Signing up for Medicare

Good article on rules of when you can sign up for Medicare....and some of the issues you should consider when working past 65 and deciding about continuing employer based cover or Medicare.

Yale Book of Quotations top 10

quotes of the year is here. Their number 1 quote of the year, 2009:

"Keep your government hands off my Medicare."
unidentified speaker at health care reform town hall meeting in Simpsonville, S.C.,

I don't know whether to laugh or cry.

If you need something to worry about

check out this cool web site about risk of death from different causes. Not sure why they use 2002 data, because there are more recent data. They show deaths categorized by disease as well as by exposure. Nice visual representation of relative risk of dying from different causes. Hint: stop watching folks on TV talking about terrorism and go for a run.

More on geographic variation

from NY Times an essay on Richmond, VA and costs and outcomes there....and the fact that often the highest quality/best outcome areas are not the most expensive. Interesting article from most recent Archives of Internal Medicine on the risks of radiation from overuse of tests as an example of the cultural notion that more is always better is not likely the case in health care. Also, here is a link to the Dartmouth Health Atlas, the group that has popularized the study of small area analysis and geographic variation in health care. Here is a recent paper in the New England Journal of Medicine from some of the Dartmouth folks responding to criticisms about small area analysis and folks saying variations are driven by race on income only....they find these factors account for about 30% of the variation in expenditures across geography, with the remainder driven by system factors (how many docs, type of facilities, etc.). Here is a recent NY Times op-ed arguing that more doctors is not only not needed but would be bad for the system if teaching hospitals allowed to simply goose the existing system.

Quote of the year....for next 40 years

In Time's year end issue interview with Ben Bernanke, Chairman of the Federal Reserve Board, when asked if he was in favor of a law adding a value added tax responds thusly:

"....the one law I strongly advocate is the law of arithmetic. The law of arithmetic says that if you are a low-tax person, then you are responsible for finding ways of saving on expenditure so that you don't have enormous imbalances between revenues and spending. And by the same law of arithmetic, if you are somebody who believes that government spending is important, and you are for bigger programs, then it's incumbent upon you to figure out where the revenues are going to come from to meet that spending."

Excise Tax

Jon Gruber a few days ago on the tax on high cost insurance plans. Well written assessment....but I do wish we would cap the tax exclusion up front instead of doing in back door via this tax so that more focus could be put on role of the end user of care--you and me--on rising health care costs. But, this tax is the best aspect of the Senate bill to slow cost inflation.

Update: Today Bob Herbert in NY Times attacks the tax...he does understand it, just doesn't like i (meaning the real goal of the tax is to be avoided, with folks shifting down into lower cost insurance policies). I agree that it is not best referred to as a Cadillac tax....that is why I call it a high cost insurance tax. Again, I would rather limit and eventually end the tax exclusion altogether....and it doesn't bother me if you want lots of insurance, I just don't think all the premium should be tax preferenced if provided via an employer.

Column in N and O, Dec. 27

highlights the two trickiest issues for a conference bill....abortion and taxes (which ones). For taxes, the big issue is income tax increase (House bill) v. tax on high cost health insurance plans (Senate). Since I wrote this last Monday....the spotlight has shone brightly on special deals for states of holdout votes in the Senate....so that is likely to be important in negotiations with House. Also, I didn't list public option as a key sticking point because I think that is dead. The key for getting to a bill that gets 218 in the House is coming up with a face saving way for the House to basically assent to the Senate bill.

Odds and ends. Ezra Klein talking about the 24 Republicans who voted for the Part D plan with no spending offsets or tax increases and how they try and justify that with what they say now. The gem, a quote attributed to Orrin Hatch ....Hatch admitted that when Republicans controlled Congress, "it was standard practice not to pay for things." Here is the original AP story....part D plan added about half Trillion over first 10 years to deficit.

Klein also has a variety of interesting interviews about the filibuster in the Senate, how its use has changed and notions of reform.

Some Republican Attorney's General say they will sue over deals associated with Senate Dem holdouts. I don't watch so much TV, but this am was cruising the cable networks and saw a few of them talking...they mostly sounded like people who wanted to be governors or Senators instead of AGs, but I was impressed with their level of outrage for the Monday after Christmas...they were pretty jacked up.

But, I think they need to get straight what they are suing about. 10th Amendment challenge of the individual mandate? If yes, then Republicans need to stop calling it a tax increase, as the fed gov't clearly can do that. 14th Amendment equal protection challenge of Nebraska, etc. deal? Wouldn't Calif and NY be able to launch same over fact that the Medicaid formula differs by state per se, based on poverty levels? And isn't all this a bit tricky when the Repubs main rejoinder in the debate has been for fed gov't to pass law allowing insurance to be sold across state lines? This is fed govt telling states how/whether they can regulate insurance. They need a more coherent plan of attack....