Sanford Escapes Impeachment

The State reports that Mark Sanford has avoided impeachment:

An impeachment resolution against Gov. Mark Sanford has been essentially killed, as a majority of the 7-member committee formed to weigh evidence against the governor voted against it today.

The vote, which came shortly after 3:30 p.m., was 6-1 against the resolution. The full House Judiciary Committee will still take up the resolution.

The Inevitability Of Marriage Equality

Ben Smith writes that the inevitability of gay marriage is in doubt:

After a year that saw laws allowing same-sex marriage expand from a lonely toehold in Massachusetts to five other states and, likely, the District of Columbia, the defeats have served at the least as a reality check to proponents of gay marriage.

A Maine referendum that was seen as the best chance for popular approval of same-sex marriage instead was soundly defeated. The state senate in liberal New York voted down a marriage bill by a margin – 38 to 24 – that stunned advocates and the state’s governor, who had predicted victory. And a same-sex marriage measure limped to the floor of the New Jersey state senate Thursday after squeaking out of committee over the opposition of prominent Democrats.

“The events of the last few months have put a serious dent in the idea that gay marriage is inevitable,” said Maggie Gallagher, the president of the National Organization for Marriage, which opposes same-sex marriage.

The movement to expand marriage to include gays and lesbians has gathered force from the perception that it’s a historic civil rights battle, and that its foes are – as advocates often say – on the “wrong side of history.” That’s a message that has animated supporters, silenced opposition – just one New York legislator, for instance, stood up to explain his “no” vote – and generated its own momentum. It has also penetrated broadly into the culture, said Democratic pollster Diane Feldman, whose surveys have found a solid majority of Americans view same-sex marriage as inevitable, “and are variously pleased or resigned to that.”

The events of this year are meaningless with regards to the belief that acceptance of same-sex marriage is inevitable. Republicans gained many votes in 2004 by using referendums on same sex marriage to get out the vote. Conditions have not changed that much since then. What is important is that tolerance is far greater among younger voters:

A Gallup poll from May, for instance, found that 18 to 29 year olds favor same-sex marriage by a margin of 59% to 37%, while people 65 and over oppose it by an even wider margin. And other studies have suggested the support among young voters is broad, and stretches across regions. One recent Columbia University study reported that more than 50% of 18-29 year olds in 38 states support same-sex marriage.

Acceptance of same-sex marriage is inevitable, but it is probably still several years away. I thought this was the case before the matters mentioned above were considered and the outcome this year does not change the long term trend towards greater tolerance.

Economic Incentives and the Medicare Buy-In

The prospect of expanding Medicare in place of a public option has led to discussion of how this is likely to be received. Matthew Yglesias writes:

Medicare doesn’t pay hospitals and doctors as much as private insurance does. Hospitals and doctors don’t like that. They want to get paid more. Which is understandable. In addition to my main job here at CAPAF, I also write columns regularly for The Daily Beast and The American Prospect Online. I won’t go into specifics, but one of these fine online journalism outfits pays me 67% more per column than the other. Naturally, I wish the stingier publication would reimburse me at the higher rate. But they don’t see it that way.

To some degree this analogy as valid, but for health care the comparison is more complicated than comparing the rates of pay between different publications.  Reimbursement for health care charges is more complicated than getting paid for writing and hopefully Yglesias doesn’t have to worry about whether he will be paid at all. While Yglesias primarily writes about hospitals and cost shifting in his post, I’ll comment regarding the situation I know first hand–physician billing.

Private insurances generally pay more than Medicare so theoretically I should prefer that we do not expand Medicare. However, Medicare has some things going for it which make me happy to see more on Medicare. If a patient is on Medicare I pretty much know I’ll get paid. (The most common real world exception is when it turns out the patient is really enrolled in a private Medicare HMO I don’t participate with.)

With private plans there are far more reasons why I might not get paid, such as pre-existing conditions, deductibles which might be thousands of dollars, patients losing coverage, or unexpected rules on what is covered. (At least Medicare posts all their rules on line, limiting surprises).

With some plans I might get paid more, but it also costs more overhead for billing and obtaining authorizations. It is  far less expensive to deal with Medicare. I simply send in an electronic claim and receive a check in three weeks. With private plans, sometimes it is this easy, and sometimes they throw a bunch of roadblocks in the way of getting paid.

While Medicare does pay less, looking at things purely from the perspective of my own economic benefits I still like the idea of more people having Medicare. Sure, at times this will mean I’ll receive less pay if a patient changes from a private plan to Medicare, but generally it will not be all that much less. Many other times it will be patients who currently have no insurance or have an insurance plan which winds up not paying all that well. My bet is that I’ll still come out ahead (although a public option which pays 5% more than Medicare would be preferable assuming it paid as reliably as Medicare).

Ezra Klein reports that hospitals are gearing up to oppose the Medicare buy-in.

Medicare pays less for services than private insurers do, or than the public plan would. To consumers, that’s called “getting a better deal.” To hospitals, it’s called “making less money.” A hospital’s total operating budget is always based on its total revenue. They add the income from patients with private insurance, Medicare, and Medicaid, add in the whatever pittance they get for uninsured patients, and use that pool of money to offset their total operating expenses. That, in the simplest form, is the business model.

That model works as long as all three major streams of revenue stay constant. But changing some of their current private patients who are billed at $4,000 per day to Medicare patients who are charged $3,000 per day scares them. Where does the money come from? A health-care wonk will optimistically tell you it comes from more efficiencies. An industry cynic will tell you it comes from increasing volume. For some hospitals, it comes from nowhere, and they’re suddenly in financial trouble.

Comparing hospital charges is also far more complicated than this example. The amounts that a hospital charges are irrelevant. Medicare pays hospitals based upon a Diagnostic Related Group (DRG) system. A fixed amount is paid based upon the DRG which the diagnosis is assigned to. For example, Medicare will pay the same amount for a patient admitted with Congestive Heart Failure regardless of whether they are in the hospital for two days or five days and regardless of all those scary prices for each individual item you might see if you look at the hospital bill.

Actually it does get far more complicated than this as other factors will also influence the total payment, but Medicare payment is not based upon charges per day or charges for individual items. This might not change the fact that hospitals would prefer to have more patients with private insurance as opposed to Medicare, but it is such a common mistake in the discussion of health care reimbursement that I thought I would address it here.

Palin Leaves Door Open On Third Party Run

Sarah Palin joins Mike Huckabee in wanting to see the Republican Party be the party of the far right. Chris Cillizza notes that she is keeping the door open on a third party run if the GOP doesn’t bet back to its conservative base:

Asked by Larson whether she would consider running as a third party candidate, Palin said: “That depends on how things go in the next couple of years.” Larson told the 2008 vice presidential nominee that answer “sounds like a yes” to which she responded: “If the Republican party gets back to that [conservative] base, I think our party is going to be stronger and there’s not going to be a need for a third party, but I’ll play that by ear in these coming months, coming years.” Which, to the Fix’s delicate ears, sounds like Palin leaving the door wide open. As we have written before, Palin is not — and never will be — a candidate of the Republican establishment. Given that, and the unpredictability she demonstrated in her stunning decision to resign as governor over the summer, no potential avenue to the presidency should be ruled out.

If the Republican Party isn’t already playing to the conservative base, where does she think the party now is?

I agree with Cillizza that Sarah Palin would have no qualms about running as a third party candidate if she saw it as a potential avenue to the presidency. I’d take this a step further. I think she would run as a third party candidate for the fame even if she realized she could not win. It’s not like she has a day job to worry about.

Huckabee Wants a Small Tent

In the past Mike Huckabee has said that it’s fine to have moderates in the Republican Party. Now he is calling for a small tent. He warns that a big tent “will kill the conservative movement.” (I thought that only a silver bullet or a stake through the heart would kill them, but that’s a different topic.)  I guess it makes sense. Only a small tent party would nominate someone like Mike Huckabee.

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Iraqi Taxi Driver Source of Information on WMD Threat

Remember the warnings that we had to stop Saddam because he could could unleash weapons of mass destruction  within 45 minutes? It now looks like the source of this discredited threat was an Iraqi taxi driver. They were so desperate to make a case for going to war that they tried to run with any story they could come up with, regardless of how weak the evidence.