Buying healthcare is hard

I've been calling doctor's offices trying to find out the price for some relatively simple and common procedures. It's ridiculously difficult. For every three receptionists I talk to, one will act as if she has no idea what a price estimate even is. She'll offer me medical codes, but dollar amounts? You must be crazy.

Another will assume I must be uninsured, because why else would I care about the price? She'll tell me that actually they charge more for cash patients. Yes, thank you, for making it clear that you practice price discrimination which hurts the most disadvantaged patients.

Probably two will require me to laboriously explain that yes, I know the price I pay may not be the same as what they charge the insurance company.

Oh, and those price comparisons?

Procedure 1:
One office told me it would be $ 20-500 --and they refused to narrow it down any more than that.
Procedure 2:
At one office it was $70, at another $470.
Procedure 3:
I called three offices: one said $800, one $1200, and one $300. The one my primary care physician recommended was the most expensive.

I think this tells us something about why our healthcare system doesn't work.

Transsexuals

Fact is, most transsexuals agree there’s something wrong with them. The difference is they think it’s with their bodies, while unsympathetic outsiders say it’s with their heads.

Are transsexuals mentally ill? Pretty meaningless question, since there is no objective definition of mental illness. In a remarkably calm and even-handed column on a contentious topic, the author of the Straight Dope suggests that a condition which causes unhappiness in itself, rather than unhappiness as a result of social disapproval, should be considered a mental illness:

DSM-III dropped the old classification of homosexuality as a disorder because of the dawning realization that whatever gays and lesbians might be unhappy about, it wasn’t about being gay or lesbian as such — the main issue was social disapproval. In contrast, even with all the social acceptance in the world, transsexuals are still going to think they’re the wrong sex.

What ought to be measured, but has not yet been with sufficient validity, is whether sex reassignment surgery makes transsexuals happier (ideally I would think the surgery group should be compared, not only to a control group, but to a group of transsexuals getting cognitive-behavioral therapy intended to help them learn to get away from the obsessive thought of being in the wrong body.)

I know there's a certain amount of controversy over terminology here, but I don't care enough to figure out whether "transsexual" is considered the correct term. 

 

 
I highly doubt whether many people would even notice a transsexual in the locker room. But it would provide a great opportunity for unscrupulous men, wouldn't it?

I have not yet seen an explanation for why there seem to be so many more male-to-female transsexuals than the other way around. Is it because it's easier for women to wear male clothing without automatically being read as transsexual, so that they can indulge their genderbending urges without having to go all the way? Or is it that women are lower-status in our culture, so that pretending to be a male when you're not doesn't have the same transgressive edge as pretending to be female?

If you buy into the PC theories about transsexuality, you'd have to say that actually there are just as many female-to-male as the other kind, but for some reason they are not as willing to be open about it.

Questioning the conservative explanation for poverty

Bryan Caplan, the iconoclastic George Mason economist and author of Selfish Reasons to Have More Kids, is planning a book on poverty. Working title: Poverty: Who to Blame. I’m excited, but judging from his blog, he has some big blind spots when talking about poverty.

The basic truth conservatives start with, when talking about poverty, is that people who finish high school, do not commit crimes, do not have children before marriage, and find and hold a full-time minimum-wage job are very unlikely to be poor. This is true. Charles Karelis makes this point in his book, The Persistence of Poverty:

One 2003 simulation estimates that if all nonelderly and nondisabled heads of families with children worked full-time at their present wages, or at the wages they could earn based on their education and other factors, the fraction of the US population living below the poverty line would fall from 13 percent to 7.5 percent.

 

Caplan’s advice for poor women in particular is to refrain from childbearing until they find an eligible (stably employed, marriage-minded, nonabusive) man to marry. It sounds very simple. So what's the problem?

Here are some complicating questions I would expect the book to address:

1) Is it true that having children out of marriage hurts women’s economic prospects? Evidence from Kathryn Edin for one suggests that women who start out in the same economic place end up in the same place whether they become single teenage mothers or not.

2) Is it true, as he asserts, that poor people drink more and use more drugs? Actually, no. The consensus seems to be that alcohol use and income are positively correlated; richer people are more likely to drink and to drink more. Use of illegal drugs is correlated with poverty, but if Caplan thinks that substance use is one of the causes of poverty, he needs to explain why drugs and alcohol are so different here. They both cost money, carry health risks, and increase the risk of getting in trouble with the law. If the poor have lower impulse control, why are they better at controlling the impulse to drink?

3) What if there aren’t enough eligible men?

For women like me, it’s a no-brainer to wait a decade or more after puberty before having children. We know that there will be eligible men out there for us. If anything, the supply of men increases and improves over time: a 25-year-old college graduate has access to a greater variety and higher quality of men than a 15-year-old high school student.

Is this true for poor women living in poor neighborhoods? Isn’t it possible that the opposite is true for them: that the number of 18-year-old men who are marriage-minded, childless, without a criminal record and out of jail  is actually greater than the number of 25- to 30-year-olds who meet those requirements?

This is something of a speculative tangent, though. But it is true that there is a very high ratio of marriage-age women to marriage-age men in poor neighborhoods. Factor in the very high unemployment rates for young black men with no college degree, and the number of eligible men goes down further. 

Caplan rightly thinks preaching abstinence is unrealistic for most, and suggests contraception instead. But suggesting that women delay childbearing until they find an eligible man, even when this might take decades and might mean giving up the possibility of motherhood altogether, is almost as unrealistic.

4) What about the dangers of marriage? Caplan says that marriage is a good economic decision: two people living together spend less than two living apart. But it's not just about the money: what about the risk that the seemingly eligible man might lose his job, become abusive, or steal the woman’s money? Not to speak of the loss of independence.

5) What if finding full-time employment is impossible? Many minimum-wage employers deliberately avoid hiring full-time staff, because after that 40-hour-a-week threshold, they will be forced to provide more benefits. Anyone can get a job at McDonald’s, but getting 40 hours a week is a lot harder.

The largest liberal objection, of course, is that it shouldn’t matter who we blame for poverty. No one denies that the poor exist and are generally worse off than the rich. That, to me, means that they are entitled to a few of my superfluous dollars (which I probably would have spent on liquor anyway.)

Why object to the execution of the stupid?

The latest liberal outrage is the execution of a murderer, Marvin Wilson, who, according to his lawyers and one IQ test but not others, has an IQ of 61, below the threshold of 70 which Texas law takes as the minimum IQ needed to take responsibility for one’s actions.

For a while I was baffled, since many people seemed outraged by this without
 really saying why.  After some thought, I’ve decided this is not really about the death penalty.

Rather, it seems to me like a difference of opinion between those who believe judicial punishments exist to punish “guilt” (whatever that means) and those who believe the purpose of the judicial system is to protect law-abiding citizens.

If you fall into the former camp, then, if the criminal is too stupid to know what he was doing, if he is young, if he is uneducated, if he is poor, and so forth, his guilt is less. He should be punished either not at all or else the bare minimum amount. We should favor more humane prisons to promote rehabilitation. The death penalty should either not be used at all, since it precludes rehabilitation, or it should only be used for older, richer, more educated, and higher-IQ criminals (of which there are very few).

If you fall into the second camp, you will be inclined to say a murderer is a murderer is a danger to society. This danger should be eliminated regardless of hard-to-ascertain metaphysical “guilt”. The seriousness of the crime matters, but not the personal characteristics of the victim. If you favor more humane prisons, you will do so to decrease recidivism. You might favor the death penalty on grounds of efficiency, or you might oppose it because you think it does not deter.

Note, of course, that these two broad schools of thought are not correlated with opposing or supporting the death penalty. That’s a whole ‘nother issue involved in the Wilson case. I suspect that most people who think a low-IQ man should not be executed also think that no one should be executed–they focus on Wilson because he’s the easy propaganda case. (Just as most medical marijuana advocates favor legalizing all marijuana, but they focus on medical uses for the easy propaganda.)       

NB: Difference between rehabilitation and preventing recidivism. Preventing recidivism means ensuring that criminals do not reoffend–this might mean changing hearts and minds, or scaring criminals with the threat of more or worse punishment, or preventing their contact with other or worse criminals in prison, or keeping drugs off the streets, or improving economic opportunities for low-income men, and so forth. Rehabilitation focuses on changing the criminal’s personality, so that he will understand that crime is bad.

Talking about single women

Most societies fear, hate and suspect young women. Therefore, talking about young, unmarried women is linguistically problematic. This is true in several languages.

• It's especially clear  in French: garce, originally the feminine of garcon, came to mean 'slut', while garcon continued to mean simply 'boy'. After garce became contaminated, fille, the feminine of fils, came to be used. But soon fille fell victim to the same contamination. Finally jeune fille was expanded from its original meaning of 'young girl' and came to be applied to young woman, similar to the English 'girl'. Jeune personne (young person) is another euphemism used in the past to avoid facing the uncomfortable fact of a young woman.
• In English, the word 'woman' came to be used only to refer to lower-class women; the words 'lady', 'young lady' and 'girl' replaced it,and in the early 20th century English even borrowed the French 'young person' to mean an unmarried woman.
• In modern English,'lady' or 'young lady' is less often used, but the discomfort with the word 'woman' persists. A new development is the use of the word 'female', which is military and bureaucratic jargon as well as giving a helpful air of pseudo-scientificity to one's speech. When you are making unsupported allegations about the difference between men and women, it's a lot easier to call them 'males' and 'females'. It makes you sounds objective, like a farmer talking about his livestock. On the other hand, using the term 'woman/women' is so unusual it actually tends to make you sound like a feminist.
• In a Language Log post which is more comprehensive than I will do justice to, the same phenomenon is shown to appear in Chinese.
  

  
  When I started to learn Mandarin nearly half a century ago, it used to be that xiǎojiě 小姐 ("miss") was a polite way to refer to or address a young, unmarried woman. You could also extend xiǎojiě 小姐 ("miss", lit., "little elder sister") to convey other, related meanings, such as lǎo xiǎojiě 老小姐 ("old maid / miss"), xiǎojiě píqì 小姐脾气 ("petulant; flirtatious; coquettish"), and so forth. Gradually, however, xiǎojiě 小姐 ("miss") evolved to the point that it often came to be used in a jocular or facetious manner.  Furthermore, when used by itself, xiǎojiě 小姐 may be applied to prostitutes, so one must be careful when referring to someone with this word.  It seems that there is no longer a broadly accepted, relatively respectful term of address for a young, single woman.

New DSM addiction disorder criteria

Among the millions of people who will be diagnosed with an addictive disorder in the new DSM are many whose lives will be derailed by their substance use, leading to car accidents, suicide, brain damage, sexual trauma...The new criteria will allow clinicians to intervene at an earlier stage in the addiction cycle, when relatively brief and inexpensive treatments can prevent more serious problems from escalating. Psycho-education, psychotherapy and group support should be available for people who seek treatment early on. Who would argue that it’s better to wait until the substance use escalates before treatment can be initiated?

Who would argue against early intervention? I would. There are costs to substance abuse treatment: big financial ones, the cost of limiting people's autonomy, and the risks of teaching someone who may never (yet) have experienced addiction that he probably will get addicted and will be powerless to stop it. Not to mention teaching that if a person continues to use drugs or alcohol, he's no longer responsible for his behavior.

I mean, imagine a bunch of typical 20-year-old drinkers sent into AA. They probably fit the diagnostic criteria (since the definitions of "binge drinking" and "heavy drinking" keep being revised downwards!), but does anyone think that such drinkers would benefit from a treatment program? In fact, we know that most young people who use drugs or alcohol heavily will age out of such heavy use naturally. In most cases, no intervention is necessary: and treatment programs have a terrible record of success. To call for early intervention drug and alcohol treatment is like calling for surgery to treat the common cold. We know it doesn't work for most people, it's expensive, and it does serious harm to the people subjected, in many cases involuntarily, to treatment.

Oh, and ignore the first sentence. As my astute readers will have noted, horror stories are totally irrelevant when talking about early intervention. For every person who will have serious problems with a substance, there are hundreds who fit the criteria for early intervention but will never have serious problems.

Abominable women proposing marriage

The offer of herself by a woman to a man is, to us all, a thing so distasteful that we at once declare that the women must be abominable...But the man to whom the offer is made hardly sees the thing in the same light.

 --Trollope, The Eustace Diamonds

Barely 150 years since this sort of attitude was mainstream. And we already hear men complaining that women don't take enough initiative. They can't imagine any reason why a woman would be reluctant to make the first move.