they must respond to people taking off their shoes and pounding the table with them. So, yes it's true that compound interest gives an advantage to frugal people, and to some extent to people who are already prosperous. But egalitarianism doesn't justify refusing to do what is in the general interest of everyone. We are currently in a pickle because we took egalitarian short-cuts in 1965, and have preferred to borrow money for healthcare, ending up paying many times what we need to pay, rather than yield to mathematical principles discovered by Euclid, or perhaps it was Archimedes.

But while Health Savings Accounts, individually owned and selected, have more investment flexibility to take advantage of the necessarily higher returns of the private sector, and the flexibility to choose superior investment techniques as they are invented, and the flexibility to adjust to personal circumstances rather than universal absolutes,-- they lack the flexibility to pool resources between different persons and times. Perhaps this flexibility could be extended to whole families since there are shared perplexities of pregnancy, age group, and divorce which must be addressed in a communal forum, and perhaps churches or clubs could fill that role. But in our system sooner or later you get mixed up with a lawyer, judge or investment advisor. And therefore must contend with moral hazard and disloyal agents. By this time, I hope we have learned the weaknesses of that new branch of government, the government agencies. As Adlai Stevenson quipped, "It used to be said, that a fool and his money are soon parted. But nowadays -- it could happen to anyone."

So I recognize that although some people in a Health Savings Account system will have barrels of money, while others will be desperately in need, the fact that on average there is plenty of money to fund everybody isn't quite good enough. Somewhere a pooling arrangement must be created, and the fact that the people running it will be overcompensated must be shrugged off as inevitable. But since the people who trust it will be fleeced, they might as well be the ones to create or select it.

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How Do I Pay My Bills With These Things?

To summarize what was just said, on the revenue side of the ledger, we noted the evidence that a single deposit of about $55 in a Health Savings Account in 1923 would have grown to more than $300,000, today in the year 2014, because the economy achieved 10% return, not 6.5%. Therefore, with a turn of language, if the Account had invested $100 in an index fund of large-cap American corporate stock at a conservative 6.5% interest rate, it might have narrowly reached $6000 at age 50, which is re-invested on the 65th birthday, would have been valued at $325,000 at the age of 93, the conjectured longevity 50 years from now. No matter how the data is re-arranged, lifetime subsidy costs of $100 can be managed for the needy, the ingenuity of our scientists, and the vicissitudes of world finance-- within that 4% margin. We expect that subsidies of $100 at birth would be politically acceptable, and the other numbers, while stretched and rounded, could be pushed closer to 10% return. Much depends on returns to 2114 equalling the returns from 1923 to 2014, as reported by Ibbotson. At least In the past, $55 could have pre-paid a whole lifetime of medical care, at the year 2000 prices, which include annual 3% inflation. An individual can gamble with such odds, a government cannot. So one of the beauties of this proposal is the hidden incentive it contains, to make participation voluntary, and remain that way. No matter what flaws are detected and deplored, this approach would save a huge chunk of health care costs, even if they might not be stretchable enough to cover all of it.

And if something does go wrong, where does that leave us? Well, the government would have to find a way to bail us out, because the health of the public is "too big to fail" if anything is. That's why a responsible monitoring agency is essential, with a bailout provision. Congress must retain the right to revert to a bailout position, which might include the prohibition to use it without a national referendum or a national congressional election.

This illustration is, again, mainly to show the reader the enormous power of compound interest, which most people under-appreciate, as well as the additional power added by extending life expectancy by thirty years this century, and the surprising boost of passive investment income to 10% by financial transaction technology. The weakest part of these projections comes in the $300,000 estimate of lifetime healthcare costs during the last 90 years. That's because the dollar has continuously inflated a 1913 penny into a 2014 dollar, and science has continuously improved medical care while eliminating many common diseases. If we must find blame, blame Science and the Federal Reserve. The two things which make any calculation possible at all, are the steadiness of inflation and the relentless progress of medical care. For that, give credit to -- Science and the Federal Reserve.

Blue Cross of Michigan and two federal agencies put their own data through a formula which creates a hypothetical average subscriber's cost for a lifetime at today's prices. All three agencies come out to a lifetime cost estimate of around $300,000. That's not what we actually spent because so much has changed, but at such a steady rate that justifies the assumption, it will continue for the next century. So, although the calculation comes closer to approximating the next century than what was seen in the last, it really provides no method to anticipate future changes in diseases or longevity, either. Inflation and investment returns are assumed to be level, and longevity is assumed to level off. So be warned.

The best use of this data is, measured by the same formula every year, arriving at some approximation of how "overall net medical payment inflation" emerges. That is not the same as "inflation of medical prices" since it includes the net of the cost of new and older treatments and the net effect of new treatments on longevity. Therefore, this calculation usefully measures how the medical industry copes with its cost, compared with national inflation, by substituting new treatments for old ones. Unlike most consumer items, Medicine copes with its costs by getting rid of them. Sometimes it reduces costs by substituting new treatments, net of eliminating old ones. It also assumes a dollar saved by curing disease is at least as good as a dollar saved by lowering prices, and sometimes a great deal better, which no one can measure. Our proposals therefore actually depend on steadily making mid-course corrections, so we must measure them.

Our innovative revenue source, the overall rate of return to stockholders of the nation's largest corporations, has also been amazingly steady at 10% for a century. National inflation has been just as non-volatile, and over long periods has averaged 3%., perhaps the two achievements are necessary for each other. Medical payments must grow less than a steady 10%, minus 3% inflation, before any profit could be applied to paying off debt, financing the lengthening retirement of retirees, or shared with patients including rent seekers. But if the profit margin proves significantly less than 10%, we might have to borrow until lenders call a halt. No one can safely say what the two margins (7% + 3%) will be in the coming century, but at least the risks are displayed in simple numbers. Parenthetically, the steadiness of industrial results (in contrast to the apparent unsteadiness of everything else) was achieved in spite of a gigantic shift from control by family partnerships to corporations. Small businesses (less than a billion dollars annual revenue) still constitute half of the American economy, however, and huge tectonic shifts are still possible. Globalization could change the whole environment, and the world still has too many atom bombs. American Medicine can escape international upheavals in only one way -- eliminate the disease. Otherwise, the fate of our medical care will largely reflect the fate of our economy. To repeat, it is vital to monitor where we are going.

Revenue growing at 10% will relentlessly grow faster than expenses at 3%. Our monetary system is constructed on the gradations of interest rates between the private sector and the public sector. It would be unwise to switch health care to the public sector and still expect returns at private sector levels. Repayment of overseas debt does not affect actual domestic health expenditures, although it indirectly affects the value of the dollar. Without all its recognized weaknesses, a fairly safe description of present data would be that enormous savings are possible, but only to the degree, we contain last century's medical cost inflation closer to 3% than to 10%. The simplest way to retain revenue at 10% growth is by anchoring the leaders within the private sector.

How Do You Withdraw Money From Lifetime Health Insurance?

Four ways should be mentioned: Debit cards for outpatient care, Diagnosis pre-payment for hospital care, Transfers from escrow, and Gifts for specified purposes.

Special Debit Cards, from the Health Savings Account, for Outpatient care. Bank debit cards are cheaper than Credit cards, because unpaid credit card payments are a loan, whereas the money is already in the bank for a debit card. Some pressure has to be applied to banks or they won't accept debit cards with small balances. Somehow, the banks have to be made to see that you start with a small account and only later build up to a big one. So it's probably fair, for them to insist on some proof you will remain with them. The easiest way to handle this issue is to make the first deposit of $3300, the maximum you are allowed to deposit in one year. That's difficult for little children and poor people, however, so some way must be devised to have family accounts for children. At the moment, you just have to shop around, that's all.

After that, you should pay your medical outpatient bills with the debit card, although we advise paying out of some other account if you can, so the balance can more quickly build up to a level where the bank quits pestering you for more funds. Remember this: the only difference between a Health Savings Account and an ordinary IRA for practical purposes, is that medical expenses are tax-exempted when paid with money from an HSA. Both of them give you a deduction for deposits, and both collect income without taxes. If you can scrape together $6000, you are completely covered from Obamacare deductibles, and since co-payment plans are to be avoided, an HSA with Catastrophic Bronze plan is your present best bet. If you have a bronze plan, you probably get some money back if you file a claim form, but those rules are still in flux at this writing. The expense of filing and collecting claims forms is one of the reasons the Bronze plan is more expensive, but that's their rule at present.

There are some other important things to say about outpatient vs. inpatient care, but it seems best to describe how inpatient care is envisioned to work in this system, before returning to the tension between the two. As will then become apparent, increasing the ease of use might create the problem of making it a little too easy to spend money.

Payment by Diagnosis Bundles, for Outpatient care. In 1983 a law was included as an unnoticed part of the annual Budget Reconciliation Act, which nevertheless later proved to have a huge effect on the health financing system. The proposal was to stop paying for Medicare patients on the basis of the itemized services each patient received as a bill, but to pay a single lump sum for the main diagnosis of each patient, using the argument that most cases of a given diagnosis were pretty much the same, and what variation there was, would soon average itself out after a few cases. Such a meat ax approach to the complexity was justified by the argument that a patient sick enough to be in bed in a hospital, was too overwhelmed by his frightening situation and too uneducated in its issues, to be able to dispute what was done to him. Market mechanisms, in short, were futile is situations with such imbalances of information and power. Consequently, a great deal of money was being wasted on accounting systems to arrive at prices which were ultimately set in an arbitrary way.

This argument prevailed in Congress, which was becoming desperate about relentless cost increases in Medicare, even sweeping aside the grossly primitive details of a system defining the solvency of vital institutions. The misgivings from economists that the accounting system was a large part of the internal hospital administrative information system, were also treated like mutterings of pointy-heads. To the extent these objections were valid, they would probably lead to a collapse of the experiment, so why worry about it. In fact, the expedient emerged that the prices of the DRG ( diagnosis "related" groupings) were simply revised to result in a 2% profit margin on the bottom line, no matter what the medical issues happened to be. It was a highly effective rationing system, not terribly far removed from a lump sum payment with a 2% markup, so live with it. Since the Federal Reserve targets 2% annual inflation, 2% profit is no real profit at all.

The hospitals might have rebelled, or might have collapsed. Instead, they accepted 2% for inpatients and set about adjusting the subsidies, aiming for a 15% profit margin on the Emergency Room, and a 30% profit on outpatient services. Subsidies from such accounting were difficult to achieve at first, so Emergency rooms were enlarged, and much-expanded outpatient facilities were built, requiring hospitals to purchase physician practices to keep them filled. The entire healthcare system was put under strain, and hardball was the game of the day. New lifesaving drugs were priced at $1000 per pill, institutions were merged out of existence, the office practice of medicine was in turmoil, and a year in business school could make you a millionaire if you could appear calm in the midst of confusion.

I tell this story to explain why, with great reluctance, I advise the management of Health Savings Accounts to base their inpatient payment system on some variation of Diagnosis Related Groups. It's a terrible system, designed by rank amateurs, which results in distortions of a noble profession. But there is no other rational choice. It does protect the paying agency from being fleeced, once it gets past negotiation of a small list of prices which aggregate to a profitable bottom line. By protecting the payment system, it protects the patients from a chaotic price jungle which, unchecked, will rapidly destroy health care. If we experience more than 2% inflation, the destruction will be quicker.

Resolving Tension Between The Two Payment Systems. Evidently, some clear thinking by some smart people have brought them to the ruthless conclusion that a two-class system of medical care is preferable to the way we are otherwise going. Rich people will have their way if their own health is at stake, and poor people will have their way if they exercise their votes. Both of these conclusions are correct, but they lead to Medieval monks retreating into monasteries. The cure for cancer and a few brain diseases might make monasteries unnecessary, and so would a drastic reduction in health care costs. Huge research budgets and major regimentation are big-government approaches, of willingness to accept some loss of freedom to achieve equality of outcome.

But we can't completely depend on either choice, so the remaining choice is to undermine a lot of recent culture change, by devolving back to leadership on the local level of small states and big cities. This is a small-government approach, willing to accept wider inequalities in order to seek freedom to act. Mostly using the licensing power, the competition will reappear if retirement villages and nursing homes are licensed to be hospitals. If not, nurses and pharmacists can be licensed as doctors. Some of this could become pretty brutal, and all of it leads to patchy results. But of its ability to restrain prices, there can be little doubt.

Escrow Subaccounts within HSA Accounts. Whether anything can restrain reckless spending of "found" money, is quite a different matter, however. It may be that supply and demand will balance, even if it takes generations. There is some hope to be gained from watching reckless teenagers become penny-pinching millennials, but there remain dismal reminders of improvidence to be found in ninety-year-old millionaires marrying teen-aged blondes, further reinforced by watching the blondes run off with stable-boys. The net conclusion is that if certain portions of a Health Savings Account must be set aside for mandatory later expenses, then the money should be set aside within partitions, like an escrow account. Even that will have limits to its effectiveness, as I have noticed when trust-fund babies in my practice worked around the restraints their grandfather's lawyer took care to put in place.

Specified Gifts to be Encouraged. Only limited restraints on spending the client's own money can ever be justified, but certain types of gifts can still be better justified than others. One of them would be the special $6000 escrow fund for deductibles and caps on out-of-pocket spending. Particularly in the early transitional years, the fund's solvency may be threatened by leads and lags, where these escrow funds could save the day. Therefore, if someone accumulates large surpluses in his account by the fortuitous conjunction of events, he should be encouraged to consider donating a $6000 escrow to one of his grandchildren or other impecunious relatives. Quite often, a prudent gift to a grandchild can lighten the burdens of his parents or other members of the family. If they wish, any number of $6000 transfers to the escrow funds of others should be encouraged.

Spending Health Savings Accounts. Spending Less. In earlier sections of this book, we have proposed everyone have an HSA, whether existing health insurance is continued or not. It's a way to have tax-exempt savings, and a particularly good vehicle for extending the Henry Kaiser tax exemption to everyone, if only Congress would permit spending for health insurance premiums out of the Accounts. To spend money out of an account we advise a cleaned-up DRG payment for hospital inpatients, and a simple plastic debit card for everything else. Credit cards cost twice as much like debit cards, and only banks can issue credit cards. Actual experience has shown that HSA cost 30% less than payment through conventional health insurance, primarily because they do not include "service benefits" and put the patient in a position to negotiate prices or be fleeced if he doesn't. Not everybody enjoys haggling over prices, but 30% is just too much to ignore.

No Medicare, no Medicare Premiums. We assume no one wants to pay medical expenses twice, and will, therefore, drop Medicare if investment income is captured in lifetime Health Savings Accounts. The major sources of revenue for Medicare at the present time fall into three categories: half are drawn from general tax revenues, a quarter come from a 6% payroll deduction among working-age people, and another quarter are premiums from retirees on Medicare. All three payments should disappear if Medicare does, too. Therefore, the benefit of dropping Medicare will differ in type and amount, related to the age of the individual. Eliminating the payroll deduction for a working-age person would still find him paying income taxes in part for the costs of the poor, as it would for retirees with sufficient income.

Retirees would pay no Medicare premiums. Their illnesses make up 85% of Medicare cost, but at present, they only contribute a quarter of Medicare revenue. However, after the transition period, they first contribute payroll taxes without receiving benefits, and then later in life pay premiums while they get benefits, to a total contribution of 50% toward their own costs. But the prosperous ones still contribute to the sick poor through their income taxes. There might be some quirks of unfairness in this approach, but its rough outline can be seen from the size of their aggregate contributions, in this scheme. At any one time during the transition, working-age and retirees would both benefit from about the same reduction of money, but the working-age people would eventually skip payments for twice as long. Invisibly, the government subsidy of 50% of Medicare costs would also disappear as beneficiaries dropped out, so the government gets its share of a windfall, in proportion to its former contributions to it. One would hope they would pay down the foreign debt with the windfall, but it is their choice. This whole system -- of one quarter, one quarter, and a half -- roughly approximates the present sources of Medicare funding and can be adjusted if inequity is discovered. For example, people over 85 probably cost more than they contribute. For the Medicare recipients as a group, however, it seems like an equitable exchange. This brings up the subject of intra- and extra-group borrowing.

Escrow and Non-escrow. When the books balance for a whole age group, the managers of a common fund shift things around without difficulty. However, the HSA concept is that each account is individually owned, so either a part of it is shifted to a common fund, or else frozen in the individual account (escrowed) until needed. It is unnecessary to go into detail about the various alternatives available, except to say that some funds must be escrowed for long-term use and other funds are available in the current year. Quite often it will be found that cash is flowing in for deposits, sufficient to take care of most of this need for shifting, but without experience in the funds flow it would be wise to have a contingency fund. For example, the over-85 group will need to keep most of its funds liquid for current expenses, while the group 65-75 might need to keep a larger amount frozen in their accounts for the use of the over-85s. In the early transition days, this sort of thing might be frequent.

The Poor. Since Obamacare, Medicaid and every other proposal for the poor involves subsidy, so does this one. But the investment account pays 10%, the cost of the subsidy is considerably reduced. HSA makes it cheaper to pay for the poor.

Why Should I Do It? Because it will save large amounts of money for both individuals and the government, without affecting or rationing health care at all. To the retiree, in particular, he gets the same care but stops paying premiums for it. In a sense, gradual adoption of this idea actually welcomes initial reluctance by many people hanging back, to see how the first-adopters make out. Medicare is well-run, and therefore most people do not realize how much it is subsidized; even so, everyone likes a dollar for fifty cents, so there will be some overt public resistance. When this confusion is overcome, there will still be the suspicion that government will somehow absorb most of the profit, so the government must be careful of its image, particularly at first. Medicare now serves two distinct functions: to pay the bills and to protect the consumer from overcharging by providers. Providers must also exercise prudent restraint. To address this question is not entirely hypothetical, in view of the merciless application of hospital cost-shifting between inpatients and outpatients, occasioned in turn by DRG underpayment by diagnosis, for inpatients. A citizens watchdog commission is also prudent. The owners of Health Savings Accounts might be given a certain amount of power to elect representatives and negotiate what seem to be excessive charges.

We answer this particular problem in somewhat more detail by proposing a complete substitution of the ICDA coding system by SNODO coding, within revised Diagnosis Related Groupings,(if that is understandable, so far) followed by linkage of the helpless inpatient's diagnosis code to the same or similar ones for market-exposed outpatients. (Whew!) All of which is to say that DRG has been a very effective rationing tool, but it cannot persist unless it becomes related to market prices. We have had entirely enough talk of ten-dollar aspirin tablets and $900 toilet seats; we need to be talking about how those prices are arrived at. In the long run, however, medical providers are highly influenced by peer pressure so, again, mechanisms to achieve price transparency are what to strive for. These ideas are expanded in other sections of the book. An underlying theme is those market mechanisms will work best if something like the Professional Standards Review Organization (PSRO) is revived by self-interest among providers. Self-governance by peers should be its theme, ultimately enforced by fear of a revival of recent government adventures into price control. Those who resist joining should be free to take their chances on prices. Under such circumstances, it would be best to have multiple competing PSROs, for those dissatisfied with one, to transfer allegiance to another. And an appeal system, to appeal against local feuds through recourse to distant judges.

Deliberate Overfunding. Many temporary problems could be imagined, immediately simplified by collecting more money than is needed. Allowing the managers some slack eliminates the need for special insurance for epidemics, special insurance for floods and natural disasters, and the like. Listing all the potential problems would scare the wits out of everybody, but many potential problems will never arise, except the need to dispose of the extra funds. For that reason, it is important to have a legitimate alternative use for excess funds as an inducement to permit them. That might be payments for custodial care or just plain living expenses for retirement. But it must not be a surprise, or it will be wasted. Since we are next about to discuss doing essentially the same thing for everybody under 65, too, any surplus from those other programs can be used to fund deficits in Medicare. But Medicare is the end of the line, so its surpluses at death have accumulated over a lifetime, not just during the retiree health program.

That may not be more accurate, but it displays its assumptions better. Michigan Blue Cross has calculated we calculate lifetime costs and Obamacare costs by starting with lifetime average health costs of $325,000 and subtracting Medicare. Although Medicare is reported by CMS to have average costs of $xxxx, for which we prefer to assume a Health Savings Account "present value" cost of $80,000 on the 65th birthday (at a 6.5% interest rate). At the same 6.5% rate, a $3300 annual deposit from age 25 to 65 (the earning years) would total $132,000 of deposits. Preliminary goals for a hypothetical average person are: To accumulate $80,000 in the Medicare fund by the age of 65, to pay off the 25-year health costs of 2.0 children per couple as a gift to them, and to pay his own relatively modest average healthcare costs from 25-45, somewhat higher costs 45-65. The Medicare goal of $80,000 is what is estimated to be what is required for a single-deposit investment fund (paid on the 65th birthday) to pay the health costs for an average person aged 65-93,(a guessed-at future average longevity), with an estimated compound investment income of 4%, also guessed, but conservative. Inflation is ignored, assuming revenue and expenses will inflate at the same rate. Our average consumer will have to set aside $1250 per year from age 25 to 65, and earn 4% compounded, to do it.

Those who disagree with the underlying assumptions should feel free to substitute their own assumptions. The interest rate of 4% is deliberately low, in order to make room for disagreements which are higher. The upper limit is set to match the HSA contribution limits of 3300 times 40, becoming hypothetically the upper bound of revenue which can ever be anticipated. Anticipating two children per couple and full employment from 25 to 65, this revenue effectively covers one full lifetime, from cradle to grave. Childhood illnesses and elderly disabilities notwithstanding, this is all the revenue we allow ourselves in this example.

Let us assume that an average person can start contributing to an H.S.A. at the age of 25, even though perhaps a quarter of the population at that age are burdened with college debts, etc. and cannot. We are well aware of the Pew Foundation poll that xxxx% of those under 30 are still living with their parents, and that xxxx% have college debts. (Congress ought to examine this condition, which could apply at any age, and provide for make-up contributions later.) The present ceiling of $3300 annual contribution is otherwise taken as the upper boundary of what is possible for the sake of example, and theoretical deficits would have to be made up from the $68 trillion dollar surplus created by such legal maximums. To plunge ahead with the example, our average person sets aside $3300, starting at age 25 toward lifetime health costs. To simplify the example, he does so whether he can afford it or not, and what he can't supply himself is provided by a subsidy or a loan. Since present law prohibits spending from the H.S.A. for health insurance premiums (this should be reconsidered by Congress, by the way), an estimated premium of $300 for his own Catastrophic insurance is taken from the set-aside, and the remainder is placed in the H.S.A., paying an estimated 4% tax-free. Within this he eventually needs to set aside a Dependent Escrow premium (remember, this example covers lifetime expenses, even though everyone has Medicare), which for twenty years (until age 45) is zero for Medicare and available for medical gifts to Children, and after that is exclusively used for Medicare, both of which will be explained in later sections.

Health Savings Accounts are tax-exempt, and they can earn investment income. Except it isn't all it could be. Professor Ibbotson of Yale, the acknowledged expert in the long term results of investment classes, has regularly published data going back nearly a century. In spite of military and economic disasters of the worst sort, investment classes have remained remarkably steady throughout the past century and presumably will maintain the same relationships for some time to come. John Bogle of Philadelphia has translated that into index funds of investment classes, with almost negligible administrative costs. (Caution: Many index funds are sold with very high trading costs, typically in charges when money is withdrawn. Be careful of your counterparty, particularly if he specifies the index fund, because he may limit it to one who gives kickbacks to him.) With this warning, there is a reasonably good chance of getting returns approaching 10% for investments in index funds of well-known American stocks, even though the typical HSA at present is yielding much less. This investment income can grow to the point where it constitutes a fairly large part of the health revenue.

SIX PIECES OF THE LIFETIME PIE

Instead of starting at birth and ending at death, this book will reverse the process. Let me explain. There is a big transition problem in a proposal like this, since the readers will be of different ages, and the system must work without gaps. Everybody has already been born, and for a long time to come, everybody will have a piece of his life behind him that he does not want to pay for. The time is past when Lyndon Johnson could solve the transition problem by simply giving a gift of many years free coverage to most of the new entrants to his system. So, although it will probably spook a number of old folks just to hear the discussion, let's begin for completeness with the Last Year of Life Coverage, and end up with the First year of Life coverage. Both of those apply to 100% of Americans in a theoretical sense, and in a sensible system would be the basic coverage. If any health insurance should be universal, these two have the strongest arguments. Unfortunately, they have the least chance of political success. Therefore, it is likely that they will be voluntary and self-pay if they are adopted at all.

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.

Sociology: Philadelphia and the Quaker Colonies
The early Philadelphia had many faces, its people were varied and interesting; its history turbulent and of lasting importance.

Nineteenth Century Philadelphia 1801-1928 (III)
At the beginning of our country Philadelphia was the central city in America.

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.